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

Section IV. Advisory Committee Findings and Recommendations

The Role and Function of Healthy People 2020

What is Healthy People 2020? What should it Do, and Why?

The Advisory Committee believes Healthy People 2020 can best be described as a national health agenda that communicates a vision and a strategy for the Nation. Healthy People 2020 should provide overarching, national-level goals. On a practical level, it is a road map showing where we want to go as a nation and how we are going to get there—both collectively and individually. Healthy People 2020 must be both inspirational and action-oriented. It should offer leadership, guidance, and direction from HHS and its many partners to stakeholders and users at all levels.

To close the gap between where we are now and where we would like to be by the year 2020, 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 many partner organizations 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. In so doing, Healthy People 2020 can touch the lives of every American.

What Form Should Health People 2020 Take?

The Advisory Committee recommends that Healthy People 2020 differ in form from previous iterations. Healthy People should no longer be known primarily as a print-based reference book that will be kept on the shelf for a decade. Instead, it should also be a Web-accessible database. Through this medium, Healthy People 2020 can more effectively help stakeholders to improve population health by helping them to access metrics and guidance.

In its electronic form, Healthy People 2020 would offer an 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, accessible to all user-levels. Insights gained from the process of developing a Web-accessible database (e.g., understanding how different objectives relate to one another within categories) can be used to prepare a more intuitive, user-friendly version of the printed volume of Healthy People 2020.

What is the Intended "End-product" of Healthy People Use?

In the past, Healthy People has given users a wealth of data, including baselines and targets, but it has not provided clear guidance on what users should do to help reach the targets. An interactive, Web-based version of Healthy People could generate state-, region-, and community-specific implementation plans based on information entered by users. As a Web-accessible database, Healthy People 2020 should engage users in an interactive, action-oriented process that would help them to: 1) enter criteria based on their own interests and needs, 2) assess priorities using Healthy People 2020 objectives and data, 3) identify research-tested intervention programs and products, and 4) act on opportunities.

One of the benefits of this proposed approach to Healthy People 2020 is that it can be used by many different groups to identify opportunities based on their respective missions, visions, and goals. Healthy People 2020 users who are focused on different populations (e.g., by geographic location, population, risk, and disease characteristics) have different informational needs. Examples of questions that may motivate users to seek out Healthy People 2020 are presented in Appendix 9.

The Vision and Mission of Healthy People 2020

The Advisory Committee believes that 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—is meant to offer clear information about what Healthy People does for the Nation, and how the public can use it. It reflects the view that Healthy People offers practical guidance on using data and knowledge, as well as education and other actions to improve population health in communities.

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 calling for healthy places and supportive public policies, placing particular emphasis on the determinants of health. They reflect the Advisory Committee recommendation that Healthy People 2020 be designed to redirect our attention from health care to health determinants. Health determinants should be a primary focus of Healthy People 2020; health care, a secondary focus.

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. To improve health in the coming decade, Healthy People 2020 should target reductions in adverse social and physical determinants as important areas for assessment and intervention.

• Social determinants include family, community, income, education, sex, race/ethnicity, place of residence, and access to health care, among others. People who lack social and economic resources are likely to be less healthy, which may both result in and result from discrimination. Frequently, issues of equity and social justice are involved in the social determinants of health.
• Physical determinants include our natural and built environments. Exposure to natural toxins (e.g., coal tar), manmade pollutants, or substandard housing are examples of physical determinants that can adversely affect our health.

The four proposed overarching goals for Healthy People 2020 are listed below, and are described in greater detail in this section. These goals are highly interrelated. In the discussion that follows, an explanation is provided for each proposed goal in terms of WHAT the goal is about, and HOW it can be implemented or achieved.

Action Model to Achieve Healthy People 2020 Goals

The action model on the next page (Exhibit 3) shows a feedback loop of intervention, assessment, and dissemination that would enable achievement of Healthy People 2020 overarching goals. It is adapted from an Institute of Medicine (IOM) model that illustrates the determinants and ecological nature of health across the life course.¹⁰ Interventions (i.e., policies, programs, and information) impact the 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. Results of such interventions are demonstrated through assessment, monitoring, and evaluation. Through dissemination of evidence-based and best practices, these findings feed back to intervention planning to enable the identification of effective prevention strategies in the future.

Exhibit 3. Action Model to Achieve Healthy People 2020 Overarching Goals

GOAL 1: WHAT? Emphasize the Importance of Prevention and Health Promotion

Healthy People 2020 serves as a champion, a guide, and a resource for the Nation's health promotion and disease prevention efforts. Since the start of Healthy People three decades ago, health promotion and disease prevention have been important emphases of the initiative. 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 overarching goals of Healthy People 2020.

Health promotion and disease prevention apply to all people, not only those without evident health problems. Even in people with significant diseases or conditions that cannot be prevented or cured with the application of current knowledge, health promotion and disease prevention efforts can slow functional declines or improve their ability to live independently and participate in daily activities and community life.

The World Health Organization defines prevention as approaches and activities aimed at reducing the likelihood that a disease or disorder will affect an individual, interrupting or slowing the progress of the disorder, or reducing disability.¹¹ This broad explanation encompasses more specific categorizations of types of prevention, such as the three levels of prevention of the Commission on Chronic Illness¹² (primary, secondary, and tertiary),^vi which is based on the continuum of disease development, or Gordon's¹³ three tiers of prevention (universal, selective, and indicated),^vii which is based on the segment of the population targeted.

Health promotion is a process of enabling people to increase control over their health and its determinants, and thereby improving their health.¹⁴ On a global scale, guiding principles in health promotion include: empowerment of individuals and communities for health promotion; achievement of health equity; development of infrastructure for health promotion; social responsibility of the public and private sectors in promoting health; partnerships, networking and building alliances for health; and improvement of individuals' attention to their own health.

A potential benefit of health promotion and disease prevention efforts is that they seek to control and limit the development of new cases of disease and disability. Improvements in the population's overall health, functional status, and longevity result when effective prevention strategies are applied to entire populations to limit the number of new occurrences of a health problem. Within a population, screening to identify established cases of disease and disorder, and early treatment for these cases, can also lead to improvements in population health.

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. For example, a body of evidence on community-based approaches and interventions, such as using community health workers and promotoras to encourage healthy behaviors (e.g., condom use, healthy eating) suggest positive outcomes in terms of empowerment, adoption of healthy behaviors, and reduction of risks.^15,16

The need to identify current and enable future effective prevention strategies is especially critical for problems affecting large segments of the population. The obesity epidemic offers a good example of this need. The large numbers of people affected and the high cost of effective treatment on a continuous basis for obesity and its associated health consequences highlight the importance of prevention.

Health promotion and disease prevention strategies include a diverse array of activities that are applied at multiple levels to improve underlying and more immediate determinants of health in the population and among individuals. Long term investments in upstream strategies (i.e., addressing factors that are rooted in broad social systems, and processes that are beyond the control of individuals or specific sectors) are as important as strategies that focus on shorter-term clinical prevention and other direct services to individuals.

A mix of preventive and treatment or remedial strategies is needed to alter the complex dynamics of biological, environmental, and psychological 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.

GOAL 1: 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 concern about an influenza pandemic 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 the issue should be highlighted in Healthy People 2020. Because preparedness for all emergencies involves common elements, an "all hazards" approach is necessary.

Most emergencies have the potential for serious adverse effects on the health of the public. Public health has primary responsibility for working to minimize the health consequences of natural or man made disasters. Preparedness requires the effective deployment of most of the core public health functions. For example, surveillance is critical to detect specific problems, to identify populations at risk, to allocate emergency resources, and to monitor the response and its effectiveness.

Establishing effective communication systems to alert and deploy personnel and other resources is also essential, as is developing timely and sensitive messages to communicate to a public that is diverse with respect to culture, language, and literacy skills. Such systems must take into consideration that many members of the pubic have been marginalized by poverty or other forms of social disadvantage. Effective communication should convey the nature of the problem, the steps being employed to ameliorate it, and what the public should do to minimize their risk, seek treatment, and help others.

Minimizing adverse health, social, and economic effects requires collaborative effort from a variety of public sector stakeholders, including agencies concerned with public health, health care, fire, law enforcement, intelligence, social service, and critical infrastructure agencies (e.g., transportation). Private sector stakeholders such as businesses must also be engaged. Persons with significant health problems and disabilities are at particular risk.

The nature of threats from some natural disasters differs substantially by geography. Different regions of the country are prone to earthquakes, wildfires, hurricanes, tornadoes, and floods. While some risks are predictable by region, others are not. For example, the first case of a novel or easily transmissible infectious diseases such as H5N1 influenza (or other new strains), SARS, or Ebola could start in one or more places almost anywhere in the United States. Emergencies also rarely respect geo-political boundaries, so inter-jurisdictional planning for coordinated response is needed.

The timing of public health responses to natural and man made disasters is critical. Often a very rapid response can reduce the number of deaths and minimize the number or and severity of illnesses and injuries. This response includes rapid assessment of the nature and extent of the problem, mobilization of appropriate assets, definition of exposure groups and countermeasures (prophylaxis, treatment, etc.) and development and delivery of key messages to the public. The rapidity and accuracy of these measures determines the degree to which human health consequences can be limited.

Various sets of requirements for preparedness of public agencies and their community partners have been developed. These are frequently modified based on changes in the nature of the threats, technology and experience. Examples of Federal agencies that have been involved in this work include the HHS Centers for Disease Control and Prevention (CDC) and the Office of the Assistant Secretary for Preparedness and Response (ASPR). Preparedness objectives for Healthy People 2020 could relate to existing preparedness goals contained in the CDC's Public Health Emergency Preparedness Cooperative Agreement, defined as follows:

• DETECT – Identify the cause and distribution of potential threats to the public's health through epidemiologic, laboratory, and intelligence agency surveillance.
• CONTROL – Provide medical countermeasures and health guidance to those affected by threats to the public's health.
• MAINTAIN – Assure continuity of essential services during a public health emergency.
• RECOVER – Restore public health services and assure environmental safety following threats to the public's health.
• PLAN – Complete and refine key public health response plans.
• TRAIN & EXERCISE – Improve the ability of the public health workforce to respond to emergencies.

Emergency preparedness health objectives should be developed for all of the intended user groups of Healthy People 2020. Since preparedness addresses our collective safety, it is essential that these objectives be compatible with those developed for and by other agencies responsible for public safety, including fire, police and intelligence agencies, the National Guard, and the military. As there is significant investment in preparedness, in new technology, in improving systems, and in enhanced training, frequent review and revision of objectives for this area would be required.

GOAL 1: 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 a trained public health workforce, information and communication systems used to collect and disseminate accurate data, and public health organizations at the state and local levels. Essential public health services include the three core public health functions (assessment of information on the health of the community, comprehensive public health policy development, and assurance that public health services are provided to the community) and the 10 essential public health services.^viii All governmental and nongovernmental agencies delivering these services are part of the public health infrastructure.¹⁷ A major task of Healthy People 2020 will be to enlist the support of other institutional sectors in improving community health.

To maximize population and individual health, multi-disciplinary, interdisciplinary and intersectoral partnerships are needed. Such intersectoral partnerships should occur with all major institutional sectorsgovernment, business, education, religion, and families. Government must be involved at all levels. Examples of stakeholders who should be engaged in efforts to improve population health include: public health, health care financing, social services, cultural organizations, schools, employers, health care organizations, municipal planners, transportation departments, food industry manufacturers and suppliers, builders, media companies, community businesses, faith-based organizations, and families. By working together, such partnerships can address the web of multi-level factors that affect health. The process of building dynamic, productive, self-determining partnerships and collaborations is critical. The partners should ultimately decide which objectives to adopt and maintain.

The Healthy People 2020 Action Model points the way to multi-level interventions that take into account the multiple determinants of health over the life course. In the IOM model upon which the Healthy People 2020 Action Model is based, "social conditions" are defined as including, but not being limited to: economic inequality, urbanization, mobility, cultural values, attitudes, and policies related to discrimination and intolerance on the basis of race, gender, and other differences. At the national level, other conditions might include major sociopolitical shifts such as recession, war, and governmental collapse. The "built environment" includes transportation, water and sanitation, housing, and other dimensions of urban planning.¹⁸

The Healthy People 2020 objectives guide interventions and enable the monitoring of progress in achieving improved outcomes. Objectives can be layered in levels of detail appropriate to the nature of the objective, the level at which action must occur (e.g., federal, state, or local), and the needs of various user groups. For example, such mapping could highlight:

• objectives that relate to different issues, but operate at the same level;
• objectives that relate to the same issue, but operate at different levels;
• objectives that work through different mechanisms;
• objectives that offer complementary influences on a single pathway; and
• coverage of priorities.

GOAL 2: WHAT? Achieving Health Equity and Eliminating Health Disparities

Eliminating health disparities and promoting health equity will require addressing all important determinants of health disparities that can be influenced by institutional policies and practices. These include disparities in health care, but also in other health determinants, such as the living and working conditions that are needed for health. Social policies related to education, income, transportation, and housing are powerful influences on health, as they affect factors such as the types of food one can buy, the quality of the housing and neighborhood where one can live, the quality of one's education, and one's access to good quality medical care. There are a variety of definitions of health disparity and health equity. For the purposes of this report, the Advisory Committee has defined the terms as follows.

A health disparity is a particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, mental health, cognitive, sensory, or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.¹⁹

The general public usually understands the term "health disparity" as referring to any difference in health. However, in the U.S. public health community and as defined by the Advisory Committee in this document, the term refers to a particular type of health difference between individuals or groups that is unfair because it is caused by social or economic disadvantage.

Health equity is a desirable goal/standard that entails special efforts to improve the health of those who have experienced social or economic disadvantage. It requires: (1) continuous efforts focused on elimination of health disparities, including disparities in health care and in the living and working conditions that influence health, and (2) continuous efforts to maintain a desired state of equity after particular health disparities are eliminated.^20,21,22,23 Health equity is oriented toward achieving the highest level of health possible for all groups. Achieving health equity requires both short- and long-term actions:

• Particular attention to groups that have experienced major obstacles to health associated with being socially or economically disadvantaged.
• Promotion of equal opportunities for all people to be healthy and to seek the highest level of health possible.
• Distribution of the social and economic resources needed to be healthy in a manner that progressively reduces health disparities and improves health for all.
• Attention to the root causes of health disparities, specifically health determinants, a principal focus of Healthy People 2020.

The concepts of health equity and health disparity are inseparable in their practical implementation. Policies and practices aimed at promoting the goal of health equity will not immediately eliminate all health disparities, but they will provide a foundation for moving closer to that goal. (See Appendix 10 for illustrative examples of Health Disparities and Health Equity.)

GOAL 2: HOW? Measuring Health Equity and Health Disparities

Assessing health equity will 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 by several HHS agencies and offices (i.e., the Office of Minority Health, the CDC, the Agency for Healthcare Research and Quality, the National Cancer Institute, the World Health Organization, and others). The data, methods, and standards for measuring and monitoring health determinants that have been compiled in this work should guide future efforts to measure health equity, and should inform immediate action by public health agencies at the federal, state, and local levels to improve capacity to monitor health equity. (See Appendix 11 for additional detail on measuring these concepts).

GOAL 3: WHAT? An Ecological Approach to health promotion

Health and health behaviors are determined by influences at multiple levels, including personal (biological, psychological), organizational/institutional, environmental (both social and physical), and policy levels. Because significant and dynamic interrelationships exist among these of health determinants, interventions are most likely to be effective when they address determinants at all levels.

The tobacco control experience indicates that multi-level interventions, including strong environmental and policy components, can be effective in creating long-term, population-wide improvements in health behavior and health outcomes. Intervention at one or two levels is usually insufficient to produce widespread and long-lasting change. Motivating people to change health-related behaviors when social and physical environments are not supportive often leads to weak, temporary change. Similarly, creating favorable physical environments does not ensure that people will take advantage of opportunities; motivation and instruction also are needed.

Healthy People 2020 should identify the most promising intervention strategies at each level and across levels. Whenever possible, it should also encourage implementation of multi-level interventions for each health area. (See Appendix 12 for a matrix intended to guide planning of such interventions.)

Given the historical focus of many health fields on individual-level health determinants and interventions, health-enhancing social and physical environments should be emphasized in Healthy People 2020. The interactions between individuals and their environments, both physical and social, can impact a wide range of health, functioning, and quality of life outcomes. 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. Improved environments may be most beneficial for those population groups who are in less favorable environments, with fewer personal resources to counteract these environments. Depending on the policies, positive or negative health impacts are more likely to be felt in low income populations.

The social environment includes interactions with family, friends, coworkers, and others in the community, as well as societal attitudes, norms, and expectations. It encompasses social relationships and policies within settings such as schools, neighborhoods, workplaces, businesses, places of worship, health care settings, recreation facilities, and other public places. It includes the social aspects of health-related behaviors (e.g., tobacco use, substance use, physical activity) in the community. It also encompasses social institutions, such as law enforcement and governmental as well as non-governmental organizations. Economic policy is one important component of the social environment.

At the community level, the social environment reflects culture, language, political and religious beliefs, social norms and attitudes (e.g., discriminatory or stigmatizing attitudes). It also includes socioeconomic conditions (e.g., poverty), exposure to crime and violence, social cohesion, and social disorder (e.g., the presence of trash and graffiti). Mass media and emerging communication and information technologies, such as the Web and cellular telephone technology, are ubiquitous components of the social environment that can affect health and wellbeing. The availability of resources to meet basic daily needs (e.g., educational and job opportunities, adequate incomes, health insurance, personal assistance services, and healthful foods) is an important facet of the social environment.

At a societal level, policies made in governmental, corporate, and non-governmental sectors can impact health and health behaviors in whole populations both positively and negatively. At the same time, individuals, their behaviors, and their ability to interact with the larger community contribute to the quality of the social environment, as do the resources available in neighborhoods and the community.

Physical environment includes the natural environment (i.e., plants, atmosphere, weather, and topography) and the built environment (i.e., buildings, spaces, transportation systems, and products that are created or modified by people). Physical environments can consist of particular individual or institutional settings, such as homes, worksites, schools, health care settings, or recreational settings. Surrounding neighborhoods and related community areas where individuals live, work, travel, play, and conduct their other daily activities are elements of the physical environment.

The physical environment can harm individual and community health, especially when it exposes individuals and communities to toxic substances, irritants, infectious agents, stress-producing factors (e.g., noise) and physical hazards. Such exposures can occur in homes, schools, worksites, and other settings, and through transportation systems. Physical barriers within these environments can present tangible safety hazards or impediments to persons with disabling conditions. The physical environment also can promote good health and wellbeing. For example, aesthetic elements can be included in a neighborhood, or community settings and environments can be provided to facilitate healthful behavioral choices in such areas as diet, physical activity, alcohol use, and tobacco use.

GOAL 3: HOW? Addressing the Social Environment

Because social environment is important to the determinants of health, interventions that can improve the social environment should be considered as a component of producing a healthy population. Policies that can improve the income of low income persons and communities—for example through education, job opportunities, and improvements to public infrastructure—may improve population health.

Improving rewards for productive economic activity, whether by eliminating disparities in pay for equal work due to discrimination, or by reducing taxes for earnings by lower income persons, could promote economic well being of vulnerable populations and thereby contribute to their health. Better education can increase incomes and empower individuals to more effectively promote their own health. These examples are not meant to suggest specific policy options. Rather, they offer a reminder that policies affecting the underlying socioeconomic determinants of health, whether positively or negatively, should be considered as a part of producing a healthier population in the United States in the coming years.

Addressing the Physical Environment by Promoting Environmental Justice

According to a 1991 report submitted by Delegates of the National People of Color Environmental Leadership Summit to the U.S. Environmental Protection Agency, the environmental justice movement represents, "the confluence of three of America's greatest challenges: the struggle against racism and poverty; the effort to preserve and improve the environment; and the compelling need to shift social institutions from class division and environmental depletion to social unity and global sustainability."²⁴

An important aim of harnessing social and physical environmental factors is to increase health equity and to decrease health-related inequalities. Doing so involves recognizing the substantial, often cumulative effects of socioeconomic status and related factors on health, functioning, and well being from birth throughout the life course. These effects occur across all determinants levels (individual, social and physical environmental, societal). Reducing inequalities in the social environment (e.g., crime) and inequalities in the physical environment (e.g., access to healthful foods, parks, and transportation) can help to improve key health behaviors and other determinants and, consequently, meet numerous health objectives.

Responsibilities for promoting healthful environments at multiple levels—including the individual, social, physical, and policy environments—go beyond the traditional health care and public health sectors. Economic incentives aimed at organizations and institutions as well as individuals can be used to promote health-enhancing policies and programs across multiple sectors of society (e.g., private and public institutions and entities). National agricultural policy affects the absolute costs (i.e., the amount of money that must be spent to acquire one unit of a commodity) of fruits, vegetables, grains, and animal products. This in turn affects their relative price (i.e., the price of a product as compared to the price of similar products on the market) and consumption.

Ensuring compliance with relevant federal statutes can help to reduce environmental barriers that compromise health and health care. For example, meeting the requirements of the Americans with Disabilities Act can ensure accessible health care services and communication accommodations for patients with vision, hearing, and speech deficits.²⁵

Highlighting Emerging Social and Physical Environments

Societal changes emerging from the rapid adoption of computer-based communication environments and similar technological advances deserve further study with respect to their current and potential impacts on the Nation's health. There is the potential for positive and negative health effects of technology, and the positive effects have not been adequately realized (e.g., social networking for health, improved health information at point-of-decision, "exer-gaming", etc.) (See Appendix 13 for information and activities that the Advisory Committee recommends for inclusion in Healthy People 2020 to address the multi-level nature of health.)

Encouraging a Focus on "Upstream" Interventions When Possible

Identifying "passive prevention" strategies that can impact the health related exposures or behaviors of broad segments of the population with minimal individual-level decision-making can be a powerful prevention tool. Examples of such strategies include: tobacco control measures such as non-smoking policies in public buildings; creating barrier-free and vehicle-free zones in downtown areas or town centers; and inclusion of fluoride in toothpaste.

GOAL 4: WHAT? A Life Course Approach to Health Promotion

The Healthy People 2020 framework should devote explicit attention to human development across the life course because exposures in early life can be linked to outcomes in later life. The perinatal and adult periods can be bridged by studying how early-life factors, together with later life-factors, contribute to health outcomes, and by identifying risk and preventive processes across the life course.²⁶

This approach goes beyond the fundamentals of monitoring health behaviors like diet and exercise, and begins to connect different stages across the lifespan in terms of physical, emotional, and cognitive development. Health is a consequence of multiple determinants, which operate in nested genetic, biological, behavioral, social, and economic contexts that change as a person develops.²⁷

The "life stages" approach and "developmental stages" approach to human development over the life course are complementary and overlapping, and one can inform the other. Nonetheless, the two approaches are distinct and have different policy implications.

Life stages are used to divide the life course into discrete blocks (e.g., infancy, childhood, etc.) to facilitate monitoring. The life stages approach is cross sectional, and offers a way to break up the life course into easily measured stages. An example of a life stages approach would be to focus on the levels of obesity among working-age adults.

Developmental stages are used to consider the effects of health determinant across different life stages. The developmental stages approach is longitudinal, and offers a way to examine the impact of early life experiences and exposures on health status later in life. For example, a developmental stages approach would examine the effects of adverse childhood experience on the risk of obesity later in life.

Why the Life Course is So Important

A life course approach is critical to population health improvement, improved length and quality of life, and reduced health disparities. The first Surgeon General's report on health promotion and disease prevention (1979) set national goals for each of five major life stages, from infancy through old age.^ix Efforts to reach the goals were largely successful (three out of five goals reached or exceeded their targets).²⁸ Healthy People 2010 did not reflect the importance of life course, except for a maternal and child health focus area.

There are three mechanisms by which exposures are thought to 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). Different health trajectories are the product of cumulative risk and protective factors as well as other factors that are programmed into bio-behavioral regulatory systems during critical and sensitive periods.²⁹ For a concrete example of how a life stages approach can be applied to specific health issues, see Exhibit 4.

GOAL 4: HOW? Clustering Life Stages

There is no single, best way to cluster life stages. Because of the lack of standard age-groups across health issues, it is recommended that the Healthy People 2020 data systems be developed to permit tracking objectives by user-defined age groups. Individuals do not reach different life-stages, (e.g., adolescence, early adulthood, middle age, and older adulthood) at the same ages, so life stage clusters may not be synonymous with age group clusters.It is also difficult in many areas to measure exact life stages among samples of populations using present knowledge, technology, and resources. However, age group clusters can serve as useful, defined proxies for life-stage clusters.

Exhibit 4. Obesity: A Life Course Approach

Source: Mary Haan, DrPH, MPH, University of Michigan. Adapted from: World Health Organization, Life course perspectives on coronary heart disease, stroke and diabetes: Key issues and implications for policy and research. Summary Reports of a Meeting of Experts, 24 May 2001. Available at: http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.4.pdf (PDF File - 587 KB). Accessed 10/03/08.

A variety of age groupings and life stages have been used for the purposes of measurement. In their early use, age-group clusters for measuring life stage may have been developed for convenience (e.g., Vital Statistics groupings by years of age, 1-4, 5-9, 10-14, 15-19, 20-24, etc.) or based on a more conceptual approach (e.g., CDC age-groups listed in Exhibit 5, below).

The variation in age groupings used to measure life stages can present challenges to working across data sets. For example, the U.S. Census Bureau clusters data one way (0-4, 5-9, 10-14, etc.), while the public schools system uses other groups (elementary school, middle school, high school, etc.). Previous iterations of Healthy People rely on existing approaches to clustering data by age group. It is empirically difficult to re-define age-group clusters, as doing so can diminish or eliminate users' ability to compare data across decades of Healthy People.

Exhibit 5. Two Examples of Age Group Clusters

In addition, large groupings by age can obscure important differences within groups, and should therefore be avoided. For example, the groupings "50 and older," or "65 and older" are not sufficient to capture trends within subcategories of older adults. (Examples of more meaningful groupings could be: 65-74, 75-84, and 85+). As another example, individuals in the age group of 20-24 years often continue to exhibit characteristics of adolescent development. Developmental stages offer more useful insights to transitional periods. Thus, age groupings used as proxies for life stages should be based on what is known about development for the specific issue being examined.

Population Metrics to Assess Healthy Development

Development occurs across the life course, from pre-conception to the end of life. It is therefore important to measure the building blocks of healthy development that occur throughout life. There have been many efforts to create "youth development" metrics for younger populations. For example, the Search Institute has produced 40 Developmental Assets,^® factors that help young people (ages 12-18 years) grow up to be healthy, caring, and responsible.³¹ Other scoring systems for success in progressing through early developmental stages have been compiled by groups such as Child Trends, UNICEF³², and the Annie E. Casey Foundation (their "KIDSCOUNT" database provides state-level data).³³

Similar metrics are needed across the life course and could be built on current work describing the influence of different determinants of health over time and throughout the life cycle.³⁴ Because low socioeconomic status (SES) is one of the strongest predictors of poor health and development across the life-course, the Advisory Committee recommends that SES measures be included in Healthy People 2020 to help articulate associations among SES and various population health metrics. Healthy People 2020 metrics to assess healthy development in the population should:

1. Be specific to each defined life-stage (age-group);
2. Include relevant critical objectives or data from Healthy People 2010 for which data sets already exist;
3. Include other critical objectives or data for which data sets already exist;
4. Include new objectives or data relevant to new problems a particular age-group may face;
5. Include new objectives or data relevant to new information about life-course and life-stage phenomena;

In addition, it would be important to explore important innovations such as:

6. Developing valid international measures, so that Americans can see how the U.S. stands in relation to other nations in the world; and
7. Emphasizing objectives that are generated at the state and local levels.^x

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