Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Phase II – Voting on Structural Issues for Topic Areas & Finalizing Target-Setting Methods
Via WebEx
Twelfth Meeting: May 15, 2009
Committee Recommendations (Approved by Vote)
Topic Areas
- There is no advantage to aggregating topic areas under broader categories of the framework (e.g., interventions, determinants, and outcomes) as they could be aggregated in many different ways.
- The proposed list of 50 topic areas can be modified and expanded to meet the needs of users.
- Indexing should be used to help users easily access groups of related objectives.
- A logic model should be created for each topic area to help explain how objectives are related.
Target Setting
- Healthy People 2020 objectives should not have separate disparities targets. However, disparities are important, and progress on eliminating them should be separately tracked.
- Specific interventions to reduce disparities should be noted.
- Guidance to regions, states and localities should indicate that there is one national target, but that national target need not be the one that they will use for local-level planning and tracking.
- Guidance and tools for states, regions and localities to use in setting their own targets should include: a set of clear principles, a list of methods to be used, and a rationale for using each type of method.
- Whenever possible, Healthy People 2020 objectives should use science-based, S.M.A.R.T. targets. However, when evidence is not available for setting an S.M.A.R.T target, other methods can be used.
- Targets can be set using other methods as long as those methods are clearly described.
Committee Decisions (Approved by Consensus)
- There is no need to specify a certain number of topic areas.
- Users can enter through any topic area as a "door" into the Healthy People 2020 relational database.
- It is not necessary to use a matrix to communicate about how objectives relate across topic areas.
Next Steps
- Differentiate between core indicators and priority objectives and define how they should be set.
- Determine if there should be a subset of objectives with targets that relate to priority objectives.
I. Welcoming Remarks
RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health and Director for Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (HHS), welcomed the members of the Secretary's Advisory Committee for National Health Promotion and Disease Prevention Objectives for 2020 (the Advisory Committee), as well as the public. She provided an update on HHS plans for developing specific Healthy People 2020 objectives and the timeline for their release.
RADM Slade-Sawyer explained that the Federal Interagency Workgroup (FIW) recently recommended including "developmental objectives" (i.e., those lacking a data source) in Healthy People 2020. These objectives would be included to identify areas of emerging importance, and to drive development of data systems that measure them. Such inclusion should be predicated on a commitment from the agency that is sponsoring the objective to identify and fund a reliable data source, and to secure baseline data to permit setting a target for the year 2020. Because health equity and the elimination of health disparities are goals of Healthy People 2020, the FIW also recommended expanding the standard data table that was used to display the baseline status of specific population groups for population-based objectives in Healthy People 2010.
The Federal Workgroup Coordinators were submitting to the FIW proposals for specific Healthy People 2020 objectives, which had been prepared using the selection criteria developed by this Committee and the FIW. The FIW would review the proposed objectives during the spring and summer of 2009. In October and November of 2009, HHS would make the draft objectives available for public comment through regional meetings and an interactive Web site.
At the conclusion of the public comment period, the Federal Workgroup Coordinators would review all public comments received and would consider revisions to the objectives. HHS hopes to release Healthy People 2020 in the final quarter of 2010. RADM Slade-Sawyer expressed her gratitude for the Advisory Committee's strong commitment to improving the health of the nation. She turned the meeting over to Dr. Jonathan Fielding, Advisory Committee Chair.
II. Desired Outcomes of the Meeting
Dr. Fielding explained that the main goals of the meeting would be to finalize the structure and organization of topic areas as well as the target-setting recommendations for Healthy People 2020. There would also be some discussion of the work of the Subcommittee on Priorities. After providing a general overview of the range of issues to be discussed and resolved, he introduced Advisory Committee member Patrick Remington.
III. Healthy People 2020 Topic Area Recommendations
Dr. Remington, Chair of the Subcommittee on Topic Areas, gave an overview of three issues for discussion: 1) the process for considering the role of topic areas in Healthy People 2020 and how they should be structured; 2) the relationships among objectives within topic areas; and 3) the relationships among objectives across topic areas. Recognizing that Healthy People 2020 could include over 1,000 objectives, the Subcommittee had recommended 50 topic areas that could be used to organize them. He explained that decisions about which objectives should be placed within each topic area would require understanding of a conceptual model to guide such decision-making processes. This would be a challenge.
He presented a slide that showed one option for how the Committee's originally proposed Action Model for Healthy People 2020 could be used as a simplifying structure to help users understand the logic of the topic areas. The model's main categories, "interventions, determinants, and outcomes," could organize the list of topic areas. These categories should not be viewed as mutually exclusive silos that distinguish some types of topic areas from others. They would offer a way to group a large number of topics into sets for ease of use. Dr. Remington opened the floor for discussion of and voting on the Subcommittee's draft topic areas report.
Responding to a question from Dr. Fielding, Dr. Remington said the central question for discussion would be, "What is the benefit of having and organizing topic areas? How would that process be put into practice?" He explained Healthy People in terms of layers, where the main categories of the model are the top layer, the middle layer is the topic areas, and the inner layer is the objectives. The question of topic areas is one of information management, so that users are not overwhelmed by thousands of objectives when they look for information on a particular issue that affects their community.
Dr. Fielding asked whether it is essential to think about how to group topics. It might be enough to say that topics fit into three categories, some fit into more than one category, and there is no "wrong door" for users to go through because all doors open onto the objectives. If a user entered into the cancer "door," that person would gain access to an understanding of determinants as well as the specific cancer-related objectives and resources for evidence-based policies and programs. Users could enter through any layer of Healthy People (i.e., broad categories, topic areas, or objectives).
Dr. Fielding said there may not be a need for a matrix to understand how objectives and topics fit together; topics and objectives flow across categories of the framework. Dr. Kumanyika replied that such an approach might not be intuitive for users. Using this kind of an indexing approach might be more useful. Objectives would be coded in relation to other things to permit linkage across categories. This would help to translate the Web site content into supplementary materials in printed, book form, and would require less effort than generating logic models. To create logic models, someone would need to think through how the different elements fit together. If there are thousands of objectives this would not be feasible.
- Dr. Fielding said the Committee would keep the approach that has been suggested by the Subcommittee on Topic Areas, but add the idea of an index. He asked if there was any disagreement. No disagreement was voiced, and Dr. Fielding said a formal vote was not necessary.
Dr. Remington posed the question of whether the number of topic areas is important. One could argue that moving from 28 to 50 topic areas is unimportant, since the number of topics would not change the number of objectives. The FIW may or may not accept the Committee's approach. Dr. Remington agreed and said that rather than locking into a specific list of 50 topics, it is more important to clarify the process. The topics presented in the Subcommittee's report represent a good starting point. He suggested it would not be necessary for the Committee to vote to approve the Subcommittee's specific report. Dr. Fielding asked if there was disagreement on this issue. None was voiced. He asked ODPHP staff members if they were comfortable with the change. RADM Slade-Sawyer requested that he clarify what was being recommended.
Dr. Fielding said the Committee had decided to recommend that: 1) there is no need to try to organize topic areas within broad categories (e.g., interventions, determinants, and outcomes); 2) a list of 50 topic areas is presented with the understanding that there are different ways to manage and aggregate material; and 3) indexing should be used to help people understand cross-cutting issues.
- Dr. Fielding asked for a vote of the Committee members. All members who were present voted in favor of the recommendations, and none were opposed.
To organize objectives within topic areas, Dr. Fielding proposed that each topic area have a logic model that would serve as a "structural scaffolding" for discussion about how objectives relate. Dr. Remington said this could become complicated, but ideally it would provide a simple way to think about how determinants relate to outcomes. Although the exact template of the logic models had not been specified, they should display the logic for why certain objectives have been grouped together.
- Dr. Fielding asked for a vote on the recommendation that logic models be created for each topic area. All members who were present voted in favor of the recommendation; none were opposed.
IV. Healthy People 2020 Target Setting Recommendations
Dr. Remington, who also chaired the Subcommittee on Target-Setting, gave an overview of that group's efforts. He explained that the group had been charged with answering four questions: 1) what data should be used in target-setting; 2) what processes should be used; 3) should targets be aspirational or realistic; and 4) should they incorporate knowledge of interventions. While the Subcommittee had addressed most of these questions in its report, some unresolved issues remained for discussion. Remaining questions included whether there should be disparities targets; what tools should be provided to states, regions, and localities to help with target-setting, and how target-setting should relate to prioritization of objectives.
He said the quality of data available for target-setting will not be uniform across all objectives. There might be two categories of objectives: those with high-quality data, and those with lower quality data for tracking purposes. Targets should be rooted in past experience and should incorporate knowledge of effective interventions. Ideally, they should be set using evidence to project what the effects of programs and policies would be, and then modeling a science-based objective. Yet targets can be set with less information by seeking a percentage improvement in the level of the objective (e.g., 10%, 20%).
The process of target-setting should vary depending on the objective. The "Better than the Best" approach is of limited value; often those targets have not been meaningful for the entire population (e.g., in situations where there are high rates of a condition). The Subcommittee proposed setting a single population target for each objective at a level that represents an improvement for most of the population, but might not be better than that of the subpopulation with the "best" health status. This method is not based on the status of a reference population. Disparity reduction would be achieved by having all groups reach the target.
Dr. Remington said the target-setting approach recommended by the Subcommittee would yield three types of objectives: a subset that have science-based or S.M.A.R.T. (Specific, Measurable, Achievable, Realistic and Time-bound) targets; a sub-set that are monitored but do not have targets (because not enough data is available for the targets to be meaningful); and a sub-set of developmental objectives that currently lack a data source. Regarding "aspirational" versus "realistic" targets, the Subcommittee preferred using the term "reach" to describe targets that are achievable, but require more effort than perpetuation of the status quo
There was discussion as to whether separate "disparities" or "equity" targets should be set in addition to the general population targets. In the past, the "Better than Best" approach was criticized for creating a single target that was not realistic for subpopulations with the greatest health disparities. A disparities target could be used to measure the gap in health status among subpopulations, which would highlight the issue. States could then be charged with setting disparities targets. Yet setting two targets (one for the population mean, and a second for variance) could lead to confusion. A variance target would be both difficult to measure and difficult to communicate about. Dr. Remington requested the Committee's feedback.
Dr. Fielding said disparities targets could be viewed two different ways. First, they could be seen as targets for groups that are not at the level of the average, mean, or reference group. Second, a disparities target could be seen as measuring dispersion. Dr. Remington expressed the view that, if the population target is based on the mean, the disparities target should focus on reducing disparities for populations at higher risk. If this approach is used, there will be population subgroups that have already reached the target at the outset of the decade. Thus, one would not reduce variation, but one would seek to reduce disparities by focusing efforts on the populations that are at greatest risk.
When asked how a separate disparities target would be expressed, Dr. Remington said one could look at the standard deviation of subpopulations. Groups that are more than one or two standard deviations away from the mean would be the focus of disparity-reduction efforts, so that ultimately there would be less variation across the subpopulation means. Ideally, there should be very little variation across subpopulation means for a particular objective (indicating low health disparities). Nonetheless, in some areas there would be tremendous variation. Dr. Fielding asked the group to address the questions of: 1) what they think of disparities targets, and 2) how such targets might be expressed.
Dr. Kumanyika was opposed to separate disparities targets, both in past iterations of Healthy People and for Healthy People 2020. She supported the notion of using disparities to measure progress towards narrowing the gap in health status. She did not support the idea of, for example, indicating that a certain level of obesity was acceptable for African American women and a different percentage was acceptable in White women. That approach was ineffective and controversial. Another Committee member agreed with this point. He said the challenge is to ensure that the best possible health is achieved for everyone, with health equity being the target. The introduction to Healthy People 2020 could address this issue, acknowledging that populations are starting from different levels of health status, but that strategies are needed to document progress toward the overall target for the population. Other members agreed and emphasized the need to inform communities about which subgroups need support to reach the target.
- Dr. Fielding asked for a vote to approve the recommendation that there should not be separate disparities targets. Nonetheless, disparities are important and progress on eliminating disparities should be tracked. Specific interventions to reduce disparities should also be noted. All members who were present voted in favor of the recommendation; none were opposed.
Dr. Remington asked for discussion of what guidance and tools should be provided for target-setting. He reviewed the Subcommittee's recommendations, including the use of a variety of methods, with a rationale for each. A decision-chart could present options in a hierarchal format. A set of clear principles for local-level target-setting should be provided; there should be an understanding that there will be one national target, but that target need not be the one that they will use for local-level planning and tracking. Methods used at the national level should be clear and transparent, so that they can be applied at the local-level. There was no additional discussion of this issue.
- Dr. Fielding asked the Committee for a vote to approve the above recommendations. All members who were present voted in favor; none were opposed.
As a final question, Dr. Remington asked whether the subset of objectives that have targets should relate in some way to topic area categories or priority objectives. For example, should target-setting methods be limited to areas that have specific and measurable targets? Or should targets be set using less complete information? (This would result in targets such as "a 20% improvement" in a certain level.) He expressed the view that it is OK to have a hierarchy of methods. The preferred method would yield very specific targets based on scientific projections, but other targets could be set using less complete information and expert judgment. Even with imperfect information, he felt that it is better to have a target than not.
Dr. Fielding asked how objectives that are set using incomplete information should relate to the evidence (for example, from the Clinical and Community Guides). Dr. Remington said that when evidence exists, it should be used to set specific, projected targets based on the evidence. A Committee member pointed out that the Committee is using many different terms (e.g., priority objectives, indicators, targets, etc.). She felt that it should be possible to have "priority objectives" that are important for the country, that do not necessarily relate to the subset of objectives that have evidence-based targets. They are not necessarily mutually exclusive, but these sets of objectives need not relate directly to each other. Others agreed with this point.
Dr. Remington reiterated the question of whether there should be a "middle category" of objectives that do not have enough evidence available to develop science-based, S.M.A.R.T. targets, but where incomplete information is available. He felt that an objective should not be eliminated because it does not have a S.M.A.R.T. target (e.g., evidence is not available to make a specific projection). After some discussion the members agreed that, whenever possible, objectives should have S.M.A.R.T targets. For some conditions, this information will not be available. Targets can be set using other methods as long as they are clearly described. (Dr. Fielding was called away momentarily and asked Vice-Chair Kumanyika to take over.)
- Dr. Kumanyika asked the Committee for a vote to approve the recommendation that, whenever possible, Healthy People objectives should have S.M.A.R.T. targets. In cases where complete information is not available, targets can be set using other methods so long as those are clearly described. All members who were present voted in favor; none were opposed.
V. Healthy People 2020 Priority Setting Recommendations
Dr. Abby King, Co-Chair of the Subcommittee on Priorities, gave an overview of her group's recent work. The Subcommittee felt strongly that priorities should be set at multiple levels (national, regional, state, and local) and be communicated publicly. There are a number of criteria that can be used to set priorities. Elements that are particularly germane include preventable burden, ease of implementation, cost-effectiveness, and health equity. Prioritizing objectives should occur in two domains: those focused on improving health (e.g., through prevention/treatment), and those influencing underlying social and environmental determinants of health. A set of national "priority objectives" should be identified and should be considered and addressed by every level of government. Priority objectives should consist of a balanced portfolio of short- and long-term issues related to systems, disease, and determinants.
The Subcommittee had said that Healthy People 2020 should re-establish a set of leading health indicators that can be used to track general progress related to priority objectives and other objectives. Leading health indicators are outcomes and are issues that should be tracked to measure progress in a certain domain. Previously established sets of health indicators, such as the leading health indicators, actual causes of death, State Health rankings, or State of the USA indicators, could be used. Dr. King requested feedback.
Upon his return, Dr. Fielding said leading health indicators need not be limited to health, but could include social and economic factors. Social and economic determinants offer a way to engage stakeholders from a variety of backgrounds in collaborative efforts. A Committee member added the role of data collection systems in gathering the data to support such efforts should be examined. The Committee discussed the fact that leading health indicators do not necessarily relate to priority objectives, although they may overlap. Determining which objectives are "priorities" may prove to be politically challenging.
RADM Slade-Sawyer commented that one way to address political challenges could be to say that these are national priorities, but priorities at the local level may look different. Dr. Kumanyika said it is important to have national priorities, but that the Advisory Committee may not be the correct body to set them. Others agreed with this stance. The Committee could talk about the role of DHHS or the FIW in setting such priorities. There are some areas where special efforts are needed to move the nation to the next level of progress, where perhaps the Federal government should do something visionary to move things along.
Dr. Fielding remarked that the word "priorities" might be problematic. Dr. Kumanyika suggested using the phrase, "areas of special emphasis" rather than "priorities." A Committee member said this approach was attempted in Wisconsin and was not successful. Community-members did not buy into the state priorities. Dr. Fielding noted the sensitivity of priority-setting with regard to the danger of disenfranchising some stakeholders. The other possibility to explore is that there might be a way to state priorities that are not disease or condition specific, such as those that are implied in the Committee's Phase I report (e.g., social or environmental determinants). Dr. Fielding asked the Subcommittee on Priorities to continue working on the questions of whether national priorities should be set and how they should relate to indicators.
RADM Slade-Sawyer noted in the past, Healthy People stakeholders have expressed confusion about where they should begin. She asked whether the Committee was saying that priorities should not be set due to the risk of leaving someone out. How should burden and amelioration be factored into decision-making? The Committee discussed these issues further, explaining that priority should be given to cross-cutting areas that have not received enough attention. Policies should be considered as potential interventions, not just additional resources for programs. Also, priority should be given to implementing evidence-based strategies that have been proven effective. It was agreed that the Subcommittee would reconvene to clarify the distinctions between core indicators and priority objectives, and to articulate a process for developing these.
Expert Presentation: The Alliance to Make US Healthiest
John Clymer, Senior Advisor to the Alliance to Make US Healthiest, presented his perspective on implementation of Healthy People. The Alliance fosters public and private collaboration to spark innovative actions and connect individuals to a national movement. Conceived by public health leaders, it is intended to move the U.S. from its ranking as 37th healthiest nation in the world to the "healthiest nation." The mission of the Alliance to Make US Healthiest is to provide leadership and facilitate actions by organizations and individuals that encourage or sustain health and well-being.
Just as Healthy People focuses on providing clear objectives and allowing diverse groups to combine efforts, the Alliance focuses on supporting individuals and organizational efforts that make it easier to adopt lifestyle choices to positively influence our nation's health. The Alliance will draw upon Healthy People goals and objectives and the leading indicators of health to choose a set of goals that will galvanize and resonate with the public. The Alliance's board had endorsed the decision to use the year 2020 as the end-date for their goals. Mr. Clymer presented screen shots of the alliance Web site via www.healthiestnation.org  . He stressed that the nation must expand the current conversation from a focus on healthcare reform to creating health and well-being and promoting health equity throughout the nation.
VI. Next Steps
Dr. Fielding would like feedback on how the Advisory Committee can help to make recommendations related to implementation of evidence-based practices in Healthy People. He thanked the Committee members and members of the public for their participation in an extremely productive meeting.
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