Phase I Report
Recommendations for the Framework and Format of Healthy People 2020

Executive Summary

Each decade since 1980, the U.S. Department of Health and Human Services (HHS) has released a comprehensive set of national public health objectives. Known as Healthy People, the initiative has been grounded in the notion that setting objectives and providing benchmarks to track and monitor progress can motivate, guide, and focus action. This year, HHS began developing the next decade's objectives, Healthy People 2020. HHS convened the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (hereinafter called the Advisory Committee) to aid in this process. The members are 13 nationally known experts with diverse expertise on different aspects of public health.

The Advisory Committee was charged with providing advice and consultation to the Secretary: 1) to facilitate the development and implementation of national health promotion and disease prevention goals and objectives, and 2) to inform the development of initiatives that will occur during initial implementation of the goals and objectives. During the first phase of its work (January 2008-October 2008), the Advisory Committee has produced recommendations for the Healthy People 2020 form (i.e., medium or format), framework (i.e., vision statement, mission statement, overarching goals, graphic model); and guidelines for implementation. The recommendations are summarized in this report.

The Advisory Committee has convened in six open, public meetings since January, 2008. It formed five subcommittees (including both internal and external members) and two informal, ad hoc groups to permit in-depth discussion of important topics. The products of these groups' efforts were presented to the full Advisory Committee at public meetings, where decisions were made about whether or not to adopt them. Advisory Committee members received input from the public via a public comment Web site; six regional meetings; and an in-person Advisory Committee meeting where the general public was invited to present oral comments.

Advisory Committee Findings and Recommendations

The Advisory Committee views Healthy People 2020 as a national health agenda that communicates a vision and a strategy for improving the health of the Nation's population and achieving health equity. It should offer overarching, national-level goals to show where we want to go as a nation and how we will get there, both collectively and individually. Healthy People should be both inspirational and action-oriented, offering leadership, guidance, and direction from HHS and its partners to public and private, health-interested organizations at all levels.

Healthy People 2020 should assist Federal agencies in setting priorities and in providing funding and support to organizations and institutions that are able to help achieve the objectives. It should enable state and local public health departments and their partners to set priorities and assign tasks to help achieve the objectives. Finally, it should offer guidance and direction to stakeholders at all levels, including local communities, and should redirect our attention from health care to health determinants in our social and physical environments.

The Healthy People initiative has been a long-term effort. It is important to reflect on lessons learned—both positive and negative—through this effort. The strengths of past Healthy People iterations are numerous, and include cross-agency collaboration within the Federal government and an extensive process of stakeholder and civic engagement. Yet it has encountered challenges as well. Some have said this resource is not easy to use; many potential users are not aware that it exists; and in some cases there has been a lack of progress or slow progress in achieving objectives. The recommendations in this report are meant to build on these strengths and to highlight opportunities for Healthy People 2020 to enhance its effectiveness.

The Advisory Committee recommends that Healthy People 2020 differ in form from previous iterations. It should no longer be known primarily as a print-based reference book to be kept on the shelf for a decade.ⁱ It should also be a Web-accessible database that is searchable, multilevel, and interactive. Through this medium, Healthy People 2020 can more effectively assist stakeholders to improve population health by helping them to access metrics and guidance about effective interventions. An electronic Healthy People 2020 would offer improved capacity to deliver information that is tailored to the needs of users. It would be successful to the extent that it has a user-friendly interface that is accessible to all levels of user.

Vision and Mission of Healthy People 2020

The Healthy People 2020 vision statement should be a crisp, brief statement that can easily be remembered. The mission statement—a framework element that has not been included in previous iterations of Healthy People—should offer clear information about what Healthy People does for the Nation and how the public can use it.

Overarching Goals of Healthy People 2020

The recommended overarching goals for Healthy People 2020 continue the tradition of earlier Healthy People initiatives of advocating for improvements in the health of every person in our country. They address the environmental factors that contribute to our collective health and illness by placing particular emphasis on the determinants of health. Health determinants are the range of personal, social, economic, and environmental factors that determine the health status of individuals or populations. They are embedded in our social and physical environments. Social determinants include family, community, income, education, sex, race/ethnicity, geographic location, and access to health care, among others. Determinants in the physical environments include our natural and built environments.

A feedback loop of intervention, assessment, and dissemination of evidence and best practices would enable achievement of Healthy People 2020 goals. The Action Model to Achieve Healthy People Goals (shown in Exhibit A) represents the impact of interventions (i.e., policies, programs, and information) on determinants of health at multiple levels (e.g., individual; social, family and community; living and working conditions; and broad social, economic, cultural, health, and environmental conditions) to improve outcomes. The results of such interventions can be demonstrated through assessment, monitoring, and evaluation. Through dissemination of evidence-based practices and best practices, these findings would feed back to intervention planning to enable the identification of effective prevention strategies in the future.

Exhibit A. Action Model to Achieve Healthy People 2020 Overarching Goals

To close the gap between where we are now as a nation and where we would like to be by the Year 2020, Healthy People 2020 must provide clear priorities for action (i.e., it should articulate "what" needs to be done) and focused strategies for addressing them (i.e., it should explain "how" this work should be carried out). The summary below highlights the Advisory Committee's suggestions for each of the overarching goals in both of these areas.

WHAT? Emphasize the Importance of Prevention and Health Promotion

There are many instances when steps can be taken to promote and preserve health and to minimize the occurrence and consequences of disease and injury. This concept is inherent in the proposed four overarching goals of the Healthy People 2020 framework. Not all prevention activities save health care dollars, but those that do not may still be very valuable because they improve health and well-being and lead to other benefits. Health promotion and disease prevention apply to all people, not only those without evident health problems. Even people with significant diseases that cannot be prevented or cured with the application of current knowledge can benefit from health promotion and disease prevention efforts that slow functional declines or improve the ability to live independently and participate in daily activities and community life.

The need to identify current and enable future effective prevention strategies is especially critical for problems affecting large segments of the population. A mix of preventive and treatment or remedial strategies is needed to alter the complex dynamics of biological, environmental, and behavioral factors that contribute to the development and progression of chronic diseases and conditions. This is also true when considering problems like violence or lack of preparedness for natural and manmade disasters. Healthy People 2020 should help users to set priorities and create an appropriate balance and mix of these strategies.

WHAT? Address "All Hazards" Preparedness as a Public Health Issue

Since the 2000 launch of Healthy People 2010, the attacks of September 11, 2001, the subsequent anthrax attacks, the devastating effects of natural disasters such as hurricanes Katrina and Ike, and concerns about an Influenza panepidemic have added urgency to the importance of preparedness as a public health issue. Being prepared for any emergency must be a high priority for public health in the coming decade, and Healthy People 2020 should highlight this issue. Because preparedness for all emergencies involves common elements, an "all hazards" approach is necessary.

HOW? Multisectoral Approach, Strong Public Health Workforce, and Infrastructure

The Nation's public health infrastructure provides the resources to deliver the essential public health services to every community. It consists of the public health workforce, information and communication systems used to collect and disseminate accurate data, and public health organizations at the State and local levels. Environmental health, occupational health and safety, mental health, and substance abuse are integral to the provision of public health, as are health care organizations, schools, faith organizations, and businesses. To maximize population and individual health, multi-disciplinary, interdisciplinary and intersectoral partnerships are needed. Such partnerships can address the web of multi-level factors that affect health.

WHAT? Achieving Health Equity and Eliminating Health Disparities

To eliminate health disparities and promote health equity, it would be necessary to address all important determinants of health disparities that can be influenced by institutional policies and practices. These include disparities in health care as well as other health determinants, such as the conditions of daily life and the circumstances in which people are born, grow, work, and age.

HOW? Measuring Health Equity and Health Disparities

Assessing health equity would require measuring changes over time in disparities in health status, health care, and the physical and social determinants of health—especially in relation to institutional policies and practices. As one approaches health equity, health disparities become smaller. Over the past 15 years, considerable work has been undertaken to monitor progress toward eliminating disparities. The data and methods that have been compiled in this body of work should guide future efforts to measure health equity.

WHAT? An Ecological Approach to Health Promotion

Health and health behaviors are determined by influences at multiple levels, including personal (i.e., biological, psychological), organizational/institutional, environmental (i.e., both social and physical), and policy levels. Because significant and dynamic inter-relationships exist among these different levels of health determinants, interventions are most likely to be effective when they address determinants at all levels. Historically, many health fields have focused on individual-level health determinants and interventions. Healthy People 2020 should therefore emphasize health-enhancing social and physical environments.

HOW? Addressing the Social and Physical Environments

Responsibilities for promoting healthful environments go beyond the traditional health care and public health sectors. Changes in social environments, physical environments, and policies can affect entire populations over extended periods of time and help people to respond to individual-level interventions. Policies that can increase the income of low income persons and communities (e.g., through education, job opportunities, and improvement in public infrastructure) may improve population health. Reducing inequalities in the physical environment (e.g., access to healthful foods, parks, and transportation) can also improve key health behaviors and other determinants, thereby helping to meet numerous health objectives.

WHAT? The Importance of Life Stages and Developmental Stages

Health is a consequence of multiple determinants operating in interacting genetic, biological, behavioral, social, and economic contexts that change as a person develops. A life course approach is therefore critical to population health improvement, improved length and quality of life, and reduced health disparities. There are three mechanisms by which exposures influence the development of health and disease over life span: accumulation of risk (whereby exposures and their effects accumulate, like weathering over time); critical periods (whereby biological or behavioral systems are "programmed" during periods of high sensitivity); and a pathway process (whereby factors in the social and physical environment reinforce other influences).

HOW? Tailored Clustering of Life Stages; Population Metrics for Healthy Development

There is no single, best way to cluster life stages, and they are not always age-determined. Healthy People 2020 data systems should permit tracking objectives by user-defined groups. Because development occurs across the life course, from pre-conception to the end of life, it is important to measure the building blocks of healthy development that occur throughout life.

Guidelines for Implementation of Healthy People 2020

The Intended Users of Healthy People 2020

Members of the public health community—especially federal, state and local health agencies—have traditionally been viewed as the primary audiences for Healthy People. The Advisory Committee proposes that Healthy People 2020 be designed for use by a wider range of key user groups in both the public and private sectors. Tailored messages and products are needed to make Healthy People useful for this expanded audience-base, which should include the general public, voluntary organizations, faith-based organizations, businesses, health care providers, decision-makers, researchers, community-based organizations, grass root advocates and other sectors whose actions have significant health consequences.

Criteria that Can Help Users to Prioritize Objectives

The Advisory Committee recommends that Healthy People 2020 seek to provide the best available information on key factors relating to each Healthy People 2020 objective in order to help organizations and individuals prioritize potential actions. Healthy People 2020 should assemble the best possible information on these factors for all objectives so that users can prioritize them as they prefer. Examples of prioritization criteria could include the effects of intervention strategies on specific at-risk groups on various outcomes, from survival to quality of life. Healthy People 2020 can help program planners in user organizations to select a realistic mix of points for intervention and action).

Organizing Objectives by Interventions, Determinants, and Outcomes

Past versions of Healthy People were primarily released in a printed, static format that could best be navigated through the use of easily recognizable chapter headings. These headings were called "priority areas" in the 1990 Health Objectives and Healthy People 2000 and "focus areas" in Healthy People 2010. For Healthy People 2020, the database approach recommended by the Advisory Committee would permit a more user-friendly approach that would not require assigning objectives to specific focus areas. Instead, objectives could be organized into three broad categories within the database: 1) interventions, 2) determinants, and 3) outcomes. These groupings would offer points of entry into the Healthy People 2020 user interface. The justification for specific objectives should include these categories to facilitate user searches.

Development of Health Objectives

Users need to know how targets for objectives are set and who has formulated them. Some targets may be set by extrapolating from recent trends; others may be based on expert opinion of what it might be possible to achieve, without assuming any new medical or scientific breakthroughs. In the absence of reliable, valid, current data, targets can be set by using the best estimate of current burden, and then assuming that existing interventions could be used to reduce that burden by a certain percentage. To help users understand their context, Healthy People 2020 objectives should be presented by type. For example, some objectives may be about improving health outcomes, while others may address processes or infrastructure.

Health Information Technology (IT) and Health Communication

Health IT and health communication should be mobilized to support the implementation of Healthy People 2020. Efforts should include building the public health IT infrastructure in conjunction with the National Health Information Infrastructure; extending the IT Strategic Plan developed by the HHS Office of the National Coordinator; integrating IT to meet the direct needs of Healthy People 2020 for measures and interventions; building on current health literacy and health communication efforts.

Next Steps

The Advisory Committee has begun work on Phase II of the Healthy People 2020 objective development process. Early discussions have addressed issues such as criteria for selecting objectives and setting targets for objectives. In the coming months, the Advisory Committee will provide ongoing advice to the HHS Secretary on topics such as: principles for formatting and writing objectives for Healthy People 2020; additional guidance on user needs for Healthy People 2020; guidance about implementation strategies to be included in Healthy People 2020; and a set of system requirements for the proposed database.

top of page

Continue to Section I. Introduction
Return to Phase I Report Table of Contents

Content for this site is maintained by the Office of Disease Prevention & Health Promotion,
U.S. Department of Health and Human Services.

Last revised: December 11, 2008