'To close the gaps in health disparities among racial, economic, geographic, andpopuhtion groups remains one of the country's most significant challenges. " (McGinnis, 1996)
Meeting the health care needs of a growing nation has been an ongoing dialogue among providers and health care policymakers since the late 1970s. Concerns have been centered around the ramifications of increased technology, an increasing immigrant population, global arms races, the effects of global warming, an increasingly aging population, and managed care. The recognized challenge is to provide adequate quality health care for all and to protect health. The launching of Health People 2010 Objectives in January 2000 provided the impetus to meet this challenge (U.S. Department of Health and Human Services [USDHHS], 2000a). These objectives will provide the road map for health care professionals in practice, education, and research to develop guidelines, curricula, and proposals that will protect and maintain the health of those who not only live in the United States but also those who come to our shores for protection. For our nation to be healthy, we must focus on the prevention of illness and the promotion of health. Many have supported this rhetoric on paper for years; now it is imperative that health care professionals come together to eliminate the existing disparities in all areas of health care. This article will discuss the origins of Healthy People; and identify the goals, objectives, community partnerships, and implications of Healthy People 2010 for an increasingly older population.
ORIGIN OF HEALTHY PEOPLE
Healthy People 2010 outlines a comprehensive, nationwide health promotion and disease prevention agenda. It is designed to serve as a roadmap for improving the health of all people in the United States during the first decade of the 21st century.
Like the preceding Healthy People 2000 initiative-which was driven by an ambitious yet achievable 10-year strategy for improving the Nation's health by the end of the 20th century - Healthy People 2010 is committed to a single, overarching purpose: promoting health and preventing illness, disability, and premature death.
THE HISTORY BEHIND HEALTHY PEOPLE 2010
Healthy People 2010 builds on initiatives pursued over the past 2 decades. In 1979, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (USDHHS, 1990) provided national goals for reducing premature deaths and preserving independence for older adults. In 1980, another report, Promoting Health/Preventing Disease: Objectives for the Nation (USDHHS, 1980), outlined 226 targeted health objectives for the nation to achieve over the next 10 years.
Healthy People 2000: National Health Promotion and Disease Prevention Objectives, released in 1990, identified health improvement goals and objectives to be reached by the year 2000. The Healthy People 2010 initiative continues in this tradition as an instrument to improve health for the first decade of the 21st century.
INDIVIDUAL AND COMMUNITY HEALTH
Over the years, it has become clear that individual health is closely linked to community health - the health of the community and environment in which individuals live, work, and play. Likewise, community health is profoundly affected by the collective behaviors, attitudes, and beliefs of everyone who lives in the community.
Indeed, the underlying premise of Healthy People 2010 is that the health of the individual is almost inseparable from the health of the larger community, and that the health of every community in every state and territory determines the overall health status of the nation. That is why the vision for Healthy People 2010 is "Healthy People in Healthy Communities."
IMPROVING THE NATION'S HEALTH
One of the most compelling and encouraging lessons learned from the Healthy People 2000 initiative is that, as a nation, we can make dramatic progress in improving the nation's health in a relatively short period of time. For example, during the last decade, significant reductions in infant mortality were achieved. Childhood vaccinations are at the highest levels ever recorded in the United States. Fewer teenagers are becoming parents. Overall, alcohol, tobacco, and illicit drug use is leveling off. Death rates for coronary heart disease and stroke have declined. Significant advances have been made in the diagnosis and treatment of cancer and in reducing unintentional injuries.
However, we still have a long way to go. Diabetes and other chronic conditions continue to present a serious obstacle to public health. Vio-lence and abusive behavior continue to ravage homes and communities across the country. Mental disorders continue to go undiagnosed and un-treated. Obesity in adults has in-creased 50% over the past 2 decades. Nearly 40% of adults engage in no leisure time physical activity. Smoking among adolescents has increased in the past decade. And HIV/AIDS remains a serious health problem, now disproportionately affecting women and minority populations. Healthy People 2010 will be the guiding instrument for addressing these and other new health issues, reversing unfavorable trends, and expanding past achievements in health.
ACHIEVING THE HEALTHY PEOPLE 2010 OBJECTIVES
Addressing the challenge of health improvement is a shared responsibility requiring the active participation and leadership of the federal government, states, local governments, policymakers, health care providers, professionals, business executives, educators, community leaders, and the American public itself. Although administrative responsibility for the Healthy People 2010 initiative rests in the U.S. Department of Health and Human Services, representatives of all these diverse groups shared their experience, expertise, and ideas in developing the Healthy People 2010 goals and objectives.
Healthy People 2010, however, is just the beginning. The biggest challenges still stand before us, and we all share a role in building a healthier nation. Regardless of your age, gender, education level, income, race, ethnicity, cultural customs, language, religious beliefs, disability, sexual orientation, geographic location, or occupation, Healthy People 2010 is designed to be a valuable resource in determining how you can participate most effectively in improving the nation's health. Perhaps you will recognize the need to be a more active participant in decisions affecting your own health or the health of your children or loved ones. Perhaps you will assume a leadership role in promoting healthier behaviors in your neighborhood or community. Or perhaps you will use your influence and social stature to advocate for and implement policies and programs that can dramatically improve the health of dozens, hundreds, thousands, or even millions of people.
FOCUS AREAS OF HEALTHY PEOPLE 2010
Whatever your role, this document is designed to help you determine what you can do - in your home, community, business, state, or schools - to help improve the nation's health.
When Healthy People 2000 was published in 1991, no one could have predicted the influence the Internet would have on the next generation of health objectives for the nation. The Healthy People 2000 document was conceived, developed, published, and distributed as a print document. Its successor, Healthy People 2010, has lived and will continue to live parallel lives in print and cyberspace.
HEALTHY PEOPLE 2010: PURPOSE, GOALS, AND OBJECTIVES
The objectives of the past 2 decades have provided the groundwork upon which the Healthy People 2010 objectives were developed . The process for development of these objectives began in 1996 with the identification of a Healthy People Consortium - a user alliance of 350 national membership organizations and 259 state health, mental health, substance abuse, and environmental agencies. A Stakeholders Report outlining this meeting appears at: http//odphp.osophs.dhhs. gov/pubs/hp2000. The whole content of the objectives commits the nation to a single, overarching purpose: promoting health and preventing illness, disability, and premature death. There are two major goals:
* Increasing quality and years of healthy life.
* Eliminating health disparities.
Research demonstrates that healthy people live longer lives. The first goal identifies that a longer life should be one in which a person experiences a quality to their life with purpose and meaning. The Healthy People 2010 states:
. . . Quality of life reflects a general sense of happiness and satisfaction with our lives and environments. General quality of life encompasses all aspects of life, including health, recreation, culture, rights, values, beliefs, aspirations, and the conditions that support a life containing these elements . . . Health-related quality of life is inherently more subjective than life expectancy and therefore can be more difficult to measure (USDHHS, 2000a, p. 10).
For older individuals, this indicates the prevention of chronic illness and, where illness exists, the prevention of exacerbations. For those with debilitating illnesses, it means providing palliative care, a pain-free environment in which to live. For those who live in long-term care facilities, it means the promotion and protection of health through monitoring the quality of care and providing adequate staff. It also means having the responsibility to continue quality care at the end of life while making judicious decisions involving the patient and family.
The second goal, the elimination of health disparities, provides the challenge to identify and address the underlying causes of higher levels of disease and disability in racial and ethnic minority communities. "These include differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation" (USDHHS, 2000b, p. 11). There is compelling evidence that race and ethnicity correlate with persistent and often increasing health disparities throughout the United States population. These diseases are well known: hypertension in the Black population, diabetes in the Native American Indian and Hispanic, stomach and cervical cancer in the Hispanic population, obesity in Black and Hispanic women, smoking in White, Black, and Hispanic adolescents as well as adult American Indians and Alaska Natives. Cultural sensitivity in the development and outreach of programs to meet these objectives and goals is imperative.
As racial and ethnic minorities age, the duration and quality of their lives are adversely affected. The aging boomers of the nation are fueling an increasing caregiver cohort. The term "sandwich generation" was coined many years ago to indicate families caring for (sandwiched between) both children and aging parents. This term may be expanded in the future to reveal a new term as families age and elderly individuals begin to care for elderly individuals. The message is clear that frontline protection of health is imperative and must be achieved in collaboration with others.
The progress in achieving these goals will be monitored through 467 objectives and 28 focus areas (Table). Many of the objectives focus on interventions designed to reduce or eliminate illness, disability, and premature death among individuals and categories of communities. Others focus on broader issues, such as improving access to services and improving the availability and dissemination of healthrelated information. Each objective has a target for specific improvements to be achieved by the year 2010. One can log onto the Web site (www.health.gov/healthypeople) and search within each of these target areas for details about the objective.
The text also can be ordered from the U.S. Government Printing Office (see additional resources on page 21). Each section begins with the goal, then proceeds to discuss the issue in detail within an overview covering issues, trends, disparities, and opportunities. It is within the opportunities phase that the practitioner is given helpful guidelines to implement strategies and collaborate to develop programs.
Figure 1. Healthy People 2010 - a systematic approach to health improvement.
Figure 2. Proportion of the population aged 20 years and older with diabetes (by age group and race/ethnicity, United States, 1988-1994). From Harris, et al. (1998).
The Healthy People 2010 goals and objectives cannot improve the health status of the nation by themselves. Instead, they should be recognized as part of a larger, systematic approach to health improvement (Figure 1).
This systematic approach to health improvement is composed of four key elements:
* Determinants of health.
* Health status.
The goals provide a general focus and direction. The goals, in turn, serve as a guide for developing a set of objectives that will actually measure progress within a specified amount of time. The objectives focus on the determinants of health, which encompass the combined effects of individual and community physical and social environments and the policies and interventions used to promote health, prevent disease, and ensure access to quality health care. The ultimate measure of success in any health improvement effort is the health status of the target population. Healthy People 2010 is built on this systematic approach to health improvement.
The 467 objectives in 28 focus areas of Healthy People 2010 are all developed with a similar framework:
* Goal is a brief descriptor of the burden of disease.
* Overview describes the public health prevention challenge with statistics to support the rationale for the goal.
* Issues identify the economic and human burden of disease and the need for preventative strategies, whether primary or secondary.
* Trends is the most extensive section, taking the reader through a lengthy discussion of the occurrences (scientific and behavioral) among population groups and the current research and barriers to primary care that have had a significant impact on the efforts to prevent disease.
* Disparities details the disproportionate rates of disease that must be addressed.
* Opportunities provides a framework for the clinician, academician, or researcher to specifically address programs and strategies for prevention efforts.
The final section, Interim Progress Toward Year 2000 Objectives, provides the baseline for further progress. Charts and statistics are incorporated and provide the health care professional with appropriate data on race, ethnicity, gender, age, educational level, disability, and geographical location.
For a better image of the document, a condensed version of diabetes is provided so readers will take this challenging opportunity to embrace Healthy People 2010 as they identify curriculum concepts, develop and test outcome-oriented research, write grants that clearly demonstrate prevention strategies, and identify the ethnic disparities that must be reduced and eliminated.
The following information is from Healthy People 2010 Objectives for Improving Health, Part A (USDHHS, 2000b).
The Healthy People 2010 goal is, through prevention programs, to reduce the disease and economic burden of diabetes and improve the quality of life for all individuals who have and are at risk for diabetes.
Diabetes poses a significant public health challenge for the United States. Approximately 800,000 new cases are diagnosed each year, or 2,200 per day. The changing demographic patterns of the United States are expected to increase the number of people who are at risk for diabetes and who eventually develop the disease. While all individuals with diabetes require selfmanagement training, treatment for Type 2 diabetes usually consists of a combination of physical activity, proper nutrition, oral tablets, or insulin injection.
The occurrence of diabetes, especially Type 2 diabetes, as well as associated complications, is increasing in the United States. The number of people with diabetes has increased steadily over the past decade. Presently, 10.5 million people have been diagnosed with diabetes, while 5.5 million are estimated to have the disease but are undiagnosed.
Over the past decade, diabetes has remained the seventh leading cause of death in the United States, primarily from diabetes-associated cardiovascular disease. While postmenopausal nondiabetic women usually are at less risk of cardiovascular disease than men, the presence of diabetes in women is associated with a 3% to 4% increase in coronary heart disease compared to nondiabetic females.
In the United States, diabetes is the leading cause of nontraumatic amputations (approximately 57,000 per year or 150 per day); blindness among working-age adults (approximately 20,000 per year or 60 per day); and end-stage renal disease (ESRD) (approximately 28,000 per year or 70 per day). Diabetes is a costly disease; estimates of the total attributable cost of diabetes are around $100 billion ($43 billion direct; $45 billion indirect). Diabetes is thus a "wasteful" disease. Strategies that would lessen the burden of this disease are not used regularly, resulting in unnecessary illness, disability, death, and expense.
The toll of diabetes on the health status of Americans is expected to worsen before it improves, especially in vulnerable, high-risk populations: Blacks, Hispanics, American Indians or Alaska Natives, Asians or other Pacific Islanders, elderly individuals, and economically disadvantaged individuals. Several other interrelated factors influence the present and future burden of diabetes.
Personal behaviors. Westernization, which includes a diet high in fat and processed foods as well as total calories, has been associated with a greater number of overweight individuals in the United States when compared to a decade ago. Obesity, improper nutrition, and lack of physical activity are occurring in individuals younger than age 15. These behaviors and conditions may explain the increasing diagnosis of Type 2 diabetes in teenagers. Increased television watching and computer time have been associated with diminished physical activity, which has contributed to the emergence of diabetes in youth.
Demographics. Diabetes is most common in individuals older than age 65. Increased insulin resistance and gradual deterioration in the function of insulin-producing cells may account for this phenomenon (Figure 2).
Other changes in the United States population can be expected to affect the number of individuals with diabetes. By 2050, almost half of the population will be of a race or ethnicity other than White (53% White; 24% Hispanic; 14% Black; and 8% Asian). Because of these racial and ethnic disparities and their adoption of the Western culture, an increase in diabetes is expected into the first few decades of the 21st century.
Ascertainment. Known as the "hidden" disease, diabetes often is undiagnosed in an estimated 5 million individuals. In addition, complications and health services associated with diabetes frequently are not recorded on death certificates or hospital discharge forms. This is a missing burden of disease that is only now being captured.
Limitations in programs to change behaviors. Scientific evidence indicates that secondary and tertiary prevention programs are effective in reducing the burden oí diabetes. Changing behavior is difficult and challenging, with more effective interventions needing to be developed and implemented to improve the practice of diabetic care. Several other factors influence the present and future burden of diabetes, including genetics, culture, socioeconomic status (SES), scientific discoveries, and the characteristics of both chronic diseases and the health care system. Patient behaviors are influenced by beliefs and attitudes, and these are greatly affected by community and cultural traditions. The public health and medical communities are increasingly recognizing the influence of SES in the occurrence of new cases and progression of chronic diseases. These chronic diseases reflect the social fabric of our nation and impact every area of development, work status, schooling, and health care. For diseases such as diabetes, the accurate measurement of quality of life as an indicator or program effectiveness and the incorporation of non-health professionals at work on the health team will influence the successes of preventive treatment programs. In addition, the apparent movement toward primary health care will affect diabetes management and outcomes. At present, about 90% of all individuals with diabetes receive continuous care from the primary care community. The degree to which improved relationships can be established between diabetes specialists and primary care health providers will determine the quality of diabetes care. The ability to understand and influence individual, community, and organizational behaviors will influence significantly the success of preventive programs in diabetes.
Gaps exist among racial and ethnic groups in the rate of diabetes and its associated complications in the United States. Racial and ethnic communities, including Blacks, Hispanics, American Indians, and certain Pacific Islanders and Asian Americans, as well as the economically disadvantaged and older Americans, suffer disproportionately compared to White populations. For example, the relative number of individuals with diabetes in Black, Hispanic, and American Indian communities is 1 to 5 times greater than in White communities, with death 2 times greater in the Black community and diabetes-associated renal failure 21A times greater than in the Hispanic community.
Within certain racial and ethnic groups, there are four potential individual reasons for the greater burden of diabetes:
* Greater number of cases of diabetes.
* Greater seriousness of diabetes.
* Inadequate access to proper diabetes prevention and control programs.
* Improper quality of care.
Opportunities to meet the challenges of diabetes reside in four "transition points" in the natural history of this disease and the preventive interventions that target them: primary prevention, screening and early diagnosis, access, and quality of care (secondary and tertiary prevention).
The transition points are described in detail as they relate to the disease, with each point representing a diabetes prevention and control opportunity that is contained in the objectives of Healthy People 2010. Objectives are categorized:
* Diabetes education.
* Burden of disease, new cases, existing cases, undiagnosed diabetes, death, and pregnancy complications.
* Macrovascular, microvascular, and metabolic complications.
* Laboratory services (e.g., lipids, glycosylated hemoglobin, microalbumin measurements).
* Health provider services (e.g., eye, foot, dental examinations).
* Patient protection behaviors (e.g., aspirin, self -glucose monitoring).
These objectives measure both the process and the outcomes of preventive diabetes programs.
INTERIM PROGRESS TOWARD YEAR 2000 OBJECTIVES
In Healthy People 2000, five diabetes-related objectives were included in a group of objectives addressing chronic conditions linked by their potential impact on quality of life and disability. Of these five objectives, eye examinations is moving toward the 2000 target. Death from diabetes, nonretinal diabetes complications, new cases of diabetes, and the number of existing cases are all moving away from the 2000 targets. Diabetes education is increasing in frequency among individuals with diabetes. These changes in direction need to be considered carefully with regard to significance, causes, and implications. As we develop new treatments, many of the undiagnosed cases will now be treatable and major preventative strategies can be developed and implemented.
- Harris M.I., Flegal, K.M., Cowie, CC, Eberhardt, M.S., Goldstein, D.E., Little, R.R., Wiedmeyer, H.M., & Byrd-Holt, D.D. (1998). The Third National Health and Nutrition Examination Survey 19981994. Diabetes Care 2/(4), 518-524.
- McGinnis, M. (1996, November 15) Building the Prevention Agenda for 2010: Lessons Learned. Healthy People Consortium Address, New York, NY.
- U.S. Department of Health and Human Services. (1990). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office.
- U.S. Department of Health and Human Services. (2000, January). Healthy People 2010 (Conference Edition) (Vols. 1-2). Washington, DC: U.S. Government Printing Office.
- U.S. Department of Health and Human Services. (2000). Healthy People 2010 [On-line] Available: http://www.health. gov/healthypeople
- U.S. Department of Health and Human Services, Public Health Services. (1980). Healthy People: The surgeon generals report on health promotion and disease prevention. Washington, DC: U.S. Government Printing Office.
FOCUS AREAS OF HEALTHY PEOPLE 2010