1. Phase II Guidance for Target-Setting and Healthy People 2020 Topic Areas Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020 Committee Chair: Jonathan Fielding, MD, MPH, MA, MBA Director, Los Angeles County Department of Public Health & Health Officer, Los Angeles County March 26, 2009

2. Revised Agenda 1.Update on HHS and FIW Activities 2.State of the USA (SUSA) Presentation 3.Guidance for Target-setting Recommendations 4.Discussion of HP2020 Topic Areas 5.Update on Other Subcommittee Efforts 6.Next Steps

3. Desired Outcomes for the Meeting  Update on HHS and Federal Interagency Workgroup progress and next steps.  Identify potential links between the SUSA initiative and the HP2020 process.  Provide guidance to the Subcommittee on Target-setting.  Clarify approach and next steps to finalize the HP 2020 Topic Areas. 3

4. Key Dates for Deliverables  Topic Area categories: March, 2009 Broad guidance to be developed at this meeting Final recommendations to be refined in coming weeks and approved on April 20  Target-setting Methodology: April, 2009  Final inclusion criteria for evidence-based resources: May, 2009  Implementation strategies: June-July, 2009 4

5. Update on HHS Activities Rear Admiral Penelope Slade-Sawyer, PT, MSW Director, Office of Disease Prevention and Health Promotion U.S. Department of Health and Human Services

6. Update on HHS Activities  Status of Phase I  HHS timeline for development of the objectives and public engagement  Work of the HHS Workgroup Coordinators  Activities of the Federal Interagency Workgroup (FIW)

7. Healthy People 2020 Framework FIW Recommendations to the Acting Secretary Vision Statement A society in which all people live long, healthy lives. Mission Statement Healthy People 2020 strives to:  Identify nationwide health improvement priorities;  Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress;  Provide measurable objectives and goals that are applicable at the national, state, and local levels;  Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge;  Identify critical research, evaluation, and data collection needs

8. Overarching Goals  Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.  Achieve health equity, eliminate disparities, and improve the health of all groups.  Create social and physical environments that promote good health for all.  Promote quality of life, healthy development and healthy behaviors across all life stages. Healthy People 2020 Framework FIW Recommendations to the Acting Secretary

9. Developing Healthy People 2020 Objectives  Sources of input on development of objectives Objective Development Process Input Public Comment Consortium Members Secretary’s Advisory Committee Federal Interagency Workgroup 2020 Planning Workgroups

10. PRESENTATION: State of the USA Christopher Hoenig President and Chief Executive Officer State of the USA

11. Discussion  How does SUSA relate to the Healthy People 2020 process?

12. Defining Objectives and Targets

13. What is an Objective? 1. Proposed definition and poll results  “Results of specific activities to be achieved over a stated time.” 5 of 9 poll participants thought this language should be used. 2 thought it should be revised, and 2 said it should be deleted.  “Objectives are specific, measurable, and realistic statements of intention.” 3 of 9 poll participants agreed with this statement. 5 thought it should be revised, and 1 said it should be deleted. 13

14. What is an Objective?  Four of five poll comments indicated that an objective should be: “Specific and measurable” “Time-bound (by 2020)” “Realistic”  One comment indicated an objective should be” “Visionary. Visionary and reality objectives need to be balanced.” 14

15. Proposed Revision: What is an Objective?  “Objectives are specific, measurable, and realistic statements of intended outcomes over a stated period of time (by 2020).” 15

16. Proposed Definition: What is a Healthy People 2020 Target?  A “target” is the level of progress or performance expected for an objective.  “Target-setting” involves the methods used to select the value for a target. 16

17. How does a target differ from an objective?  More specific?  More practical?  Focus on “sub-objectives,” (e.g., intermediate measures based on a logic model)?  May be for shorter periods of time (e.g., 3 to 5 years for achieving target vs. 10-year frame for objective). 17

18. Target-Setting Recommendations Guidance to Help the Subcommittee on Target-setting Prepare Draft Recommendations

19. Subcommittee on Target-setting  Charge of the Subcommittee on Target-setting is to answer: What processes and data should be used in setting targets? Should single or multiple targets be recommended for the same variable? (e.g. can realistically be achieved, vs. optimistic) How should targets incorporate knowledge of effective interventions? How should time frames for targets be set? (e.g. availability of data to monitor, time to mobilize interested organizations and individuals around the issue etc.)  What can be learned from the 2010 experience to help inform the work of the Healthy People 2020 Working Groups? 19

20. Target-setting: Types of Questions to Address (Issues Previously Raised)  What methods have been used in the past?  What are the pros and cons associated with each method?  If multiple methods are used, how should one determine which method is appropriate?  What would an ideal method of target-setting look like?  What tools are available now that were not available for 2010?  What compromises are acceptable… When there is essentially no evidence base? When the available evidence is weak? When the available evidence is strong but relevance is limited? To account for the influence of secular trends? 20

21. Other issues to consider in setting targets  Should some objectives be tied to assumptions about other objectives? Example: Where evidence suggests that effectiveness depends on a multi- level intervention.  How can logic models be used?  Should one target be set for the entire population? Or should targets be set based on the current status of subpopulations? Example: the “better than best” approach uses a single target.  When should modeling be used?  Other issues?

22. Ad Hoc Group on Topic Areas Subcommittee Chair: Patrick Remington, MD, MPH University of Wisconsin Population Health Institute Committee Chair, Jonathan Fielding, MD, MPH, MA, MBA

23. Review: Definitions Proposed by the Subcommittee on Topic Areas in February  Vision: A single, broad statement of what society will look like in 2020  Goal: The broad result toward which effort is directed  Focus Area/ Topic Area: Points of entry for each interested group into the Healthy People framework  Priorities: Priorities are given attention before competing alternatives. 23

24. Question: How should objectives relate to the HP2020 framework?  For example: Should objectives related to a given topic link determinants, to risk factors, to outcomes?  The Subcommittee considered connecting objectives to the framework by aligning Topic Areas with 5 broad categories of the framework: Broad determinants; Individuals across the life course; Outcomes; Assessment, monitoring, evaluation, dissemination; Interventions.  This approach was dropped because these five categories are not mutually exclusive.

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26. Overview of Recent Subcommittee Activity  Proposed another way to link objectives to framework: developing topic areas independently of objectives. Rationale: The framework emphasizes overlapping issues, so it is not problematic that objectives fall into multiple categories. Objectives for each topic area should be developed independently, and then mapped to the framework.  Grid was conceptualized to list all topic areas and show which areas of the framework are relevant for each one. 26

27. Proposed Approach to Link Topic Areas to the HP2020 Framework Proposed Topic Areas for HP2020 Programs and Policies Social, Economic, and Environ- mental Determ- inants Health Behaviors Disease, Mental Disorders, Disability, and Injury Life Stages and Health Outcomes Access to health care XXXX Quality of health care XXXX Reproductive Health XXXXX 27

28. Decisions Needed to Prepare and Finalize Topic Area Recommendations 1.What are the functions of HP2020 topic areas? Are the functions of HP 2020 Topic Areas the same as those of Healthy People 2010 Focus Areas? 2.How should topic areas be conceptualized to best meet the needs of users? What criteria should be used to decide what is and is not a “topic”? 3.What specific topic areas should be proposed? Poll of Committee members was conducted, 3/16/09 - 3/20/09. Process for refining and finalizing the list will be discussed. 28

29. The Functions of Topic Areas Based on the roles of HP 2010 Focus Areas, HP2020 Topic Areas can be said to serve the following functions :  “Topic Areas serve three main functions: organizational, managerial, and communication.”* 7 of 9 participants agreed with this statement. 1 participant proposed edits to make definitions more understandable to those who are new to HP. *Note: There is currently a one-to-one correspondence between “Focus Areas” and HHS “Working groups” that develop, track and monitor objectives in each area. 29

30. Would an expanded number of Topic Areas change their function?  Committee members indicated preference for an expanded number of topic areas: Participants voted to retain all 28 of the current HP2010 Focus Areas (with some revisions). Participants voted to include all 8 new Topic Areas proposed by the Subcommittee on Topic Areas (with some revisions). Participants recommended adding another 7 new Topic Areas. In addition, some participants recommended splitting existing HP 2010 categories into multiple sub-categories (an additional 9 Topic Areas). If all of these are retained, there would be approximately 52 Topic Areas in HP 2020. 30

31. Defining the Function of Topic Areas: Organizational  Would an expanded number of topic areas change their function as organizing principle?  Draft element of Topic Areas definition (adapted from poll): 1.Organizational: Topic areas identify and group objectives of related content; a single topic highlights like or closely related subjects. Objectives could be arrayed under one “primary” Topic Area, and multiple “secondary” topic areas. 31

32. Defining the Function of Topic Areas: Managerial  Would an expanded number of topic areas change their function in terms of designating responsibility for management?  Draft element of Topic Areas definition (adapted from poll): 2.Managerial: Topic Areas are assigned by HHS to “lead agencies” within the Federal government. Lead agencies coordinate the process of developing Topic Area objectives, and are responsible for tracking, monitoring, and periodically reporting on those objectives over the course of a decade. Should “Working Groups” address more than one Topic Area? Should agencies “adopt” responsibility for specific objectives, instead of topic areas? 32

33. Defining the Function of Topic Areas: Communication  Would an expanded number of topic areas change their function in terms of communicating about Healthy People content?  Draft element of Topic Areas definition (adapted from poll): 3. Communication: Topic areas enable users to locate the content they are seeking by organizing Healthy People information in a user-friendly way. HP 2020 Topic Areas should be more than a “point of entry” How can criteria ensure they reflect a coherent, available literature that can be accessed to improve health and prevent disease/ injury? 33

34. Criteria Used for HP2010 Focus Areas  Criteria that were informally used to choose HP2010 Focus Areas: The focus area was an “organizing principle” (i.e., groups of related objectives could be organized within that category) The number of objectives was not too large to manage, and it was not too small to be of consequence (Injury & Violence Prevention had 39 objectives; Chronic Kidney Disease had 8 objectives). A Federal agency was willing to be the “lead agency” for the Focus Area (i.e., to take responsibility for coordinating the development, tracking of, and reporting on objectives for the Focus Area). 34

35. What criteria should be used to select Healthy People 2020 Topic Areas?  A logic model to clarify pathways of intervention  Coherence of content; clarity of boundaries between Topic Areas: Reflects a body of available literature that can be accessed to promote health and prevent disease and injury; Reflects our understanding of the pathophysiology and multiple underlying determinants of health; Relates to a schema or logic model that links back to the HP2020 framework; Can be “owned” by a group of individuals with complementary expertise to adequately address the issue; Allows sufficient focus (e.g., a manageable number of objectives). 35

36. Healthy People 2010 Focus Areas 1. Access to quality health services 2. Education & community-based programs 3. Family planning 4. Food safety 5. Health communications 6. Immunization & inf. disease 7. Medical product safety 8. Public health infrastructure 9. Environmental health 10. Occupational safety & health 11. Nutrition & overweight 12. Physical activity & fitness 13. Substance abuse 14. Tobacco use 15. Arthritis 36 16. Cancer 17. Chronic kidney disease 18. Diabetes 19. Disability 20. Heart disease/stroke 21. HIV 22. Injury & violence prevention 23. Mental health/mental disorders 24. Oral health 25. Respiratory diseases 26. STDs 27. Vision & hearing 28. Maternal, infant, & child health

37. Topic Areas Poll: Choosing Topic Areas 1. HP2010 Categories: majority voted to retain without revisions Physical activity & fitness Tobacco use Arthritis, Osteoporosis, Chronic back conditions Chronic Kidney Disease Diabetes Mental health/ mental Disorders Oral Health Respiratory diseases Occupational safety & health Heart disease/ stroke Public health infrastructure Disability 37 HIV Nutrition & overweight Substance abuse Medical product safety.

38. Examples of Topic Areas that Could be Split  Nutrition & Overweight Nutrition Overweight  Substance Abuse Alcohol Tobacco Illicit Drugs Prescription Drugs 38

39. Topic Areas Poll: Choosing Topic Areas 2. HP2010 Categories: majority voted to retain with revisions See “Topic Areas Poll” Report for Proposed Revisions Access to quality health services Food safety Immunization & Infectious disease Environmental health Education & community-based programs Vision & hearing Maternal, infant & child health Injury & violence prevention Health communication Family planning 39

40. Examples of Topic Areas that Could be Split  Access to quality health services Access to health care Quality health care  Immunization and Infectious Disease Immunization Infectious disease 40

41. Topic Areas Poll: Choosing Topic Areas 3. Subcommittee’s Proposed New Topic Areas: Majority voted to Add Emergency Preparedness Health equity/ disparities Quality of Life Healthy Aging Adolescent Health Global Health Blood Diseases 41

42. Topic Areas Poll: Choosing Topic Areas 4. Additional New Topic Areas Proposed by Poll Participants Costs Healthy People Community Overall measure for the U.S. Social and Economic Determinants Health Promotion 42

43. Conceptual Groupings for Topic Areas  What should guide decisions about when to split and when to clump Topic Areas?  Review objectives within existing HP 2010 Focus Areas to understand how content is currently arrayed. 43

44. Process for Finalizing Topic Areas Next Steps:  Refine and finalize a list of topic areas offline by: Apply today’s decisions about guidance for conceptual groupings of topic areas Finalize a list of criteria for selecting Healthy People 2020 topic areas Complete a second round of “word-smithing/” revision of topic areas through a web-based poll Apply selection criteria to yield a final list of recommended topic areas. 44

45. Other Subcommittee Efforts  System Specifications Final report has been submitted  Implementation  Data & IT  Priorities 45

46. Summary and Next Steps  Remaining work on topic areas  Next steps for subcommittees  Next Committee meeting dates Monday, April 20th: 12:00- 2:00 PM (ET) Friday, May 15 th : 1:00 PM- 3:00 PM (ET)  Other issues 46