Dr. Kumanyika explained that the Committee has woven the concept of social determinants of health into their recommended, overall approach to organizing Healthy People 2020. They are aware that the concept is difficult to operationalize and had set time aside to discuss it. In framing challenges of a social determinants approach she noted: 1) it is a long-range proposition that may appear to take the immediate focus off of health issues, and 2) it is not clear to people how one would go about addressing social determinants, particularly when setting objectives.
Dr. Kumanyika defined “societal” determinants of health (e.g., promoting quality child care, safe roads, schools and other areas of the social and physical environments) and said the term is widely used in Europe. The Committee wanted to introduce it into the lexicon in the U.S. because “societal” is broader than “social” determinants, encompassing both social and physical environments. Healthy People 2020 is prevention oriented, so it should help different users to think about their role in addressing societal determinants of health. A job of public health is to convince other people that they’re doing public health. Point out policies and activities that can improve health and reduce disparities. Policies that are made in other sectors that inadvertently have an effect on health must be pointed out.
Health in All Policies (HiAP) is being used to replace the older phrase, “Healthy Policies,” because that terminology implies it’s the responsibility of HHS; the phrase “All Policies” sends the message that it is everybody’s responsibility. To operationalize social determinants theory, one could use tools such as problem and solution trees or logic models,1 as part of a participatory approach working at either the professional or agency decision-making level, or in communities. A group of informed stakeholders can identify the problem by asking, “Why does this situation occur?” And then, “What are the causes of the causes?” Then they can look at the solutions to the problems. This approach raises awareness among stakeholders. Using a systems approach, one can develop the broad interventions that are needed.
Health Impact Assessment (HIA) is another tool for engaging public and private decision-makers to make decisions that take into account the impact on health—positive, negative, and distributional. HIA is particularly useful when health issues tend to be neglected. When people are working on agriculture or transportation committees, we must say to them, “You are making health policy.” Health is one critical factor—certainly not the only one—that should be taken into account in making decisions. The usage of HIA is growing in the U.S.; it takes a broad, population-based perspective and is multidisciplinary. Public health can use HIA to collaborate with people who have a background in these other issues, so that everyone is not talking in different lexicons.
Dr. Fielding described specific approaches to HIA. He said that many politicians have fairly short-term views. HIA can help them to think of future generations. He mentioned his hope that HIA will become a priority for the Domestic Policy Council. If we want to say broadly, “How do we improve health?” that would change the nature of the discussion. He mentioned a UCLA Web site that summarizes HIAs that have been conducted to-date (http://www.ph.ucla.edu/hs/health-impact/), emphasizing that it will become important for intersectoral efforts to quantify the impact of a social determinants approach.
Dr. Kumanyika outlined two potential directions: 1) operationalize social determinants that relate to identified health problems and make the case that they would impact health; or 2) evaluate potential actions to identify where you would get the most value and the fewest adverse effects. Dr. Fielding said one must look for the best opportunities to affect policies and programs in other sectors. How can we be opportunistic (i.e., plan for the periodicity of legislation such as the Agriculture bill and Transportation bill), and help people to prepare for policy approaches in addition to the program approaches. He opened the floor for comments.
A member said that the Committee’s Phase I report referred to “social and physical” environments, rather than “societal determinants,” and asked if it would confuse people to use a new term. Dr. Kumanyika responded that “societal” is being used to refer to factors that are of the social structure, including social and physical and economic factors. The meaning is the same, but the new term is more inclusive of different types of societal factors. After discussion, the Committee decided that “social and physical environmental determinants” was preferable to overarching terms (e.g., “social determinants” or “societal determinants”) and agreed to use this phrase in future.
A Committee member pointed out that “health is not everything.” It is important to be respectful of other sectors (e.g., don’t try to tell transportation people about transportation policy). Consider that the techniques for evaluating things are often denominated in dollars; things are not discussed in terms of health. Others suggested that HiAP runs the risk of sounding like hubris. A member commented that HiAP will happen when people want to integrate health into their area. What is that incentive structure? What’s the value exchange? It is clear how the health sector benefits when transportation integrates health into its decision making, but it is less clear how transportation benefits.
Dr. Fielding said the purpose of HIA is not to say that health is the most important thing; it is to make health one of the factors that decision-makers take into account. The people who make decisions are often elected officials who are trying to balance many factors. For example, they’re not necessarily experts in transportation. To illustrate that HIA can make a difference, he offered the example of Los Angeles County’s advocacy to require menu-labeling in fast food restaurants. Initially the Governor did not approve it. An HIA was conducted using data from New York City to show that relatively small changes in ordering could affect the increase in pounds of weight gain. That information was given to the Governor and his staff, as well as LA County supervisors, and it affected their final decisions.
Several members noted a need for tools to help community level users understand the social determinants approach, including clear examples of what a social determinant is and models of what policies should be implemented upstream to address the factors downstream. Participatory action approaches may be useful. A member said it is important to recognize that this is a shift from what is familiar to many stakeholders. Another member noted that understanding of social determinants is limited even among health officers throughout the U.S. Dr. Fielding emphasized that HHS should take a leadership role in communicating about this issue.
Because the Office of Management and Budget (OMB) reviews regulations that various Federal agencies put forward, a member said it should be one of the organizations represented in the FIW. The Committee should look at how OMB defines health to ensure that they take a public health perspective on it. Dr. Fielding said that several members of the Committee had been trying to address this issue for years; OMB’s scoring is limited to cost implications for the Federal government over a limited period of time. They take direction from the Senate Budget Committee regarding the method by which the Congressional Budget Office (CBO) does its scoring. OMB may be easier to approach about this than CBO, so it might be good to bring them to the table. Other key points discussed are summarized below:
- Look at the international experience with social/physical environmental determinants. Many countries have done well in developing these areas and it would behoove us to call upon our international colleagues and bring their resources into Healthy People.
- Engage the collaboration of experts in the social determinants of health, such as Michael Marmot or David Satcher, as an informational resource for background papers and guidance.
- Look into adding a Committee Member slot for an international representative.
VI. Exploring Implementation Strategies in Greater Depth
12:45 PM- 2:30 PM
Dr. Kumanyika reviewed milestones of the Implementation Subcommittee’s work to-date, including proposed recommendations and resources, and then opened the floor for discussion. Dr. Fielding asked ODPHP for an update on HHS activities for planning the implementation of Healthy People 2020, particularly in relation to a strategic communications plan. Carter Blakey, ODPHP Senior Advisor, explained that the FIW is still developing objectives. ODPHP has a communications contract, but these efforts are in their early stages. They hope to engage stakeholders through the social media. They have reestablished the Healthy People Consortium, but haven’t yet determined how to engage members beyond having a list of interested people. She mentioned that the National Opinion Research Center (NORC) has conducted, on behalf of HHS, an assessment of the needs of Healthy People 2010 users, which will be shared with the Committee once it is completed.
Dr. Fielding commented on the need for a strategic communication plan to articulate what the communications will be, and how they will be rolled out. This groundwork must be done in advance of the actual release of Healthy People 2020. A member agreed that good ideas have been put forth for potential products, but no discussion has yet occurred about how to create a demand for these products. Social media are a channel, not a strategy. Later, it was noted that the Committee may want to think about the diffusion of social change and social norms (e.g., how do people adopt active lifestyles). Dr. Fielding asked Dr. Douglas Evans, Committee Member, to reinvigorate the Subcommittee on Communications, which he chaired last year, in order to discuss needs for a strategic communication plan.
A member said it is important to think about how best to generate evaluation data on cost-effective interventions. How would you evaluate Healthy People 2020 interventions? Do we anticipate that there might be the equivalent of community clinical trials? What about efforts to accomplish the objectives with a particular population or select population? There should be a public space where people can go to learn about who is doing what; this could be a feature of the Healthy People Web site.
The Committee’s list of implementation recommendations mentions HiAP in several places, but the actions it prescribes are not concrete. Dr. Fielding felt it important to create areas of the Web site that are specifically designed for other sectors (e.g., Housing and Urban Development [HUD] or the Department of Transportation [DoT]). People from these target audiences should help to configure material for these parts of the site, and the right links should be used to direct them to it. A member asked what lessons were learned about this type of approach through Environmental Impact Assessment (EIA). Dr. Fielding said EIAs are paid for by the people who want to do a project, but the approach is more procedural than practical. There is a huge set of very expensive processes required. Those who are promoting HIA feel that requiring it is not the right model to use. EIAs have gotten people involved, but participation is not great, and the material is not easy to understand.
1See Snowdon et al. Problem and solution trees: a practical approach for identifying potential interventions to improve population nutrition. Health Promotion International, Vol. 23 No. 4; 16 September, 2008.