This study offers new insight into Americans’ understanding of the factors that impact health, as well as the extent to which they value health equity. Despite efforts by the public health community, equity advocates, and a growing coalition of nonprofits, governments, and foundations, our research shows that the dominant narrative about drivers of health and health equity is powerful and resistant to change: Most Americans believe that health is predominantly influenced by individual behaviors and access to health care, as opposed to structural and social factors, and health equity is still not a widespread priority.
Findings from the latent class analysis show that the majority of Americans surveyed in 2018 still lack knowledge about the social determinants of health or the role of community on health outcomes. Nearly 90 percent of respondents were members of a class (class 3) characterized by high endorsement of THI (including access to health care, stress, and health behaviors), but lower endorsement of SDoH (including having a job, neighborhood options for healthy food and exercise, social support, housing quality, and race/ethnicity), and very low endorsement of SoC (including that the community can work together to improve its health, has the resources to improve its health, and works together to make positive changes for health). Hallmarks of belonging in this class are that members were predominantly White (74%), educated (74% reporting at least some college education) and high-income (nearly half the members reported annual incomes in the highest two categories). Each of these percentages were highest for this class compared to the other three classes. In contrast, the class found to have the broadest comprehension about what drives health (class 2), as evidenced by high endorsement of both THI and SDoH and the highest endorsement of SoC of all classes, was also the class representing only 3.2% of respondents. Members of this class were the most racially and ethnically diverse out of all classes, with the highest percentages of Black (33%), Hispanic (27%), and Asian (5.2%) people. This class was also the poorest, with 56% of individuals reporting income in the lowest two categories. The stark differences between these two classes in terms of their understanding of what drives health suggest that lived experiences based on race and income may be instructive about how SDoH and SoC can impact health.
Findings from the logistic regression examining health equity perceptions echoed previous findings and revealed new ones (14, 16, 17). None of the three health equity outcomes received over 50 percent endorsement of the highest response category. In fact, only 31 percent of the sample strongly agreed that it would be unfair if some people had more of an opportunity to be healthy than other people. Respondents endorsing all three health equity outcomes tended to be female, older, Black or Hispanic, have more education, and have lower incomes. The relationship between income level and perceived importance of health equity showed a dose-response pattern in which the lower a respondent’s income level, the higher the likelihood of perceiving health equity to be important (observed across all three outcomes). In terms of class membership, class 2 (who had the broadest understanding of what drives health) had significantly higher probabilities of endorsing all three health equity outcomes compared to the reference class (class 3). Class 1 shared the same pattern of health equity outcome endorsement as class 2; class 1 similarities to class 2 include racial and ethnic diversity (24% Black and 19% Hispanic representation) and high endorsement of both THI and SDoH as drivers of health. The differences between these two groups are also important to understand. Class 1 is overall richer (45% reporting in two highest income categories) and more educated (20% increase in members reporting some college education) than class 3. Therefore minority status was the factor most strongly associated with understanding of health drivers and the perceived value of health equity, even beyond the role of income, which was also significant.
These findings also have implications for how we understand the roots of beliefs about the SDoH and health equity, and the role of demographics in those beliefs. We found evidence that those who may have experienced disadvantage as a result of their race or income may more readily connect their circumstances to health-related challenges. On the flipside, those who experience relative privilege based may fall back on cultural schemas regarding the role of individual behaviors, rather than considering structural influences (30), and prior research shows they may even actively oppose efforts to level the playing field, citing “reverse discrimination” (31). Prior to this work, there has been limited research to date on the role of demographics and lived experience on beliefs about factors that determine health and values of health equity.
As with any study, there are important limitations to note. The NSHA is being fielded approximately every three years, but this paper only reports on the 2018 survey. As such, it will be useful to look at the relationship between health mindset and understanding and health equity, if and how that evolves over time, and why. We are potentially living through an inflection point when it comes to demands for racial equity, and it will be valuable to continue to track health equity beliefs among this nationally representative sample in future iterations of the survey. Additionally, the items used to capture perspectives on health equity are mostly based on broad beliefs, and we do not know yet if these beliefs are mutable or change in different contexts or scenarios. While we built on established scales of SDoH recognition, the scales we used to assess SoC are comparatively new given the limited research on this topic.