NORC Final Report: Healthy People User Study. Healthy People 2010

Healthy People 2010 had a high level of visibility with the responding health organizations/agencies. Overall, 91 percent of the responding organizations/agencies were aware of the initiative. This percentage shows a statistically significantn increase from the 83 percent that were aware of the initiative in the 2005 User Assessment. All of the responding HP Coordinators and Chronic Disease Directors, 92 percent of the local health organizations, 78 percent of the MTAHB, and 71 percent of the tribal health organizations reported awareness of the initiative. These levels of awareness show a statistically significant increase since 2005 for local health organizations. Furthermore, while awareness is growing among local and tribal health organizations, While tribesthese organizations continue to be significantly less likely to be aware of the initiative compared to both local and to state health organizations, awareness among tribal health organizations has greatly increased since 2005 (see Exhibit 7).

Exhibit 7: Healthy People 2010 Awareness^H1

Exhibit 7 is a bar chart showing the percent of responding HP Coordinators, Chronic Disease Directors, MTAHB, Tribal Health Orgnaizations, and Local Health Organizations that are aware of Healthy People 2010, and the percent that were aware of Healthy People 2010 from the 2005 Assessment.

Overall, 78 percent of the 327 organizations/agencies that were aware of Healthy People 2010 reported using the initiative. This is an increase over the 71 percent of organizations/agencies that reported use of the initiative in the previous study. One-hundred percent of the Chronic Disease Directors and MTAHB who were aware of Healthy People 2010 reported using the initiative compared to 96 percent of HP Coordinators⁹, 74 percent of local health organizations, and 43 percent of tribal health organizations. These results show a statistically significantn increase in the percentage of local health organizations that reported using the initiative from the 2005 User Assessment, while also showing that states are significantly more likely than local and tribal health organizations to use the initiative, and local health organizations are significantly more likely than tribal health organizations to use the initiative. Between HP Coordinators and Chronic Disease Directors, the results indicate that all 49 responding states use Healthy People 2010¹⁰. Exhibits 8-11 display the variation of use across sample type, region, and organization/agency size. These results indicate a general tendency of higher use of Healthy People 2010 among larger organizations. None of the differences in use between the 2005 and 2008 studies are statistically significant by sample type.

Exhibit 9: Use of Healthy People 2010 among Those Aware of the Initiative¹¹

Exhibit 9 is a bar chart showing the percent of small, medium, and large organizations among HP Coordinators, Chronic Disease Directors, Tribal Health Organizations, and Local Health Organizations that are aware of Healthy People 2010.

Exhibit 10: Percent of Respondents Who Use Healthy People 2010 by Size of Population Served

Exhibit 10 is a bar chart showing the percent of small, medium, and large organzations among all respondents that use Healthy People 2010.

Exhibit 11: Percent of Respondents Who Use Healthy People 2010 by Census Region

Exhibit 11 is a bar chart showing the percent of respondents that use Healthy People 2010 by census region. The regions are Northeast, Midwest, South, and West.

Healthy People 2010 users reported the different ways in which they use the initiative at their organization/agency in terms of use for research, collaboration and outreach, and for internal planning. Exhibit 12 presents the type of use by respondent type. MTAHB and tribal health organizations were more likely than the other organization/agency types to report using Healthy People 2010 for research purposes. Tribal health organizations have greatly increased their use of Healthy People 2010 for research purposes, with only 55 percent of tribal health organizations reporting use for research in 2005 compared to over 80 percent in 2008.

Exhibit 12: Healthy People 2010 Types of Use by Organization Type^s2

Exhibit 12 is bar chart showing the percent of HP Coordinators, Chronic Disease Directors, MTAHB, Tribal Health Organizations, and Local Health Organizations that use Healthy People 2010 for research, collaboration/outreach, and for setting internal priorities (among users of Healthy People 2010).

Over 81 percent of respondents in each sample type reported using Healthy People 2010 as a data source, as well as a framework for planning, goal-setting and decision making. Organizational/agency uses also include using the initiative to help legislators and as a surveillance tool. While 85 percent of overall users reported using Healthy People 2010 to support applications for grants or other funding and 84 percent reported using the initiative to guide priorities for the organization/agency, only 37 percent used it as a guide to set spending priorities within the organization/agency.

Variations in how the use of Healthy People 2010 changed over time did exist among respondents in the different sample types. Approximately 40 percent of states and 47 percent of tribal health organizations reported their use of the initiative changing over time, while only 26 percent of local health organizations and 29 percent of MTAHB reported any change. Of those that did report changes in usage, the types of changes included increased use for performance measurement and priority/goal setting as well as greater use for program planning and evaluation. Many also reported increased use for forging community partnerships and coalitions and conducting community health assessments. Also noted was greater use of the Healthy People 2010 initiative in directing and writing grant applications.

Healthy People 2010 users were asked to select the most useful aspect of the program to the organization/agency (see Exhibit 13). Both of the state respondent groups cited the specific health objectives as the most useful aspect, with the overarching program goals and leading health indicators ranking second and third, respectively. MTAHB reported leading health indicators to be the most useful aspect, while tribal health organizations cited the overarching goals as the most useful. Local health organizations also varied from the other respondent types, citing data resources and leading health indicators as the most useful; however the overarching goals and specific health objectives also received high rankings from this group.

Healthy People 2010 users also reported on ways the initiative impacted development of new programs and expanded existing programs within their organization/agency. While all respondent types indicated they used Healthy People 2010 to develop new programs, and expand existing programs, tribal health organizations were the only group for which Healthy People 2010 served this role for the majority of users. Seventy-three percent of tribal health organizations have developed new programs resulting from Healthy People 2010, while only 37 percent of HP Coordinators, 23 percent of Chronic Disease Directors, 43 percent of MTAHB and 43 percent of local health organizations reported using Healthy People 2010 in this manner. Similarly, 80 percent of tribal health organizations expanded existing programs. This is in contrast to the 37 percent of HP Coordinators, 41 percent of Chronic Disease Directors, 57 percent of MTAHB and 51 percent of local health organizations that indicated their organizations/agencies have expanded programs as a result of Healthy People 2010. Organizations/agencies were most likely to cite new or expanded programs in the areas of nutrition, physical activity and obesity, cancer, and diabetes prevention and education. In addition, several organizations/agencies mentioned new or increased programming in the area of health disparities. Exhibit 14 displays the Healthy People 2010 focus areas that have garnered program planning by organizations/agencies. For example, 72 percent of users reported they planned programs around the nutrition and overweight focus area.

A total of 229Ninety-two percent of Healthy People 2010 users reported they were aware of at least one objective. They were asked to indicate how relevant the objectives were to their organization/agency’s work, on a scale of 1 to 5; 1 meaning not relevant and 5 meaning significantly relevant. Overall, the mean rating was 3.9. The highest percentage within each respondent type rated the relevancy of objectives at 4 or 5 (see Exhibit 15). The degree of relevancy reported in 2008 is similar to that reported in 2005. Relevancy has increased for tribal health organizations, from an average of 3.3 in 2005 to 4.3 in 2008. The reasons among those rating the objectives as highly relevant to the work of their organization/agency were that the objectives allowed for a comparison of state progress to national objectives, and the objectives assisted in planning, goal setting, and benchmarking. Among those rating the objectives as not very relevant to the work of their organizations/agencies the reasons included not having appropriate state or county level data sources to measure the objectives, objectives being too specific, and organizations/agencies lacking the resources and funds to support efforts to measure the objectives.

To further assess how Healthy People 2010 impacted organizations/agencies’ program development, and the extent to which Healthy People 2010 objectives were used, respondents were asked about program planning around specific objectives. Eighty percent of tribal health organizations reported planning programs intentionally around one or more Healthy People 2010 objectives. This was higher than the 57 percent of Chronic Disease Directors, 54 percent of HP Coordinators, 49 percent of local health organizations and 43 percent of MTAHB reporting use for planning purposes.

In addition to questions on current use of Healthy People 2010, the 2008 User Study sought to identify whether and how organizations/agencies assessed progress towards their own objectives as well as whether user organizations/agencies anticipated conducting final assessments at the end of the decade. There was variation among respondent types’ likelihood of measuring changes in health behaviors or outcomes related to the use of Healthy People 2010. Chronic Disease Directors reported the highest likelihood of efforts to measure change at 89 percent. This is followed by HP Coordinators at 74 percent, tribal health organizations at 60 percent, MTAHB at 57 percent and local health organizations at 50 percent. Exhibit 16 shows the different methods users employed to measure changes in outcomes and behaviors related to the use of Healthy People 2010 at the organization/agency. For state and local health organizations the most common method of measuring change was conducting an evaluation of trends, using existing data on health outcomes. MTAHB and tribal health organizations used the collection and evaluation of new data on health outcomes to measure changes in behavior or outcomes. MTAHB also reported using the collection and assessment of qualitative data, such as case studies and focus groups, to measure change.

The survey also asked respondents if their organizations/agencies conducted assessments of the achievement of program goals related to Healthy People 2010 objectives and targets. Over 70 percent of MTAHB and 60 percent of state organizations conduct such assessments, while only 47 percent of tribal health organizations and 42 percent of local health organizations conducted these assessments. Of the Healthy People 2010 users who conducted assessments of the achievement of program goals related to Healthy People 2010 objectives and targets, 100 percent of MTAHB, 89 percent of HP Coordinators and Chronic Disease Directors, 86 percent of tribal health organizations, and 75 percent of local health organizations found that progress toward the program goals was made (Exhibit 17). In terms of specific areas of progress, respondents were most likely to mention improvements in the areas of tobacco use, oral health, nutrition and fitness, and childhood immunization services.

Exhibit 17: Proportion Measuring Progress towards Program Goals, among Those Measuring Change

Exhibit 17 is a bar chart showing the percent of HP Coordinators, Chronic Disease Directors, MTAHB, Tribal Health Organizations, and Local Health Organizations that have measured progress towards program goals (of those who measure change) (among users of Healthy People 2010).

Respondents were asked whether their organization/agency planned to conduct a final assessment of progress toward objectives at the end of the decade. Forty-one percent of users did not know if their organizations/agencies would be conducting a final assessment of the achievement of program goals, while 27 percent expect to conduct a final assessment and 29 percent do not.

When asked for suggestions of ways HHS could encourage more progress toward the goals and objectives of Healthy People 2010, respondents most commonly recommended increasing funding, with an emphasis on provision of increased staff resources. Many also suggested greater guidance at the local level. In addition, several respondents requested that HHS provide more technical assistance and data analysis tools to facilitate reporting. Finally, organizations/agencies indicated they would also benefit from the dissemination of best practice guidelines and examples of programs that have been particularly successful.

Healthy People 2010 users provided feedback about the barriers they experienced to implementing the initiative within their organization/agency. Barriers were classified as being related to the Healthy People initiative or being related to the respondent’s organization/agency. Overall, respondents were less likely to select barriers related to the initiative, as compared to barriers related to their organization/agency. In fact, barriers imposed by the initiative itself were selected by less than 45 percent of any sample type. When looking at barriers related to the Healthy People initiative, the most commonly reported barrier was the lack of data to track objectives (32 percent), followed by too much material (22 percent) and a lack of guidance on how to implement (21 percent). However, the percent of users indicating too much material, and a lack of guidance on how to implement as barriers to use has statistically significantly decreased since 2005. Exhibit 18 illustrates how each respondent type reported each of these three barriers.

Exhibit 18: Barriers Related to Healthy People 2010

Exhibit 18 is a bar chart showing the percent of HP Coordinators, Chronic Disease Directors, MTAHB, Tribal Health Organizations, and Local Health Organizations that consider lack of guidance, no data, and/or too much material, a barrier to using Healthy People 2010 more (among users of Healthy People 2010).

When examining barriers related to the respondents’ organization/agency overall, insufficient resources was the barrier cited most frequently (76 percent), followed by competing priorities (65 percent) and lack of buy-in from primary decision makers (30 percent). The two leading barriers (insufficient resources and competing priorities) have decreasesd significantly since the 2005 User Assessment. Exhibit 19 illustrates the percentage for each barrier, by respondent type. The exhibit also shows that these barriers did not vary greatly among respondent types.

Exhibit 19: Barriers Related to Organizations

Exhibit 19 is a bar charting showing the percent of HP Coordinators, Chronic Disease Directors, MTAHB, Tribal Health Organizations, and Local Health Organizations that consider insufficient resources, lack of buy-in, and/or competing priorities a barrier to using Healthy People 2010 more (among Healthy People 2010 users).

In general, an organization/agency’s size did not correlate with barriers to use. This was true for barriers related to the Healthy People initiative and for barriers related to the respondents’ organization/agency. However, “lack of guidance on how to implement” was a significantly stronger barrier of use for small organization/agencies than large organizations/agencies. Thirty-two percent of small organization/agencies using Healthy People 2010 indicated that lack of implementation guidance was a barrier to using the initiative more, while only 16 percent of large organizations/agencies cited this as a barrier.

Healthy People 2010 users identified different types of technical assistance (TA) that they believed might improve the organization/agency’s ability to further implement the initiative (Exhibit 20). When asked to select specific areas where technical assistance is needed, respondents were most likely to request technical assistance in providing examples of programs demonstrating progress towards Healthy People 2010’s goals, followed by examples of how other states and/or organizations/agencies use Healthy People, and how they translate Healthy People into action. MTAHB were most also likely to request guidance on collecting data to track progress toward achieving Healthy People objectives. MTAHB and Ttribal health organizations also stated they would benefit from assistance with translating Healthy People 2010 into action, and from HHS identifying individuals who can provide assistance..

Respondents were also given the opportunity to comment in a “free-text” field of the survey about other ways HHS could help users progress toward reaching the Healthy People 2010 goals. Providing increased funding led the list of suggestions in this area. Respondents specifically cited the need for funding of evidence-based interventions. Additionally, respondents reported a need for more “user friendly” materials and more technical assistance. Many also suggested that HHS provide examples of success stories of Healthy People 2010 use.

Non-users of Healthy People 2010 (n=73) were almost entirely local and tribal health organization respondents; however two HP Coordinators did indicate their organizations/agencies did not use Healthy People 2010. In reviewing demographic information on the organizations/agencies that do not use Healthy People 2010, 44 percent of small, 31 percent of medium, and 22 percent of large organizations/agencies were found to be non-users of Healthy People 2010. Additionally, 47 percent of respondents in the Northeast, 27 percent of respondents in the Midwest, 19 percent of respondents in the South, and 40 percent of respondents in the West were non-users of Healthy People 2010.

Non-users were also given the opportunity to describe through specific answer options as well as through “free-text” fields the barriers that prevent them from using the initiative. Exhibit 21 displays the distribution of responses of potential barriers listed on the questionnaire. As was true in 2005, the most frequently cited barriers relate to organization/agency issues, such as resources and competing priorities. However, nearly 60 percent of non-users cited a lack of implementation guidance as a barrier to use.

Notably, the percentages of organizations/agencies reporting each type of barrier have greatly decreased from 2005, with the top five leading barriers showing a statistically significant decrease. For example, in 2005, 93 percent of non-users reported lack of buy-in from decision makers as a barrier that prevented them from using the initiative, compared to only 40 percent in 2008. Likewise, the percentage of non-users who reported competing priorities as a barrier decreased from 93 percent in 2005 to 67 percent in 2008. Issues related to the Healthy People initiative itself have also decreased as barriers to use. In 2005, 63 percent of respondents indicated that “too much material” was a barrier. This percentage has gone down to 39 40 percent in the 2008 User Study. Similarly, the percent reporting that lack of guidance on how to implement as a barrier to use decreased from 76 percent in 2005 to 57 56 percent in 2008.

Further information regarding barriers to use was gathered through respondents’ answers to questions about the number of focus areas and objectives in Healthy People 2010 (Exhibit 22). Both of the HP Coordinators who were non-users of Healthy People 2010 indicated that there were too many focus areas and objectives. Forty-six five percent of the local and tribal health organizations had no opinion about the number of focus areas, while 30 31 percent said there are too many, 19 18 percent said there is an appropriate number, and one respondent reported too few focus areas. Respondents felt similarly about the number of objectives; 50 51 percent had no opinion, 29 28 percent reported too many, 14 percent said it was the appropriate number, and 3 percent reported too few. When asked about the organization of objectives in Healthy People 2010, 60 percent had no opinion, 18 percent indicated reorganization would be useful, and 17 16 percent reported it is appropriately organized.

To gather a more complete understanding of how Healthy People could better meet the needs of its target audiences, non-users were asked to specify which framework(s) their organization/agency does use to set health objectives. Tribal health organizations reported reliance on tribal council strategic planning and IHS priorities. Two tribal health organizations specified the Indian Health Services Manual as a framework used by their organization/agency to set health objectives. Local health organizations cited community assessments and community health improvement plans as well as Board of Health Guidelines, the Public Health Competency Handbook, the United Health Care Foundation Index, the Public Health Core Priorities, and NACCHO’s protocol for assessing community excellence in environmental health. Non-users were also asked if they felt Healthy People 2010 was lacking in some way, and 19 percent indicated they did. Specifically, these non-users cited a lack of funding for implementation and follow-up, and non-applicability to local and small jurisdictions as ways in which Healthy People 2010 was lacking.