Dr. Remington went on to describe a chart showing the relationships between determinants and outcomes, subcategorized into physiologic and pathologic causes, proximal causes, and distal causes which illustrated how objectives might be positioned within the logic model. He presented a list of candidate topic areas which fell into the general categories of programs, policies and interventions; some of the proposed topic areas were holdovers from 2010, while others were new. Dr. Remington added that this framework requires a good understanding of the literature and pathophysiology. Downstream outcomes are the ultimate point of accountability, where we are trying to increase quality and length of life. Dr. Remington reviewed the list of potential new, revised, and retained topic areas proposed by the Subcommittee (see Appendix A).
A Committee member asked where in the list of topics the Committee would include the concept of “prevention.” Dr. Remington replied that health promotion is focused on preventing disease, but the member recommended making that point more explicit. Dr. Fielding indicated that the preamble would clarify that the Committee intends to emphasize the importance of prevention throughout its recommendations for Healthy People 2020. Dr. Remington added that the Subcommittee had discussed the importance of prevention, concluding that “health promotion and disease prevention” is a somewhat flawed label because it focuses on disease and not on promoting health through physical and social determinants. The member suggested using the term “access to health promotion” for the topic area, mirroring the term “access to health care.”
Dr. Remington replied that health care is an intervention. He emphasized that in the U.S., access to health care is an important determinant of health, and thus it may not be possible to categorize it as either an intervention or a determinant under this model. Another member agreed, adding that many of the topics listed could either be categorized as interventions, determinants, or outcomes. She expressed concern that it might be limiting to lock these topics into specific organizing categories; it could be more fluid than that. Dr. Fielding recalled that the Committee had, at an earlier meeting, discussed the possibility of creating a matrix, but soon found that most of the topics could be categorized across all columns of the matrix (e.g., interventions, determinants, outcomes). He also pointed out that the Committee’s recommendations would be confusing if they were not aligned with the Healthy People 2020 Action Model.
Dr. Remington agreed that valid issue is whether there is a benefit to clustering topic areas instead of saying that each topic area should address the continuum. The member who had raised this issue said she felt there could be ramifications for Federal funding. For example, if NIH sees that Healthy People 2020 categorizes physical activity under “interventions,” the understanding would be that a health outcome should be attached to research on changing physical activity. Yet many would argue that physical activity should be viewed as a behavioral outcome in itself. This could be problematic. Dr. Remington agreed with this point, and asked for the Committee to consider whether the Healthy People 2020 topic areas should simply be listed, without categorizing them.
Shiriki Kumanyika, Committee Vice-Chair, commented on the importance of preserving the ability to make some determinants into outcomes and to cross-reference them. For example, physical activity could be in the behavioral outcomes category, but it could also be cross-referenced to other categories as a determinant. On a separate issue, she said it would be important for the Committee to define health promotion because she felt members did not have a common understanding of what the term means. Many items on the topic areas list could be called health promotion (e.g., built environment, interventions, etc.). Thus, health promotion should not be defined too narrowly—as just health education, for example.
Dr. Kumanyika went on to say that all of Healthy People 2020 is health promotion, so specificity is needed about what types of health promotion are being described (e.g., behavior change, health education, nutrition education, etc.) It might be better to avoid the term “health promotion” entirely. A Committee member endorsed the phrase that had been suggested earlier, (e.g., access to preventive care, preventive activities, or preventive resources). She noted that health promotion is like health care and that access to preventive care needs to be available. Another member added that not all of health promotion occurs at the individual level; there are structural ways of promoting health. For example, Johnson & Johnson just purchased two companies to implement health promotion for their employees, including measures such as benefits for an insurance package for the company, or population interventions for all employees in the company together.
Dr. Remington asked if there was strong leadership in the “education and community based programs” focus area from Healthy People 2010. Carter Blakey said that “education and community based programs” was not a strong focus area for a variety of reasons, one of which was a lack of leadership. In some cases, there could be a lack of leadership and identity.
Dr. Fielding asked how members would like to change the wording of this topic area. An extensive discussion ensued, in which members offered various permutations of the phrase “preventive policies and programs” (e.g., “health promoting structures and strategies,” “health education,” “promotion policies and programs”). A member said that the Committee had forged a new perspective. As they had done with environmental health, the Committee is trying to redefine health promotion by saying that this is not just about access to disease care structures or health care structures, but that it is also about access to preventive activities. She felt that access should be redefined to encompass structures that are oriented towards prevention.
Dr. Fielding expressed the concern that there is a policy emphasis and a large body of studies on health care access. He said “health promotion” should be a separate topic area and reiterated that the Committee’s role is to make recommendations, not policy. A Committee member agreed that promotion should be kept separate, but said the language about access should be retained. Dr. Fielding then called for a vote to approve the phrase. Dr. Kumanyika was opposed to the phrasing “access to health promotion” because she felt it narrowed the meaning in ways that the Committee did not intend. Seven Committee members voted in favor of the topic area, “access to health promotion and disease prevention programming.”
A Committee member pointed out that the lifespan, as it is currently conceptualized, would not include death. She said that it might be helpful to think about death as a life stage, given the impact of the palliative care movement and hospice movement in recent years. She emphasized the importance of confronting how Americans address the last moments in life. She also pointed out that Healthy People includes prenatal care but not the final stage of life. Another member said that he thought “dying” would make a better life stage than death, but generally agreed with the previous point. Dr. Remington concurred that the exclusion of dying was an oversight, noting that its inclusion would be forward-looking. Others agreed that it is important to look at life stages and transitions, particularly because of the importance of transitions between life stages and our limited knowledge of them. Dr. Fielding asked if any Committee members disagreed with adding “dying” as a life stage. None were opposed. Dr. Fielding noted that “dying” should be added as a life stage.