Dr. Fielding asked whether the current implementation recommendations are sufficiently fleshed out to be of use to ODPHP. Ms. Blakey explained that the limitation they face is one of resources. Dr. Fielding pointed out that ODPHP is not engaging in this work alone. He cautioned that if the intersectoral, multi-level activities being proposed do not take place, there is risk that Healthy People 2020 won’t be very effective. The Committee takes implementation very seriously. Healthy People has always been a little short on the implementation side, although it has been strong on the planning side. He and other Committee members said Healthy People should be an organizing framework for the progress that the Secretary and President want to make in health. He offered to present to senior level Federalofficials (e.g., via the Domestic Policy Council) on this issue.
Ultimately, the members agreed that a document is needed that further explains the Committee’s list of Implementation Recommendations. Dr. Kumanyika suggested matching resources with recommendations. It would also be worthwhile to have a subcommittee explore barriers to implementation (especially barriers to a cross-cutting, social determinants approach). What are the factors that keep people in silos? As part of this exercise, the Committee should revisit some of NORC’s earlier work describing barriers to effective implementation of Healthy People 2010. Other issues discussed by the Committee included:
- Dr. Fielding noted that the Implementation Recommendations document should be edited to refer to “social and physical environmental determinants” throughout.
- Include Healthy People in schools and university-level curricula, and engage schools of public health.
- Incentivize effective implementation of Healthy People, such as a Pay for Performance approach.
- There is not only a need for State Healthy People Coordinators but, in some cases, local coordinators as well.
- Think about how to take advantage of existing community networks and make sure they have a health chair.
- Take advantage of the blurring lines between population health and clinical health, integrate the concept of a “medical home,” and include social and behavioral health, as well as health promotion.
- Use innovative media strategies to promote behavior change and shifts in social norms (e.g., incorporating public health messages into soap operas and other entertainment).
VII. Committee Discussion: Selecting National Priorities
2:30 PM- 3:30 PM
Dr. Fielding explained that, when it comes to priorities, perspective is everything. A tobacco control person will view priorities one way; a local health official will view them another way; and the Secretary of HHS or the President will have other perspectives. Dr. David Meltzer, Chair of the Subcommittee on Priorities, provided an overview of his group’s work in addressing priority-setting issues. He explained that in its first phase of work, the Subcommittee had addressed the broad question of how should priorities be set, and within that, what objective criteria, objectives and sub-objectives should be used in selecting interventions. In its second phase, the subcommittee was charged with thinking about priorities at the National, state, and local level, with particular emphasis on priorities for government. Some basic questions addressed were: Should there be one set of national priorities? Should there be flexibility at the local level? And what methods should be used to prioritize?
Dr. Meltzer reviewed the Subcommittee’s second-phase decisions. First, they said that priorities should be established at all levels of government, and that as each level should incorporate public input into its priority-setting. Secondly, there was a strong belief that HHS should identify several key national priority objectives to target over the next decade. There were two main foci for this discussion: 1) we should prioritize by health areas, and 2) we should prioritize within areas that have a pervasive effect across disease groups. Particularly appealing is the 3four50 approach (http://www.3four50.com/), the idea that there are three factors (physical inactivity, smoking, and obesity) driving the prevalence of four chronic disease that, in turn, account for about 50 percent of all mortality. Finally, the Subcommittee has suggested that, for pervasive impact, the concept of social and physical environmental determinants of health must be operationalized so it is not too nebulous to address.
Dr. Meltzer explained several quantitative approaches that were explored by the Subcommittee for setting priorities, both within health areas, and as tools to identify national priorities. Within health areas, they produced a grid demonstrating that criteria vary in their importance, depending on the perspective of the user. For national priority-setting, he offered perspectives on the strengths and limitations of several approaches, highlighting common elements. The Subcommittee recognized that no one formula captures everything. In the end, judgment plays a big role.
Dr. Fielding acknowledged that one size does not fit all; it is not always possible to set priorities that are relevant to both policies and programs. He asked if the group felt the term “priorities” was appropriate, since it implies that everything that is not a priority is of lesser importance. Dr. Kumanyika offered the term, “Challenges.”
Dr. Fielding said one could think of priorities in three categories: cross-cutting social determinants; diseases/risk factors; and topic-specific. This would help to cut through the clutter of objectives and subobjectives for each topic. A member asked what would be the practical implications of designating an issue as a priority objective. Ms. Blakey explained that the issue of priorities had come up recently, as the FIW developed the individual objectives. At the start of the development process for Healthy People 2020, ODPHP had thought that they would limit the number of objectives and topic areas. Yet the more they received input from users, the more they heard that people wanted issues pertinent to them to be reflected in Healthy People. As a result, the proposal to narrow the focus of Healthy People 2020 was set aside.
There are advantages to an encyclopedic approach, but if you have a thousand objectives, where do you start? A local health department may not have specific objectives of interest, but may want to develop a health plan; their feedback is a preference for a broad range of objectives from which to choose. They might look to the Federal government for national objectives that offer guidance for some of the priority areas that should be addressed. Priority objectives could focus attention and resources. The Committee discussed various approaches to setting national priorities within Healthy People 2020. Options that were vetted included:
- Identifying the highest benefit (i.e., the things that are going to have the greatest impact);
- Identifying the highest value objectives at the state- and local-levels;
- Avoiding setting national priorities, but providing “how to” guidance for priority-setting at the local level;
- Taking leadership at the national-level by providing clear guidance about the 3four50 approach;
- Recommending a process for setting national priorities;
- Recommending that the Domestic Policy Council convene a group to determine the priorities;
- Looking for opportunities for social justice to be served; and
- Highlighting that very little research has been done on effective ways to reduce health disparities and the differential effects of interventions.
Dr. Kumanyika commented that this was not the first circular discussion the Committee had held on this issue. She suggested that the group put forth some options. Through additional discussion, the Committee eventually proposed four options for prioritization:
- Option 1: Cross-cutting social and physical environmental determinants
- Example: High quality primary & secondary education
- Option 2: Modifiable risk factors
- Option 3: Highest potential opportunities in each non-health sector
- Example: Support mass transit
- Option 4: Within-topic prioritization
- Example: Colon cancer screening
A Committee member asked whether the intent was that, for any situation that a group setting priorities might find themselves in, these four methods would cover the landscape. Dr. Fielding affirmed this interpretation. He and Dr. Kumanyika agreed that these options should be remanded to the Subcommittee on Priorities so that they could be refined for presentation on the following day. The meeting was adjourned at 3:28 P.M.
Day 2: September 18, 2009
I. Issues to be Addressed in the Coming Months
9:00 AM – 10:00 AM
Dr. Fielding called for discussion of issues that the Committee should address in the coming year. He began by presenting a list that some of the members had helped him to compile:
- Assuring that adequate weight is given in the Healthy People 2020 process to the physical and social environmental determinants of health. It should infuse and inform the work of the FIW topic areas.
- Addressing health information technology through both infrastructure and the Healthy People Community.
- Identifying priorities.
- Developing recommendations for an evidentiary hierarchy—what can be recommended, what should be recommended, and how do we talk about different sources of action steps?
- Developing recommendations for indicators. These include tracking progress in each of the topic areas, as well how to track progress in health, and in the underlying factors that will affect future health.
- Developing recommendations regarding the broad issue of implementation, including both dissemination and adoption.
- Developing recommendations regarding the important and bi-directional interplay between Healthy People 2020 and health reform.
Dr. Fielding asked for additional suggestions. A member explained that the previous day, the HHS Secretary had announced the availability of $650 million in grants for prevention and wellness through the American Recovery and Reinvestment Act (ARRA). He said the Committee should recommend efforts be undertaken to develop the interface between Healthy People 2020 and the prevention and wellness fund as grants are implemented. He also noted that the Secretary has been given $400 million in discretionary funds to promote prevention and wellness activities outside of the grant structure. This is a wonderful opportunity to integrate Healthy People 2020 more broadly into the work of HHS, and to support key activities of Healthy People 2020 in states and communities. Dr. Fielding asked if there was any disagreement that the Committee should recommend to the Secretary that she consider allocating some of the discretionary funding to support implementation of and communication about Healthy People 2020. No objections were voiced. RADM Slade-Sawyer said it would be helpful if the Committee could operationalize its recommendations in this area.
Dr. Fielding proposed discussing how to advance these issues in the coming months. How should other agencies be involved in efforts to address social determinants of health? Dr. Kumanyika recommended engaging other agencies to identify indicators that could be tracked with respect to health implications. It would not be necessary to set targets at this stage. Indicators of social and physical environment determinants in other arenas could be monitored, and trends and implications for the health status of the nation could be reported. Those indicators could be linked to indicators along the continuum, from upstream to downstream factors. For example, the FIW could engage the Department of Education to find out what indicators they are tracking and would like to see movement on, and the FIW could show how those indicators are tied to health (e.g., high school graduation rates, number of schools, quality of teachers). This would help people who talk about health to also look at education.
Dr. Fielding said that a stronger foundation of Health Impact Assessments is needed in other sectors to quantify the areas that have the strongest relationships to health, and to estimate an effect size for changes. He said some Committee members were concerned that work on social and environmental determinants of health might be disconnected from the rest of the Healthy People effort. One way to address this would be to involve experts in the social determinants of health in the key workgroups of the FIW and invite the participation of senior representatives from other agencies. This would generate commitment to integrating and operationalizing social determinants within Healthy People. A member suggested that the Committee develop fact sheets that HHS could use to educate people about the social and physical environmental determinants of health. Dr. Fielding warned against “getting too operational” in the Committee’s role as an advisory group. The Committee agreed to form an ad hoc group to develop some very simple, collective guidance for the FIW workgroups on how to address HiAP and HIA issues in areas traditionally considered non-health sectors. Volunteers to participate in this group included Abby King, Shiriki Kumanyika, Adewale Troutman, and Lisa Iezzoni.
Dr. Kumanyika suggested thinking about how to disseminate some of the Committee's ideas in these areas. How can some of the enthusiasm for finding the linkages between these issues be harnessed? For example, people would be interested in Committee’s thinking about evidence issues and how they relate to priority-setting. Some ideas that she outlined included: creating a place on the Web to which interested stakeholders could be directed; publishing in the peer-reviewed literature; cultivating a relationship with a publication (e.g., the APHA newsletter); or reaching out to the press. Dr. Fielding noted that because of FACA regulations, the Committee can submit recommendations to the Secretary, but they must be reviewed for 30 days before becoming available to the public. Ms. Blakey added that while there are regulatory constraints against having HHS put out press releases, it might be possible to engage the press so that they can report on the Committee's discussions. ODPHP will revisit relevant regulations with the public affairs office.
A Committee member pointed out the need for strategic communication objectives. The Committee has identified a set of key audiences, but has not discussed what information should be communicated to them. What actions does the Committee want members of these target audiences to take? What metrics should be used to gauge how well Healthy People is engaging people? Ms. Blakey again noted that NORC is finalizing a study of the needs of Healthy People users, the results of which should be presented at the next WebEx meeting. Dr. Fielding asked Douglas Evans, who chaired the Subcommittee on User Questions and Needs, to reinvigorate his subcommittee to look at the broader issue of developing a strategic communication plan. The Committee discussed other recommendations for disseminating current thinking about Healthy People 2020, including:
- Developing a standard set of PowerPoint slides about Healthy People 2020 that all Committee members could integrate into their own presentations. The slides could be made available to the State Healthy People Coordinators and Healthy People Consortium members so they can be ambassadors for Healthy People.
- Stimulating interest in the regional meetings and using those to promote Healthy People 2020.
- Identifying key conferences that will be taking place over the next few months to promote participation in Healthy People 2020, as well as understanding of its key concepts. (e.g., A focal, plenary session could be held at APHA in 2010, and Healthy People 2020 could be released at that meeting.)