Addressing Health Equity and Social Determinants of Health Through Healthy People 2030

Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Dr Gómez, Dr Kleinman, Dr Pronk, and Dr Wrenn Gordon); Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, US Department of Health and Human Services, Rockville, Maryland (Ms Ochiai, Ms Blakey, and Ms Johnson [former staff]); and Health ConTexts, LLC, Silver Spring, Maryland (Ms Brewer).

Correspondence: Emmeline Ochiai, MPH, Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, US Department of Health and Human Services, 1101 Wootton Pkwy, Ste 420, Rockville, MD 20852 (vog.shh@iaihcO.enilemmE).

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Abstract

The evolution of Healthy People reflects growing awareness of health inequities over the life course. Each decade, the initiative has gained understanding of how the nation can achieve health and well-being. To inform Healthy People 2030's visionary goal of achieving health equity in the coming decade, the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary's Advisory Committee) provided the US Department of Health and Human Services with guidance on key terms, frameworks, and measurement for health equity. Conditions in the environments in which people are born, live, learn, work, play, worship, and age influence health and well-being outcomes, functioning, and quality-of-life outcomes and risks and are mostly responsible for health inequities. No single individual, organization, community, or sector has sole ownership, accountability, or capacity to sustain the health and well-being of an entire population. The COVID-19 pandemic in the United States highlights underlying inequities and disparities in health and health care across segments of the population. Contributing factors that were known prior to the pandemic have led to major discrepancies in rates of infection and death. To reduce health disparities and advance health equity, systems approaches—designed to shift interconnected aspects of public health problems—are needed.

Over 4 decades, the Healthy People initiative has played an integral part in the public health system of the United States, blending its function as a federal-level strategy for health promotion and disease prevention with its national roles as a leader and provider of information.1,2 State-, local-, and community-level users employ Healthy People to guide their own health-related policy and programmatic agendas. Healthy People is a foundation for many state health plans, a guidepost for progress, and a source of needed data, tools, and resources.

The evolution of Healthy People reflects growing awareness of the problem of health inequities over the life course. Each successive decade of the initiative has expressed a deeper understanding of how to achieve health and well-being for the nation.3 Advances have included identifying causes of and differences in health outcomes across US population groups and investigating how to address them. The progression is summarized in Table ​ Table1. 1 . The Healthy People 2030 framework guides diverse, distinct disease prevention and health promotion efforts throughout the United States toward a common goal: improving the health and well-being of all people.5

TABLE 1

Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death.

Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.

Create social, physical, and economic environments that promote attaining full potential for health and well-being for all.

Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.

Abbreviation: HHS, US Department of Health and Human Services.

a As part of Healthy People 2030's development, the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (the Committee) and external subject matter experts prepared an issue brief that lays the groundwork for the visionary goal of achieving health equity in the coming decade. The issue brief presents key terms, frameworks, and measurement for health equity and is the basis for this article.4

Health Equity and Social Determinants of Health as Pivotal Concepts in Healthy People

A robust evidence base has accumulated over the past 20 years, documenting that conditions in the environments in which people are born, live, learn, work, play, worship, and age—the social determinants of health6—influence a wide range of health and well-being outcomes, functioning, and quality-of-life outcomes and risks.6,7 The social determinants of health are shaped by distributions of money, power, and resources at global, national, and community levels. They are “mostly responsible for health inequities.”8,9

Healthy People 2030 envisions “a society in which all people can achieve their full potential for health and well-being across the lifespan.”4 One of Healthy People 2030's foundational principles is that “achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy.” Healthy People 2030 advances these outcomes by increasing its crosscutting emphasis on health equity throughout the initiative.

Health Equity: Key Concepts and Related Definitions

Multiple definitions of health equity exist. Ten years ago, Healthy People 2020 defined health equity as “attainment of the highest level of health for all people,”10 suggesting that people should have equal access to opportunities to lead healthy lives. The past decade's public health research and practice have shown that health equity entails more than the “opportunity” for health and well-being. Fair and just access to opportunity is needed.

A 2017 report for the Robert Wood Johnson Foundation went beyond the notion of “access” and added the critical role of taking action to remove barriers. It states,

Health equity means that everyone has a fair and just opportunity to be healthy. This requires removing obstacles to health, such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.11

The Secretary's Advisory Committee suggested that these core ideas be included in a definition of health equity for Healthy People 2030:

Focusing on ongoing societal efforts to address avoidable inequities, as well as historical and contemporary injustices;

Health equity is associated with other concepts (eg, health disparities, health care disparities, health inequalities, health inequities). Distinctions among these terms are explained in Table ​ Table2. 2 . There are important differences between inequality and inequity in health. Some health inequalities are unavoidable because they can be attributed to biological differences or free choice. Health inequities are avoidable.12,13

TABLE 2

Strategies to Achieve Health Equity in the United States

No single individual, organization, community, or sector has sole ownership, accountability, or capacity to sustain the health and well-being of an entire population.14,15 The education, housing, health care, justice, and other sectors should play roles in giving everyone a fair and just chance to be healthy. To reduce health disparities and advance health equity, systems approaches—designed to shift interconnected aspects of public health problems—are needed. Examples might include aligning society's actions to advance health literacy with the complex factors affecting people's ability to find, understand and use health information, or supporting health and well-being in all policies and laws.

Efforts to increase social cohesion, defined as “a group or population that works toward the well-being of all of its members, fights exclusion and marginalization, creates a sense of belonging, and promotes trust,”16 will be essential for sharing responsibility to protect each other and promote our nation's health.14,17–19 Social cohesion encompasses the domains of social equality, social inclusion, social development, social capital, and social diversity.20 Since the latter half of the 20th century, social capital and civic engagement have been in decline in the United States.21 Empowered collaborations that act based on community-specific assessments of local assets and needs and that invite the participation of all concerned have carried out effective interventions to increase social cohesion in US communities.22

Cross-departmental coordination of innovative federal programs to address social determinants of health is a step on the path to health equity.23 Additional collaborations are needed across all sectors and at all levels. These actions help expand the public's understanding of health as encompassing the well-being of communities.24

COVID-19: A Case Study in the Repercussions of Health Inequity

Early stages of the COVID-19 pandemic in the United States highlight underlying inequities and disparities in health and health care across segments of the population. Contributing factors that were known prior to the pandemic have led to major discrepancies in rates of infection and death among racial and ethnic minority communities compared with White communities. As of spring 2020, preliminary data show disproportionately high burdens of illness and death among these groups that also share higher rates of poverty and overcrowded living conditions.25

The Centers for Disease Control and Prevention released a limited data set of 1452 patients who were hospitalized with COVID-19 in 14 states from March 1 to March 30, 2020. An analysis compared characteristics of hospitalized patients with those of populations from the same geographic areas.26 It found that a third (33%) of hospitalized COVID-19 patients were Black, while fewer than one in 5 (18%) people in these areas were Black. Similarly, the San Francisco Department of Public Health reports that Latinos comprised 42% of confirmed COVID-19 cases as of May 12, 2020, but Census Bureau data indicate Latinos account for 15% of San Francisco's population.27,28 In New Mexico, 57% of COVID-19 cases and 50% of COVID-19 deaths occurred among Native Americans, although they comprise 11% of the state's population.29,30

Patients with preexisting conditions, such as high blood pressure, obesity, diabetes, heart disease, and chronic lung disease, are at a greater risk of serious illness due to COVID-19. These conditions are more common among African Americans than in the general population.31,32 Structural factors (eg, poverty, decaying physical and social structures, limited opportunities) that have shaped long-standing racial disparities in rates of chronic disease also drive vulnerability to serious illness from COVID-19 infection.33

In this example of “syndemics,” 2 or more epidemics interact synergistically, leading to excess burden of disease within racial and ethnic minority populations.34 African Americans and Latinos are more likely than Whites to live in densely populated areas, use public transportation, and/or work in jobs on the front lines, such as in grocery stores, food service, or transportation. Racial and ethnic minority communities, including those that are relatively affluent, are more likely to be exposed to air pollution and other environmental hazards.35,36 These trends highlight the unacceptable price of failing to address health inequities in the United States (Table ​ (Table3 3 ).