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The third stage of health promotion started at beginning of the 21st century with the realization that even within high income countries there could be a difference of almost 20 years in life expectancy—even in those countries that had a well-developed healthcare system providing care to all citizens (Kaplan et al., 2015). Individual decisions about health behaviors were rooted in the social environment in which people are born, live, work, and play (Marmot, 2005). The social institutions (economic systems, housing, healthcare system, transportation system, educational system), the surrounding environment, social relationships, and civic engagement all provide opportunities for individuals to make healthy choices—or not. One’s opportunities for a healthy life style are severely limited if there is no affordable low-income housing, no transportation infrastructure that allows individuals to pursue employment outside of their neighborhood, no supermarkets in the neighborhood with fresh fruits and vegetables, no safe parks in which to play or exercise, or no quality schools to provide a quality education in the neighborhood.

Today, health promotion is a specialized area in the health fields that involves the planned change of health-related lifestyles and life conditions through a variety of individual and environmental changes. Figure 1.2 illustrates the dynamic interaction between strategies aimed at the individual and strategies for the entire population.

Figure 1.2 Dynamic interaction between strategies aimed at the individual and strategies for the entire population

Source: Phase I Report - Recommendations for the Framework and Format of Healthy People, U.S. Department of Health and Human Services, 2020.