At the request of the Department of Health and Human Services’ (HHS’s) Office of the Assistant Secretary for Health, the National Academies of Sciences, Engineering, and Medicine appointed a committee of experts to assist HHS with one component of the Healthy People initiative. Healthy People is a decadal HHS effort launched in 1979 to “develop a framework for improving the health of all people in the United States” and offer “a strategic agenda to align health promotion and disease prevention activities in communities around the country” (Azar, 2018). The National Academies committee was given the following Statement of Task:
The Department of Health and Human Services, Office of the Assistant Secretary for Health, requests that the National Academies of Sciences, Engineering, and Medicine convene an ad hoc committee to assist in the development of Leading Health Indicators (LHIs) for Healthy People 2030. The committee will develop (1) recommendations regarding the criteria for selecting LHIs and (2) a slate of LHIs that will serve as options for the Healthy People Federal Interagency Workgroup to consider as they develop the final criteria and set of LHIs for Healthy People 2030. The committee may identify gaps and may recommend new objectives for LHI consideration that meet the core objective criteria.
This brief report represents the National Academies committee (or “the committee”) response to the first portion of the charge, providing a review of the criteria for selecting LHIs along with—in response to the
last sentence of the charge—comments about the Healthy People 2030 objectives (HP2030 objectives), currently in draft form. This report lays the groundwork for the second report, which will provide additional comments about the HP2030 objectives from which LHIs are to be selected, and will recommend a slate of LHIs.
At the time the National Academies committee began its work in late 2018, the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (SAC) had met 12 times and had developed the framework for Healthy People 2030 (HP2030 Framework) incorporating a round of public comments. The SAC has prepared seven reports, on topics including the criteria for selecting the HP2030 objectives and the criteria for selecting the LHIs, and the SAC also worked with outside experts to prepare a series of briefs intended to “clarify, discuss, and offer insights” about the HP2030 Framework (see Box 1-1 for the Framework) (SAC, 2019a). By late 2018, the Federal Interagency Workgroup (FIW), which includes HHS agencies and representatives of other federal departments, had also met to generate the HP2030 objectives, which were expected to be aligned with the HP2030 Framework. The draft objectives were released for public comment between December 2018 and January 2019.
Because the HP2030 objectives will not be finalized and released until 2020, the National Academies committee was asked to first comment on the draft LHI criteria and then, in preparation for its second report proposing a set of LHIs to inform the work of the FIW, review the objectives and identify relevant gaps in the core objectives in accordance with the core objective criteria. Figure 1-1 describes the main inputs and timeline for the LHIs for Healthy People 2030.
REFLECTIONS ON THE HP2030 FRAMEWORK
The SAC’s Recommendations for the Healthy People 2030 Leading Health Indicators (2018a) described the HP2030 Framework as “a foundation for the criteria for selecting LHIs for the Healthy People 2030 initiative.” In the same report, the SAC stated that it was proposing “criteria for selecting Healthy People 2030 LHIs that are informed by the Healthy People 2030 Framework,1 including the vision, mission, foundational principles, overarching goals, and plan of action.”
The National Academies committee recognizes that the HP2030 Framework has built considerably on the foundation of previous Healthy People efforts by broadening the conceptual framing of the initiative to strengthen the emphasis on health equity; expand the consideration of the social, environmental, and economic determinants of health; and add the useful and multidimensional notion of well-being. This evolution of the HP2030 Framework is consistent with recent advances in the understanding of those factors that lead to better health and well-being, and the set of issue briefs released by the SAC provides context and the evidence base for the main elements of the Framework (SAC, 2019a). Below, the National Academies committee further discusses the relevance of the major elements of the HP2030 Framework to the HP2030 objectives and LHIs:
- The health equity focus of the Framework underscores the importance of disaggregating information, when feasible, about the LHIs by race, ethnicity, rurality, and other characteristics.
1 Underline added for emphasis.
However, this is not enough. Measures of health equity are also needed. In defining health equity as “the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including social determinants,” Braveman (2014) referred to Healthy People 2020 as the first time that a federal government entity defined health disparity with specificity. Healthy People 2020 described disparities as “linked with economic, social, or environmental disadvantage” or with other “characteristics historically linked to discrimination or exclusion” (SAC, 2010). Braveman added to the definition that “pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions” (Braveman, 2014).
- The determinants of health focus calls for both acknowledging the evidence showing those factors account for the largest effect on health outcomes, and highlighting the value of a cross-sector and all-levels-of-government approach to health promotion.
- The well-being focus is consonant with the longstanding World Health Organization definition of health and its physical, mental, and social dimensions (WHO, 2014), and it offers a further link for engaging the attention of sectors that make important contributions to population well-being, for exploring the metrics available from those other sectors, and for comparing against what other countries measure. A key aspect of this focus is that health is not simply the absence of disease or injury; it is also related to being well in social and emotional terms.
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