Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Revising the Phase I Report to the Secretary
Via online meeting
Fifth Meeting: September 4-5, 2008
Day 1: September 4, 2008
I. Introductions and Desired Outcomes of the Meeting
Dr. Jonathan Fielding, Committee Chair, welcomed the audience and
Committee members to the fifth meeting of the Secretary's Advisory
Committee on National Healthy Promotion and Disease Prevention Objectives
for 2020. He provided a brief overview of the agenda and meeting
expectations. The main purpose of the meeting would be to reach final
consensus on the Committee's Phase I recommendations to the Secretary.
Members would discuss how to translate these recommendations into a
well-organized, understandable report. While there would be subsequent,
limited opportunities for final edits to the report, revisions dealing
with more weighty issues would occur during this meeting. Dr. Fielding
noted that a secondary purpose of the meeting would be to begin discussion
of the Committee's work for Phase II of the Healthy People 2020
development process.
The main audience for the Committee's Phase I report is the HHS
Secretary, but Dr. Fielding said the report will also be important to the
Federal Interagency Workgroup (FIW) and various stakeholders. The
Committee can only make recommendations to the Secretary—it is not laying
plans for Healthy People itself. In its recommendations, the Committee has
sought to learn from past iterations of Healthy People in terms of how
objectives were set and how targets were reached. Dr. Fielding emphasized
that it is important to ask what has gone wrong in the past in instances
where objectives failed to reach their targets or regressed away from
them. He felt the Committee should focus on continuous quality improvement
(CQI) so that a higher percentage of objectives will reach their targets
in the future. He also called for stronger emphasis on disseminating
effective intervention strategies for all levels of the ecological model.
Dr. Fielding explained the process for reviewing and finalizing the
draft report. The WebEx meeting would finish early that afternoon so that
Committee members could complete follow-up writing assignments in smaller
groups. Their changes would be incorporated into a revised draft of the
report in time for the next day's meeting. Because each member would be
listed as co-author on the final report to the Secretary, Dr. Fielding
emphasized that their focused attention to the task at hand was critical.
He noted that the Committee's discussion of the report would focus on key
concepts and ideas during the meeting's first day, and would shift to how
these ideas can be operationalized in Healthy People 2020 during the
second day.
II. Update on the Healthy People Development Process
RADM Penelope Slade Royall, Office of Disease Prevention and Health
Promotion (ODPHP) indicated that the FIW, which is composed of
representative from all HHS agencies and offices plus other federal
departments, has begun drafting its own report for Phase I of the Healthy
People 2020 development process. The FIW's Phase I report will be released
in January of 2009. She then provided updates on the activities of the
FIW's various subgroups:
- The Non-HHS Partners subgroup had been exploring ways to engage new
partners. Federal departments external to HHS that were participating in
the FIW at that time included: the Department of Agriculture, Department
of Education, Environmental Protection Agency, Department of Veterans
Affairs, and Department of the Interior.
- The Vision and Framework subgroup endorsed a risk factors and
determinants approach to Healthy People and supported the Advisory
Committee's vision, mission, and overarching goal statements. Moving
forward, it will consider how objectives will be developed.
- The Health Communication and Health Information Technology (health
IT) subgroup has recommended that health IT be integrated with health
communications in Healthy People 2020. They have also recommended
developing a virtual, nationwide "Healthy People Community" that would
provide an infrastructure for engaging the entire nation in Healthy
People 2020.
- The Preparedness subgroup recommended that existing measures be used
for preparedness within Healthy People whenever possible. RADM Royall
noted the rapid evolution of and difficulty of measuring preparedness
issues. The scope of the section on preparedness should be broad but not
comprehensive, and should permit change over time. Healthy People 2020
may include a focus area on preparedness in an effort to link to the
current actors in preparedness. A preparedness section could also
provide an overview of preparedness for public health practitioners.
III. Building on Past Experience
Dr. Fielding suggested the Committee begin its discussion of Draft I of
the report (dated August 27, 2008) with the section on "Building on Past
Experiences." He asked whether the draft highlights the right strengths
and weaknesses of past efforts and whether proposed solutions were
adequate. Committee members commented extensively on the need to: present
final assessments of progress in achieving Healthy People objectives when
available; comment on instances when progress in reaching objectives has
been inadequate; and add a "lessons learned" column for each of the
columns in the exhibit on page 13 (see
Appendix A).
A committee member noted that the page 13 exhibit relied on Midcourse
Review data in several cases. When final assessments are not available, he
felt it was important for the report to clearly note this. There has been
great enthusiasm for assessing progress during midcourse reviews, but at
the end of the decade the focus tends to be on setting objectives for the
coming decade, rather than on looking back. He asked whether there had
been a final review of Healthy People 2000. Ms. Carter Blakey, ODPHP, said
the Healthy People 2000 data in the exhibit were from the final review.
She offered to find out whether final results for the 1990 Health
Objectives had been published. A Committee member commented that the
category "Unlikely to Achieve" is a projection based on provisional data.
He suggested that the table be revised to include a column, "Did Not
Achieve." Dr. Patrick Remington and Dr. Shiriki Kumanyika agreed to
work on this revision.
Dr. Fielding recommended such a discussion include details on a CQI
process for Healthy People 2020. A Committee member added that data are
needed to accomplish CQI. She was struck by the fact that 40 percent of
the objectives for Healthy People 2010 did not have data to track
progress. Dr. Fielding said that there are many different levels of data.
CQI should occur around the country at the state and local levels, in
medical societies, and among public health organizations and other
stakeholders. It does not need to take place within the federal
initiative. He argued that Healthy People shouldn't be hamstrung by
insufficient national-level data. There may be enough data for people to
act regionally or locally. A Committee member stated that the Committee
should comment specifically on the need for data, since funding for
national survey initiatives has waned recently. Dr. Fielding asked Dr.
Lisa Iezzoni to write language about survey funding. He agreed to work
with others on language about CQI.
Dr. Kumanyika, Committee Vice-Chair, felt it was important to comment
on the percentage of objectives that have achieved their targets each
decade. It might be helpful to look at the nature of the objectives that
have been achieved—especially for subgroups that experience disparities.
Dr. Fielding said that targets for Healthy People objectives were set in
different ways; some could be reached easily; others were ambitious. The
Committee should examine how objectives were developed so they can
interpret the columns. Dr. Kumanyika noted that it is important to look at
how success is evaluated. She noted that this table is descriptive, but
analysis is required to clarify how we can learn from it. Dr. Kumanyika
agreed to write this analysis.
A Committee member directed the Committee's attention to the exhibit on
page 10 (see Appendix B). He said it is important to differentiate between
the terms "priority area" and "focus area." This may help the Committee in
its efforts to recommend terminology for Healthy People 2020. NORC staff
clarified that a reason for the change from the term "priority area" to
"focus area" was that people had mistakenly concluded that "priority
areas" had been prioritized. The term "focus area" was adopted to address
this area of confusion. The Committee member felt that the distinction in
language was important. Other issues raised by Committee members for this
section were as follows:
- The Committee should take a position on the utility of
"developmental objectives" (these have traditionally been created when
no baseline data sources exist for an indicator). Developmental
objectives highlight important issues, but there is a risk that data
sources will not be created to track them; in such cases they would fall
into the "data unavailable" category at the end of the decade. It is
therefore important to monitor progress toward finding baseline data for
developmental areas.
- Healthy People 2020 should draw on best evidence and discuss how to
use it. This explanation could be placed in the section on past
iterations and insufficient progress, or elsewhere in the document.
- The percentages in the second and third row of the table on page 13
do not total 100 percent.
IV. User Questions and Needs
Dr. Fielding directed the Committee's attention to the exhibit on pages
17 and 18. Dr. William Douglas Evans, Chair of the Subcommittee on User
Questions and Needs, said the exhibit appears without an introduction
stating that user needs are a high priority for Healthy People 2020. The
notion that the Committee recommends using consumer needs as a way to
organize Healthy People 2020 is not communicated until a later section.
The strongest way to emphasize the importance of users would be to create
a new goal. An alternate approach could be to list this issue among the
conceptual recommendations. A Committee recommended including the full
audience matrix that had been prepared by the Subcommittee on User
Questions and Needs in the body of the report. This would clarify that
consumers are an important user group. Dr. Evans went on to explain that
the proposed relational database would operationalize a consumer
orientation. Dr. Fielding asked if it would be enough to change the
exhibit in the draft, or if an additional goal would be necessary. Dr.
Evans said that an additional goal may not be necessary. Dr. Evans
agreed to present a suggestion for where this principle should be inserted
in the report's introduction.
Dr. Kumanyika raised concerns about the term "consumer," which can be
interpreted as referring to the individual citizen; the Committee
generally recommends emphasis on structural changes. The report should
clarify that use of this term does not shift responsibility for meeting
Healthy People goals to individuals. Another member argued that the report
should not leave the impression that consumers are less important than
power brokers. Outreach will be necessary to engage consumers, but it is
impossible to discuss social determinants without discussing how they
impact consumers. Dr. Kumanyika suggested it may help to delineate
non-primary audiences that are not directly accountable. Dr. Fielding said
thinking through user groups could help to guide development of the
database. Dr. Evans said that the group should make sure that the language
is clear. Dr. Evans and Dr. Kumanyika agreed to take on this writing
assignment.
Dr. Fielding expressed concern about including "broad levels" (i.e.,
national, state, and local) in the table. He felt the categories assigned
at each level were not accurate and that the organizations should not be
differentiated by level. Another member volunteered to work with others to
come up with a more informative table. She expressed concern that
"non-traditional partners" were not adequately represented in the exhibit.
Dr. Kumanyika suggested discussing the users list from a recent WHO
report. She suggested adding the private sector as a user group.
V. The Value of Prevention
Dr. Fielding stated that the Committee should not suggest that
prevention is effective in all situations. There are cases when disease is
not preventable and treatment is necessary. He suggested revising the
language accordingly. A Committee member said that someone who has a
disease that is not preventable and currently cannot be treated would find
this section upsetting. There must be some recognition that not all
diseases or conditions can be prevented. Politicians have been discussing
potential cost savings from prevention, but she noted this idea remains
controversial.
A Committee member said that prevention is a tool, but is not
intrinsically a "value." He expressed the view that sometimes it is
beneficial to prevent things, and sometimes prevention is a waste of
resources that can do harm. The Committee discussed whether prevention is
a tool, value, or area of emphasis. Another member voiced concern about
diminishing the importance of prevention in favor of greater emphasis on
cost effectiveness. Dr. Kumanyika also argued against the suggestion that
prevention might be harmful to patients, and questioned the need for
negativity on this issue. Members agreed that this section's tone should
acknowledge that prevention is not the only solution, but it is a solution
that deserves attention.
Other issues mentioned included the influence of social determinants on
the effectiveness of prevention, and the importance of advocating for
future prevention research. Health promotion activities should also be
mentioned as an important aspect of prevention. Dr. Kumanyika, Dr.
David Meltzer, Dr. Abby King, Dr. Iezzoni, and Dr. Ron Manderscheid
volunteered to contribute to revising this language.
VI. Ecological Approach
Dr. Abby King, Chair of the Subcommittee on Environment/Determinants,
directed the Committee's attention to the draft action model described on
page 35 of the report, and said it needed further revision. Dr. Fielding
said the model was on the agenda for discussion during the second day of
the meeting, and asked whether the members would prefer to discuss it now.
Dr. Kumanyika indicated that at this point in time, she would prefer to
talk about the ecological approach and how it aligns with the model. The
Committee went on to discuss the section of the report addressing an
ecological approach. Dr. Fielding noted that one of the written comments
on the draft recommended including a chapter or a short section on the
multilevel nature of health determinants. Dr. Manderscheid agreed to
develop this language.
Dr. Kumanyika asked whether the term "ecological approach" should serve
as a header or an explanation. She felt the term "multilevel approach"
would sound less abstract to those who have not read the Institute of
Medicine report. Dr. King supported this change, but suggested including
the words "ecological model" in parentheses as well, for people who are
familiar with the term. The Committee agreed to this revision.
Dr. Fielding asked whether the multilevel graphic on page 49 (see Appendix
C, "Healthy People 2020 Proposed Multi-Level [Ecological] Approach")
should be placed in an appendix or in the main report. There was
disagreement on this issue; one member felt it should be included in the
main report to inform the text; another believed it did not clarify the
text enough to merit inclusion. Members discussed the need to simplify the
graph and to clarify the meaning of the colored bars. Some felt the
graphic was a distraction; others found it useful. A Committee member
proposed two possible solutions: either use an existing socio-ecological
model (such as the one in the IOM's Future of Public Health report) or
continue to work on it. Another member suggested combining the ecological
model with the Healthy People 2020 Action Model on page 24 (see Appendix
D) to suggest that sophisticated interventions to address complex problems
often operate at multiple levels. Dr. Remington, Dr. King and Ms. Eva Moya
agreed to revise the graphic.
A Committee member expressed disagreement with the way that the left
column of the Action Model was prioritized. He felt that family life
should be shown as a primary concern and secondary concerns should
include: 2) equity and social justice, 3) social environment, 4) physical
environment and 5) health systems. Dr. Fielding said these concerns would
be more fully discussed on the second day of the meeting.
Dr. Fielding added that the report's verbiage should address the
importance of policies. Another key issue would be to add clear examples
from other sectors. He went on to say that agricultural and energy
policies can affect health and pointed to distributional effects. A
Committee member requested that the Americans with Disabilities Act (ADA)
should be included, although it's a law, not a policy. Examples of the
ADA's relevance in this context would be ensuring that parks and
healthcare settings are accessible. Dr. Iezzoni agreed to add a sentence
on ADA to this section. Dr. Fielding offered to write sentences on
agriculture and energy policy.
VII. Health Equity and Disparities
Dr. Fielding moved on to the subject of health equity and disparities.
A Committee member said that the report's discussion of root causes (e.g.
income, education, discrimination) of health disparities was inadequate.
Dr. Meltzer agreed to draft language on root causes. Another
Committee member found the definition of health disparities to be
circular. Dr. Kumanyika referenced the national strategic plan for health
disparities, saying that the language was far simpler. That document
discussed social inequities. Dr. Kumanyika said that she would look at
that definition as the Committee's current definition may be too
complicated for the average person. Dr. Fielding commented that some
readers of the definition might have difficulty with it because to them,
disparities just mean "differences," without all of the connotations in
this definition. He asked if there was a way to convey the same
information more succinctly. Dr. Troutman and Dr. Siegel agreed to
expand on the current definition of health disparity.
A Committee member asked "whose" effort is being referred to in the
definition of health equity. She objected to the framing of health equity
as an individual issue, and said it should be a societal effort. Another
Committee member argued that health equity is not a continuous effort, but
a phenomenon. A Committee member who had taken part in the Subcommittee on
Health Equity and Disparities reminded the Committee that they had all
agreed at a previous meeting to frame health equity as both a definition
and a process. He asked members to keep the extensive previous
conversations on this issue this in mind when rewriting. Dr.
Manderscheid agreed to revise the definition of health equity with input
from Vincent Felitti.
Dr. Fielding indicated that the Committee would take a 40 minute break
and reconvene at 1 PM EDT. Members who were working on brief revisions met
during the break. Groups that needed a longer discussion to work on
revisions planned to meet after the meeting. Members agreed to send
revisions to NORC staff.
Break
VIII. Developmental Stages, Life Stages
Dr. Fielding directed Committee members' attention to pages 29-31 of
the Draft I report. A Committee member noted that the report's
discussion of life stages does not offer any specific cut points (e.g.,
specific clusterings of age groups). Dr. Remington, Chair of the
Developmental and Life Stages subcommittee, said the group received
input from experts in the field who concluded that there is no single
best way to cluster life stages. Cut off points vary significantly by
organization, such as the Census, CDC, and others. The subcommittee
thought it would be better to give examples of age group clusters and
then point out that there is no way to categorize them definitively. A
Committee member said that early childhood development deserves
additional attention. Dr. Fielding noted that the report includes
examples of age group clusters, such as gestation and infancy. Dr.
Fielding asked NORC to draft some language on these issues.
Some members found the definitions of life stages and developmental
stages to be overly academic and long. Dr. Kumanyika pointed to page 30,
saying that this section includes an important discussion of the
categories as they are used in the context of monitoring. Dr. Remington
agreed that the section could be shortened. He said the report should
recommend flexible use of life stages (without specific cut off points)
and developmental stages (e.g., adolescence, menopause, and retirement).
Another member added that the definition of "life stages" should be
further refined. Dr. Remington agreed to update this language.
VIII. Developmental Stages, Life Stages
Health IT
Dr. Fielding said the Committee should decide to what extent health
IT should be detailed in Phase I of its work, versus Phase II. He noted
that Dr. Manderscheid had led the effort to prepare the section on page
20 of the draft and asked him to lead this discussion. Dr. Manderscheid
indicated that the health IT working group looked into a number of
issues, including: the status and future of the public health IT
infrastructure; the structuring of epidemiological data nationally; and
local health officials access to data and subsequent application of data
to local health problems. Other questions addressed included: What has
the nation done to provide IT support for local public programs? How can
IT be used to reach out to the general population?
Dr. Manderscheid discussed how the Office of the National Coordinator
(ONC) strategic plan for IT addresses personal health, health care, and
population health. The plan considers the issues of privacy,
interoperability, accountability and collaborative governance. The
subcommittee's discussions thus far have revolved around the reporting
of Healthy People data. Dr. Manderscheid recommended working towards
building measures, getting solutions for those measures, and developing
plans for achieving the stated goals. The role of the relational
database in organizing these aspects of Healthy People 2020 has not yet
been defined. He said the Committee should not think of health IT as
completely apart from health communication, as the latter relies heavily
on IT infrastructure. Dr. Manderscheid then reviewed the subcommittee's
recommendations for Healthy People 2020. He recommended that the
Committee devote more time to discussing these areas during Phase II.
Healthy People 2020 should address the agenda for public health IT infrastructure through the National Health Information Infrastructure, including how it would affect operations at all levels.
Healthy People 2020 should capitalize and build upon the vision of the ONC IT strategic plan, extending beyond the plan's current 2012 end date to an end-date of 2020.
Healthy People 2020 should use IT to better meet its own goals around measures and solutions.
Healthy People 2020 should build on current work on health literacy and health communication. The idea of a
"Healthy People Community" is being considered for this purpose.
Dr. Fielding asked Committee members if they were satisfied with the
idea of the Healthy People Community (a network of Healthy People users)
and the draft section on the digital divide. One Committee member
indicated that the language as written may not be accessible to the
general public. Dr. Manderscheid offered to work with Dr. Felitti to
adjust this language accordingly.
Dr. Fielding believed that the Committee should be cautious when
discussing the digital divide. Today, access to computers may be less of
a problem than access to legitimate information. Dr. Kumanyika indicated
that the discussion of the digital divide on page 20 could be made more
general—expanding beyond socioeconomic considerations to include
cultural, psychosocial, and age inclinations to use computers—regardless
of whether or not they're available. Dr. Manderscheid volunteered to
rework the language on page 20.
Another Committee member said that she liked this section's emphasis
on health literacy. She cautioned that there are broader literacy
challenges, and that different languages are also important to consider.
Dr. Manderscheid referred to the appendix on page 48 linking the
proposed Healthy People Community to specific determinants of health. A
Committee member said this section should mention that there are other,
non-digital options for those with limited access to Healthy People
online. Dr. Fielding agreed that Healthy People 2020 needs to offer a
range of distribution channels to the public.
All Hazard Preparedness
The Committee moved on to discuss the section on all hazards
preparedness. Dr. Fielding asked Committee members if they had problems
with the section in general. A Committee member noted that a fellow
member had left the meeting early to attend to evacuees from Hurricane
Ike who were sheltered in his area. His work highlights the important
role of the public health sector in preparedness. Another Committee
member suggested including ways to engage the business community in
preparedness response (e.g., providing a fleet of vehicles in emergency
situations), especially at a local level. Dr. Fielding agreed with this
suggestion.
X. Summary of Overnight Assignment
Writing Assignments for Revising the Draft Report
Writing assignments were emailed and read out loud to the Committee
(see Table 1 on page 10). Members
agreed to submit revisions to NORC staff by 5 PM that evening. The
submitted revisions would be incorporated into an updated draft of the
report and emailed back to Committee members. Dr. Fielding added that
the Committee would not allot as much time for thorough discussion of
the report's content on the meeting's second day.
Dr. Fielding suggested that the Committee reach out to individuals
who have not been involved in the writing the report and ask them to
review it for flow and consistency. He asked Committee members to send a
total of three to four recommendations via email to him and Dr.
Kumanyika.
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