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Social Determinants of Health

Rethinking the Leading Health Indicators for Healthy People 2030

  • 1Population Health Institute, Department of Population Health Sciences, University of Wisconsin–Madison School of Medicine and Public Health, Madison
  • 2New York Academy of Medicine
  • 3National Academies of Sciences, Engineering, and Medicine

Beginning in 1979, the Healthy People initiative, led by the US Department of Health and Human Services (DHHS), has set health promotion and disease prevention objectives and targets every decade in an effort to engage a broad constituency in achieving health gains for the nation. A subset of objectives—the Leading Health Indicators (LHIs)—are intended to sharply focus attention on the highest priorities. At the request of DHHS, the National Academies of Sciences, Engineering, and Medicine appointed a committee in 2019, on which we served and which 1 of us staffed. The committee was charged with informing the selection of LHIs through 2 reports, the first to provide recommendations regarding the criteria for LHIs and the other to recommend a slate of LHIs. Criteria for Selecting Leading Health Indicators for Healthy People 20301 was released in August 2019, and Leading Health Indicators 2030: Advancing Health, Equity and Well-being2 was released in January 2020.

As the understanding of health inequity and its antecedents has deepened, the framework for Healthy People has evolved. The 2030 framework, developed by a federal advisory committee, has health equity and well-being at its center. The criteria for selecting LHIs call for measures that serve as sentinels or bellwethers, and the current public health emergency may spotlight how social, economic, and environmental conditions produce inequities.

The 34 LHIs proposed by the National Academies committee differ from the 2020 LHIs in important ways, which both show alignment with the Healthy People 2030 framework and reflect the state of population health science and practice. Fewer LHIs relate to specific diseases, clinical care, or individual behaviors. Rather, the proposed LHIs are intended to reflect a balanced set of factors that contribute to overall health and drive equity. These indicators were selected for their relevance to current life in the US and the ways in which it has been shaped by historic policies at different levels of government and by institutional practices, systems, and social structures.

LHIs to Measure Well-being and Adversity

Proposed measures of well-being and adversity include the Cantril self-anchoring striving scale and the rate of adverse childhood experiences (ACEs). The Cantril ladder is used as a benchmark for well-being (also called life satisfaction or happiness) internationally. The US population ranks between 17th and 19th among high-income nations, at 6.9 on a scale from 0 (suffering) to 10 (thriving).3,4 The ACEs include 3 types of adversity to which children may be exposed: abuse, neglect, and household dysfunction. Research has shown that ACEs are highly associated with life-long trajectories toward poor outcomes in physical, mental, and social well-being. Evidence indicates that many ACEs can be prevented, and interventions to prevent long-term negative effects of ACEs exist.5 In these times of likely toxic stress related to the coronavirus disease 2019 (COVID-19) pandemic and associated negative psychological, social, and economic effects, the consequences of ACEs on long-term health and well-being become crucial to monitor, especially for those with historic and cumulative exposures.

LHIs for Health Equity

Healthy People measures may be disaggregated by various demographic categories as past efforts have done, but the National Academies report found this insufficient. To be fully responsive to the goal of advancing health equity, the committee recommended including LHIs measures that explicitly focus on structural drivers of health, including 2 measures of residential segregation, the Neighborhood Disinvestment Index, and voting as a measure of civic engagement.

LHIs of Priority Health States

Recent years have seen a fall-off in life expectancy for a number of US subpopulations, and wide gaps between racial and ethnic groups persist. Proposed LHIs include deaths by suicide, deaths by drug overdose, maternal mortality, and firearms-related mortality. Mortality related to opioid and other substance overdoses as well as suicide has increased.6 Firearms-related mortality remains a persistent problem in this country, dwarfing levels in other wealthy nations. For maternal mortality, the US ranks last among peer nations.

LHIs Drawn From the Social, Economic, and Physical Determinants of Health

Proposed LHIs include several related to the determinants of health, including fourth-grade reading proficiency; measures of poverty, food insecurity, and housing insecurity; the Environmental Quality Index; and the Heat Vulnerability Index. The committee sought to engage other sectors and the public about what and who creates health. In the environmental domain, measures of climate effects on health and a broader measure of environmental exposures were included (on this point, COVID-19–related policies dramatically illustrate human effects on air pollution). Moreover, social distancing recommendations, including requirements to stay indoors, may make management of heat vulnerability especially challenging in the coming months.

Public Health Expenditures: A Missing LHI

A requirement for all Healthy People objectives is regular tracking of progress through reliable metrics and sources of data. Missing at the time of this report is a method for accurately and consistently recording public health expenditures. The report reviewed evidence showing that greater public health expenditures have been associated with better health outcomes and proposed a developmental objective on the topic. As the COVID-19 pandemic shuts down the nation, it highlights the necessity of an LHI on public health funding.

Moving Forward During a Public Health Crisis

Selecting a limited set of LHIs for the nation is challenging. In identifying a slate of candidate measures, the National Academies committee sought to provide forward-thinking indicators that aligned with the Healthy People 2030 framework: equity, well-being along the lifespan, and broad engagement.

In hindsight, the prolonged public health emergency arising from the COVID-19 pandemic suggests that tracking all-cause mortality—with attention to subpopulations, including people with disabilities; immigrants, including those who are undocumented; people who lack housing; and people who are incarcerated—will be critical to understanding how well the nation supports health equity. We must not allow the inequitable distribution of resources—social, environmental, and economic—to devastate the health and well-being of many disadvantaged communities and groups in the US.

Article Information

Corresponding Author: Alina Baciu, PhD, MPH, The National Academies of Sciences, Engineering, and Medicine, 500 Fifth St NW, Room 861, Washington, DC 20001 (abaciu@nas.edu).

Conflict of Interest Disclosures: Dr Johnson reported being a member of the National Academies of Sciences, Engineering, and Medicine committee that authored the report on the Leading Health Indicators; receiving grants from the Robert Wood Johnson Foundation during the conduct of the study; and receiving personal fees from Triple P America outside the submitted work. Dr Gold reported being a member of the National Academies of Sciences, Engineering, and Medicine committee that made recommendations with respect to the Leading Health Indicators. Dr Baciu reports being a senior program officer at the National Academies of Sciences, Engineering, and Medicine, where she was the study director for Leading Health Indicators 2030: Advancing Health, Equity, and Well-being, which was supported by the Office of the Assistant Secretary for Health.

Additional Contributions: We are grateful to George Isham for his substantive input and to Paula Lantz and David Kindig for their assistance.

National Academies of Sciences, Engineering, and Medicine.  Criteria for Selecting the Leading Health Indicators for Healthy People 2030. National Academies Press; 2019.
National Academies of Sciences, Engineering, and Medicine.  Leading Health Indicators 2030: Advancing Health, Equity, and Well-Being. National Academies Press; 2020.
Helliwell  JF, Huang  H, Wang  S. Changing world happiness. In: Helliwell  JF, Layard  R, Sachs  JD, eds.  World Happiness Report 2019. Sustainable Development Solutions Network; 2019. Accessed May 14, 2020. https://s3.amazonaws.com/happiness-report/2019/WHR19.pdf.
Organisation of Economic Cooperation and Development. OECD Better Life Index: United States. http://www.oecdbetterlifeindex.org/countries/united-states/
National Academies of Sciences, Engineering, and Medicine. Development Happens in Contexts: Overview of Early Life Critical Influences. In:  Vibrant, Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. National Academies Press; 2019:141–206.
Case  A, Deaton  A. Mortality and morbidity in the 21st century. Brookings Papers on Economic Activity; Spring 2017. Accessed May 14, 2020. https://www.brookings.edu/wp-content/uploads/2017/08/casetextsp17bpea.pdf
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