Sixth Meeting: October 15, 2008

Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020

Approval of the Phase I Report to the Secretary,
and Planning for Phase II
Via WebEx

Sixth Meeting: October 15, 2008

Committee Recommendations (Approval by Vote)

• Approve the Phase I Report to the Secretary with minor revisions, as discussed. (9 in favor, 4 absent)

Next Steps: Finalizing and Distributing the Phase I Report

• Dr. Remington will send edits of the mission statement to the Committee Chair and Vice-Chair.
• Dr. Manderscheid will send specific examples of multi-sectoral partners to the Committee Chair and Vice-Chair.
• Dr. Fielding and Dr. Kumanyika (Committee Chair and Vice Chair) will integrate Committee members' revisions into the final report and submit it to ODPHP.
• ODPHP will submit the Committee's Phase I report to the Secretary of Health and Human Services. The report will be released to the public 30 days later.
• During the 30-day embargo period, ODPHP will ensure that the report is in compliance with 508(c) regulations to ensure its accessibility, and NORC will prepare a set of summary PowerPoint slides.
• ODPHP has a list of organizations that will be sent copies of the report (the Healthy People listserv). The Advisory Committee members may add organizations to the list.

 Next Steps: Beginning the Committee's Work for Phase II

• ODPHP will prepare a briefing memo summarizing the FIW's upcoming needs for the Committee's advice.
• ODPHP will provide a briefing memo on the FIW's proposed selection criteria for Healthy People objectives.
• A new subcommittee on System Specifications will convene to produce a briefing paper outlining specifications for producing Healthy People 2020 as a Web-accessible database.
• ODPHP will invite NCHS to provide a presentation on data issues at the January meeting.
• Dr. Remington will lead Committee's efforts to provide guidance to states. ODPHP will share early findings from the Healthy People User Study with him to support this work.
• Dr. Remington will share with Committee members a current project that includes a draft review of 350 interventions intended to address the determinants of health and reduce health disparities.
• NORC will produce briefing papers on target-setting and evidence-based implementation strategies.
• NORC will produce draft agendas for the Committee's next meetings (December 17, 2008 and January 7-8, 2009) and will send them to the Committee Chair and Vice-Chair for review.

I.  Introductory Remarks

RADM Penelope Slade Royall, Deputy Assistant Secretary for Health, Disease Prevention and Health Promotion, and Director of the Office of Disease Prevention and Health Promotion (ODPHP), welcomed the audience. The Advisory Committee had been engaged in extensive deliberation since January, 2008, and she noted that the leadership of the Department of Health and Human Services (HHS) is eager to receive the Committee's Phase I report and recommendations. The Federal Interagency Workgroup (FIW) has been finishing its recommendations for key elements of Healthy People 2020, which it will transmit to the HHS Secretary before the end of the year. RADM Royall introduced the Committee's Chair, Dr. Jonathan Fielding.

II.  Desired Outcomes of the Meeting

Dr. Fielding explained that the main purposes of the meeting would be to:

1. provide an overview of how the report has evolved since the Committee members last reviewed it;
2. offer an opportunity for final discussion of the draft before it is approved and submitted to the Secretary;
3. vote on approval of the report with any final revisions, and
4. begin discussion of the Committee's charge for Phase II.

III.  Overview of Final Draft, Phase I Report

Reorganization of Content

Dr. Fielding explained that the report had been significantly reorganized since the members had last reviewed it. Initial drafts had been prepared by knitting together the separate deliverables of the subcommittees. These drafts explained the Committee's recommendations, cross-cutting themes, and background on the Healthy People initiative. The second draft also included an executive summary that presented a broad-brush overview of the framework, which was detailed in the main body of the report.¹

To streamline Draft 3 and improve the report's readability, sections of text (e.g., the timeline for the Committee's work, past processes for developing objectives, past challenges, and a summary of feedback from the Healthy People 2010 User Study) were moved to appendices. A detailed explanation of the Advisory Committee's recommendations for the form and framework of Healthy People 2020 was provided; beneath each goal, an explanation was provided of what that goal is about and how it is to be accomplished. There had been numerous small revisions to the document, but Dr. Fielding said the Committee's discussion should focus on significant revisions. He added that the Committee recently received comments from Dr. Michael McGinnis, who was involved in the first three Healthy People iterations; these comments would be discussed.

Revised definitions for health disparities and health equity

Dr. Fielding said the definitions of health equity and health disparities were one area where there had been extensive discussion. He asked Dr. Ronald Manderscheid, Chair of the Subcommittee on Health Equity and Health Disparities, to explain recent changes to these definitions. Dr. Manderscheid said external reviewers of the Committee's draft definitions had offered comments in several key areas, as summarized below. He shared and explained the updated versions of these definitions. (Bolded font denotes changes to definitions from last iteration)

• Health equity: Some external reviewers suggested the definition should focus more on healthcare. The Subcommittee, however, believed the definition should address both the determinants of health and healthcare. It did not adopt the suggestion to narrow the definition of health equity.

  • o An introductory sentence was added to highlight health equity as being oriented toward achieving the highest possible level of health for all groups.

  • The word goal was broadened to "goal/standard" to broaden health equity as a standard.

  • Revised definition: "Health equity entails special efforts to improve the health of those who have experienced social or economic disadvantage. It is a desirable goal/standard that requires

    1. a continuous effort focused on elimination of health disparities, including disparities in health care and in the living and working conditions that influence health, and
    2. a continuous effort to maintain a desired state of equity after particular health disparities are eliminated."

• Health disparities: Comments suggested that the definition be broadened to include any differences in health status. Dr. Manderscheid said the subcommittee has tried to convey that disparities are a particular type of difference that exists due to problematic treatment of individuals in the past, especially with respect to the determinants of health and healthcare. The definition was not broadened to include all differences because we currently lack the technology to explain how some differences lead to disparities in health status (e.g., genetic factors).

  • The word "cause" was replaced by the words "closely linked" because it is hard to prove these factors are causal in all instances.

  • The word "rural" was replaced with "geography" because the former did not recognize potential disparities in urban populations.

  • Revised definition: 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 experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, ender, mental health, cognitive, sensory, or physical disability, sexual orientation, geography, or other characteristics historically linked to discrimination or exclusion."

Additional Substantive Changes

The Action Model for Healthy People 2020
Dr. Fielding presented a revised version of the Healthy People 2020 Model. It was recently updated to show the role of interventions in affecting determinants and yielding various outcomes. The new model shows a feedback loop in which needs assessment, monitoring, and dissemination lead to the subsequent revision of interventions. Dr. Fielding thanked Dr. Shirki Kumanyika, Committee Vice-Chair, as well as the Models Subcommittee for their hard work on the new model. He asked the Committee whether anyone believed the model should not be submitted in its present form. No objections were raised.

IV.  Discussion of Final Draft, Phase I Report

External Reviewer's Suggested Revisions to the Mission Statement
Dr. Fielding asked the Committee members to turn to the report's updated mission statement (shown below).

Dr. Fielding explained that in this updated statement, the words "and information" had been added to the third bullet in response to concerns that Dr. Lawrence Green, one of the report's reviewers, had raised in his written comments. Dr. Fielding also read aloud written remarks that had been received that morning from Dr. McGinnis. Dr. McGinnis suggested the following changes to the mission (shown in bold below):

• Increasing public understanding of the determinants of health, disease, and disability—and the opportunities for improvement.
• Marshaling national attention to the magnitude of health gains achievable with current knowledge.
• Catalyzing action directed by the evidence and engaging multiple sectors.
• Enhancing the focus and capacity for monitoring health progress on key dimensions at the national, state, and local levels.
• Identifying and initiating research activities needed to accelerate progress.

Dr. Fielding felt these changes would be consistent with the information in the main body of the report. He asked the Committee members to review the recommendations, and to email their comments to NORC staff. He and Dr. Kumanyika would make a final decision on the wording of the mission statement, based on the members' final comments. A Committee member did not entirely agree with the proposed changes. He offered his understanding of the intent of the suggestions, as well as some alternate phrasing (see Table 1, below). Dr. Kumanyika suggested the phrase "best available knowledge" be used instead of "best available evidence" or "best available information." This would be a point to consider during later word-smithing. Dr. Fielding asked Dr. Patrick Remington to e-mail suggestions for mission statement revisions to the entire Advisory Committee.

Table 1. External Reviewers' Suggestions for the Mission Statement, and Committee Reactions

External Reviewers' Suggested Revisions to the Body of the Report
Dr. Fielding said Dr. McGinnis had offered corrections to some of the historical background information about Healthy People that had been provided in the report. For example, Dr. McGinnis emphasized the important role of states and localities in Healthy People and said this had not been adequately addressed. Dr. Fielding felt it would be appropriate to make this and other corrections.

Dr. Georges Benjamin, another external reviewer, had submitted comments suggesting that the report did not address in a concentrated way the issues of public health infrastructure or ensuring a trained public health workforce. In his written suggestions to the Committee, he suggested the report should discuss these issues; information and communication systems to collect and disseminate accurate data; the role of public health organizations at the state and local levels; and the need for multi-disciplinary, intersectoral partnerships. These suggestions had been incorporated into page 26 of the revised draft report. Dr. Fielding asked if the Committee members had any concerns about this change.

A Committee member suggested the Committee craft a paragraph to define what is meant by a multi-sectoral approach, offering specific examples. Dr. Fielding said that many specific examples are already included in the report, but he urged this member to review the relevant section and see whether any additions are needed. Dr. Manderscheid agreed to review pages 26 and 27 of the draft report and submit any suggested revisions or additions.

Revised Audience Matrix
Dr. Kumanyika explained that revisions had been made to the audience matrix (page 38 of the final draft). It had originally classified audiences into "information seekers" and audiences that "need awareness raised." In the updated version, the audiences were classified as "primary" and "secondary," rather than active and passive. The secondary audiences are "targets for information about Healthy People," and the primary audiences are "seekers of information." Dr. Kumanyika asked Dr. Douglas Evans, Chair of the Subcommittee on User Questions and Needs, if the changes were acceptable. Dr. Evans said that he had not had a chance to discuss the changes with members of the Subcommittee, but he felt they were useful. Other members agreed that the changes were an improvement.

Additional Changes to the Report
Dr. Fielding briefly reviewed additional substantive changes that had been made to the report. For example, the language in the section describing the importance of prevention was reworked emphasize balance between over-selling the monetary savings of prevention versus under-selling the importance of prevention. The current version of the report mentions that not all prevention activities save healthcare dollars, but some prevention activities remain valuable because they improve the health and well-being of individuals.

Other changes included adding more emphasis of the importance of meeting the needs of diverse audiences (e.g., in terms of race, ethnicity, language, background); clarifying what is meant by "upstream;" and noting the need for measuring actual interventions (e.g. policies, programs, etc.)—not just measures of outcomes.

Dr. Fielding asked the Committee members if they had found any other changes in the report to be problematic. The members did not raise any issues. Dr. Fielding stated that the only remaining revisions to be made were minor adjustments to the mission statement, and an additional paragraph from Dr. Manderschied to clarify the meaning of "multi-sectoral partnerships." He also noted that Dr. Vincent Felitti (Committee member) had submitted comments on the report earlier that day and that his remarks would be reviewed. Dr. Fielding asked whether members wanted to wordsmith the mission statement by full Committee, or if they would delegate that task to the Chair and Vice-Chair. (Dr. Remington had offered to provide preliminary revisions). The Committee members agreed to entrust Dr. Fielding and Dr. Kumanyika with making final changes to the mission statement, with Dr. Remington's help.

A Committee member asked whether it would be possible to invite other individuals with relevant experience or insight to review the report and offer comments at this stage. Dr. Fielding responded that individuals have been able to comment on the ongoing work of the Advisory Committee through the Healthy People web site, regional meetings and public comment at the June 2008 meeting of the Advisory committee, and while there was no doubt that they could obtain other comments, it was necessary to finalize the report and move forward. This would not preclude others from making their own comments, continuing to submit comments through the Healthy People web site, or blogging, or providing feedback in other ways. However, Dr. Fielding said that on balance the report was strong, and that it was time to finalize it.

V.  Vote To Approve Final Report

Dr. Fielding asked for a motion to approve the report, subject to the minor revisions discussed by the full Committee. All Committee members who were present voted to approve the Phase I report to the Secretary. (9 in favor, 4 absent.)

Dr. Fielding congratulated the Committee members on their work. He estimated that minor edits to the report would be completed within a week. Once the report had been finalized, the Committee would submit it to ODPHP. ODPHP would submit the report to the Assistant Secretary for Health, who would send it through appropriate channels to the HHS Secretary's Office. The report would be embargoed for 30 days, to permit the Secretary adequate time to review, and allow the report to be made 508 (c) compliant to ensure accessibility to all populations. It would then be released to the public.

VI.  Next Steps

Dr. Fielding proposed discussing the agenda for the Committee's next meeting (scheduled for December 17, 2008 1:00 PM-3:00 PM EST), when the Advisory Committee would begin its Phase II efforts. He also reviewed potential topics for the Committee's next in-person meeting, which would be held in Washington, DC on January 7-8, 2009. He suggested that NORC develop briefing papers in advance of these meetings to ensure productive discussions. Members offered additional suggestions, as summarized below. Each agenda item was designated to either the December or January agenda. The description of each item is followed by the month of the meeting in which it will take place (in parentheses). A final list of topics for each meeting is provided in Table 2.

Agenda Topic 1.      Progress of the FIW

Dr. Fielding suggested having a presentation on the FIW's work and progress. He felt it would be useful for the FIW to identify issues and areas that the Committee's recommendations could be helpful and to perhaps have a short paper on that topic. Dr. Fielding said that the FIW's work is a high priority and should be the centerpiece of the December discussion, with key issues carried over into the January meeting. (December)

Dr. Kumanyika noted that some time should be allocated to discussing the relationship between the Committee's work and the FIW's work. She said that she did not fully understand that relationship. She wished to avoid duplicating efforts, while also maximizing the chance that the advice that the Committee offers will actually be taken. (January)

Agenda Topic 2.      Selection of Objectives

The criteria for selecting objectives should be a topic for discussion in December. Dr. Fielding suggested producing a short paper that highlighted the FIW's criteria for selecting objectives. (December)

Agenda Topic 3.      Healthy People Consortium

RADM Royall mentioned that she would announce the revitalization of Healthy People Consortium at the American Public Health Association conference in San Diego, California. She would invite participants in that meeting to join Healthy People efforts towards developing objectives and targets. She noted that a hallmark of Healthy People has been its reputation as an open and transparent process. The Healthy People Consortium would be a comprehensive group of dedicated public health workers and others who wish to participate in the process of developing Healthy People 2020 objectives. She asked the Committee members to help ensure that this happens. Dr. Fielding asked RADM Royall to update the Advisory Committee on the Healthy People Consortium at the upcoming December WebEx meeting. (December)

Agenda Topic 4.      New Subcommitte on System Specifications

Dr. Fielding suggested creating a small subcommittee that would work to outline system specifications for the proposed relational database and make recommendations to HHS for a Web-accessible version of Healthy People 2020. He noted that at this stage it would not be necessary to have a high level of detail. A specifications briefing paper would be useful for laying out the Committee's ideas in a more developed form. What features should the database have in order to be useful to target audiences? He asked for volunteers for the subcommittee. Dr. Manderscheid agreed to serve as chair, and Dr. Evans, Dr. Fielding, and Dr. Lisa Iezzoni agreed to serve on the committee. (Dr. Remington was absent for this part of the discussion, but had agreed to be involved in such efforts at an earlier meeting.) (January)

Agenda Topic 5.      State-level Healthy People Efforts

ODPHP explained that it is working on a project to assess Phase I of Healthy People 2020 at the state level. Once the Phase I framework is released, state agencies such as state health departments will use the framework to inform their own planning efforts. ODPHP is working on a project to support competitive grants for states for assessing the use of the Healthy People 2020 framework. RADM Royall said that the Committee should discuss state-level efforts during the December meeting, since the Request for Proposal will be released in January. Committee members agreed this topic is important, especially since they were involved in Healthy People efforts in their respective states. Ms. Blakey explained that NORC recently sent out surveys to state Healthy People Coordinators and Chronic Disease Directors to find out how they are using Healthy People. Preliminary findings of these surveys may be available by December. Dr. Fielding said this information would be very valuable. He asked Dr. Remington to lead discussion of state-level Healthy People efforts and how the Committee can add value. (December)

Agenda Topic 6.      Quality and Availability of National Data Sets

A Committee member suggested that the availability and quality of national data sets an agenda item. Specifically, he mentioned the quality of national epidemiological and health services be data to reach into subgroups of interest for measuring health disparities and health equity. A representative from the National Center for Health Statistics (NCHS) could present on the main issues confronted as they implement data systems over time. ODPHP agreed to contact NCHS to see whether such a presentation could be arranged. (January)

A Committee member later added that the Advisory Committee should produce a series of questions during the December meeting that NCHS could answer during the January meeting. She added that the interaction between regional/local data systems and national data systems is important. (December)

Agenda Topic 7.      Sources of Knowledge for Evidence-based Actions

ODPHP added that another point of discussion could be the action steps that users can take to achieve targets for individual objectives. Dr. Fielding noted that this idea relates to sources and use of knowledge. Specifically, what criteria should be used to decide which interventions and actions to recommend as being effective? The Advisory Committee must consider tools that are currently in existence or need to be developed for different user groups in order to catalyze actions based on objectives. A brief is needed to describe and how they can be explained to users (for example, through a toolkit). (January)

Agenda Topic 8.      Selection of Focus Areas

ODPHP added that HHS would be interested in the Advisory Committee's feedback on the selection of focus areas. (January)

Agenda Topic 9.      Interventions to Eliminate Health Disparities

Dr. Fielding said it would be important to help people understand the notions of disparities and inequities. There has been limited research in this domain, so it will be important to look at the current evidence-base and future efforts to accumulate evidence of what works to narrow gaps. Dr. Remington mentioned that he is currently working with colleagues to review 350 interventions across multiple determinants if health. This review examines the strength of the evidence, the size of population impact, and the effect on disparities. Dr. Remington said he would be happy to share this work-in-progress with Advisory Committee members. (January)

Agenda Topic 10.      Target Setting Methodologies and Met vs. Unmet Targets

Healthy People has used several methodologies for setting targets in the past (e.g., "better than best," "percentage improvement"). The Committee's feedback would be useful. Dr. Fielding agreed this was valuable, because people do not know how targets were set, or whether they were realistic. Dr. Kumanyika said an analysis of why some targets have been met and others have not is important, and deserves time on the agenda. Dr. Fielding asked whether NORC could put together a briefing paper of what has been learned from the past (i.e. assessments from past decades, midcourse review) and what are the critical questions regarding this issue. (December)

Agenda Topic 11.      User Needs Focus Groups

ODPHP added that user needs focus groups are being conducted and the results of the findings of these focus groups should be discussed. These findings could go hand in hand with the implementation/dissemination strategies discussion. Dr. Fielding agreed that should be placed in the January meeting's agenda. (January)

Table 2. Summary of Suggested Agenda Topics for December and January Meetings

Dissemination of Report, Closing Remarks
Dr. Fielding noted that RADM Royall would provide a list of organizations that will receive a copy of the Phase I report, which she will provide to the Advisory Committee. If any important organizations are missing from that list, the Committee will be able to add to it. He noted that one possibility would be to have NORC support this effort, but it would be necessary to verify that such activities are within their scope of work. A Committee Member requested that NORC put together 10-20 slides about the Phase I recommendations that could be used to explain them to stakeholders. Dr. Fielding agreed that those slides would be valuable to have by the time the Secretary's 30-day review period elapsed. They could be distributed along with the final draft of the report.

Dr. Fielding thanked the Committee members for their hard work, and congratulated them on completing the first phase of their charge. He also thanked the members of the public who had signed into the WebEx meeting. A Committee member also thanked Dr. Fielding and Dr. Kumanyika for their leadership. The meeting was adjourned.

1. Draft 2 of the report had been distributed to Committee members and external reviewers via email on September 12, 2008. Their comments were due to NORC staff one week later. Dr. Fielding and Dr. Kumanyika worked with NORC staff to revise the document in order to address members' and reviewers' comments and suggestions.

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