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DOI: 10.1177/1090198111428646

2011 38: 551Health Educ Behav Howard K. Koh, Julie J. Piotrowski, Shiriki Kumanyika and Jonathan E. Fielding

: A 2020 Vision for the Social Determinants ApproachHealthy People

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1U.S. Department of Health and Human Services, Washington, DC, USA 2University of Pennsylvania, Philadelphia, PA, USA 3Los Angeles County Department of Public Health, Los Angeles, CA, USA

Corresponding Author: Dr. Howard Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201, USA Email: [email protected]

Healthy People: A 2020 Vision for the Social Determinants Approach

Howard K. Koh, MD, MPH1, Julie J. Piotrowski, MPH1, Shiriki Kumanyika, PhD, MPH2, and Jonathan E. Fielding, MD, MPH, MA, MBA3

Abstract For the past three decades, the Healthy People initiative has represented an ambitious yet achievable health promotion and disease prevention agenda for the nation. The recently released fourth version—Healthy People 2020—builds on the foundations of prior iterations while newly embracing and elevating a comprehensive “social determinants” perspective. By clearly articulating a new overarching goal to “create social and physical environments that promote good health for all” and a new topic area dedicated to defining the social determinants of health approach, it breaks new ground. Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Improving health is too multifaceted to be left to those working in the health sector alone. Using a social determinants approach can reframe the way the public, policy makers, and the private sector think about achieving and sustaining health. This article describes why such a social determinants approach can enhance our collective efforts to improve population health. This is achieved by defining the context for this new perspective, the process by which the Healthy People 2020 goals and objectives were developed, and the challenges and opportunities ahead. Adding this broad, social determinants perspective and vision for shared societal responsibility for change leaves Healthy People 2020 poised to promote a stronger legacy for a healthier nation and reaffirm a unity of purpose for the future.

Keywords health disparities, health policy, health promotion, measurement development

For the past three decades, the Healthy People initiative has represented an ambitious, yet achievable, agenda for health promotion and disease prevention. In this time-honored ini- tiative coordinated federally by the U.S. Department of Health and Human Services (DHHS), a network of thousands of governmental and private sector partners set priorities for national public health improvement in an open and transpar- ent process. Healthy People encompasses several mutually reinforcing tasks: setting overarching goals; identifying base- line data and 10-year targets for a wide range of quantifiable health and related health care objectives; monitoring out- comes; and evaluating progress based on the collective effects of national-, state-, and local-level interventions. It increases public awareness of the determinants of health, uni- fies national dialogue, and motivates action by articulating goals, specific topics to organize health improvements, and measurable objectives. Through all these efforts, Healthy People offers a public health roadmap and compass for the country, while encouraging new directions (Koh, 2010).

Its introduction in 1979 as Healthy People: The Surgeon General’s Report on Disease Prevention and Health Promotion,

followed in 1980 by the inaugural set of national 10-year objectives, signified a growing understanding of the causes of chronic diseases and sparked a renewed interest in the linked concepts of disease prevention and health promotion (U.S. Department of Health, Education and Welfare, 1979). That first iteration of Healthy People sought to define health promotion as “any combination of health education and related organizational, political, and economic interventions designed to facilitate behavioral and environmental changes con- ducive to health.” This was done to give equal weight to physical environmental efforts of “health protection” and the

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health care emphasis of “preventive health services” and to convene representatives of each of five minority and other special populations for advice on adapting the 1990 objec- tives to their particular health challenges and issues (Green, McGinnis, Phillips, Devereaux, & Montes, 1981).

Since then, successive plans of Healthy People 2000 (released in 1990) and Healthy People 2010 (released in 2000) have identified emerging public health priorities and aligned them with health promotion strategies driven by the best available evidence. Each iteration builds on past achievements while addressing unfinished business (Koh, 2010). For example, whereas each decade’s Healthy People has acknowledged the critical array of influences that deter- mines health (e.g., biology, behaviors, social and physical environment, and policies and interventions), the recently released fourth version, Healthy People 2020, newly embraces and elevates a comprehensive “social determinants” per- spective. For the first time, a clearly articulated overarching goal, a reinforcing foundation measure, and a dedicated topic area underscore the importance of the social determinants of health approach (see Table 1). Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Using a broad social determinants approach can reframe the way the public, pol- icy makers, and the private sector think about achieving and sustaining health. Such an approach can complement preced- ing emphases that focus more narrowly on disease outcomes or individual risk factors (DHHS, 2010b). In this way, Healthy People 2020 offers a renewed vision for the 21st century: a society in which all people have a chance to live long, healthy lives.

Context for the Social Determinants Approach In 2008, to launch the broad process of updating Healthy People for its fourth version, the DHHS convened for the first time a Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (the “Advisory Committee”). Convened under the “Federal Advisory Committee Act” (Public Law 92-463, Sec. 1, Oct. 6, 1972, 86 Stat. 770), it represented the first fully public advisory committee to be involved in planning for Healthy People (past initiatives were guided by internal DHHS councils).

The Advisory Committee’s members, 13 nationally prom- inent experts in their fields, were tapped to share their exper- tise in areas related to health promotion and disease prevention, including health policy, state and local public health, busi- ness, outcomes research, health economics, health communi- cation, special populations, biostatistics, international health, health behaviors, environmental health, health systems, and epidemiology. These individuals served in a variety of professional

settings, including public, private, foundation, community- based, and academic organizations.

Citing the mounting scientific evidence (Acheson, 1998; Committee on Physical Activity, Health, Transportation, and Land Use, 2005; Institute of Medicine, 2002; Lalonde, 1974; Sallis & Glanz, 2006; World Health Organization, Commission on Social Determinants of Health, 2008) noting that a range of social, economic, and other environmental factors drive health and health outcomes for all, the Advisory Committee explored expanding the new iteration to encompass a social determinants perspective. One motivating factor for change was that although physical environmental issues had received some attention in prior iterations, they needed to be broad- ened to include both the natural and human-made aspects. Even greater attention was necessary for the key aspects of the social environment that fundamentally influence health and disease. Therefore, the Advisory Committee called for a Healthy People 2020 approach that moved beyond control- ling diseases to one that addressed the factors of their root causes. Doing so could catalyze and broaden healthier public policies and private sector practices outside of what had been traditionally considered the public health domain. For exam- ple, it would require new collaborations between those with a primary responsibility for health and others in areas such as education, transportation, community design, food and agri- culture, and housing and social services.

The Advisory Committee observed that “health results from the choices that people are able to make in response to the options that they have. Conditions in both the social and physical environments determine the range of options that are available, their attractiveness, and their relative ease or diffi- culty of use” (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2010). The Advisory Committee also noted that “many of the same factors are at play and, over time, can result in physiologic changes that exacerbate chronic disease.” Some preferred the term societal determinants over social determi- nants. Using such a term would acknowledge that “the effects of societal determinants begin to take hold well before disease processes appear on the clinical horizons” and “addressing societal determinants often offers an opportunity to prevent or delay the development of disease” over the life course—from preconception to aging (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2010). Other articles have reviewed the promise of using this term to better convey these broad concepts (Fielding & Teutsch, 2011). However, for a number of reasons that included consistency with the emerging literature on the topic, the term social determinants term was used moving forward.

The social determinants approach held promise for reduc- ing persistent health disparities, defined as health differences that are closely linked with social, economic, and environmen- tal disadvantage (Braveman, Kumanyika, et al., 2011; Koh et al., 2010). Reducing inequalities in the social environment

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Table 1. Evolution of Healthy People

1990 Health Objectives Healthy People 2000 Healthy People 2010 Healthy People 2020

Overarching goals 1. Reduce mortality among infants

1. Increase the years of healthy life for Americans

1. Increase the quality and years of healthy life

1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death

2. Reduce mortality among children

2. Reduce disparities in health among different population groups

2. Eliminate health disparities

2. Achieve health equity, eliminate disparities, and improve health for all groups

3. Reduce mortality among adolescents, young adults

3. Achieve access to preventive health services for all Americans

3. Create social and physical environments that promote good health for all

4. Reduce mortality among adults

4. Promote quality of life, healthy development, and healthy behaviors across all life stages

5. Increase independence and quality of life among older adults, reducing days of restricted activity

Categories/enabling

goals/foundation measures

1. Preventive services 1. Preventive services 1. Promote healthy behaviors

1. General health status

2. Health protection 2. Health protection 2. Protect health 2. Disparities and equity 3. Health promotion 3. Health promotion 3. Assure access to

quality health care 3. Social determinants of

health 4. Data and surveillance 4. Strengthen

community prevention

4. Health-related quality of life and well-being

Number of focus/

priority/topic areas

15 22 28 42 (Social determinants of health included for the first time)

Number of

objectives/ measures

226/NA 312/NA 467/969 573/1,200

(e.g., conditions that give rise to homelessness, poor school attendance, social marginalization, high rates of unemploy- ment, and high crime rates) and in the physical environment (e.g., access to healthful foods, parks, and recreation centers) could help improve key health behaviors and other determi- nants and, consequently, advance numerous health objectives. Fundamentally, such health efforts could also affect the pros- perity and health security of the nation, increasing our global competitiveness and our standard of living (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2010).

Healthy People 2020 could thereby offer broad inte- grated policies as a shared responsibility to achieve health

equity—defined as “the principle underlying a commitment to reducing disparities in health and its determinants” (Braveman, Kumanyika, et al., 2011). The Advisory Committee noted that the global community was moving in the same direction: In 2008, the World Health Organization Commission on the Social Determinants of Health report made recom- mendations to promote health equity in countries at all levels of income and development, and foster a global movement to improve daily living conditions to achieve it within a gen- eration (Marmot et al., 2008).

In that light, the Advisory Committee moved to (a) empha- size an ecological approach to disease prevention and health pro- motion (i.e., focusing on both individual- and population-level

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determinants of health and multi-interventions) and (b) develop goals and objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies. Addressing the broader social determinants of health held the promise of complementing the traditional efforts of the health care and public health sectors with new cross-cutting efforts involv- ing many diverse sectors of society (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2010).

Development Process for Healthy People 2020 Goals and Objectives The Advisory Committee then moved to expand Healthy People’s fundamental overarching goals for the next decade. Previously, Healthy People 2010 had focused on two over- arching goals: (a) increasing the quality and years of healthy life for Americans and (b) eliminating health disparities. After a number of versions, the Advisory Committee ulti- mately recommended, four interrelated overarching goals for Healthy People 2020:

1. Attain high-quality, longer lives free of prevent- able disease, disability, injury, and premature death

2. Achieve health equity, eliminate disparities, and improve the health of all groups

3. Create social and physical environments that pro- mote good health for all

4. Promote quality of life, healthy development, and healthy behaviors across all life stages.

Fittingly, these overarching goals reflected the Healthy People theme that “the health of the individual is almost inseparable from the health of the larger community and that the health of every community in every State and terri- tory determines the overall health status of the Nation.” (DHHS, 2000).

Moreover, the Advisory Committee encouraged the inclu- sion of broad multisectoral representation on the interdisci- plinary Healthy People Federal Interagency Workgroup, which had begun to take shape in mid-2007. Comprising representatives from DHHS and other federal agencies (e.g., the departments of agriculture; education; environmental protection, housing and urban development; the interior; jus- tice; labor, transportation; veterans affairs), the Federal Interagency Workgroup had the primary responsibility for guiding the operational elements of Healthy People 2020 and addressing the cross-cutting aspects needed for imple- mentation of the social determinants approach. Ensuring broad federal partner collaboration helped advance the “health in all policies” approach to achieving national health promotion and disease prevention goals and objectives (Kickbusch, McCann, & Sherbon, 2008; Stahl, Wismar, Ollila, Lahtinen, & Leppo, 2006). In other words, for 2020

and beyond, improving health is too multifaceted to be left in the hands of those working in the health sector alone.

Improving Tracking of Social Determinants to Mobilize Action Released in December 2010, Healthy People 2020 identifies 42 focus areas, including nearly 600 measurable objectives. Hence, this version offers a comprehensive, more detailed agenda than its Healthy People 2010 predecessor, which fea- tured 28 focus areas encompassing 467 measurable objec- tives. Final analysis indicates that for 71% of these objectives and subobjectives with definitive data, the United States had either progressed toward (48%) or met (23%) the target.

In joining time-honored topic areas such as tobacco use and immunization, the new social determinants of health topic area now moves the nation closer to assessing the fun- damental foundations of health, not just disease. Currently, a multisectoral group is actively working on the development of specific objectives for the social determinants topic area. To start, the availability of improved national data sources to track progress in some relevant domains prompted the Advisory Committee to propose a small, initial set of three to five objectives. Although the precise metrics are still under discussion, areas currently under consideration include those related to education, employment, income, housing, family and social support, community safety, and characteristics of the built environment. Meanwhile, complementary national efforts have begun with the University of Wisconsin Population Health Institute’s and Robert Wood Johnson Foundation’s County Health Rankings (University of Wisconsin Population Health Institute, 2011) with metrics that include education, employment, income, family and social support, and community safety. In addition, the characteristics of the built environment and measures of air quality are factored into the rankings, reflecting the continuing emphasis on physical aspects of the environment. The new Healthy People draft social determinants objectives are planned for release by the end of 2012.

Reaffirming the urgency of addressing the underlying factors for health, not just disease, the Institute of Medicine (IOM) also recently recommended improving the processes, tools, and approaches used to gather information about social and other environmental factors affecting health. The IOM urged DHHS to “develop and implement a standardized, core set of health outcome indicators and indicators of com- munity health that can reflect national, state, and local priori- ties and enable . . . comparison of jurisdictions” (IOM, 2010b, p. 2). This would provide clear direction for any part- ner committed to understanding, monitoring, and improving population health.

Ultimately, some aspects of the Healthy People 2020 social determinants approach should also affect the selection and framing of Leading Health Indicators (LHIs), initially unveiled for Healthy People 2010 as high-priority areas for

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motivating societal action. The LHIs provide both a concise summary of major, preventable health threats and a gateway into the broader framework (IOM, 2011). For Healthy People 2020, the IOM identified 12 key topics and 24 LHIs thought to be critical to the nation’s health needs. The IOM recommendations served as the starting point for the Advisory Committee and the Federal Interagency Workgroup in pro- posing a final set of LHIs for Healthy People 2020. DHHS is currently reviewing these recommendations and expects to make its final determination in late fall 2011.

Opportunities and Challenges in Developing a Social Determinants Focus

The new social determinants vision of Healthy People 2020 offers immediate opportunities. Stretching beyond tradi- tional health sectors can engage nontraditional partners to create healthier choices that are easier for all people to make. For example, such efforts could prioritize broader approaches to three modifiable risk behaviors (tobacco use, poor diet, and lack of physical activity) that contribute to four major chronic diseases (heart disease, type 2 diabetes, lung dis- ease, and cancer) causing more than half of all U.S. deaths each year (National Center for Health Statistics, 2008). Healthy People 2020 thus sets the stage for tracking the social determinants that influence these modifiable risk fac- tors and aligning efforts for addressing them.

Specifically, for tobacco control, the leading cause of pre- ventable death worldwide, direct cessation services for indi- viduals are certainly of value (Fiore et al., 2008). But they also need to be complemented by sustained comprehensive, population-based, tobacco control policies, including increased tobacco prices, accelerated adoption of smoke-free policies and laws, media counter-advertising, and decreased access for underage youth. Indeed, such strategies have accelerated decreases in consumption in a number of states, although sustaining such progress is always a challenge (Deyton, Sharfstein, & Hamburg, 2010). DHHS has recently unveiled “Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services,” which outlines specific, evidence-based actions to help create a society free of tobacco-related death and dis- ease. Endorsing a broader adoption of evidence-based inter- ventions, the plan sets a goal to lower the adult smoking rate to 12% by 2020 (DHHS, 2010a).

Combating obesity can also benefit from a social determi- nants approach. This refractory national health problem requires complementary individual and population based efforts to reach the Healthy People 2020 targets of 30.6% obesity rates for adults and 14.6% for children and adoles- cents aged 2 to 19 years—a 10% improvement for both pop- ulations. Recent developments offer promise. At the individual level, the 2010 Patient Protection and Affordable

Care Act (“The Affordable Care Act”) involves provisions for screening and counseling individuals without cost- sharing. At the community level, more than 600 communi- ties have signed on to be “Let’s Move! Cities and Towns” that advance policies and actions framed around this national childhood obesity prevention campaign’s key action areas in nutrition and physical activity. The 2010 reauthorization of the Child Nutrition Act (“Healthy, Hunger-Free Kids Act”) will support these efforts by requiring more nutritious food options and increased access to affordable, healthy food for millions of school children. Moreover, the new Healthy Food Financing Initiative, a partnership of DHHS with the federal departments of treasury and agriculture, seeks to eliminate areas with limited access to affordable healthful foods (referred to as “food deserts”) through tax credits, grants, or low-cost loans to corner stores or mobile vendors. Finally, the DHHS CDC Communities Putting Prevention to Work initiative, launched in February 2010, expands the use of evidence-based strategies and programs at the community and state levels to increase physical activity and improve nutrition.

The broader social determinants approach also reinvigo- rates efforts to tackle complex health disparities in a way that engages people in all sectors and communities to become advocates for change (Kumanyika & Morssink, 2006). The recently released “HHS Strategic Action Plan to Reduce Racial and Ethnic Health Disparities” (DHHS, 2011) uses this approach as a foundation for action, since disparities stem from the distant past, have causes that are deeply entrenched, affect a vast array of stakeholders, and require solutions that lie well beyond the control of any single authority (Koh & Nowinski, 2010). Capitalizing on community- based prevention approaches and other opportunities embed- ded in the Affordable Care Act (Koh & Sebelius, 2010), the Action Plan offers broad-based opportunities for equity in areas such as health care coverage, workforce, population health and data (DHHS, 2011).

Battling limited health literacy is a critical step in address- ing social determinants. The DHHS National Action Plan to Improve Health Literacy seeks to engage organizations, pro- fessionals, policymakers, communities, individuals, and families in a linked, multisector effort addressing this key issue (DHHS, 2010b). The plan is based on the principles that (a) everyone has the right to health information that helps them make informed decisions and (b) health services should be delivered in ways that are understandable and ben- eficial to health, longevity, and quality of life. Limited health literacy affects people of all ages, races, incomes, and educa- tion levels, but the impact of limited health literacy dispro- portionately affects lower socioeconomic and minority groups. It affects people’s ability to search for and use health information, adopt healthy behaviors, and act on important public health alerts. Limited health literacy is also associated with worse health outcomes and higher costs (Berkman et al., 2004). Innovative initiatives and capacity building strategies

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will bring new resources to bear. Improved application of health information technology, with leadership from the DHHS Office of the National Coordinator for Health Information Technology, offers potential for better joining clinic and community. Updated web-based capacity (www .healthypeople.gov) provides data and tools to enable part- ners across the country to integrate their efforts to achieve the target objectives. Increased accessibility and standard- ization of indicators and health data provided via the HHS Health Indicators Warehouse (www.healthindicators.gov) promise to improve the ease of use of the Healthy People 2020 objectives. Databases about environmental and policy changes, such as the National Association of Counties (2008) Healthy Counties Database or the Prevention Institute’s Strategic Alliance ENACT Local Policy Database can help monitoring at the local level (Prevention Institute, 2005).

We also need to communicate the social determinants of health, a term still largely confined to academic circles, in ways that better resonate with the general public. The Robert Wood Johnson Foundation (2010) has committed to promot- ing to expanding national dialogue about where health starts, not just where it ends, using messages such as “your neigh- borhood or job shouldn’t be hazardous to your health,” and “all Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of income, education or ethnic background.”

Of note, although the Task Force on Community Preventive Services has made many evidence-based recommendations on programs and policies that can improve aspects of the social and physical environment, more research is desper- ately needed. Such “practice-based research” and “practice- based evidence” at the community level can help document the effectiveness of interventions to address social determi- nants. Since randomized trials are difficult or impossible in such settings, more attention must address study designs that can capture the effects of naturally occurring phenomena (e.g., require menu labeling through the Affordable Care Act, or alter zoning regulations to improve the balance of food outlets in a given community; IOM, 2010a). Standards for evidence to guide social policy must be rigorous but also more comprehensive than those traditionally used to inform clinical interventions since they apply to complex causal pathways over potentially long time periods (Braveman, Egerter, Woolf, & Marks, 2011).

Conclusion In 1988, the IOM defined the essence of our field as “fulfill- ing society’s interest in assuring conditions in which people can be healthy.” Assessing and addressing those conditions in the social, physical and economic environment and the interactions between them through a broad social determi- nants approach opens the door to innovation at all levels of society (Koh, 2011). Adding this new perspective leaves Healthy People 2020 poised to promote a stronger legacy for

a healthier nation. Through this expanded perspective and vision for shared societal responsibility for change by the public, policy makers and the private sector, Healthy People 2020 can help the nation renew and reaffirm a unity of pur- pose for the future.

Acknowledgments Grateful thanks to Carter Blakey, Penelope Slade-Sawyer, Wanda Jones, Kirby Bumpus, Dr. Claudia Arrigg, and the HHS Office of Disease Prevention and Health Promotion; Richard Klein; Ed Sondik; and members of the Healthy People Federal Interagency Workgroup for their help and support in the preparation of this article.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, author- ship, and/or publication of this article.

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