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Appendix 7
Physical and Social Environment
Draft Definitions and Key Concepts
Proposed Modification of Healthy People 2010 Definitions of Social and
Physical Environments
Social environment includes interactions with family, friends,
coworkers, and others in the community, as well as societal attitudes,
norms, and expectations. It encompasses social relationships and policies
within such settings as schools, neighborhoods, workplaces, businesses,
places of worship, health care settings, recreation facilities, and other
public places. It includes social modeling of healthful behaviors (e.g.,
tobacco use, substance abuse, physical activity) in the community. It also
encompasses social institutions, such as law enforcement and governmental
as well as non-governmental organizations. At the community level, the
social environment can reflect culture, language, political and religious
beliefs, social norms and attitudes (e.g., discriminatory or stigmatizing
attitudes), as well as socioeconomic conditions (e.g., poverty), exposure
to crime and violence, social cohesion, and social disorder through
indicators such as trash and graffiti. Mass media and emerging
communication and information technologies such as the worldwide web and
cellular telephone technology are a ubiquitous component of the social
environment that can affect health and wellbeing. The social environment
also includes availability of resources, based on socioeconomic
conditions, to meet basic daily needs, including adequate incomes, health
insurance, personal assistance services, and healthful foods. 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 same time, individuals,
their behaviors, and their ability to interact with the larger community
contribute to the quality of the social environment, as do the resources
available in neighborhoods and the community.
Physical environment can be thought of as including the natural
environment, which refers to plants, the atmosphere, weather, and
topography, and the built environment, which refers to buildings, spaces,
transportation systems, and products that are created, or modified, by
people. Physical environments can consist of particular individual or
institutional settings (e.g., homes, worksites, schools, health care
settings, recreational settings) as well as surrounding neighborhoods and
related community areas where individuals live, work, travel, play, and
conduct their other daily activities. The physical environment can harm
individual and community health, especially when individuals and
communities are exposed to toxic substances, irritants, infectious agents,
stress-producing factors (e.g., noise), and physical hazards in homes,
schools, worksites, and other settings and as part of transportation
systems. Physical barriers within these environments can present tangible
safety hazards or impediments to persons with disabling conditions. The
physical environment also can promote good health and wellbeing, for
example, through exposure to nature or favorable aesthetic attributes of
neighborhoods, or by providing community settings and environments that
facilitate healthful behavioral choices in such areas as diet, physical
activity, alcohol use, and tobacco use.
The interactions between individuals and their environments, both physical
and social, can impact a wide range of health, functioning, and quality of
life outcomes.
Environment and Determinants
Subcommittee
Proposed Overarching Principles and Recommended Activities
Relevant to Healthy People 2020
Recommended Overarching Principles:
- The Multi-level nature of health determinants and interventions
should be an organizing principle for Healthy People 2020
- Health and health behaviors are determined by influences at multiple
levels, including personal (biological, psychological),
organizational/institutional, social and physical environmental, and
policy levels. Given that significant and dynamic inter-relationships
exist among these different levels of health determinants, interventions
are most likely to be effective when they address determinants at all
levels.
- Extensive experience indicates that intervention at one
or two levels is usually insufficient to produce widespread and
long-lasting change. For example, motivating people to change
health-related behaviors when social and physical environments are
unsupportive often leads to weak, temporary change. Similarly,
creating favorable physical environments does not ensure people will
take advantage of opportunities; motivation and instruction also are
needed. The tobacco control experience indicates that multi-level
interventions, including strong environmental and policy components,
can be effective in creating long-term population-wide improvements in
health behavior and health outcomes. Healthy People 2020 should
identify the most promising intervention strategies at each level and
across levels, and encourage implementation of multi-level
interventions for each health area, whenever possible.
- Given the historical focus of many health fields on individual-level
health determinants and interventions, a particular emphasis on
health-enhancing social and physical environments should be
reflected in Healthy People 2020. Changes in social environments,
physical environments, and policies are expected to affect entire
populations over extended periods of time and to make it easier for
people to respond to individual-level interventions.
- Necessity of building multidisciplinary and inter-sectoral
partnerships
- Multi-disciplinary and inter-sectoral partnerships are needed to
maximize population and individual health, by addressing the web of
multi-level factors pertinent to health (e.g., public health, health
care financing, social services, cultural organizations, schools,
employers, health care organizations, municipal planners, transportation
departments, food industry manufacturers and suppliers, builders, media
companies, etc.).
- The process of building dynamic and productive partnerships
and collaborations and harnessing these partnerships to develop and
deliver relevant interventions is key to their success. The partners
ultimately decide which programs and policies are implemented, and which
objectives are put into practice and maintained. It is likely that such
inter-sectoral partnerships will need to occur at the highest levels of
government in order to enact the types of multi-level interventions
necessary to significantly impact the health of the nation.
- Promoting environmental justice
- An important goal of harnessing social and physical environmental
factors is to increase health equity and decrease health-related
inequalities. Doing so involves recognition of the substantial impacts
of socioeconomic status and related factors on health, functioning, and
well being from birth throughout the life course. These impacts occur
across all determinants levels (individual, social and physical
environmental, societal). Reducing social environment inequalities, like
crime, and physical environment inequalities, like access to healthful
foods and parks, can help to improve key health behaviors and other
determinants and, consequently, meet numerous health objectives.
- The responsibilities for promoting healthful
individual-level, social, physical, and policy environments go beyond
traditional public health sectors, thus other public and private sectors
need to be engaged to promote environmental justice.
- Promoting health-enhancing policies and programs across multiple
sectors of society (private and public institutions and entities) will
likely benefit from implementation of economic incentives (aimed
at organizations and institutions as well as individuals) for healthier
behaviors and environments.
- Encouraging a focus on higher-level "upstream" interventions
whenever possible
- Identify 'passive prevention' strategies that can impact broad
segments of the population with minimal individual-level decision-making
(e.g., tobacco control measures such as non-smoking policies in public
buildings; creating vehicle-free zones in downtown areas or town
centers; offering competitively priced healthful choices in food vending
machines; including fluoride in toothpaste).
- Highlighting emerging social and physical environments that deserve
increased attention
- The societal changes emerging from the rapid uptake of
computer-based communication environments and similar technological
advances deserve further study and focus vis-à-vis their current and
potential impacts on the Nation’s health. There is the potential for
positive and negative health effects of technology, and the positive
effects have not been adequately realized; e.g., social networking for
health, improved health information at point of decision, "exer-gaming",
etc.
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