Eighth Meeting: January 7-8, 2009

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

Phase II –Recommendations for Implementation of the
Healthy People 2020 Objectives
U.S. Department of Health and Human Services,
Hubert H. Humphrey Building
200 Independence Avenue, SW, Washington, DC

Eighth Meeting: January 7-8, 2009

Day 2: January 8, 2009

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

Overview of the day's agenda

Dr. Fielding welcomed the Committee and audience and moved directly to the morning's first presentation by Paul Jarris, Executive Director of the Association of State and Territorial Health Officers (ASTHO).

II.  Expert Presentation: ASTHO
9:15 AM - 9:45 AM

Dr. Jarris began by saying that the Healthy People process is very important to states. ASTHO recently did a survey of states in which 49 reported using Healthy People. It is widely used to coordinate work, grants, and programs. He noted dramatic budget cuts are occurring at state health departments throughout the U.S. Some state health agencies are reducing their staff by a third. He further commented that only so much can be cut before they collapse. It's time to look at what the field of public health is doing, and how it is judging the success of its efforts. He felt these were critical questions for Healthy People, as well.

Dr. Jarris expressed the view that the process of Healthy People has been successful from the point of view of engaging and convening people and also in terms of recognizing and validating many diseases and conditions. However, it is no longer sufficient to look at process alone; we have to look at outcomes. He offered five suggestions for Healthy People 2020:

1. Success should be judged by the extent to which it measurably improves the health of the nation.\
2. Healthy People should do fewer things, but do them well.
3. Targets should be measurable, realistic, and achievable.
4. If it can't be measured, don't make it a target.
5. Continuous quality improvement is critically important through frequent, periodic measurement.

He applauded the notion of moving to an interactive, Web-based format. While that shift will not be easy, it is the direction that Healthy People needs to move in. This will facilitate linking measurement from the national level to state and local levels. There is a need for a community where promising practices can be shared, even if they turn out to be mistakes. It is important not to limit ourselves to what's been proven because there is too much that we don't know and that has not yet been studied and published. Finally, Dr. Jarris applauded the new focus on determinants of health, which will offer perspective on why the incidence is increasing for many conditions. A measure of dispersion is also needed to show the range between the most greatly affected members of our society, and those with the best health status.

Dr. Fielding thanked Dr. Jarris and asked him to remain at the front of the room for a discussion after the next presentation. He then introduced Robert Pestronk, Executive of the National Association of City and County Health Officials (NACCHO).

III.  Expert Presentation: NACCHO
9:30 AM - 10:15 AM

Dr. Pestronk explained that before he became the Executive Director of NACCHO, he was the Health Officer for Genesee County, Michigan for 22 years. Two key activities of local health departments across the U.S. are community health assessment and community health improvement. The Healthy People objectives have been useful in those processes. The members of NACCHO have also been prodigious users of Healthy People 2010 objectives. A 2005 profile indicated 81 percent of local health departments used the data either alone or in combination with the objectives. Dr. Pestronk then offered a series of suggestions for planning.

He said the public health infrastructure focus area in Healthy People 2010 brought attention to infrastructure in local health departments, especially in the areas of workforce, technology, and organization. These areas remain important. Data should continue to show all elements used in 2010 (e.g. population group, educational level, geographic location, etc.) Developmental objectives were useful in 2010, and should be continued for 2020. Specific objectives about social conditions and institutions that affect health should be included. A logic model should show proximal and distal relationships between diseases/conditions and determinants. Local data should be included when available. Partnerships could enable data sharing.

Permitting public comment on Healthy People 2010 objectives through the use of technology was helpful and should be repeated. The large number of objectives in Healthy People 2010 was useful, because we are a nation of constituencies. A limited number (e.g., 10) of leading health indicators should be considered. The objectives themselves don't accomplish anything, but they alert people in executive, administrative, and legislative positions to things that need to be accomplished. Make it easier for people to achieve their priorities by coordinating planning across levels and sectors of government. Reporting should take place more frequently (e.g., every 3 years). The NACCHO profile could be used as a source for planning. Mental health and preparedness are important issues that should be addressed in the 2020 objectives.

Dr. Fielding thanked both presenters for their insightful remarks and opened the floor to the Committee for discussion and questions. Issues raised in the ensuing discussion are summarized below.

Maintaining Focus amidst the Distraction of the Economy and other Issues.

• Provide a vision around health in the U.S. that people can relate to and rally behind. There is a problem of fragmentation. Reframe the nature of the debate so that the goal is health, not health insurance. Get people behind it. Government only has so many levers. The fact that Target does not sell cigarettes is a major public health initiative. For example, Wal-Mart is using the slogan, "Be healthy for less."
• There is need for additional engagement after the objectives are set. Despite all the information and best practices that are available, the information isn't out there. Make Healthy People less daunting. Show people how it's being used over time, and how it's being successful.
• Use a systematic process to implement Healthy People. The report is important, but it's not enough. Encourage cooperation among federal, state, local, tribal, and territorial governments.
• Write the text in more plain language, newspaper vernacular so that it is accessible to people.

Shifting the Focus to Social Determinants.

• Done correctly, determinants are critical. Done incorrectly, they're a third axis. Determinants must be integrated into every content area and each intervention level: policy, community, individual, and clinical. To address these issues, one must consider policy. What drives behaviors? What needs to be done at each level to address inequity? Make sure that these issues are the job of everyone.
• Experts on marketing and media are needed. Emphasize health disparity issues first, and more familiar issues second. Form partnerships to help others format the objectives for Healthy People for various audiences.

Determining the Number of Objectives, and How to prioritize them.

• Localities will do what they must, based on their own priorities and interests. Show how the objectives are arrayed on a sequence of effects. Show the relationships among these things. There should be aspirational objectives. The failure to reach them should tell us something.
• It is important to indicate national priorities. For example, if there are 467 objectives, the leadership should highlight the importance of working on the top 10 causes of death. Guidance should indicate that, while one may work on all the 450 objectives, it is imperative to address the highlighted ones.

Dr. Fielding suggested that Healthy People hasn't been used as much as surveys say it has. Within his department, they asked people if they were using Healthy People and they said yes. Then quality assurance people looked at usage, and in fact it wasn't being used. He asked the Committee and presenters how to ensure that partners use Healthy People.

• Offer incentives for utilization.
• Point out good examples of how Healthy People is being used.
• Embed Healthy People 2020 into the governmental public health structure.
• Look into the possibility of organizing the proposed relational Website as an ".org," not a ".gov" (For example, the Web site for Healthiest Nation was established as an ".org" outside of the federal government.)
• Make sure that it's useful for state and local health departments, or it won't be used.
• Refocus on social determinants; this is critical.

Dr. Fielding said it has been problematic that Healthy People has been considered a product, not a process or a system. The release of Healthy People should only be the beginning of the process. Incentives should be put into place at the local, state, national levels to ensure that the process is effective.

IV.  Strategic Approaches to Facilitate Healthy People Efforts
10:30 AM - 11:15 AM

Dr. Fielding explained that the agenda for the remainder of the morning would be reorganized. There would be a discussion of objectives, followed by the Committee's Phase II recommendations for action, and lastly, their work plan for the rest of the year.

Discussion of objectives and topic areas

A Committee member said the morning presentations underscored that the overarching themes of Healthy People 2020 should be determinants. Starting the process with Healthy People 2010 would not yield that end-product. Instead, objectives should be developed by starting with determinants, and having the objectives flow from them. If objectives are developed based on Healthy People 2010, trying to go back to fit them into the determinants would be a backwards process.

Another member suggested four broad categories for objectives: biomedical disease; mental health; environment; and human development. Agreeing, a third member said that the 28 focus areas of Healthy People 2010 could be mapped onto biomedical disease. What's missing in Healthy People 2010 are the middle drivers—the social, economic, and cultural determinants. Given the planned shift to a relational database as the primary frame for engagement, another member asked what difference it makes what the objectives are. He was unsure that he could answer for himself what the objectives are supposed to do.

A member agreed there is not necessarily a need for set, pre-determined objectives, but she also agreed with Paul Jarris' earlier point that Healthy People should articulate national priorities. Another member suggested that the group is talking about two different things: the content of the objectives, and the process for creating them. On the issue of how to create the objectives, he felt they should not just be assigned to committees. People should be brought together to be educated on key IT concepts, the functions of a relational database, the Murray model, etc. They won't be able to make good recommendation about content for a relational database if they don't understand these elements.

Dr. Fielding said that the ideas he was hearing seemed to suggest the need for groups in certain areas: including the social, economic, and physical environment. A member said Healthy People 2010 is organized according to a medical model, but that's not the model that makes the difference for health of populations. He recommended bringing the WHO report "Closing the Gap" into this discussion. WHO spent years going through social determinants. Part of the next step ought to be embracing that document, and incorporating it into discussion. Dr. Fielding felt the WHO document would need to be particularized for the U.S. setting.

Dr. Fielding asked members if they had a clear sense of what they wanted to do with the objectives. What they would change about the 28 focus area categories of Healthy People 2010? Should objectives be organized around techniques? One could argue the need for groups that look specifically at the two ends of life—early infancy and human development, and aging and elder health. On the one end we have a lot of new knowledge, and on the other end we have a rapidly growing population. He was not proposing omission of other life stages, but those two would be important for focused discussion. Another issued raised was that focus areas should be organized around techniques, rather than risk factors and diseases, the way that the Healthy People 2010 focus areas are organized. Some would say they are the wrong way to start, but since this is how funding and departments are organized, it is understandable that one would start there.

A member said the focus area of "Disability" encompasses conditions faced by 54 million Americans who have an incredible range of conditions from Attention Deficit Disorder to Alzheimer's disease. We have a "Vision and Hearing" category, but one could argue that vision and hearing relate to disabilities. The term "disability" has no inherent meaning; it's a funding stream. Stroke and heart failure are diseases that are leading causes of disability. Although the funding thread is tiny, disability could be highlighted within these other areas, but it must be adequately resourced.

A member suggested that there could be a single group for socio-economic determinants which would encompass housing, education, and other factors. A second group would be for diseases; here should be an organizing framework to indicate that many diseases overlap. For example, people with heart disease often get depression. Overlap is the norm rather than the exception. Another suggestion was to provide a simple logic model for the categories to show the cross-cutting, overlapping issues. Dr. Fielding summarized, saying the Committee would recommend creating a logic model for each area to show how it relates to the other 28 focus areas. That would cover disability, but also deal with risk factors and diseases.

It was noted by another member that the concept of health can be lost when one focuses only on disease. What are predictors and interventions that promote health and make healthy people even healthier? A focus on positive health—or wellness—should be incorporated. Dr. Fielding pointed out that he didn't see how this idea would change any of these groups. There are appropriate areas in mental health and socioeconomic conditions. The idea of wellness is implicit in the phrase, "Improve quality of life and well-being."

A member commented that the 28 focus areas of Healthy People 2010 should not be lost. There are some advantages to building on those areas. Another member suggested that if 2020 builds on 2010, it will be important to ask, "How did we get there?" What is the role that the 28 focus area categories are playing? Dr. Fielding also felt the Committee should be pointed in asking why techniques are mentioned in some areas and not others. For example, health communications is critically important, but it's unclear why it is a focus area when other techniques are not. Topics for techniques, risk factors, and diseases should be separated.

Asking for clarification of the Committee's charge in relation to the Healthy People working groups, a member speculated on how to provide guidance to the working groups regarding using the existing data that's been collected while providing suggestions for creating something that's more homogenous. Another question asked was whether the working groups will be able to address some of the factors influencing objectives that have been moving in the right or the wrong direction.

Carter Blakey said the reason HHS began with the current approach was that over the last year, in regional meetings and the Committee's deliberations, it was expressed that Healthy People not cut the number of objectives. The current guidance that the Committee is providing is that the objectives should be organized around the determinants. It would be difficult to create groups on socioeconomic status, or on determinants, but the department will use this guidance to move forward and refine the process that's in place. Dr. Fielding clarified that the Committee did not say to retain the same number of objectives, but that one should not arbitrarily limit the number of objectives.

Dr. Fielding shifted discussion to the set of recommendations that he had drafted on the first day of the meeting for immediate actions to advance the Healthy People 2020 goals and objectives. He had asked the members to discuss and revise them. The updated list (see Table 1) was reviewed by the group.

Table 1.  Draft Recommendations for the Coming Year

Dr. Fielding suggested that Committee members write a preamble, finalize the list of recommendations, and prepare a document that could be submitted to HHS within the coming month. The document would be approved at the Committee's next Web-based meeting.

Members discussed the range of issues that they wanted to work on in the coming months. Dr. Fielding facilitated discussion of what subcommittees should be formed, what the charges should be, and who should be assigned to lead each of the groups. He asked Subcommittee Chairs to think carefully and selectively about external members who could contribute to these groups. The endpoints of this discussion are summarized in Table 2. Subcommittees would report on progress at the next Committee meeting

Table 2.  Preliminary Charges for Phase II Subcommittees

V.  Summary, Next Steps, and Next Meetings
11:45 AM - 12:00 PM

Dr. Fielding suggested that the Committee convene through a Web-based meeting in February, with subsequent, monthly Web-based meetings through the spring. The Committee agreed to consider at a later date whether an in-person would be needed in the late spring or early summer. Dr. Fielding thanked the members for their exemplary work said he looked forward to working with them in the coming year.

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Last revised: May 1, 2009