Secretary’s Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Phase II–Recommendations for Implementation of the Healthy People 2020 Objectives
Via WebEx
Eleventh Meeting: April 20, 2009
Committee Recommendations (Approved by Vote)
- Approve the topic area, “Access to health promotion and disease prevention programming.”
(7 in favor, 1 opposed, 5 absent)
- Approve the addition of “Dying” as a life stage topic area. (None opposed).
- Approve revision of the topic area, “substance abuse” to “substance abuse and dependence.” (Unanimous approval.COMMITTEE DECISIONS (BY CONSENSUS)
Committee Decisions (By Consensus)
- The topic area “overweight” should be revised to read, “energy balance and overweight.”
Next Steps
- The Committee raised the issue of whether topic areas should simply be listed, rather than organizing them within broad categories that parallel components of the Healthy People 2020 Action Model.
- Target-setting methods will be the primary focus of the Committee’s May 15th meeting.
- Dr. Remington and the Targets Subcommittee will explore the potential for using intermediate targets.
- The Implementation Subcommittee will present at the July FACA meeting.
- The date and time for a potential in-person meeting of the full Committee during the first week of September 2009 will be explored.
I. Welcoming Remarks
Dr. Jonathan Fielding, Chair of the Secretary’s Advisory Committee, explained that the agenda was designed to permit adequate time for discussion of two key issues: target-setting methodologies and topic area selection. He provided a brief overview of issues to be addressed. He said that Patrick Remington would present an overview of his subcommittee’s work on topic areas, and then the Committee would seek to take a vote on recommendations in this area. Members would also provide guidance to the Subcommittee on Target-setting for finalizing its recommendations.
RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health and Director of Office of Disease Prevention and Health Promotion (ODPHP) at the U.S. Department of Health and Human Services (HHS), welcomed the Committee members and members of the public. She said the proposed Healthy People 2020 framework (including the vision, mission, and overarching goals) had been submitted to the Acting Secretary. Once the incoming Secretary is appointed, it is anticipated that the framework would receive final approval. ODPHP would notify the Committee and post the framework online. RADM Slade-Sawyer shared HHS plans for gathering public input on the development of Healthy People 2020 through a variety of means, including the Internet and public meetings. Public comments on existing Healthy People 2010 objectives would be accepted online until April 24, 2009.
RADM Slade-Sawyer said current departmental leadership had authorized ODPHP to move forward with developing specific Healthy People 2020 objectives. HHS and other Federal staff members were convening in workgroups to recommend which Healthy People 2010 objectives should be eliminated, retained, or revised as a starting point for developing the Healthy People 2020 objectives. The Federal Interagency Workgroup (FIW) would be reviewing these recommendations, along with suggestions for new topic areas, in the coming months. A draft set of objectives would be ready by the fall of 2009, at which time a more extensive public comment process would take place. HHS plans to convene three public meetings across the country in the fall; details of locations would be announced on the healthypeople.gov Web site. RADM Slade-Sawyer explained that ODPHP had shifted the timeline of the launch for 2020 from January 2010 to the last quarter of 2010. This would allow the time necessary to vet objectives and evidence-based resources and develop the online, relational database. RADM Slade-Sawyer expressed the Department’s gratitude to the Committee. Dr. Fielding thanked RADM Slade-Sawyer and ODPHP for their support.
II. Desired Outcomes of the Meeting
Dr. Fielding explained that the Committee would vote on recommendations for topic areas and finalize provide feedback to the subcommittee that is working on target-setting. During the Committee’s May meeting, the focus would be on criteria for selecting evidence-based resources. Issues and questions related to implementation strategies would be discussed at the Committee’s upcoming meetings in May, June, July, and possibly even extending into August. Dr. Fielding then introduced Patrick Remington, Chair of the Subcommittee on Topic Areas.
III. Healthy People 2020 Topic Area Recommendations
Dr. Remington reminded the Committee that they had begun discussing topic areas during the January, 2009 meeting. A Subcommittee on Topic Areas was formed and has met twice since then. The Subcommittee addressed four general issues: 1) clear definitions of terminology; 2) clarification of the function of topic areas; 3) the need to build on the 2020 framework; and 4) the need for logic models that would facilitate the shift from a paper-based format to an online, relational database.
The Subcommittee viewed topic areas as serving several functions: they organize groups of related objectives; they assist in Federal management of objectives in that a Federal lead agency is tasked with tracking each topic area; and they help users to locate the content that is of interest to them within Healthy People. In Healthy People 2010, focus areas tended to be mutually exclusive. For Healthy People 2020, this Subcommittee views topic areas as interrelated. In the past, a group could work exclusively on one focus area, but in Healthy People 2020 there would be an expectation that objectives overlap. Thus, topic areas would continue to have lead agencies, but communications within groups would be needed. Objectives would be located in multiple topic areas—some “upstream,” and others “downstream” in disease outcomes.
The Subcommittee used a broad framework of interventions, determinants, and outcomes to organize the topics, but did not view this as a fixed classification. Many objectives may be an outcomes in addition to being important determinants and interventions. A Healthy People 2020 user would enter a topic area to explore Healthy People 2020. Therefore, it is important to have a strong understanding of how interventions relate to determinants and how determinants relate to outcomes, which would require a significant amount of work. The map of these interrelationships could be straightforward for some areas; for others, more complex modeling of independent effects and relationships between different determinants could be needed.
Dr. Remington discussed the Healthy People 2020 Action Model, including interventions (e.g., policies, programs, and information), determinants of health, and then more traditional health outcomes, all working across the life course. He explained that this is the model upon which logic models should be based, and there would generally be topic areas that fall into the three areas of interventions, determinants, and outcomes. He provided an example based on selection of the topic area, “cancer,” to show how the user would enter “interventions” and then “cancer” to pull up relevant objectives. He noted that there could be controversies about the causal relationships between risk factors and diseases (e.g., diet and breast cancer). The real test of this approach would come when people try to develop the logic models, because solid evidence is not available in all areas. Dr. Remington posed the issue of how to determine what should be done in areas where evidence is accumulating for an association between risk factors and outcomes, but is not yet proven.
Dr. Remington explained that Federal staff would be working in each topic area and could show where objectives should be positioned on a logic model. These tags would be relevant along a spectrum from interventions to determinants to outcomes. This would be an iterative process in that coordination would be needed, for example, to ensure that objectives relating to nutrition would be aligned across cardiovascular disease and cancer prevention. It is important that the objectives converge on a single common objective that crosses topic areas.
Dr. Remington went on to describe a chart showing the relationships between determinants and outcomes, subcategorized into physiologic and pathologic causes, proximal causes, and distal causes which illustrated how objectives might be positioned within the logic model. He presented a list of candidate topic areas which fell into the general categories of programs, policies and interventions; some of the proposed topic areas were holdovers from 2010, while others were new. Dr. Remington added that this framework requires a good understanding of the literature and pathophysiology. Downstream outcomes are the ultimate point of accountability, where we are trying to increase quality and length of life. Dr. Remington reviewed the list of potential new, revised, and retained topic areas proposed by the Subcommittee (see Appendix A).
A Committee member asked where in the list of topics the Committee would include the concept of “prevention.” Dr. Remington replied that health promotion is focused on preventing disease, but the member recommended making that point more explicit. Dr. Fielding indicated that the preamble would clarify that the Committee intends to emphasize the importance of prevention throughout its recommendations for Healthy People 2020. Dr. Remington added that the Subcommittee had discussed the importance of prevention, concluding that “health promotion and disease prevention” is a somewhat flawed label because it focuses on disease and not on promoting health through physical and social determinants. The member suggested using the term “access to health promotion” for the topic area, mirroring the term “access to health care.”
Dr. Remington replied that health care is an intervention. He emphasized that in the U.S., access to health care is an important determinant of health, and thus it may not be possible to categorize it as either an intervention or a determinant under this model. Another member agreed, adding that many of the topics listed could either be categorized as interventions, determinants, or outcomes. She expressed concern that it might be limiting to lock these topics into specific organizing categories; it could be more fluid than that. Dr. Fielding recalled that the Committee had, at an earlier meeting, discussed the possibility of creating a matrix, but soon found that most of the topics could be categorized across all columns of the matrix (e.g., interventions, determinants, outcomes). He also pointed out that the Committee’s recommendations would be confusing if they were not aligned with the Healthy People 2020 Action Model.
Dr. Remington agreed that valid issue is whether there is a benefit to clustering topic areas instead of saying that each topic area should address the continuum. The member who had raised this issue said she felt there could be ramifications for Federal funding. For example, if NIH sees that Healthy People 2020 categorizes physical activity under “interventions,” the understanding would be that a health outcome should be attached to research on changing physical activity. Yet many would argue that physical activity should be viewed as a behavioral outcome in itself. This could be problematic. Dr. Remington agreed with this point, and asked for the Committee to consider whether the Healthy People 2020 topic areas should simply be listed, without categorizing them.
Shiriki Kumanyika, Committee Vice-Chair, commented on the importance of preserving the ability to make some determinants into outcomes and to cross-reference them. For example, physical activity could be in the behavioral outcomes category, but it could also be cross-referenced to other categories as a determinant. On a separate issue, she said it would be important for the Committee to define health promotion because she felt members did not have a common understanding of what the term means. Many items on the topic areas list could be called health promotion (e.g., built environment, interventions, etc.). Thus, health promotion should not be defined too narrowly—as just health education, for example.
Dr. Kumanyika went on to say that all of Healthy People 2020 is health promotion, so specificity is needed about what types of health promotion are being described (e.g., behavior change, health education, nutrition education, etc.) It might be better to avoid the term “health promotion” entirely. A Committee member endorsed the phrase that had been suggested earlier, (e.g., access to preventive care, preventive activities, or preventive resources). She noted that health promotion is like health care and that access to preventive care needs to be available. Another member added that not all of health promotion occurs at the individual level; there are structural ways of promoting health. For example, Johnson & Johnson just purchased two companies to implement health promotion for their employees, including measures such as benefits for an insurance package for the company, or population interventions for all employees in the company together.
Dr. Remington asked if there was strong leadership in the “education and community based programs” focus area from Healthy People 2010. Carter Blakey said that “education and community based programs” was not a strong focus area for a variety of reasons, one of which was a lack of leadership. In some cases, there could be a lack of leadership and identity.
Dr. Fielding asked how members would like to change the wording of this topic area. An extensive discussion ensued, in which members offered various permutations of the phrase “preventive policies and programs” (e.g., “health promoting structures and strategies,” “health education,” “promotion policies and programs”). A member said that the Committee had forged a new perspective. As they had done with environmental health, the Committee is trying to redefine health promotion by saying that this is not just about access to disease care structures or health care structures, but that it is also about access to preventive activities. She felt that access should be redefined to encompass structures that are oriented towards prevention.
Dr. Fielding expressed the concern that there is a policy emphasis and a large body of studies on health care access. He said “health promotion” should be a separate topic area and reiterated that the Committee’s role is to make recommendations, not policy. A Committee member agreed that promotion should be kept separate, but said the language about access should be retained. Dr. Fielding then called for a vote to approve the phrase. Dr. Kumanyika was opposed to the phrasing “access to health promotion” because she felt it narrowed the meaning in ways that the Committee did not intend. Seven Committee members voted in favor of the topic area, “access to health promotion and disease prevention programming.”
A Committee member pointed out that the lifespan, as it is currently conceptualized, would not include death. She said that it might be helpful to think about death as a life stage, given the impact of the palliative care movement and hospice movement in recent years. She emphasized the importance of confronting how Americans address the last moments in life. She also pointed out that Healthy People includes prenatal care but not the final stage of life. Another member said that he thought “dying” would make a better life stage than death, but generally agreed with the previous point. Dr. Remington concurred that the exclusion of dying was an oversight, noting that its inclusion would be forward-looking. Others agreed that it is important to look at life stages and transitions, particularly because of the importance of transitions between life stages and our limited knowledge of them. Dr. Fielding asked if any Committee members disagreed with adding “dying” as a life stage. None were opposed. Dr. Fielding noted that “dying” should be added as a life stage.
Dr. Remington moved on to discuss disease areas. The new disease area topics that the Subcommittee has proposed for Healthy People 2020 are blood diseases, global health, digestive diseases, and quality of life. It has been suggested by HHS that hearing and vision be separate topic areas in Healthy People 2020. A Committee member suggested revising the topic area “overweight” to “energy balance and overweight,” noting that this is a timely and important issue. Dr. Remington added that this is an upstream issue, and thus groups working on issues from nutrition and physical activity to the built environment would need to collaborate. Dr. Fielding stated that the phrase “energy balance” should be added to the topic area on overweight.
Dr. Fielding added that quality of life and global health are additions. A member commented on the proposed topic area on “quality of life.” He pointed out that there are many aspects of quality of life and asked if the Committee intended the concept to be so broad. Dr. Fielding asked if this would be better placed in the preamble as it is a cross-cutting issue. Another member said that quality of life deserves to be included as an outcome. She suggested the Committee adopt the term “quality of life and wellbeing;” quality of life is generally considered to be a legitimate and important outcome in itself. Another member noted that she would approve the phrase, “quality of life” as long as the definition of it is left to individuals. She explained that using a wheelchair could be unacceptable for some people but fine for others; therefore, the individual must be left to determine what is meant by quality of life.
A Committee member pointed out that the proposed list of topics areas continues to emphasize diseases, rather than positive health outcomes for people. He suggested that the Committee’s discussion of diseases should try to frame outcomes in a more positive way. He said that Healthy People 2020 should move the health agenda in a positive direction. Dr. Kumanyika said that it was her understanding that the model reflects that.
Dr. Fielding asked if Committee members had thoughts on the inclusion of “global health.” Dr. Remington said global health is a cross-cutting issue. He also noted that while Healthy People is a plan for the United States, global health needs to be considered. Dr. Fielding asked for clarification of what is meant by this phrase, and whether it refers specifically to the intersection of health in the U.S. and health elsewhere. Dr. Remington said that global health was raised as an issue in Subcommittee discussions in terms of social, economic, and infectious disease issues, particularly within the context of an economic crisis that affects the health of the nation.
Dr. Fielding said that the Committee should make clear that the focus is on the point of intersection between health from outside our borders and health inside our borders. He said that if the connection was not clear, Healthy People could spend all of its time on the health of developing nations. Dr. Remington said that the increasing view is that as infectious disease and community health evolve globally and have an impact on health in the United States. Dr. Fielding was comfortable with this rationale.
Dr. Manderschied recommended that the Committee change the phrasing of the topic area “substance abuse” to “substance abuse and dependence.” The Committee expressed unanimous approval for the change.
IV. Healthy People 2020 Target-Setting Recommendations
Dr. Remington moved on to address the issue of target setting. He said that the Subcommittee on Target-setting met twice and circulated a draft proposal via email. Summarizing their work, Dr. Remington said that the subcommittee’s members emphasized that the targets should be SMART (Specific, Measurable, Achievable, Realistic and Time-bound). He indicated that the definition of a target is a level of performance for an objective. Target-setting is the method to set the target. Dr. Remington said that in the past, a number of methods were used. He said that Richard Klein (National Center for Health Statistics) had been a resource for the group.
Dr. Remington indicated that the “better than the best” target-setting method was the most aggressive approach. Using the “better than the best” target setting method, the population group with the lowest rate for a given disease is considered “the best” and the target is set better than that. A challenge of the better than the best target setting method is that there are often inaccuracies or cultural reasons why a particular population group has a low rate. Thus, some targets that were set using a “better than best” approach were unrealistic for some groups. On a positive note, “better than the best” targets set ambitious levels for improvement, but those targets were not relevant in all cases. Other target setting methodologies used include percent improvement, universal coverage, and retention of the Healthy People 2000 target.
Dr. Remington noted that Healthy People 2010 was not always transparent about target-setting methods used. Dr. Remington said there is a need to look back at the past decade of experience, project where things would be in 2020 if those trends continued, and then decide how that trend can be improved. “If/then” scenarios might be helpful. He said that the important thing would be to clearly describe whatever methods are used. The Subcommittee felt that targets should be set at levels that are realistic, but also a reach. If targets are set at unrealistic levels, it could be demoralizing. Ultimately, target-setting should tie to putting effective programs and policies in place; evidence should be used when available. He added that Healthy People should acknowledge when targets are not evidence based.
Dr. Remington asked the Committee if objectives should have a single target (for the entire population) or multiple targets (for select populations). A single target offers the advantage of being easy to communicate about, but there might be select populations that have already achieved the target. The subcommittee felt that a single target would be useful for eliminating disparities. It should be recognized that there may be some populations that have already achieved the target, but should be encouraged to continue improvement. Dr. Remington said it was important to reduce the overall distribution of disease among racial and ethnic populations. Healthy People could attempt to reduce the mean and improve health or reduce variation between groups. He briefly discussed the issue of whether “disparities targets” should be set, but felt the most important resource for addressing disparities would be tools for states and regions. NCHS should provide guidance on this issue.
A Committee member indicated that one of the major criticisms of Healthy People 2000 was that it set two separate targets for communities of color and other populations. The use of two sets of targets was viewed as tacitly endorsing health disparities between populations. In 2010, Surgeon General David Satcher developed a single target.
Another member noted that there should be separate disparities targets, stating that having such a target would bring disparities to people’s attention. Rather than calling it a disparities target, he suggested called it an equity target. Dr. Fielding added that one critical principle is transparency. The methodology for setting targets may not be consistent, so it needs to be made clear which method is being use. The Committee noted that trends are another issue that needs to be considered. The Committee considered recommending a single overall target to which all groups need to progress a certain amount. Dr. Fielding expressed satisfaction with the Committee’s discussion and suggested that the Subcommittee provide guidance and tools to get this done. He also indicated that relating sub-objectives to objectives is important.
A Committee member commented that the lead-in language to Healthy People 2020 should concentrate on determinants and health equity. He reiterated that having another set of objectives for disparities detracts from the overall cause and may reduce buy-in from the nation as a whole. Dr. Fielding added that he did not think it would be possible to create tools right now and suggested that the Committee consider a core indicator set based on SMART targets or a holistic set. The work of State of the USA around national indicators should be considered.
Dr. Fielding also noted that determinants are critical to the equity issue. For most of these categories, the social and economic aspects are important. As targets are set for 2020, there may be some objectives where data are not available. To move forward, it is important to include emerging areas. In these areas, it is reasonable to allow several years for improvement. This means that midcourse reviews are all the more important. Dr. Remington agreed and emphasized that it may make sense to set some of the objectives with a shorter timeframe. Dr. Fielding added that there are proximal and distal outcomes. Dr. Remington added that this could be an important recommendation that could change 2020. The path to achieve targets might start from other objectives. There should be steps toward the overall targets. Dr. Fielding said that the Committee would send this issue back to Dr. Remington and the Subcommittee for further work. He noted that this would be the major topic of discussion on the Committee’s next call, on May 15, 2009.
V. Next Steps
Dr. Fielding noted that the Subcommittee on Implementation has a lot of work to do.
Subcommittee co-chairs Eva Moya and Adewale Troutman indicated that the Subcommittee could be ready to present by June or July.
The Committee discussed possibilities for the next in-person meeting. ODPHP staff Carter Blakey and RADM Slade-Sawyer suggested the Committee target the week of Labor Day 2009. Dr. Fielding indicated that there were scheduling challenges at that time of year, but members could work with NORC to identify potential dates for the next in person meeting. |
