ABOUT THE HEALTHY PEOPLE 2030 DRAFT OBJECTIVES AND RELEVANCE FOR LEADING HEALTH INDICATORS (LHIs)
The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (SAC) has defined the LHIs as “a selected set of measures of determinants and sentinel indicators of current and potential changes in population health and well-being” that “will be drawn from Healthy People objectives to communicate the highest-priority health issues.”1 Moreover, “The set of LHIs should contain a small number of objectives” and “enough LHIs should be included in that set to focus attention and drive action on top health priorities” (SAC, 2018a).
The Healthy People 2030 (HP2030) draft objectives prepared by the Department of Health and Human Services (HHS) and the Federal Interagency Workgroup (FIW) are divided into three categories: core, research, and developmental. These are defined in Box 3-1. The core objectives will provide the basis for selecting the LHIs, as described in the SAC’s Recommendations for the Healthy People 2030 Leading Health Indicators (2018a).
To inform its work, the National Academies of Sciences, Engineering, and Medicine committee reviewed all seven extant SAC reports,2 including Report on Healthy People 2030 Leading Health Indicators and Report 7, Assessment and Recommendations for Proposed Objectives for Healthy People 2030. Because the LHI selection criteria begin with “[a]ll core objectives,”
1 Italics added for emphasis.
2 All reports are available at https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Committee-Meetings (accessed June 21, 2019).
the National Academies committee also reviewed the HP2030 draft objectives available on the HHS Healthy People website and the objective selection criteria (see Box 3-1) to understand the material from which the LHIs are intended to be drawn (HHS, 2019b).3
3 The HP2030 draft objectives posted for public comment between December 2018 and January 2019 are available at https://www.healthypeople.gov/sites/default/files/ObjectivesPublicComment508_1.17.19.pdf (accessed June 20, 2019).
COMMENTS ON THE CRITERIA FOR SELECTING HEALTHY PEOPLE 2030 OBJECTIVES
The National Academies committee agrees with the five criteria described by the SAC for selecting the HP2030 objectives, two of which are specific to core objectives (see Box 3-2). Below, the committee clarifies its interpretation of criteria 2, 4, and 5 in anticipation of proposing in its second report new core objectives that may be necessary for some of the LHIs.
With respect to the need for criterion 2, current baseline data, the National Academies committee suggests that the FIW and the Secretary of HHS consider the use of new data sources when indicators that track needs related to critical health and well-being are unavailable. These may include other sources of federal data-gathering efforts (e.g., in the Department of Housing and Urban Development and the Department of Transportation), as well as comparably rigorous data from private entities (e.g., Gallup Well-Being Index) and from large external data sets such as those made possible by “big data.” Although reliance on many types of data sources, whether public or private, may be affected by a level of uncertainty about a source’s quality and sustainability over time, it is likely a federal agency could support continuing an especially valuable data source. (The HP2030 draft objectives include a narrow subset of data sources from other federal agencies, such as the Department of Agriculture data pertaining to food security and the Department of Education data pertaining to educational milestones and to disability.) In all cases where new objectives are identified, the data sources from which they are gathered would need to conform to the same stringent quality review as do those currently in use.
With respect to criterion 4, evidence, the committee notes that the LHIs are to be drawn from core objectives (those in the current draft that will remain in the final HP2030 objectives as well as newly added items). The committee underscores the need to accommodate levels of evidence appropriate to the domain, time frame, and type of intervention in assessing the adequacy of evidence emerging from interventions conducted by other sectors that address upstream drivers of health and well-being. This approach would allow for the inclusion of a broad range of interventions that address food, shelter, climate change threats and resiliency, education, transportation, built environment, and economic security, recognizing that these are prerequisites for health and well-being. Although in principle, all population health interventions will be based on the highest level of evidence, studying the effects of policy and regulatory interventions outside of health and medical care can be extraordinarily challenging. Evaluation of the effect of these interventions is complicated
by (1) the fact that all populations in a region would be exposed (and may benefit to lesser and greater extents), (2) the myriad outcomes they are intended to address (not all directly health related), (3) the typically long time frame required to analyze policy effectiveness, and (4) the paucity of resources that are available to evaluate outcomes. The effect of interventions at the policy level may often be first, and perhaps only, understood through observational studies and natural experiments. The committee believes that this type of evidence is valid and useful in the policy context, and it may work to ensure that more upstream objectives—that reflect the HP2030 Framework—are identified.
The committee reviewed a number of documents and presentations that the FIW references in its definition of effectiveness as it pertains to
core objectives. The Healthy People 2020 process rated evidence on a scale of 1–4, with the highest level (4, rigorous) described as that emerging from recommendations of the U.S. Preventive Services Task Force, the Community Preventive Services Task Force, or systematic reviews published in peer-reviewed journals. Level 3, or “strong” evidence, rests on nonsystematic reviews published by the federal government and nonsystematic reviews published in peer-reviewed journals. Level 2, seen as “moderate” evidence, emerges from journal articles of individual studies, published intervention research, and published pilot studies. Level 1, regarded as “weak,” lists intervention evaluations or “studies without peer review that have evidence of effectiveness, feasibility, reach, sustainability, and transferability” (HHS, n.d.). The committee recognizes the tension
inherent in broadening the framework of considerations of health and well-being at the same time that Healthy People 2030 seeks to promote and adhere to high standards of evidence for intervention effectiveness. It is the committee’s view that in seeking LHIs that best represent high-level priorities for the nation, it will be important to maintain accommodation of levels of evidence appropriate to the domain, time frame, and type of intervention with respect to what constitutes evidence adequacy when drawing from work conducted in other sectors. This view resonates with the Healthy People 2020 publication Evidence-Based Clinical and Public Health: Generating and Applying the Evidence, which discusses the “limitations of the traditional hierarchy of evidence” and “the need for contextual information” (SAC, 2010, p. 11). That report acknowledges that “many public health interventions are not amenable to randomized trials” because of their “complexity and interdisciplinary nature,” but the report notes that many other types of analyses “can provide a rigorous assessment that can justify a broad recommendation.” As one example, the report describes health impact assessment as a tool for evaluating the effects on health of policies in other sectors (SAC, 2010).
With regard to contributions from other sectors, the National Academies committee notes with appreciation that the SAC meetings included discussion about the role of other sectors on several occasions. For example, the ninth meeting of the SAC in May 2018 included an update about the FIW efforts to generate HP2030 draft objectives. A member of the SAC asked how the FIW plans to engage nontraditional health sectors (e.g., agriculture, education, transportation) in the selection of objectives and the development of Healthy People 2030. The FIW representative responded that the group includes representatives from every federal department (HHS, 2018). The cross-sectoral connections implicit in creating well-being also were acknowledged at the eighth meeting of the SAC in February 2018, where one member noted that the FIW “has worked diligently to build bridges between different sectors and agencies, particularly among those with data who might not consider themselves as typically included in the health sector.” A co-chair of the SAC added, “Other sectors and partners may be more receptive to language about improving well-being rather than health, and that their data sources could be viewed through this lens.” For example, decision makers in transportation might not think of their work as directed toward improving health, but the notion of enhancing the well-being of people and communities may resonate with concepts familiar to them, such as livability and quality of life.4
4 Summary of the February 28, 2019, Meeting of the Secretary’s Advisory Committee can be found at https://www.healthypeople.gov/sites/default/files/Feb_28_2018_Meeting%20Summary_Secretary-s_Advisory_Committee_for_2030_1.pdf (accessed June 25, 2019).
Criterion 5, health equity and disparities, outlines the many social and economic factors that have created or contributed to current inequities in health and well-being. The committee notes the listing of the many subpopulations that continue to experience unjustly disparate levels of health (Braveman, 2014). In the selection of candidate LHIs, the committee recognizes that not all LHIs will demonstrate inequities for all listed subpopulations, the detraction from health and well-being may be systematically greater for certain subpopulations, and limitations on data availability may make disaggregation difficult to achieve for all indicators. The committee believes that at minimum, all LHIs need to track progress on the basis of educational attainment, race, ethnicity, income or wealth (or equivalent), and geographic location, primarily urban versus rural.
COMMENTS ON THE HP2030 DRAFT OBJECTIVES
Clearly, the HP2030 draft objectives5 represent a broad range of topics (from “Adolescent Health” to “Vision”) and reflect issues of importance to a wide community of stakeholders in the public and private sectors. However, on its review of the more than 350 draft core objectives for their suitability as potential LHIs, the committee made four findings.
Finding 1: The committee finds that the Healthy People 2030 draft objectives document is missing some key topics necessary to fully reflect the intent of the Healthy People 2030 Framework’s vision, mission, foundational principles, and overarching goals.6
The draft topics and the objectives nested in each topic demonstrate a disconnection from the aspirations of the HP2030 process reflected in the Framework and the explanatory issue briefs. The key words of the HP2030 Framework include health equity; well-being; social, physical, and economic determinants of health; shared responsibility and [the roles for] multiple sectors, all levels of government; all life stages; and all dimensions of health (i.e., physical, mental, and social). The 41 HP2030 topics under which the 355 draft core objectives (and additional research and developmental objectives) are organized could be classified as follows, in order of prevalence: health states (approximately 14 that primarily pertain to health states),
5 The HP2030 draft objectives released by HHS for public comment in December 3, 2018, to January 17, 2019, are available at https://www.healthypeople.gov/sites/default/files/ObjectivesPublicComment508_1.17.19.pdf (accessed June 19, 2019).
systems (approximately 10 that primarily pertain to systems), life stages, and the social, physical, and economic determinants of health. The social determinants of health are primarily organized in one eponymous topic area, with a small number in two to three additional topic areas, but they are not shown and do not operate as a cross-cutting topic, such as social determinants of health that apply to different life stages, or with systematic attention to upstream factors that are linked with several different health states or outcomes. Having topics and objectives that are explicitly aligned with the concept of well-being is not only consistent with the ecological model of health, but it may also help explain the importance of cross-sector coordination and collaboration, and “shared responsibility.” This is articulated in the foundational principles of the HP2030 Framework, which state “[h]ealthy physical, social, and economic environments strengthen the potential to achieve health and well-being” and “[p]romoting and achieving the nation’s health and well-being is a shared responsibility that is distributed across the national, state, tribal, and community levels, including the public, private, and not-for-profit sectors.”
The misalignment of draft objectives with the HP2030 Framework may be a result of the two different processes involved in (1) developing the HP2030 Framework and (2) generating the HP2030 draft objectives. The process of developing the HP2030 Framework was a top-down or big-picture process that sought to provide the high-level parameters for the nation’s path toward equitable health and well-being. In contrast, the objective development process was a bottom-up nominal process that gathered draft objectives from three work streams of the Federal Interagency Workgroup and 42 HP2020 topic-specific workgroups (HHS, 2018). Workgroups were instructed to reduce the number of objectives compared to Healthy People 2020 (from more than 1,200 to approximately 375). This process appeared to emphasize a continuity of topics and objectives from the past decade’s Healthy People effort, which might be a primary reason the objectives do not fully represent the ideas of the HP2030 Framework. It also is unclear whether the FIW workgroups generating and vetting objectives were explicitly asked to consider what would make good LHIs and include such objectives in their contributions.
Finding 2: The committee finds that the draft objectives do not offer an appropriately balanced and comprehensive range from which to derive Leading Health Indicators that also reflect the intent of the Healthy People 2030 Framework’s vision, mission, foundational principles, and overarching goals.
As noted above, a major change to Healthy People 2030 is the emphasis on well-being and the determinants of health and well-being. There
are important objectives that lack a focus “across all life stages” (one of the overarching goals in the HP2030 Framework); for example, child poverty has been discarded, and only an overall measure of poverty remains. Health measures specific to children are leading indicators of future national health in 2030 and for decades to come, yet few objectives address, for example, the proportion of children with access to effective early intervention programs.7 One possible way to disaggregate a larger objective or to consolidate many fragmented objectives would be to develop some objectives that have sub-objectives (see, for example, the proposal in IOM, 2011, starting on p. 77). Examples could include an objective on poverty with sub-objectives for child poverty, poverty among older adults, and poverty in specific categories of race/ethnicity, or an objective on foodborne illness with sub-objectives for specific foodborne illnesses, such as those currently listed under the food safety topic of the current HP2030 draft objectives.
The six core objectives under the social determinants of health topic of the HP2030 draft objectives represent a disparate assortment that includes two objectives related to employment, two on education, one on housing, and one on incarceration and criminal justice. A more systematic approach to each of the social, physical, and economic determinants of health—as described in the HP2030 Framework and in the issue briefs—would consider all areas where the evidence is robust or strong, as well as linkages with life stages, among other cross-cutting considerations. For example, the objectives for older adults are limited to objectives on dementias, injury prevention, and kidney disease, but there are no objectives that reflect the physical and social determinants of healthy aging, such as frailty, sensory deficits, social connectedness (i.e., to address loneliness or social isolation), or aspects of livability, such as universal design elements that makes residences, commercial structures, sidewalks, and other parts of the built environment broadly accessible (see, for example, the AARP Livability Index [AARP, 2018]).
Well-being, health equity, and collaboration across multiple sectors represent some of the key aspects of the HP2030 Framework, yet they are insufficiently reflected in the draft objectives. This includes upstream macro-level social structural factors related to patterns of opportunity and risk within society, including employment rates, structural racism, residential segregation, wealth accumulation, and access to health care services, and the public policies that influence these patterns. In addition, there are few objectives that capture community or neighborhood-level factors for which there is strong evidence of a relationship to health
7 See https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Maternal-Infant-and-Child-Health (accessed July 16, 2019).
and availability of high-quality data, including data related to housing affordability and stability,8 air quality, food availability, public safety, educational attainment, and poverty. In fact, objectives linked to four of the five key domains related to the social determinants of health from HP2020 are missing, including the domains of economic stability, education, neighborhood and built environment, and social and community context. The only domain that is well represented is that of clinical care. The shortage of objectives for the other four domains, including measures of community well-being, is a noteworthy and critical gap in the current iteration of draft objectives.
Several important analyses have emerged over the past two decades that have sought to quantify the relative contributions of various factors on health, such as the proportion of mortality attributable to smoking versus medical treatment versus education attainment. These include the work of McGinnis et al. (2002), the Booske et al. (2010) schema for weighting the different influences on health for the County Health Rankings model, and the more recent work from Kaplan and Milstein (2019). The pathways by which upstream social factors shape health and well-being are characterized by multiple interactions and a great deal of complexity (Braveman and Gottlieb, 2014); therefore, all available analyses have limitations, and the relative contributions of various factors surely do not add up to 100 percent (see Krieger, 2017). Given the modest contribution of medical care to health outcomes, and the robust evidence that factors ranging from income inequality, to adverse childhood experiences, to housing instability considerably influence population health, it is striking that the draft core objectives are largely oriented toward clinical measures/measures of health states. Although those measures are necessary, they are insufficient as a representation of the health and well-being of the nation or of communities.
Having reviewed the HP2020 evidence-based resources (and scoring system),9 the committee noted, for example, that despite the evidence base for tenant-based rental assistance programs and despite the contemporary housing crisis faced by many American communities, with considerable implications for their health,10 there is no reference to rental assistance
8 See https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full (accessed July 16, 2019).
9 See https://www.healthypeople.gov/2020/Implement/EBR-glossary#4-star (accessed July 2, 2019).
10 See Taylor, 2018 (https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full, accessed July 2, 2019); and also the Healthy People 2020 discussion about the quality of housing and implications for health.
among the HP2030 objectives.11 There are many areas of robust evidence on social, physical, and environmental factors that shape health and well-being, but the objectives do not include a sufficient array to reflect such multisectoral contributions.
The objectives lack any mention of health equity (an HP2030 foundational principle) or addressing health disparities, there are no health equity measures, and some objectives give rise to questions about exacerbating certain types of inequities (to include ethnicity/race, gender, geographical, economic, and others as described in the health equity criterion for the HP2030 objectives). For example, because there is no objective related to life expectancy (especially surprising given the overall decline in life expectancy), there is also no focus on reducing the significant disparities in life expectancy by race in the United States. Similarly, reducing racial/ethnic and socioeconomic differences in leading causes of morbidity and mortality, such as cardiovascular disease, cancer, diabetes, and suicide, is a fundamental prerequisite for improving overall population health in the United States.
As another example, a family planning objective focuses on increasing “the proportion of females in need of publicly supported contraceptive services and supplies who receive those services and supplies” but misses the opportunity to measure males’ use of public family planning, embodying the unfair expectation that women ought to manage contraception, placing a logistical and resource burden on females, thus leading to increased inequity. Additional objectives related to power and civic participation, such as measures of voter enfranchisement or voting registration are missing (Blakely et al., 2001; Chandra, 2019).
The committee has read the recommendations made by the SAC in its Report 7 (SAC, 2019b), which contains a review of the draft objectives, and believes that if the SAC’s recommendations are implemented, they are likely to strengthen the final set of HP2030 objectives, providing a more well-rounded and HP2030 Framework-aligned complement of core objectives from which to select LHIs.
Finding 3: The committee finds that the Healthy People 2030 draft objectives document includes too few objectives that allow for making important comparisons to other countries, including to peer nations in the Organisation for Economic Co-operation and Development.
11 See https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/housing-tenant-based-rental-assistance-programs%E2%80%94-social (accessed July 2, 2019). See also newer evidence on supportive housing and health care cost savings at https://www.rand.org/pubs/research_reports/RR1694.html (accessed July 2, 2019).
This finding is referring not to rates of specific health outcomes, but rather, broader measures of population health such as life expectancy at birth, healthy life expectancy, or neonatal mortality. This could also include such measures as immunization coverage rates; social protection factors such as health insurance coverage, disability insurance, and parental leave; and well-being indicators such as civic engagement and trust in government, personal economic security, work–life balance, and subjective well-being.12 Given the poor performance of the United States in global health rankings, noted in previous reports from the Institute of Medicine (IOM, 2012, 2013) and elsewhere (CIA, 2019; IHME, 2018), providing summary measures of population health and employing indicators used by peer nations could be helpful. A nation’s health cannot be measured in a vacuum—international comparisons contribute an important aspect to ascertaining a nation’s performance on key indicators. That is analogous to the state-to-state or county-to-county comparisons informed by such indicator efforts as America’s Health Rankings and County Health Rankings, respectively.
ON OBJECTIVES FROM OTHER SECTORS IMPORTANT TO HEALTH AND WELL-BEING
Although Healthy People 2030 emphasizes that well-being is produced not only by health sectors, but across all sectors of society, we note that only a small subset of the data sources for the HP2030 draft objectives reside outside the health domain. These include data from the Department of Agriculture, Department of Education, Department of Housing and Urban Development, and Department of Transportation. However, some departments remain underrepresented, and the objectives that draw on data from the aforementioned departments are small in number, narrow in scope, and not reflective of the full breadth of domains where moderate or robust evidence may be available to inform action. As noted above, the committee believes that the topic area on the social determinants of health is overly limited and more objectives are needed to provide adequate material for deriving some of the LHIs. Similar suggestions were made by the SAC in its Report 7 (SAC, 2019b).
A great deal has been written elsewhere about the fact that the macrosocial upstream factors that shape health outcomes, ranging from educational attainment to housing, reside in other sectors and are the responsibility of other government agencies, organizations, and disciplines (see, for example, NASEM, 2017). At the same time, however, communities
12 See, for example, presentations given at the May 28, 2019, committee information-gathering meeting.
and states around the country are recognizing that the common good of all who reside in a community or state requires cross-sector dialogue and collaborative action. This is beginning to occur in many places. Some examples at different levels of government and from the private sector underscore that this is a moment of great opportunity for cross-sector collaboration including in the realm of metrics. The U.S. Surgeon General’s initiative and forthcoming report on community health and economic prosperity acknowledges the linkages among employers, communities, health care organizations, and others.13 The state of California has for nearly a decade had a Strategic Growth Council that includes a Health in All Policies Task Force.14 Several federal government departments or agencies have set goals that could align with the Healthy People effort. For example, several federal departments and agencies list emergency preparedness and response activities in their strategic plans, such as the Department of Homeland Security, Department of the Interior, and the Small Business Administration.15 In terms of the social determinants of health, the Department of Education, Department of Housing and Urban Development, and Department of the Treasury address issues such as educational attainment, sustainable homeownership, housing security, and safety in their strategic plans as well.16 In considering health exposures and outcomes, the language in the strategic plans of the Department of Transportation and the Environmental Protection Agency aligns with HP2030 objectives related to protecting air quality and ensuring clean and safe water, and reducing the number of fatalities and serious injuries, respectively.
Another example of an area of alignment may be found in the Department of Education highlighting absenteeism as a key metric of educational success.17 Research from the George W. Bush Presidential Center and the Brookings Institution,18 among others, has explored the relationships among health, educational attainment, absenteeism, and other
13 See https://www.hhs.gov/sites/default/files/community-health-and-economic-prosperity-infographic.pdf (accessed July 2, 2019).
15 Department of Homeland Security: https://www.dhs.gov/sites/default/files/publications/ST_Strategic_Plan_2015_508.pdf (accessed July 2, 2019); Department of the Interior: https://www.doi.gov/sites/doi.gov/files/uploads/fy2018-2022-strategic-plan.pdf (accessed July 2, 2019); Small Business Administration: https://www.sba.gov/sites/default/files/files/FINAL-2017-SBA-Disaster-Preparedness-Plan-signed.pdf (accessed July 2, 2019).
17 See https://www2.ed.gov/datastory/chronicabsenteeism.html (accessed June 27, 2019).
18 See https://www.bushcenter.org/stateofourcities/spotlight/chronicabsenteeism (accessed July 2, 2019).
community factors. At the local level, other examples of cross-sector partnerships to improve health and well-being exist around the country. Richmond, California, has been a pioneer in adopting a health-in-all-policies approach in public–private collaboration involving the city and county;19 the city of Appleton in Wisconsin has enacted a Health in All Policies ordinance; Fairfax County, Virginia, has a health-in-all-policies program and a health-in-all-policies manager that engages with other government agencies in the county; and Kent County, Michigan, has a Health in All Policies learning lab and toolkit.20
19 See https://www.phi.org/uploads/files/Health_in_All_Policies-A_Guide_for_State_and_Local_Governments.pdf (accessed July 2, 2019).
20 See https://www.appleton.org/home/showdocument?id=22076 (accessed July 2, 2019); https://www.fairfaxcounty.gov/livehealthy/sites/livehealthy/files/assets/documents/pdf/community-health-improvement-plan.pdf, pp. 3, 16 (accessed July 2, 2019); https://www.accesskent.com/Health/HiAP (accessed July 2, 2019).