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Minutes: Second Meeting: May 1, 2008

Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020

WebEx-Based, VirtualSecond Meeting: May 1, 20084:00-5:30 PM

Recommended Strategies for Immediate Follow-up

  • Schedule a conference call among subcommittee chairs to discuss how their work can be integrated to help prepare for a more fruitful discussion in June
  • Include Representatives from HHS on the next Health Equity subcommittee call
  • Clarification is needed about what this committee means by "prioritization." This should be addressed on both the subcommittee chairs and the prioritization subcommittee calls.
  • Seek information and feedback on the needs of user groups
  • Consider inviting non-HHS agencies to attend the June meeting as "observers"
  • Subcommittee chairs should contact Karen Harris to ask for staff support to finalize work for the June meeting.
  • Anyone who would like to suggest additional agenda topics should contact Dr. Fielding or Dr. Kumanyika.

Recommended Issues for Discussion at the June Meeting

  • A logic model for population health improvement over the life course
  • Discuss issues such as healthy life course metrics, bi-directional influences
  • Definitional issues for health: disparity, inequity, equity, equality, and quality: Review and reach consensus on definitions
  • How to think about reframing opportunities for intervention: This is particularly important for highlighting social and physical environments
  • Prioritization, and whether priorities should vary by user group: Should we propose one set of priorities, or help different user groups to think about priorities, given their opportunities to influence health?
  • How should the Healthy People document be organized? How should it look? Decisions will affect who uses Healthy People 2020
  • A presentation from a representative of a state or city health department on partnering outside of the public health sector to address social determinants.
  • Time permitting, representatives from LA County or Philadelphia could address this issue.
  • Presentations from experts on Health Information Technology and Preparedness.
  • ODPHP and NORC will seek to identify expert speakers for these topics.

Welcome and Introductions

Carter Blakey, Senior Advisor and Lead for the Community Strategies Team, Office of Disease Prevention and Health Promotion (ODPHP), welcomed participants to the second meeting of the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. She explained that the committee operates under the regulations of the Federal Advisory Committee Act, and offered operational guidelines. Though there was no opportunity for public comment at this meeting, she encouraged audience members to send any written comments electronically to hp2020@hhs.gov.

Ms. Blakey remarked that four Healthy People 2020 Regional Meetings had taken place to date, in Atlanta, GA; San Francisco, CA; Fort Worth, TX, and Chicago, IL. Two additional meetings were scheduled to take place in New York, NY (May 14), and Bethesda, MD (May 28). A total of 816 individuals attended the first four meetings, and 170 comments were made. In addition, 91 comments have been received through the Healthy People 2020 Web site. Public comments have generally supported a shift toward a risk factor based approach to organizing the focus areas and objectives. Yet many contributors have also said that specific disease areas should be included in the risk factor framework. Ms. Blakey noted that, since its first meeting in January, the Secretary's Advisory Committee had accomplished a great deal. It has created five subcommittees, and members have worked hard to prepare progress updates for this meeting. She then turned the meeting over to Dr. Jonathan Fielding, the Chair of this Committee.

Expectations and Desired Outcomes of the 2nd Meeting

Dr. Fielding explained that the focus of the meeting would be to hear progress updates from all chairs of the Secretary's Advisory Committee's subcommittees; to discuss how best to integrate the subcommittees' work; and to discuss and propose agenda items for the next in-person meeting of the Secretary’s Advisory Committee (scheduled for June 5 and 6, 2008 in Arlington, VA).

Reports of Progress from Subcommittees

Subcommittee on User Questions and NeedsSubcommittee Chair: Douglas Evans, PhD, RTI International

Dr. Evans explained that the subcommittee has met twice, and has drafted a list of target audiences for information about and from Healthy People 2020. In their discussions, the group has proposed a departure from previous iterations of Healthy People by suggesting that Healthy People 2020 could also include the general public as an intended audience. This would raise questions about whether more extensive segmentation needed in order to reach such a broad audience.

As they considered the informational needs of audiences listed, they drew a distinction between those who are active seekers of information from or about Healthy People 2020, and those who may need to know more about the initiative. The subcommittee discussed the need for targeted messages and products to reach specific audiences and segments, as well as potential barriers to reaching them. There were some unresolved issues, including whether a unifying theme or brand image for Healthy People can be used to reach out to audiences in an effort to raise awareness. How should target audiences and their needs be prioritized? Dr. Evans concluded that the subcommittee plans to develop a more robust conceptual model for segmenting audiences and needs.

Subcommittee on Developmental Stages, Life Stages, and Health OutcomesSubcommittee Chair: Patrick Remington, MD, MPH, University of Wisconsin Population Health Institute

The subcommittee considered a life-span approach to be critical to population health improvement, improved length and quality of life, and reduced health disparities. Members noted that Healthy People 2010 did not reflect the importance of life course (except for a maternal and child health focus area), but this should be a visible priority for 2020. Dr. Remington said the group had looked at various examples, including obesity. There is evidence that pre-natal developments influence early childhood health (e.g., adiposity, growth trajectories). Later adult diseases are determined largely by the time that people become adults, but continued influences are important, such as inactivity, nutrition, and smoking. Currently, little attention is focused "upstream" on early life course.

Dr. Remington presented a logic model for population health improvement across the life course (see Appendix 1). It includes a modification of the two overarching goals from Healthy People 2010 (improved health outcomes and health equity). The determinants approach shows that healthy development across the life course not only influences outcomes (disease, disability, and injury rates) but also behaviors. "Life course," is shown at the bottom, indicating that exposure to health programs, policies, and systems early in life affects later outcomes. The model could also show how life stages (e.g. infant health, child health) are affected by health determinants. The subcommittee discussed the model as being a fairly simplistic approach; it’s easy to understand, but bi-directional interactions between some determinants may be needed. The metrics for healthy life course development are also important. Dr. Fielding suggested putting this model on the agenda for June’s meeting as an item for discussion and finalization.

Subcommittee on Health Equity and DisparitiesSubcommittee Chair: Ronald Manderscheid, PhD, SRA International

The subcommittee decided to sort out key issues on definitions of health: disparity, inequity, equity, equality, and quality. They want to be able to communicate clearly about these issues to the health field. Members view health equity and disparities as vital issues for Healthy People 2020. They reviewed the core literature on health equity, and posted it on the SharePoint Extranet (a Web-based tool for internal use by members of the Committee). They also prepared criteria considerations for a definition of health equity, and began work on an actual definition (see Appendix 2).

The subcommittee feels it is important, once the draft definition has been completed, to work with federal agencies with interests in this area—principally the Office of Minority Health (OMH) and the Centers for Disease Control and Prevention (CDC). They want to ensure that they reach consensus with these agencies, and also within the Secretary’s Advisory Committee. Dr. Manderscheid highlighted key criteria for a definition of health equity, and offered a progress update on the current version of the draft definition. Dr. Fielding noted that the definitional issues (not only health equity, but also disparities, equality, etc.) should be addressed in the agenda for the June meeting.

Subcommittee on Environment and Health DeterminantsSubcommittee Chair: Abby King, PhD, Stanford Prevention Research Center

The subcommittee has focused on the domains of physical and "social environments" (the latter was considered broadly, e.g. cultural and economic environments). Key issues discussed included the importance of: 1) multi-level framing of interventions (from the individual through the environment and policy levels); 2) building multi-disciplinary, inter-sectoral partnerships across the U.S.; 3) promoting environmental justice to increase health equity and decrease inequalities. 4) Focusing on "higher-level" interventions (e.g., passive prevention strategies) when possible. The subcommittee felt these responsibilities should extend beyond the public health sector, and brainstormed about how to identify and get buy-in from other appropriate sectors.

Members discussed emerging environments, such as virtual environments that are being created by interactive communication technologies. They would like to create a separate, introductory section that talks about themes of social and physical environments and lays out the multi-level nature of health. These themes should also be woven throughout the Healthy People documents. They liked the model that Dr. Remington’s group developed, and could create a "mini-framework within a framework" to talk about behavioral, physical, and social environments. The subcommittee is currently: adding to the Healthy People 2010 definitions of social and physical environments, refining overarching principles, and recommending activities. Unresolved issues include: best ways to include this multi-level focus within each area of the document; finding ways to highlight opportunities for intervention; surveillance; and how to obtain buy-in from all sectors. Dr. Fielding agreed it is important to think about what the opportunities are, as well as the interventions.

Subcommittee on Priorities Subcommittee Chair: David Owen Meltzer, MD, PhD, University of Chicago

The subcommittee sought to gain insight into how to prioritize the goals and objectives of Healthy People, since there have been an increasing number of objectives in each iteration. The group addressed three main questions: (1) what principles should be used to guide prioritization? 2) What logic model should be used? (3) How were these issues addressed in previous iterations of Healthy People? The subcommittee drafted a list of principles, some of which included: the need for framework, need for specified objectives, and need for measures across multiple domains (see Appendix 3). It will be important to provide a process and tools to inform prioritization efforts. The question of whether we are talking about prioritizing objectives or interventions has also been raised.

Dr. Meltzer reviewed a number of potential logic models to help frame this discussion. He highlighted the model proposed by Dr. Remington, as well as other possible models. He added that more discussion is needed about whether any of these models is adequate. The subcommittee has begun to review previous approaches used to develop priorities for Healthy People. He noted that earlier processes were categorization exercises. They were strong in generating long lists of possible objectives and interventions, but they were weaker in winnowing through them. Thus, guiding principles must be integrated into the process. Unresolved issues for this subcommittee include: mapping principles to an actual process, both in the short-run and the long-run; deciding what framework or logic model will be used; deciding how to build on previous iterations; and preparing recommendations. Some discussion of how costs will figure in is also needed.

Preparations for June Meeting

Dr. Fielding asked Ms. Blakey if there were specific expectations for what should be accomplished by the June Meeting. Ms. Blakey said that ODPHP would like to have a discussion by the full committee of issues that have been addressed by the subcommittees. They would like to have a clear direction or near-final draft that they could put forward for formal public comment. Ultimately, this would be submitted for clearance throughout the Department, although a final draft is not needed by June. For example, the Advisory Committee could produce definitions of health equity and a draft framework.

Dr. Fielding stated his understanding that the Secretary’s Advisory Committee would need to fit together the work of the subcommittees to get close-to-final agreement on key definitions and terms, to the extent possible. They would provide an outline of what the final product might look like, and whether it would consist of a single product or a group of products. Ms. Blakey confirmed that this was in line with her thinking.

Suggestion #1: Schedule a conference call among subcommittee chairs

Dr. Fielding commented that it would be useful to have a conference call of the subcommittee chairs to think about how the various pieces come together, and to integrate them for a more fruitful discussion in June. Other members agreed that some themes seem to recur across areas. A Committee member added that staying in touch with external members would be important because their feedback and expertise has been valuable.

Suggestion # 2: Invite HHS representative to take part in Health Equity discussions

Dr. Manderscheid mentioned that his subcommittee could benefit from speaking with HHS representatives who are working on parallel issues. Dr. Fielding encouraged the suggestion, and mentioned that other subcommittee chairs can decide whether a similar effort would benefit them. He noted that ODPHP could provide specific recommendations to the chairs if he was helpful.

Suggestion # 3: Clarify what the Secretary’s Advisory Committee means by "prioritization"

Dr. Kumanyika mentioned that the priorities subcommittee has a difficult job because of the number of objectives and the question of where to focus. Their work will be critical to the June Meeting. She suggested that the Advisory Committee discuss how to resolve some of challenges facing this subcommittee. Which direction is the prioritization framework or concept is going in? A couple of options could be: 1) If we had a list of objectives, how would we decide which ones were most important? And (2) what important priorities can we develop to guide the objective setting process?

There seems to be some overlap between the issue of a framework that would help us set specific objectives, and a framework for deciding what health issues are important (the risk level, the severity, the population affected, how far we are from the goals, etc.). The Committee has many different ideas of what priorities are. Dr. Kumanyika felt there is a need for more clarification on what we is meant by prioritization. There can’t be 800 priorities. Dr. Kumanyika recommended that this be a topic on the subcommittee chairs call and on the priorities subcommittee.

Suggestion # 4: Decide whether priorities should vary by user group

Dr. Fielding commented that there are a lot of different users of Healthy People, and the priorities will look different depending on who those users are. He wasn’t sure whether the Committee should propose one set of priorities, or help people to think about priorities, given their opportunities to influence health. He felt this could be another topic for the agenda. Dr. Evans asked whether Dr. Fielding was suggesting that there should be some interaction between the thinking about user groups and priorities. Dr. Fielding confirmed his view that priorities are different, for example, among clinicians, versus staff at a state or local health departments, versus staff at NIH.

Dr. Remington said the Committee should look at federal programs that use Healthy People a way to highlight their programs, and how that differs from the needs of a state or local health officer. Local health officers may feel that at the community level, the many different categories that federal and state agencies think about aren’t as important—communities are more holistic. But the reality is that categorical funding isn’t going to go away. The document needs to be responsive to the importance of state and federal agencies, but also useful to communities. State and federal agencies need the depth and detail of a document this big, but users at the community-level want straightforward information about how to help people live longer healthier lives with fewer disparities, and the most cost-effectiveness approaches.

Dr. Fielding suggested the Committee spend time on this issue in June. How the document is organized and how it looks will affect who uses it. Dr. Evans suggested conceptualizing the document as a dynamic information source, rather than a static report. Users could approach the resource (e.g., through a Web-based format) with queries, and there could be multiple entry points depending on the user’s needs. That would enable tailoring to user needs and interests. Dr. King envisioned a set of algorithms that would vary by user, to help them get the information they need.

Issues and Challenges Related to Prioritization

Dr. Kumanyika pointed out the difference between setting priorities for the health of nation and tools for prioritizing specific objectives. One is a task of deciding which interventions are most appropriate for a particular user to choose, given a wide range of options. But there’s also set of health issues that should be everyone’s priorities, before one gets to a user-specific perspective. Is there a set of guidelines for setting overarching priorities so everyone feels they’re pulling towards improving health in certain key areas that were decided upon using a set of criteria? And then, within their corners, this is how specific users could go about figuring out what their contribution is.

Dr. Fielding agreed that it is important to highlight the greatest opportunities, given current knowledge and techniques. As part of the prioritization effort, a set of criteria is needed for how those are chosen. Dr. Meltzer said that tools are used to inform priorities, so our goal is to establish first a set of tools to help us think about what is important, and then to apply those tools to decide what becomes important. He added that there are multiple decisions at multiple levels, the tools are often poor, and the data are insufficient. Looking at earlier Healthy People processes, large lists of issues were identified, but they were not narrowed down, and decisions were not made about what matters most. He expressed doubt that this Committee would be able to do any better in terms of deciding what matters most. However, he hoped that the Committee could describe a set of "tools" that could be used to enable more informed choices about what matters most in the next decade.

Dr. Fielding suggested that it should be possible to come up with a set of overarching priorities based on preventable burden, available interventions, and similar criteria. Since social environmental and physical environmental factors impact health; shouldn’t these be highlighted? Dr. Meltzer said felt that, given the lack of resources or time, this group would have difficulty drilling down deeply to decide what is important and what is less important. Dr. Fielding thought it should be possible to establish the criteria for priorities, and/or evidence.

Dr. Kumanyika preferred the term "principles" to tools; others agreed. Dr. Remington mentioned that principles for population health improvement are different from how public health agencies are currently organized. There’s a delicate balance between creating a document that supports public health agencies, and yet provides the principles for the actions that are most important to undertake. The priorities are often set at the local level. The 2020 plan should be equally useful in completely different communities—urban and rural. They need principles they can apply for achieving overall goals, and then simple tools that they can apply to decide what’s most important for their area.

Dr. Kumanyika asked whether others agreed with her that they are seeking a set of overall health objectives for the nation. Dr. Fielding agreed. Others were concerned that our priorities now may be very different from priorities over time. Flexibility is important. Dr. King liked the idea of principles because this approach is flexible enough to capture changes in the future. Dr. Fielding asked the subcommittee chairs how much support they need to move forward on these issues. He asked them to contact Karen Harris (harris-karen@norc.org) with questions about staff support for compiling materials and finalizing work for the June meeting.

Non-Federal Partnerships

Committee members felt that public health can’t address issues of this magnitude without the involvement of federal agencies from other sectors. Ms. Blakey mentioned that currently, only HHS representatives are taking part in the federal committee that is steering the development effort (the Federal Interagency Workgroup, or FIW). However, an FIW subgroup is developing criteria for Non-HHS federal partners, such as the departments of transportation, education, and agriculture. This approach would be a departure from previous Healthy People iterations. The FIW has not yet formally engaged these agencies, but would like to do so in the fall of 2008. Dr. Fielding suggested inviting these agencies to the table sooner. Having agencies take with "observer status," for the June meeting with formal representation at the Secretary’s Advisory Committee meeting in the fall, might be a viable option. Ms. Blakey said that reaching out informally for the June meeting was a great idea.

Other Issues for the June Agenda

Dr. Fielding said it will be a challenge to integrate the work of the subcommittees, and that this will be critical to the discussion in June. A suggestion was raised that subcommittees could meet in-person prior to the June meeting, but this was left to the discretion of subcommittee chairs.

Dr. Kumanyika suggested having a presentation from a representative of a state or city health department that had had experience with going outside public health sector to address social determinants, if time permits. Dr. Fielding suggested that he knows a county health official who may be able to do a brief session; he could also speak to this issue. Another option could be a representative from the Philadelphia health department. It was agreed that this would be discussed further offline.

Dr. Evans suggested that the Committee should seek information from the regional groups about user needs. Dr. Fielding thought another option could be to ask NACCHO or ASTHO to identify content that their members would find to be helpful for Healthy People 2020. Dr. Evans pointed out that those organizations are represented on the User Question and Needs subcommittee.

Dr. Manderscheid added that preparedness and health technology are issues that need to be discussed and potentially incorporated, or considered as separate focus pieces. Dr. Fielding agreed that these should be put on the agenda, and that particularly preparedness is an issue of importance. Dr. Remington further added that from a systems approach, Health IT addresses the issue of enhancing public health system infrastructure.

Dr. Fielding added that if anyone would like to suggest additional agenda topics, they should contact him or Dr. Kumanyika.