Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Framework and Areas of New Focus for Healthy
People 2020
Via WebEx
Fourth Meeting: July 30, 2008
Committee Recommendations (Approved by Vote)
-
General approach: Healthy People 2020 should be in the form of a
relational database, with no a priori limit on the number of
objectives. (11 votes in favor, 1 abstention, 1 absent)
-
A single model should be used to communicate about both the causes
of health and the process for creating solutions. (12 votes in favor,
1 absent)
-
This version of the Healthy People 2020 model should be used in the
report, although there will be additional opportunities to modify it.
(12 votes in favor, 1 absent)
-
The relational database should enable user groups to define how
they will access and organize the objectives. Thus, focus groups need
not be defined in advance.
(12 votes in favor, 1 absent)
Issues For Follow-up
- Dr. Kumanyika, Committee Vice-Chair, will coordinate final
revisions to the wording in the Healthy People 2020 model. (The
concepts in the model have already been approved.)
- The FIW will instruct current Healthy People 2010 focus area
coordinators to begin considering objectives within their respective
areas. The Committee may seek to ensure that topics that are not
covered by the Healthy People 2010 categories are not overlooked.
- The Committee will modify the "preamble" draft so that it can be
presented to the Secretary as a suggested introduction for the
Healthy People 2020 objectives.
- The National Opinion Research Center (NORC) will distribute a
draft of the Phase I report in advance of the September meeting.
Committee members should plan to comment on that fairly quickly.
- Dr. Manderscheid will develop a draft report section on health
information technology (IT) and will also draft language for a
potential goal about health IT and health communication.
Issues To Be Discussed At The September Meeting
-
Decide whether a goal related to health IT should be included in
Healthy People 2020
-
Review and reach agreement on a draft of the Phase I report to the
Secretary
-
Clarify and discuss issues for Phase II of the Committee's efforts
-
Discuss how the proposed relational database for Healthy People
2020 should be organized
I. Orientation
Jeff Gallagher of WebEx Communications reviewed the meeting technology
and Federal Advisory Committee Act rules.
II. Welcome and Introductions
RADM Penelope Slade Royall, Deputy Assistant Secretary for Health,
Disease Prevention and Health Promotion, introduced herself and welcomed
participants to the fourth meeting of the Secretary's Advisory Committee
on National Health Promotion and Disease Prevention Objectives for 2020
(Committee). RADM Royall provided an overview of Federal Advisory
Committee Act (FACA) regulations and guidelines for communicating with the
Committee. She noted that the focus of the meeting would be the
Committee's production of its Phase I report to the Secretary. She
provided a brief update on the progress of the HHS Federal Interagency
Workgroups (FIW), noting that it is on track to produce a separate report
on recommendations to the Secretary in October.
III. Expectations and Desired Outcomes of the 4th Meeting
Dr. Jonathan Fielding, Committee Chair, thanked the members for their
work. He noted there were over 200 participants on the call and expressed
appreciation for their interest and engagement in the development of
Healthy People 2020. Dr. Fielding offered an overview of the agenda and
main goals for the meeting. First, the Committee would take stock of the
work that has been done to date, especially within the subcommittees, and
discuss how best to integrate it into a cohesive product. Second, they
would formally vote on and approve issues and questions about which there
has been tacit consensus in the past. Third, the Committee would assign
responsibilities for writing and editing various sections of its first
report to the Secretary.
IV. Overview of Work To Date, Voting on General
Approach
Synthesis of Committee Progress to Date
Dr. Fielding indicated that the Committee had accomplished a great deal
since its first meeting in January, 2008. He explained that voting during
the current meeting would be limited to broad, overarching concepts to be
included in the report. He provided a brief summary of the work
accomplished at each of the previous meetings of the full Committee and
reviewed the important work that has been done by the subcommittees.
The Subcommittee on Health Equity and Determinants has sought to develop
and agree on definitions. The Subcommittee on Priorities has worked on
criteria for prioritization. The Subcommittee on Developmental/Life Stages
concluded that Healthy People 2020 should emphasize these are important
concepts. The Subcommittee on User Questions and Needs is considering how
Healthy People 2020 can respond directly to the needs of target audiences.
The Subcommittee on Environment and Determinants has attempted to
concretely apply an ecological perspective to Healthy People 2020. Two ad
hoc groups have also provided special attention to developing a graphic
model for Healthy People 2020 and the issue of health IT.
Voting on the General Approach to Healthy People 2020
Dr. Fielding suggested that the Committee turn their attention to
voting on issues that had been discussed to date. He explained that the
Committee had previously reached informal consensus that Healthy People
2020 should be in the form of a relational database, and there should be
no a priori limit on the number of objectives. Committee members noted
that a relational database could help to increase access and usability for
specific users. The Committee voted to approve the stated approach to
Healthy People 2020 (11 in favor, 1 abstention, 1 absent).
Advisory Committee Recommendation #1: General Approach to Healthy
People 2020
- Healthy People 2020 should be in the form of a relational database
- There should be no a priori limit on the number of objectives.
Future Work
Dr. Fielding suggested that the day's discussion address strategies for
finalizing and approving the end products of the subcommittees' efforts,
as well as integrating them into a single document. This document would
become the basis for Advisory Committee discussion at the September 4-5
meeting. He asked NORC staff to work together with the subcommittee chairs
to prepare the individual report sections that were shown in the draft
outline (see Appendix A). Dr. Fielding
noted that Committee members would be able to review an electronic version
of the draft report in advance of the September meeting.
Dr. Fielding clarified that the production timeline for the Committee's
Phase I report would vary from that of the FIW report. The FIW must
prepare a first draft by early September to allow time for it to go
through the HHS clearance process. Since the Advisory Committee report
will not go through HHS clearance, the timeline is slightly more flexible.
The Committee should aim to finish their Phase I report by late September
of 2008.
V. The Draft Healthy People 2020 Model: Report, Vote
Dr. Shiriki Kumanyika, Committee Vice-Chair, reviewed the work that the
Committee has completed to date on a Healthy People 2020 graphic model
that illustrates the relationship between causes of health and the process
for creating solutions. Before turning to the specific version that the
models ad hoc group had prepared, she gave an overview of why a model is
needed and what it is designed to do. A model of Healthy People 2020
should show how the different objectives and elements of the initiative
relate to each other and fit together. It should be broad-stroked enough
that it could be expanded to show the details beneath each category of the
model. The group agreed to use a single model to address both the causes
of health and the process for creating solutions.
Dr. Kumanyika explained the current draft version of the model to
Committee members, including both other static and animated versions. The
model is meant to show that Healthy People 2020 will prompt action in
three different areas: determinants, pathways of action, and outcomes.
Intervention in each area will impact health problems in different ways.
By addressing determinants, one seeks to change the quality and quantity
of those factors. If determinants are held constant, one could try to
change the pathways of action of those determinations. If determinants and
pathways cannot be blocked, one can increase the population's resistance
and resiliency, which would change the effect of determinants through
those pathways. Healthy People 2020 objectives could act in any one of
those three areas. Dr. Kumanyika showed an example of how the model might
apply to a population of adolescents in low-income communities.
A Committee member asked how the model incorporates information that
people receive from their environment, e.g. through the media. Dr.
Fielding suggested that this issue could be addressed by substituting the
phrase "social environment" for "resources." After some discussion of how
specific elements of the model should be phrased or defined, Dr. Kumanyika
noted that definitions in the "determinants" rows should be aligned with
those used elsewhere in the report.
Several members said that they liked the model and found it to be
straightforward and logical. They approved the model's "upstream" focus on
population health determinants, especially its treatment of health
behavior as an outcome. Concerns included the fact that actions and
interventions are not clearly incorporated into the "static" version of
the model, and that it is not clearly a model for action. Dr. Kumanyika
acknowledged the difficulty of addressing certain concepts within a
two-dimensional model and noted that a three dimensional version would be
preferable.
Dr. Fielding noted that a narrative will be important to explain
various elements of the model, including the place and role of behaviors
(as they could be categorized as both determinants and intermediate
outcomes). After some discussion of phrasing, the members agreed that the
specific wording could be adjusted later. Dr. Kumanyika emphasized that
producing a glossary would give the Committee a chance to determine which
terms they wish to use to convey key concepts. Dr. Fielding asked the
Committee for a vote to approve the use of a single model to communicate
about both causation and process in Healthy People 2020. Committee members
voted to approve this approach to the Healthy People 2020 model (12 votes
in favor, 1 absent).
Advisory Committee Recommendation #2: A Single Model to Show
Causation and Process
- A single model should be used to communicate both the causes of
health outcomes and the process for creating desired health outcomes and
solutions.
Dr. Fielding asked Committee members for a vote to approve the use of
this version of the model, with the understanding that the wording of
specific elements may change in the future. He added that, at a later
point, it will also be important to reach agreement on the definitions of
terms used in the model. Committee members noted that some edits will be
forthcoming (Dr. Kumanyika will coordinate this effort), but that the
concepts put forward in this model are appropriate. As they finalize the
model, a member suggested that the Committee consider the Evans and
Stoddart model,1 which addresses the concepts of wellness and
prosperity. Committee members voted to approve this version of the model,
noting that there will be additional opportunities to modify it in the
future (12 votes in favor, 1 absent).
Advisory Committee Recommendation #3: This Version of the
Model will be used in the Report.
- The concepts put forth in version of the Healthy People 2020 model
should be used in the report, but there will be additional opportunities
to modify the model in future.
VI. Organizing Objectives Into Focus Areas
Dr. Fielding said the concept of "focus areas" was important when their
purpose was essentially to a organize book of objectives (i.e., the
earlier, printed versions of Healthy People) into chapters. He questioned
whether focus areas would be the right approach for organizing information
within a web-accessible database; "areas of emphasis" might be more
useful. Dr. Fielding noted that, when using a relational database, focus
areas would be determined by users. For example, if someone is part of the
Scleroderma Society the information that they want is about scleroderma
(i.e., their focus area). Yet a local or state health department official
might be more interested in determining how to prioritize preventable
burdens or ameliorable risks. Dr. Fielding asked the Committee to discuss
the notion of focus areas and whether Healthy People 2020 should still
have them.
A Committee member commented that, over past Healthy People iterations,
focus areas evolved to become less conceptual and more advocacy-based. The
model discussed earlier in the meeting offers categories that could be
used to organize objectives; they could be less advocacy-based, and more
conceptually-based. Another member added that Dr. Kumanyika's model
provides the opportunity to look at focus areas in multiple ways—in terms
of determinants, interventions, and outcomes, but also in terms of
specific issue areas. Technology could permit both cross-cutting and
issue-specific approaches. It would be a mistake to completely abandon an
issue-specific approach, because advocacy groups support the work of
Healthy People and will help to drive it forward.
A Committee member asked whether having focus areas helped people to set
priorities and motivate change in their communities in the past. While he
did not have any specific information on that issue, Dr. Fielding said he
believed that not many health departments have used the focus areas for
priority setting. People set priorities based on their circumstances. For
example, a health department that does not have funds for programs may
look for opportunities to improve health through policy. If a health
department has a small amount of funding, it may look at interventions
that are most likely to be effective, based on a certain effect size. It
might seek to implement a program that will produce outcomes within a
certain timeframe. Focus areas have been used in a variety of ways, which
is why Dr. Fielding believes that a relational database will be so
important.
A Committee member noted that search terms will be important to
developing the database. Dr. Fielding said that the Advisory Committee
could assign a small group of Committee Members, with external help, to
delineate requirements for the database. Search terms would be a critical
part of that effort. Another member said that Wisconsin had developed
eleven priority determinants without mentioning specific diseases, but
this may have had an impact and effect in terms of stakeholder buy-in. The
best use of the objectives may be as a call to action. The issue of
whether objectives are organized within 10 or 27 focus areas may be less
important. If past trends continue, Healthy People 2020 could have 45
focus areas. There's no real need to go against this trend because focus
areas are simply an organizing concept.
One could take an alternative approach that, instead of having a
laundry list of focus areas, the categories of the model/conceptual
framework could be used. Another member agreed with the idea of organizing
the final product conceptually, rather than having a laundry list. A third
member argued for integrating information about users needs into the
organization of objectives. Such an approach could reduce the need for
having focus areas in the first place. Dr. Fielding agreed that it would
be important to ensure that all areas of emphasis for different user
groups can be incorporated into search terms for the database so that
users can easily access the information they are seeking.
Members discussed various ways to think about focus areas—as entry
points to the proposed relational database, or as a way for users to
decide where in the process (i.e. determinants, pathways, and outcomes)
they want to impact health. Dr. Fielding said the Committee seemed to want
to focus on users and to make sure the priority needs of the different
user groups are accommodated in the model, rather than making an a priori
decision about a certain number of focus areas. He asked if this was the
general consensus of the group. Committee members liked the idea of using
user groups, but noted that it might be necessary to add other things. Dr.
Fielding said the recommendation to the Secretary could be that the user
groups should help to define different ways into the database and
different questions they might ask, so that the database should be easily
searchable.
A member commented that this would require formative research and
usability testing with these user groups. That could occur in two stages:
first, research could be undertaken to understand users' informational
needs and habits and the things that would influence their use of Healthy
People 2020. And second, web-usability studies could explore the
human-computer interface aspect of it.
Dr. Fielding asked the Committee whether there was agreement that
Healthy People 2020 should enable user groups to define how this database
can be accessed (e.g., by risk factors, by life stages, etc.), rather than
making an a priori decision about focus areas. Committee members voted to
approve this approach to organizing the Healthy People 2020 objectives (12
votes in favor, 1 absent).
Advisory Committee Recommendation #4: Approach to Organizing
the Objectives.
- The relational database should enable user groups to define how they
will access and organize the objectives. Thus, a priori focus
groups need not be defined.
RADM Royall offered to explain how the FIW is approaching this issue.
She indicated that the FIW is in agreement with the Committee on including
a health determinants approach in Healthy People 2020. As a practical
matter, the FIW has suggested mobilizing the current Healthy People state
coordinators around the current 2010 focus areas, with a focus toward
developing the 2020 objectives. Those topics would not necessarily be the
focus areas for 2020, and groups are likely to form around new topic areas
as discussions progress. Since technology enables the creation of a
searchable database, objectives can be reconfigured to represent a more
cross-cutting approach after they have been developed. Federal teams
responsible for coordinating Healthy People can also be rearranged at a
later point in time.
Dr. Fielding asked Committee members for their thoughts on the FIW's
approach of starting the work to develop objectives in workgroups
organized around the original twenty-eight focus areas of Healthy People
2010. He noted that the Committee did not want to impede the FIW's
progress in any way. Yet based on their last vote, he also said the
Committee did not necessarily want to bless the previously existing 28
categories as being the "right way" to organize Healthy People 2020. The
objectives can be organized in other ways.
One member cautioned that other issues have emerged in the decade since
these focus areas were developed (e.g., such as socio-economic
determinants and early developmental milestones) that are not covered by
an existing Healthy People 2010 focus area. Such topics may be overlooked
in this early period of the FIW's work. The Advisory Committee may want to
help bring some of these issues forward to ensure they receive appropriate
attention. RADM Royall agreed with this point, adding that preparedness
and health information technology have also emerged as important issues
since the drafting of Healthy People 2010.
Dr. Kumanyika brought up the fact that, as the Healthy People
initiative has evolved over the decades, the term "priority areas" was
used in early decades, and then later it became "focus areas." She
expressed concern about the differences between these two terms, and the
fact that they leave different impressions. She felt it is important to
clarify that "focus areas" offer a way to group objectives, but they are
not priorities. A Committee member said that vote #4 should be clarified
to indicate that the approach was to organize objectives into focus areas,
rather than priority areas. Dr. Fielding clarified that vote #4 was simply
about ensuring that the database enables user groups to easily search for
areas of their concern.
Dr. Fielding said the committee supported the FIW's decision to move
forward with the existing 28 focus areas without necessarily agreeing that
these should be the primary areas of emphasis or the focus. A member added
that the group should go further and state explicitly that the term should
be "focus areas," not "priority areas." Dr. Fielding stated that, for
Healthy People 2020, the group hasn't suggested that focus areas will
really be a component—apart from user-defined focus areas. Another member
commented that the issue is not that the Committee members don't have an
opinion about focus areas; it's that they're not ready to address this
issue yet. This is simply the best way for the FIW to start their work.
RADM Royall thanked the Committee for their feedback.
Dr. Kumanyika expressed concern that if the FIW does too much work
using an approach that lacks any particular conceptual organization, the
results will be inconsistent across focus groups. She asked whether it
would be possible for the FIW to try to arrange the objectives using some
of the concepts in the Healthy People 2020 model (i.e., determinants,
pathways, outcomes). She asked whether there was a guiding principle that
would help the focus areas to fit with the model once the work is done.
RADM Royall explained that ODPHP has already done that. They have assigned
interns within the office to go through all of the Healthy People 2010
objectives and put them into cross-cutting categories. Dr. Fielding noted
that this work will be useful to the Committee, as it will highlight areas
where there is a great deal of emphasis, and other areas where attention
is inadequate.
RADM Royall indicated that ODPHP's work is almost ready to share.
VII. Preparing Final Report of the Committee to the
Secretary
Dr. Fielding said that NORC would draft sections of the final report
for each of the subcommittees for September, working with the Committee
members for review and editing. Writing teams can parallel the
subcommittees, but they can involve more people if necessary. He
emphasized that the real issue is integration, at this point—not having
separate subcommittee reports. At this point, the voting will not be on
subcommittee products, but on the final report itself. The subcommittee
reports will be excellent background material for those who want to delve
deeper into particular issues. The subcommittee reports will be useful
background for preparing report sections.
The Committee briefly reviewed the draft outline for the report. Key
topics to be addressed included the value of prevention, health IT, and
preparedness in public health. The committee moved on to discuss and
finalize the preamble. Dr. Kumanyika indicated that the current draft
incorporates the concepts of leadership, vision, and the belief that
socioeconomic factors are critical determinants of health. It generally
consists of motivational language outlining the purpose of the Healthy
People 2020 objectives. Even though it says who the audiences are, it
doesn't really state who is writing the preamble. She asked whether this
document should be read as coming from the Secretary, or the Committee.
The document does not convey a sense of governmental responsibility, but
in some places seems to suggest that responsibility lies with citizens
themselves. She felt it was important that the preamble not be silent on
the issue of who is doing the talking.
Dr. Fielding expressed the view that this should be considered the
preamble to the Committee's September report to the Secretary. The tone
and language of the preamble would be directed toward the Secretary. NORC
staff clarified that the current draft was based on a document that had
been prepared in 2007 by a "Technical Expert Panel" that had convened to
make recommendations for the Healthy People 2020 framework. That version
had been intended to serve as a preamble to the Healthy People 2020
objectives themselves. After some discussion, the Committee felt that the
document should be modified and offered to the Secretary as a suggestion
for the HHS preamble. While the Committee is in an advisory role, they
felt it would be important for the Secretary's voice to be behind the
objectives. They agreed to modify the preamble draft as a suggested
approach for the Secretary to consider.
Dr. Fielding noted that Ron Manderscheid had asked for time on the agenda
to propose the addition of a new goal. Dr. Manderscheid asked the
committee to consider adding a goal on health information technology and
health communication. He summarized the work that he had done with some
representatives of the FIW who have been addressing these issues. They
defined a set of requirements having to do with what type of information
technology system population health should have, how it should be driven,
what role health communication should have, and how efforts should relate
to the Office of the National Coordinator for Health IT (ONC) strategic
plan. Dr. Manderscheid went on to say that Healthy People 2020 should
include a strong focus on health IT and health communication. He described
early planning to create a "Healthy People Community" that would include
the IT infrastructure for Healthy People 2020. He described these plans in
detail.
Dr. Fielding noted that Dr. Manderscheid's presentation was, in essence,
the outline for the health IT section in the final report. He asked
whether this would be a Committee product that would be endorsed by the
FIW. Dr. Manderscheid clarified that it would be both an Advisory
Committee and FIW product. He thought the two groups should carry the same
message as frequently as possible, although there are differences between
the groups. Dr. Fielding agreed that it makes sense to harmonize whenever
possible, although these are two different groups with different charges.
He asked Dr. Manderscheid to produce a draft of the document by August.
A Committee member pointed out that, historically, the goals have been
broad statements of what Healthy People 2020 will achieve and cautioned
against including processes and infrastructure issues. Another member
asked whether technology-based health literacy has been discussed. Dr.
Manderscheid indicated that health literacy will be part of the health IT
subgroup's efforts, and that this will be part of the recommendations that
will be made. Dr. Fielding suggested that health IT may be how to achieve
the goals, rather than a goal in itself. The issue of whether to consider
an additional goal about health IT was tabled until the next meeting.
VIII. Preparations for the September Meeting
The September meeting will involve reviewing an integrated draft of a
final report for Phase I of the Committee's activities, as well as an
initial foray into topics for Phase II of the group's work. Topics that
will be important to address include the organizational structure of the
Healthy People report or database. The Committee will also work with ODPHP
to clarify the charge for the second year of its work. NORC will
distribute a draft of the report in advance of the September meeting, and
Committee members should plan to comment on that fairly quickly. Dr.
Fielding said that the main task for the September meeting will be to get
final agreement on the Advisory Committee's Phase I report to the
Secretary.
With regard to logistics for the next meeting, Dr. Fielding said it
might be best to use WebEx as a vehicle for future meetings—even if they
are full day meetings on successive days. After some discussion, the group
agreed that the September meeting would consist of two WebEx meetings
lasting six hours each; members should block off time in the afternoons of
both days so that they can work on writing assignments.
IX. Summary and Closing Remarks
Dr. Fielding thanked the Committee members for their commitment to this
very important process, and expressed his hopes that their work would be
helpful to the HHS Secretary and to the FIW.
1
A model
of determinants of health. R.G. Evans and G.L. Stoddart, "Producing
Health Consuming Health Care," Social Science and Medicine,"
31:1359, with permission from Elsevier Science Ltd, Kidlington, UK.
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