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The Evolution of the Healthy People Initiative: A Look Through the Decades

Each decade, the US Department of Health and Human Services launches a new iteration of the Healthy People initiative. Healthy People strives to create a healthier nation and tracks data-driven outcomes to monitor progress toward achieving the initiative's goals throughout the decade. Although the initiative's mission, vision, and goals have evolved over time, since the initiative's inception in 1979, Healthy People remains dedicated to addressing the social determinants of health and improving the nation's health and well-being. In 2020, the US Department of Health and Human Services released the fifth iteration of the initiative, Healthy People 2030. This decade-long initiative provides a focused set of science-based, national objectives with targets to achieve by the year 2030. Healthy People 2030 is available online and offers users access to updated information and tools and resources for implementation. This article discusses the evolution of Healthy People across the decades, highlights Healthy People 2030 and its tools, and illustrates how stakeholders can use Healthy People to achieve their missions and improve the health and well-being of the nation.


S ince 1980, the US Department of Health and
Human Services (HHS) has released at the beginning of each decade a new set of sciencebased, national health objectives with 10-year targets to achieve by the end of the decade. These national objectives are part of the Healthy People initiative, one of the longest spanning disease prevention and health promotion initiatives in the United States. Healthy People provides a strategic framework for promoting, strengthening, and evaluating the nation's efforts to improve the health and well-being of all people. Its specific measurable objectives serve as a national agenda for eliminating disparities and advancing health equity. The initiative tracks datadriven outcomes to monitor progress and motivate, guide, and focus action by individuals and entities at the national, state, and local levels. Instrumental in encouraging action toward better health 1 and providing an estimate of the achievable and desired changes over the decade, Healthy People targets are established on the basis of statistical constructs, trends, and policy considerations. Achieving the targets requires collaboration and efforts from both federal and nonfederal individuals and entities across multiple sectors.
In August 2020, HHS released the newest iteration of the Healthy People initiative, Healthy People 2030, launching the fifth decade of national disease prevention and health promotion objectives. This article discusses the evolution of Healthy People across the decades, highlights Healthy People 2030 and its tools, and illustrates how users can use Healthy People to achieve their missions and improve the health and well-being of the nation. Surgeon General's report, HHS released in 1980 Healthy People 1990, the first measurable health objectives with targets. Prior to the 1950s, notable disease prevention efforts included sanitary reform and vaccination. In the 1950s, health initiatives shifted from focusing primarily on infectious diseases to addressing lesser-understood chronic diseases. At the time, there was a limited emphasis on disease prevention efforts. 2 Several critical events in the 1960s advanced the field of public health. First, in 1964, Surgeon General Luther Terry released the first Surgeon General's report on smoking and health that highlighted the risks associated with cigarette smoking. Then, in 1966, the Medicare and Medicaid programs were passed and the Partnership in Health Act introduced block grants as a mechanism to provide federal funding to state and local public health. 3 As the health field became increasingly aware of the preventability of many leading causes of premature morbidity and mortality, 2 the Surgeon General's 1979 report called for a renewed commitment to disease prevention and emphasized the role of both population and community health and individual and personal lifestyle choices and risk factors.
Over the decades, Healthy People has evolved to address emerging public health challenges and reflect new public health trends and priorities. Keeping pace with an increasingly robust evidence base, Healthy People focuses on the both the downstream outcomes and increasingly upstream factors, including the social determinants of health, that impact health and well-being. 4 The first Healthy People objectives, which HHS released in 1980, focused on health across the life span: the initiative sought to decrease mortality in infants, children, adolescents, and adults, and increase independence among older adults. Healthy People 2000, released in 1990, included the goal to increase access to preventive services and was the first to include language on reducing health disparities. Healthy People 2010, released in 2000, strengthened this language to "eliminate health disparities," which prompted Public Law 106-525 (the Minority Health and Health Disparities Research and Education Act of 2000), requiring a study of HHS' data collection systems and practices relating to data on race or ethnicity. 5 Notably, Healthy People 2010 also established the inaugural set of Leading Health Indicators (LHIs), a smaller set of measurable objectives selected to communicate high-priority health issues and actions that can be taken to address them. While not discussed in-depth in this article, the LHIs, and their role in Healthy People 2030, are addressed in greater detail in another article within this special supplement.

FIGURE 1 Social Determinants of Health Domains
Healthy People 2020, released in 2010, provided definitions of health disparities and health equity that are grounded in ethical and human rights principles 6 and are widely cited. 7,8 Healthy People 2020 also included a goal of addressing social and physical environments that influence health, representing a clear commitment to reducing health inequities and eliminating avoidable disparities in health and well-being outcomes. Healthy People 2020 defined the social determinants of health as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." 4 The goals for each iteration of Healthy People are shown in Table 1. The 5 social determinants of health domains used in Healthy People are shown later in Figure 1.
In a reflection of Healthy People's use as a resultoriented tool that also serves to promote collaboration, articulate common outcomes, and leverage resources, the US Government Accountability Office (GAO) cited Healthy People as a model for resultsoriented government activities and collaboration as part of the GAO's assessment of practices among federal agencies. 9 Citing 21st century challenges and a range of barriers facing federal agencies attempting to work collaboratively, the GAO featured Healthy People to illustrate key practices that can help enhance and sustain agency collaboration, including defining and articulating a common outcome; establishing mutually reinforcing or joint strategies; identifying and addressing needs by leveraging resources; agreeing on roles and responsibilities; establishing compatible policies, procedures, and other means to operate across agency boundaries; developing mechanisms to monitor, evaluate, and report on results; reinforcing agency accountability for collaborative efforts through agency plans and reports; and reinforcing individual accountability for collaborative efforts through performance management systems.

Healthy People 2030 Framework
The first phase of the development of Healthy People 2030 focused on determining the framework, which includes the vision, mission, and overarching goals. Informed by the work of the Secretary's Advisory Committee, the Healthy People 2030 framework places an increased emphasis on improving well-being in addition to improving health. Well-being is referenced in the Healthy People 2030 vision ("A society in which all people can achieve their full potential for health and well-being across the life span"), its mission ("To promote, strengthen, and evaluate the nation's efforts to improve the health and well-being of all people"), and is reflected in the first overarching goal ("Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death"). In addition, the Healthy People 2030 framework continues to highlight the need to achieve health equity and eliminate disparities and expands the overarching goals to create social, physical, and economic environments that promote health and well-being for all. The Healthy People 2030 framework also recognizes The Evolution of the Healthy People Initiative the importance of engaging multiple sectors to take action to improve health and well-being. Figure 2 presents Healthy People 2030's vision, mission, and overarching goals.

Healthy People Topic Areas and Objectives
The cornerstone of Healthy People is each decade's set of measurable objectives for tracking the health of the nation. In response to user feedback, for Healthy People 2030, the HHS Secretary charged the Advisory Committee with assisting "in reducing the number of objectives while ensuring that Healthy People 2030 identifies the most critical public health issues that are high-impact priorities supported by current, national data sets." 11 Over the decades, the number of objectives in Healthy People had increased. Healthy People 1990, which was set forth in the 1980 report Promoting Health/Preventing Disease: Objectives for the Nation, included 226 measurable health objectives for the year 1990, organized within 15 topic areas, including objectives related to health status, risk reduction, public and professional awareness, health services and protective measures, and surveillance and evaluation. 12 The number of objectives grew each decade through Healthy People 2020 (Table 2), which included more than 1300 objectives organized within 42 topic areas. The initiative's increase in size accommodated a broad vision of health, which fostered participation by additional federal agencies and users, furthering engagement, and implementation efforts. However, user feedback and assessments conducted by HHS indicated that the size of the initiative made it hard to navigate. 13,14 Critics of the initiative's large scope noted that it disperses efforts, resources, and focus, 15 and diverted resources to tracking data instead of interventions. 16

Selecting Objectives for Healthy People 2030
The process for selecting objectives drew on recommendations from the Secretary's Advisory Committee, which identified 3 types of objectives: core, developmental, and research. Most Healthy People 2030 objectives are core, or measurable, objectives that have valid, reliable, nationally representative data, including baseline data and associated targets to achieve by the year 2030. Core objectives reflect highpriority public health issues and are associated with evidence-based interventions. Developmental objectives represent high-priority public health issues that are associated with evidence-based interventions but do not yet have reliable baseline data. Research objectives represent public health issues with a significant health or economic burden or significant disparities between population groups, but for which evidencebased interventions have not yet been identified. 17 Table 3 describes the 3 types of objectives included in Healthy People 2030 and the criteria used to select them.

TABLE 3 The 3 Distinct Types of Objectives Included in Healthy People 2030
Core objectives: Core objectives are measurable objectives of high national importance. The criteria used to guide the selection of the core objectives include (1) national importance, direct impact on health, broad and comprehensive applicability, substantial burden, and/or national public health priority that (2) have reliable, nationally representative baseline data using data no older than 2015, (3) have an assurance of at least 2 additional data points throughout the decade, (4) have identified effective evidence-based interventions to achieve progress, (5) address health equity and/or health disparities, and (6) include a target to be achieved by the year 2030. HHS actively tracks and assesses progress on Core objectives in relation to their respective targets. Developmental objectives: Developmental objectives represent high priority issues that do not have reliable baseline data but for which evidence-based interventions have been identified. The Developmental objectives represent areas that Healthy People Workgroup subject matter experts (SMEs) identified as requiring attention. Targets are not set for the Developmental objectives. Developmental objectives are not actively assessed for progress. Developmental objectives have a strong expectation of being able to meet Core objective criteria within 5 years of being designated as Developmental. Developmental objectives are not actively assessed for progress and may be added during the decade. Once a Developmental objective meets the criteria used to guide selection of the Core objectives, HHS will review and consider moving it to Core objective status and a target will be set at that time. After 5 years, the Developmental objectives will be reassessed for continued inclusion in Healthy People 2030.

Research objectives and emerging issues:
Research objectives focus on the need to advance research and develop evidence-base interventions in an area. Research objectives highlight public health issues for which there may be data but for which research and evidence-based interventions may not yet be identified. These objectives represent significant opportunities for progress in areas with limited research, a high degree of health or economic burden (preventable or otherwise), or evidence of substantial disparities between populations. Research objectives vary in scope and specificity and may be considered priority areas for future research or emerging issues. Targets are not set for the Research objectives. Research objectives are not actively assessed for progress and may be added during the decade. Once a Research objective meets the criteria guiding the selection for Core objectives, HHS will review and consider moving the Research objective to Core objective status and a target will be set at that time. After 5 years, the Research objectives will be reassessed for continued inclusion in Healthy People 2030.

Abbreviation: HHS, US Department of Health & Human Services.
For Healthy People 2030, a set of rigorous criteria guided the selection of the core objectives. To be selected for Healthy People 2030, core objectives had to have a reliable, nationally representative data source with baseline data no older than 2015, have at least 2 data points in addition to baseline data throughout the decade, be of national importance, have effective evidence-based interventions that would help improve the objective, help address disparities and achieve health equity, and include a target to be achieved by the year 2030. Table 4 provides a comparison of the objective selection criteria between Healthy People 2020 and Healthy People 2030.
The final core objectives were selected after careful consideration by federal SMEs and a review of more than 2000 public comments received from Healthy People users and members of the public. Healthy People 2030 includes 355 core objectives, 114 developmental objectives, and 40 research objectives. Together, the core, developmental, and research Each Healthy People 2030 core objective must: 1. Reflect an issue of national importance, direct impact on health, broad and comprehensive applicability, substantial burden, and/or national public health priority 2. Have reliable, nationally representative baseline data using data no older than 2015 3. Have an assurance of at least 2 additional data points throughout the decade 4. Have identified effective evidence-based interventions to achieve progress 5. Address health equity and/or health disparities 6. Identify a target to be achieved by the year 2030 objectives comprise the full set of Healthy People 2030 objectives. The final set of 355 core objectives for Healthy People 2030 is approximately one-third the number of measurable objectives in Healthy People 2020. This narrower set of objectives focuses priorities and allows HHS to conduct more analysis, provide technical assistance to Healthy People users, and develop additional tools for implementation.

Tracking Progress Toward Achieving Healthy People Objectives
Healthy People is founded on the principle that achieving desired improvements requires targets to inspire action, assess progress, and create accountability. Healthy People specific targets to be achieved by decade's end have become a hallmark of the initiative and its science-based objectives. For Healthy People 2030, HHS has implemented a more rigorous and transparent target setting process than used in prior iterations of Healthy People.
The Healthy People 2030 targets are intended to be challenging but achievable. The methods used for setting Healthy People 2030 targets include projection based on trend analysis or statistical models; a specific percentage point improvement from the baseline; a percent improvement from the baseline; minimal statistical significant change from the baseline; maintain consistency with national programs, regulations, policies, or laws; and maintain the baseline. Table 5 includes a list of the target-setting methods used to establish the Healthy People 2030 targets.
Federal experts, with support from the National Center for Health Statistics, considered several important factors, including the current data trends for the objective, evidence-based knowledge, the extent of health disparities, and user feedback when selecting targets. Federal SMEs serving on the Healthy People 2030 work groups were responsible for selecting targets. These experts, representing a variety of federal agencies, used data-driven approaches whenever possible, but they also considered subject matter expertise, public health policies, and agency or national priorities.
The National Center for Health Statistics developed new target-setting method tools, including a Trend Analysis Tool and a Percent Improvement and Minimum Statistical Significance Tool, to help with the selection of targets for Healthy People 2030. The Trend Analysis Tool creates a trend line based on historical data to inform changes to programs impacting the specific health topic. The Percent Improvement and Minimal Statistical Significance Tool provides candidate targets without using historical data. For example, the Trend Analysis Tool was used to set the target for the Healthy People 2030 objective to reduce coronary heart disease deaths to 71.1 coronary heart disease deaths per 100 000 population. Both tools incorporate data-driven methods to inform the establishment of targets for Healthy People 2030. These tools are available online for users, such as state and local public health officials, to use in setting their target-setting method efforts. 18 When developing Healthy People 2030, HHS strove to provide increased transparency about the target-setting process and selection of target-setting methodologies. For each core objective, HHS has documented the target-setting method and provided a clear justification for use of the selected target-setting method. This additional information is available online as a new feature in the data details section for each core objective. State and local health officials may find this information useful as they set a public health agenda for their community and benchmarks for their priorities and goals.

Healthy People Users
Healthy People's primary users are individuals and organizations in public health and clinical settings (eg, state, local, tribal, and territorial public health departments, hospitals, academic departments, foundations, and others), and include public health professionals, clinicians, researchers, academics, students, nongovernmental organizations, foundations, and communities that are interested in improving health and well-being. In addition, Healthy People is used by and relevant to individuals and entities across sectors, including environment and environmental regulation, transportation, law, law enforcement, public safety, housing, education, urban planning and development, labor and labor organizations, food and agriculture, commerce and business, among others. 19 In 2015, HHS conducted a study to examine awareness and uses of Healthy People among various users. 13,14 Healthy People was most frequently referenced as a data source by partners; participants also cited their use of the specific health objectives, the LHIs, and the data tools. Healthy People's communications tools (eg, Stories from the Field, LHI bulletins, and eLearning) were not as well recognized. Barriers to Healthy People 2030 use among users included lack of buy-in from decision makers; lack of guidance on how to implement Healthy People 2020; not having data to track relevant objectives; and insufficient resources and competing priorities. Finally, the study's participants pointed out that narrowing the scope of issues covered and reorganizing IID-07: Reduce infections due to human papillomavirus (HPV) types prevented by the 9-valent vaccine in young adults

Projection
The projection target-setting method can be based on trend analysis, statistical models, or both. Trend analysis involves examining historical data to estimate a trend that can be projected into the future. The most common projection used in Healthy People 2030 is a trend analysis using weighted or ordinary least squares to fit a trend line. In addition, because Healthy People 2030 objectives have a desired direction (increase or decrease), the confidence level of a 1-sided prediction interval (eg, 25, 33, 50, 66, or 75) can be used as an indication of how likely it is that a target will be achieved on the basis of the historical data, and the 1-sided prediction interval can be used to set a target.

Minimal statistical significance
Targets are set using a minimally statistically significant change from baseline (at the .05 level of significance), assuming the same SE for the target as for the baseline. This target-setting method requires that the estimates have SEs.

SU-02: Reduce cirrhosis deaths
Maintain consistency with national programs, regulations, policies, or laws The target-setting method of maintaining consistency with national programs, regulations, policies, or laws allows the Healthy People work groups to take federal agency programs and policies into consideration or to align with statistical analyses, including modeling or trend projections, conducted outside National Center for Health Statistics.
TU-03: Reduce current use of combustible tobacco products among adults Maintain the baseline The target-setting method of maintaining the baseline is used when an objective is already at a desired level nationally or because the objective is moving or expected to move in an undesirable direction.

FS-05: Prevent an increase in the proportion of nontyphoidal
Salmonella infections in humans that are resistant to 3 or more drug classes the objectives would be helpful for Healthy People 2030.

Healthy People and Its Tools and Resources
Over the decades, as the focus and size of Healthy People have evolved, so has its format, including the tools and resources available for users. The first 3 iterations-Healthy People 1990, Healthy People 2000, and Healthy People 2010-were each published in print volumes or on a static Web site and updated mid-decade. The launch of Healthy People 2020 ushered in the first version of the initiative that was available online with user-centered and dynamic tools and resources for action, 20 including eLearning modules, content syndication, literature summaries for the social determinants of health, infographics, data charting, webinar slides, and evidence-based resources.
Among the new tools for achieving specific Healthy People 2020 goals and targets were an evidence-based resources tool and products from a Healthy People 2020 Law and Health Policy Project. The evidencebased resources tool included published reviews of systematic and rigorous studies and interventions to improve health. Individuals and entities can use the evidence-based resources to create a custom list of science-and evidence-based interventions demonstrated to improve health and prevent disease and to develop their own efforts and activities based on those interventions. 21 In addition, through a partnership with the Robert Wood Johnson Foundation, the CDC Foundation, and the CDC, HHS led a Healthy People 2020's Law and Health Policy Project. The Law and Health Policy Project created a number of reports and webinars and shared innovative examples of how communities are using law and policy to improve health. 22 Like Healthy People 2020, Healthy People 2030 is available online and offers a number of tools and resources for users. Healthy People 2030's Web site was designed on the basis of user testing and integrates best practices for dynamic and user-centered tools. The Web-based format enables users to customize their experience as they access up-to-date information on the objectives, examine data, and easily navigate to data sources, resources for implementation, and opportunities for learning and professional development. Recognizing the interdisciplinary nature of the Healthy People objectives, the Web site organizes information in a way that is simple, intuitive, and accessible to a diverse multidisciplinary user base.
Healthy People 2030 builds on the data charting, evidence-based resources, content syndication, and social determinants of health literature summaries initiated in Healthy People 2020 and launches several new tools and features. Users can use a Crosswalk feature on the new site and search for specific Healthy People 2020 objectives by objective number or key word. 23 The Crosswalk will let users know whether their objective is retained, modified, related to, or removed from Healthy People 2030. Another new Healthy People 2030 tool allows users to select specific objectives of interest and create a "Custom List" with a link to share those objectives with others. Anyone with the link can see the custom objective list, so this feature is ideal for funders, program planners, and even social media. The new site is mobile friendly allowing all content and features to display well on mobile devices. Data visualization features including data tables, population data, charts, graphs, and maps will be added throughout the decade. Users will be able to select population groups and data years of interest. Utilizing new technology, HHS is examining how to share data with users by syndicating content, such as infographics and widgets. Special emphasis will be given to highlighting disparities data and improving the site's data literacy to accommodate new users.

How to Use Healthy People 2030
Healthy People 2030 is used by a wide variety of users, including state, local, tribal, and territorial health officials; community health advocates; nongovernmental organizations; businesses; foundations; and academia. Potential uses of Healthy People 2030 are extensive, including as a data tool for measuring program performance, a guide to developing community health assessments, a framework for program planning and development, and benchmarks to compare state and local data, to name a few. Table 6 provides a list of examples of how selected entities can use Healthy People 2030.
The following are 2 examples of how stakeholders leverage Healthy People, its tools, and resources to achieve their missions and goals. The National Association of County and City Health Officials (NACCHO) is one example of an organization leveraging Healthy People. NACCHO represents about 3000 local health departments nationwide, providing funding, training, and resources to build their capacity. NACCHO has teamed up with Healthy People 2030 to demonstrate just how important local health departments are to achieving national health objectives, and they connect them to Healthy People tools and resources to highlight how clear, shared metrics and objectives, like those in Healthy People, can be used to advance their missions and ultimately contribute to progress at the national level.
NACCHO offers webinars, presentations, reports, and other resources to help health departments and their community partners use Healthy People in community health assessment and planning activities. NACCHO also is using Healthy People to support health departments' efforts to address the social determinants of health at a community level to reduce health disparities and has developed a community health improvement matrix. 24 Health departments and their partners, including hospitals, use the matrix to map their public health interventions and to identify gaps and opportunities to advance their work. The matrix provides a framework for them to consider which activities are most effective at addressing the social determinants of health. NACCHO provides training regarding how to use the matrix and how Healthy People can be used to inform their efforts to Governmental organizations (eg, state, local, tribal, and territorial health departments) Decide internal priorities.
Create a road map to achieve goals.
Identify clear benchmarks and directions for progress.
Align activities of local health departments with state and national public health priorities.
Find common language that public health officials at all levels can use to communicate priorities.
Facilitate partnerships around common goals and metrics, foster shared vision, and build momentum across settings. Academic and professional health-related educational institutions Align general curricula and accreditation standards with national goals.
Align education for students of health professions from all disciplines with national goals.
Use interprofessional approaches in curricula to train professionals in health care and other health service-related fields, thus setting the stage for collaboration across disciplines. Cross-disciplinary leaders (eg, transportation, commerce, agriculture) Use Healthy People to align common goals and standards across disciplines.
Raise awareness of Healthy People among decision makers in other sectors.
In fields that influence social determinants of health, offer professional education and training that model collaboration with the public health and health care sectors.
fill in those gaps, including how to transition from individual to more community-level interventions with their community partners. The Peace Corps offers another example of how Healthy People's objectives and framework can serve as a useful model for international, state, and local program planning. When the Peace Corps conducted an evaluation of the health metrics of their volunteers, they compared their data sets to relevant Healthy

Implications for Policy & Practice
■ The Healthy People initiative provides guiding objectives with data-driven targets to promote health and well-being, address the social determinants of health, and advance health equity.
■ State, local, tribal, and territorial governments can use Healthy People 2030's science-based health objectives and targets to benchmark and implement evidence-based public health policies and interventions designed to improve health and well-being.
■ To support organizations and individuals who are interested in improving the health and well-being of their populations, the Healthy People 2030 Web site provides access to the national science-based health objectives, targets, and comprehensive data and user-centered and interactive tools, including a new "Custom List" tool, a Crosswalk from Healthy People 2020 to Healthy People 2030, and an evidence-based resources tool, to inform and support users' efforts.
People 2020 LHIs (ie, 17 out of the 26 LHIs) and to their national health benchmarks. This comparison allowed the Peace Corps to develop a set of volunteer health indicators to track and analyze in order to improve the health of and health care for their volunteers. 25

Conclusion
Since its inception, Healthy People has served to provide a comprehensive set of data-driven, evidencebased, measurable objectives to assess progress toward improving health over the decade. While its purpose has remained constant, Healthy People has evolved over the decades to address the most pressing public health issues while emphasizing other key factors, including the social determinants of health and health equity. Healthy People 2030 continues that evolution while also responding to the needs of users, resulting in a focused set of objectives that chart a path to creating a nation of health and well-being into the next decade.