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Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always … More Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. You do not currently have access to this chapter. Learn about how to address social determinants of health in your community initiative. What broader factors determine whether people in a community are healthy? What accounts for differences in health outcomes among people in different groups, communities, and countries? The health of a community – and its people – is dependent on a number of social, political, economic, and environmental conditions. Social determinants of health refer to access to power, money, and resources and the conditions of daily life that affect health and well being for groups of people (Solar, Irwin, WHO 2010). These conditions support or limit the health of a community or a population. Health disparities or inequalities occur when there are differences in conditions—where people are born, live, work, and play—across different groups. For instance, racial/ethnic minorities experience poorer health when they are more:
Throughout the world, there are efforts to address social determinants of health. For instance, in the United States, the health objectives for the nation include the goal of create social and physical environments that promote good health for all by addressing social determinants of health (Healthy People, 2020). Globally, the Rio Political Declaration on Social Determinants (2011) reaffirmed the global commitment to take action on social determinants of health. Key action areas include improving governance, community participation, attention to health inequities, and monitoring progress. To achieve this vision will require a whole community approach in which different sectors—health, education, housing, labor, justice, transportation, agriculture, and the environment—all work together to assure conditions for health. To be successful, this approach requires changes at the levels of individuals, relationships, communities, and broader systems. It requires environmental, economic, and policy strategies along with individual behavioral change and health services. The approach also requires developing partnerships among different groups including public health, community organizations, education, government, business, and civil society. Health equity and health disparities. A basic principle of public health is that all people have a right to health. Health disparities refer to differences in the existence and frequency of health conditions and health status among groups. Most health disparities affect groups that have been marginalized or excluded because of socioeconomic status, race/ethnicity, sexual orientation, gender, disability status, geographic location, or some combination of these. People in such groups not only experience worse health but also tend to have less access to the social determinants or conditions that support health and well being; for instance, healthy food, good housing, good education, safe neighborhoods, and freedom from racism and other forms of discrimination. Health disparities are referred to as health inequities when they are the result of the systematic and unjust distribution of these critical conditions. Health inequities are “avoidable inequalities in health between groups of people within countries and between countries” (World Health Organization, 2010). Health equity, then, is when everyone has the opportunity to “attain their full health potential” and no one is “disadvantaged from achieving this potential because of their social position or other socially determined circumstance.”
What do we mean by developing an initiative to address social determinants of health?Many communities embark on initiatives aimed at improving the health of citizens. Generally, they are intended to change individual behavior by offering opportunities and information that make it easier for people to quit smoking, get more exercise, eat healthier foods, or obtain health screenings for various diseases. Although these efforts can certainly lead to good outcomes, they often don’t address the social determinants that are at least partially responsible for positive or negative health conditions. In this section, we’re presenting ideas from a report of the U.S. Centers for Disease Control and Prevention on how to assess and address important social determinants of health in your community. The model promotes inclusiveness, community participation, careful assessment and planning, implementation, evaluation, and maintenance of effort. In other words, it is in many ways similar to the other models for community health and development in this chapter. The major difference is that it suggests how to influence health and health-related issues by addressing their social determinants. This model also aims to promote health equity, since that is the ultimate goal. In most communities and most societies, some people have better access to health care and health resources and live in healthier environments than others. As a result, they are generally healthier and longer-lived than those with fewer advantages. In many cases, these differences are caused, at least partially, by social conditions – income, education, discrimination, politics, and geography – rather than by genes or luck. When conditions for health are unequal, these are health inequalities. When these conditions are unjustly distributed, the result is health inequity. By effectively addressing the social determinants of health, we can create a healthier community, and improve the quality of life for all. Why develop a social determinants of health initiative in your community?
How to take action to address social determinants of healthThe link between social determinants of health -- including social, economic, and environmental conditions -- and health outcomes is widely recognized in public health. It is increasingly understood that inequitable distribution of these conditions across various populations is a significant contributor to widespread and persistent health disparities. So... you understand social determinants of health (SDOH) and their relationship to health outcomes and health equity. And you see ways that social determinants can be changed in your community to improve health and the quality of life for everyone. How do you go about making those changes? What follows is step-by-step guidance for implementing an initiative to do just that. Be aware that these steps are only a guideline. All communities are different, and what works well in one might not work in another. Although these steps are arranged in the order they might logically be taken, in some cases it might make more sense to change the order, or to act on more than one step at a time. Some parts of the guideline are important in all cases, however. The formation of a partnership that incorporates people from all sectors of the community – particularly those who experience inequity in health and other areas – is crucial if the process is to lead to long-term social change. Focusing on SDOH, as well as careful planning and evaluation are also necessary. Perhaps most important is maintaining and building on successes. Too many initiatives founder after their initial success because everyone thinks the problem is solved, and that the changes will ride on their own momentum indefinitely. A neglected house will eventually fall down, and a neglected initiative will do the same, only much more quickly. With that caution in mind, let’s get to work. The Figure below (from the CDC Report) outlines seven phases and related steps in addressing social determinants of health in your community. By clicking on the phase, you can skip to ideas and resources for implementing related steps. Figure: CDC Phases of a Social Determinants of Health Initiative Phase 1: Create or Enhance Your PartnershipThe foundation for a successful initiative is the development of a multi-sector partnership. This alliance is responsible for conceiving, planning, implementing, evaluating, and maintaining the effort over time. A partnership is an intentional relationship between two or more parties (individuals, groups, or organizations) committed to pursuing an agenda or goal of mutual benefit. It is essential to build partnerships to address social determinants of health because no one group, whether health care providers, public health practitioners, community organizations, or community members, can accomplish the many tasks required for changing social, economic, and environmental conditions that affects health. Partnerships are necessary to:
The first step toward creating a successful partnership is to assemble a group of interested community members and organizations to discuss ideas and concerns for the community. You may choose to work within existing partnerships that have helpful knowledge and experience. Existing groups, however, may not address the social determinants of health or include people or organizations from the community who can inform initiatives to address social determinants. Therefore, you might wish to invite others to join your efforts, particularly those who have insight into or experience harm from the political, social, economic, and environmental conditions in your community. Listening to the voices of people and organizations in the community who experience inequitable distribution of resources can help to build a strong partnership to address social determinants. This can be strengthened by ties to diverse groups in your community and involvement of relevant sectors of your community (e.g., government, education, business, public services, faith, funding agencies). To identify who should be involved, it helps to consider how your community is defined. Define your community. A community is essentially a group of people who have something in common and who see themselves, or are seen by others, as part of that group. It’s most often thought of as a geographic area – a neighborhood, a town, a city, or a village, for example. Shared experience can also define a community including:
Once you’ve clarified the physical and/or social boundaries of the community you’re working with, it will be easier to determine who from that community needs to be involved. Determine who should be included in the partnership. Start with those who are obvious and/or who have the largest networks, and ask them to help you identify others. Be sure that your initial group is diverse enough, and that you have enough knowledge of the community, so that no one will be left out and resentful. Some people you ask may choose not to participate, and some groups may go unrepresented no matter how hard you try, but it’s important to make a serious and sincere effort to involve everyone. Those who might be included, depending on the initiative, are:
The people and groups identified should reflect the diversity of the community, including gender, race, ethnicity, age, income, sexual preference, and other dimensions of social exclusion. Contact potential partners and convince them to participate. Once you’ve identified some of the individuals and groups needed to make up the partnership, you have to recruit them. In general, the best way to do this is personally, face to face. For individuals, that may mean sharing a meal together or meeting with several people in a group. For larger groups and organizations, talking to a regular gathering of the board and/or staff might be the best approach, perhaps after meeting with the director or board chair. As you bring people on board, you can ask them to recruit others that they know. In general, people are more likely to respond to those whom they know and trust. If you can engage a few particularly respected individuals, others will become interested because they trust those people’s judgment. Once you’ve signed up a core group, it’s more likely that the rest of the members will fall into place. Choose a facilitator. Your partnership will need someone to run meetings, help to resolve conflicts, and generally hold things together. This could be a partnership member or, if the partnership has the resources and the need, someone hired from outside the community. In either case, it should probably be someone who is seen as neutral (having no bias toward or against one group or another), fair, ethical, open to new ideas, and flexible. The facilitator might be only that, or might be seen, both within and outside the partnership, as the leader of the initiative. If so, that person should be collaborative, encouraging and safeguarding the partnership’s participatory process, and facilitating problem solving. Establish guiding principles for the partnership. What are the principles the partnership is firmly committed to, regardless of what the initiative chooses to address and how it chooses to address it? A collaborative process? Treating every person and idea respectfully, even when there’s disagreement? A focus on social determinants? The basic principles, if they’re worked out and recorded at the beginning, will make the work easier down the road. They’ll provide the foundation for the vision and mission statements that come later, and they’ll also provide the framework within which the partnership will operate, reminding members what they’re there for, and structuring how they treat one another. Guiding principles provide security for partnership members: the principles show that they’re all on the same track, and that no one will be abused or disadvantaged by the process. (See Tool #1 below for examples of guiding principles.) Phase 2: Focus Your Partnership on Social DeterminantsThis step is about assessing community resources and challenges. If the purpose of an assessment is to identify a particular health condition and treat it, the assessment will take a different shape than it will if its focus is to identify the social determinants underlying that condition. An assessment that emphasizes social determinants will prepare the partnership to make changes that aim at the root causes of the condition, and thereby diminish or eliminate it. Assess social determinants. Your first decision here is to consider what you want to assess. You have a choice in how to approach your assessment:
Remember that social determinants can have either positive or negative effects on health. Discrimination and poverty generally have negative effects; by contrast, a healthy environment and good educational opportunities usually have a positive influence. You may choose to address social determinants by eliminating (moderating) negative factors or by increasing (strengthening) positive factors.
Develop a vision and mission. Clear vision and mission statements are crucial to the success of any initiative. It is particularly important for them to be developed through a participatory process, and that you take whatever time is necessary to craft wording that everyone can support. The time taken for this process will be well worth it for its contribution to the cohesion and focus of the partnership. Your partnership’s vision -- such as “health for all” or “safe and caring communities” -- is what you want the community to look like when everything you hope to accomplish has been achieved. Your partnership’s mission statement includes the essential “why” (e.g., “Achieving health for all…” and essential “what” (e.g., through policy advocacy and collaborative action”). It is focuses the effort to realize the vision. In simplest terms, your mission statement describes the essential work of your initiative. Your vision and mission statements should be as short and to the point as possible. They should fit together: carrying out the mission should lead to fulfillment of the vision. (See Chapter 8, Section 2, Proclaiming Your Dream: Developing Vision and Mission Statements.) Identify and prioritize goals and objectives. An initiative planning model can be very useful as you identify your goals, objectives, and action steps. This model can be used to inform your planning process by guiding your community to understand current needs and to plan for the future. To develop an initiative planning model, outline your overall long-term goal and a series of objectives that will help move you toward achieving this ultimate goal. These objectives can be used to identify the specific action steps necessary to create change and benchmarks to determine your progress. In developing this model, be sure to include who will be responsible for each action step and the time frame for the steps’ completion. Combined into a model or framework, these goals, objectives, and action steps provide the sequence of necessary actions. From this information, you and your partners can prioritize activities according to the timeline laid out in the plan. For example, community awareness and support may be needed before you can secure resources to create structural changes. In addressing social determinants of health, you may decide to focus on one specific determinant (e.g., housing, racism) within an initiative or specific health outcomes, such as asthma or heart disease, and the social determinants that influence them.
Phase 3: Build Community Capacity to Address Social Determinants“Community capacity” refers to the resources, infrastructures, relationships, and operations that enable a community to create change and improvement. Assess community capacity. Assessing community capacity involves identifying existing community strengths that can be mobilized to address social determinants; those economic and environmental conditions affecting health equity. In general, you should look at the places (e.g., parks, libraries) and organizations where assets are found. These will likely be located in different sectors of the community: education, health care, business, housing, transport, faith-based groups, social services, civic/volunteer groups, local government, and non-governmental organizations. It is also important to identify the nature of the relationships across these sectors (e.g., norms, values), with the community (e.g., civic participation), and among various subgroups within the community (e.g., distribution of power, trust). Build community capacity. Once people and organizations in the community have a common understanding of social determinants, they can work to improve the conditions that affect the health of all its members. Much of the work to increase community capacity relies on processes that you will develop working in and with your community. The following recommendations provide some guidance for developing these processes.
Ensure that your group’s leaders are representative of the community and that they understand its assets and needs. They need to be able to engage all community representatives in identifying problems and devising solutions that will have broad support. You should also establish mechanisms to ensure that leadership roles and responsibilities are widely shared. These may include mentoring new leaders or creating bylaws that require periodic changes in leadership. Attempt to understand how the beliefs, perspectives, and histories of people and organizations in the community influence their willingness to participate in efforts to change community conditions and encourage them to consider alternative ways of thinking. Phase 4: Select Your Approach to Create ChangeNow it’s time to develop interventions to address social determinants of health. These may include programs or policy initiatives intended to move your community closer to your vision. There are a number of approaches you might use. In general, they are complementary; using them in some combination increases the likelihood that changes will lead to the desired goal. This step describes six approaches or strategies for changing community conditions that others have found useful: consciousness raising, community development, social action, health promotion, media advocacy, and policy change. The best approach depends on your situation, what your partnership wants to accomplish, and how well the strategies fit your situation. In some cases, the decision to incorporate certain approaches may be partially determined by funding guidelines or other restrictions based on work already occurring in your community or organization. Consciousness raising. Consciousness raising is a process through which people come together to discuss the relationship between individual or group experiences or concerns and the social or structural factors that influence them. It can be useful in creating a partnership to increase community-wide support for addressing specific health inequities and their root causes. This approach is useful for ensuring that both “insiders” and “outsiders” develop a common understanding of issues and concerns, stimulating discussion and motivating partners to address the issues and concerns. Consciousness raising is a good approach when some people in a group do not see or understand how social and structural factors influence health inequities. It also helps individuals and groups identify specific social determinants or structural factors to develop goals and objectives for change. In addition, this approach can help the partnership frame issues in ways that bring groups together for action rather than creating factions (e.g., among different ethnic groups) that lessen the ability to create change. Methods used to raise consciousness typically generate discussion by asking individuals to share their experiences. This can be done in listening sessions presenting hypothetical vignettes or situations. This can be done by having the group discuss responses to a picture or photograph, or reading a story or poem. Encourage critical reflection by asking individuals to describe what they saw or heard as the major issue, followed by asking “but why does this happen?” or “why is this the situation?” Community (locality) development. Community development is a set of processes or efforts to create community change at the local level. It involves strengthening social ties, increasing awareness of issues affecting the community, and enhancing community member participation in addressing these issues. This involves bringing together individuals affected by a particular health inequity so they can cultivate a shared group identity and develop a specific set of processes for addressing their common purpose. Though all work in this field should be participatory, community development is unique in that those who experience the problem are the leaders in addressing it. Those most affected by health inequity and the social determinants that lead to it are in control of changing the situation. This approach is in accordance with the Ottawa Charter, a 1986 document drafted by the World Health Organization at a meeting in Ottawa, Canada, that lays out the basis for a SDOH approach. Community development seeks to enhance or establish a group of individuals who work together to create changes in health or the social determinants of health. In community development approaches, capacity building is paramount: the goal is to use the community’s capabilities and strengths to increase community control. As this suggests, the process of community problem solving is seen as the process of health promotion. Building and using existing capacities for problem solving can improve health equity, both directly and indirectly. This approach may sound similar to community capacity building. But, community development specifically seeks to establish and enhance the power of those most affected by inequity, rather than just creating enhanced community capacity for planning or program implementation. Community development may be useful when you first develop a partnership or later when the partnership has accomplished other goals. The process encourages partners to develop a shared group identity that relies on understanding, trust, acceptance of differences, and cohesive relationships. This goes beyond other partnership-building activities described earlier, such as inviting stakeholders, identifying social and health inequities in the community, deciding on a shared vision and mission. This approach may be particularly useful when an existing partnership decides to use a more participatory approach, as opposed to one that relies on public health or other experts taking the lead. In community development efforts, community members lead the initiative. Others, such as public health practitioners, researchers, and community organizers, can assist community members by supporting group processes for problem solving and consensus building. It is important to ensure that the models and processes suggested by outsiders can be modified by community members as needed. It also could be helpful to engage community members in consciousness-raising processes before, or as part of, community development efforts to increase their awareness of the social determinants of health. In addition to representatives from the community, partnerships should include community agencies or organizations that will be asked to help implement change. Organizations are more likely to take part in changing social determinants of health if they have been included in the discussions and have worked with the community from the start, rather than just being asked to implement a solution designed by others. Social action. Social action is an approach that focuses on altering social relationships and/or resources available to address health inequities. This strategy spotlights how social factors can affect people’s health and how inequities in the social determinants of health can be influenced. Social action often includes activities that explicitly highlight an issue. For example, a group of community members might join together to light a candle for each person in their community injured by an alcohol-impaired driver in the past five years as a way to encourage the enforcement of laws that prohibit driving while under the influence of alcohol.
Social action can be used to help raise awareness of issues and to increase community participation in efforts to address them. For instance, it can be especially useful at the beginning of change efforts since media attention can help get people’s attention when other approaches have failed. Although this strategy can help define and bring attention to a problem, it does not necessarily identify effective solutions. Practitioners can take part in social action in a variety of ways. For example, they can provide current, relevant information and data to help develop the messages conveyed through social action activities. They can also help identify appropriate audiences for a particular message (e.g., an elected official, the public at large). Practitioners can assist the partnership in determining how to convey the message from the data to the audience in a way that will capture its attention. This is usually a public action involving a large number of people. Because the intent of social action is to influence public opinion, it is often useful to organize media coverage of the event and ensure that public officials are aware of it. Health promotion. Health promotion refers to the process of people working together to create conditions that improve health and well being for all members of the community or prevent illness through changes in environments, lifestyle, and behavior. It includes efforts to reach individuals or families, activities in the workplace to reach employees, and community initiatives focused on larger populations. Traditionally, health promotion in the United States has focused on changing individual knowledge, attitudes, and skills to encourage particular behaviors. Health promotion efforts may also include organizational, policy, or environmental changes that facilitate positive health outcomes. These health promotion efforts are more likely to address social determinants of health, such as increased access to quality fruits and vegetables through development of community gardens or reduced exposure to environmental toxins through policies supporting improved air quality.
Within community settings, it is not unusual for organizations and individuals to want to focus on the behavioral determinants of health such as healthy nutrition or physical activity. However, even when the effort focuses on a particular health or risk behavior, it is useful to incorporate program elements that address social determinants. For example, educating people about the health benefits of eating fruits and vegetables is important. However, people must have access to affordable produce if they are to incorporate it into their diets. Thus, increasing access to affordable food (the social determinant), in conjunction with knowledge and skill development, is more likely to create the desired change in behavior and thus the improvement in health outcomes. Health promotion efforts may attempt to improve health by creating change at the level of individuals, relationships, organizations, community, or society. For example, an intervention aimed at altering individuals’ knowledge, skills, attitudes, or behaviors might include educating community members on the benefits of physical activity. Because the costs of exercise facilities might constitute a barrier for many people, your health promotion effort might address social determinants by working with a local recreational facility to lower fees for those who cannot afford them. Similarly, your efforts to improve healthy nutrition might work with local with local government officials to increase access to healthy food options through tax and zoning policies that encourage the development of full-service grocery stores in neighborhoods where they are lacking. When working to incorporate changes in social determinants into health promotion programs, it is important to:
Media advocacy. Media advocacy refers to the strategic use of print, broadcast, and social media to encourage social, economic, or environmental change. It is an excellent way to reach large populations and capture the attention of decision makers who influence policy. Mass media campaigns reach people through newspapers, radio, television, and other means (e.g., Facebook, Twitter, billboards, posters, brochures). Historically, mass media campaigns in public health have focused on encouraging individual behavior change such as reducing tobacco use or underage drinking. Alternatively, media advocacy can be designed to influence change in norms, policies, and collective responses by the community to inequities. Mass media campaigns have been used to increase public understanding of specific health issues, such as how individuals can change their own or their loved ones’ behavior to improve health outcomes. To address social determinants of health, it is important to shift the focus to also address broader social, economic, and environmental conditions. This type of media advocacy helps to reframe public health concerns as the result of community rather than individual causes. This can help initiate collective community responses to create change. Media campaigns are most useful when high visibility is desired and public debate or discussion is useful in reframing the issue to focus on broader social change. Begin planning a media campaign by referring to your partnership’s vision and mission. Decide on the goals and objectives of your media campaign and identify the main audience for the message such as the general public or elected and appointed officials. Once you have chosen your audience, invite media representatives to become involved with the planning, implementation, and evaluation of your media campaign. In addition, consider the most appropriate media outlet – given your audience – for delivering your message and make sure that a representative of that medium is included in your partnership. Media outlets may include television (PSAs, news, public affairs, popular culture, paid advertising), newspapers (editorials), radio, billboards, interactive media (chat rooms, bulletin boards, Web sites), or public information forums (news releases, special events, town meetings).
Next, plan your message. Identify the community health problem and offer solutions. Consider how to frame the problem and the solution to attract the interest of your audience and ensure the message is culturally sensitive. For example, if your objective is to increase access to health care and screenings, you may want to direct your media campaign toward local decision makers, health planners, and other influential individuals or organizations in the community. Messages may emphasize increased funding for health screenings, expansion of existing transportation or service routes, improved hours of operation, or other changes assure access to health services in the community. Be sure to frame your message in a way that moves the focus for change away from individual behavior and toward social, economic, or environmental conditions. Work with local media representatives to learn how to develop a marketable story, create sound bites, and determine who will be the public spokesperson. Additional points to keep in mind:
(See Tool #2 for an outline of how to run a media campaign and references to more detailed Tool Box information.) Policy and environmental change. Achieving community-level improvement in health and health equity typically requires changes in policies and environmental conditions. This requires active participation of people and organizations in the community and key decision makers from different sectors. Local decision makers include elected and appointed officials, institutional or organizational leaders, and other individuals or groups involved in policy making in your community. Your partnership may focus on changes in policy (e.g., zoning regulations, tax policies, and worksite or school policies) and other conditions that affect health (e.g., equal access to education, employment, recreation facilities, and healthy food). A policy is a plan or course of action intended to influence and determine decisions, actions, and rules or regulations that govern our collective daily life. Policies can be created and enforced by organizations, businesses and corporations, communities, or the government at local, state, or federal levels. One purpose of creating new or changing existing policies is to change the social determinants that influence health equity (e.g., tax incentives for the food service industry to provide healthy foods, or combining state taxes for education and distributing them across districts to assure fair access to public education). The environment includes physical facilities (e.g., roads, sanitation, schools, parks) and structural and cultural amenities (e.g., benches, streetlights, recycling bins, public art). It also includes the social environment – economic and social conditions. Changing the environment requires informed decision making about urban design, land use, transportation, and political and social systems and their relationships to health outcomes. Changing policy and/or the environment is useful when you want to promote health and health equity. People and organizations in the community may consider using policy change to affect whole groups of people. Policy changes can be designed to regulate the behavior of individuals (e.g., smoking bans), organizations (e.g., flex-time policies in workplaces), or communities (e.g., housing codes for minimizing exposure to hazards). Policy changes can also affect the built environment, such as zoning related to new grocery stores or fast food restaurants, maintenance of sidewalks and streetscapes, or architectural design features such as public plazas with signage communicating the history and culture of the community. Your partners can be active players in the policy-making process by educating decision makers about how changes to policy or the environment can promote health equity. For example, they can provide current data on health and social determinants, information about existing policies, or examples of policies that have worked well in other communities. They can also help by identifying key decision makers to contact based on their interest in the issue or their position on certain decision-making bodies (e.g., committees, boards). Your partnership may also consider engaging in policy change by connecting to larger organizations that can help define concerns and develop potential solutions. A well-structured, well-positioned organization can support policy change by defining a problem that affects many individuals or communities (e.g., consumer legislation, air quality). It can help unit voices and actions to create change, and assist local organizations in finding resources and support for their work. Some groups may work directly on health-related topics (e.g., land-use policies to increase parks and greenways), whereas others may work on policies that influence the social determinants of health even if they are not explicitly focused on health (e.g., housing, early childhood development).
Selecting your approach. Which approach or combination of approaches to addressing social determinants is right for your effort? Here are some factors to consider as you make that decision:
Mold your approach to your situation – your resources, knowledge and experience of partners, community history, etc. Don’t be afraid to modify an approach, or to try something new if you have good reason to think it might work. If you settle on a combination of approaches, think about the advantages and disadvantages of using them at the same time or in sequence – resources needed, one approach paving the way for the next, etc. The important thing is that the group agrees on the best way to proceed. Document your decision-making process to help develop support for the selected approach. Remember to consider new partners who can support your use of different approaches. Be willing to modify your approach as you track your successes and challenges. This is the learning-from-doing model. Phase 5: Move to ActionNow it’s time to get moving, by creating and carrying out a plan to reach your goals. Assemble a planning team. This may include members of the partnership, as well as others recruited for their experience, perspective, special skills, or expertise. Be sure to include people from the groups most affected by the social determinants addressed by the initiative. After the planning group has been organized, it should meet to determine what action steps are necessary. Once these steps have been developed, agree on specific roles and responsibilities for partners and devise a timeline for all action steps. (See Chapter 18, Section 2, Participatory Approaches to Planning Community Intervention.) Develop your action plan. An action plan describes the specific steps necessary to meet clearly defined goals and objectives. Begin to develop an action plan as soon as your partnership’s vision, goals, objectives, and approaches have been determined. An action plan will help keep you on track toward achieving your goals and tell the community that you’re making progress. Keep in mind, however, that you may need to modify your action plan to meet changing conditions in your community over time. To be effective, an action plan should include the following key elements:
A good action plan:
Implement your plan. This is it – the point where you actually put all your planning into effect. Some helpful guidelines include:
You can help prevent conflicts from damaging the partnership by encouraging members to openly discuss actual or potential conflicts, modifying the action plan if necessary and feasible, and ensuring that community members help define the actions most appropriate for their communities. Other problems your partnership may need to address include members’ perception that the partnership threatens their autonomy, disagreement about community needs, and conflicts over funding decisions. Other potential challenges include lack of consensus about membership criteria or coalition structure, lack of leadership, competing interests, and failure to include relevant constituencies. To overcome these problems, the members of the partnership must work together to identify expected challenges, prepare for unexpected challenges, agree to disagree, and create strategies to overcome both expected and unexpected challenges. If challenges prohibit progress of the partnership, it may be useful to seek assistance from an outside consultant or mediator. Phase 6: Document and Share Your WorkFrom the beginning of your effort, you should also be evaluating your work, both to document it for your partnership, your community, and others who might want to try something similar, and to find out where you need to make changes in order to be as effective as possible. That means you have to keep careful records of everything you do, and of all that happens as part of the initiative. There are three areas to evaluate:
Evaluate your efforts. Your evaluation should be organized at the very beginning of the initiative, so that you’ll record information about the formation of the partnership and the first stages of planning as they happen. The first step is to formulate evaluation questions that reflect what you want the evaluation to tell you. Then, you should structure the evaluation, using the form, tools, and methods that will best answer the questions you have chosen. An important element is the participatory nature of the evaluation, as well as of the rest of the process. To the extent possible, partners should be involved in formulating evaluation questions, choosing methods, taking part in the evaluation, analyzing the results, determining adjustments to be made, and presenting what you’ve learned to the community. Some evaluation questions you might want to answer:
Link your evaluation to your community assessment and action plan. This may seem obvious, but it is sometimes difficult to remember that all of these elements of the initiative should fit together. Your action plan should address issues and their social determinants identified by your community assessment, and your evaluation should tell you how well it did so. Formulate objectives as milestones along the road to achieving long-term goals, and help partners and community members understand that realizing the overall vision is a long process. Their expectations have to be aimed at attaining milestones, rather than quickly reaching the end of the journey. Carefully record what you do. This will enable others to reproduce what works in the initiative and know what to expect if they take the same actions you’ve taken. Share your work. Your initiative should communicate the findings and lessons learned to others in the field. You should share general information with others – for instance, about what was effective and what wasn’t, how your process worked, ways to increase participation, the outcomes, and how long things take to accomplish. Some communication methods you can use include:
Phase 7: Maintain MomentumNo matter how successful your initial efforts have been, you’re not done yet. To effect real social change, which is, after all, what changing social determinants is about, you have to keep at it for the long term. Remain flexible and dynamic. Dynamic organizations continually change, both in response to changes in the environment and to incorporate new and better methods and approaches. Organizations, initiatives, and movements that aren’t dynamic are dead. No matter how good your work is, it can always be better. Never be afraid to test out new ideas or to abandon old truths and traditions if they don’t work anymore. It’s the best way to keep your work fresh, and to make sure that everyone maintains enthusiasm for it. A willingness to adapt (e.g., to abandon strategies that don’t work and to try new unconventional strategies) will help your group sustain its work over time and ultimately accomplish its goals. Some ways to keep flexible and dynamic:
Combat fatigue and burnout. Social change is hard work. It often involves dealing with injustice and human tragedy on a daily basis, and its results may be slow in coming. People and organizations get tired, and the temptation to quit can grow strong. It’s important to recognize the possibility of fatigue and burnout, and to make sure to address them in various ways.
Sustain the partnership and the work. The work of addressing social determinants can be a long process. Funders get tired just as partners do, and the community may also lose interest in the partnership. If you’re going to realize your vision, you have to find ways to keep the work going. Some important ideas for sustainability:
It’s easy, once routines are established, to let things slide. In fact, for a community change effort to be successful, it has to maintain its momentum indefinitely. It must be sustained for as long as it takes for the ideas, processes, and practices to be integrated into the community. There was a time when fire departments, police departments, and public libraries were new and radical ideas. Now, their presence is the norm in many parts of the world. Until social and health equity become the norm, until all of us are healthy, our job is not done. In SummaryAddressing social determinants is an important strategy for working toward healthier and more just communities. This cross-cutting approach is more comprehensive than narrower efforts to address particular categorical health issues such as preventing violence, diabetes, or infant mortality. By working together to modify the differential exposures, vulnerabilities, and consequences that produce disparities, we can help to assure conditions for health and well being for all. We encourage the reproduction of this material, but ask that you credit the Community Tool Box: http://ctb.ku.edu/. Adapted from **Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Social Determinants of Health Workgroup at the Centers for Disease Control, U.S. Department of Health and Human Services. Contributor Laura K. Brennan Ramirez, PhD, MPH Elizabeth A. Baker, PhD, MPH Marilyn Metzler, RN Stephen Fawcett, Edits/additional contributions Phil Rabinowitz, Edits/additional contributions What is an effective strategy for addressing social determinants of health?Partnerships are a crucial component of addressing the social needs of patients. Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.
What is the most important social determinant of health?Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning and influences health-related behaviours such as quality of diet, extent of physical activity, smoking and excessive alcohol use.
What are the three most important social determinants of health from the perspective of personal choice?Education, job opportunities, and income.
What are the 5 determinants of public health?Health is influenced by many factors, which may generally be organized into five broad categories known as determinants of health: genetics, behavior, environmental and physical influences, medical care and social factors.
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