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Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
U.S. Department of Health and Human Services, Hubert
H. Humphrey Building
Room 800, 200 Independence Avenue, S.W., Washington, DC 20201
First Meeting: January 31-February 1, 2008
Day 2: February 1, 2008
Recap of Day #1 and Charge for Day #2 9:00 AM - 9:30 AM
Dr. Fielding commended the Committee on its previous day's discussion
encompassing the Healthy People 2020 vision, goals, mission, and
framework. He introduced Dr. Everold Hosein, who spoke to the Committee
about related international efforts to help the group think about the task
before them. Dr. Hosein described his work on the WHO's Integrated
Marketing Communication for Behavioral Impact, a strategic communication
planning approach to achieving results in health.
Continued Committee Discussion: Vision, Mission, Overarching
Goals, Framework, and Focus Areas 9:30 AM -
12:00 noon
Vision
Dr. Fielding explained that some Committee members met informally on
the previous evening to draft statement's that reflected the Meeting Day 1
discussion. They created a document, "Draft for Committee Consideration
1-31-08 (see Appendix D)," which served
as a starting point for Committee work on Meeting Day 2. Referring to this
draft, Dr. Kumanyika introduced the Committee members to preliminary
versions of a vision statement. Yesterday's discussion indicated that this
statement should be short, inspiring, memorable, enduring, and would not
need to be measurable. The previous night, Committee members had drafted
two different types of vision statements, shown below.
Preliminary Draft: Vision Statements for Committee Consideration
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A society in which all people attain maximum years of healthy life.
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The healthiest people in the healthiest nation.
Dr. Kumanyika explained that in the first statement, the words, "A
society in which..." address the issue of social determinants of health.
The phrase "all people" touches on the need for equity, and "…maximum
years of healthy life" offers continuity with the previous Healthy People
2010 goals. The second statement is short and sweet, but Dr. Kumanyika
remarked, "It's interesting how much that one says when you think about
it." Dr. Fielding opened the floor for comments.
Committee members preferred the first statement, "A society in
which all people attain maximum years of healthy life." They
worked collaboratively to edit the phrase. Suggestions included making the
phrase more active, addressing behavior, and thinking about "individual
versus collective aggregations." One member felt the term healthy should
be defined in the glossary as "not just being about the body." The WHO
definition of health could be useful for this purpose. For the second
statement, "The healthiest people in the healthiest nation,"
one person asked, "Does it mean something that no verb is associated with
that?" but the group felt this issue was not problematic. Some cautioned
against relying too heavily on a glossary to convey the statement's
intended meaning. The Committee voted unanimously in favor of the vision
statement:
Advisory Committee Recommendation #1: Healthy People 2020
Vision Statement
- A society in which all people live long, healthy lives.
Goals
Dr. Kumanyika introduced goal statements that had been prepared the
previous evening. In the first goal, the group tried to avoid defining
environment narrowly, and included explicit reference to the economic
environment. For communication, they sought to address a range of issues
from patient-doctor relations to the media. The second goal, "Eliminate
preventable disease..." is a rewording of the one proposed by the FIW.
The third goal addresses health disparities and specifies that we must
improve the health of all populations. The Committee examined each goal
and adjusted the phrasing to be acceptable to most members. There was
discussion regarding the order of the statements. The Committee agreed
that health equity and prevention were seen as being the most important,
and a goal should be added to talk about the "life course." The
preliminary draft statements are listed below.
Preliminary Draft: Goal Statements for Committee
Consideration
- Create health-promoting environments: physical, social,
cultural, economic, and communications.
- Eliminate preventable disease, injury, and disability, and
premature death.
- Eliminate health disparities while improving the health of all
groups.
For the first goal, "Create health promoting
environments: physical, social, cultural, economic, and
communications," some members feared the public would not
understand the broad usage of the word "environment." Access to
health was raised as an element of health economics. A member said
the group must clarify what is meant by a "communications
environment," but discouraged using the word "marketing." Some
thought the word "community" might be clearer than environment, but
the group discarded this idea. Members explored whether they should
be specific about types of environments, (i.e., family, school, or
worksite). It was noted that because the concept of environment is
too great to focus on specific examples. Dr. Fielding put forth the
goal statement: "Create social and physical environments
that promote good health for all."
- The Committee voted in favor of this statement, with one
opposed.
The second goal, "Eliminate preventable disease,
injury, and disability, and premature death," highlights
the importance of prevention. One member said this should be
phrased positively, and suggested changing, "Eliminate
preventable" to "promote healthy." Another member suggested that
the word "lifestyles" could address health behavior. Others were
concerned this could be viewed as implying that health is within
the control of the individual. It was recommended that this
statement put emphasis on prevention. Dr. Fielding called for a
vote on the goal statement, "Eliminate preventable
disease, injury, disability and premature death."
- The Committee voted in favor, with one abstention, and none
opposed.
The third goal, "Eliminate health disparities while
improving the health of all groups," addresses the
importance of health disparities. One member felt that the word
"create" is more empowering than eliminate, but it was decided
that it is more important to be clear than to express this idea
in a positive light. The Committee agreed that "achieving health
equity is just one of several ways to eliminate health
disparities." Dr. Fielding called for a vote on the goal
statement, "Achieve health equity, eliminate
disparities, and improve the health of all groups."
- The Committee voted unanimously in favor.
As they discussed the goals, the Committee realized none of
them addressed healthy behaviors or healthy development over
the life course. They agreed it was important to cover
families, family life, and child development, and to mention
health behavior while avoiding use of the word "lifestyle,"
given that "lifestyle" is open to misinterpretation. Dr.
Fielding called for a vote on the goal statement, "Promote
healthy development and healthy behaviors across every stage
of life."
- The Committee members voted in favor, with one
abstention.
Advisory Committee Recommendation #2: Healthy
People 2020 Goals
- Achieve health equity, eliminate disparities and
improve health of all groups.
- Eliminate preventable disease, disability, injury
and premature death.
- Create social and physical environments that promote
good health for all.
- Promote healthy development and healthy behaviors
across every stage of life.
The Committee then took a 10 minute recess.
Mission Statement
Dr. King presented the preliminary draft mission
statement that had been prepared the previous evening.
The group began with the FIW's draft mission statement
and decided to break up the revised version into
bulleted sentences to facilitate wordsmithing and to
ensure sure it captured all relevant points. The group's
initial draft is shown below.
Preliminary Draft: Mission Statement
Elements for Committee Consideration
- Increase recognition of the underlying
determinants of health and disease.
- Identify highest value opportunities to improve
health through use of best knowledge.
- Provide a framework for selecting and
implementing strategies and tactics.
- Provide a framework for assessing progress to
guide further improvement.
- Incorporate new science and technology to
strengthen policy and program effectiveness and
efficiency.
Committee members discussed the function of the
mission statement, and whether it should refer to
the framework, objectives, or overall categories to
be addressed by the initiative. Should it talk about
the work that the Healthy People initiative has
done, or what it will do in the future? They agreed
that the mission statement should motivate action
and provide a framework for planning, but at the
same time, the statement is meant to be the mission
for the entire Healthy People enterprise, not a set
of instructions for what the user is supposed to do.
The members felt it was important strive for
simplicity and that key elements of the mission
statement should highlight the concepts of
understanding, action, results, and new knowledge.
Under these rubrics, Committee members discussed key
concepts that should be conveyed in the mission
statement and revised phrasing of each component
accordingly. The salient points in their discussion
are summarized below.
"Preamble" for Users
The Committee felt there should be some articulation
of who the document is for, without being overly
specific about intended audiences. A preamble was
drafted to clarify the initiative's purpose and
intended audiences:
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 individual,
communities, and our nation.
Due to time limitations, no formal vote was taken
on the preamble. Suggested edits were: adding
researchers, or all categories in the Institute of
Medicine's definition of the "public health
community" (e.g., academics, communities, employers,
governmental public health, and the healthcare
system). Mission Element #1: Understanding
The concept of health determinants inspired much
discussion. Some members wished to avoid the "jargonesque" aspect of the
word "determinants;" others felt it would be worthwhile to educate the
primary audience about this term. One member felt that this element
should comprise the entire mission statement. Dr. Fielding called for a
vote on the statement, "Increase public awareness and
understanding of the underlying causes of health, disease and
disability."
- The Committee voted unanimously in favor.
Mission Element #2: Results Committee members
discussed the value of Healthy People for improving results. It was
suggested that the concepts of data, measurement, evaluation,
assessment, and progress might be nested under "results." It was agreed
that the word "priorities" was important for inclusion as Healthy People
is a guide to objectives, strategies and tactics. Dr. Fielding called
for a vote on the statement, "Improve results by providing priorities,
measurable goals and objectives, and guidance on effective strategies
and tactics."
- The Committee voted in favor, with one abstention.
Mission Element #3: Action Committee members
felt a key mission of Healthy People is motivating people to act is
and that people can be catalyzed to act through health policy,
programs, and other actions, both public and private. The point was
made that policies and programs should be evidence based. Dr.
Fielding called for a vote on the statement, "Catalyze action
through the use of best available evidence, practice, and policy."
This was later modified to, "Catalyze action using best
available evidence to improve policy and practice."
- The Committee voted in favor, with one abstention.
Mission Element #4: New Knowledge The
Committee discussed issues of new knowledge, science, new
evidence, data, and trends. The Committee also considered the
need to identify gaps in knowledge in order to stimulate new
research, new science, and the development of new evidence. The
gaps could be in measurement, programs, or the knowledge of what
works, in general. Dr. Fielding put forth the statement, "Identify
research and measurement priorities for improving the evidence
base for effective action and evaluation."
- Due to time limitations, no formal vote was taken on
this element of the mission statement.
The Committee then adjourned for lunch.
Advisory Committee Recommendation #3: Healthy People 2020
Mission
- Increase public awareness and understanding of the underlying
causes of health, disease and disability.
- Improve results by providing priorities, measurable goals and
objectives, and guidance on effective strategies and tactics.
- Catalyze action using best available evidence to improve policy
and practice.
- Identify research and measurement priorities for improving the
evidence base for effective action and evaluation. (Not approved by
formal vote of the Committee due to time limitations)
Dr. Fielding explained that he and Dr. Kumanyika had decided to depart
from the agenda, as it was important to address the framework. He noted that
a draft of the Committee's discussion and consensus of the mission, vision,
and goals had been distributed to the Committee members. The group then turned to the framework.
Framework
1:00 PM - 2:30 PM
Dr. Remington explained that several Committee members met the
previous evening to consider the FIW's draft organizational chart and
add the concepts discussed by the Committee. He described a chart that
the group had produced which included a sector and ecologic approach
with elements ranging from individuals and families to systems
(including, but not limited to, public health and health care), the idea
of preparedness, health IT, and the social and physical environment,
built on a base of measurement of health outcomes. (A draft of the
diagram can be found in Appendix E.)
Dr. Remington also shared examples of frameworks that are being
considered in Wisconsin, including a logic model and a Venn diagram. The
Committee's discussion of the framework highlighted individuals,
systems, and environments; these categories are being used by the
National Committee on Vital and Health Statistics to organize the
statistical system and the IT system for the 21st century.
The Committee agreed that it was premature to finalize the look of
the framework, but agreed that these are the organizing principles the
Committee would like to use. The Committee generally agreed that, for
now, a Venn diagram would be an appropriate choice for the organizing
framework. A formal vote was not made on the framework.
Advisory Committee Pro Tem Decision: Graphic Depiction of
Framework
- The Committee informally agreed to use a Venn diagram
showing the three circles of individuals, systems, and
environments (social and physical), to organize their thinking
about the framework.
The Committee explored the issues of how topics should be configured,
what level of aggregation is needed, what topics should be used, and
whether determinants or risk factors should be the organizing
principles. Committee members did not reach any conclusions. They sought
to examine the best ways to think about the totality of health
improvement, including setting priorities, organizing objectives, and
catalyzing action. To provide some structure for this exchange, Dr.
Fielding pointed out that this component of the Healthy People 2020
model involves a couple of different issues. The first deals with how
one identifies and set priorities. The second deals with how the
objectives should be organized. Because it is difficult to address both
issues at the same time, Dr. Fielding suggested the Committee consider
how to organize the framework in a parsimonious way, given the challenge
that is presented when categories overlap.
It was noted that the group should consider whether they were
outlining a model that would make sense to other people when they
communicate about it. The Committee's discussion moved across a variety
of topics. Members' comments are summarized below under the headers of
priorities/ organizational structure, risk factors/ determinants,
targets/ outcomes, and user groups/ communication.
Priorities/ Organizational Structure
Dr. Fielding noted that it's hard to separate the issue of priorities
from that of organizational structure. Indeed, many Committee members
referred to these two issues interchangeably, or linked them together.
There were other areas of overlap, including health issues and focus
areas that fall within both determinants and outcomes.
The Committee considered the priority and focus areas from Healthy
People 2000 and Healthy People 2010, mapping the objectives onto a
framework, and a modeling approach to developing the priorities and
focus areas.
In thinking about what should be included in Healthy People 2020, the
Committee addressed the need to continue the measurement work of Healthy
People 2010 and determine what interventions are efficacious and
efficient.
Risk Factors/ Determinants
It was noted that one state's model was built entirely on health
determinants, but that it is important to also address outcomes:
morbidity, mortality, quality of life and that organizing objectives by
disease-specific categories (e.g., cancer, heart disease, and oral
health) drives a set of objectives that may overlap.
The Committee addressed a concern about focusing on risk factors,
noting the importance of taking an approach that considers broad
environmental factors as risk factors given that “risk factors” or
“determinants” are not mutually exclusive. The Committee also considered
organizing the objectives by four overarching principles, given that
this approach would reflect the topics that had been outlined in the
Venn diagram (Environment, systems, individual/ families) but looked at
them in another way.
Targets/ Outcomes
The Committee highlighted the need to: build on the targets and work
done in Healthy People 2010; recognize that while many objectives in
Healthy People are moving in the right direction, others are not;
acknowledge that an objective should not necessarily be a priority
because it is moving in the wrong direction (i.e., away from its
target); create accountability; and consider the value of data reporting
for policy development and tracking progress.
User Groups/ Communication about Healthy People
The Committee considered whether the objectives should be organized
by problem, stakeholder user groups, audience, or population (i.e., in
terms of the groups that take action). For example, what can the health
care system do? What can the public health system do? From a functional
perspective, this approach might be more helpful for the target
audience, but it would be a significant departure from what's been done
in the past.
The Committee discussed the need to provide Healthy People users
(e.g., community groups) with tools or guidance for achieving the
objectives. In the past, Healthy People has given users a wealth of
data, including baselines and targets, but it hasn't provided clear
guidance on what to do under various circumstances. The advent of the
internet could allow for the creation of an interactive database that
would generate community-specific implementation plans based on
demographic information entered by users, such as local health
departments. ODPHP is working on such an interactive web-based tool. Dr.
Fielding asked the Committee to think of questions that the users of
Healthy People are seeking to answer when they consult this resource:
- Are we on track? If it works, why? And if it doesn't,
why not?
- Can I continue to work with this level of disability or
problem?
- Does this support the things I'm already doing? Does
this threaten my job?
- How are these adverse conditions reflected in the health
data?) How can I achieve the target?
- How can we address this health problem both in the
clinic and in the community? (Thinking upstream.)
- How do the health data reflect the situation in my
community? (e.g., Housing issues, loss of jobs.
- How is my community the same or different from the norm?
- Should we use HHS data to help us try to figure out the
framework?
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- We're considering intervention X for population Y. Does
it work?
- What are the best interventions to reduce burden based
on existing evidence?
- What are the greatest causes of preventable disease,
injury and disability in my area?
- What is the health profile of smaller populations within
my community?
- What is the relationship between individual behaviors
and the larger structure?
- What key health behaviors should I be focusing on?
- Who else in my state, region, or locale cares about the
problem I care about? Who can I collaborate with for
programming?
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Discussion of Subcommittees to the Secretary's Advisory Committee
The Committee discussed the need to establish subcommittees to advance
the Committee's work before its next meeting, and agreed to create a
subcommittee for each of the four draft goals proposed by the Committee.
Dr. Fielding stated that the subcommittees would be charged with
providing directional advice and recommendations to the Committee for
consideration. Prior to the next in-person meeting, subcommittees will
be asked to provide Committee members with short, written reports. They
will also orally present their recommendations. Dr. Fielding noted that
the reports will help to inform the next meeting and help to set the
next meeting's agenda. The Subcommittees will work via conference calls
and the extranet. Once specific subcommittees were named, a sign-up
sheet was circulated so that members could indicate their interest. The
titles of the subcommittees are listed below; the subcommittees' charges
and interested members are shown in
Appendix F.
- Subcommittee on User questions and Needs
- Subcommittee on Developmental Stages, Life Stages, and Health
Outcomes
- Subcommittee on Environment/ Determinants
- Subcommittee on Health Equity and Disparities
- Subcommittee on Priorities
Topics for Future Meetings
The Committee identified the following agenda items for the next
meeting:
- Issues related to target-setting, (e.g., evidence, context,
aspirational vs., realistic targets;
- Focus areas for objectives;
- Subcommittee reports;
- Debriefing from feedback for regional meetings;
- Opportunity for public comment.
Unfinished business and Action Items
Dr. Fielding noted that the subcommittees will be able to communicate
via conference calls. He and Dr. Kumanyika will select chairs for the
subcommittees. The group discussed the possibility of holding a public
webinar before the next in-person meeting. Committee members mentioned
several issues that they may wish to consider in greater depth at later
meetings, or at subcommittee meetings. There is also the possibility
that they could invite experts to speak to them about these issues.
These topics included:
- Health Information Technology
- Preparedness
- Preventive services/ health systems
- The public health system
- The media
Dr. Fielding thanked the Committee. He said that this is a wonderful
group, and that they will be able to make a difference. He complimented
the Committee members for their productivity, compatibility, and for
sharing their complementary perspectives.
Meeting Adjourned
3:00 PM
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