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The first prong, priority setting within topic areas, would involve the use of quantitative algorithms for setting priorities. He noted that priorities are not monolithic and would vary by stakeholder. Another challenge is that there may well be thousands of objectives, which would make it nearly impossible to apply a rigorous quantitative algorithm to all of them—especially within the context of the limited resources that the FIW will have for prioritization.

Dr. Meltzer then turned the session over to Dr. Teutsch, who presented a grid that could be used to set priorities among multiple sets of stakeholders. The grid includes various elements that pertain to how well an intervention works and how big of an impact it can be expected to have. Comparative effectiveness will be increasingly important for decision-making. Decisions should be about more than whether an intervention works at all, but whether it works better than something else. Another consideration that should be weighed is whether an intervention works better for some select populations than others. The grid provides transparency and demonstrates that there is no simple, formulaic way to arrive at the right answer. Deliberative processes are needed in order to adequately assess the various dimensions of these decisions.

After reviewing the proposed processes for prioritization, Dr. Meltzer asked for Committee feedback. Dr. Fielding clarified that there was no expectation that the Committee would come to the point of approving the recommendations on this day. It would be an important area of discussion for the September meeting. A member said the CDC and others are presently involved in trying to develop clear messages about social determinants for the public and stakeholders. There is emerging evidence in this area that may be useful.

Another member noted that his department had commissioned past research on framing health determinants and health disparities which he could share with the group. He also supported the idea of incorporating social determinants based on evidence that differences in health outcomes by population are 25 percent due to individual behavior and 75 percent due to social and environmental determinants. He added that the Subcommittee should incorporate recommendations from the World Health Organization's Commission on the Social Determinants of Health report. Dr. Fielding noted that the Subcommittee should work to produce a revised version of prioritization recommendations that would be discussed more extensively at the September 2009 in-person Advisory Committee meeting.

VII.  Supplementary Report on Social Determinants

Dr. Kumanyika explained the rationale for developing a separate report to highlight how social determinants of health could be operationalized for users. The intent of this document was to offer additional guidance on concrete steps that could be taken to address these issues. Paula Braveman, Director of the University of California San Francisco's Center on Social Disparities in Health, had commented on an initial draft, and had also offered to point the Committee to additional resources that were used by the Robert Wood Johnson Foundation's Commission on Building a Healthier U.S. to write their report.

Dr. Kumanyika noted that the preliminary draft had been compiled from text from earlier Committee documents, such as the preamble in the Phase I report, that explicitly addressed social and physical environmental determinants. A more complete draft would be prepared for review in time for the September 2009 meeting. She said that Committee members should provide feedback on the report's content and structure to ensure that the social determinants perspective was clearly articulated. After a brief discussion about terminology (whether to use the term "social determinants," "societal determinants" or "social and physical environmental determinants") the Committee decided that these issues required additional discussion.

VIII.  Wrap-Up and Next Steps

On behalf of the Advisory Committee, ODPHP, and the FIW, Dr Fielding thanked all Subcommittees for their hard work and members of the public for their attendance at the meeting.

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