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].
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].
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].
Thus, interventions and systemic changes must be implemented at population and societal
levels [3,4]. 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].
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]. 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]. 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] and collective health and well-being (e.g., climate change and
civic engagement) [8]. The NASEM indicator set includes measures currently not selected
in the Healthy People 2030 set of indicators (Table 1).
Table 1
National academies of sciences, engineering, and medicine (NASEM) proposed, but not
accepted, indicators for healthy people 2030.
Table 1
Topic
Proposed New Indicator
Child health
Reduce the prevalence of one or more Adverse Childhood Experiences (ACEs) from birth
to age 17
Mental disability
Reduce the rate of mental disability
Mental health
Reduce 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 health
Reduce discharges for ambulatory care-sensitive conditions per 1000 Medicare enrollees
Healthier physical environment
Improve the Environmental Quality Index
Healthier physical environment
Lower the Heat Vulnerability Index
Healthier social environment
Increase the proportion of voting eligible population who votes
Healthier social environment
Lower the Neighborhood Disinvestment Index
Healthier social environment
Reduce the level of residential segregation captured by the Index of Dissimilarity
Healthier social environment
Reduce the level of residential segregation captured by the Isolation Index
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]. 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].
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.
Declaration of Competing Interest
The authors have nothing to disclose.