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 People 2020

• Healthy People 2020 should be in the form of a relational database
• There should be no a priori limit on the number of objectives.

Future Work
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 of 2008.

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 preferable.

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 solutions.

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.

1 A model 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.