As a grant requirement, recipients must align all programs to the health objectives established by the Healthy People initiative, a set of national goals and measurable objectives to improve health and wellbeing in the United States.²² The alignment to Healthy People allows recipients to focus on their jurisdiction’s unique needs while also making progress toward national public health priorities. As these national priorities change over time, recipients can use the PHHS Block Grant to shift and pivot their efforts to undertake new, emerging, and evolving issues, such as health disparities and health equity.

Throughout the decades, the knowledge, understanding, and science behind health equity have evolved.^6,23 In response, Healthy People has increased its focus on health equity, health disparities, and SDOH.^24,25 The fifth and current iteration of the initiative, Healthy People 2030, includes a goal of eliminating health disparities and achieving health equity, as well as a goal to address SDOH. Healthy People defines SDOH as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” It operationalizes SDOH through its place-based framework outlining 5 domains: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context. A subset of the national objectives is associated with each domain of the SDOH framework.²⁶

Given the attention on health equity and health disparities as well as the refinements to Healthy People’s approach to SDOH, this study explores the extent to which PHHS Block Grant recipients are aligning their programs to the Healthy People 2030 SDOH-related objectives. The aim of this study is to understand and describe the use of the PHHS Block Grant in addressing health disparities and advancing health equity.

The CDC’s PHHS Block Grant Information System (BGIS), a web-based platform that houses program administrative information by fiscal year, such as workplans and budgets, provided the secondary data necessary to complete this study. Specifically, the following program variables for federal Fiscal Year 2021 (FY21) were extracted: recipient name, program name, associated Healthy People 2030 objectives, planned funding allocation, and the funding role of grant funds (only source of funding or supplement source of funding for the program). The initial data extraction included programs from all 61 PHHS Block Grant recipients. This activity was reviewed by CDC, deemed research not involving human subjects, and was conducted consistent with applicable federal law and CDC policy.^†

To prepare the data for analysis, several new variables were created. The first variable categorized the recipients into 4 funding levels: less than $1 200 000, $1 200 000 to $1 989 999, $1 990 000 to $3 883 999, and $3 884 000 or greater. The funding levels were determined by calculating the interquartile range for the total FY21 grant award amount. The second dichotomous variable indicated whether the objective was a Healthy People SDOH-related objective. Those objectives were then categorized by SDOH domain—health care access and quality, education access and quality, economic stability, neighborhood and built environment, and social and community context. Objectives that were not SDOH focused and did not align to an SDOH domain were coded as not applicable.

Upon reviewing the dataset, it was observed that, in some cases, recipients entered the same program in BGIS multiple times. To establish an unduplicated dataset, a new variable called unique program was created. To populate this variable, the dataset was reviewed for duplicate data based on the program name, goal, strategy, and funding amount. All duplicate data were removed so that the dataset reflected only 1 unique program reducing the dataset from 550 programs to 494 unique programs across all recipients.

The scope for this study included 47 states and the District of Columbia (n = 48). For the purposes of this study, the District of Columbia is treated as a state. Three states were excluded due to budgetary errors reported in BGIS. In addition, due to the unique structure, geography, capacities and needs, the 8 territorial agencies/freely associated states and 2 tribal agencies were also excluded.

A cross-sectional, descriptive analysis, including frequencies and crosstabulations, was performed. The study measures included the percentage of states that used PHHS Block Grant funds to address SDOH; proportion of funding allocated to address SDOH; percentage of programs that addressed SDOH; and number and type of SDOH domains addressed by PHHS Block Grant-funded programs. Subanalyses of data by program characteristics of interest, such as funding level, were also conducted. Funding designated for administrative purposes, such as staffing, was excluded from the analysis.

Thirty-six of the 48 states (75%) allocated funds to programs that aligned with at least 1 Healthy People 2030 SDOH-related objective (“HP-SDOH programs”). Figure 1 shows that, across 4 levels of funding, the percentage of states that allocated funding toward SDOH programs increased as the funding level increased. For example, 42% of the 12 states that received less than $1 200 000 allocated funds to HP-SDOH programs as compared to all 12 states with a funding level of more than $3 885 000 that allocated funds to HP-SDOH programs.

Overall, $121 235 051 of grant funding was used to fund programs. Twenty-eight percent ($33 436 954) of this funding went to HP-SDOH programs within each of the 5 SDOH domains. As shown in Figure 2, the largest share of this funding was allocated to the health care access and quality domain ($24 221 172), followed by neighborhood and built environment ($4 105 849) and social and community context ($3 625 312). Economic stability and education access and quality domains received the least amount of funding ($1 194 870 and $289 751, respectively.)

We also examined to what extent the grant served as the only or primary source of funding for the HP-SDOH programs (defined in Figure 3). For 50 of the 97 HP-SDOH programs (51%), the PHHS Block Grant served as the only or primary source of funding, which accounted for $23 092 691 (69%) of HP-SDOH funding (Figure 3). Further, 18 states used only grant funds for at least 1 of their HP-SDOH programs, while 6 states funded all HP-SDOH programs using only grant funds. However, the degree to which the grant served as the only or primary source of funding for HP-SDOH programs varied by SDOH domain. For example, although the education access and quality domain received the least amount of PHHS BG funds, 60% of those funds served as the only source of funding for programs within this domain. Where only 11% of funding for the economic stability domain was used to fully fund programs.

Of the 426 public health programs^‡ funded by states in FY21, 96 (23%) were HP-SDOH programs. For the purposes of analysis, we counted 1 program twice because it aligned with 2 SDOH-related Healthy People Objectives; therefore, the number of programs is 97. Most HP-SDOH programs (60%) fell under health care access and quality domain, followed by neighborhood and built environment (19%), social and community context (12%), education access and quality (5%), and economic stability (4%).

When examining allocation to programs under each SDOH domain by state funding levels, variation was observed across levels. As shown in Figure 4, programs under the health care access and quality and neighborhood and built environment domains were funded by states within each funding level, whereas none of the states receiving less than $1 990 000 funded programs under the economic stability domain.

Upon review of the selected Healthy People 2030 objectives by SDOH domain, results demonstrate a wide variety of topic areas addressed by state recipients. Thirty-four percent of programs focus on the following 2 topic areas: community—which aims to promote health and safety in community settings, and healthcare—which seeks to improve healthcare quality and making sure all people get the services they need (Table 1). The following section describes the topics addressed under each SDOH domain.

States funded 58 programs under this domain ranging from family planning to health information technology. The top 2 subtopics addressed were community and health care. Nineteen programs focused on community organizations that provide prevention services (HECBP-07). Fourteen programs focused on addressing health care, such as reducing the proportion of people who cannot get medical care when they need it (AHS-04), increasing the proportion of people with a usual primary care provider (AHS-07), and increasing use of the oral health care system (OH-08).

Eighteen programs were funded under this domain, of which 8 addressed respiratory diseases, such as reducing asthma attacks (RD-04), reducing emergency department visits for people with asthma (RD-02, RD-03), and reducing hospitalizations for asthma and COPD (RD-D01, RD-DO2, RD-DO4). Four programs concentrated on health policy for increasing the proportion of people whose water systems have the recommended amount of fluoride (OH-11). Another 4 programs focused on environmental health, such as reducing exposure to unhealthy air (EH-01), increasing water supplies that meet Safe Drinking Water Act regulations (EH-03), and reducing health and environmental risks from hazardous sites (EH-05).

The states funded 12 programs under this domain. Eight programs focused on increasing the proportion of adults who talk to friends or family about their health (HC/HIT-04) and increasing the health literacy of the population (HC/HIT-R01). The remaining programs focused on increasing the proportion of adolescents who have an adult they can talk to about serious problems (AH-03), children and adolescents who communicate positively with their parents (EMC-01) and show resilience to challenges and stress (EMC-DO7), and adults who use IT to track health care data or communicate with providers (HC/HIT-07).

The 5 programs funded under this domain addressed increasing the proportion of children and adolescents who get preventive mental health care in school (EMC-D06) and increasing interprofessional prevention education in health professions training programs (ECBP-D08).

Of the 4 programs under this domain, 3 programs sought to reduce household food insecurity and hunger (NWS-01) and 1 program focused on reducing work-related injuries resulting in missed workdays (OSH-02).