The Subcommittee on Health Equity and Determinants has sought to develop
and agree on definitions. The Subcommittee on Priorities has worked on
criteria for prioritization. The Subcommittee on Developmental/Life Stages
concluded that Healthy People 2020 should emphasize these are important
concepts. The Subcommittee on User Questions and Needs is considering how
Healthy People 2020 can respond directly to the needs of target audiences.
The Subcommittee on Environment and Determinants has attempted to
concretely apply an ecological perspective to Healthy People 2020. Two ad
hoc groups have also provided special attention to developing a graphic
model for Healthy People 2020 and the issue of health IT.
Voting on the General Approach to Healthy People 2020
Dr. Fielding suggested that the Committee turn their attention to
voting on issues that had been discussed to date. He explained that the
Committee had previously reached informal consensus that Healthy People
2020 should be in the form of a relational database, and there should be
no a priori limit on the number of objectives. Committee members noted
that a relational database could help to increase access and usability for
specific users. The Committee voted to approve the stated approach to
Healthy People 2020 (11 in favor, 1 abstention, 1 absent).
Advisory Committee Recommendation #1: General Approach to Healthy
- Healthy People 2020 should be in the form of a relational database
- There should be no a priori limit on the number of objectives.
Dr. Fielding suggested that the day's discussion address strategies for
finalizing and approving the end products of the subcommittees' efforts,
as well as integrating them into a single document. This document would
become the basis for Advisory Committee discussion at the September 4-5
meeting. He asked NORC staff to work together with the subcommittee chairs
to prepare the individual report sections that were shown in the draft
outline (see Appendix A). Dr. Fielding
noted that Committee members would be able to review an electronic version
of the draft report in advance of the September meeting.
Dr. Fielding clarified that the production timeline for the Committee's
Phase I report would vary from that of the FIW report. The FIW must
prepare a first draft by early September to allow time for it to go
through the HHS clearance process. Since the Advisory Committee report
will not go through HHS clearance, the timeline is slightly more flexible.
The Committee should aim to finish their Phase I report by late September
V. The Draft Healthy People 2020 Model: Report, Vote
Dr. Shiriki Kumanyika, Committee Vice-Chair, reviewed the work that the
Committee has completed to date on a Healthy People 2020 graphic model
that illustrates the relationship between causes of health and the process
for creating solutions. Before turning to the specific version that the
models ad hoc group had prepared, she gave an overview of why a model is
needed and what it is designed to do. A model of Healthy People 2020
should show how the different objectives and elements of the initiative
relate to each other and fit together. It should be broad-stroked enough
that it could be expanded to show the details beneath each category of the
model. The group agreed to use a single model to address both the causes
of health and the process for creating solutions.
Dr. Kumanyika explained the current draft version of the model to
Committee members, including both other static and animated versions. The
model is meant to show that Healthy People 2020 will prompt action in
three different areas: determinants, pathways of action, and outcomes.
Intervention in each area will impact health problems in different ways.
By addressing determinants, one seeks to change the quality and quantity
of those factors. If determinants are held constant, one could try to
change the pathways of action of those determinations. If determinants and
pathways cannot be blocked, one can increase the population's resistance
and resiliency, which would change the effect of determinants through
those pathways. Healthy People 2020 objectives could act in any one of
those three areas. Dr. Kumanyika showed an example of how the model might
apply to a population of adolescents in low-income communities.
A Committee member asked how the model incorporates information that
people receive from their environment, e.g. through the media. Dr.
Fielding suggested that this issue could be addressed by substituting the
phrase "social environment" for "resources." After some discussion of how
specific elements of the model should be phrased or defined, Dr. Kumanyika
noted that definitions in the "determinants" rows should be aligned with
those used elsewhere in the report.
Several members said that they liked the model and found it to be
straightforward and logical. They approved the model's "upstream" focus on
population health determinants, especially its treatment of health
behavior as an outcome. Concerns included the fact that actions and
interventions are not clearly incorporated into the "static" version of
the model, and that it is not clearly a model for action. Dr. Kumanyika
acknowledged the difficulty of addressing certain concepts within a
two-dimensional model and noted that a three dimensional version would be
Dr. Fielding noted that a narrative will be important to explain
various elements of the model, including the place and role of behaviors
(as they could be categorized as both determinants and intermediate
outcomes). After some discussion of phrasing, the members agreed that the
specific wording could be adjusted later. Dr. Kumanyika emphasized that
producing a glossary would give the Committee a chance to determine which
terms they wish to use to convey key concepts. Dr. Fielding asked the
Committee for a vote to approve the use of a single model to communicate
about both causation and process in Healthy People 2020. Committee members
voted to approve this approach to the Healthy People 2020 model (12 votes
in favor, 1 absent).
Advisory Committee Recommendation #2: A Single Model to Show
Causation and Process
- A single model should be used to communicate both the causes of
health outcomes and the process for creating desired health outcomes and
Dr. Fielding asked Committee members for a vote to approve the use of
this version of the model, with the understanding that the wording of
specific elements may change in the future. He added that, at a later
point, it will also be important to reach agreement on the definitions of
terms used in the model. Committee members noted that some edits will be
forthcoming (Dr. Kumanyika will coordinate this effort), but that the
concepts put forward in this model are appropriate. As they finalize the
model, a member suggested that the Committee consider the Evans and
Stoddart model,1 which addresses the concepts of wellness and
prosperity. Committee members voted to approve this version of the model,
noting that there will be additional opportunities to modify it in the
future (12 votes in favor, 1 absent).
Advisory Committee Recommendation #3: This Version of the
Model will be used in the Report.
- The concepts put forth in version of the Healthy People 2020 model
should be used in the report, but there will be additional opportunities
to modify the model in future.
of determinants of health. R.G. Evans and G.L. Stoddart, "Producing
Health Consuming Health Care," Social Science and Medicine, 31:1359, with permission from Elsevier Science Ltd, Kidlington, UK.