Secretary’s Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
July 26, 2010
I. Healthy People 2020: A New Focus on Societal Determinants of Health
The values of a nation are reflected in its willingness to secure better health, well-being, and vitality for all. Healthy People 2020 establishes national goals and objectives for policy, programs, and activities to address the major health challenges facing our country today, and seeks to assure conditions in which people can be healthy, both now and for generations to come. Healthy People 2020 must inspire with the spirit of its reach; encourage with its sense of the possible; compel actions by policymakers, professionals, and community members at multiple levels; highlight the determinants of health not only at the individual level but also in the broader society; and lay bare the unacceptable.
Healthy People 2020 envisions a day when preventable death, illness, injury, and disability, as well as health disparities, will be eliminated and each person will enjoy the best health possible. This transformation will occur by changing our thinking about health, examining root causes and societal determinants, and directing more interventions to address primary, causal factors that affect health. Healthy People 2020 is being established on a foundation of three decades of work, but it also fosters innovative thinking about how we can collaborate to achieve health promotion and disease prevention objectives for the nation.
This report builds on the Phase I report (October 2008) of the Secretary’s Advisory Committee on Healthy People Objectives for 2020 (the Committee).1 Overarching goals proposed in that report are shown below. A focus on societal determinants of health is necessary to achieve these goals.
In this document, which is one of several prepared by the Committee to elaborate on key concepts, the concept of societal determinants of health is elucidated; suggestions are also provided for types of actions that can be taken to improve societal determinants. The report explains what we mean by societal determinants and examines them as causes of health disparities. It describes a “Health in All Policies” approach to addressing those determinants and health impact assessment (HIA) as a way to assess the likely impact of a wide range of policies on health. It also discusses how disease prevention and health promotion can be undertaken, both narrowly and broadly, to mesh population-based approaches with individual-level strategies.
- Eliminate preventable disease, disability, injury, and premature death
- Achieve health equity, eliminate disparities, and improve the health of all groups
- Create social and physical environments that promote good health for all.
- Promote healthy development and healthy behaviors across every stage of life.
Two critical approaches in Healthy People 2020 are examined in this brief:
- Healthy People 2020 reflects scientific insights from past decades showing that family and social, economic, and physical environmental factors are primary, interrelated determinants of health.
- Healthy People 2020 encompasses both individual-level and population-level risk factors and disease-specific information and approaches. The Healthy People 2020 framework is based on the view that individual-level and population-level solutions are complementary elements of an integrated, comprehensive strategy for disease prevention and health promotion in the United States.
What are “Societal Determinants of Health”?
Societal determinants of health can be defined as conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community factors. Societal determinants include, but are not limited to, factors commonly referred to as “social determinants.” The Committee uses the term “societal” to clarify that aspects of the social structure influence the health of populations through both social and physical environments and the interactions between these environments.
In its Phase I report, the Committee defined these terms as follows:
- The social environment is the aggregate of social and cultural institutions, norms, patterns, beliefs, and processes that influence the life of an individual or community.
- The physical environment, comprising both the natural and built environments, is the structure and function of the environment and how it impacts health.
The social environment includes interactions with family, friends, coworkers and others in the community, as well as cultural attitudes, norms, and expectations. It encompasses social relationships and policies in settings such as schools, neighborhoods, workplaces, businesses, places of worship, health care settings, recreation facilities, and other public places. It includes the social aspects of health-related behaviors (e.g., tobacco use, substance use, physical activity) in the community. It also encompasses social institutions like law enforcement (e.g., the presence or lack of community policing), and governmental as well as non-governmental organizations. At a societal level, policies made in governmental, corporate, and non-governmental sectors can impact health and health behaviors in whole populations both positively and negatively.
At the community level, the social environment reflects culture, language, political and religious beliefs, and social norms and attitudes (e.g., discriminatory or stigmatizing attitudes). It also includes socioeconomic conditions (e.g., poverty), exposure to crime and violence, and the degree and quality of social interactions and social disorder (e.g., reflected in the presence of trash and graffiti). Mass media and emerging communication and information technologies like the Internet and cellular telephone technology are ubiquitous elements of the social (as well as physical) environment that can affect health and well-being. Economic policy is an important component of the societal environment.
Availability of resources to meet basic daily needs (e.g., educational and job opportunities, adequate incomes, health insurance, personal assistance services, healthful foods) is an important facet of the social environment. Individuals, their behaviors, and their ability to interact with the larger community also contribute to the quality of the social environment, as do the resources available in neighborhoods and the community. Entrenched, institutionalized patterns–such as the racial segregation of residential areas–can be so deeply embedded that they persist without anyone intending to discriminate. For example, such phenomena systematically track black and Hispanic children onto paths that lead to diminished life chances and less opportunity to be healthy.
The physical environment consists of the natural environment (i.e., plants, atmosphere, weather, and topography) and the built environment (i.e., buildings, spaces, transportation systems, and products that are created or modified by people). Physical environments can consist of particular individual or institutional settings, such as homes, worksites, schools, health care settings, or recreational settings. Surrounding neighborhoods and related community areas where individuals live, work, travel, play, and conduct their other daily activities are elements of the physical environment.
The physical environment can improve or harm individual and community health. Community health can be improved when, for example, aesthetic elements (e.g., good lighting, trees, and benches)2 are included in neighborhood or community settings to facilitate healthful behavioral choices in such areas as diet, physical activity, alcohol use, and tobacco use.
The physical environment can harm health when it exposes individuals and communities to toxic substances, irritants, infectious agents, stress-producing factors (e.g., noise) and physical hazards. Exposures can occur in homes, schools, worksites, through transportation systems, and in other settings. Physical barriers in these settings can present safety hazards or impediments to persons with disabling conditions. Ensuring compliance with relevant federal statutes can help to reduce environmental barriers that compromise health and health care. For example, meeting the requirements of the Americans with Disabilities Act can ensure accessible health care services and communication accommodations for patients with vision, hearing, and speech deficits.3
Potentially harmful factors in the physical environment have been the focus of efforts to promote environmental justice. According to a 1991 report submitted to the U.S. Environmental Protection Agency by Delegates of the National People of Color Environmental Leadership Summit, the environmental justice movement represents, “the confluence of three of America’s greatest challenges: the struggle against racism and poverty; the effort to preserve and improve the environment; and the compelling need to shift social institutions from class division and environmental depletion to social unity and global sustainability.”4 Environmental justice is a key element of a societal determinants approach, as it seeks to eliminate disparities in exposure to harmful environmental factors and lack of access to beneficial ones.
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II. The Rationale for Focusing on Societal Determinants of Health
In its 2008 Phase I report, the Committee provided clarification and examples of health disparities and health equity to elucidate the types of population-based differences in health status that should be given high priority in Healthy People 2020.5 The report noted that every person should be able to achieve the highest level of health possible, without distinction based on race, ethnic group, religion, socioeconomic status, gender, physical or mental disability, sexual orientation, rural/urban residence, or other characteristics that have historically been linked to discrimination or having less influence or acceptance in society. The rationale for focusing on societal determinants includes: the need to move beyond controlling disease to address factors that are root causes of disease, the importance of achieving health equity; and practical considerations related to national prosperity and security
- Achieving health requires more than just controlling disease. It requires us to assure conditions in which people can be healthy. Health results from the choices that people are able to make in response to the options that they have. Conditions in the social and physical environments determine the range of options that are available, their attractiveness, and their relative ease or difficulty of use. Extensive evidence points to ways that environmental factors influence health.
- A close examination of the underlying causes of specific diseases reveals many of the same factors are at play and, over time, can result in physiologic changes that exacerbate chronic disease. Therefore, focusing on these common underlying societal determinants has the potential to impact many different health and disease outcomes. Because the effects of societal determinants begin to take hold well before disease processes appear on the clinical horizons, addressing societal determinants often offers an opportunity to prevent or delay the development of disease.
- Healthful social conditions can ensure that all members of society—especially the most vulnerable—benefit from the same basic rights, security, and opportunities. This nation has within reach the ability to assure that all residents have equal access to quality public health, health care, and essential community services that preserve and protect health. By addressing inequalities in social and physical environmental factors, we can increase health equity and decrease health disparities. Doing so involves recognizing the substantial, often cumulative effects of socioeconomic status and related factors on health, functioning, and well-being from even before birth throughout the entire life course. These effects occur across all determinants levels (individual, social and physical environmental).
- Reducing inequalities in the social environment (e.g., crime) and inequalities in the physical environment (e.g., access to healthful foods, parks, and transportation) can help to improve key health behaviors and other determinants and, consequently, meet numerous health objectives.
- Population health is also of critical importance to national prosperity and security. A recent study found that labor time lost in the United States due to health reasons costs $260 billion per year.6 The National School Lunch Program was originally established because, during World War II, nearly 40 percent of potential recruits were too undernourished to be eligible for the military. Now, three out of four young adults between the ages of 17 and 24 are ineligible for military service, often due to obesity. Nearly 21 percent of military recruits were rejected in 2008 because they were overweight.7
III. Where Do We Begin? Integrating the Priorities of Multiple Sectors
Throughout the process of developing Healthy People 2020, disease-specific and population-based perspectives were reflected in debates about how the objectives should be arrayed and managed. Some stakeholders argued that the 2020 objectives should be organized around cross-cutting risk factors and determinants that would emphasize primary prevention and offer a means of controlling and limiting the number of narrowly focused objectives.8 Others said that the public health universe is currently organized by disease areas, and therefore a sudden shift to an exclusive focus on risk factors and determinants would confuse users and reduce perceived relevance to some groups. The organization of Healthy People 2020 incorporates both the disease-specific elements that characterized past iterations of Healthy People and a new emphasis on cross-cutting societal determinants.
Guided by its broad vision of health, Healthy People 2020 offers ten-year goals and objectives that can be achieved only if many sectors of our society—such as transportation, housing, agriculture, commerce, and education, in addition to medical care—become broadly and deeply engaged in promoting health. What can be done to engage these key sectors? What can the agricultural sector do to help with obesity? What can the housing sector do to address second-hand tobacco smoke? As a leading voice for disease prevention and health promotion in the United States, Healthy People 2020 must compel its users to examine how they can address the societal determinants of health.
Many agencies do not have a mandate to address cross-cutting issues, so Healthy People users in the public health community must involve them in working collaboratively to promote quality child care, schools, safe roads, and other elements of the social and physical environments that affect health. As a consequence of national health reform legislation, additional opportunities are emerging to engage in cross-sectoral actions as part of Healthy People 2020 activities.
Health promotion and disease prevention must be a shared priority of those who work in both health and non-health sectors. Responsibilities for promoting healthful environments at multiple levels—including the individual, social, physical, and policy environments—go beyond the traditional health care and public health sectors. For example, agricultural subsidies affect the relative price of different produce at the market and therefore influence patterns of consumption.
To identify overarching areas for federal investment, greatest impact can most likely be achieved by addressing the societal determinants that affect disparities and inequities. Attention should be paid to elements of both the social and physical environment that undermine health. For example, three risk factors (tobacco use, poor diet, and lack of physical activity) contribute to the four major chronic diseases (heart disease, Type 2 diabetes, lung disease, and many cancers) that cause 50 percent of deaths in the world.9 For each societal determinant that has been shown to influence these three risk factors, interventions that would make a difference should be identified and well-described and new knowledge should be generated to add to the currently inadequate knowledge base.
A Health in All Policies Approach (HiAP) to Address Societal Determinants at the Population-Level
Societal determinants are a key cause of population health problems, and “Health in All Policies” is an approach that can be used to address them.10 HiAP is an innovative strategy that introduces as goals to be shared across all areas of government improved population health outcomes and closing the health gap among different socio-demographic groups.
HiAP tackles complex health challenges through an integrated policy response across sectors.11 It leads to investment in addressing societal determinants, because issues like education, housing, agriculture, transportation, and urban development are in the domain of other sectors (not health), and other agencies (not Health and Human Services or its state and local counterparts). The World Health Organization recently released a document presenting the promise and challenges of the HiAP approach.12
Both tobacco control and obesity prevention stakeholders have been at the forefront of separate efforts in the United States to implement HiAP through multisectoral partnerships. In obesity prevention, efforts are currently underway to survey the full range of local policies/supports that have been implemented to support healthy eating and physical activity and to identify interventions of proven effectiveness.13
As systematic analysis of available information is released, it can be used to identify and prioritize needs and to monitor progress over time. Over the longer term, we need to evaluate how multiple environmental and policy factors impact health behaviors and health outcomes. Databases of information about environmental and policy supports have been compiled (see the National Association of Counties’ Healthy Counties Database14 or the Prevention Institute’s Strategic Alliance ENACT Local Policy database).15
IV. Specific Actions to Address Societal Determinants
Integrating Individual-Level and Population-Level Approaches to Prevention and Health Promotion
At the start of the decade, public health leaders suggested the need for an “ecological approach” to address chronic disease in populations by engaging multiple sectors in collaborative strategies,16 and incorporating understanding of the interconnectedness of biological, behavioral, physical, and socio-environmental domains.17 Discussions of preventing chronic disease centered on two paradigms: personal responsibility (individual-level) and environmental factors (population-level), yielding very different sets of policy responses. Disease-specific and population-based perspectives have sometimes been presented as being oppositional to one another, but they can also be viewed as two components of an integrated solution in which both elements offer advantages and disadvantages (see Table 1).18
Public health has increasingly sought to look beyond traditional, individual-level interventions (e.g., clinical counseling and health education campaigns that emphasize personal behavior change) to identify points of intervention in the environment.19 Tobacco control efforts have successfully combined evidence-based clinical counseling for individuals with comprehensive programs to address multiple facets of the social and physical environment (e.g., home, work, social networks, and organizational, community, and broader societal influences). The success of this experience points to interventions that target the individual as well as the broader social and physical environment.
Similar strategies are being applied to address the U.S. obesity epidemic. The energy balance between how much one eats and how much one is physically active is useful for explaining changes in an individual’s body mass composition over time, but this paradigm does not address wider environmental influences.20 At a population level, environmental factors are key determinants of obesity rates.21, 22 The “food environment” and physical activity-related aspects of the built environment are of interest because they have the potential to influence individual behavior that can change energy balance.23
For example, the advertising for and ready availability of inexpensive, high energy/high fat foods, fast foods, and super-sized portions increases the likelihood that individuals will consume high-calorie foods with low nutritional value.24 Technical innovations over the past century have also decreased the physical activity requirements of daily living, while the decentralization of metropolitan area populations and employment have increased the amount of time that people spend in their cars.25
Improved environments may be most beneficial for population groups in less favorable environments, with fewer personal resources. Depending on the policies, positive or negative health impacts are more likely to be felt in low income populations. Examples of interventions from Los Angeles County that employed a social determinants approach are included in Appendix 1.
Specific Recommendations for Using the HiAP Approach in Healthy People 2020
Healthy People 2020 should catalyze innovation by providing users with the tools they need to embrace a societal determinants orientation to their work. It should offer strategies for using a HiAP approach to map societal determinants to health outcomes. Implementing a HiAP approach would require activating and fully involving non-health sector leaders through the formation of intersectoral partnerships at the federal, state, and local levels. This approach is included in the health reform law.
The Committee has recommended that Healthy People 2020 offer technical assistance on HiAP to Healthy People 2020 users through short courses, Web-based training, and/or conference sessions. The Committee has also recommended that Health and Human Services (HHS) disseminate models of local-level efforts to address health determinants in the social and physical environment through intersectoral partnerships and partnerships with non-traditional organizations and agencies whose focus has been on social and environmental justice, human rights, and equity. Economic incentives aimed at organizations and institutions as well as individuals can be used to promote health-enhancing policies and programs across multiple sectors of society (e.g., private and public institutions and entities).
As the interdisciplinary, multi-agency workgroup that is responsible for developing Healthy People 2020, the Federal Interagency Workgroup (FIW) should help to operationalize the cross-cutting elements of Healthy People 2020 that extend beyond the field of health and relate to physical and social environments. Moreover, all federal agencies should be required to include Healthy People in their strategic plans. Examples of agencies that could be engaged to work with HHS include the U.S. Departments of Agriculture, Education, Transportation, Defense, the Environmental Protection Agency, and Housing and Urban Development.
Filling Gaps in Evidence for the Effectiveness of Policy and Environmental Interventions
A large volume of work is being implemented throughout the United States to foster policy and environmental interventions that support healthy lifestyles. It is important to build the evidence base for this work. Just as clinical evidence is limited for some populations (e.g., people with disabilities and chronic conditions are often excluded from clinical research), there is less data available for some communities to demonstrate the effectiveness of community-based interventions that are designed to affect health behaviors or the social determinants of health. (For example, some communities may be excluded from research because they are less accessible to academic institutions.)
The availability of high-quality data for all communities is ultimately a health equity issue, and should be a priority for public health departments and clinical preventive research. Greater equity for individuals and groups that are the subjects of community-based and clinical research should be assured. The push for diversity in clinical trials occurred in response to lack of data for some population segments. It is equally important to produce evidence for approaches that fit the different circumstances of populations. The idea that “uniformity of evidence” is the goal of research efforts should be resisted. “Practice-based research” and “practice-based evidence” can help document the effectiveness of interventions to address societal determinants. Community-based participatory research may be a useful strategy for closing some gaps in the evidence base.
It is critical that Healthy People 2020 help to fill gaps by prioritizing the need for evidence and linking the evidence to objectives. More attention should be paid to how we measure the impact of societal determinants on health outcomes. HHS should place particular emphasis on examining ways to track policies that impact the social and physical environments, and identifying groups that are already conducting cross-sectoral policy scans (e.g., nutrition/physical activity, tobacco, HIV, etc.).
IV. Health Impact Assessment: A Tool for Making Health-Informed Decisions
Over the past 30 years, the World Health Organization has made several declarations arguing that it is essential to return to an environmental approach as the major opportunity to improve the health of our population.26 These same points have been emphatically made by the Lalonde Report in Canada27 and the Acheson Report in the United Kingdom.28 Their common theme has been that many of the determinants of disease and injury lie outside the traditional health sector, and therefore intersectoral cooperation is a critical aspect of a broad health improvement effort.
The concept of “Collective Risk” is used to discuss the need for investment to address climate change, and it is also relevant to thinking about investments in population health. Such investments would help the population but not necessarily every individual. Similarly, interventions to address societal determinants of health would benefit society in ways that may be difficult to pinpoint. It is therefore important to demonstrate how such investments might impact health, just as one might measure their impact on the environment or the economy.
What is Health Impact Assessment (HIA)?
Health impact assessment (HIA) is a relatively new tool that is being used to document these impacts. One commonly used definition of HIA is: “A multidisciplinary process within which a range of evidence about the health effects of a proposal is considered in a structured framework. It is…based on a broad model of health which proposes that economic, political, social, psychological, and environmental factors determine population health.”29 The most widespread application of HIAs has been in Canada, Europe, Australia, and New Zealand, but interest in the United States has grown substantially in the past decade.
HIAs are used to document the long-term health effects of investments, policies, and projects in other sectors that affect social and physical environments. Examples include projects in community design, transportation planning, and other areas outside the traditional realm of public health concerns. HIAs serve to: make the health and equity impacts of social decisions more explicit; provide an accountability mechanism to prevent harm; shape projects, plans, and policies to promote and improve the population’s health, and support meaningful, inclusive participation in governance institutions.30
What is the HIA Process?
In December of 1999, the WHO European Centre for Health Policy (ECHP) and the Nordic School of Public Health met to develop common understanding of core procedures to be used to monitor the impact of community policies and activities on health and health care. The Gothenburg Consensus Paper that was released as an outcome of this meeting outlined values, core definitions, and steps for conducting HIAs. Steps described included: screening for possible health impact, scoping of health impact assessment, reporting of findings and recommendations, monitoring by interested stakeholders (in the aftermath of the report) to track the outcomes of the decision and implementation, and evaluating the HIA.31
Since the Gothenburg paper’s release, many HIAs have been conducted in Europe.32 The concept has not been adopted as broadly in the United States,33, 34 but interest in conducting HIAs is increasing and examples of local-level HIAs in the United States are available.35, 36 37, 38 The stages of HIA outlined in the Gothenburg paper still structure the HIA process, but no single, uniform set of methods for HIA has been developed.39, 40 The diversity of HIA practices and products exists due to the variety of decisions that are assessed, the range of practice settings in which HIA is used, and the fact that HIA remains an emerging field.41
Despite this diversity, there are five defining characteristics of HIAs:
- A focus on specific policy, program, or project proposals.
- A comprehensive consideration of potential health impacts, positive and negative.
- A population-based perspective incorporating multiple determinants and dimensions of health.
- A multi-disciplinary systems-based analytic approach.
- A transparent approach that is highly structured but sufficiently flexible to confront a wide range of proposals.42
The main tenet underlying HIA is that, by using accepted analytic methods to yield reproducible findings that bring health considerations into the policy decision-making process in sectors where health is not the primary consideration, these decisions can be influenced to improve health and/or reduce adverse health effects. A great advantage of HIA is its ability to identify and communicate significant health impacts that are under-recognized or unexpected, addressing such issues as agricultural subsidies, zoning, wage laws, transportation funding, educational programs, and urban development projects.
HIAs may be an important source of “promising practices” that point to early successes before a large body of evidence can be compiled through comprehensive literature reviews. At the state and local levels, such data can be used to convince decision-makers of the need to undertake policies, programs, and projects that will improve population health. Healthy People 2020 can play a critical role in disseminating such information by providing access to the latest evidence of the effectiveness of policies, programs, and projects that are implemented to address societal determinants of health.
For three decades, the Healthy People initiative has led efforts to educate the nation that health is about more than the absence of disease, and that it is created through the conditions of our daily lives—not at the doctor’s office. Healthy People has long provided a vehicle for channeling diverse and distinct disease prevention and health promotion efforts throughout the United States toward the common goal of improving the nation’s health. It has offered an undergirding structure for tracking and monitoring health and disease, and has sought to inspire action by setting science-based targets for progress.
As we begin a new decade, Healthy People 2020 re-energizes this long-standing vision, infusing it with a new focus on creating a society in which all people live long and healthy lives. Yet this vision cannot become reality without the active and deep engagement of many sectors of our society.
The goals and objectives of Healthy People 2020 are intended to be aspirational, yet achievable. Translating noble aspirations into tangible progress will require the commitment of all to implementing evidence-based strategies to improve health, and to building the evidence base for such actions where one does not currently exist. A key focus of these efforts must be on addressing the social and physical environmental factors that affect population health.
Healthy People 2020 can be used as a tool to convene partners from across sectors—including housing, urban planning, education, transportation, and the environment—to improve the health of the nation. Such multi-sectoral efforts will require innovation and flexibility. To accomplish the goals of Healthy People and improve the health of the nation, we must find common cause with sectors beyond health.
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