Drivers of differential views of health equity in the U.S.: is the U.S. ready to make progress? Results from the 2018 National Survey of Health Attitudes

Abstract

Objectives The public health sector has long recognized the role of the social determinants of health in health disparities and the importance of achieving health equity. We now appear to be at an inflection point, as we hear increasing demands to dismantle structures that have perpetuated inequalities. Assessing prevailing mindsets about what causes health inequalities and the value of health equity is critical to addressing larger issues of inequity, including racial inequity and other dimensions. Using data from a nationally representative sample of adults in the United States, we examined the factors that Americans think drive health outcomes and their beliefs about the importance of health equity. Methods Using data from the 2018 National Survey of Health Attitudes, we conducted factor analyses of 21 survey items and identified three factors from items relating to health drivers—traditional health influencers (THI), social determinants of health (SDoH), and sense of community health (SoC). Health equity beliefs were measured with three questions about opportunities to be healthy. Latent class analysis identified four groups with similar patterns of response. Factor mixture modeling combined factor structure and latent class analysis into one model. We conducted three logistic regressions using latent classes and demographics as predictors and the three equity beliefs as dependent variables. Results Nearly 90% of respondents comprised one class that was characterized by high endorsement (i.e., rating the driver as having strong effect on health) of THI, but lower endorsement of SDoH and SoC. Logistic regressions showed that respondents endorsing (i.e., rated it as a top priority) all three health equity beliefs tended to be female, older, Black or Hispanic, more educated, and have lower incomes. The class of respondents that endorsed SDoH the most was more likely to endorse all three equity beliefs. Conclusions Results suggested that people historically impacted by inequity, e.g., people of color and people with low incomes, had the most comprehensive understanding of the drivers of health and the value of equity. However, dominant beliefs about SDoH and health equity are still generally not aligned with scientific consensus and the prevailing narrative in the public health community.

Has COVID-19 changed how people think about the drivers of health? If so, does it matter?

“…To examine the relationship between health mindset, vaccine status, and perceptions of COVID-related policies, we used Wave 4 data to conduct logistic regressions controlling for respondent race/ethnicity, income, age, gender, education, and urban/rural residence. These model specification decisions were informed by earlier work that analyzed 2018 data from the same survey that found differences among racial/ethnic groups in beliefs about social determinants of health (25). We subsequently added urban/rural residence to the models as a rough proxy for local-level differences in factors, but did not observe any change in results.…”

Pro-health measures as a creator of new behavior norms and attitudes

“…Research conducted in the USA suggests that good health is determined by access to medical care and individual predispositions aimed at maintaining it. Social and material factors are of less importance in that case [16].…”

The Profound Implications of the Meaning of Health for Health Care and Health Equity

“…Barriers to change are substantive. These include current system inertia, economic incentives, political differences regarding the role of government if not health care in promoting health rather than treating disease, legacy systems, institutional barriers, and costs of retooling among others 132–135 . There are no simple solutions.…”

“…These include current system inertia, economic incentives, political differences regarding the role of government if not health care in promoting health rather than treating disease, legacy systems, institutional barriers, and costs of retooling among others. [132][133][134][135] There are no simple solutions. Some of the solutions overlap with those of establishing a "culture of health," i.e., clarifying and demystifying the concept, grounding community intervention in broader structural change, and building consensus in a divided nation.…”