In 2007, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services (HHS) contracted with the National Opinion Research Center (NORC) to conduct the 2008 Healthy People User Study. The study serves two purposes. First, it builds on findings from a similar study of Healthy People users conducted in 2005, which allows HHS to examine changes over time. Second, it informs HHS about patterns of awareness and usage of the initiative among state, local and tribal health organizations. Specifically, the results document the extent of awareness; describe the nature of use and assess whether use is changing over time; identify barriers to use among these critical audiences; and offer insight to assist in the development of the next iteration of Healthy People, Healthy People 2020. Healthy People 2020 is using current evidence and data, as well as lessons learned from Healthy People 2010, to establish new national health objectives reflective of evolving public health priorities. The process of developing Healthy People 2020 relies on input from the initiative’s key stakeholders to ensure a product that is responsive to the needs of its users. The development of Healthy People 2020 is well underway with release of the initiative’s overarching framework scheduled in 2009 and the release of health objectives planned for 2010.
The results of the 2008 Healthy People User Study provide HHS with important information on the utilization of Healthy People 2010, and for the development of Healthy People 2020. First, results of the study indicate that awareness and use of the Healthy People initiative is very high among key stakeholders, with overall use of the initiative increasing since the 2005 study. The results also show that both non-users and users of Healthy People 2010 were more likely to cite issues related to their organization/agency as a barrier to greater use of the initiative, as opposed to issues related to the Healthy People initiative itself. However, it is important to recognize that some barriers associated with the initiative itself are impacting key stakeholders’ use of the initiative, such as the lack of implementation guides. Finally, study respondents expressed distinct, and conflicting, preferences regarding the format and content of Healthy People 2020, which suggests that Healthy People is utilized by different organizations in different ways.
Each decade since 1979, the U.S. Department of Health and Human Services (HHS) has published a comprehensive set of national public health objectives. Known as Healthy People, this initiative is based on the premise that setting objectives and monitoring progress can motivate action. The most recent iteration, Healthy People 2010, consists of 467 objectives, organized into 28 focus areas. It has two overarching goals: (1) to increase the quality and years of healthy life, and (2) to eliminate health disparities.
In 2005, the Office of Disease Prevention and Health Promotion (ODPHP) and ASPE determined a need to investigate the awareness and use of Healthy People among the initiative’s target audiences. ODPHP and ASPE contracted with the National Opinion Research Center (NORC) to conduct an assessment of how the Healthy People 2010 initiative was being used by state, local and tribal health organizations/agencies. NORC’s Assessment of the Uses and Users of HealthierUS and Healthy People 2010 (hereafter referred to as the “2005 User Assessment”) identified important differences among states, localities, tribes, and organizations/agencies of various sizes in terms of their exposure to and use of the initiatives, as well as the extent to which they found them relevant and effective.
Since the 2005 User Assessment, HHS has undertaken a number of efforts to increase awareness of the Healthy People initiative among certain stakeholder groups. For example, ODPHP worked with Regional Health Directors and State Healthy People Coordinators to conduct targeted outreach to tribes and local health organizations/agencies to increase their knowledge and use of the initiative. Other HHS and non-federal partners have also disseminated program and implementation tools such as Healthy Youth (Centers for Disease Control and Prevention, 2004), Rural Healthy People 2010 (Gamm & Hutchinson, 2004), and models for state-based Healthy People initiatives (State Healthy People Plans, 2008). To assess the cumulative impact of these efforts and the current level of awareness and uses of Healthy People 2010, a follow-up study—the 2008 User Study—was conducted.
The 2008 User Study collected data using a mailed, self-administered questionnaire (SAQ), which was sent to members of state, local, and tribal health organizations/agencies. The survey was developed by reviewing the questionnaire and findings of the 2005 User Assessment, gathering information on HHS-sponsored activities that have taken place over the past two years, and reviewing planning activities that are currently underway to prepare the next decade’s set of national objectives for health promotion and disease prevention.
The sample for the 2008 User Study was constructed from multiple sources, with separate sampling frames for state, local, and tribal health organizations/agencies. Included were two groups within each State’s Department of Health; the Healthy People State Coordinator (HP Coordinator) and the Chronic Disease Director, as well as a sample of local health organizations. The study also sought responses from two different types of tribal health organizations: individual tribal health organizations and Multi-Tribal Area Health Boards (MTAHB). The project surveyed all HP Coordinators, Chronic Disease Directors, and MTAHB, and, it sampled local and tribal health organizations. The study’s sample sizes and response rates are shown in the table below. Survey results were then summarized within and across organization/agency type.
To supplement the information gathered through the survey responses, 10 informal discussions with users and non-users of Healthy People 2010 were conducted. These discussions provided an opportunity for key stakeholders to describe in greater detail their utilization of Healthy People, and how the initiative could be improved.
Overall, 91 percent of the responding organizations/agencies were aware of the initiative. This percentage shows an increase from the 83 percent who were aware of the initiative during the 2005 User Assessment. Of the 327 organizations/agencies that were aware of Healthy People 2010, 78 percent reported using it in their organization/agency. This is an increase from the 71 percent of organizations/agencies that reported use of the initiative in the previous study; though not a statistically significant increase.
Users of Healthy People 2010 indicated the various ways in which their organization/agencies use the initiative. Some of the highlights of these uses are listed below:
- Over 81 percent of users in each sample type reported using Healthy People 2010 as a data source, to support applications for grants or funding, and as a framework for planning, goal-setting and agenda building.
- The data revealed variation between respondent types pertaining to the aspect of the initiative that is most useful. State level respondents cited the specific health objectives, MTAHB respondents reported leading health indicators, tribal health organization respondents cited the overarching goals, and local health organization respondents indicated data resources and the leading health indicators to be the most useful aspect of Healthy People 2010.
- Eighty percent of tribal health organizations reported intentionally planning programs around one or more of the Healthy People 2010 objectives. This was substantially higher for the other Healthy People 2010 respondent types.
Study respondents also provided information on barriers to using Healthy People 2010:
- In terms of barriers related to the Healthy People initiative, the most commonly reported barrier by users of Healthy People 2010 was lack of data to track objectives (32 percent).
- In terms of barriers related to the respondent’s organization/agency, insufficient resources was the most commonly cited barrier (76 percent).
- Almost 60 percent of non-users indicated that a lack of implementation guidance was a barrier to greater use of Healthy People 2010.
- Notably, the proportion of respondents reporting each type of barrier greatly decreased from 2005.
Finally, to inform the development of Healthy People 2020, study respondents were asked various questions about ways to improve the Healthy People initiative, and their anticipated uses of Healthy People 2020:
- Overall, 47 percent of Healthy People 2010 users felt that fewer focus areas should be included in Healthy People 2020.
- Overall, 70 69 percent of Healthy People 2010 users indicated that a reorganization of Healthy People would be useful for the next iteration. When asked which format for organizing objectives would be most useful, 37 percent of Healthy People 2010 users felt it would be most useful to reorganize by risks/determinants (such as tobacco use, genetics, physical environment), 31 30 percent felt it would be most useful to reorganize by disease area, and 12 percent felt it would be most useful to reorganize by life stages.
- Overall, Healthy People 2010 users reported that they are most likely to use Healthy People 2020 as a framework for planning, goal-setting or decision making (79 percent).
- Healthy People 2010 users report that they are least likely to use Healthy People 2020 as a guide to set spending priorities within their organization (42 percent).
The 2008 User Study provides an updated snapshot of awareness and use of Healthy People 2010 three-quarters of the way through the decade, allowing for an assessment of whether use is changing over time; identifying barriers to use of Healthy People 2010 among state, local and tribal health organizations; and offering insight to assist HHS in preparing the next iteration of national health objectives, Healthy People 2020. In synthesizing the key findings of this study, eight conclusions were identified:
- Awareness and use of Healthy People has grown over time, but there continues to be a need for targeted efforts directed toward local and tribal health organizations.
- The vast majority of Healthy People 2010 users do not utilize the initiative as a guide for setting spending priorities at their organizations. Rather, spending priorities are determined by available funding mechanisms, which may not be aligned with Healthy People goals. Efforts to align Healthy People goals and funding resources for state, local, and tribal health organizations may help overcome this barrier
- User groups utilize Healthy People differently and for different purposes. These variations indicate that there may be opportunity for expanded use of the initiative as users learn of other users’ Healthy People activities. The variations also indicate there is a continued need for targeted outreach efforts to support continued expansion of Healthy People utilization.
- Barriers to use or increased use of Healthy People are primarily attributed to organizations/agencies, rather than the Healthy People initiative itself. This distinction may be useful when developing outreach efforts to encourage greater use of the initiative.
- The lack of implementation guidelines is the leading barrier to use among non-users of Health People. The extent of this barrier shows an important need that is not being fulfilled by the initiative.
- In addition to outreach to tribal health organizations, MTAHB’s appear to be an effective avenue for communication with tribal health organizations.
- Chronic Disease Directors have similar levels of awareness and use of Healthy People as HP Coordinators, indicating that Federal outreach to states is effective and extends beyond HP Coordinators.
- To further improve Healthy People and its usability, Healthy People 2020 should include implementation guides and evidence-based practices, and HHS should increase communication with stakeholders to ensure users are aware of the complete spectrum of uses of Healthy People (rather than users continuing to use Healthy People only in the ways previously established by their organization/agency).