Creating Equal Opportunities for Healthy Weight
VIEWING LOCAL GOVERNMENT DECISIONS THROUGH A HEALTH EQUITY LENS
There is a growing national awareness of the major role social, economic, and environmental factors can play in determining the health of individuals and populations. Unequal exposure to positive social, economic, and environmental influences can result in health differences, viewed more properly as inequities, among groups of people. For example, lower-income neighborhoods tend to have environments that are unlikely to encourage or provide access to opportunities for healthy eating and adequate physical activity (Day, 2006).
These neighborhoods are less likely to have the grocery store options or the park and playground facilities found in higher-income neighborhoods (Black and Macinko, 2008; Booth et al., 2005; Kumanyika and Grier, 2006). Additionally, their streets are more likely to be unsafe and difficult to navigate for walkers and cyclists, with fewer walking and bike paths, and their playgrounds are often unsafe. Analyses of the availability of high-calorie, low-nutrient foods and beverages, and the prevalence of advertising, show higher levels in lower-income neighborhoods (Black and Macinko, 2008; Kumanyika and Grier, 2006; Yancey et al., 2009). On the other hand, the availability of nutritious foods, and social marketing on the value and attractiveness of nutritious foods, are less likely in these neighborhoods. Children that are born, grow up, live, work, and age in these environments are more likely to be obese than children from more affluent communities. They are also more likely to suffer from the chronic diseases associated with obesity. Unless changes are made in the social, economic, and environmental factors affecting many children’s lives, these seemingly intransigent health problems are likely to continue.
The Institute of Medicine (IOM) report The Future of the Public’s Health in the 21st Century (IOM, 2003, p. 4) states, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change.” This view is echoed by researchers studying the effect of the social environment on physical activity: “Advising individuals to be more physically active without considering social norms for activity, resources, and opportunities for engaging in physical activity, and environmental constraints such as crime, traffic, and unpleasant surroundings, is unlikely to produce behavior change” (McNeill et al., 2006, p. 1012). Conversely, changing people’s environments to provide equal access to factors that determine health will enable them to better control their health and its determinants, make healthier choices, and thereby improve their health.
The charge to local governments, then, is to work with community leaders, members and others to eliminate the inequities outlined above—that is, to create health equity. Many people nationwide at the local, state, and federal levels are working to define this concept and identify ways of applying it to policy, planning, and service delivery. One such definition has been developed by the Centers for Disease Control and Prevention’s (CDC’s) Health Equity Workgroup: “Health equity is the fair distribution of health determinants, outcomes, and resources within and between segments of the population, regardless of social standing” (CDC, 2007).
Just as glasses with 3-D lenses allow movie audiences to see three-dimensional images that they could not see unaided, looking at communities and their members’ health status through the lens of health equity can help policy makers understand the health impacts of such factors as racism, poverty, residential segregation, poor housing, lack of access to quality education, and limited access to health care. Using the health equity lens can also suggest the actions needed to achieve optimal health and health justice. The new perspective provided by seeing through a health equity lens allows local government officials to reframe their viewpoint. Thus, for example, instead of simply noting that a lower-income child eats few fruits and vegetables and does not engage in sufficient physical activity, local government officials can be encouraged to question the equity of distribution of supermarkets, the adequacy of transportation, the safety of neighborhoods, and the availability of parks and recreation opportunities in the context of residential segregation, high rates of unemployment, and an absence of social capital.
This new perspective can point policy makers in the right direction to pursue policies and actions that can reverse the situation in communities with disproportionately high rates of obesity and remove barriers to health equity and good
health. Some of the actions local governments can take to make these changes happen are listed below. (Chapters 4 and 5, respectively, outline more specific actions that can be taken to promote healthful eating and physical activity.)
Improve coordination among agencies and organizations whose activities address determinants of health in such areas as education, housing, planning, agriculture, employment, and economic development.
Engage with communities in planning and implementing actions to improve health and health equity.
Find ways to increase the availability of healthy, affordable food in underserved communities and reduce access to unhealthy foods.
Create a built environment that encourages walking, cycling, and other physical activity.
Consider cultural barriers that keep lower-income, minority, and immigrant populations from purchasing healthier foods or seeking opportunities for physical activity.
Work with community partners to identify and build upon cultural assets, such as dance traditions or gardening for groups with a rich farming heritage.
Finally, it is important to recognize that many decisions made by local governments that appear unrelated to childhood obesity actually may have a significant effect. For example, decisions about employee income, education, public assistance, housing assistance, affordable housing plans, transportation, health insurance, commercial development, community involvement in government and decision making, and community policing, to name a few, may have positive or negative impacts on the prevalence of childhood obesity overall and especially among those who are most vulnerable.
Viewing local government decision making through a health equity lens is fundamental to preventing childhood obesity and promoting health equity. This is a matter of ethics and fairness, but it is also a practical necessity because of the financial and human costs associated with obesity. Efforts aimed at preventing childhood obesity should target those areas of the community where the problem is greatest and where social, economic, and environmental factors appear to promote obesity and act as barriers to its prevention. As policy makers and community partners review the strategies and action steps offered in this report, they should focus on those actions that are most likely to lessen health disparities related to childhood obesity and to bring the community’s children and their families closer to a state of health equity.
Black, J. L., and J. Macinko. 2008. Neighborhoods and obesity. Nutrition Reviews 66(1):2–20.
Booth, K. M., M. M. Pinkston, and W. S. C. Poston. 2005. Obesity and the built environment. Journal of the American Dietetic Association 105(Suppl. 5):S110–S117.
CDC (Centers for Disease Control and Prevention). 2007 (unpublished). Health Equity Working Group. Atlanta, GA: CDC.
Day, K. 2006. Active living and social justice: Planning for physical activity in low-income, black, and Latino communities. Journal of the American Planning Association 72(1):88–99.
IOM (Institute of Medicine). 2000. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: National Academy Press.
Kumanyika, S., and S. Grier. 2006. Targeting interventions for ethnic minority and low-income populations. Future of Children 16(1):187–207.
McNeill, L. H., M. W. Kreuter, and S. V. Subramanian. 2006. Social environment and physical activity: A review of concepts and evidence. Social Science and Medicine 63(4):1011–1022.
Yancey, A. K., B. L. Cole, R. Brown, J. D. Williams, A. Hillier, R. S. Kline, M. Ashe, S. A. Grier, D. Backman, and W. J. McCarthy. 2009. A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising. The Milbank Quarterly 87(1):155–184.