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Healthy People Home > Healthy People 2020 > Secretary's Advisory Committee > First Meeting Minutes > Day 1 | |
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Secretary's Advisory Committee on
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RADM Royall thanked Committee members for their contributions to the field of public health. She introduced Rich McKeown, HHS Chief of Staff, U.S. Department of Health and Human Services. Mr. McKeown highlighted the importance of disease prevention and health promotion, the Secretary's commitment to prevention, and offered background and historical context for the U.S. Department of Health and Human Services (HHS). Mr. McKeown expressed his enthusiasm for the Secretary's Advisory Committee and said its members comprise a remarkable group of people. He invited them to come forward to be officially sworn in. All present members recited the oath together with Mr. McKeown. (Dr. Everold Hosein was not present due to a delayed arrival.)
Donald Wright, Acting Assistant Secretary for Health, added his words of appreciation to the Secretary's Advisory Committee for their participation and explained their official responsibilities. The Secretary's Advisory Committee will provide advice and assistance to the Secretary and the Department of Health and Human Services in the development of health promotion and disease prevention objectives to improve the health of Americans by 2020. The Committee, whose duties are solely advisory and time-limited, will provide to the Secretary advice and consultation to facilitate the process of developing and implementing national health promotion and disease prevention goals and objectives. Dr. Wright then introduced Dr. Jonathan E. Fielding, the Committee's chair.
Dr. Fielding thanked all who were present for attending the meeting. He also thanked the members of the Committee, and acknowledged Shiriki Kumanyika, the Committee's Vice Chair. He noted that the Committee operates under the Federal Advisory Committee Act, which specifies certain procedures for the Committee's work. He asked for cooperation from the audience regarding communication with the Committee. There was no time allotted for public comment at the Committee's first meeting, but there will be opportunities for public comment at future meetings.
Dr. Fielding announced the address for a Web site where the public can formally submit their comments on Healthy People 2020 throughout the development. The address is: http://www.healthypeople.gov/hp2020/. If approached by special interests, he asked the Committee to invite these individuals to submit their comments through the Web site so that they can be shared with the entire Committee. He also asked the public to check the Healthy People Web site for updates and to sign up for the Healthy People listserv.
Dr. Fielding explained that the Committee's charge for the day included examining the past history of the Healthy People initiative and some products of the Federal Interagency Workgroup (FIW)—an internal HHS workgroup that has been developing draft elements of Healthy People 2020 for the Committee's consideration. The FIW will assist the Secretary's Advisory Committee in providing guidance to HHS for Healthy People 2020.
Dr. Fielding noted that for the Healthy People initiative to be successful, its intended users and the public need to be able to use it and apply it to their world and communities. Furthermore, he noted that the meeting offers a chance to take a step back to determine what can be most important to improving the public's health. He clarified that when the Committee members talk about "public health," they're referring to the population's health. He emphasized that it's important to make sure that the group is not challenged by operational definitions.
With regard to future meetings, Dr. Fielding explained that the Committee members can decide if there are special topics that they wish to address in more detail. At their next meeting—which will take place in late spring or early summer—the Committee can ask HHS to arrange for presentations from experts if the members request more information.
Dr. Fielding remarked that it's the Committee's responsibility to provide a coherent, realistic vision of what the health of our nation can be in twelve years. Dr. Fielding offered a set of questions that the Committee members should ask themselves as they embark on this effort. (See Appendix B for the complete list of questions presented by Dr. Fielding.)
RADM Royall explained that Healthy People is a comprehensive set of ten-year objectives that offers a framework for public health actions and priorities. The initiative is now in its third decade. It was launched in 1979, and subsequent iterations have been issued at the beginning of each decade. The Midcourse Review for Healthy People 2010 was completed in 2006. As the initiative has moved through the decades, it has expanded. The number of focus areas and objectives has increased. Thus, HHS has begun examining possible ways to organize Healthy People 2020. HHS contracted with the National Opinion Research Center (NORC) to produce an independent analysis of framework options for Healthy People 2020. NORC convened a technical expert panel of nationally known public health experts. The panel drafted recommendations for a framework, and NORC conducted a public comment period. The report called for organizing objectives by cross-cutting risk factors and determinants of health, and limiting the number of objectives and focus areas.
Taking these issues into consideration, HHS has developed a starting point for a framework for Healthy People 2020. The primary focus is on risk factors and health determinants, with a secondary focus on diseases and disorders. This departure from NORC's recommendations comes from recognition that many funding streams and programs in public health are currently ordered by diseases categories. As the initiative progresses, it must bring along its stakeholders to move public health policy and practice towards a cross-cutting approach. Healthy People 2020 will also emphasize the Department's priorities of health information technology, preparedness, and prevention. The Healthy People objectives must be scientifically valid, relevant, and sustainable. Stakeholder input and participation are essential.
Carter Blakey, Senior Advisor and Lead for the Community Strategies Team, ODPHP, explained that, due to the tremendous amount of resources required to develop Healthy People 2010, HHS felt it was time to take a step back and look at how it was approaching the planning process. For the first time, HHS has convened a fully public advisory committee, the Secretary's Advisory Committee. Development of past iterations of Healthy People was guided by a Secretary's Council made up of HHS Operating Division heads and former HHS Assistant Secretaries for Health. Public comment will be sought throughout the year via regional meetings and an online Web site.
HHS has a Healthy People Steering Committee that meets quarterly. For Healthy People 2020, they have also established a broader Federal Interagency Workgroup (FIW). The FIW is intended to ensure that the goals and objectives reach across all federal agencies, and to serve as a conduit for information. The FIW includes 44 members, representing 21 HHS agencies. It has seven topic-specific subgroups, and has invited non-HHS federal agencies to participate. The FIW and its subgroups are comprised of federal staff or officials interacting with federal agents. The Secretary's Advisory Committee is composed of non-federal national experts, offering a connection to the public. A two-phased release of Healthy People 2020 is planned. The framework, overarching goals and vision and mission statement will be released in the first phase (in late 2008 or early 2009) to permit states, local health departments, and other stakeholders to use it for their planning. In the second phase, the complete set of objectives and strategies for achieving the objectives will be released in January 2010. This approach will enable HHS to get input, compile evidence-based practices, and make Healthy People a more useful product for stakeholders and users.
Richard Klein, Acting Chief, Health Promotion Statistics Branch, Office of Analysis and Epidemiology, National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC), described the role of NCHS in Healthy People. NCHS maintains a comprehensive database of measures, serves as a statistical advisor to the Secretary, and tracks progress towards the objectives in collaboration with the lead HHS agencies and ODPHP.
NCHS produced a statistical compendium to Healthy People 2010, Tracking Healthy People 2010. Mr. Klein discussed approaches to setting targets for objectives. In the last decade, only 20 percent of Healthy People objective targets were met. At the midpoint of this decade, progress had been made on two-thirds of objectives, and ten percent met their targets.
When no data sources existed for issues considered to be important, developmental objectives have been created. In 1990, a third of the Healthy People 2000 objectives were not measurable; by the end of the decade, all but seven had data sources. At the start of the current decade, 140 objectives lacked data sources, now only 49 lack baseline data. Creating developmental objectives drove the identification of data sources.
Mr. Klein mentioned DATA2010, an interactive Web site that allows users to find the most recent data for monitoring progress on Healthy People 2010. In moving forward to 2020, he noted that it is important to think about future data and measurement issues. He also raised the importance of working through data issues such as target attainment, target-setting methodology, integrating targets across focus areas, inclusion of developmental objectives, and continuity of objectives across decades. The Committee then took a 10 minute recess.
Lee Wilson, Director, Division, Office of the Assistant Secretary for Planning and Evaluation (ASPE), reviewed the Healthy People User Study, which began in 2002 with the goal of obtaining a comprehensive picture of how the document was used, identifying key users, and determining how they use the document. The study issued a self-administered questionnaire to representatives at the state, local and tribal levels. A round of follow-up interviews was conducted to provide insight into obstacles to implementation.
Summarizing overall lessons learned, Mr. Wilson stated that Healthy People 2010 is a visible, practical document that is being used by the field. One of the study's conclusions was that there was a lack of buy-in from primary decision makers at the state level. Healthy People didn't reflect the same political priorities of these stakeholders, as it didn't respond to the needs of state legislatures. Other findings were that additional federal level communications and support for implementing Healthy People were needed. Efforts have been made to address this since the study was implemented. Results also indicated that less than a quarter of respondents were familiar with the DATA2010 Web site. Non-users said they prefer using state sources of data.
ASPE heard from tribes that they were using the document in a different way than other users. A small sample of 50 tribes was used, due to resource limitations; there was a response rate of approximately 72 percent. The sample was stratified by size of tribe as well as region. Tribes were less likely than other Healthy People Users to use the document for planning or research and were more interested in using the participatory goal-setting. Also, tribes found that the ten-year timeline of Healthy People was too long for them; they had their own agendas that they wanted to advance and using a ten-year timeframe would lose momentum.
Commonly cited barriers included a lack of implementation tools, and resource constraints. ASPE is now working on a second iteration of the User Study that will include formative research questions to inform the development of Healthy People 2020. That survey is currently under review by the Office of Management and Budget (OMB). The Committee then adjourned for lunch.
Carter Blakey presented to the Committee the process that has been followed thus far to develop Healthy People 2020. This work began with the NORC report. ODPHP reviewed the NORC recommendations with the FIW; which in turn drafted a vision and a framework for the initiative. These drafts were provided to the Secretary's Advisory Committee as a starting point for their work. The Committee may, if they choose, use these drafts in their deliberations. Regional meetings, scheduled for this spring, will provide additional input into Healthy People 2020 from the public.
Federal Interagency Workgroup
Draft Overarching Goals for Healthy People 2020
- Promote health to end preventable death, illness, injury, and disability.
- Achieve health equity by eliminating health disparities.
OR
Eliminate health disparities to achieve health equity.- Promote healthy places and environments.
Ms. Blakey explained that the FIW has proposed keeping the first goal constant through the decades. The second goal about achieving health equity and eliminating disparities was discussed extensively. The FIW talked a great deal about whether it should highlight health equity. New to Healthy People 2020 would be an overarching goal that addresses healthy places and environments. This goal is meant to acknowledge that improving health should address the environment broadly.
Committee members examined the draft Healthy People 2020 Goals prepared by the FIW. Their discussion during Meeting Day 1 addressed both conceptual issues and phrasing of the vision, mission, and goals. The members delved into the conceptual underpinnings of Healthy People 2020, and discussed how they can best provide input into the development process. No final decisions were made during the first afternoon's discussion.
The Committee's initial foray into this material addressed structural topics—such as the functions and phrasing of the vision, mission, and goal statements. It also touched on concepts addressed by the FIW's draft statements (i.e., health equity and health disparities, the social and physical environment, and wellness, quality of life, and preventable death). The Committee also spoke about strategic issues related to identifying the needs of Healthy People users for information and support.
Dr. Fielding noted that there's no single way to go about structuring the vision, mission, and goals for Healthy People. One approach would be to create a general vision statement, and then align the goals with that statement. This would be different from the approach taken in the past. A Committee member noted the need for a driving vision that moves the health of the nation forward since the priorities highlighted by HHS will touch the health and lives of the population. Another member suggested ideas for taking a lofty approach to the vision, along the lines of U.N. vision statements. An example could be, "Health for all by the year 2020."
Committee members asked whether emerging trends should be reflected in the vision statement. Committee members raised issues regarding personal health records (PHR) and electronic health records (EHR) that will change the nature of the health care process, demographic shifts, including the aging baby boomer population, increasing rates of chronic disease, and rising rates of disability among children. Committee members suggested that Healthy People 2020 needs a vision that will lead to the goals for addressing these trends.
Dr. Fielding asked for input on the mission statement, noting that this piece has not been included in previous iterations of Healthy People. There was discussion of framing the Healthy People mission by user groups (i.e., "What are the explicit functions tied to each customer?") Committee members commented that the mission statement should be explicit about what Healthy People does for the nation and how the public can use it; it should consider how local health departments and federal agencies use the initiative differently, and how Healthy People 2010 has been used to date. The Committee noted that, while the initiative has 30 years of experience, there is a lack of data on how the initiative is used, despite significant anecdotal evidence on its use.
A Committee member thought the mission of Healthy People could be seen as educational (i.e., to teach people about how to think about health). He proposed a mission focused on four different elements: health outcomes; determinants; health equity; and evidence. Dr. Fielding sought Committee responses to this idea, and noted their agreement on the general elements to be included in the mission statement. He also noted the need to involve other sectors. The Committee acknowledged that the actions of other sectors have a major impact on health and while the health care system is important, it's not the only way to improve health.
Offering an overview of the FIW's draft goals, a member said the first goal addresses "healthy people;" the second, "less disparity," and the third "healthy places." Looking at the trend across three decades, he commented that the FIW goals go beyond healthy people to healthy places, and incorporate health disparity.
Another member said lack of internal consistency in phrasing of the goals seems to imply that, if we promote healthy environments and promote health, we achieve health equity. He questioned whether these ideas should be so closely tied. Another agreed there are risks in tying objectives to the goals. "It will be hard to have a goal that talks about death, disability, etc. The logic would say that objectives should drive you towards your goal. With the end of ‘preventable death,' this would be difficult to achieve," since it is difficult to prove that a preventable death has been averted.
Dr. Fielding asked for input on the concepts reflected in the goals: Health equity, environment, and ending death that is "preventable at a particular time." One member highlighted the issue of health financing and economics, as well as financial access to care (i.e., health insurance), since not having access to care has medical consequences.
A Committee member pointed out, "None of the prior goals use the word ‘population' although we are talking about populations, and asked whether ODPHP has struggled with this, when the document could be seen as addressing the health of groups of individuals. The member elaborated that one of the challenges of health policy in this country is the individualistic focus and suggested the need to look beyond that.
Regarding the phrase "preventable death," the Committee wrestled with various concepts, including "healthy years of life," "quality of life," "well-being," and modifiable behaviors versus genetics. There was discussion of the idea of "helping everyone to achieve their health potential." A Committee member stated that a tool with this type of focus "could be a guide for all sectors about what it's going to take to have a healthy population."
Dr. Fielding remarked that a problem with the term preventable death is that death is not preventable. He added that people intuitively understand what it means to increase years of healthy life; they don't really know what it means to end preventable death. The concept of healthy years of life is important, especially with disability issues, as functional issues become important. A member said it would be critical to include a section that addresses measurement of concepts such as quality of life, or years of healthy life.
With regard to promoting health and quality of life, another member asked for clarification on what is meant by quality of life, and specifically whether Healthy People 2020 should be more expansive than simply talking about a medical model of health. If so, the concept of quality of life goes to many of the issues that the document is talking about. The same Committee member said "promoting health" is the central goal and saw the other goals as being complementary; for example, promote health by...eliminating health disparities, facilitating healthy places.
Another Committee member said he would like to bring in the idea of well-being as well as health, including emotional well-being. It's at the core of understanding what many of the risk factors are related to. This term introduces the ideas of depression, chronic anxiety, and understanding the risk factors for those problems. He clarified that he was advocating a return to the basic goal of going back to promoting the health and well-being of all Americans.
Other concepts that were raised included the notion of independence as a factor in quality of life, as well as the concept of human development. A Committee member felt that little attention was paid to primary prevention in childhood, suggesting that the overarching goal could be "To reduce the basis for the risk factors underlying the ten most common causes of death in America." Another Committee member felt this phrasing placed too much emphasis on physical health.
Dr. Fielding raised the issue of whether the public would understand what health equity is. A Committee member responded that the public probably would not even be able to define the term, "health disparities," but it is important to be forward-looking, and using the term "health equity" is one way to get there. It was noted that the concept of health equity is, "a loftier goal than health disparities" because inherent to the concept of achieving health equity is the need to look at issues of human rights and social justice. It was further noted that the Committee should help define, describe, and translate what health equity is.
The Committee agreed that it will be this group's charge to communicate that the initiative is talking about an integrated, ecological approach to health promotion because incorporating an ecologic approach goes to the heart of the issue of disparities. A Committee member commented that one of the hidden problems in talking about health disparities and health equity is that they are relative concepts; there is no absolute baseline. It must be made clear that "health equity" means raising the level of health of all population groups to the same high level, not lowering the health status of healthy subpopulations. A Committee member stressed that Healthy People 2020 highlights the "elimination of health disparities" and returning to "reducing disparities" would be a step backwards. It was noted that the National Association of County and City Health Officials (NACCHO) has been working on these definitions for the last 10 years, and could be an important resource. Other populations affected by disparities include the disabled and mentally ill.
A Committee member expressed enthusiasm for the ecologic approach, calling it "an exciting innovation that will get us closer to achieving the objectives and recommendations." Regarding the concept of, "Promoting healthy places and environments," a Committee member said Wisconsin, which uses a determinants model, has been careful to talk about the "physical and social environment" separately, and to explain what is meant to avoid confusion.
The need to provide a glossary defining key concepts such as health and environment was discussed. It was agreed that, "The more we stray from common definitions, the more likely it is that we'll lose people." A member said that the Institute of Medicine's Committee on Disability in America defined the concept of the environment as referring to the attitudinal, as well as the physical, environment. While she supports use of the term "environment," she felt it is important to define it. "Disability" is a reflection of the environment that causes people to be disabled. A Committee member stated that one of the main drivers in public health is the changes in lifestyles being wrought by developments in technology, environments, and in the media and marketing.
The Committee took up the issue of the value added by Healthy People to specific user groups. A Committee member said it's important to identify the ultimate consumer: "We're moving into an era of consumer-directed health care. If you start there and move up the system, what is the role of the state and the federal health system?" A member who works at the state level said he has used it as a framework for evaluation. Another who works at the local level said, "One of the ways I've used this is to talk to my city council. They can see where we stand in relation to the nation's goals. I can...give them information based on the data that we collect." Another member noted that, "Part of the audience for this has to be the people who control the budgets for healthcare."
A member agreed, "You need to think about your primary customers. I guess that would be people who are willing to carry that book around." Secondary audiences might not be interested in the book, but they might be interested in its contents. He said the documents are so far from what the average consumer would use that, "I don't think it makes sense to craft the message in terms of the people on the street. It's incomprehensible to people with limited literacy or limited health literacy." He felt the primary customers are federal state, and local agencies.
Those working in the scientific field should be identified as users. Researchers should be prompted to ask how they can contribute to the evidence base of Healthy People in a specific way. The Committee agreed that, in some cases, evidence is not available because there isn't funding for that research and that community-based interventions should be integrated into the initiative. One Committee member commented that users seemed to appreciate the surveillance aspect of Healthy People, so it's important to think about how to retain that piece. Members agreed on this point, but said it's important to set some priorities.
Noting that the 2005 Healthy People User Study results suggest that users want implementation strategies, specific strategies, programs, and recommendations should be provided, along with an evidence tier that people can use. Focus areas could be grouped into those evidence areas. A Committee member recommended that the implementation guide include interventions that have been attempted and have been successful. She brought up a potential vehicle for dissemination of Healthy People, saying, "I look at universities, the power that they have, and the little that they know about Healthy People. It's like an unknown resource. It needs to be a movement."
Committee members asked whether thought had been given to developing "mini Healthy Peoples" for specific audiences, after the major Healthy People 2020 initiative is released. The initiative could be packaged differently, using market segmentation. Dr. Fielding prompted the group to be more explicit about what the initiative needs to talk about if the objectives are to be actionable. Offering the example of reaching out to different sectors, he said, "We don't know what the potential is to improve health through place-redesign, or by improving walkability to schools. But we certainly know about preventive services, providing people with access, and making sure that people can retain their functional capacities. If we don't indicate that—then everything has equal valence."
Carter Blakey responded that ODPHP has thought about that. She explained, "One of our difficulties in using a risk factors/determinants approach is that you lose a lot of your specific customers. We've thought about producing spin-out documents, or a multi-dimensional model. Now that we have the Internet, we can approach this from different perspectives. So, users could press a button and the model would spin around." The Committee reacted to this idea with interest.
Richard Klein (NCHS) presented a draft flowchart (See Appendix C) illustrating a framework for Healthy People 2020 that had been prepared by the FIW. He showed the Committee a diagram in which the goals flow through the risk factors and determinants into three broad "buckets" of objectives: health promotion (individual behaviors), health protection (work safety, etc.), healthy environments. From these areas of focus flows health: the outcomes that we can measure. These include years of healthy life, disability, and specific disease rates.
Committee members reacted favorably to the FIW's framework, but had a number of questions about the approach it describes. One said, "I like the social ecological approach, but underneath that you do have to think in clusters. Underneath that you do need to have health systems. Healthy Places—this is not just traditional public health environment. It's a subtle difference: thinking about healthy systems and preparedness." Committee members asked a number of questions, including:
The members liked the "logic model" aspect of the framework and its depiction of targets for assessment and intervention, and interactions between individual systems and the environment. It was noted that the model could be revised as a Venn diagram to depict shared systems, and the ways they overlap. Others pointed out that the areas in the FIW's flowcharts are aligned with community risk factors and determinants, and the thinking in NORC's Assessment Report. Ms. Blakey said the FIW had talked about how life stages fit into this framework. Dr. Fielding said, "We haven't talked about life stages—issues like the childhood determinants of disease." He suggested that the group think about how to conceptualize that. He also warned, "We have to be careful when we put something in a graphic that's very complicated. Just because a graphic artist can do it, doesn't mean the public will necessarily understand it." The Committee then took a 10 minute recess.
Martina V. Taylor, Senior Advisor for Disease Prevention, Office of Disease Prevention, National Institutes of Health addressed the opportunities for public comment on Healthy People 2020. Ms. Taylor stated that the FIW Subgroup on Outreach and Education is charged to foster nationwide awareness and engagement. While it cannot fulfill the outreach needs for Healthy People on its own, the subgroup can provide consistent and clear information and messages.
The main outreach that has occurred thus far has consisted of informing people about the development of Healthy People 2020. In November 2007, plans for the two-phased release of Healthy People 2020 were explained in presentations at APHA and the National Health Promotion and Disease Prevention Summit. To continue gathering public feedback, Regional Meetings are scheduled between March and May. A Public Comment Database will also be available throughout the Healthy People development process. The Secretary's Advisory Committee can provide support by helping to disseminate information, including the public comment Web site address.
Dalton Paxman, Regional Health Administrator (RHA) for Region III, presented a regional perspective on Healthy People. He described the Office of the Regional Health Administrator and the role of the RHA in prevention, preparedness and coordination. He summarized public input received to date at various conferences and meetings. APHA session participants were primarily concerned with specific objectives and topic areas that would be included in Healthy People 2020. Participants in the Prevention Summit were more interested in discussing new approaches to the Healthy People Framework and process. The Healthy People State Coordinators meeting included a large group session in which participants discussed potential approaches to developing a framework for Healthy People 2020.
The current draft agenda for the Healthy People 2020 Regional Meetings includes time for the public to comment on the draft vision, mission, goals and framework, as well as presentations by state and local experts. Committee members may lend support by attending these meetings, recommending state and local experts to present, and spreading the word to colleagues and partners. The dates and locations for the regional meetings are:
Dr. Fielding said that HHS should ask people how they would prefer to receive information, such as in the form of examples and diagrams, keeping in mind that what may be helpful at one level of an organization may not be most helpful at another level. Another member thanked ODPHP for doing both outreach and "in-reach" (within the federal government). She noted that language and cultural needs are extremely important. The Committee suggested avenues for outreach including:
Dr. Paxman asked, "How can we reach non-traditional partners, such as agriculture, education, housing, and other sectors?" Dr. Fielding said that Los Angeles County has started to make such efforts and, "We find that they're open to it." He said that they've worked with partners on nutrition issues (e.g., vending machines in schools). They've also worked with regional planners. One way to identify opportunities is to speak with trade organizations for other sectors to see what they suggest.
Dr. Fielding congratulated the Committee on a productive day. He said the group would talk more about populating the framework when they reconvened the next day. They would make specific recommendations for the mission, vision, and goals, and also offer their ideas for how to organize the framework. Another discussion topic would be how to organize the initiative using the Venn diagram that was mentioned earlier. RADM Royall thanked the Committee members and the public. Dr. Fielding thanked the public for attending and mentioned that there will be opportunities for them to provide comments and feedback in the future.
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Last revised: July 9, 2008