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IV. Target-Setting Recommendations

Definition of the Term, “Objective”
The Subcommittee on Target-setting, chaired by Dr. Patrick Remington, had circulated in advance of the call draft definitions for the terms “objective” and “target.” An initial, proposed definition for “objective” was:

  • “Results of specific activities to be achieved over a stated time. Objectives are specific, measurable, and realistic statements of intention.”

Based on the written comments of Committee members on this definition, it was revised as follows:

  • “Objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).”

Dr. Remington said that he has found the acronym S.M.A.R.T. (Specific, Measurable, Attainable, Realistic and Time-limited) to be helpful in his work with communities, and he argued for using that if possible. Regarding the phrase, “activities to be achieved over time,” he felt that objectives should not be limited to activities, because there are also process and outcome objectives as well. The proposed definition seemed to him to be a definition of outcome objectives. Dr. Fielding said the definition should be something everyone can understand. Dr. Remington was fine with the draft, and felt strongly that “time” should be included in it.

Dr. Shiriki Kumanyika, Committee Vice-Chair, said that the Committee should look the definition of objectives in conjunction with the definition of targets. One could envision a broad objective that would have within it specific targets. Dr. Fielding agreed that targets and subobjectives could be for different periods of time. He said that the group should be clear about what these differences are for the sake of consistency. Dr. Kumanyika asked whether the FIW is using existing definitions of these terms, but RADM Slade-Sawyer said the FIW had not tackled this issue yet. Carter Blakey, ODPHP, noted that Healthy People has historically considered an “objective” to be a general statement, and a “target” to be an actual percentage. So an objective could be, “Increase the proportion of women who’ve received mammograms at the recommended rate,” and the target could be, “100% of women should receive mammograms at the recommended rate.”

Dr. Remington suggested the possibility that an objective would be standard nationwide, but the target would vary by community. It could be based on baseline data and take into consideration specific barriers in communities, since it’s a component of an objective. RADM Slade-Sawyer clarified that there does need to be a national target. Communities can use the national target as a starting point for setting their own targets. A Committee member noted that the use of different targets for different sub-populations had been a source of criticism for Healthy People 2010. Some interpreted that approach as a tacit approval of health disparities. However, he said it would be acceptable to have a subobjective focused on reducing disparities.

Dr. Fielding reviewed the proposed definition of objective. He noted that it does not specify that the objectives are national, and felt it was important to add this concept. Also, every state should be setting objectives that are mindful of the national objectives. He asked if anyone disagreed with this definition of “objective.” No Committee members voiced disagreement. Dr. Fielding indicated that the Committee would adopt the definition, “National objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).”

Definition of the Term, “Target”

Dr. Fielding then reviewed a proposed definition of the term “target.”

  • A “target” is the level of progress or performance expected for an objective.
  • “Target-setting” involves the methods used to select the value for a target.

He felt that the definition should be revised to state that a target is the level of progress for an objective or a subobjective. He felt that the definition of “target-setting” makes sense, and asked if anyone disagreed with either definition. No Committee members voiced disagreement. The Committee adopted the definition, “A target is the level of progress or performance expected for an objective or subobjective.”

Dr. Kumanyika indicated that many issues have been raised around target setting, as discussed in the briefing book materials. Why were Healthy People targets not met in previous decades? How can those reasons inform current target-setting efforts? Dr. Fielding agreed that this is a critical issue, adding that the methods used to set targets should be transparent. It should be clear if targets are being set by expert opinion because we don’t know which interventions would work, versus being set through application of the best evidence. Dr. Fielding added that being clear about who was involved in the target-setting process is part of transparency. A Committee member commented that there should be a role for communities in setting targets to ensure that community groups and the public have ownership of Healthy People 2020.

Dr. Fielding suggested there should be a logic model for everything that Healthy People does, an objective or a target, to clarify where Healthy People is trying to intervene in the process and what outcomes are expected. Without a logic model, the thinking can be unclear. He also suggested that in setting targets, one should look at the effects of targets on multiple outcomes. Effective interventions could be expected to affect multiple topic areas, so it is important to look at how such interventions would cut across topic areas. A Committee member agreed that logic models should be used, but said they need not be complicated. Simply showing how an objective that is focused on determinants links to outcomes, and vice-versa, would be a useful way to employ the framework. Logic models will require integration across topic areas, and topics are scattered across a continuum (i.e., from downstream to upstream).