III. LHI Subcommittee Discussion
Dr. Kumanyika welcomed Committee member Ronald Manderscheid, the Chair of the LHI Subcommittee. She explained that Dr. Manderscheid would be presenting the Subcommittee’s recommendations, including an overview of the Subcommittee’s process for selecting the LHIs. Following his presentation, the Committee will discuss and vote on the LHIs that will be presented to the Secretary. Dr. Manderscheid thanked all who contributed to the LHI recommendation development process. Before presenting the set of recommendations, he provided an overview of the Subcommittee’s general process.
Subcommittee discussion on LHIs: The LHI Subcommittee held six calls, the first of which was on March 31, 2011. The Subcommittee reviewed the IOM’s recommendations as well as other national indicator sets. In coming to consensus around the role of LHIs, the audience for LHIs, a framework to organize the LHIs, and the criteria for selecting indicators, the Subcommittee considered the recommendations of the IOM Committee, as well as other indicators sets, such as the National Prevention Strategy, Healthy People 2010 LHIs, County Health Rankings, State of the USA, CDC Vital Signs, Secretary’s Priorities, ASH initiatives, and numerous other sources. He explained that the indicator and objective labels used by the Subcommittee is consistent with that of the IOM. He defined an indicator as statements that reflect whether something increases or decreases (e.g. dental caries should decrease) whereas objective in this context refers to the Healthy People 2020 objectives. Dr. Manderscheid provided an overview of the framework for the LHIs.
He shared that the framework for the LHIs is a combination of the Healthy People 2020 framework that was developed by the Committee and the IOM framework. The Life Stages and Health Determinants/Health Outcomes make up two different dimensions in this framework. He said that the indicators nicely align with the four central categories of Health Determinants/Health Outcomes framework (Physical and built environment, Social environment, Health behavior, and Health and clinical care services). For the policies that lead to health change category, he shared that the Subcommittee thought that this was an important area to highlight because to achieve a healthy nation, every single law and regulation should consider health going forward. The Outcomes category on the other hand refers to how well the LHIs work. (Refer to Figure 2 from meeting agenda documents or page 12 on the PowerPoint slides to see the Healthy People 2020 framework).
Regarding criteria for selecting the LHIs, Dr. Manderscheid explained the Subcommittee created the criteria on their own and considered the criteria used by the IOM. The Subcommittee used a series of seven criteria for the selection of LHIs. First, they wanted indicators that are central and important as a determinant of health status. The LHIs are indicators that can be influenced now, not years from now. Second, they must be instinctive, or easily recognized as intimate to health status. Third, they must be translatable to national, state, community, and individual levels, and will enable communities to mobilize around these issues to create initiatives that will improve the health status in their community. Fourth, they must be measureable at a point in time and over time, or able to be changed. Fifth, they must be divisible into key subpopulations, or looked at over the life course. Sixth, they must be actionable, or convey a sense of the possibility to act. Finally, they must be immutable, or convey a sense of the obligation to act.
Subcommittee Recommendations and Additional Recommendations (Foundational Measures, Overall Health): Dr. Manderscheid provided an overview of the Subcommittee’s three general recommendations. He explained that the first LHI recommendation made by the Subcommittee has three components. First, the Subcommittee proposed 14 LHI topics with associated objectives. Twelve of the topics reflect factors related to health, and the remaining two (preparedness and public health) are infrastructure-oriented. Second, each LHI should be analyzed for disparities and equity and age, as both factors are critically important to future health status; however, the analysis will depend on the specific Healthy People 2020 objective. Third, a continuous analysis of Healthy People 2020 Foundation Health Measures is needed, and these measures reflect important upstream factors that determine future health status and outcomes. There are four major factors for Health Foundation Measures:
- Health status - years of potential life loss, health status, etc.
- Health-related quality of life and well-being
- Determinants of health
- Disparities – race, ethnicity, gender, geography, etc.
The Subcommittee’s second LHI recommendation encourages HHS to develop multi-measure health indices that are composed of social and economic determinants of health, health behaviors, prevention and clinical care services, health status and outcomes. Dr. Manderscheid added that the Secretary made an announcement recently that she wants a greater effort to collect health determinant variables. The indices should be broader than issue-specific measures, but focused enough to be actionable. Dr. Manderscheid noted that this work could be used to improve LHI objectives and increase parsimony.
The Subcommittee’s third LHI recommendation promotes the creation of an overarching measure of health. Dr. Manderscheid stated that this could be a synthetic product of the Healthy People 2020 Foundation Health Measures and is essential to summarizing HHS work in simple communications to the public and in comparing the US to other countries. He called this measure “the holy grail of health,” and acknowledged that many measures would need to be pulled together to create it.
Dr. Manderscheid then presented the LHI Subcommittee’s 14 recommended LHI topics:
- Healthy and Active Lifestyle
- Substance Abuse
- Oral Health
- Injury and Violence
- Responsible Sexual Behavior
- Mental Health
- Maternal, Infant, and Child Health
- Environmental Determinants: Natural and Built Environment
- Social Determinants
- Clinical Preventive Services
- Access to Care Services
- Preparedness Infrastructure
- Public Health Infrastructure
Dr. Manderscheid noted that eight out of the first 12 topics are identical to those in NPS, and nine out of the first 12 topics are identical to those in the IOM recommendations. Areas unique to the Subcommittee’s recommendations are oral health as well as preparedness and public health infrastructure. After presenting the 14 topic areas, he detailed the specific objectives associated with each indicator. When discussing the objectives connected to the Social Determinants indicator, Dr. Manderscheid noted that the Economic Hardship Index is comprised of six factors: employment, dependency, education, income level, crowded housing, and poverty. The Economic Hardship Index is very important in terms of future health status.
Dr. Manderscheid also mentioned that the developmental objectives in Healthy People 2020 helped to establish the Social Determinants indicator. In reference to the Preparedness and Public Health Infrastructure indicators, he emphasized the importance of infrastructure to achieving success on the first 12 indicators. These two indicators were also influenced by the developmental indicators in Healthy People 2020.
In conclusion, 41 Healthy People 2020 objectives have been used in developing the Subcommittee’s recommended LHIs, and they encompass 78 different measures. Dr. Manderscheid said the Subcommittee’s believed that the recommendations for LHIs were true to the goals set forth by the Committee, particularly in regards to emphasizing social and physical determinants of health, the focus being across life stages, and the highlighting of health disparities and equity. He hoped that the Subcommittee’s recommendations would be helpful to HHS as they move forward with the national health agenda.