Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Via WebEx
Seventh Meeting: December 17, 2008
Committee Recommendations (Approved by Vote)
- No formal votes were taken during the meeting.
Next Steps
- HHS has requested timely feedback from the Committee in two key
areas:
- "Topic area" categories that can be used to organize the objectives,
and
- Methodologies that can be used to set targets for the objectives.
- NORC and Committee members will help to disseminate the Phase I
report
- Committee members agreed to issue their recommendations for Phase II
through a series of short documents rather than a single, long report.
- The Committee will prepare a statement noting that achieving Healthy
People goals is tied to economic and social policy and key actions could
make a big difference.
- NORC will develop for the Committee's use a bulleted list of key
issues relating education, health reform, and economic recovery to
health status.
- ODPHP will prepare an analysis of two or three "exemplar" objectives
from Healthy People 2010: one where the target was reached, one where
the target was not relevant or where results were mixed, and one where
the target was not reached.
- Dr. Patrick Remington will share a document that lists over 400
evidence-based programs and policies that he and his colleagues are
compiling in Wisconsin.
- RADM Slade-Sawyer will submit in writing her questions for the
Committee.
- Committee members will review the Partnership for Preventions
"Action Guides" http://www.prevent.org/ as examples of how Healthy
People materials could be translated into practical, how-to guidance for
program planning and development.
Potential Topics for the January Meeting
- A presentation from the Office of the National Coordinator for
HealthIT
- Comment from the National Center for Health Statistics on health
inquiry data
- Exemplars of past progress on Healthy People objectives
- Findings from the User Questions and Needs focus groups.
All Committee members were present except for Dr. Everold Hosein
I. Introductory Remarks
RADM Penelope Slade-Sawyer, 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
to the seventh meeting of the Secretary's Advisory Committee on Health
Promotion and Disease Prevention Objectives for 2020 (the Committee).
She noted that the Committee's Phase I Report has been posted on the
Healthy People 2020 public Web site at
http://www.healthypeople.gov/.
The Federal Interagency Workgroup (FIW) considered the Committee's
recommendations in developing the framework that will be released by the
Department. RADM Slade-Sawyer noted that the FIW's Phase I
recommendations for the overall vision, mission, goals and organizing
framework would be submitted for departmental clearance. Phase II of the
Healthy People 2020 development process will encompass the development
of objectives and strategies for achieving them. The objective selection
process will include extensive public input. The entire Healthy People
2020 initiative will be launched in early 2010.
II. Desired Outcomes of the Meeting
Dr. Jonathan Fielding, Committee Chair, thanked the members for their
work and indicated that the Committee would be discussing dissemination
of Phase I report and the possibility of briefing the incoming HHS
Secretary. In addition, the timeline and work plan for Phase II,
including public engagement, would be addressed. Additionally, the
Committee would talk about potential topics for their in-person meeting
in Washington D.C. in January, 2009.
III. Current Work of the FIW & HHS' Direction
RADM Slade-Sawyer reported that the FIW had continued to add
representatives from other federal departments, including the Department
of Justice and the Department of Housing and Urban Development. A
timeline for the FIW's Phase II activities was being prepared. She
indicated that the FIW recognizes the need to look at health issues from
a global perspective and has established a new subgroup to interface
with other global initiatives and consider the development of a global
health topic area.
The Healthy People 2010 Focus Area workgroups were starting to review
and revise specific objectives based on scientific evidence and had
received final objective development criteria; they will submit proposed
objectives and baseline data sources to the FIW in early 2009. The FIW
would soon undertake development of a target-setting methodology. Among
the questions being considered were whether targets should be
aspirational or achievable, and what rationale should be required for
setting targets. Strategies for implementation and translation of
research into practice were also being reviewed. RADM Slade-Sawyer said
feedback from the public and non-HHS federal agencies would be critical
in answering these questions. The FIW is working on issues related to
the format of Healthy People 2020, including how an electronic version
would interface with other systems.
RADM Slade-Sawyer offered other updates on FIW activities, as
summarized below:
- The Healthy People Consortium, first convened in 1988, is now
reaching out to and engaging agencies and organizations that are
interested in becoming involved. There are currently 364 member
organizations in the Consortium.
- ODPHP will seek input from states through several mechanisms
over the next year. They will co-sponsor (with the Association for
Prevention Teaching and Research) the Fourth Healthy People State
Coordinators workshop. They will also release a request for
applications for states, territories, and tribal health agencies to
compete for funds to conduct strategic planning activities that
support states' use of the Healthy People framework and population
health improvement concepts.
HHS' Charge to the Committee for Phase II Efforts
RADM Slade-Sawyer then explained specific products that HHS would
like to receive from the Committee during Phase II. They included:
- Feedback on objectives, topic areas, target-setting and
cross-referencing of objectives.
- Broad guidance for translating Healthy People to the federal,
state, and local levels, including assistance with implementation
strategies and tools to assist users. Should materials be
strategically released throughout the decade to encourage momentum?
- Suggestions for types of companion documents and case studies to
be included, along with strategies for using new media, such as
Webinars and other options.
- Further detail on specifications for the proposed relational
database format.
- Recommendations for increasing public engagement in Healthy
People 2020 during three critical time periods: the final year of
development, launch, and post-launch.
- Further detail on how to develop the Consortium, engage more
partners, and increase public involvement.
- Feedback on what services should be developed for interfacing
with partners? (This could include concrete examples of how
technical assistance for users could be provided to encourage
creativity and flexibility to meet individual users' needs.)
- Guidance on data mining, including sustaining reliable data for
the objectives and finding reliable, population-specific data.
Healthy People will be changing, adding, and eliminating objectives
throughout the decade, making timely and transparent information
related to objective revision very important.
Dr. Fielding said there is a need to prioritize these questions and
to think about the level of detail the Committee can provide in
response. He asked for clarification of timeframes and whether there are
critical things that should be addressed right away. At the Committee's
January 2009 meeting, the FIW could provide briefings on issues where
multiple courses of action are being considered so that the Committee
can opine on which ones might be most fruitful. He suggested that the
Committee start by thinking about what the end-products of its work
should be, and then decide how to get there. Mechanisms for completing
the Committee's work could include ad hoc groups and subcommittees.
RADM Slade-Sawyer indicated that the most important areas where input
is needed right now are target-setting methodologies.
The FIW would also like the Committee's input on topic areas
and how they are going to fit together across the whole document.
Dissemination of the Committee's Phase I Report
Dr. Fielding asked what can be done to maximize dissemination of the
Phase I report, which is of significant interest to many people at the
local and state levels. He asked if there had been any effort to have
the report disseminated through other members and organizations. RADM
Slade-Sawyer said the primary dissemination vehicle is the Healthy
People listserv. ODPHP is working to make the report available, but
there are privacy issues that are challenging. These issues should be
sorted out within the next couple of weeks.
Dr. Fielding requested that the National Opinion Research Center (NORC)
be enlisted to send out the report to relevant organizations,
highlighting the report's availability and offering a brief summary of
its contents. RADM Slade-Sawyer indicated that this would be acceptable.
Dr. Fielding asked NORC staff to distribute notification of the report
to any organizations that they are aware of. Committee members should
also help disseminate the document in the short term, as ODPHP resolves
issues with the Healthy People listserv.
He also asked whether there had been feedback on the Phase I report.
RADM Slade-Sawyer said ODPHP has received positive feedback about the
report, along with questions about when the FIW report would be
available.
Dr. Fielding asked NORC to produce briefing papers to help guide the
Committee's discussions of target-setting and topic areas in January.
Karen Harris (NORC) noted that NORC had already produced two draft
briefing papers for the Committee in preparation for this session—one on
target-setting, and a second on knowledge-based resources. Dr. Fielding
noted that he had reviewed the papers and asked whether the additional,
more specific information from the FIW is available to update the
briefing papers. Carter Blakey (ODPHP) responded that there was no
additional information from the FIW at that point.
IV. Committee Goals, Products and Work Plan for Phase II
Dr. Fielding asked Committee members to discuss their activities for
Phase II, including how they should be prioritized and what
subcommittees would be needed. He felt the most important issue to be
discussed in January would be the question of what would make Healthy
People 2020 a successful effort. This discussion can be informed by
NORC's earlier review of previous Healthy People initiatives, as well as
peer-reviewed articles that have chronicled the successes and challenges
of previous iterations of Healthy People.
Overview of Issues for Phase II
Dr. Fielding said health disparities could increase with the current
economic downturn. Although the Committee may not be able to address
macro issues on a topic-by-topic basis, they may want to comment on
economic development as a way to improve health and possibly reduce
disparities. A member said that economic recovery will be a major focus
going forward, and that the Committee's work in 2009 should address the
role of Healthy People 2020 with regard to improving the nation's
economy. He also recommended that the Committee address the issue of
health reform.
Another Committee member commented that access to health insurance
coverage and primary health care services are critical. She emphasized
the need for engaging communities in the process. Commenting on the
nomination of Chicago Public Schools CEO Arne Duncan as Secretary of
Education, a member indicated that education will be a top priority for
the administration, and the relationship between health and education
will be very important. RADM Slade-Sawyer reminded the Committee of Dick
Riegelman's presentation at an earlier meeting on the Healthy People
Curriculum Taskforce. This group focuses on education across the
lifespan, including what Dr. Riegelman is calling the "Educated
Citizen," as well as prevention education through college into graduate
and medical school.
Dr. Fielding suggested that the Committee issue a document
highlighting the role of Healthy People 2020 in the economic recovery
and the key actions by HHS that would improve the nation's economy and
facilitate achievement of the Healthy People 2020 objectives. Dr.
Fielding added that it may be useful to consider issue papers regarding
health and the economy that have been issued recently by organizations,
including Trust for America's Health, and Partnership for Prevention. A
recent forum was held on the issue of health reform called, "Rhetoric to
Reality." Dr. Fielding asked NORC to use these resources to prepare
bullets for the Committee to use in preparing recommendations.
Overview of Processes for Phase II
Dr. Fielding brought up the fact that, for Phase I of its activities,
the Committee issued a single document. He asked whether the Committee
should take the same approach for Phase II, or if they should issue a
set of shorter documents on specific subject areas. He felt the latter
approach might be helpful to a broader audience and would not require
waiting to put recommendations on paper. RADM Slade-Sawyer agreed that a
series of shorter documents with the Committee's recommendations would
be more useful for HHS for Phase II of the Healthy People 2020 process.
This would allow HHS to take the Committee's advice into consideration
in a timely manner. Dr. Fielding solicited the Committee members to see
whether any members preferred to issue a longer report at the end of
Phase II, but none preferred this option.
V. Guidance for the Objective Development Process
Target-Setting Methodologies
Dr. Shiriki Kumanyika, Committee Vice-Chair, said NORC's draft report
had not made clear why certain objectives had not met their targets in
the past. RADM Slade-Sawyer responded that this is a complex issue that
would require research to answer completely. The target setting method
for Healthy People 2010 was "better than the best" (i.e., targets for
all groups were set to exceed the level of the racial/ethnic population
with the best status.)
RADM Slade-Sawyer commented that she views the targets as being "aspirational,"
for the reason that one would want every population in America to exceed
the best population group within a decade. However, she noted that it is
not a practical method of target-setting. This is part of the
explanation for why so few of the objectives met their targets.
Additionally, multiple factors influence whether many of the objectives
are achieved; for example, one factor influencing target achievement is
people's behavior. As Healthy People looks upstream towards issues that
are not health-related (e.g., social determinants and disparities), the
problems are harder to fix. Ms. Blakey added that for some cases, such
as the obesity epidemic, we face an overwhelming increase in disease
incidence that may take more than a decade to fix.
Dr. Fielding said it is nearly impossible to separate targets from
objectives. Specific targets are very different, depending on the
quality of the data and the extent to which there are known
evidence-based interventions, and whether those interventions will have
impact over the short or long term. The effect sizes of those
interventions and the secular trends add to the difficulty of setting
comparable targets. However, he felt it would be helpful to suggest
approaches for how different groups should go about setting targets, so
that there is not one target that is aspirational and another that uses
the best data and is realistic. Dr. Fielding suggested that the
Committee opine on approaches that lie between the range of the
aspirational and the practical, data-driven efforts, where
target-setting can be accomplished.
Another member asked whether there were exemplars from Healthy People
2010 of objectives that moved in the right direction. There is a wealth
of information from past efforts that would help to understand how and
why objectives did or did not move towards their targets. She asked if
there were advances with which ODPHP has been particularly pleased. RADM
Slade-Sawyer answered that objectives related to smoking have made good
progress. Yet even this issue is fraught with challenges. Many streams
of combined effort are required for an objective to achieve its target.
Major policy decisions, or budget decisions at all levels, can affect
the degree to which progress is made. Achievement of the objectives is
multi-factorial.
RADM Slade-Sawyer offered to have ODPHP staff review the Healthy
People 2010 Midcourse Review and determine whether identity is possible
to identify factors that affected progress. Dr. Kumanyika requested
analysis of two or three exemplars—one where the targets was reached,
one where the target was not relevant or where results were mixed, and
one where the target was not reached. Dr. Fielding said the Committee
should make a recommendation that there be some a finer-grain analysis
of which targets have been met and which have not to identify lessons
learned that can be included in technical assistance materials for
implementers.
Another member brought up the tension between aspirational and realistic
objectives. He felt there should be a set of rules for deciding how
targets will be set. These should address the nature of data used to set
realistic targets; when it is appropriate to use aspirational targets;
and overall decision criteria for setting targets.
A member asked for clarification of when assessments of progress are
completed for each decade of Healthy People. He requested clear guidance
to help states answer the question, "If you set targets for a given
year, what year do you evaluate progress?" He had heard that the
baseline data for the 2000 data was collected in 1987 and that the final
evaluation was based on data from the late 1990s. In the past,
evaluations were not based on data collected in the final year of the
decade; this is an important detail that should be clarified.
He also asked when the baseline data for 2020 be collected. If the
objectives are framed as measuring progress from 2010 to 2020, but the
data that are collected are really from 2007 to 2017 this should be
clearly explained in advance. States will try to replicate Healthy
People and match their objectives to it, and most will assume that the
2010 objectives are evaluated with data from 2010. Dr. Fielding agreed
that this is an important issue to discuss.
Evidence-based Actions
Dr. Patrick Remington, Committee member, noted that Wisconsin has
been compiling a list of over 400 evidence-based programs and policies,
which he would be happy to share. This has highlighted the difference
between asking the question of, "where we want to be?" versus, "how do
we want to get there?" He said the Committee should spend time on the
complex issues related to deciding where we want to be in ten years;
that process relates to setting targets and tracking data sources. For
example, should one look at inputs? Should one measure outputs,
processes, and short-, immediate-and long-term outcomes for all of these
health problems? Should they each have logic models? That would be a
large task. The question of how to get there would add another layer of
complexity.
Dr. Kumanyika said that the Committee should create an "upstream to
downstream" sense of these issues, perhaps by arraying some of the
objectives and targets in the ecological layers of the Committee's
Action Model. This would allow the members to see how the objectives and
targets fit together without creating a logic model for every single one
of them. She added that interim targets and objectives are important
because 10 years is not long enough but it is too long. If the Committee
can show actions to be taken in the short-term, as well as issues that
are longer-term, it might help to clarify the question of "how we get
there."
Another member agreed with the suggestion to apply an ecological
model to identify "low-hanging fruit." She expressed that Healthy People
2020 should be relevant, showing how it is tied to the nation's crises
and ongoing issues. She went on to suggest that environmental health and
preparedness issues could be featured very prominently as well. The more
the Committee can tie into those issues, the better. The goal of
"relevance" should be explicit.
VI. Developing Recommendations for Phase II Efforts
Dr. Fielding asked the Committee what would make Healthy People 2020 a
successful effort. They had already agreed that work was needed on
target-setting and topic area categories over the short-term, and had
already done some work on objective development, although this may need
to be refined. The Committee would like to offer recommendations on
technical assistance and refine its recommendations regarding the
proposed relational database. He asked what three or four deliverables
the Committee would like to produce by the end of Phase II, such as
technical assistance or interfacing with the evidence-base.
RADM Slade-Sawyer offered to submit in writing the questions that she
had posed to the Committee earlier. She added that it would be helpful
to get the Committee's feedback on how to devise a system that is
flexible enough to change as priorities and data sources evolve over
time. Dr. Fielding said that part of this would have to do with software
used, as well as a standardization process.
Objective Development and Selecting Topic Areas
A member asked for clarification of the Committee's role in setting
objectives. Specifically, should there be a Subcommittee on Development?
This could be very time-consuming from the Committee's perspective. As a
realistic charge for this group, he did not think it would be viable to
have a subcommittee delve deeply into data sources, regression models
for projecting into the future. Instead, he noted it would be more
appropriate for the Committee to react to work that has already been
done by the FIW and ODPHP.
RADM Slade-Sawyer commented that the FIW has already tasked several
interagency work groups with looking at the Healthy People 2010 focus
areas and objectives. They are reviewing which objectives should be
retained, revised, or eliminated as Healthy People 2020 objectives. She
said ODPHP would be happy to make the FIW's work available for review by
the Committee. A member asked for an update from the FIW about where
they are heading.
Dr. Fielding agreed and felt that the Committee should opine broadly
on data issues, requirements, and the degree to which existing data
systems will meet the needs for setting targets and tracking progress
over time. He felt the Committee should not get involved in
methodological concerns. Dr. Fielding said that intermediate targets and
data sources are also important. There are multiple questions relating
to data, including sources of data, types of data, quality of data, and
timeliness of data. He indicated that a very brief set of lessons
learned and recommendations in that area should be part of the
Committee's Phase II work.
A Committee member later said the issue of health reform makes it
even more important to determine what kinds of data would be useful for
future surveillance and performance assessment. He felt that the
Committee should develop an opinion on this so that they can comment on
this subject in the future. Dr. Fielding agreed that data
recommendations would be important in supporting this effort. He said
that this topic should be addressed by a subcommittee, but not at the
January Committee meeting. Another member raised the role of primary
prevention in the area of human development. He suggested that the
Committee make recommendations in the realm of primary prevention,
beyond immunization. Dr. Fielding asked the member to make sure the
subcommittee addresses that issue, potentially designating primary
prevention as a topic area.
Technical Assistance and Tools
A member explained that constituents are seeking a simple way to go
from a health plan (e.g., deciding to improve diabetes quality and care
and looking to set a level for that improvement) to a source. They want
a more user-friendly guide to evidence-based public health actions than
what is currently offered by the Cochrane Reviews, the Guide to
Community Preventive Services, and the Clinical Guide to Preventive
Services. Such a guide should offer an entry point that is less
complicated, less comprehensive, and probably does not involve
cost-effectiveness information. Dr. Remington and his colleagues are
drafting such a document and will share it with the Committee in
January.
Another member agreed that the Committee should apply the idea of
simplicity throughout Healthy People 2020 to maintain effectiveness. Dr.
Fielding concurred that it is always harder to keep things simple, but
important do so. He added that, in looking for pools of evidence-based
actions, Healthy People should include the work that goes on in other
sectors to health. Health impact assessments and forecasting are
valuable tools.
Dr. Fielding noted the need to provide Healthy People users with
understandable tools. An example would be the Action Guides that the
Partnership for Prevention created for the Centers for Disease Control
and Prevention (CDC) to translate recommendations into practical "how
to" guidance. (See:
http://www.prevent.org/content/view/141/166/). It's an issue of translating
of targets into action and going from a document that is designed as a
reference to one that is useful for program planning and development. He
suggested Committee members review the Action Guides for their January
meeting. Dr. Fielding suggested that this issue be discussed at the
meeting in January.
Systems Specifications Subcommittee
Given the Committee's discussion of the desire for more specificity
for the database, Dr. Fielding asked Dr. Ronald Manderscheid, Systems
Specifications Subcommittee Chair, what would be a realistic scope of
work for his group to undertake. Dr. Manderscheid recommended that the
members not waste their time reviewing the first draft of his group's
report as a second draft would be produced for the January meeting. He
went on to say that the document should lay out the underlying concepts
for a query system that could replace the paper version of Healthy
People 2020. It would use fixed queries from a fixed database to make it
easier to access and use the data.
Dr. Manderscheid raised several questions that remain to be
addressed, including the form for the basic database and the mode for
accessing it. As the Healthy People 2020 system is built, people at the
local level are going to want to upload data to compare themselves to
the national benchmarks. In addition to these issues, Dr. Manderscheid
said that the Committee should consider what the appropriate role for IT
is within public health. Part of this is related to economic recovery
because of the need to develop IT infrastructure. While he recognized
that it would not be possible to pursue all of the possibilities now, he
felt that the Committee should at least express an opinion about this
issue. Dr. Fielding indicated that it would be helpful to know if the
new administration will embrace a database format for Healthy People
2020. He recommended an IT subcommittee remain in place going forward.
VII. Issues for Inclusion in the January Agenda
Dr. Fielding asked if there were other areas where the members felt it
would be important to focus attention during their January meeting. He
noted that there were four expert presentations planned, including
Shawna Mercer (Branch Chief, CDC Community Guide); Ed Sondik, (Director,
NCHS); Robert Pestronk (Executive Director, NACCHO); and Paul Jarris
(Executive Director, ASTHO). He asked whether it would be helpful to
have more interaction with the FIW. RADM Slade-Sawyer agreed that this
would be a good opportunity for such interaction. He asked the Committee
whether additional presentations or issues for discussion might be
useful to add to the agenda. Suggestions included:
- A presentation from the Office of the National Coordinator for
Health IT (ONCHIT)
- Comment from NCHS on the extent to which data gaps on health
equity are or are not being closed.
- Exemplars of objectives that have successfully moved toward
their targets, including tabulation by type of target setting method
used.
- The results of the focus groups conducted by the subcommittee on
User questions and Needs should also be addressed.
VIII. Summary and Closing Remarks
Dr. Fielding thanked the Committee for their work over the course of a
remarkable year. He noted it is a time of trepidation and hardship
for many, but it is also a time of great hope.
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