Fifth Meeting: September 4-5, 2008

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

Revising the Phase I Report to the Secretary
Via online meeting

Fifth Meeting: September 4-5, 2008

Day 2: September 5, 2008

I.  Recap of Day 1 and Charge for Day 2

Dr. Fielding explained that during the previous day's discussion members agreed to writing assignments and. had sent their revisions to NORC staff. The updated draft was distributed to the Committee by email and available to the public for download. Issues to be discussed that day included: edits to the draft report; the Healthy People Action Model; recent progress of the FIW in developing criteria for selecting objectives; and next steps for Phase II of the Committee's work.

Discussion of New Material

Dr. Fielding asked Committee members to look through the revisions that had been made to the draft report and offer their comments on substantive issues. Editorial changes could be addressed at a later time. A summary of assigned revisions and issues discussed for each section of the draft report is presented in Table 1 (see next page). Dr. Fielding thanked the members for their efforts to prepare the revised language for the report within such a rapid timeframe.

II.  Review of Key Structural Decisions in the Draft Report

Dr. Fielding asked Committee members to comment on the outline of the draft report. A Committee member expressed that the report should be streamlined and offered suggestions for reorganizing the content. Dr. Fielding asked if ODPHP had any strong preferences on this point. Ms. Blakey replied that the Committee's report belongs to the Committee. The FIW will draw on the Committee's report and build on it. Ms. Blakey said that there is a great deal of interest in the report and it will be made available to the public. Other Committee members said that the report should be written "for public consumption," i.e., it should be succinct and clear; the action model should be placed near the front. A Committee member suggested moving the description of the Advisory Committee, its mission, history, and timelines to the appendices. Details of the subcommittees' efforts could be taken out as well.

The report should not eliminate the useful content that has been developed through the work of the subcommittees. A member stated that one way to streamline while retaining content would be to add a five-page executive summary, highlighting what is new and distinctive about this approach to Healthy People 2020. The more detailed material would be in the main body of the report. Members agreed to delay decisions about moving sections of the report to an appendix until they have seen a draft of the executive summary. NORC agreed to draft an executive summary and send it out to Dr. Fielding and Dr. Kumanyika for review before circulating it to the rest of the Committee.

III.  Healthy People 2020 Framework

Dr. Fielding moved on to discuss the Healthy People 2020 framework, including the vision, mission, overarching goals, and model. He began with the mission statement, reminding the members that there had been a suggestion to change the phrase "underlying causes" to "underlying determinants." The word "causes" is more commonly used, but the word "determinants" is more ingrained in this report. A Committee member believed that the word "causes" may be misleading because there is not enough scientific evidence in many fields to be able to claim causality. Another member pointed out that if the audience for the report is the general public, "causes" would be a better "plain language" word. Dr. Kumanyika said certain determinants might not be considered causes (e.g., lack of access to healthcare services, or ineffective programs). Determinants are defined more broadly, but readers might not be certain of that word's meaning. Dr. Fielding suggested leaving the mission phrasing as "determinants" and revisiting this issue later.

Table 1.  How Writing Assignments from Day 1 were Incorporated into a Revised Draft of the Report

Dr. Fielding brought up a member's suggestion from the previous day to add a new goal about engaging consumers in health promotion and disease prevention. He asked if this change was still needed. This member who had made this suggestion said he was satisfied with the additions that had been made to the report under "conceptual recommendations."

Dr. Fielding noted that the Committee had made a tentative decision that they did not want to recommend organizing objectives by focus areas. Instead, Healthy People 2020 should use general categories of determinants, interventions, and outcomes. There was some concern that this approach was not aligned with the thinking behind the Healthy People 2020 Action model. Dr. Fielding asked Dr. Kumanyika to lead discussion of this issue so that a resolution could be reached.

IV.  Healthy People 2020 Model

Dr. Kumanyika said the model (see Appendix D) should allow users to map different types of objectives to it. There are many different kinds of objectives (e.g., developmental vs. measurable/evidence-based) but no standard classification for them. The meaning of the word "objective" should be clarified: some objectives specify how to improve outcomes; others are about improving programs. A Committee member mentioned that the 1990 Health Objectives classified objectives in three categories: health promotion, health protection, and health services. He saw need for objectives that relate to outcomes, determinants, and processes for intervention. In a relational database, it would not be problematic to cross-classify these three categories with another set of categories, such as the focus areas of Healthy People 2010.

Regardless of their specific topics, each focus area should have three categories of objectives: determinants, interventions, and outcomes, suggested another member. As objectives in each area are being developed, the model should be used to provide continuity throughout the document. Dr. Kumanyika asked about the sequencing of determinants, interventions, and outcomes in the model. She felt that placing interventions between determinants and outcomes is confusing. A Committee member replied that interventions and actions are, by definition, determinants, because they ultimately have an impact on health and outcomes. Other Committee members said that if this is to be an action model, it should not include distracting mechanisms. They recommended taking out the mechanisms, clarifying actions and interventions, and aligning the categories with the IOM's ecological model .

Dr. Fielding reminded the Committee that they had previously agreed to change the model to suggest that interventions and actions occur at multiple levels. A member argued that the model should reflect a causal chain from Healthy People 2020 objectives to specific interventions/actions by people at multiple levels, interacting with determinants to lead to health outcomes. Another member said the IOM's social ecological model may serve as a helpful point of reference; determinants should be the focal point for action and intervention. Dr. Kumanyika supported using the multilevel model and referencing the IOM model. Dr. Fielding asked that Dr. Kumanyika, Dr. King, Dr. Manderscheid, and Dr. Remington to work on the model during the break.

Dr. Kumanyika asked whether Healthy People has used a formal classification of objectives in the past that could be used to inform the direction of the model. Dr. Fielding answered that discussion about objectives would take place later in the day. He mentioned, however, that one-to-one mapping of objectives on determinants, outcomes, and interventions may not be possible—at least at this stage of discussion. Dr. Kumanyika believed that the broad categories for classifying objectives should match the three categories. A Committee member urged additional consideration of how these categories relate to and affect each other. Dr. Fielding pointed out that the interactions between various mechanisms are complex and not fully understood; it may not be possible to have a model that is as clean as one would like. Dr. Kumanyika suggested using the term "interventions" broadly to refer to programs and policies. The Committee members then took a 45 minute break.

Break

Dr. Kumanyika presented a revised version of the model to the Advisory Committee (see Table 2, Page 14). The purpose of this model was to show points of intervention that can be acted upon, types of actions that can be taken, and outcomes that would result from those actions. The workgroup had debated whether to use the terminology "intervention with other actions" or just "actions." Dr. Fielding believed that the term "intervention" should be used for consistency. Another Committee member stated that a limitation of the model is that it does not show the role of Healthy People 2020. He believed it was a model for public health, not a model for Healthy People 2020. Dr. Kumanyika said that adding a logic model on top of this diagram would not be effective. During Phase II, a separate model could be prepared using a more standard, logic format that would show how Healthy People works. Dr. Fielding said that the current model would need to be further refined for inclusion in the Phase I recommendations.

V.  Update on Healthy People 2020 Development Process

FIW Draft Criteria for Objective Selection

RADM Royall explained that the FIW had used the Healthy People 2010 objective selection criteria to develop draft criteria for selecting Healthy People 2020 objectives. The criteria are meant to guide focus area workgroups in their efforts to select objectives. Like the Advisory Committee, the FIW believes that the number of objectives should not be limited and developmental objectives should be highlighted. The process for creating objectives for next 10-year cycle should be streamlined for input and should be flexible enough to accommodate scientific advances. Since data on the cost effectiveness of interventions are lacking and future changes to budgets and cost are unforeseeable, the FIW does not wish to include cost considerations as part of the objective selection process. There must be continuity of objectives across Healthy People iterations. Processes for documenting objective selection should accommodate these changes. The FIW's specific criteria for selecting Healthy People 2020 objectives were presented to the Committee (see Appendix E). RADM Royall noted that the FIW is interested in receiving the Committee's feedback.

VI.  Committee Discussion of Objectives and Criteria

Criteria for Selecting Objective

Dr. Fielding opened discussion to the Advisory Committee, noting that issues such as the ongoing maintenance of objectives, data, and timing are important. A member said a criterion should be put forth for measuring interventions and social determinants. Another member asked RADM Royall whether the FIW had discussed past successes and challenges in meeting previous objectives, especially with regard to how those should be handled in setting future targets. RADM Royall said if a target has been met, that does not mean the target will be dropped; there will be continued surveillance. And if a target was not met, the assumption is that the objective would also be continued in Healthy People 2020. The FIW did not discuss prioritizing targets that were not met.

Measures related to infrastructure and support (e.g., health IT and health communication) are also important. Dr. Fielding asked the members whether infrastructure issues should have their own objectives and whether there should be information about inputs to support Healthy People interventions. A member answered that there is insufficient knowledge of specific infrastructure interventions for each Healthy People intervention. However, objectives and targets related to infrastructure are needed; the United States needs to build public health data infrastructure. This can be achieved by reviewing the epidemiological data systems operated by HHS by a certain deadline. RADM Royall mentioned that Healthy People 2010's Chapter 23 included infrastructure objectives. The Advisory Committee then offered their reactions to and suggestions for the FIW's revised Objective Selection criteria, summarized in Table 2, below.

Table 2.  Advisory Committee Comments on the FIW's Draft Selection Criteria

Dr. Fielding suggested that the Advisory Committee develop a specific process for assessing why previous objectives have not met their targets. It is important to be clear that 1) Targets must be realistic, and 2) dissemination of interventions known to be effective is necessary. Dr. Fielding suggested putting this issue on a future meeting agenda for further discussion. He pointed out that the Advisory Committee must build on previous iterations but update and reorganize objectives and targets with newly acquired knowledge. Surveillance should be further discussed as a separate issue.

Dr. Fielding asked the Advisory Committee if it would be appropriate to eliminate objectives based on economic analysis. Should development of objectives incorporate discussion of costs? Committee member responded that objectives should not be cut based on economic issues, but Healthy People 2020 should be explicit in stating that objectives have not been excluded based on economic information.

A Committee member suggested that Healthy People should include a macroeconomic objective to increase the national investment on disease prevention, health promotion, public health, and public health infrastructure (e.g. from half of 1% to 5%). Specific objectives should also aim to incorporate economic principles when possible, or at least provide resources and sources where people can access that information. Dr. Kumanyika said that criteria for looking at economic issues will differ by user levels; different criteria should be used for micro and macro level issues. Another Committee member believed that resource constraints should be mentioned in the executive summary of Healthy People 2020, rather than a specific percentage increase for funding. She felt the Committee would be remiss if it did not state that more resources should be allocated to the Healthy People enterprise in general. Dr. Fielding said the Committee should make a general recommendation to the Secretary on this issue.

Organizing Objectives by User Needs

The Advisory Committee discussed how user needs could inform objective setting. Dr. Evans noted that the Subcommittee on Users Question and Needs has developed a set of questions that will be operationalized to conduct focus groups. Key audiences listed in the audience matrix have been selected for participation in the focus group sessions. The subcommittee is attempting to leverage limited resourced through SAMHSA, while also trying to see whether other federal agencies are able to lend additional financial support. The focus groups will explore users' informational needs on a number of dimensions.

Dr. Evans believed that the comprehensibility and feasibility of objectives would be two important issues for users. Objectives should be aligned with what their users are seeking to accomplish. A Committee member asked whether feedback from users and consumers will inform the objective-setting process. Dr. Fielding suggested that the Advisory Committee devise a list of questions for objective-setting workgroups to encourage them to involve user groups at critical stages in the process, or even throughout the process.

Dr. Fielding asked whether the Committee should recommend a specific format for objectives. A member suggested using the SMART objective format (specific, measurable, achievable, time-limited). Instructions for creating SMART objectives are provided on the CDC Web site. Dr. Fielding suggested that this should be an issue for the next in-person meeting. He asked Dr. Evans to report back to the Committee on CDC instructions at the next meeting.

Dr. Fielding asked if the Advisory Committee had suggestions for how to organize the objectives within a database form. For Healthy People 2010, 28 focus areas were used. He read out a list of some of the focus area topics and asked whether organization of objectives for Healthy People 2020 should be flexible, based on the needs and interests of users. A Committee member replied that a relational database would enable organization of objectives by user or by specific topics, such as "mental health." Dr. Fielding suggested that the audience matrix could be used to organize objectives in a manner that would help users to click on their specific area of interest and go directly to the issues of interest to them.

Another Committee member agreed that elements in the database could be selected and sorted for reports. There has been an increasing level of involvement among stakeholder organizations and advocacy groups for each Healthy People iteration. He suggested it might be beneficial to retain focus areas from Healthy People 2010, as they would provide a familiar point of entry for stakeholders who are working in specific areas. He added that other entry points could be added to enable users who are interested in policy approaches to understand the downstream effects of their policy interventions. It would be important to consider how fields will be sorted and selected—whether by outcomes, by determinants, or by topic areas of interest.

Dr. Kumanyika noted that it might be useful to look at certain cross-cutting issues, such as health equities, across a set of related topics, such as chronic diseases. She said some of these diseases have common determinants that operate through factors such as diet or physical activity. It would be inefficient to have people working separately on these related issues.

Dr. Fielding said that the Advisory Committee should move forward in developing a set of system requirements for this database. These should not be set arbitrarily, as they will be important from a usability perspective. He commented that Dr. Kumanyika's point about cross-cutting issues would be an important input to this work. Dr. Remington agreed take this task on with the support of a small group or new subcommittee, in order to present some suggestions for the next in person meeting.

Prioritization of Objectives

A member noted that the exhibit on page 35 of the Draft I report (see Appendix E) was well-aligned with the discussion that had just taken place. Dr. Kumanyika asked how an objective about interventions would differ from ones addressing determinants or outcomes. She voiced her understanding that objectives for determinants are like goal statements about the status of the issues, and objectives for interventions are about implementing a policy or program. Dr. Fielding said one could argue that an intervention is a determinant. He offered the example that one may try to change a determinant by reducing high school drop-out rates from X to Y through an intervention. One would affect the determinant by increasing the percentage of schools using an evidence-based intervention to reduce the drop-out rate. The line is not very clear, and it seems circular. Ms. Blakey mentioned that ODPHP tried to map Healthy People 2010 objectives to single determinants and found this to be very challenging, as many objectives fell under multiple determinants.

Dr. Kumanyika said that the exhibit on page 35 did not clearly explain what the Advisory Committee was trying to organize. She felt that the difference between an intervention and a determinant was unclear. A Committee member replied that it is a struggle to define categories within a continuous process. To make objectives fit neatly in the boxes, you would have to create arbitrary lines between an intervention and a determinant. Behaviors are a good example, as they could be defined as both determinants and outcomes; they could even be defined as an intervention if one talks about changing the behavior of policy makers. Dr. Kumanyika said she understood the exhibit better, and that the Committee should move on with the agenda.

Dr. Fielding drew the Committee's attention to the issue of the eight prioritization criteria discussed on pages 34-38 of the updated Draft I report (burden, reducibility, cost-effectiveness, net health benefit, synergy, timeframe, potential to reduce health inequities, and willingness to accept accountability. He asked for their comments. He began by asking whether the members were comfortable with the written description of net health benefit and asked if it would be better to discuss it in terms of opportunity cost. Another member said that this section relied too heavily on jargon. Dr. Meltzer offered to revise the discussion of "net health benefit" to make it more understandable to the lay-reader. He would also change the term "relative cost effectiveness" to "cost effectiveness."

A Committee member raised concern about the FIW's decision to avoid cost as a criterion because of the lack of evidence in this area. Dr. Fielding clarified that the decision was made with regard to the development of individual objectives, but not for prioritization of objectives. Whenever possible and whenever there is available data, economic considerations should be indicated. The Committee member requested that language be included in this section to clarify that cost issues should be considered "whenever possible/appropriate/available." A Committee member said lack of data should not limit the importance of criteria. For example, if data on disease burden are lacking, this would not negate the importance of burden.

The same member asked whether a ninth prioritization criterion should be added to the list to address the degree of confidence in data for the eight prioritization criteria. Dr. Fielding argued that there are two separate issues to deal with: one is the degree of confidence in the data; and the second is an absence of data altogether. The Committee member argued that these limitations could be applied to all eight criteria, not only those dealing with cost-effectiveness. Another member pointed out that data for some criteria are far less likely to be available than for others. Dr. Meltzer and Dr. King agreed to work on a revision of this section.

Dr. Kumanyika said that the language and concepts presented in discussions of the prioritization criteria are based on interventions. She felt the Committee should develop language to talk about how to think about criteria for issues that are far "upstream." For example, cost-effectiveness and net health benefit, which look at impact on individuals, would not be as relevant to social determinants. Dr. Fielding commented that the criteria are not only relevant to clinical services, but work for issues in other initiatives, such as the Community Guide. One may need indicators for policies, but it would be difficult to tie to specifics of any particular pathway. One could prioritize a policy based on the potential effect on disparities, or the number of people reached by a policy. Dr. Kumanyika agreed to draft a paragraph to address this idea.

NORC staff reminded the Advisory Committee that they had earlier commented on the need to better align efforts at the national, state, and local levels. Dr. Fielding said a paragraph was needed to discuss the synergy of having different groups, stakeholders, and audiences focusing on the same targets. He noted that it is important to obtain concerted action on issues where there has been some alignment of resources across stakeholders and across all levels. Dr. Fielding requested that NORC draft this paragraph.

Dr. Fielding commented on serious knowledge gaps in areas where the Committee could offer recommendations. Limited funding is a noteworthy problem that has slowed progress on The Community Guide, as well as health impact assessments. He felt that the Advisory Committee should at least consider making recommendations about how small amounts of money for targeted research could enhance existing efforts to improve the database for Healthy People objectives and targets. Dr. Kumanyika raised the point that interventions should be evaluated against the indicators they were meant to change. She said it is important to figure out how one would obtain a sensitive indicator of progress for how an upstream intervention fits into the picture. Dr. Kumanyika and Dr. Fielding agreed that this is a broader issue of evaluation that needs to be sorted out in Phase II.

Once work has been finalized on the model, Dr. Kumanyika noted that the remaining text should be updated to be consistent with the new changes. She noted that it would be useful to add a paragraph at the front of the prioritization section to show how it aligns with the model. Dr. Remington agreed to make any needed revisions to an existing paragraph that aligns fairly well with the current model.  

VII.  Recommended Next Steps

Expectations and Next Steps for Phase II

Dr. Fielding reviewed a list of issues that Committee members had previously discussed for the next phase of their efforts. Topics included: (1) principles for formatting and writing objectives; (2) recommendations for setting targets; (3) looking at past experience in terms of whether targets were met or not; (4) guidance about user needs (increasing the level of usability of Healthy People 2020 relative to the past iterations); (4) guidance about implementation strategies; and (5) discussing ways to increase overall progress towards achieving the objectives. He asked Committee members whether there were other issues that they would like to address.

A Committee member said it would be important to plan for distribution of the Phase I report. Ms. Blakey told the Advisory Committee that ODPHP had not discussed distribution of the report with the Assistant Secretary for Health or the Secretary. However, she noted that any reports that the Advisory Committee produces are in public domain. The exact distribution channels have not yet been discussed. Dr. Fielding felt that the document should be distributed electronically to many user groups. Core groups, such as NACCHO and ASTHO, National Business Group on Health, and Partnership for Prevention, could be involved in the distribution. Dr. Fielding requested that Dr. Manderscheid draft recommendations for distributing the report and present them at the next meeting.

Dr. Kumanyika suggested that the Committee could work on case studies for objective areas where there has been comprehensive planning. These could serve as models for the way the Advisory Committee believes the document should be used. Federal and state groups might already have developed logic models that show how a set of objectives might be formally implemented. There might also be examples of coordination between national, state, and local levels. Dr. Fielding suggested placing this topic on the agenda for the next in-person meeting as part discussion for "guidance for implementation strategies."

Dr. Fielding said recommendations for evaluation should be added to Phase II. Dr. Kumanyika stressed that evaluation has several meanings: (1) the monitoring of progress of objectives, (2) evaluation of the Healthy People 2020 objective setting process, and (3) evaluation of Healthy People dissemination. A Committee member noted that the midcourse review constitutes an extensive evaluation of progress toward each objective, but there must also be broader evaluation of obstacles to achieving the targets.

Another member added that Healthy People 2020's success will largely depend on data sources. At the regional meetings, many people commented on problems with data sources. He felt that the Advisory Committee should develop recommendations about improving the quality of federal data sources. Dr. Fielding agreed that this topic should be added to the list of issues to be addressed in Phase II.

Logistics and Future Meetings

Dr. Fielding reviewed the timeline for completion of the Phase I report, which included three additional opportunities for revision. Members agreed to meet via WebEx on October 15, 2008 at 2 PM (EDT) to finalize and approve the document. Once that has occurred, the report will be submitted to the HHS Secretary. Ms. Blakey noted that ODPHP had compiled a list of writing assignments during the afternoon, and would distribute it to Committee members via e-mail that afternoon.

Dr. Fielding requested that a brief, two-hour meeting be scheduled to take place in November via WebEx. The meeting should focus on Phase II of the Advisory Committee's work. The next in-person meeting of the Advisory Committee will be scheduled to take place in Washington, D.C. in mid-December or late January. Dr. Fielding thanked the Advisory Committee and the public, and thanked ODPHP for their leadership. 

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