Promoting Health and Well-being in Healthy People 2030.

Healthy People 2030 describes a vision and offers benchmarks that can be used to track progress toward the goal of all people in the United States achieving their full potential for health and well-being across the life span. This vision can be realized through evidence-based interventions and policies that address the economic, physical, and social environments in which people live, learn, work, and play. Securing health and well-being for all will benefit society as a whole. Gaining such benefits requires eliminating health disparities, achieving health equity, attaining health literacy, and strengthening the physical, social, and economic environments. Implementation of Healthy People 2030 will by strengthened by engaging users from many sectors and ensuring the effective use and alignment of resources. Promoting the nation's health and well-being is a shared responsibility-at the national, state, territorial, tribal, and community levels. It requires involving the public, private, and not-for-profit sectors.

Healthy People provides science-based national objectives with 10-year targets for improving the health of the nation. Healthy People 2030—the fifth edition of the Healthy People initiative—describes a vision and offers benchmarks that can be used to track progress toward the goal of helping all people in the United States achieve their full potential for health and well-being across the life span. Healthy People 2030 expresses an expanded focus on health and well-being and an understanding that health and well-being for all people is a shared responsibility. This vision can be achieved through evidence-based interventions and policies that address the economic, physical, and social environments in which people are born, live, learn, work, play, worship, and age. High-quality data that are accurate, timely, and accessible are required to record and report on progress1 over the course of the decade and to direct interventions to populations that are most likely to benefit from them.

Healthy People sets the federal agenda for the nation's health, guides its direction and allocation of resources, informs federal data collection and programmatic activities, and provides a model for promoting health and well-being at the state and local levels. The initiative's emphasis on promoting health and well-being signals to the nation that it is time to work across sectors to achieve health equity. This decade Healthy People 2030 is a resource for all sectors.

As part of the development of Healthy People 2030, the US Department of Health and Human Services (HHS) sought guidance from the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary's Advisory Committee), a federal advisory committee composed of nonfederal, independent subject matter experts. The Secretary's Advisory Committee presented recommendations to the HHS Secretary for developing and implementing the objectives for 2030. The Secretary's Advisory Committee convened regularly between December 2016 and September 2019, with meetings open to the public.

Health promotion has been a cornerstone of the Healthy People initiative since its inception in 1979. The Secretary's Advisory Committee recommended that the focus of Healthy People 2030 expand beyond health promotion to the broader purpose of promoting “health and well-being.” The process that has been called health promotion no longer focuses on health alone, but now leads to health and well-being for individuals in addition to society as a whole. This offers a chance to balance the needs of individuals and society. Society is defined as “a voluntary association of individuals for common ends.”2 Health and well-being are elements among the common ends that motivate us, as individuals, to act for the good of all. In return for participating in society, individuals expect fair and just opportunities to be as healthy and well as possible. This article provides insights into defining health and well-being, promoting health and well-being, fostering user collaboration to improve health and well-being, and measuring health and well-being, in addition to implications for policy and practice.

The Secretary's Advisory Committee produced 2 detailed briefs that offered guidance for promoting health and well-being. Secretary's Advisory Committee members, joined by additional subject matter experts, developed these 2 briefs. The original documents are available on the HealthyPeople.gov Web site.3,4

Defining Health and Well-being

Healthy People 2030 refers to health and well-being in every aspect of the framework, including the vision, mission, foundational principles, plan of action, and overarching goals.5 The expanded role for health and well-being in Healthy People 2030 was supported by the Secretary's Advisory Committee's recommendations and its definition of health and well-being as how people think, feel, and function—at a personal and social level—and how they evaluate their lives as a whole.6 How people think, feel, and function affects their beliefs about whether their lives have meaning and purpose7,8 (Table 1). This definition recognizes the multilevel nature of health and well-being. It acknowledges that social structures, such as families, neighborhoods, communities, organizations, institutions, policies, economies, societies, cultures, and physical environments, strongly influence health and well-being. Such influence is reciprocal between individual, social, and societal health and well-being.*

TABLE 1

Elements of Health and Well-being: Think, Feel, and Function

“Think” reflects the ability to understand, evaluate, and solve problems in daily life; experience optimism; express gratitude; acknowledge self-worth; and believe that life and social circumstances are to some degree under personal control, even while seeking personal growth, autonomy, and competence.

“Feel” reflects a sense of security and a feeling of satisfaction with life. It involves vigor and vitality, feeling healthy and full of energy, and being able to flourish psychologically, balance negative and positive emotions, and maintain fulfilling social connections.

“Function” reflects physiological conditions within the body, along with the ability to meet personal and collective (eg, family, neighborhood, community) needs under changing conditions in society. It entails being accepted into and belonging to a community, providing and receiving support from others, and acting as a legitimate contributor to a common world.

The terms “health” and “well-being” describe separate but related states; health influences well-being and, conversely, well-being affects health.9 Health incorporates both physical and mental conditions; it implies fitness under changing circumstances, such as degradation of the physical, social, or economic environments, and must be safeguarded against threats from illness, injury, or death. Safety, as a result, is an important determinant of health. Well-being is both a determinant and an outcome of health.10 It encompasses objective and subjective elements and reflects many aspects of life and states of being. These include physical and mental, as well as emotional, social, financial, occupational, intellectual, and spiritual, elements.11 The terms apply to individuals as well as to groups of people (eg, families, communities) and environments (eg, physical, social, economic).

The World Health Organization defines health promotion as:

The process of enabling people to increase control over, and to improve, their health.12 Health promotion ... covers a wide range of social and environmental interventions that are designed to benefit and protect individual people's health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.12

The World Health Organization identifies 3 key elements for health promotion: good governance for health; health literacy; and healthy cities. Adding the concept of well-being to this definition emphasizes that promotion of health and well-being takes place across different environments and users.

Promoting Health and Well-being

The concept of promoting health and well-being at both personal and systems levels has evolved over history, starting with ancient and classical civilizations.13 Policy strategies for promoting health have been proposed since the 1970s.14 More than 3 decades ago, the Ottawa Charter for Health Promotion described health as a “resource for everyday life, not the objective of living.” It noted that prerequisites for health include “peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.”15 This guidance remains relevant today. Promoting well-being requires engaging an expanded and diverse array of users, disciplines, and sectors that extend beyond public health, such as mental health, housing, childcare/education, business, and aging.

Interventions to promote health and well-being occur at the individual, site-specific community, and societal levels. They address economic, social, and physical environmental and political factors (“determinants of health”) that influence health and well-being. Promoting health and well-being is critical because determinants of health—the physical, social, and economic circumstances in which people are born, live, learn, work, play, worship, and age—have disparate effects on vulnerable populations. These factors interact to affect people disproportionately based on race and class. All sectors are needed to remedy such disparities and achieve health equity.

At the individual level, interventions to promote health and well-being might focus on health behaviors, employment, housing, food security, or childcare. These interventions also would apply to the community level since they target settings where people spend their time, including home, school, work, or places where they socialize such as community centers and parks. These interventions can address designs of the built environment for ease of access and to ensure safety. The Robert Wood Johnson Foundation's Culture of Health initiative is one such national model. The Foundation defines a culture of health as one in which “good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities guides public and private decision making; and everyone has the opportunity to make choices that lead to healthy lifestyles.”16

The concept of promoting health and well-being has evolved over the decades (Figure). Health and well-being operate on more than 1 level. Broader conditions shape individual experiences of health and well-being, and organized efforts can influence those conditions. Social structures, such as families, neighborhoods and communities, and policies, economies, and cultures also play important roles.17–21

How the Concept of Health Promotion Has Evolved Over Decades of Healthy People

Engaging users from many sectors and ensuring the effective use and alignment of resources will strengthen implementation of Healthy People 2030. To promote health and well-being for all people and foster equity and social justice, socioecological factors and determinants of health must be addressed at all levels. A dynamic mix of resources will be needed for long-term improvements to livability (eg, stable housing, healthy food, clean air, education, living wage jobs) and for urgent needs (eg, acute care for illness or injury, food assistance, shelter, addiction treatment, disaster relief). Such resources will need to address a more diverse range of factors than in the past.

All too often, communities and institutions function in a reactive and responsive mode, deferring or delaying long-term investments. This way of functioning generates persistent needs for urgent services, along with pressure to maintain them. Collaborative decision-making across sectors can optimize the positive impact of resources and reduce the number of crises that happen in the first place. Identifying evidence-based programs to promote health and well-being among users can serve common interests, help users expand their thinking about solutions, and set priorities for limited time, money, and other scarce resources.

Multisectoral Collaborations to Improve Health and Well-being

Achieving population-level improvements in the coming decade will require users working at all levels to function across sectors and establish or participate in multisectoral collaborations. Such efforts can improve outcomes—not only in the health sector but also in nonpublic health or health care sectors, such as education, economics, the environment, and social cohesion. Collaboration among various users groups can benefit all partners by creating win-win solutions that recognize the interrelatedness of population health status with factors that lie outside the health care and public health systems.

Achieving optimal health and well-being requires efforts that include partners from different sectors, who operate at multiple levels (eg, state, local, community) and address the circumstances of people's lives.† Such efforts could span the behavioral, psychosocial, socioeconomic, cultural, and political circumstances of the population. No single actor has sole ownership of, accountability for, or capacity to sustain the health and well-being of an entire population.22–24 The 10 “causes of the causes” of poor health comprise psychological influences (eg, social gradient, stress, and social exclusion), as well as elements of community infrastructure, such as food and transportation.25 Thus, success depends on strengthening the capacity of communities to cocreate their own futures.26

The COVID-19 pandemic is a case study of the reciprocal, complex relationships between the health of individuals and the health of society as a whole, as well as the resulting unintended consequences. An individual's decision not to wear a mask at a grocery store or other indoor gathering place can result in the virus' spread to other people who are present. Defining some workers as essential and required to work, such as those who work in grocery stores, transportation, health care, and in other occupations that require interaction with the public, increases the risk of infection for many low-wage earners. When essential workers are compensated with low wages, lack of financial viability creates challenges to their overall health and well-being. When health insurance is tied to employment and unemployment is soaring, unemployed people often delay seeking care. When older adults stay in isolation to avoid the possibility of infection, they can experience loneliness, depression, and mental health issues. When schools are closed and children stay at home, those who lack Internet connectivity are at risk of falling behind in their schoolwork. Those who receive free school lunches may go hungry.

To help local health departments identify strategies for promoting population health and well-being and addressing determinants of health, the National Association of County and City Health Officials (NACCHO) identified 9 domains of determinants,27 as well as data sources for each (Table 2). Healthy People users at the state and tribal levels may find NACCHO's domains and data sources useful for identifying and acting upon opportunities to improve and monitor measures of health and well-being. These include indicators that are important to the success of other sectors, such as high school graduation, crime reduction, and economic prosperity.

TABLE 2

Nine Domains for Regional and Local Action to Improve Population Health (NACCHO)

1. Economic security and financial resources

2. Livelihood security and employment opportunities

3. School readiness and educational attainment

4. Environmental quality

5. Availability and utilization of medical care

6. Adequate, affordable, and safe housing

7. Community safety and security

8. Civic involvement

9. Transportation

Measuring Health and Well-being

Monitoring and documenting changes to the population's health and well-being will require the use of new data sources and types of measures. The way people evaluate their own lives as a whole is one indicator of health and well-being. Yet, systems that are outside of an individual's control shape the exposures, choices, and services that people experience. An important distinction exists between individuals' subjective ratings of their own health and well-being and the objective conditions that surround and support people as they strive to improve their health and well-being.

Measures of progress that go beyond those specific to public health and health care settings will require tapping into existing data sources across other domains and sectors. For example, data used by agricultural extension offices, planning departments at all levels, schools, businesses, parks and recreation agencies, transportation systems, the Bureau of the Census, aging services, and the financial sector, among others, can inform health and well-being. Data partnerships between public health, health care settings, and other sectors can often benefit collaborators by providing a much richer source of information for each partner as well as for the entire partnership.28

Healthy People 2020 used functional measures, including Healthy Life Expectancy,‡ Summary Mortality and Population Health,§ and Disparities, as global health measures for assessing progress. Earlier iterations of Healthy People used life expectancy and other measures.∥ Holistic evaluations of health and well-being status of individuals, communities, and systems require broad measures, such as life satisfaction or social cohesion.29–33 Assessing progress toward improved health and well-being must consider health disparities, health literacy, multisectoral policies, and determinants of health and well-being.

Realizing the potential of Healthy People 2030 will require accurate data from credible sources at all levels, with a renewed emphasis on local action. There are barriers to generating high-quality data (eg, funding, staffing, technology). Healthy People supports local action by providing guidance for consistent data collection methods and measures, as well as examples of best practices and innovations. A data partnership infrastructure and network focused on Healthy People objectives could address and respond to new developments in data sources and data analytics. For example, a data partnership could expand the availability of locally relevant data, stimulate access to new data sources to measure determinants of health and health equity, and enable linkage of geographic and demographic data in presentation formats for Healthy People users.

Partners would be able to share data, methods, and analyses and access guidance on data developments relevant to all 3 Healthy People objective types—core, developmental, and research. A data partnership infrastructure and network that links national, tribal, state, territorial, and local data through partnerships and collaborations could enhance the nation's capacity to identify and record the achievement of Healthy People objectives and overarching goals.

Discussion

Healthy People 2030 continues the Healthy People initiative's tradition of serving as a catalyst for action by expanding the focus of health promotion to promoting health and well-being (see Supplemental Digital Content file, available at http://links.lww.com/JPHMP/A716). This emphasizes the need to shift from a disease-specific orientation to more upstream policy efforts. Healthy People 2030 offers data, objectives, and tools for creating well-being and a healthier nation. Realizing the potential of Healthy People 2030 will require the active involvement of a variety of public and private institutions and organizations, including national, tribal, state, territorial, and local health departments. Health departments at all levels can contribute to this work by engaging multiple sectors in the implementation and monitoring of objectives.

Discussions within the public health community, and between public health and other sectors, around defining health and well-being offer opportunities to engage partners that historically have not been involved in Healthy People. Engaging new partners in the Healthy People initiative will require those who traditionally have led the initiative to understand what those partners need to succeed, communicate how new partners' goals complement those of Healthy People, and convey how engaging with Healthy People can benefit the new partners. For example, partnering to improve high school graduation rates benefits the education and public health sectors, as well as the financial sector and potentially the criminal justice system. Accomplishing that goal might involve engaging with the telecommunications sector to support students' access to affordable Internet service. By engaging in such partnerships, everyone would become more familiar with the goals of other sectors and discover more win-win opportunities.

In their health improvement plans, public health departments at all levels should think broadly about which partners from other sectors could help them advance health and well-being goals, while considering what public health can offer those sectors in achieving their own goals. For example, in Maryland, each county has been charged with having a local health improvement coalition that brings together key users to achieve locally identified needs for health and well-being and to eliminate health disparities. Organizations and individuals often need to see value for investing their time and resources before they agree to participate. Involving partners early allows them to be part of identifying issues and finding solutions.

Open access data portals at the state level are proliferating and can inform decision makers as well as the public. These data portals and related data dashboards provide community leaders and residents with current geographically tracked data and tools that support assessments and linkages to evidence-based interventions. These data initiatives offer yet another opportunity for partners to convene and develop collaborative programs for their respective populations.

One of Healthy People 2030's foundational principles is that “the health and well-being of all people and communities are essential to a thriving, equitable society.” Achieving health and well-being for all will benefit society as a whole. Achieving such benefits requires eliminating health disparities, achieving health equity, attaining health literacy, and strengthening the physical, social, and economic environments. Promoting the nation's health and well-being is a shared responsibility—at the national, state, territorial, tribal, and community levels. By enlisting the involvement of the public, private, and not-for-profit sectors in efforts to promote the health and well-being of our populations, we will improve the health of the nation and the achievement of Healthy People 2030's targets.

Across the field of public health, the focus on health promotion should be expanded to include health and well-being.

No one sector has the ability, responsibility, or needed expertise to promote health and well-being for all. Multisectoral approaches are needed to address the social, economic, and physical determinants of health and well-being.

It will be critical to identify common data sources and indicators that can be used to measure and evaluate trends in health and well-being.