Stakeholder Engagement and Communication for Healthy People 2030

Secretary's Advisory Committee Report #5: Stakeholder Engagement and Communication for Healthy People 2030

Final Report, 10-29-2018

Introduction

The Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (the Committee) is a Federal advisory committee composed of non-federal, independent subject matter experts. It is responsible for making recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS) for the development and implementation of national health promotion and disease prevention objectives for 2030.

After its inaugural meeting in December of 2016, the Committee appointed several subcommittees, charging each with providing guidance on aspects of the initiative's development. The Committee tasked the Stakeholder Engagement and Communication Subcommittee with: 1) developing an approach to increase awareness and use of Healthy People 2030; 2) delineating primary and secondary audiences for the initiative, and 3) considering the past use and impact of the Healthy People initiative.

This report presents the Committee's recommendations for engaging and communicating with stakeholders for Healthy People 2030. It is based on discussions of the Stakeholder Engagement and Communication Subcommittee during 9 meetings that took place between September 2017 and August 2018, as well as intermittent discussions of the full Committee. The report was approved by the full Committee during its meeting in Washington, D.C. on September 6 to 7, 2018.

During the Committee's in-person meeting on September 6 and 7, 2017, members reviewed an initial set of 3 proposed recommendations and a proposed list of sectors to be engaged for the development and implementation of Healthy People 2030. The Committee approved 2 recommendations (Recommendations 1 and 2) and approved the sector list pending minor edits. The sector list was updated based on the feedback from the Committee. A sector template, designed to gather input on how Healthy People 2030 can optimize engagement with sectors in the final sector list, was also developed. A completed template is provided in the Appendix for each identified sector.

1. Developing an Approach to Increase Awareness and Use of Healthy People 2030

Tools that have supported the implementation and use of Healthy People 2020 include Stories from the Field and evidence-based resources (EBRs) that relate to the objectives. The Spotlight on Health webinar series and "Stories from the Field" enable Healthy People 2020 stakeholders to learn what others are doing to improve the health of communities. Such efforts could potentially be expanded in the coming decade to engage the interest of new audiences (e.g., the media and/or policymakers).

Going forward, Healthy People may wish to consider the possibility of expanding on such approaches by engaging stakeholders through virtual discussions designed to reach a wide array of stakeholders. A series of webinars could be conducted with individuals from non-health sectors as the primary audience and public health stakeholders as the secondary audience. Each of the webinars could focus on how one

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specific sector can impact health. A survey could be administered during the webinar to gather feedback from the attendees. As an example, the Public Health Institute administers surveys throughout their webinars in a manner that could be replicated by Healthy People.

Options for disseminating Healthy People 2030 might include leveraging health rankings (i.e., county and national) to keep Healthy People in front of key audiences. Early lessons and progress status updates are other types of content that could be of interest to audiences and that Healthy People 2030 may wish to consider disseminating.

New, immersive technologies, such as virtual reality and augmented reality, may lend themselves to efforts to increase awareness and use of Healthy People. To avoid the high production costs and low reach of formats such as apps, Healthy People 2030 should focus its efforts on website revisions to enhance mobile responsiveness and paid digital ads that drive users to the Healthy People content once responsive design is implemented. Although there is space for using technology to engage audiences, it is important for Healthy People 2030 to target those who lack access to or understanding of technology.

In seeking ways to more meaningfully engage policymakers and others to understand the value of the Healthy People process and products, the Committee reviewed the feasibility and desirability of using simulation and gamification techniques to illustrate the cause-and-effect impact of various health indicators on health and non-health outcomes. Simulation modeling may offer opportunities to inform the development of Healthy People 2030 and is discussed in greater detail later in this report.

Recommendation 1. Broad engagement should include more than structured public comment, periods for testimony, or written comment.

The Healthy People initiative has historically used public comment (a mechanism that the federal government uses to gather input on policy issues from the public) as one means of engaging stakeholders. Other ways of gathering input have included conducting regional meetings or listening sessions where individuals or organizations can provide feedback on the initiative's development. Such approaches should be expanded and broadened for 2030. If Healthy People 2030 were to strategically target individuals and organizations, it is likely they would participate in regional meetings and/or listening sessions.

Widespread, two-way communication using multiple approaches will be essential to disseminate information about and gather feedback on Healthy People 2030. HHS has begun this process by conducting focused listening sessions, for example, at the National Association of City and County Health Officials'(NACCHO) annual meeting, American Public Health Association'(APHA) annual meeting, National Conference of State Legislators' annual meeting, American College of Epidemiology's annual meeting, the Public Health Law Conference, and the Association of Prevention Teaching and Research's annual meeting. These meetings of governmental public health officials offer one important example of platforms for engaging key stakeholders in the Healthy People development and implementation processes. A more extensive yet similar approach should be pursued with other key stakeholders.

Focus group research to gather the opinions of stakeholders is one possible strategy. Other possible approaches could include dissemination strategies such as: publishing information in newsletters or scholarly articles, presenting at meetings, and creating virtual networks of key stakeholder groups. Sector-specific listservs could be established to provide updates on how the Healthy People initiative is

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performing over time. Online platforms could be used to engage participants in ongoing, continual dialogue virtually, rather than relying on in-person interactions. Such efforts could ensure that Healthy People 2030 reaches sectors outside of health, thereby enhancing awareness and use of the initiative.

It will be important to engage speakers who can disseminate information about the Healthy People process at scientific meetings, panels, and other venues within both health and non-health sectors. Likewise, a systematic and targeted approach to broadly communicating about Healthy People should be encouraged within platforms such as industry-specific newsletters, blogs, and online and print journals. The relevance of Healthy People to each particular sector should be emphasized.

Finally, the Committee encourages the targeted use of social media platforms and web-based, mobileresponsive tools to inform the public of the presence and relevance of the Healthy People process and products as well as providing easy and convenient ways for comment and feedback.

2. Delineating Primary and Secondary Audiences for the Initiative

The Committee distinguishes between primary and secondary audiences. It defines the primary audience as stakeholders who have health or public health knowledge and are seeking additional information, and the secondary audience as "targets" for further dissemination and implementation of information. It would be worthwhile for Healthy People 2030 to employ distinct outreach plans for these two groups. In determining the most effective strategies to engage Healthy People 2030 stakeholder groups, it is necessary to identify what groups to target and, at what point in the development of Healthy People, HHS should solicit feedback. These tasks should be completed before determining the most appropriate strategies for engagement with stakeholders.

As Healthy People 2030 builds a feasible approach to reaching out to stakeholders beyond the health sector, it will first need to define what sectors to engage and then determine how to encourage them to take part in the process. It would also be helpful to identify useful areas of overlap across sectors. Healthy People 2030 may wish to approach other sectors by asking them how Healthy People can help to further their agenda and how certain measures could be useful to them in their environment. Throughout such efforts, it will be important to keep vulnerable populations at the forefront of the work. Healthy People 2030 can seek input from these groups and look for ways to capitalize on efforts that are already underway; existing points of interaction are extremely valuable. For example, upcoming Population Health Roundtable activities that are focused on rural health represent one such effort.

Recommendation 2. To identify sectors for inclusion in the process, adopt a Health and Well-Being in All Policies, Programs, and Systems approach

If we are to achieve our goals of changing the culture of health and well-being in America, developing health objectives for the nation will require input from more than the health sector alone. It is important to include all sectors of the economy as stakeholders in Healthy People 2030. Health and well-being are determined by social, economic, and physical determinants that shape people's lives outside of the doctor's office, not just by medical care provided.

As an example, consider the transportation sector. Transportation influences health in a variety of ways. The distance and time to get from one's home to a health care facility may be a barrier to accessing care. Transportation also plays a role in physical fitness opportunities and access to grocery stores. The

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transportation sector could benefit from a partnership by the expanded service opportunities, new mechanisms, and funding streams created as a result of increased transportation options. For example, Lyft and Uber are being contracted in some communities to take patients to their health care appointments. While these aren't public transit solutions, they provide examples of emerging business activities to try and close transportation gaps. Policy solutions such as "complete streets" initiatives and walkable and bike-able communities are important health interventions.

The Health in All Policies approach created new awareness of the health implications and impact of policy development. A Health in All Policies approach seeks to improve the health of all people by incorporating health considerations into decision-making across sectors and policy areas. Its goal is to ensure decision-makers are informed about health, equity, and sustainability consequences of various policy options during the policy development process.1 The Committee proposes to use the terminology Health and Well-being in all policies (not only health policies), and to add programs and systems to policies in the phrasing (i.e., Health and Well-being in all Policies, Programs, and Systems.)

Health and well-being is produced by many factors. Health refers to a person's physical and mental condition. It implies fitness under changing circumstances and must be safeguarded against threats from illness, injury, or death. Well-being reflects many aspects of life and states of being, such as physical, mental, emotional, social, financial, occupational, intellectual, or spiritual elements. Health and wellbeing reflect the circumstances in the settings of our lives, including our homes, schools and communities. Therefore, we must reach out to all the major sectors of our economy to engage in a process of mutual goal-setting that is much broader than has previously taken place.

Ongoing discussion within the public health community around defining what creates health offers an opportunity to engage partners that have not historically been involved in Healthy People. Nontraditional partners, such as key players in the transportation and housing fields, should be involved. For example, education experts should be enlisted to impact high school graduation rates. To achieve a mutually beneficial impact, it is important for the health sector to fully understand a given situation from other sectors' perspective. Creating avenues for open dialogue could facilitate such understanding.

Even within the health sector, it is important to engage with a variety of partners to determine the right indicators for some topics. For some areas, indicators could include clinical outcomes (e.g., A1c levels for diabetes patients) as well as indicators that measure functionality or quality of life. Indicators for outcomes and quality of life, and not simply prevalence of disease, are important to measure. This may require a change in mindset for some public health stakeholders who are accustomed to using precise clinical measures to gauge progress, rather than less precise measures of health and well-being. The sector list below was presented to the Committee for approval in September 2017. The list was approved, pending updates based on the Committee discussion. Modifications and updates to the sector list were made after the 2017 meeting and additional updates were made based on the September 2018 Committee discussion. The complete sector list is presented below.

? Health and health care o Public health o Hospitals and health care delivery systems

1Rudolph L, Caplan J. Health in All Policies: A Guide for State and Local Governments, 2013. Accessed 10/18/2018 at:

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o Health insurance companies o Pharmaceutical companies o Emergency response ? Environment/environmental regulation ? Transportation ? Criminal justice, juvenile justice, law enforcement, public safety ? Civil legal sector o Civil legal aid o National law firms o General counsels ? Housing ? Education ? Energy and utilities ? Urban planning and development ? Labor/labor organizations o Worker safety ? Food and agriculture ? Commerce and business, including investment and financial institutions ? Defense and military ? Technology and IT ? State and local government, tribes, and territories ? Foundations and non-profits ? Faith-based organizations ? Identity-based organizations

Recommendation 3.

Use the existing sector-specific information sheets in targeted conversations to encourage greater participation of other sectors in developing, disseminating, implementing, and using Healthy People. Such activities should yield further insight into how these templates can be used to engage diverse stakeholders.

Successfully engaging stakeholders requires presenting them with a defined and specific request. Organizations and individuals need to see value in their participation before they will be willing to engage with the initiative. Engagement efforts should be broader than simply focusing on a particular topic area (e.g., by including stakeholders in topic area workgroups) because, if a topic-specific approach to engagement is pursued, organizations that have a broader, higher level vision may be missed.

Using the sector template, the Committee has developed sector-specific information sheets that Healthy People 2030 stakeholders (including those within the federal government) can use to conduct outreach to other sectors. Specific sector information sheets are presented at the end of this report as an appendix. The purpose of outreach to multiple sectors should be to encourage stakeholders to play an active role in developing, disseminating, and implementing Healthy People 2030.

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The Sector Template

Organized outreach to key sectors and stakeholders should include asking key questions to ascertain whether, and to what extent, they are interested in becoming an engaged partner in advancing the Healthy People 2030 agenda. Such questions should be posed directly to contacts at specific stakeholder organizations. The purpose of such discussions would be to create a sector-specific or stakeholderspecific network of non-traditional or "emerging" stakeholders that are critical to Healthy People 2030. The Sector Template below presents a series of questions that the Committee's Stakeholder Engagement and Communications Subcommittee used to develop Sector Information Sheets (see appendix). The template is designed to effectively engage potential partners by discussing these questions. Healthy People 2030 stakeholders within and beyond government can use the Sector Information Sheets to engage cross-sectoral partners in Healthy People 2030. What values are shared between the identified sector and health? How does the sector influence health? How would healthier people benefit the sector?

What would a successful partnership between the identified sector and Healthy People 2030 look like? Outline an example of a time when the sector successfully engaged a health partner. Outline specific areas of overlap between the sector and relevant Healthy People goals, topics, and objectives.

How would the development of relevant targets benefit the sector? How could we facilitate better interaction and partnership between the identified sector and the Healthy People initiative? What metrics could be used to measure the success of the partnership?

Recommendation 4.a. Healthy People 2030 should proactively engage stakeholders to provide "meaningful input" into the development and implementation of objectives.

Healthy People 2030 should be strategic and deliberate in its engagement of multi-sectoral stakeholders. The Committee believes that the meaningful input of stakeholders into Healthy People 2030 will influence the priorities and areas of focus of Healthy People 2030. Moreover, it will include audience-generated content that enables stakeholders to advance their own goals by using the initiative's resources and communication channels. The Committee believes that meaningful engagement of stakeholders in Healthy People 2030 will require their participation throughout the process. Stakeholders should play a role in shaping Healthy People 2030 from its inception through development, implementation, and evaluation of the initiative. The Committee also identified other activities that could inform the overall initiative as well as stakeholder engagement.

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Modeling can be used to fill in gaps in evidence and expand results. It can also serve as a bridge to research translation. While it does not replace other study methodologies, there are advantages to building engaging simulation models, as demonstrated by simulation models that have been built to demonstrate impact in areas such as health reform and obesity. One way that Healthy People could make use of simulation modeling might include developing GeoCHRONUS (Geospatial Computational Health Resource Outlook Navigator for the US). This entails a computational platform of a microsimulation model (MSM) of the entire United States population. The model would show the impact of achieving selected Healthy People goals.

Another possibility might include an approach based on mapping instead of modeling. It could provide a rationale and/or business case for potential partners/ stakeholders to play an active role in Healthy People that relates the outcome of interest. It would enable other sectors to see how they fit within Healthy People and how various actions impact their sectors, creating shared value. One example of a simulation was developed by Dr. Robert Milstein. It was a game for policy makers that tested the scenario of giving all residents an insurance card. The purpose was to help policy makers understand the impact of prospective legislation. Although a simulation model would be valuable and worth pursuing, Healthy People 2030 would need to consider the benefits of such an approach in light of budget considerations. Such approaches should be considered if funds become available and/or if partners are identified who can assist with this work.

Another useful mechanism might be to provide a structure for informing communities where to invest. There has been discussion of moving from the determinant benchmark to an investment benchmark. Such a framework could provide a way for individuals to see a graphic depiction of their geographic location as a whole, and how indicators can be combined to inform development and investment.

Recommendation 4.b. Healthy People 2030 topic area workgroups should include and engage representatives from multiple sectors within and beyond government.

Stakeholders from other sectors who participate in Healthy People 2030 could inform content on ; guide discussions with and invitations to sector associations and other representatives to become actively involved in Healthy People 2030; and prompt internal HHS stakeholders (e.g., the FIW, workgroups, or others) to consider specific implementation strategies.

Recommendation 4.c.

Healthy People 2030 topic area workgroups should meaningfully engage with the public during the development and implementation processes. Such engagement should include involving other sectors in the development and implementation of Healthy People 2030 objectives.

The Healthy People 2030 Foundational Principles explain that "the health and well-being of all people and communities are essential to a thriving, equitable society." Efforts to promote health and well-being are linked, encompassing dimensions of physical, mental, and social health. Investing to achieve the full potential for health and well-being for all provides valuable benefits to society. Achieving such benefits requires eliminating health disparities, achieving health equity, and attaining health literacy. Moreover, healthy physical, social, and economic environments strengthen the potential to achieve these benefits. Promoting and achieving the Nation's health and well-being is a shared responsibility that is distributed across the national, state, tribal, and community levels. It includes the public, private, and not-for-profit sectors, and is a component of decision-making and policy formulation across all sectors.

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3. Considering the past use and impact of the Healthy People initiative

The U.S. has made significant progress since Healthy People initiative was first launched in 1979. The initiative has learned that a widely accessible plan containing achievable goals and objectives can guide the action of individuals, communities, and stakeholders to improve health. To achieve the health and well-being of all people, however, stakeholders from across the public, private, and non-profit sectors must be involved as active partners. Significant changes are achievable through persistent effort, even if they are difficult. Despite its advances, the U.S. lags behind other developed countries on key measures of health and well-being, even as it spends more of its gross domestic product on health. The Committee is therefore seeking a broadened approach that promotes progress on the objectives and goals while also increasing the diversity of entities involved. Evidence-based practices in other sectors can help to move us forward, with health equity as a driver and well-being as a guide.

A Final Consideration

While desirable, it may not be practical to engage every sector in all areas of Healthy People 2030 objective development and implementation. Nonetheless, the Committee strongly recommends strategically engaging as many relevant sectors as is feasible. Such an approach will increase the likelihood of deeper, multi-sectoral engagement that will enhance opportunities for making significant progress on and/or achieving the Healthy People 2030 goals.

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