Third Meeting: June 5 and 6, 2008

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

Framework and Areas of New Focus for Healthy People 2020

Hyatt Regency Crystal City at Reagan National Airport

Third Meeting: June 5 and 6, 2008

Day 2: June 6, 2008

Recap of Day 1 and Charge for Day 2
9:00 AM - 9:15 AM

Dr. Fielding welcomed members of the Committee and audience back to the meeting. Items to be discussed that day included: draft models; the Healthy People framework; and recommendations for how to go about setting objectives. The Committee would: revisit the draft vision, mission, and goals that were prepared in January; decide how to divide the User Questions and Needs Subcommittee into different audience groups; and develop a more complete definition of a "framework." Finally, members would look at the charges of existing subcommittees and determine what their future roles should be. Dr. Fielding noted that members of the audience had registered to present oral remarks to the Committee; he explained how this process would unfold. 

Public Comment Period
9:15 AM - 9:45 AM

Seventeen members of the general public each presented two-minute oral comments. Of these, most advocated for the inclusion of specific topic areas (8) or subpopulations (5). The other four commenters supported specific strategies for Healthy People 2020 to promote progress in public health (see Appendix: Public Comments Presented During Open Session). Topics addressed during this session are listed in Table 1, below.

Table 1.  Audience Recommendations for Issues to be addressed by Healthy People 2020

Discussion of the Framework
9:45 AM - 10:45 AM

Reaffirming the Vision and Goals Statements

The Committee members reviewed the vision and goal statements that they had drafted and approved during their January 31-February 1 meeting. Dr. Fielding asked for a vote to reaffirm approval of these statements. All members who were present (12) voted to reaffirm approval of the draft vision statement and goals.

Finalizing the Draft Mission Statement

During its January 31-February 1 meeting, the Secretary's Advisory Committee developed four draft elements of a mission statement. While the first three elements were approved by vote, the Committee did not have adequate time to vote on or approve the fourth element, and had not approved the mission statement as a whole. The Meeting 1 draft elements were:

1. Increase public awareness and understanding of the underlying causes of health, disease, and disability; (Approved)
2. Improve results by providing priorities, measurable goals and objectives, and guidance on effective strategies and tactics; (Approved)
3. Catalyze action using best available evidence to improve policy and practice; (Approved)
4. Identify research and measurement priorities for improving the evidence base for effective action and evaluation. (No vote taken)

Members conversed about whether the fourth mission statement element falls within an academic research domain or one of public health practice. They believed it could highlight the need to evaluate the research base and define gaps in knowledge, rather than defining research priorities. Healthy People 2020 should inform the research agenda; perhaps more importantly, it should close the loop between research and practice by encouraging translation from the field of research to the field of public health practice, and vice-versa. Members also commented that everything Healthy People does is meant to improve policy and practice. Therefore, the overriding mission should be "To improve policy and practice," with other statements subsumed beneath it. The fourth mission statement element was updated, and a new "overriding mission statement" was added.

There was a motion to approve the revised Mission statement in its entirety; all members who were present (12) voted in favor.

A Committee member said it is important to think about how the vision statement, goals, and mission all fit together. Another member noted the importance of clarifying that each of these pieces is part of the same system. It was suggested that a phrase be added to the mission statement addressing the need to bring in stakeholders. Dr. Fielding asked if there was a motion to re-open the discussion regarding the mission. Only one member was in favor of this; all others were opposed.

A Committee member mentioned the "preamble" that was drafted during the January 31, February 1 meeting, but was not approved. The draft preamble was as follows:

Healthy People 2020 will be useful to anyone interested in improving health. Users will include members of the general public, health professionals, and civic leaders. Healthy People 2020 will also be used by private and public health agencies, educational institutions, and other community organizations. Healthy People 2020 is an essential tool to any individual or agency striving to improve the health of individuals, communities, and our nation.

Next Step: Dr. Fielding asked that the Committee members review the vision, goals, and mission, and think about how they fit together. This could be an agenda item for the next meeting. He also asked members to review the proposed preamble and think about it for the next meeting.

The Committee members then took a break. Upon their return, they continued discussion of the framework for Healthy People 2020.

Continued Discussion of Framework
11:00 AM - 12:00 PM

What is Healthy People

Dr. Fielding asked the Committee to articulate a coherent explanation of what Healthy People 2020 "is." He suggested that language is needed to communicate effectively with the public about Healthy People. In the past, Healthy People has been a volume that one could order; it featured some metrics and some information on tools. Dr. Fielding pointed out that the notions of Healthy People 2020 that are currently being vetted seem to refer to a database that is designed to help stakeholders improve the health of populations. This approach would differ from previous Healthy People iterations. In essence, it would be a substantial IT project, and its success would be determined by how user-friendly it is. He asked Committee members whether they agreed with this perception.

Dr. Kumanyika would prefer to view Healthy People 2020 as a national health plan that communicates a vision and a plan for the nation. It would have a database and a set of objectives, but as a "plan," it would offer direction to keep users from getting lost in specifics. Dr. Fielding said he thinks of a plan as delineating responsibilities and tasks. A Committee member agreed that a plan specifies "who, where, and when;" he viewed Healthy People as a "strategy." Another member said Healthy People has been thought of as the "national agenda;" it must be inspirational and aspirational, but is missing an implementation strategy. Using a term such as strategy would imply action and leadership. Another member seconded the view that it should be inspirational and action-oriented; she said Healthy People is a "map," showing "where you want to go, and how to get there."

A Committee member said the concept of a database is foundational, but Healthy People must be highly motivational to bring about action. What will be the roles of data, education, and stakeholders to ensure that Healthy People 2020 touches the lives of every American? He later said a tagline is needed to characterize Healthy People, such as "Championing Health for Everyone."

Arguing against the idea of Healthy People as a database, another member said that a database is "flat, lifeless, and just sits there. You can either access it or not." He felt Healthy People should articulate an inspirational, action-oriented direction that the nation needs to take. Just saying that Healthy People is a database doesn't get at this. Dr. Fielding clarified that he was trying to see if the members have a notion of what Healthy People 2020 will be, because it has big implications for how HHS will invest resources. If it's a Web-based database, having a user-friendly interface would be important. Committee members raised various issues and questions in the ensuing discussion.

• A noun is needed to describe what Healthy People IS (as opposed to what it does).
• What's needed is a marketing strategy (to convey what Healthy People is).
• Healthy People is a "searchable, multilevel, interactive, Web-based tool."
• An electronic resource would enable delivery of information that is tailored to user needs.
• In describing what Healthy People is, it's important not to include so many things that users can't get their heads around it.
• If Healthy People is a national plan, perhaps tasks and responsibilities are assigned at the state level.

Next Step: Dr. Fielding suggested that the issue of how to describe Healthy People should be deferred to the User Subcommittee. He felt that there was general agreement about what Healthy People is, but agreement is needed about what to call it. Clarity is also needed about what kinds of resources should be devoted to Healthy People initiative. There should be an architecture into which the content fits.

Overall Approach

Dr. Fielding referred to a handout that he had distributed to Committee members that morning, outlining an overall approach to Healthy People 2020 (see Appendix: Draft Framework Elements and overall Approach). He asked members whether the ideas it presents would be useful for the Committee's work. Dr. Kumanyika noted that the outline deals with operational issues, for people who have already decided that they want to do something about a health issue. She asked what would be included in the end product to convince people that they should do something. Dr. Fielding agreed this was important, and said this piece was missing from the NORC report (i.e., a "push" that says, "Here's how others have done it, why aren't you doing it?") Other issues raised during this discussion were as follows:

• The CDC operates an 800 number called CDC Info. Healthy People should link to that and help it to evolve to the next generation.
• Healthy People should link with existing, federal-level, Web-based tools such as the U.S. Preventive Services Task Force. AHRQ already has Web-based archives of tools for different user groups. It should foster the interconnectivity of all the data systems within HHS.
• How will Healthy People get people who go to other Web sites to come back to this one?
• Change the discussion to one of marketing. What are the different niches?
• Advise the Secretary that this effort will not be successful without resources for marketing.
• If Healthy People aspires to reach young health professionals, it must be on the Web.
• Be careful about "mission creep" (i.e., expansion of the mission). Not all of the issues listed in the "Overall Approach" outline were addressed by Healthy People 2010.
• Do not forget rural communities and populations with limited literacy. An implementation guide will be important to help communities to think about how to mobilize.
• Think about organizations that are reaching out to communities to help organize on public health issues, such as the American Public Health Association, the Institute of Medicine.
• There should be derivative products, as well as a Web site, for Healthy People.

Dr. Fielding asked RADM Royall whether this was the kind of input that would be helpful to the Secretary. RADM responded affirmatively, and agreed there is a need to increase awareness of Healthy People, as highlighted by the Committee member who had mentioned that only three out of 100 medical students he addressed at a meeting had heard of it. For example, having schools of medicine, undergraduate institutions, and professional schools teach Healthy People would increase awareness of Healthy People, health promotion, and disease prevention.

Models

The Committee returned to the previous day's work of refining models to illustrate key elements of Healthy People 2020. Four models were presented by their authors.

Model 1: Determinants Person in the Environment, and Effects
Dr. Manderscheid explained that Model 1 reflects an attempt to translate Dr. Remington's logic model into something that moves from left to right. It focuses on interventions to improve population and personal health by modifying determinants of health, and acting upon the family and community in which someone lives. Committee members' comments are summarized below.

• Individual determinants are not captured.
• The concept of "embeddedness" is lacking (i.e., people embedded in families, communities).
• The idea of starting with the interventions is useful—it's about action.
• Health disparities should be reflected as outcomes.

Model 2: Implementation and Feasibility of Change
Dr. Meltzer commented that he has always found it difficult to figure out what Healthy People is: whether it's a set of objectives, a source of data, or an intervention. Model 2 shows that Healthy People begins with action and intervention, and shows how data can feed back to all individuals to produce accountability. What actions have taken place to produce changes in population health? Members' comments are summarized below.

• This is not the logic model for health improvement, but it shows what Healthy People is doing, in terms of its constituents, and what actions might be derived.

Model 3: Proposed Multi-level (Ecological) Framework
Model 3 places the individual at the center, and reflects evidence that cross-cutting domains (e.g., life course, information environment, social/ cultural environment, etc.) each come into play.

Continued Discussion of Framework
1:00 PM - 2:00 PM

After a break for lunch, the Committee reviewed a revised version of the "population health improvement" model that had been prepared by Dr. Remington.

Model 4: Population Health Improvement-Revised
Dr. Remington explained the elements of the new version of the population health improvement model (Model 4). Thinking in terms of a Web-based design, each area of the model could have drop down menus. For example, "Tobacco" could be addressed under individual behaviors.

Next Step: Dr. Fielding asked the Committee whether there was consensus that more than one model is needed. After some discussion, it was agreed that three models are needed to show: 1) the Healthy People process; 2) broad interventions, and the results of these inputs; and 3) the causal Web. Dr. Fielding asked Dr. Kumanyika to lead the process of finalizing the models. He later added that, for each of the models, the authors should work with Dr. Kumanyika to develop an explanatory narrative that is associated with it.

Inclusion of All Hazards Preparedness in Healthy People 2020

Dr. Fielding asked the group to return to the issue of whether All Hazards Preparedness (including preparation for both natural and manmade disasters of various kinds) should be addressed by Healthy People 2020. He asked for a vote on this issue. All members who were present (12) voted to recommend including All Hazards Preparedness in Healthy People 2020.

Definitions

Health Equity
The Committee revisited the draft definition of Health Equity that Dr. Manderscheid had presented on Meeting Day 1 (see Appendix: Health Equity and Health Disparities—Draft Definitions and Key Concepts. Dr. Fielding asked the Committee if there was general agreement on the definition. In the ensuing discussion, the question was raised of whether it is appropriate to call for "fairness in efforts to achieve the best possible health for everyone." There was concern that this phrasing makes health seem to be the most important priority, when this may not always be the case. A suggestion for rewording the phrase was, "...achieve fairness in efforts to improve health for everyone." Other requested changes and questions raised were as follows:

• Add "persons with disabilities" to the definition
• Change the phrase, "who have systematically experienced" to "who do systematically..."
• Is "health equity" a process, or a destination?

Health Disparities
In reviewing the definition of Health Disparities (see Appendix: Health Equity and Health Disparities—Draft Definitions and Key Concepts), Dr. Fielding focused on the phrase, "experienced worse health and greater social obstacles to health and health care, particularly discrimination." He felt that either the definition should include other factors, or it should omit the word "discrimination." Explaining his position, he noted that discrimination has been an important factor among African Americans, but Latinos have better health status than the general population, so discrimination is not the only important factor. A Committee member requested that "persons with disabilities" be included in the definition.

Next Step: Dr. Fielding asked that the subcommittee on health equity and disparities continue to refine its definitions of health equity and health disparities. Dr. Manderscheid said the subcommittee would prepare explanations of the rationale behind the wording that they choose.

Social Environment and Physical Environment
Dr. King asked that Committee members send her any comments about edits or changes that are needed for the definitions of "social environment" and "physical environment" (see Appendix: Physical and Social Environment—Draft Definitions and Key Concepts).

Action Items
2:00 PM - 2:30 PM

Dr. Fielding noted that an additional, Web-based meeting of the Secretary's Advisory Committee would be necessary; he asked NORC staff to schedule this for approximately six weeks in the future.

Future Work of the Subcommittees

Dr. Fielding asked the subcommittee chairs to indicate whether their work was complete, or should continue. The subcommittee chairs all felt that their groups had additional work to do.

1. Subcommittee on User Questions and Needs

   Since Dr. Evans had left the meeting early, two other subcommittee members offered additional next steps. They said the subcommittee would rethink the audience matrix to verify that it includes all groups discussed by the Committee. They would also revisit the "multi-level table," and add another column to show what actions are needed to generate information and awareness.

   Dr. Fielding asked the subcommittee to convene a series of small focus groups of users via informal conference calls. The purpose should be to identify user requirements and to maximize the utility of Healthy People 2020. Discussions should reveal differences between audiences, rather than commonalities. It will be important to determine what factors would encourage diverse participants to "buy into" Healthy People as a whole. How do participants see themselves fitting into overall, national efforts to improve health? What information would be most helpful to them? What attributes of the process would they like to see? Potential audiences to be explored through the User Groups include:

   1. State and local public health officials
   2. People who are familiar with the informational needs of the general public
   3.  Community-based organizations, advocates
   4. Academics (research and training)
   5. Business/ private sector
   6. Voluntary organizations
   7. Federal officials (the FIW could ask non-HHS partners about their informational needs)
   8. Media representatives
   9. Policy-makers/ congressional staffers (if permissible under FACA guidelines).

2. Subcommittee on Health Equity and Health Disparities

   Dr. Manderscheid stated that his subcommittee will continue to work on definitions and measurement issues for health equity and health disparities. (Measurement is a particular concern of groups that have been working to address health disparities.) The subcommittee would like to produce a framework or suggestion for how Healthy People would address health equity.

3. Subcommittee on Priorities

   Dr. Meltzer suggested that the next steps would involve taking the draft model and tying it to the principles to show how to make the principles more usable. A Committee member asked if Dr. Meltzer concurred with the view that the discussion should be more focused on priorities for what Healthy People might do, and less focused on priorities for metrics. Dr. Meltzer said he thought the subcommittee could, at a high level, examine the classes of measures that are useful. It could be useful to talk about the advantages or disadvantages of trying to measure things.

   Dr. Kumanyika said it would help to understand where the priorities are going to appear in the framework. Dr. Meltzer noted that there is a question of whether "prioritization" means that an issue will be listed among the objectives, or whether it means that within a list, some issues are more important than others. If Healthy People will be on the Web, it may not be necessary to prioritize objectives in just one way; objectives could be sorted across different categories to yield multiple lists. Dr. Fielding said there is a question of whether it is important to rank objectives by greatest disease burden, ameliorable burden, and other measures, to the degree that this information is available. He felt users would want the ability to sort information this way.

4. Subcommittee on Developmental Life stages and Health Outcomes

   Dr. Remington said the subcommittee could further discuss developmental approaches. He noted that they could explore in greater depth the question of what it means to take a life stages approach. How are life stages clustered? Dr. Fielding commented that discussion of the notion of trajectories would be helpful. Help people to understand that different ages and stages have different goals. A Committee member remarked that she liked the life stages example of obesity; she suggested creating similar examples for other issues, such as oral health or physical activity.

5. Subcommittee on Environment and Determinants

   Dr. King asked for the Committee's feedback on the draft definitions of "social environment" and "physical environment." Her subcommittee would work with Dr. Kumanyika to incorporate the revised models into their work. She noted the most important next step would be to find concrete, actionable ways to reflect the ecological framework, such as the multi-level table. Subcommittee members would like to translate the esoteric labels in the model into interventions, and to provide clear descriptions about which interventions have evidence and which ones lack it.

The Number of Objectives in Healthy People 2020

Referring to public feedback from the Regional Meetings, Dr. Fielding commented that audiences had said, "I like what you're doing (in moving towards a risk factors and determinants approach), but don't take my objective out." He felt that the question of how objectives are related and nested was more important than how many are included in the set, because people want to find their issue reflected within Healthy People.

A Committee member said his own bias is that there is not a problem with too many objectives. The encyclopedic approach provides a rich source of metrics. He noted the concern that, over the decades, there has been a push to expand Healthy People. Yet he felt that the question of how the objectives are organized and explained through a conceptual model is critical. Having relatively few categories (e.g., a dozen) would be more important than limiting the number of objectives.

Dr. Fielding asked if there was consensus among Committee members that the Committee should recommend not reducing the number of objectives. The Committee concurred that "there needn't be some arbitrary number" of objectives, but a member said this recommendation should be coupled with guidance that a better conceptual framework is needed to help cluster objectives and identify the focus. The Committee members began preliminary discussion of how focus areas could be clustered.

Next Step: Dr. Fielding stated that the number and organization of objectives should be a major topic of discussion for the next Advisory Committee meeting (to take place in late July, via WebEx). In the interim, he asked Committee members to send Dr. Remington their thoughts about how objectives should be clustered into focus areas to enable intuitive querying of the Healthy People database. Members' feedback will facilitate a robust discussion of this issue in July.

Selection Criteria for Objectives

Dr. Fielding asked Committee members to think about what evidence should be considered in creating an objective. What are the assumptions that go into drafting objectives? The process may not follow the same logic in every case. This issue will be added to the agenda for the next meeting. A Committee member asked how this work was done for Healthy People 2010. Ms. Blakey explained that each objective was evaluated against a list of criteria. She offered to send the list of Healthy People 2010 selection criteria to Committee members. Dr. Fielding emphasized that Healthy People 2020 should not be thought of as a static document. Given limited resources, he asked whether periodic revisions would be realistic, now that Healthy People will be an electronic resource.

Next Step: NORC staff will send the Committee members a list of follow-up items to help them move forward on their remaining work, and will schedule a WebEx-based meeting of the full Advisory Committee for late July, 2008.

Meeting Adjourned
2:30 PM

Citations

1. Kindig D, Asada Y, Booske B, A Population Health Framework for Setting National and State Health Goals. JAMA, May 7, 2008—Vol 299, No. 17.
2. Homeland Security Presidential Directive / HPSD-21, Accessed 6/12/08 at: http://www.whitehouse.gov/news/releases/2007/10/20071018-10.html
3. The ONC-Coordinated Federal Health IT Strategic Plan: 2008-2012, is available online at: http://www.hhs.gov/healthit/resources/HITStrategicPlan.pdf [680 kb].

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