Healthy People 2030: Moving toward equitable health and well-being in the United States
Nicolaas P. Pronk, Dushanka V. Kleinman, Therese S. Richmond
Abstract
What should major public health efforts emphasize in achieving optimal health and well-being for all in the midst of a pandemic, structural racism, and visible climate change? Collective experiences of the coronavirus pandemic and its observable bonds to poverty, inequality, and structural racism suggest the time has come to increase focus on the contexts that shape how people live their lives. Globally recognized as a roadmap for charting a healthier future, the Healthy People initiative delineates achievable objectives with 10-year targets to guide multi-sectoral action. Healthy People 2030, the fifth decade of setting U.S. national goals and objectives for health promotion and disease prevention, expands the dialog from health alone to an intentional focus on health and well-being and calls for achieving health equity, eliminating health disparities, attaining health literacy, and extending an explicit emphasis on the social, physical, and economic determinants of health and well-being [[1]Secretary's advisory committee on national health promotion and disease prevention objectives for 2030: recommendations for an approach to healthy people 2030. Accessed January 20, 2021: https://health.gov/healthypeople and https://health.gov/healthypeople/objectives-and-data/leading-health-indicators.Google Scholar]. The term “health and well-being” is new to Healthy People and implies separate but related states that influence each other in a mutually reinforcing relationship [[2]Pronk N.P. Kleinman D.V. Goekler S.F. Ochiai E. Blakey C. Brewer K.H. Promoting health and well-being in Healthy People 2030.J Public Health Pract Manage. 2020; (published ahead of print)https://doi.org/10.1097/PHH.0000000000001254Crossref PubMed Scopus (2) Google Scholar]. Together, equitable health and well-being describes factors deeply rooted in personal and societal values, such as social justice, safety, prosperity, civic engagement, and environmental integrity. Elevating the need to achieve health equity is a central theme in Healthy People 2030. Structural racism—the totality of ways in which societies foster racial discrimination through mutually reinforcing inequitable systems—affects health and well-being and is not moderated by age, sex, birthplace, or education [[3]Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Summary Full Text Full Text PDF PubMed Scopus (914) Google Scholar]. Thus, interventions and systemic changes must be implemented at population and societal levels [[3]Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Summary Full Text Full Text PDF PubMed Scopus (914) Google Scholar,[4]Paradies Y. Ben J. Denson N. et al.Racism as a determinant of health: a systematic review and meta-analysis.PLoS ONE. 2015; 10e0138511Crossref PubMed Scopus (627) Google Scholar]. Multisector partnerships represent a requisite strategy to address much-needed changes in health care spending while increasing life expectancy in order for the United States to reach parity with other high-resource nations [[5]McCullough J.M. Speer M. Magnan S. Fielding J.E. Kindig D. Teutsch S.M. Reduction in US health care spending required to meet the institute of medicine's 2030 target.Am J Public Health. 2020; 110: 1735-1740Crossref PubMed Scopus (1) Google Scholar]. The pivot from Healthy People 2020 to 2030 comes with a need to strengthen the objectives and measures that reflect upstream determinants of health more fully. In support of this measurement challenge, the National Academies of Sciences, Engineering, and Medicine (NASEM) proposed a priority subset of 34 indicators, Leading Health Indicators (LHIs), designed to close the gap in upstream objectives and support a departure from sole reliance on more traditional metrics reflecting health care delivery system capabilities and specific medical conditions by prioritizing upstream social, physical, and economic determinants of health and well-being [[6]National Academies of Sciences, Engineering, and MedicineLeading health indicators 2030: advancing health, equity, and well-being. The National Academies Press, Washington, DC2020https://doi.org/10.17226/25682Crossref Google Scholar]. These indicators can assess inequities and differences among and between groups that are unjust and unfair and when made visible, these measures can stimulate action. Recently launched 2030 LHIs and Overall Health and Well-Being Measures (OHMs) reflect the importance of subjective well-being, life expectancy, disability, and self-perceived health status through measurement examples such as household food insecurity, exposure to unhealthy air, 4th grade reading level proficiency, employment of working-age people, and persons living in poverty [[1]Secretary's advisory committee on national health promotion and disease prevention objectives for 2030: recommendations for an approach to healthy people 2030. Accessed January 20, 2021: https://health.gov/healthypeople and https://health.gov/healthypeople/objectives-and-data/leading-health-indicators.Google Scholar]. Yet, to reach the Healthy People 2030 vision of equitable health and well-being, envisioned upstream determinants would address root causes of health inequalities (e.g., racism) [[7]Khazanchi R. Evans C.T. Marcelin J.R. Racism, not race, drives inequity across the COVID-19 continuum.JAMA Netw Open. 2020; 3e2019933https://doi.org/10.1001/jamanetworkopen.2020.19933Crossref PubMed Scopus (34) Google Scholar] and collective health and well-being (e.g., climate change and civic engagement) [[8]Solar O. Irwin A. A conceptual framework for action on the social determinants of health. Social determinants of health discussion paper 2 (policy and practice). World Health Organization, 2010https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdfGoogle Scholar]. The NASEM indicator set includes measures currently not selected in the Healthy People 2030 set of indicators (Table 1).Table 1National academies of sciences, engineering, and medicine (NASEM) proposed, but not accepted, indicators for healthy people 2030.TopicProposed New IndicatorChild healthReduce the prevalence of one or more Adverse Childhood Experiences (ACEs) from birth to age 17Mental disabilityReduce the rate of mental disabilityMental healthReduce percentage of adults who reported their mental health was not good in 14 or more days in the past 30 days (i.e., frequent mental distress)Mental healthReduce discharges for ambulatory care-sensitive conditions per 1000 Medicare enrolleesHealthier physical environmentImprove the Environmental Quality IndexHealthier physical environmentLower the Heat Vulnerability IndexHealthier social environmentIncrease the proportion of voting eligible population who votesHealthier social environmentLower the Neighborhood Disinvestment IndexHealthier social environmentReduce the level of residential segregation captured by the Index of DissimilarityHealthier social environmentReduce the level of residential segregation captured by the Isolation Index Open table in a new tab Incorporating these additional indicators would further inform actions to achieve health equity. It would support a more appropriate balance in resource investments to close gaps in cultivating healthier environments such as, for example, in the assessments of civic engagement (proportion of eligible population that votes), social environment measures that would address neighborhood disinvestment and residential segregation (e.g., by using the Neighborhood Disinvestment Index, Index of Dissimilarity and the Isolation Index), and measures of environmental quality and heat vulnerability. Work is already underway through efforts such as the Neighborhood Atlas, a resource that provides measures of neighborhood disadvantage, incorporating the Area Deprivation Index, to be used for planning, policy development and research [[9]University of Wisconsin; Department of Medicine. Neighborhood Atlas. Accessed January 20, 2021: https://www.neighborhoodatlas.medicine.wisc.edu/.Google Scholar]. Further, the adoption of these additional indicators would strengthen the portfolio of measures for Healthy People 2030 and align with other global approaches to equitable health and well-being, such as the Sustainable Development Goals of the United Nations [[10]United NationsTransforming our world: the 2030 agenda for sustainable development.2021https://sdgs.un.org/2030agendaGoogle Scholar]. Healthy People 2030 provides a vision to substantively shift the focus toward changing systems that perpetuate upstream determinants of poor health and move us closer to a society of equitable health and well-being. Adoption of this broad, upstream set of indicators will undoubtedly improve the health and well-being of Americans and support progress in aligning the United States with the way other countries around the world consider the pursuit of health and well-being. The authors have nothing to disclose.