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4 Results of the Bottom-Up Procedure: Gaps in the Draft Objectives
Pages 31-64

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From page 31...
... .1 LHIs DRAWN FROM EXISTING (DRAFT) HP2030 CORE OBJECTIVES The committee found that 19 of its LHI candidates had draft HP2030 core objectives that matched the indicators committee members proposed (in Table 4-1, those are the items that include an acronym or abbreviation that represents the topic and the draft objective number, such as, SU-2030-03 Reduce drug overdose deaths, found under the topic heading "­ ubstance Use" in the draft HP2030 objectives in Appendix E)
From page 32...
... 5 Well-being Increase proportion Health and Well-Being Across "thriving" on Cantril's Self- the Lifespan: Physical Health Anchored Striving Scale 6 Disability Reduce the percentage of Health and Well-Being Across adults aged 65 years and the Lifespan: Physical Health over with limitations in daily activities 7 Mental disability Reduce the rate of mental Health and Well-Being Across disability  the Lifespan: Mental Health 8 Substance use SU-2030-03 Reduce drug Health and Well-Being Across overdose deaths the Lifespan: Physical Health 9 Unintentional IVP-2030-03 Reduce Increasing Knowledge and injury deaths unintentional injury deaths Action: Physical Health 10 All cancer deaths C-2030-01 Reduce the overall Health and Well-Being Across cancer death rate the Lifespan: Physical Health 11 Suicide MHMD-2030-01 Reduce the Health and Well-Being Across suicide rate the Lifespan: Mental Health 12 Firearm-related IVP-2030-12 Reduce firearm- Health and Well-Being Across mortality related deaths the Lifespan: Physical Health 13 Maternal MICH-2030-04 Reduce Closing Gaps: Health Equity mortality rate maternal deaths
From page 33...
... 15 Oral health OH-2030-08 Increase the Health and Well-Being Across access proportion of children, the Lifespan: Physical Health adolescents, and adults who use the oral health care system 16 Reproductive FP-2030-07 Increase the Health and Well-Being Across health care proportion of sexually active the Lifespan: Access to Quality services adolescents aged 15 to 19 Public Health and Clinical Care years who use any method Systems of contraception at first intercourse 17 HIV incidence HIV-2030-03 Reduce Health and Well-Being Across the number of new HIV the Lifespan: Physical Health diagnoses among persons of all ages 18 Tobacco TU-2030-13 Reduce use of Increasing Knowledge and any tobacco products by Action: Evidence-Based Laws, adolescents Policies, and Practices 19 Obesity NWS-2030-03 Reduce the Health and Well-Being Across proportion of children and the Lifespan: Physical Health adolescents aged 2 to 19 years who have obesity 20 Alcohol use SU-2030-13 Reduce the Health and Well-Being Across proportion of people with the Lifespan: Physical Health alcohol use disorder in the past year 21 Immunization Increase the proportion of Increasing Knowledge and 19–35-month-old children Action: Evidence-Based Laws, up to date on DTaP, MMR, Policies, and Practices (also polio, Hib, HepB, varicella, public health successes) and pneumococcal conjugate vaccines 22 Hypertension HDS-2030-04 Reduce the Health and Well-Being Across rate proportion of adults with the Lifespan: Physical Health hypertension continued
From page 34...
... Systems hospitalization 24 Medical AHS-2030-01 Increase the Health and Well-Being Across insurance proportion of persons with the Lifespan: Access to Quality coverage medical insurance Public Health and Clinical Care Systems 25 Affordable SDOH-2030-04 Reduce the Cultivating Healthier housing proportion of all households Environments: Social that spend more than Environment 30 percent of income on housing 26 Environment Improve the Environmental Cultivating Healthier Quality Index Environments: Physical Environment 27 Environment Lower the Heat Vulnerability Cultivating Healthier Index Environments: Physical Health 28 Education AH-2030-04 improve the Cultivating Healthier fourth grade reading level  Environments: Social Environment 29 Poverty SDOH-2030-03 Reduce the Cultivating Healthier proportion of persons living Environments: Economic in poverty Environment 30 Food security NWS-2030-01 Reduce Cultivating Healthier household food insecurity Environments: Social Environment 31 Civic Proportion of voting eligible Cultivating Healthier engagement population who voted in last Environments: Social election Environment 32 Social Lower the Neighborhood Closing Gaps: Health Equity environment Disinvestment Index 33 Social Reduce the level of Closing Gaps: Health Equity environment residential segregation captured by the Index of Dissimilarity
From page 35...
... LHIs REQUIRING NEW CORE OBJECTIVES Next, the committee discusses the LHIs proposed that do not have a corresponding objective. This responds to the part of the charge to the committee "to identify new objectives that meet the core objective criteria" (see Box 2-1 for the core objective selection criteria developed by the SAC)
From page 36...
... The committee offers the following recommended LHIs. For three of the areas above, the committee was unable to find sufficiently robust objectives that met the objective selection criteria, finding instead that they were better suited for consideration as developmental objectives.
From page 37...
... It is a widely available and used measure, with ample current baseline data, it is of obvious national importance, and it is useful for assessing health equity and health disparities. The life expectancy objective has a known evidence base because there is deep knowledge about the factors that shape life expectancy.
From page 38...
... Self-Rated Health The recommended objective statement for this LHI is: "Increase the mean healthy days (CDC HRQOL–14 Healthy Days) ." Although wellbeing is a core aspect of the HP2030 Framework and is paired with health (i.e., health and well-being)
From page 39...
... CDC HRQOL-14 Healthy Days meets all objective selection criteria. It is regularly collected as part of the BRFSS, and it could also be oversampled for some demographic groups.
From page 40...
... and capture wellbeing for OECD members. The Cantril Scale is one of the Well-Being in the Nation measures proposed by the 100 Million Healthier Lives public–private partnership with the National Committee on Vital and Health Statistics, which advises the National Center on Health Statistics (100 Million Healthier Lives and the National Committee on Vital and Health Statistics, 2019)
From page 41...
... 263) The measure Limitations in Activities of Daily Living in Adults 65 and Older meets the following LHI Phase 1 criteria: public health burden; relevance to addressing health disparities; and actionability.
From page 42...
... Although it is a somewhat heterogeneous measure in that it combines having "physical, mental, or emotional condition lasting 6 months or more" that produces "difficulty in learning, remembering or concentrating" this measure has the advantage of having easily accessible data for the entire country. The mental disability measure is not a measure of m ­ ental health in the population; rather it is a measure of cognitive disability in the population (which would include dementia, a condition that has a draft core objective associated with it)
From page 43...
... , and actionability. Immunization The recommended objective statement for this LHI is: "Increase the proportion of 19–35-month-old children who are up to date on DTaP, MMR, polio, Hib, HepB; varicella, and pneumococcal conjugate vaccines." The draft core objectives for HP2030 include eight items that refer to vaccines and immunization, but none of those are sufficiently broad to warrant consideration for the LHIs.
From page 44...
... ." The HP2030 draft objectives contain 15 core objectives under the Environmental Health (EH) topic, ranging from "Reduce the number of days people are exposed to unhealthy air" (EH-2030-01)
From page 45...
... RESULTS OF THE BOTTOM-UP PROCEDURE 45 BOX 4-1 EPA's EQI (Environmental Quality Index) : Domains, Measures, Sources EQI Domain Measure and Source Air 1.
From page 46...
... Physical Environment: Heat Vulnerability Index The recommended objective statement for this LHI is: "Lower the Heat Vulnerability Index." The committee did not find any HP2030 draft core objectives that could be used to serve as a sentinel or bellwether related to climate change effects on health, but it was pleased to see the developmental objective "PREP-2030-D03 Increase the proportion of adults who are aware of their transportation support needs to evacuate in preparation of a hurricane, flood, or wildfire" under the "Preparedness" topic. Because an LHI relevant to the health effects of climate change would be timely and important, the committee recommends the Heat Vulnerability Index (HVI)
From page 47...
... and demographics (aging populations) dimensions are actionable in the sense that they inform planning and preparation The Lancet HVI meets objective selection criteria -- it is a composite of several measurable items, and both baseline data and additional data points are available at the national level, and in many cases at the state, county, or local level.
From page 48...
... Social Environment: Civic Engagement -- Voter Participation The recommended objective statement for this LHI is: "Increase the proportion of voting-eligible population who votes." The committee believes that because dimensions of social capital (i.e., civic engagement and social cohesion) have implications for health, it is important to consider them in composing the set of LHIs.
From page 49...
... Culture of Health measures also include voting participation, as does America's Health Rankings, and the Department of Housing and Urban Development (HUD) Healthy Communities Index, which uses "proportion of voting-eligible population who voted in last election." Voting is a way to operationalize social capital.
From page 50...
... 12  Described in the Objective Selection Criteria for Core Objectives as having "a direct im pact or influence on health, broad and comprehensive applicability, a substantial burden," and "address a national health priority."
From page 51...
... The recommended objective statements for this LHI are: "Reduce the level of residential segregation captured by the Index of Dissimilarity; and Reduce the level of residential segregation captured by the Isolation Index." As noted earlier, the draft core objectives lack measures of equity that shed light on the causes of health disparities (i.e., structural inequities)
From page 52...
... , but ultimately concluded that a structural and/or community-level measure would be more useful as an LHI. The measures of residential segregation meet core objective selection criteria: measurable, with baseline data and two additional data points; of national importance, with robust evidence on the relationship between segregation and well-being and health; and of great relevance to addressing disparities and improving health equity.
From page 53...
... . The core objective SDOH-2030-03 "Reduce the proportion of persons living in poverty" meets core objective selection criteria, and so does child poverty, but the committee would like to underscore the robust evidence base that links child poverty with a range of poor health outcomes, extensively discussed and documented in two recent National Academies reports on child health and well-being (NASEM, 2019b)
From page 54...
... CONSIDERATIONS FOR POTENTIAL DEVELOPMENTAL OBJECTIVES A Developmental Objective for Early Childhood Care and Education The HP2030 draft core objectives contain several good options: fourth grade reading proficiency, chronic school absence, and on-time high school graduation. (It is important to note that these measures reflect ­ ystem-level s failure or success and should not be interpreted as simply measures of individual effort or capability.)
From page 55...
... Casey Foundation, which produces the annual Kids Count Data Book, includes the following four education measures: young children ages 3 and 4 not in school, fourth graders not proficient in reading, eighth graders not proficient in math, and high school students not graduating on time. Although the discussion of the first measure (enrollment in early childhood education)
From page 56...
... , or excess prices relative to other high-income countries, the committee concluded that tracking per capita expenditures alone would not be sufficient. Instead of recommending an LHI of per capita or percent GDP health care expenditures, the committee discussed tracking the cost of a ­ arket m basket of widely used pharmaceuticals in comparison to their cost in other affluent nations as a next best measure relevant to health care spending.
From page 57...
... Given the evidence of a stunning difference in administrative (and overall) spending between the United States and peer nations, and juxtaposed with the nation's lackluster health performance, the committee believes that an actionable administrative cost measure that is not linked with any political agenda could be a useful and compelling indicator.
From page 58...
... The conclusion was that local and national public health interventions are highly cost-saving and that therefore disinvestments in public health interventions are a "false economy" because these decrements induce additional costs to health care services and the economy in general. In terms of morbidity, research has shown that public health investments yield results for specific outcomes (Singh, 2014)
From page 59...
... The measure also meets LHI Phase 1 selection criteria: addresses a public health burden, may be a sentinel given association between drops in public health funding and health status, and is actionable (see, for example, IOM, 2012)
From page 60...
... months Determinants of Health Equity •  Neighborhood Disinvestment Index •  Residential Segregation: Index of Dissimilarity •  Residential Segregation: Isolation Index Environmental Quality Environmental Quality •  ir Quality Index >100 (EH-1) A •  Environmental Quality Index •  Children exposed to secondhand •  Heat Vulnerability Index smoke (TU-11.1)
From page 61...
... •  IVP-2030-12 Reduce firearm-related deaths •  IVP-2030-03 Reduce unintentional injury deaths • Homicides (IVP-29) Maternal, Infant, and Child Health Maternal, Infant, and Child Health •  ll Infant deaths (MICH-1.3)
From page 62...
... HIV diagnoses among persons of all ages Social Capital/Civic Engagement •  Proportion of eligible voters who voted in the last election Serious Illness •  C-2030-01 Reduce the overall cancer death rate Social Determinants Social Determinants •  Students graduating from high school •  H-2030-04 Increase the proportion of A within 4 years of starting ninth grade fourth grade students whose reading skills (AH-5.1) are at or above the proficient achievement level for their grade •  SDOH-2030-03 Reduce the proportion of persons living in poverty •  NWS-2030-01 Reduce household food insecurity •  SDOH-2030-04 Reduce the proportion of all households that spend more than 30 percent of income on housing Substance Abuse Substance Abuse •  dolescents using alcohol or illicit A •  SU-2030-03 Reduce the drug overdose drugs in past 30 days (SA-13.1)
From page 63...
... The proposed LHIs also include a combination of upstream root causes (e.g., poverty, residential segregation, educational attainment) and of high-priority health states (e.g., overdose deaths, rate of hypertension)


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