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PromotingHealthEquityA Resource to Help Communities Address

Social Determinants of Health


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CoverartisbasedonoriginalartbyChrisReedevelopedfortheLiteracyforEnvironmentalJustice/YouthEnvisionGoodNeighborprogram,whichaddresseslinksbetweenfoodsecurityandtheactivitiesof

transnationaltobaccocompaniesinlow-incomecommunitiesandcommunitiesofcolorinSanFrancisco.Inpartnershipwithcitygovernment,community-basedorganizations,andothers,GoodNeighborprovidesincentivestoinner-cityretailerstoincreasetheirstocksoffreshandnutritiousfoodsandtoreducetobacco

andalcoholadvertisingintheirstores(seeCaseStudy#6onpage24.Adaptedandusedwithpermission.).


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PromotingHealthEquityA Resource to Help Communities AddressSocial Determinants of Health

LauraK.BrennanRamirez,PhD,MPHTranstriaL.L.C.

ElizabethA.Baker,PhD,MPHSaintLouisUniversitySchoolofPublicHealth

MarilynMetzler,RNCentersforDiseaseControlandPrevention

ThisdocumentispublishedinpartnershipwiththeSocialDeterminantsofHealth

WorkGroupattheCentersforDiseaseControlandPrevention,U.S.Departmentof

HealthandHumanServices.

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Suggested CitationBrennanRamirezLK,BakerEA,MetzlerM.PromotingHealthEquity:AResourcetoHelp Communities Address Social Determinants of Health. Atlanta: U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention;2008.

For More InformationE-mail:[email protected]:CommunityHealthandProgramServicesBranch

DivisionofAdultandCommunityHealthNationalCenterforChronicDiseasePreventionandHealthPromotionCentersforDiseaseControlandPrevention4770BufordHighway,MailStopK30Atlanta,GA30041

E-mail:[email protected]:LauraBrennanRamirez,TranstriaL.L.C.

6514LansdowneAvenueSaintLouis,MO63109

Online:Thispublicationisavailableathttp://www.cdc.gov/nccdphp/dach/chapsandhttp://www.transtria.com.

AcknowledgementsTheauthorswouldliketothankthefollowingpeoplefortheirvaluablecontributionstothepublicationofthisresource:theworkshopparticipants(listedonpage5),LyndaAndersen,EllenBarnidge,AdamBecker,JoeBenitez,JulieClaus,SandyCiske,Tonie

Covelli,GailGentling,WayneGiles,MelissaHall,DonnaHiggins,BethanyYoungHolt,JimHolt,BillJenkins,MargaretKaniewski,JoeKarolczak,LeandrisLiburd,JimMercy,EvelizMetellus,AmandaNavarro,GeraldinePerry,AmySchulz,EduardoSimoes,KristineSuozziandKarenVoetsch.AspecialthankstoInnovativeGraphicServicesforthedesignandlayoutofthisbook.

This resource was developed with support from:>NationalCenterforChronicDiseasePreventionandHealthPromotion

DivisionofAdultandCommunityHealthPreventionResearchCentersCommunityHealthandProgramServicesBranch

>NationalCenterforInjuryPreventionandControl

Websiteaddressesofnonfederalorganizationsareprovidedsolelyasaservicetoourreaders.ProvisionofanaddressdoesnotconstituteanendorsementofanorganizationbyCDCorthefederalgovernment,andnoneshouldbeinferred.CDCisnotresponsibleforthecontentofotherorganizationswebpages.


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TableofContents

Introduction p.4

Participants p.5

Chapter One: Achieving Health Equity p.6

Whatishealthequity?p.6 Howdosocialdeterminantsinfluencehealth?p.10 Learningfromdoingp.11

Chapter Two: Communities Working to Achieve Health Equity p.12Background:TheSocialDeterminantsofDisparitiesinHealthForump.12Small-scaleprogramandpolicyinitiativesp.14

CaseStudy1:ProjectBrotherhoodp.14CaseStudy2:PoderEsSalud(PowerforHealth)p.16CaseStudy3:ProjectBRAVE:BuildingandRevitalizinganAnti-ViolenceEnvironmentp.18

Traditionalpublichealthprogramandpolicyinitiativesp.20CaseStudy4:HealthyEatingandExercisingtoReduceDiabetesp.20CaseStudy5:TakingAction:TheBostonPublicHealthCommisionsEffortstoUndoRacismp.22CaseStudy6:TheCommunityActionModeltoAddressDisparitiesinHealthp.24

Large-scaleprogramandpolicyinitiativesp.26CaseStudy7:NewDealforCommunitiesp.26CaseStudy8:FromNeuronstoKingCountyNeighborhoodsp.28CaseStudy9:TheDeltaHealthCenterp.30

Chapter Three: Developing a Social Determinants of HealthInequities Initiative in Your Community p.3289

Section1:CreatingYourPartnershiptoAddressSocialDeterminantsofHealthp.34

Section2:FocusingYourPartnershiponSocialDeterminantsofHealthp.42Section3:BuildingCapacitytoAddressSocialDeterminantsofHealthp.54Section4:SelectingYourApproachtoCreateChangep.58Section5:MovingtoActionp.76Section6:AssessingYourProgressp.82Section7:MaintainingMomentump.88

Chapter Four: Closing Thoughts p.90

TablesTable1.1:ExamplesofHealthDisparitiesbyRacial/EthnicGrouporbySocioeconomicStatusp.7

Table1.2:SocialDeterminantsbyPopulationsp.8Table3.1:ApplyingAssessmentMethodstoDifferentTypesofSocialDeterminantsp.47

FiguresFigure1.1:PathwaysfromSocialDeterminantstoHealthp.10Figure1.2:GrowingCommunities:SocialDeterminants,Behavior,andHealthp.11Figure3.1:PhasesofaSocialDeterminantsofHealthInitiativep.33

Suggested Readings and Resources p.92

References p.106

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Introduction

Thisworkbookisforpublichealthpractitionersandpartnersinterestedinaddressingsocialdeterminantsofhealthinordertopromotehealthandachievehealthequity.Inits1988landmarkreport,andagainin2003inanupdatedreport,1,2theInstituteofMedicinedefinedpublichealthaswhatweasasocietydo tocollectivelyassuretheconditionsinwhichpeoplecanbehealthy.

Earlyeffortstodescribetherelationshipbetweentheseconditionsandhealthorhealthoutcomesfocusedonfactorssuchaswaterandairqualityandfoodsafety. 3

Morerecentpublichealthefforts,particularlyinthepastdecade,haveidentifiedabroaderarrayofconditionsaffectinghealth,includingcommunitydesign,housing,employment, access to health care, access to healthy foods, environmentalpollutants,andoccupationalsafety.4

Thelinkbetweensocialdeterminantsofhealth,includingsocial,economic,andenvironmentalconditions,andhealthoutcomesiswidelyrecognizedinthepublichealthliterature.Moreover,itisincreasinglyunderstoodthatinequitabledistributionof these conditions across various populations is a significant contributor topersistentandpervasivehealthdisparities.5

Oneefforttoaddress theseconditionsandsubsequenthealthdisparities isthedevelopmentofnationalguidelines,HealthyPeople2010(HP2010).DevelopedbytheU.S.DepartmentofHealthandHumanServices,HP2010hasthevisionofhealthypeoplelivinginhealthycommunitiesandidentifiestwomajorgoals:increasingthequalityandyearsofhealthylifeandeliminatinghealthdisparities.To achieve thisvision, HP2010 acknowledges that communities,States,andnationalorganizationswillneedtotakeamultidisciplinaryapproachtoachievinghealthequityanapproachthatinvolvesimprovinghealth,education,housing,labor,justice, transportation, agriculture,andthe environment,as well asdatacollectionitself(p.16).Tobesuccessful,thisapproachrequirescommunity-,policy-,

and system-level changes that combine social, organizational, environmental,economic, andpolicy strategies along withindividualbehavioralchange andclinicalservices. 6Theapproachalsorequiresdevelopingpartnershipswithgroupsthattraditionallymaynot have been partof public health initiatives, includingcommunity organizations and representatives from government, academia,business,andcivilsociety.

Thisworkbookwascreatedtoencourageandsupportthedevelopmentofnewandtheexpansionofexisting,initiativesandpartnershipstoaddressthesocialdeterminantsofhealthinequities.ContentisdrawnfromSocialDeterminantsofDisparitiesinHealth:Learning from Doing,aforumsponsoredbytheU.S.CentersforDiseaseControlandPreventioninOctober2003.Forumparticipantsincludedrepresentatives from community organizations, academic settings, and public

healthpracticewhohaveexperiencedeveloping,implementing,andevaluatinginterventionstoaddressconditionscontributingtohealthinequities.Theworkbookreflects the views of experts from multiple arenas, including local community

Inequalities in health status in the U.S. are large, persistent, and increasing.Research documents that poverty, income and wealth inequality, poorquality of life, racism, sex discrimination, and low socioeconomicconditions are the major risk factors for ill health and health inequalitiesconditions such as polluted environments, inadequate housing, absenceof mass transportation, lack of educational and employment opportunities,

and unsafe working conditions are implicated in producing inequitablehealth outcomes. These systematic, avoidable disadvantages areinterconnected, cumulative, intergenerational, and associated with lowercapacity for full participation in society.Great social costs arise fromthese inequities, including threats to economic development, democracy,and the social health of the nation.7

knowledge,publichealth,medicine,socialwork,sociology,psychology,urbanplanning,communityeconomicdevelopment,environmentalsciences,andhousing.

Itisdesignedforawiderangeofusers interestedindevelopinginitiativestoincreasehealth equity in their communities. Theworkbookbuilds on existing resourcesandhighlightslessonslearnedbycommunitiesworkingtowardthisend.Readersareprovidedwithinformationandtoolsfromtheseeffortstodevelop,implement,andevaluateinterventionsthataddresssocialdeterminantsofhealthequity.

Wehopeyouwilljoinusinlearningfromdoing.


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Participants

October 2829, 2003Social Determinants of Disparities in Health: Learning From Doing

Alex AllenCommunityPlanning&ResearchIsles,Inc.Trenton,NJ

Alma AvilaSanFranciscoDepartmentofPublicHealthSanFrancisco,CA

Elizabeth BakerSaintLouisUniversitySaintLouis,MO

Adam BeckerTulaneUniversityNewOrleans,LA

Rajiv BhatiaSanFranciscoDepartmentofPublicHealth

SanFrancisco,CA

Judy BigbyBrighamandWomensHospitalBoston,MA

Angela Glover BlackwellPolicyLinkOakland,CA

Laura Brennan RamirezTranstriaLLCSaintLouis,MO

Gregory ButtonUniversityofMichiganSchoolofPublicHealthAnnArbor,MI

Cleo CaldwellUniversityofMichiganSchoolofPublicHealthAnnArbor,MI

Sandy CiskePublicHealth-Seattle&KingCountySeattle,WA

Stephanie FarquharSchoolofCommunityHealthPortland,OR

Stephen B. FawcettUniversityofKansasLawrence,KS

Barbara FerrerBostonPublicHealthCommissionBoston,MA

Nick FreudenbergHunterCollegeNewYork,NY

Sandro GaleaNewYorkAcademyofMedicine

NewYork,NY

H. Jack GeigerCityUniversityofNewYorkMedicalSchoolNewYork,NY

Gail GentlingMinnesotaDepartmentofHealthSaintPaul,MN

Virginia Bales HarrisCentersforDiseaseControlandPreventionAtlanta,GA

Kathryn HorsleyPublicHealthSeattle&KingCountySeattle,WA

Ken JudgeUniversityofGlasgowGlasgow,UnitedKingdom

Margaret KaniewskiCentersforDiseaseControlandPreventionAtlanta,GA

James KriegerPublicHealth-SeattleandKingCountySeattle,WA

Alicia LaraTheCaliforniaEndowmentWoodlandHills,CA

Susana Hennessey LaverySanFranciscoDepartmentofPublicHealthSanFrancisco,CA

E. Yvonne LewisFaithAccesstoCommunityEconomicDevelopmentFlint,MI

Marilyn Metzler

CentersforDiseaseControlandPreventionAtlanta,GA

Yvonne MichaelOregonHealthandSciencesUniversityPortland,OR

Linda Rae MurrayProjectBrotherhood/WoodlawnHealthCenterChicago,IL

Ann-Gel PalermoMountSinaiSchoolofMedicine

NewYork,NYJayne ParryUniversityofBirminghamBirmingham,UnitedKingdom

Jim RandelsProjectDirector,StudentsattheCenterNewOrleans,LA

William J. RidellaDetroitHealthDepartmentDetroit,MI

Amy SchulzUniversityofMichiganAnnArbor,MI

Eduardo SimoesCentersforDiseaseControlandPreventionAtlanta,GA

Mele Lau SmithSanFranciscoDepartmentofPublicHealthSanFrancisco,CA

Kristine SuozziBernalilloCountyOfficeofEnvironment

HealthAlbuquerque,NM

Bonnie ThomasProjectBrotherhood/WoodlawnHealthCenterChicago,IL

Susan TortoleroScienceCenteratHoustonSchoolofPublicHealthHouston,TX

Junious Williams

UrbanStrategiesCouncilOakland,CA

Mildred WilliamsonProjectBrotherhood/WoodlawnHealthCenterChicago,IL

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AchievingHealthEquity Whatishealthequity?

Abasicprincipleofpublichealthisthatallpeoplehavearighttohealth.8 Differencesintheincidenceandprevalenceofhealthconditionsandhealthstatusbetweengroupsarecommonlyreferredtoashealthdisparities(seeTable1.1).9Mosthealthdisparitiesaffectgroupsmarginalizedbecauseof socioeconomicstatus, race/ethnicity,sexualorientation, gender,disability status,geographiclocation,orsomecombinationofthese.Peopleinsuchgroupsnotonlyexperienceworsehealthbutalsotendtohavelessaccesstothesocialdeterminantsorconditions(e.g.,healthyfood,goodhousing,goodeducation,safeneighborhoods,freedomfromracismandotherformsofdiscrimination)thatsupporthealth(seeTable1.2).Healthdisparitiesarereferredtoashealthinequitieswhentheyaretheresultofthesystematicandunjustdistributionofthesecriticalconditions.Healthequity,then,asunderstoodinpublichealthliteratureandpractice,iswheneveryonehastheopportunitytoattaintheirfullhealthpotentialandnooneisdisadvantaged

from achieving this potential because of their social position or other socially determinedcircumstance.10

Social determinants of health are life-enhancing resources, such asfood supply, housing, economic and social relationships, transportation,education, and health care, whose distribution across populations

effectively determines length and quality of life.11


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Table1.1:ExamplesofHealthDisparitiesbyRacial/EthnicGrouporbySocioeconomicStatus

InfantmortalityInfantmortalityincreasesasmotherslevelofeducationdecreases.In2004,themortalityrateforinfantsofmotherswithlessthan12yearsof

educationwas1.5timeshigherthanforinfantsofmotherswith13ormoreyearsofeducation. 12,13

Cancerdeaths In2004,theoverallcancerdeathratewas1.2timeshigheramongAfricanAmericansthanamongWhites.12,13

DiabetesAsof2005,NativeHawaiiansorotherPacificIslanders(15.4%),AmericanIndians/AlaskaNatives(13.6%),AfricanAmericans(11.3%),Hispanics/Latinos(9.8%)wereallsignificantlymorelikelytohavebeendiagnosedwithdiabetescomparedtotheirWhitecounterparts(7%).14

HIV/AIDSAfricanAmericans,whocompriseapproximately12%oftheUSpopulation,accountedforhalfoftheHIV/AIDScasesdiagnosedbetween2001and2004.12Inaddition,AfricanAmericanswerealmost9timesmorelikelytodieofAIDScomparedtoWhitesin2004.12,13

ToothdecayBetween2001and2004,morethantwiceasmanychildren(25years)frompoorfamiliesexperiencedagreaternumberofuntreateddentalcariesthanchildrenfromnon-poorfamilies.Ofthosechildrenlivingbelow100%ofpovertylevel,MexicanAmericanchildren(35%)andAfricanAmericanchildren(26%)weremorelikelytoexperienceuntreateddentalcariesthanWhitechildren(20%).12,13

InjuryIn2004,AmericanIndianorAlaskaNativemalesbetween1524yearsofagewere1.2timesmorelikelytodiefromamotorvehicle-relatedinjuryand1.6timesmorelikelytodiefromsuicidecomparedtoWhitemalesofthesameage.12,13

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Table1.2:SocialDeterminantsbyPopulations*

In 2006, adults with less than a high school degree were 50% less likely to have visited a doctor in the past 12 months compared to those with atleastabachelorsdegree.Inaddition,AsianAmericanandHispanicadults(75%and68%,respectively)werelesslikelytohavevisitedadoctoror

Accesstocare otherhealthprofessionalinthepastyearcomparedtoWhiteadults(79%).15

In 2004, African Americans and American Indian or Alaska Natives were approximately 1.3 times more likely to visit the emergency room at leastonceinthepast12monthscomparedtoWhites. 12

Insurancecoverage

In 2007, Hispanics were 3 times more likely to be uninsured than non-Hispanic Whites (31% versus 10%, respectively).15

In 2007, people in families with income below the poverty level were 3 times more likely to be uninsured compared to people with family incomemorethantwicethepovertylevel.12

Residents of nonmetropolitan areas are more likely to be uninsured or covered by Medicaid and less likely to have private insurance coverage thanresidentsofmetropolitanareas. 12

As of December 2007, the unemployment rate varied substantially by racial/ethnic group (4% among Whites, 6% among Hispanics/Latinos, and 9%

EmploymentamongAfricanAmericans)andbyageandgender(4.5%amongadultmen,4.9%amongadultwomen,and15.4%amongteenagers).16

In 2007, African Americans and Hispanics/Latinos were more likely to be unemployed compared to their White counterparts.16Further,adultswithlessthanahighschooleducationwere3timesmorelikelytobeunemployedthanthosewithabachelorsdegree. 16

Education

Since the Elementary and Secondary Education Act rst passed Congress in 1965, the federal government has spent more than $321 billion (in2002dollars)tohelpeducatedisadvantagedchildren.Yetnearly40yearslater,only33%offourth-gradersareproficientreadersatgradelevel. 17

Whilethereadingperformanceofmostracial/ethnicgroupshasimprovedoverthepast15years,minoritychildrenandchildrenfromlow-income

familiesaresignificantlymorelikelytohaveabelowbasicreadinglevel. 18

According to the National Assessment of Adult Literacy, African American, Hispanic/Latino, and American Indian/Alaska Native adults weresignificantlymorelikelytohavebelowbasichealthliteracycomparedtotheirWhiteandAsian/PacificIslandercounterparts.Hispanic/Latinoadultshadthelowestaveragehealthliteracyscorecomparedtoadultsinotherracial/ethnicgroups.19

The high school dropout rates for Whites, African Americans, and Hispanics/Latinos have generally declined between 1972 and 2005. However,asof2005,Hispanics/LatinosandAfricanAmericansweresignificantlymorelikelytohavedroppedoutofhighschool(22%and10%,respectively)comparedtoWhites(6%).20


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Table1.2:SocialDeterminantsbyPopulations(continued)*

Accesstoresources

Lower income and minority communities are less likely to have access to grocery stores with a wide variety of fruits and vegetables.21,22

In spite of recent legislation, many teenagers who go to a store or gas station to purchase cigarettes are not asked to show proof of age. AfricanAmericanmalestudents(19.8%)weresignificantlylesslikelytobeaskedtoshowproofofagethanwereWhite(36.6%)orHispanic(53.5%)

malestudents.23,24

Income

Low socioeconomic status (SES) is associated with an increased risk for many diseases, including cardiovascular disease, arthritis, diabetes, chronicrespiratorydiseases,andcervicalcanceraswellasforfrequentmentaldistress.15

Therealmedianearningsofbothmenandwomenwhoworkedfulltimedecreasedbetween2005and2006(1.1%and1.2%change,respectively),withwomenearningonly77%asmuchasmen.25

Housing

In2005,AmericanIndiansorAlaskaNativeswere1.5timesmorelikelyandAfricanAmericanswere1.3timesmorelikelytodiefromresidentialfiresandburnsthanWhites.26

Homeless people are diverse with single men comprising 51% of the homeless population, followed by families with children (30%), single women (17%)andunaccompaniedyouth(2%).Thehomelesspopulationalsovariesbyraceandethnicity:42%African-Americans,39%Whites,13%Hispanics/Latinos,4%AmericanIndiansorNativeAmericansand2%AsianAmericans.Anaverageof16%ofhomelesspeopleareconsideredmentallyill;26%aresubstanceabusers.27

Transportation

Ruralresidentsmusttravelgreaterdistancesthanurbanresidentstoreachhealthcaredeliverysites.28 38.9% of Hispanic/Latinos, 55.2% of African Americans, and 29.6% of Asian Americans live in households with one vehicle or less comparedto24.5%ofWhites.29

Low-income minorities spend more time traveling to work and other daily destinations than do low-income Whites because they have fewer privatevehiclesandusepublictransitandcarpoolsmorefrequently. 29

*Socialinequitiesandsocialdeterminantsrefertothesameresources(e.g.,healthcare,education,housing)butsocialinequitiesreflectthedifferentialdistributionoftheseresourcesbypopulationandbygroup.

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Howdosocialdeterminantsinfluencehealth?

Multiplemodelsdescribinghow socialdeterminantsinfluence health outcomes have been proposed.3040

Althoughdifferencesin themodelsexist, somefairlyconsistent elements and pathways have emerged.The model presentedhere contains many of these

elementsandpathwaysandfocusesonthedistributionofsocialdeterminants(seeFigure1.1).Asthemodelshows,socialdeterminantsofhealthbroadlyincludeboth societal conditions and psychosocial factors,suchasopportunitiesforemployment,accesstohealthcare, hopefulness, and freedom from racism. Thesedeterminants can affect individual and communityhealth directly, through an independent influence oran interaction with other determinants, or indirectly,throughtheirinfluenceonhealth-promotingbehaviors

by, forexample,determiningwhether a person hasaccesstohealthyfoodorasafeenvironmentinwhichtoexercise.

Policiesandotherinterventionsinfluencetheavailabilityanddistributionofthesesocialdeterminantstodifferentsocialgroups,includingthosedefinedbysocioeconomicstatus,race/ethnicity,sexualorientation,sex,disabilitystatus, andgeographic location.Principlesof socialjustice influence these multiple interactions and theresulting health outcomes: inequitable distributionofsocialdeterminantscontributestohealthdisparitiesandhealthinequity,whereasequitabledistributionofsocialdeterminantscontributestohealthequity.Appreciationof how societal conditions, health behaviors, andaccess to health care affect health outcomes canincreaseunderstandingaboutwhatisneededtomovetowardhealthequity.

Figure1.1:PathwaysfromSocialDeterminantstoHealth

FigureadaptedfromBlueCrossandBlueShieldofMinnesotaFoundation,http://www.bcbsmnfoundation.org/objects/Tier_4/mbc2_determinants_charts.pdfandAndersonetal,2003.38,39


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Learningfromdoing

Chapter2ofthisworkbookcontainsexamplesofcommunityinitiatives that have addressed inequities in the socialdeterminantsofhealtheitherdirectlyorindirectlythroughmore traditional public health efforts. These examplesidentifyskillsandapproachesimportanttodevelopingandimplementingprogramsandpoliciestoreduceinequitiesin

socialdeterminantsofhealthandinhealthoutcomes.Afteryouhave seenhow other communitieshave addressedtheseinequities,Chapter3willdescribehowtodevelopinitiativestoreduceinequitiesinyourcommunity.

Figure1.2:GrowingCommunities:SocialDeterminants,Behavior,andHealth

FigureadaptedfromAndersonetal,2003;Marmoetal,1999;andWilkinsonetal,2003. 3941

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1

C A S E S T U D Y

ProjectBrotherhood Whoweare:AblackmensclinicatWoodlawnHealthCenter,Chicago,Illinois.

Whatwewanttoachieve:ProjectBrotherhoodseeksto:1)createasafe,respectful,male-friendlyplacewhereawiderangeofhealthandsocialissuesconfrontingblackmencanbe addressed;and2)expandthe rangeof healthservicesforblackmenbeyondthoseprovidedthroughthetraditionalmedicalmodel.

Whatwearedoing:ProjectBrotherhoodwasformedbyablackphysicianfromWoodlawnHealthCenterandanurse-epidemiologistfromtheTraumaDepartmentatCookCountyHospitalwhowereinterestedinbetteraddressingthehealthneedsofblackmen.Partneringwithablacksocialscienceresearcher,theyconductedfocusgroupswithblackmentolearnabouttheirexperienceswiththehealthcaresystem,andmetwithotherblackstaffattheclinic.Asaresultofthisresearch,ProjectBrotherhoodusesthefollowingstrategicapproaches:

>Offersfreehealthcare,makesappointmentsoptional,andprovideseveningclinichourstomakehealthcaremoreaccessibletoblackmen.

>Offershealthseminarsandcoursesspecificallyforblackmen.

>Employsabarberwhogives3035freehaircutsperweekandwhoreceivedhealtheducationtrainingtobeahealthadvocateforblackmenwhocannotbereachedbyclinicstaff.

>Providesfatherhoodclassestohelpblackmenbecomemoreeffectivelyinvolvedinthelivesoftheirchildren.

>DiscouragesviolenceamongthenextgenerationofblackmenbyproducingCountyKids,acomicbookthatteacheschildren

howtodealwithconflictwithoutresortingtoviolence.

>Buildsaculturallycompetentworkforceabletocreateasafe,respectful,male-friendlyenvironmentandtoovercomemistrustinblackcommunitiestowardthetraditionalhealthcaresystem.

>Organizesphysicianparticipationinsupportgroupdiscussionstopromoteunderstandingbetweenprovidersandpatients.

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Howwewillknowwearemakingadifference:InJanuary1999,ProjectBrotherhoodaveraged4medicalvisitsand8group

participantsperweek.BySeptember2005,theaveragegrewto27medicalvisitsand35groupparticipantsperweek,plus14haircutsperclinicsession.Theno-showrateforProjectBrotherhoodmedicalvisitsaverages30%perclinicsessioncomparedtoano-showrateof41%atthemainhealthclinic.Tomeetthegrowingneeds,additionalstafftimehasbeensecuredandProjectBrotherhoodclinichourshavebeenextended.Asof2007,ProjectBrotherhoodhasprovidedservicetoover13,000peoplesinceopening.

Summingup:By providing a health services environment designed specifically for blackmenwheretheyarerespected,heard,andempowered,ProjectBrotherhoodishelpingtoreducethehealthdisparitiesexperiencedbyblackmen.

How to reach us:Mildred WilliamsonProject Brotherhood(773) [email protected]://www.projectbrotherhood.net

What we are learning:

When our patients learn that the health care providers at Project Brotherhood share an interest in manyissues that affect them, they gain a sense of social support that becomes a powerful dynamic. Knowing thatthey will see physicians of their own race and gender increases the level of trust they have in their physician.Originally met with skepticism, most Project Brotherhood activities are now being successfully implemented.

This is an excellent environment for more seasoned black male professionals to mentor younger blackprofessionals as well as black high school and college students.

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C A S E

2

S T U D Y PoderesSalud(Power for Health)

42

Whoweare:We are a partnership of theLatinoNetwork, theEmmanuel Community General Services,the Community CapacitationCenterof theMultnomahCountyHealthDepartment,theSchoolofCommunityHealthatPortlandStateUniversity,theDepartmentofPublicHealthand

PreventiveMedicineattheOregonHealthandScienceUniversity,andseveralcommunityandfaith-basedgroups.

Whatwewanttoachieve:ToaddresssocialdeterminantsofhealthandreducehealthdisparitiesinblackandLatinocommunitiesinMultnomahCounty,Oregon,byincreasingsocialcapital,whichisaresourceavailabletoallmembersofacommunitythroughdurablesocialnetworksforthepurposeoffacilitatingtheachievementofcommunitygoalsandhealthoutcomes.

Whatwearedoing:Ourprojectproposesthathealthinequitiesareshapedbyfundamentalsocialdeterminants,includingracialdiscrimination,socialexclusion,andpoverty.Theproject,whichusesexistingresourcestoenhanceresidentsaccesstosocialandeconomicresources,exploreshowraciallyandethnicallydissimilarcommunitiescanuseexistingsocialcapitaltochangecommunityconditions.

Werelyonthreestrategiestoaddresssocialdeterminantsofhealth:

>Weusecommunity-basedparticipatoryresearchtosupportcross-culturalpartnershipsinwhichpartnersshareresourcesanddecision-makingpower.

>Weusepopulareducation,whichmeansteachingthroughaprocessofmutuallearningandanalysis(emphasizingthatstudentsneedtobeactiveinthelearningprocessandshouldbeconsideredagentsofchangeratherthanreceptaclesofknowledge)toidentifyimportantcommunityhealthissuesandtheirsocialdeterminants,toidentifyusefulexpertiseamongcommunitymembers,andtodevelopthecommunityleadershipnecessarytotakeaction.

>Weselectcommunityhealthworkers(CHWs)andprovidethemwithspecializedtraininginleadership,localpolitics,governancestructure,advocacy,communityorganizing,populareducation,andhealth.

Weelectedtoworkwithfivegroups:threeblackfaith-basedcommunities,theComunidadCristiana(aLatinocoalitionoffiveevangelicalcongregations)andageographicallydefinedLatinocommunityconsistingoffourapartmentcomplexes.Thisdecisiontoworkwithrelativelysmallgroups(40107members)helpedthesteeringcommitteeandCHWsaddressissuesofspecificconcerninthesecommunitiesinsteadofbroaderissuescommontoallLatinoandblackcommunitymembers.Inanongoingprocess,CHWsusepopulareducationtoidentifyhealthissuesintheircommunitiesandtodesignprojectstorespondtothoseissues.Projectshaveincludedformingapublicsafetycommittee,organizingacommunityhealthfair,establishingadiabetessupportandinformationgroup,andahomeworkclub,andaphotovoiceprojectthatprovides community members withcamerasto documentcommunityproblemsandstrengths.The photovoiceprojectled communitymemberstodevelopacampaigntoaddresstrashproblemsandotherenvironmentalhealthissues.

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Howwewillknowwearemakingadifference:Todeterminewhetheropportunitiesforbuildingskills,increasingknowledge,andsharingdecisionmakingwillincreasesocialcapital,weadministeredabaseline

surveyto170adultsrandomlyselectedfromthecommunitiestoassesssocialcapital,generalhealth,andhealth-relatedqualityoflife.Wealsoconductedin-depthinterviewswithselectedcommunitymemberstohelpusdeterminehowthedevelopmentandfunctionofsocialcapitalinblackcommunitiesdiffersfromthatinLatinocommunities.Follow-upsurveysshowedsignificantimprovementsinsocialsupport,self-ratedhealthandmentalhealthamongcommunitymembersthatparticipatedintheinterventionswithCommunityHealthWorkerswhousepopulareducation.43

Summingup:Thedatadescribedabovewerereviewedtoidentifyandprioritizetheconcernsofparticipatingcommunities.Wefoundthatpopulareducationisaneffectivetooltoencouragemembersofdifferentcommunitiestotalkaboutandbeginto addresstheir unique andcommon health concerns.Our challenge is tobetterunderstandhowapersonshealthisaffectedbysocial,economic,andpoliticalcontexts.

How to reach us:Stephanie A. Farquhar, PhDPortland State University(503) 725-5167

[email protected] What we are learning:We have learned that although Latinos and blacks have a shared interest in reducing health inequities,the ways in which the two groups identify health concerns, create solutions, and think about social capitaldiffer. We embrace these differences and are working with both groups to identify opportunities forcross-cultural collaboration.Building trust between members of different demographic groups is difficult but essential work. A specificchallenge of working across cultures is the language barrier. Popular education, which uses role-playing andother creative learning methods, can help provide a common language and reduce potential divisiveness oflanguage barriers.

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C A S E

3

S T U D Y

ProjectBRAVE:Building and Revitalizing an Anti-Violence Environment

44

Whoweare:ProjectBRAVEisaschool-basedinterventiondevelopedbyStudentsattheCenter,aschool-basedorganization;theCrescentCityPeaceAlliance,acommunity-basedorganization;andaresearcherandstudentsfromTulaneUniversitySchoolofPublicHealthtoreduceyouthviolenceinNewOrleans,Louisiana.

Whatwewanttoachieve:Toreducethesocialdeterminantsofviolencebychanginglearningandteachingmethodsinelementary,middle,andhighschools.

Whatwearedoing:ProjectBRAVEclassesbeginwithastorycircle,wheresmallgroupsofstudentstellstoriesaboutviolencetheyhaveexperiencedorseen.Aftersharingthesestoriesorally,thestudentswritethemdownandeditthem.Inourpilot,apublichealthresearcherhelpedthestudentscritically

analyzetheirexperiencesand identifythe socialdeterminantsof violencein theircommunity.Thisanalysis,basedonatechniqueknownasconscientizationorraisingcriticalawareness,involvedanumberofstepsoverseveralweeks.Relevantthemesthatemergedduringthisprocessincludedthe importanceof attendingschooland increasing the levelof social support among students.Participatingstudentscameto seethemselvesasagentsofchangeintheschoolandinthecommunitywiththeabilitytomotivateotherstoimplementsolutionstoviolence.Afinalthemewasthatheightenedawarenessofviolencecouldhelppreventitinthefuture.Artistsworkedwithstudentstotranslatetheirstoriesintoaplaythatcommunicatedtheimportanceofreducingyouthviolencetoneighborhoodmembers,organizations,andotherkeystakeholderswhomighthavearoleinaddressingsuchviolence.Theirplay,InhalingBrutality,ExhalingPeace,toldastudentsstoryaboutamurderwitnessedatalocalpark.Oneoftheperformanceswasconductedintheneighborhoodnexttotheparkwheretheeventsinthestorytookplace.Thediscussionthatfollowedledsomeneighborstoexpressshockatwhatwashappeningintheirneighborhoodparkandtobeginorganizingcommunityeffortstopreventfurtherviolence.

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9

Howwewillknowwearemakingadifference:Attheendofthesemester,projectteammemberstape-recordedgroupinterviewswithstudents,analyzedandcodedthecontentoftheinterviews,andusedthesedatatoidentifyvariousthemesrelatedtosocialdeterminantsofviolence(e.g.,schoolattendance,socialsupport,self-perceptionsaschangeagents).Interestinthe ProjectBRAVEclasshas ledto anincrease inschoolattendance, animportantsocialdeterminantofviolenceandcommunityhealth.Futureevaluationeffortswillincludeschoolandcommunitysurveystomeasurechangeinstudent-relatedvariables,suchasschoolattachmentandsocialsupport,andcommunity-levelvariables,suchascollectiveefficacyandcommunityempowerment.Finally,wewillmonitorlonger-termoutcomessuchascrimerates,toassesstheprojectsimpactontheoverallcommunity.

Summingup:Project BRAVE builds on existing relationships among schools, communitymembers, community-based organizations,and local researchers to support

already-establishedopportunitiesforstudentstosharetheirexperiencesandtoparticipateincommunitychangetoreduceviolence.

PostHurricaneKatrinaupdate:DespitethedevastationofschoolsandneighborhoodscausedbyHurricaneKatrina,theworkofProjectBRAVEisbeingcontinuedbyStudentsattheCenter.ThegroupisteachingwritingclassesatMcMainSecondarySchoolandintheDouglasscommunityusingBRAVEmaterialsandmethods,workingtopublishacollectionofstudentwritingonviolence,andparticipatinginmanyeffortstowatchdogtherebuildingprocessasitpertainstopublicschools.ManyyoungpeopleareworkingtoimproveeducationasNewOrleansrebuilds.

How to reach us:Jim RandelsStudents at the Center (SAC)(504) [email protected]


We are learning that Project Brave is an effective approach for addressing youth violence but that thereare many challenges.44These include poor attendance by many students and minimal time available forspecial courses. Securing funding has also been challenging because funders often require school-basedprojects to use standardized curricula. Unfortunately, due to lack of funding, Project BRAVE is no longerin existence.

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C A S E

4S T U D Y

Healthy Eating and Exercisingto Reduce Diabetes

45

Who we are:The East Side Village Health Worker Partnership (ESVHWP) is a community-based participatory research effort formed to understand andaddress social determinants of womens health on Detroits east side.

What we want to achieve:To identify facilitators and barriers to sustained community efforts addressing social factors that contribute to diabetes and to develop aprogram that reduces the risk or delays the onset of Type II diabetes.

What we are doing:The ESVHWP and Village Health Workers (VHWs) work together to identify and develop ways to address health concerns in their communities.VHWs and members of the ESVHWP identified diabetes as a high-priority health concern and developed Healthy Eating and Exercising to

Reduce Diabetes, a program that encourages community members to engage in moderate physical activity and healthy eating to reduce their riskfor diabetes. The project is built upon the recognition that social and economic policies as well as social and physical environments contribute tothe complexity of the disease. The main objectives for this program are to:

> Increase knowledge among VHWs and other community members on the east side of Detroit about how to reduce the risk ordelay the onset of type II diabetes.

> Increase resources (e.g., community gardens, cooperative buying clubs, social support for a healthy diet) and reduce barriers(e.g., lack of affordable fresh produce in local stores) to healthy meal planning and preparation.

> Identify and create opportunities for safe, enjoyable, and low-impact physical activities for community members.

> Strengthen and expand social support for practices that help to delay the onset of diabetes or reduce the risk of complications.

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Howwewillknowwearemakingadifference:We have conducted both process and outcome evaluations. We usedevaluationresultsfromthefirsttrainingsessiontomodifythetrainingprogramforsubsequenttrainingsessions.Wehavealsotrackedparticipationandsalesvolumeatmini-markets,bothtodocumentthedemandforfreshproduceandtoallowtheprojectcoordinatortotailorthequantityandtypesofproductstobeofferedatfuturemarkets.Wejoinedforceswithanothercommunityinitiativetoexpand themini-marketsandfooddemonstrationsandtoconductamoreextensiveevaluation.

Summingup:

HealthyEatingandExercisingtoReduceDiabetes(HEED)emergedwithinthecontextofanongoingpartnershipthathadbuiltcapacitythroughcollaborativework.Thesepartnersworkedtodevelopananalysisofdiabetesriskthatplacedhealthinthecontextoftheirparticularcommunityenvironments.Fromthisanalysis,theywereabletoaddressbarrierstothemanagementofdiabeteswithintheircommunities. Such partnerships offer a great opportunity for dialogue thatincreasesunderstandingofdiverseperspectivesandcanprovideafoundationforaddressingsocialandenvironmentalfactorsthataffecthealth.Morerecentactivities from theHEED projectinclude impacting local policies inorder toaddressstructuralandenvironmentalissuesthatlimitaccesstohealthyfood.

How to reach us:Amy Schulz, PhDUniversity of Michigan(734) [email protected]


> Diabetes-related dialogue, research, and intervention are iterative processes that are informed by and can helpinform an understanding of how diabetes risk is affected by social conditions and the social relationships thatcreate them.

> Community initiatives to address health issues or their social determinants are largely dependent on local fundingsources that may or may not support efforts to address these social determinants.

> The success of collective efforts to address health disparities depends on convincing community members andother stakeholders that these disparities are caused in part by inequities in the social determinants of health.

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5

C A S E S T U D Y

TakingAction:The Boston Public Health Commissions

Efforts to Undo RacismWhoweare:TheBostonPublicHealthCommission(BPHC)inpartnershipwithcityagencies,healthcareorganizations,community-basedorganizations,andcommunitymembers.

Whatwewanttoachieve:Todeterminehowalargepublichealthorganizationcanrecreateitselftoincorporateananti-racistagenda.

Whatwehavedone:TheeliminationofracialandethnichealthdisparitieswasdeterminedtobeoneofourpriorityareasinresponsetodatashowingthatblacksinBostonfaresignificantlyworsethanwhiteson15of20measuresofhealth.Oureffortstounderstandandeliminatetheimpactofracismonhealth

arebasedonthefollowingprinciples:1)raceisasocialandpoliticalconstructthatestablishesandmaintainswhiteprivilege;2)understandingtheroleofracisminperpetuatingdisparitiesinhealthrequiresacommonlanguageandcontextualframework;and3)undoinginstitutionalracismrequiresparticipatoryapproachesplacingleadershipanddecisionmakinginthehandsofthosebeingserved.Wefocusonlackofequalopportunity,discrimination,andrace-relateddifferencesinexposuretohealthrisksaswellasinstitutingquality-improvementinitiativeswithinthehealthcaresystembyadoptingthreemainstrategies:

>Promote a non-racist work environment.ActivitiesincludetrainingBPHCstaffandmanagers,creatingexecutivepositionstocoordinatetheseefforts,reviewingandadaptingpoliciesandpracticestoeliminatediscrimination,increasingeffectivenessinhandlingcomplaintsaboutracism,increasingstaffdiversity,creatingperformancemeasurestoassessprogressinaddressingracism,andestablishingstandardsforculturallyappropriatematerialsandcompliancemechanisms.

>Build partnerships.Activitiesincludetrainingcommunityleaders,employingcoalitionmembers,conductingcommunityassessmentstodocumenttheeffectsofracismonresidents,andsponsoringworkshopsforcommunityresidents.

>Refocus external activities.WeformedtheTaskForcetoEliminateRacialDisparitiesinHealth,whichincludeshospitalCEOs;communityhealthcenterdirectors;communitycoalitionchairsandrepresentativesfromhealthplans,businesses,andhighereducation.TheBostonmayoralsoestablishedahospitalworkinggrouptoimprovetheassessmentofhealthdisparities,workforcediversity,culturalcompetencetraining,andhospitalparticipationincommunity-basedeffortsbylinkingfundingtotheREACH2010/BostonHealthyStartCoalitionsoutreachandeducationactivities.

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Howwewillknowwearemakingadifference:Projectstaffaretrackingtheimpactofeffortstomaketargetedpolicychanges.Sinceitsbeginning,theBPHCDisparitiesProjecthasreachedover6,100peopleacross Boston through education, training, and planning activities focusedon understanding and addressing health disparities. A city-wide blueprintforaddressingracialandethnichealthdisparitieshasbeendevelopedand,in2006,the MayorofBostonwasawardedtheU.S.DepartmentofHealthandHumanServicesDirectorsAwardinrecognitionofhisleadershipontheproject.In2007,BPHCreceivedaREACHUS(RacialandEthnicApproachestoCommunityHealth)cooperativeagreementawardfromCDCtoestablisha

learningcollaborativetosharethisworkwithothercommunities.

Summingup:The first step in addressing institutional racism is the collection and use ofappropriate health disparity data to engage key leaders and encouragecommunitymembers, health care providers,and electedofficials toaddresshealthdisparitiesanddevelopconcreteplansforeliminatingthem.ImplementingtheBPHCTakingActioninitiativehasrequiredshiftingexistingpersonnelandfinancialresourcesaswellasidentifyingnewfundingsources.Fortunately,wehavebeenabletodobothbecauseofthecommitmentofpoliticalleadersandthestrengthofcommunitycoalitions.

How to reach us:Meghan PattersonBoston Public Health Commission(617) [email protected]/disparities


We have found that many people are uncomfortable discussing or unwilling to discuss issues related toracism. In addition, many public health staff members feel a tension between attempting to be serviceproviders and attempting to be change agents; many are not trained as organizers, and they do notnecessarily have an interest in this role.

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6

C A S E S T U D Y

TheCommunityActionModeltoAddressDisparitiesinHealth

46

Whoweare:SanFranciscoTobaccoFreeProject(SFTFP)oftheCommunityHealthPromotionandPreventionsectionoftheSanFranciscoDepartmentofPublicHealthandlocalcommunity-basedorganizations.

Whatwewanttoachieve:Wehavetwoprimarygoals:1)tomobilizecommunitymembersandagenciestochangeenvironmentalfactorsthatpromoteeconomicandenvironmentalinequalities;and2)toprovideaframeworkforcommunitymemberstoacquiretheskillsandresourcestoinvestigatethehealthoftheircommunity,andthenplan,implement,andevaluateactionsthatchangetheenvironmenttopromoteandimprovehealth.

Whatwehavedone:WedesignedtheCommunityActionModel(CAM)toincreasecommunityandorganizationalcapacitytoaddressthesocialdeterminantsofhealthassociatedwithtobacco-relatedillness.AkeycomponentofCAMishelpingcommunitymembers(advocates)identifyunderlyingsocial,

economic,andenvironmentalforcesthatcreatehealthinequitiesusingthefollowingprocess:>Skill-based training. Train515advocatesintheCAMprocess,discussissuesofconcern,andchooseafocusareathathas

meaningtothecommunity.

>Action research. Define,design,andimplementacommunitydiagnosistofindrootcausesofcommunityconcernsanddiscoverresourcestoovercomethem.

>Analysis. Analyzetheresultsofthediagnosisandpreparefindings.

>Organizing. Select,plan,andimplementanactiontoaddresstheissuesofconcern.

>Implementation. Enforceandmaintaintheactiontoensurethattheappropriategroupswillsustainthecommunitysefforts.

Since1996,SFTFPhasimplementedtheCAMmodelbyfundingcommunity-basedorganizations(CBOs)toworkwithcommunityadvocatestocarryouttheprocessabove.SFTFPhasfunded37projects,andthefollowingareexamplesofsuccessfulactionsaccomplishedbyCBOs:

>SanFranciscoSchoolBoardpoliciestobantobaccofoodsubsidiaryproducts.

>Tenant-drivensmoke-freepoliciesinmulti-unithousingcomplexes.

>City-widebanontobaccoads.>Enforcementoflocalandnationallaws

prohibitingbiditobaccoproductandcigar usebyyouth.

>AGoodNeighborprogramtopromoteinnercityaccesstohealthyalternativestotobaccofoodsubsidiaryproducts.(Seeposteroninsidefrontcoverofthisworkbook).

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Howwewillknowwearemakingadifference:We are conducting evaluations to determine whether funded projects havecompleted thefiveCAM steps, met thecriteria foraction (i.e.,is achievable,haspotentialfor sustainability,and compelspeople to change thecommunityfor thewell-being ofall),and increasedthe capacityof advocates/agenciestoparticipateintheCAMprocess.Preliminaryfindingssuggestthat30oftheprojectsimplementedactionplansthatmetthecriteriaand28ofthemsuccessfullyaccomplishedthe proposedactionsthemselves.Futureevaluationswilladdresslong-termsustainabilityofprojectsandidentificationoffactorsthatcontributetoaprojectssuccess.

Summingup:CAMisdesignedtoenhanceindividualandorganizationalcapacitytoaddresssocialdeterminantsofhealththroughpolicyinterventions.Helpingthecommunitymembersmostaffectedby healthdisparitiesto develop theskillsto changesocialstructuresunderlyinghealthinequitiesisanimportantfirststep.Althoughwehavefocusedontobacco-relatedissues,theskillsandcapacitiesdevelopedbyparticipantsin theprojectswehave fundedcanalsobeusedto addressotherhealthissuesaffectingcommunities.

How to reach us:Susana Hennessey Lavery

San Francisco Department of Public Health(415) [email protected]://sftfc.globalink.org


> Categorical funding sources focused on behavior-change models often lack the infrastructure to coordinatea community-driven advocacy campaign focused on policy development.

> Projects to make health-related environmental changes require sustained funding and can be laborintensive, limiting the number of such projects that can be funded.

> Because categorical funding often requires that the Community Action Model process have a predetermined

area of focus, making the issue relevant to the community can sometimes be difficult (i.e., tobacco controlmay not be a priority for the community advocates).> To address these funding challenges, we have adopted the following strategies:

Require funding applicants to demonstrate that their proposed project is achievable and sustainableand that it will compel a group, agency, or organization to change the specified conditions for the

well-being of all area residents. Require funding applicants to be community based, to demons trate a history of or interest in activ ism,

and to have the infrastructure necessary to support the proposed project. Develop simple work plans and budget processes to alleviate some of the administrative burdens. Address the challenge of working with groups by training and providing technical assistance to CBOs

and community advocates.

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47

7

C A S E S T U D Y

NewDealforCommunities Whoweare:Partnershipsbetweencommunitymembers,communityandvoluntaryorganizations,localauthorities,businesses,andtheUnitedKingdomgovernment.

Whatwewanttoachieve:Toreducehealthinequitiesbyrestructuringlocalsocioeconomicenvironments.

Whatwearedoing:Wedesignedthe National Strategy forNeighborhood Renewal (NSNR) to reduce social inequitiesthrough thedevelopmentof healthycommunitiesandneighborhoods.AkeyelementoftheNSNRwastheNewDealforCommunities(NDC)initiative,anarea-basedregenerationinitiativebeingimplementedin39ofthemostdeprivedcommunitiesintheUnitedKingdom.Theinitiativesupportsintensiveregenerationofneighborhoodsthroughpartnershipsamonglocalpeople,communityandvoluntaryorganizations,localauthorities,businesses,andgovernmentagencies.EachNDCpartnershiphasdevelopedaplanfocusedononeoffourkeyareasdeterminedtobebarrierstolastingchangeindeprivedneighborhoods:unemployment,poorhealth,crime,andloweducationlevels.Theyareattemptingtoovercomethesebarriersbyimprovingthe

physicalenvironment;improvingneighborhoodmanagement;improvinglocalservices;creatingbetterfacilitiesforarts,sports,andleisureactivities;buildingthelocalcommunityscapacitytotakeactiononhealth-relatedgoals;tacklingdisadvantagesresultingfromracialdiscrimination;andencouragingenterprisetosupporteconomicdevelopment.

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Howwewillknowwearemakingadifference:TheNDChasaformalevaluationplanthatincludesthecollectionofbaseline

and follow-up data, though the vast scope of the project makes formalevaluationan extremely complexprocess. Evaluation activities willfocus onthreemainprocessestoassesshowtheinitiativesimpacthealth,includinghowdirectorindirectactionscontributetohealthimprovement;howtheprocessofselectingcommunitiesforparticipationimpactshealth,eithernegatively,duetoidentificationasacommunityinneed,orpositively,duetorecognitionofunmetneeds;andhow thisapproachinfluences health byincreasing thecapacityof community members to participate in health enhancing activities. Interimevaluationresults, which varyby neighborhood, show increased satisfactionwiththe neighborhood asaplace to live; significant improvements in crimeand fear of crime; community elected Boards to oversee neighborhood

regeneration activities (average voter turnout 23%); improvements in youtheducationalattainmentandin schoolretention;andmodestimprovementsinself-ratedhealth.48

Summingup:Thereisagreatdealtolearnabouttheeffectivenessofinterventionsthatseekto modify the macro-socioeconomic environment, though we do know thattheactiveparticipation ofaffectedcommunitymembersinallstagesof suchinterventionsisessentialtotheirsuccess.Also,thelongertheintervalbetweenaninterventionandananticipatedchangeinagroupshealthstatus,thegreater

thelikelihoodthattheevaluationwillfailtocaptureaneffect.

How to reach us:Jayne ParryUniversity of Birmingham+44 (0)121 414 [email protected]://www.neighbourhood.gov.uk/page.asp?id=617


We are learning that implementing the NDC initiative is a complex process with many strengths and

challenges. Initiative strengths include: 1) collaboration of intersectoral and multiagency partnerships withcommunity members to identify needs and develop and implement projects designed to meet those needs;2) an evidence-based approach to demonstrate progress toward stated objectives; 3) a large financialinvestment over 10 years; 4) strong national leadership; 5) expert and administrative engagement andsupport; 6) linkages to primary health care; and 7) a history of community development and involvement.Our challenges include: 1) pressure from national leaders to achieve outcomes in a short time; 2) lackof support for health care practitioners engaging in community work; 3) reliance on expert consultants,

which, without transfer of skills, minimizes the ability to build commun ity capacity; 4) inexperienced andoverworked staff; and 5) conflicts between community groups.

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8

C A S E S T U D Y

FromNeuronstoKingCountyNeighborhoods

49

Whoweare:PublicHealthSeattle&KingCounty,localandstategovernments,humanservicesandchildadvocacyorganizations,communityresidents,andotherearlychildhooddevelopmentstakeholders.

Whatwewanttoachieve:Todevelopacoordinatedpolicyagendathatwillstrengthenearlychildhoodenvironmentsandcomplementexistingeffortsfocusedonfamiliesandindividuals.Ourultimategoalistocreateuniversalaccesstoenvironmentsthatsupporthealthydevelopment,schoolreadiness,andsuccessinschool.

Whatwearedoing:

Wedesignedapolicy-orientedinterventiontoenhanceearlychildhoodenvironmentsinKingCounty,Washington.Theinterventioninvolvesthefollowingfivesteps:

>Developpartnershipswithearlychildhooddevelopmentstakeholderstodiscusscurrentandproposedpoliciestosupportearlychildhooddevelopment.

>Buildacommonknowledgebasebydevelopingadocumentthatdescribeswhatweknowaboutpoliciesthatsupportearlychildhooddevelopment.

>Developpolicyrecommendationsin14areasbyworkingwithstakeholderstocompareexistinggovernmentalpolicieswithproposedpolicies.

>Organizesupportforproposedpolicychangesthroughcommunitymeetingstodisseminateanddiscussthepolicyagenda.

>Monitorthe14governmentalpoliciesontheagenda,reportprogresstostakeholdersonaregularbasis,andidentifyopportunitiesforaction.

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Howwewillknowwearemakingadifference:Wewillformallymonitorandperiodicallyreporttostakeholdersonthestatusof thepolicies. We conducted interviews to assess stakeholder knowledgeoneachofthepolicyareas.Theresultsoftheseinterviewshelpedusidentifyopportunitiesforaction(e.g.,tohelpmovepeopleoutofpoverty,stakeholders

canadvocateforincomeassistancebyenrollingalleligiblefamiliesinEarnedIncomeTaxCredit/TemporaryAssistanceforNeedyFamilies/SocialSecuritybenefits)aswellastheneedformorecoordinatedpartnerandcommunitysupportbeforeaproposedpolicychangecouldbeattempted.Theoutcomegoalsofpartnershipsarealsousedasabasisforassessmentactivities.Forexample,afterweselectedschoolreadinessasanoutcomegoal,weconductedapopulation-based assessment of school readiness among King County kindergartenchildreninthreeschooldistricts.Theresultingdatahasbeenusedtomobilizecommunityengagement,fundingandactionparticularlyinoneneighborhoodinKingCounty.Weareintheprocessofconductingasecondassessmentintheseschooldistrictsandwillhavethebaselinedataagainstwhichtocompareand

trackimprovementinschoolreadiness.

Summingup:Weareintheprocessofdevelopingstrategiestopromotelocal,county,andstatepoliciesthatsupportenvironmentsconducivetoearlychildhooddevelopment,schoolreadiness,andsuccessinschool.However,ensuringthatallAmericanchildrengrowupinsuchenvironmentswillrequiretheongoingcommitmentandcooperationofallpartnersinthisendeavor.

How to reach us:Sandy Ciske, Regional Health Officer

Public Health Seattle & King County(206) [email protected]

What we are learning:It is difficult to keep partners engaged long enough for them to become fully informed participants inbuilding a policy agenda to support childhood development and to keep them focused on the environmentrather than on individuals or families as the unit of change. Although people say they want to changeconditions in their community, they may lose interest in the proposed policy agenda before it can beimplemented, because the changes necessary can seem daunting and the benefits of such changesseem distant. There is a continuous need for better collaboration among groups, stronger leadership,a commitment to prioritized policies, and the protection of existing funding for early childhood servicesand programs.

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9

C A S E S T U D Y

TheDeltaHealthCenterMound Bayou, Mississippi

A Historical Case Study

Whoweare:TheDeltaHealthCenter,locatedinMoundBayou,Mississippi,wascreatedin1965followingayearofintensiveworktoestablish10localcommunityhealthassociations.Theselocalassociations,whichmodeledthemselveson blackchurchesandofferedpublichealthand nursingservices,eventuallymergedtoformtheNorthBolivarCountyHealthCouncil,whichbecamecharteredasacommunitydevelopmentcorporation.

Whatwewantedtoachieve:Todevelopahealthcenterthatprovidedprimarymedicalservicesandtochangesocialdeterminantsofhealthbyhelpingthelocalcommunitytoorganize,articulatetheirhealth-relatedneeds,andacttomeetthoseneeds.

Whatwedid:

Inadditiontoprovidingmedical,dental,andnursingcare,thehealthcenterofferedthefollowingservices:>Environmental services. Activitiesincludeddiggingaprotectedwell,buildingsanitaryprivies,repairingandscreeninghousing,andestablishing

rodentandpestcontrol.

>Nutritional services. ActivitiesincludedobtainingmoneyforanemergencyfooddistributionprogramanddevelopingtheNorthBolivarCountyFarmCooperative,inwhich1,000familiesworkedtogrowvegetablesinsteadofcotton,sharingtheharvestandsellingthesurplusinlocalmarkets.

>Transportation services. Activitiesincludedcreatingandoperatingabustransportationsystemthatlinkedthecontactcentersofthe10communityhealthassociationcenterstotheDeltaHealthCenter.

>Educational services. Activitiesincludedtrainingcommunitymembersasmedicalsecretaries,medicallibrarians,nursingaides,andcommunityhealthworkers/educators/organizers;establishingaGeneralEducationalDevelopmentcertificateprogramunderthecredentialingumbrellaofalocalblackcommunitycollege;operatingacollegepreparatoryprogram;operatingapublichealthsanitarianprogram;andestablishingthe

OfficeofEducationwithintheDeltaHealthCentertoassistcommunitymemberswithapplicationstocollegesandtomedical,nursing,andotherprofessionalschools.Withinthefirsteightyears,thisprogramproducedsevenphysicians,fivedoctorsintheclinicalsciences,twoenvironmentalengineers,morethantwelveregisterednurses,andsixsocialworkers.

>Financial services. ActivitiesincludedestablishingabankbranchinMoundBayou,wherelocalblackcommunitymemberswerehiredastellersandsupervisorsandracialdiscriminationinmortgagelendingwasdecreased,whichledtotheconstructionofnewhousingandanincreaseinhomeownership;hiringapart-timelawyertoapplyforfederalandstatehousing;andestablishingeconomicandcommunitydevelopmentprograms.

Inaddition,weworkedtoreducethesocialisolationofpoorandruralcommunitiesbyestablishingsummerinternshipsforstudentsaswellasHeadstart,teenguidance,andcounselinginterventions.

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Howweknewweweremakingadifference:ThesuccessofoureffortshasbeenreflectedinthepersonalcommitmentofthosewhoreceivedservicesfromtheDeltaHealthCenterandthenreturnedtojointheCenterstaffinvariouspositions,includingasexecutivedirectors,physicians,andnurses.

Summingup:Community health centers can partner with local communities to function asmultidisciplinarycommunityinstitutionsthataddressawiderangeoffactorsaffectinghealth outcomes. The Delta Health Center, originally sponsored by Tufts MedicalSchool,is now owned andoperated by a nonprofit community board in Mound

Bayou,Mississippi,andservespartsofthreecountiesintheMississippiDelta.

How to reach us:Seymour Mitchell, Executive Director

Delta Health Center(662) 741-2151http://www.tecinfo.com/~dhc1/history.html

What we learned:After initially resisting many Delta Health Center activities, the state government, state and local medicalsocieties, and other Mississippi resources ultimately cooperated with the Center; some poverty-alleviatinginterventions led to conflict within the black community because they were perceived as threatening tomiddle class community members and institutions; and many Center activities fostered important attitudinaland opportunity changes among community members (e.g., educational interventions led to higher levels ofeducational aspiration and achievement). The Delta Health Center can serve as a model for other federallyqualified health centers attempting to increase community capacity to improve the social determinantsof health.

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DevelopingaSocialDeterminantsof

HealthInequitiesInitiativeinYourCommunityThischapterprovidesguidelinesyoucanadapttodevelopasocialdeterminantsofhealthinitiativeinyourcommunity.Asyouprepareyourinitiative,engagingmultiplesectorsofthecommunity and encouraging active participation in collaborative processes are criticalto improving theconditionsfor health.Theseprocessesinvolvepersonal andprofessionalcommitmentstobuildtrust,acceptresponsibility,listentoneworopposingperspectives,andmaintainauthenticity.

>Section1ofthischapterdiscusseshowtoenlistparticipationfrommembersofyourcommunitytocreatepartnershipsandbuildcapacity.

>Section2providesmethodsforassessingsocialdeterminantsofhealthanddevelopingasharedvisionforcommunitychange.

>Section3describesprocessesforbuildingcommunitycapacitytoaddresssocialdeterminantsaspartofyoursharedmissionandvision.

>Section4offersapproachesusefulforfocusingyourinitiativeonsocialdeterminantsofhealthinequities.

>Section5describeshowtodevelopandimplementanactionplanforyourinitiative.>Section6discusseshowtoassessyourinitiativesprogress,makeadjustmentsas

needed,andshareyourresultswithothers.

>Section7providesrecommendationsforhowtomaintainyourinitiativesmomentumovertime.

Sections17arepresentedinsequentialorder,buttheframeworkfordevelopingyourinitiativeillustrateshowtheinformationpresentedinthesesectionsformsacumulativeknowledgebaseorprocessforachievinghealthequity(seeFigure3.1).Thisframeworkrecognizesthattheinformationpresented ineachstepmaybe useful tochange socialdeterminantsof healthinequities,whetheryou are forminga partnership,developing goals andobjectivesfor aprogram,orevaluatingwhyaprogramwasorwasnotsuccessfulinyourcommunity.

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Each section provides information, tools, and processes that you canincorporate into your ongoing work or use to start a new initiative.Someoftheseresourcesareprovidedincall-outboxesasfollows:

> MovingForwardIncludesthoughtsandrecommendationsfromothersengagedinthiswork.

> ForumSpotlightPresentsworkfromthecommunityinitiativesdescribedinChapter2.

> ExamplefromtheFieldProvidesanexampleadaptedfrommultipleinitiativesofhowtheseresourceshavebeenappliedindiabetesprevention.

> PerspectivesOfferinsightsfromexpertsinthefield.

Finally,thischapterpresentsinformationandresourcesthatcanbeusedtoproducechange,whetheryouarecreatinganewpartnership,transformingan existingpartnership,or working on organizational change to addresssocialdeterminantsofhealth.

Figure3.1:PhasesofaSocialDeterminantsofHealthInitiative

FigureadaptedfromBrownsonetal,2003andGreenetal,1991. 51,52

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S E C T I O N 1 CreatingYourPartnershiptoAddressSocialDeterminantsofHealth

Becausesocialrelationshipsarecomplexandhavevaryingeffectsondifferentmembers ofa community, establishing abroad-basedcollaborative partnership is fundamental to addressing the socialdeterminants of health inequities. Partnerships can be describedbothby their structure(thenumberand typesofgroupsthat formthepartnership)andbythemethodsandprocessesofcollaborationtheyuse (thewayspartners work togetherto createchange andthedegreetowhichall partnersareengagedinthepartnershipsactivities).53 Thissectiondescribes howto createa partnership toaddresssocialdeterminantsofhealthwithinyourcommunity.

Developingthestructureandcollaborativeprocessesforyourpartnership

A partnership is a purposive relationship between two or moreparties(individuals,groups,ororganizations)committedtopursuinganagendaorgoalofmutualbenefit. 54 Partnershipsareformedformanyreasons,includingto helpmembersofthe partnershiplearnandadopt newskills, gainaccessto necessaryresources, sharefinancialrisksandbenefits,exchangeviewpointswithabroadrangeofindividualsandorganizationsfromthecommunity,andrespondto the changing needs of a community.53 It is essential to buildpartnershipsto addresssocial determinantsof healthbecauseno

onegroup,beit healthcareproviders,publichealthpractitioners,orcommunitymembers,canaccomplishthemanytasksrequiredforchangingsocial,economic,andenvironmentalconditionsthatimpacthealth.Partnershipsarenecessaryinorderto:

>Poolinformation.

>Increaseunderstandingofacommunitysneedsandassets.

>Improvepublicpoliciesandhealthsystems.

>Engagenewissueswithouthavingsoleresponsibilityformanagingordevelopingthem.

>Developwidespreadpublicsupportforissuesoractions.

>Shareordevelopthenecessaryresourcesforactionandproblemsolving.

>Minimizeduplicationofeffortandservices.

>Recruitparticipantsfromdiversebackgroundsandwithdiverseexperiences.

>Promotecommunity-widechangethroughtheuseofmultipleapproachesproposedbyrepresentativesfromdifferentsectorsofthecommunity.

>Improveyourchancesofmakingmeaningfulchangesincommunity

conditionsbygainingcommunitymemberstrustinabroad-basedcoalitionofpartners.5357

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Thefirststeptowardcreatingasuccessfulpartnershipistoassembleagroupof interested community members and organizations to discuss ideas andconcerns for the community. In doing so, it is important to recognize thatindividuals andgroupsmight already be gatheringin your community. Youmaychoose towork within existingpartnerships tominimize theburdenputonthembyaskingthemtojoinyetanothergroup.Theseexistingpartnershipsmay have helpful knowledge and experience. However, although existinggroupsareimportant,theymaynotaddressthesocialdeterminantsofhealthor include people or organizations from the community who can informinitiativesto addresssocialdeterminants. Therefore, youmight wishto inviteotherstojoinyourefforts,particularlythosewhohaveinsightintoorexperience

harm from the political, social, economic, and environmental conditions inyourcommunity.5559

Listening to the voicesof people andorganizations in the communitywhoexperience inequitable distribution of social, economic, and environmentalresourcescanhelptobuildastrongpartnershiptoaddresssocialdeterminantsofhealthinequities.Togetherwithothermembersofyourcommunity,youcanidentifytheseimportantnontraditionalpartnersbymakingalistoftherelevantsectorsofyourcommunity(e.g.,government,education,business,publicservices,faith,fundingagencies)andensuringthatyourpartnershipincludesrepresentativesfromeachofthesesectorsaswellasothercommunitymembers.Toeffectively

identifythosewhomaybeinterestedintheworkofyourpartnership,itmayfirstbenecessarytoconsiderhowyourcommunityisdefined.

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PERSPECTIVESCommunityYvonneLewis:Faith Access to Community Economic Development; Flint, Michigan (Participant in Learning From Doing forum)

Involving the community into the decision-making process is criticalfor ensuring that decisions concerning community health are just andrightforall,notonlythose incharge.Peopleincommunitiesknowwhat

theirproblems are, andresearchers canlearn from theexperiencesofcommunitymembersbytalkingwiththemratherthantalkingaboutthem.

Communities have been defined or characterized in a number of ways,including asgroupsof peoplewho live ina particular geographic area,havesomelevelofsocialinteraction,shareasenseofbelonging,orsharecommon political and social responsibilities.6065 Each community has itsownsetofstructuresandnormsthatgoverninteractionsamongitsmembers.A personmaybe partofmany overlapping communities,some of whichinfluenceaccesstosocialresourcesmorethanothers.Thus,someonelivinginageographicallydefinedcommunitythatiseconomicallydepressedmighthavelessaccesstoaffordablehealthyfoodoptions(e.g.,grocerystoresorsupermarkets)andmedicalcare(e.g.,hospitalsorclinics)thansomeonelivinginamoreprosperousarea,eventhoughthisindividualmayhavearelativelyhighpersonalincome.

The following questions can help you think about how to define yourcommunity: Whodoes thecommunity include?Who does it notinclude?Does the community have definite geographic boundaries? Are theresocialorculturaltiesthatlinkcommunitymembers?Whataresomesharedcharacteristics of the community? (See Example from the Field: Building

CommunityPartnerships.)

Onceyourpartners have been gathered, consider ways to meaningfullyinvolvethisdiversegroupofcommunityleaders(e.g.,businesspersons,clergy,

Correcting inequities requires knowledge of how systems work. Forexample,communitiesneedtounderstandhowthelegislaturedecidestoallocatemoney.Thentheycanaskquestionsofthefolkssaying,please

voteforme,andworktoachievethingsthatwillmakeadifferenceintheircommunities.

healthcareproviders)andcommunitymembers.Thismayincludeinformalaswellasformalstrategies.Forexample,itisoftenusefultohaveaninformalmeetingatarestaurant.Informalactivitiessuchasicebreakerscanencouragememberstogettoknoweachotherandenablethemtolearnhowtoworkacrossinherentpowerdifferenceswithinthegroup.66,67 Itcanalsobeusefultochooseaneutralfacilitatororfacilitatorstohelpkeepthegroupfocusedandmovingforward.Afacilitatorrecognizesthatagroupcanaccomplishmorethanonepersonalonebecauseofthevaryingskillsandtalentsofgroupmembersaswellasdifferentnorms,cultures,andprocessesofyourpartners.Afacilitatorcanencourageallpartnerstotakepartinthegroupandhelpthegroupaddressconflictwhenitarises.

Animportantformalstrategyistoestablishguidingprinciplesforpartnershipinteraction.Theseprinciplescanincludehowpartnersagreetointeractwithinthepartnershipandhowinformationissharedwithinthepartnershipandwiththoseoutsidethegroup.SomeprinciplestoconsiderarelistedinMovingForward:PartnershipPrinciples.Youandyourpartnerscanusethesetoguidethedevelopmentof yourownprinciples.Onceagreedonby allpartners,

yourprinciplescanbepostedatmeetingsandreferredtowhennecessary.Tosustainthepartnership,itisusefultorevisitandmodifyyourprinciplesasnewpartnersjoinyourgroup.

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EXAMPLEFROMTHEFIELDBuildingCommunityPartnerships

Alocalpublichealthagencyhasjustreceivedfundingfora community-basedinitiativetoaddressdiabetes,agrowingcommunityhealthconcern.Evidencesuggeststhatatleast10%15%ofadultsinthiscommunityhave

diabetes(note:thisdoesnotincludepeoplewithundiagnoseddiabetes)andthisnumbercontinuestorise.Localhospitalsreportanincreaseoverthepastyearinthenumberofpeoplecomingtotheiremergencydepartmentsseekingcareforuncontrolleddiabetes,includinghighbloodglucoselevels,footinfections,highbloodpressure,andvisionproblems.Doctorsadvisethepatientstoeathealthy,bephysicallyactive,andtaketheirmedications.However,manyoftheseindividualslackaccesstomedicationsorhealthinsurance. In addition, livingconditions,such asinadequatehousingorhomelessness,lackofresourcesorplacestopurchasehealthyfoods,andanabsenceof employmentopportunities,makeit difficultto eathealthy

or bephysicallyactive.For these reasons, theagency decidedit wasimportanttofocusonthesocialdeterminantscontributingtodiabetesandoverall health.Toget started,agencyrepresentativesbeganwithintheirownorganizationandlistedpartnersasfollows:

>Someonewithcommunityhealthassessmentexperience.

>Anepidemiologist.

>Someonewhoknowsabouthealthsurveillance.

>Someonewithcommunityoutreachexperience.

>Someonewithhealtheducationexperience.

Next,theyidentifiedpotentialpartnersintheircommunity,including:

>Nurses,doctors,orotherhealthcareproviders,particularlythose

whotreatpeoplewithdiabetes.>Hospitalandhealthclinicadministrators.

>Individualsfromvolunteeragencies.

>Representativesfromlocalbusinesses(e.g.,pharmacies,recreationalfacilities,andgrocerystores).

>Representativesfromlocalhomelesssheltersandfoodpantries.

>Faith-basedorganizationleadersandmembers.

>Localmediarepresentatives.

>Policymakersandlocalgovernmentofficials.

>Communitymemberswhoknowthehistoryofthecommunity,includingthosewithdiabetesandthosewhocareforpeoplewithdiabetes.

>Localschooladministrators.

>Fundingagencyrepresentatives.

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Assessingpartnershipresourcesandbuildingcapacity

Itishelpfultotakeaninventoryoftheindividual,organizational,andstructural >Doesyourpartnershipspeakwithaunifiedvoice?resourcesthatinfluenceyourpartnershipscapacitytocarryoutitsactivities. >Doseveralindividualshelpwithday-to-dayoperations?Whenconsideringyourpartnershipscapacity,itisusefultoaskyourpartners >Doyouhavesharedleadership?thefollowingquestions: >Doleadershavetheskillsnecessarytofacilitateameeting?Doyoushare

>Whatisthedemographicmakeupofthepartnership(e.g.,gender,race/ethnicity,religion,age)?Isthereavarietyofgroupswithinyourpartnership?Whoismissing?Howwillthisinfluenceyourabilitytocreatechangeinyourcommunity?

>Doallpartnersfeeltheyhaveavoice?Areallopinionsandideas takenintoconsiderationandrespected?

>Aremeetingsheldinaplaceandatatimethatencouragesparticipationbymultiplegroupswithinyourcommunity?

informationfromthemeetingwiththosewhowereandwerenotpresent(e.g.,minutes)?

>Docurrentleadersknowhowtomentornewleaders?

>Domemberstrustthepartnershipleader?

>Doesyourpartnershipinfluenceeventsoutsideyourgroup?

>Doesyourpartnershiphavephysicalspaceandotherresources(e.g.,facilities,equipment,supplies)forday-to-dayactivities?

>Haveyouandyourpartnersclearlydescribedwhatyouwanttodo? EXAMPLEFROMTHEFIELD>Doyouhaveprocessesinplaceforshareddecisionmaking?

IdentifyingPartnershipAssets

68

>Doyouhaveprocessesinplaceformanagingconflictwhenitarises?(SeeAnticipatingchallengesonpage79) Toidentifypartnershipassets,the communitypartnershipto addressthe social

determinantsofdiabetesdecidedtoengagepartnersinthefollowingdiscussion:PERSPECTIVESFunding >Whoaretheindividuals,organizations,andinstitutionsthatmakeupthis

Alicia Lara: California Endowment; Woodland Hills, California partnership?Arepeoplewithdiabetesinvolved?(Participant in Learning From Doing forum) >Doourpartnersrepresentthepeoplelivinginthiscommunityintheirrace/

ethnicity?Gender?Income?Education?Age?Abilitystatus?Sexualorientation?For funders,the two most important elements in improving the>Whatindividualandorganizationalassetsdopartnersbringtothetable?Thesesocialdeterminantsofhealthatthecommunitylevelareachieving

mightinclude,forexample,thecapacitytoprovidehealthservices;relationshipsbalancebetweenindividualandsocialresponsibilityforhealthandtopolicymakers,healthcareadministrators,orthemedia;connectionstounderstandingthe power dynamics of community interventions.otherimportantsectors,suchassocialservices,education,jobs,orhousing; Fundersshouldbepreparedto: communityorganizingskills;officeexperience;researchorevaluationskills; >Ensurethattheprojectstheysupportstrivetoachieveaplacestomeet;andresourcessuchascomputersorcopymachines. balancebetweenindividualandgroupresponsibility.

>Haveweestablishedcommunicationanddecision-makingprocesses?>Supportchangingthepowerdynamicbyhelpingcommunity>Whatiscurrentlybeingdonetopreventtheonsetofdiabetesinourcommunity?basedorganizationsaccessandmanageresources.

Whatisbeingdonetoaddressthediagnosisandmanagementofdiabetes?>AcceptthatcreatingsustainablechangeinacommunityWhatisbeingdonetoaddresssocialdeterminantsthatcontributetorequiresalong-termcommitmentfromfunders. diabetes?Whoisdoingthis?Canwepartnerwiththem?>Learntoworkcollaborativelywithotherfunders.

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BuildingpartnershipcapacityResponses to these questions will help point to areas where the partnership isdoing well and areas that need improvement. This inventory can lead to changesin where and how often the partners meet, how long meetings should last, decision-making processes, conflict-management strategies, and the roles and responsibilities ofindividual partners.

In addition to your partnership principles, it is important to create and agree upon groundrules for running partnership meetings. Ground rules are a set of standards for groupbehavior that establish a safe and comfortable environment and may include sharinginformation, respecting others opinions, refraining from dominating the discussion,correcting misperceptions and maintaining confidentiality. For further informationand assistance with creating partnerships, see Moving Forward: PartnershipMeetings below.

MOVINGFORWARD

PartnershipMeetings 69

>Conveneyourpartnerstodiscussaproposedagenda.

>Buildsocialtimeintoyourgatheringsfornetworkingorjustgettingtoknoweachother.

>Prepareaninvitationwithacatchysloganandreadingmaterialsto

attractcommunitymemberstothediscussion.>Considerinvitinganeutralfacilitatorforthediscussion.

>Agreeupon,post,andrevisitasneededasetofgroundrulesforthemeeting.

>Develop,post,andrevisitasneededasetofprinciplestoguidethepartnership.

>Meetonaregularbasiswithaclearpurpose;startandendmeetingsontime.

>Definerolesandresponsibilitiesforallpartners(e.g.,appointsomeonetotakenotesandpreparemeetingminutes).

>Preservesharedleadershipandresponsibilitybydelegatingmeaningfultaskstosmallgroupsorsubcommitteesanddevisingrealistictimelines.Formactivecommitteesthatallowpartnerstobeinvolvedinissuesofconcerntothem.

>Preparetoengagepartnersusingmultiplemethodsofcommunication(e.g.,oral,written,pictorial)toensurethatpeopleunderstandinformationandfeelcomfortableexpressingthemselves.

>Avoidconversationsaboutstrategiesforaddressingproblemsuntilyouhavejointlydefinedthenatureoftheproblems.

>Createanatmosphereinwhichparticipantsfeelcomfortableexpressingcontradictoryopinions.

>Focusoncommongroundbutdontbeafraidtoaddressconflicts. >Bepreparedtodealwithconflictasitarises.(SeeSection5formore

informationonconflictresolution)

>Preparemeetingsummariesandsharethemwithallpartners.

>Establishconsensusonthefinancialresponsibilitiesofmembersand developabudgetforthepartnership.

>Buildrelationshipswithelectedofficialsandotherkeycommunityleaderstogainsupportforthepartnership.

>Ensureconsistentandclearcommunicationamongallpartners.Considercreatinganewslettertokeepeveryoneinformed.

>Seektechnicalassistanceandsupportifresourcesareneededfrom outsidethepartnership.Thismayincluderecruitingpeoplewithneeded skillstobecomemembersofthepartnershiporaskingoutsiderstohelp (butnotnecessarilyjoin)thepartnership.

>Recognizehardworkanddedicationthroughcelebrationsand funactivities.

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Yourpartnershipwilllikelyincludeawiderangeofindividualsandgroups(e.g.,members,researchers,healthcareprofessionals,counselors,educators,communityactivists,communityplanners),soyoumaywanttoconsiderdividingpartnersintosmaller,morefocusedsubgroupsto enable thepartnershipto functionmore efficiently (e.g., financecommittee, executivecommittee,youthcommittee,seniorcommittee).Thestructureofthepartnershipshouldspecifyhowthesecommitteesaretocoordinatetheireffortswiththeentirepartnership.Forexample,

youmaydecidetohavecommitteesreporttothelargergrouponaregularbasis.

Establishingstrongrelationshipsamongpartnersandensuringthateachpartnerhasclearrolesandresponsibilitiesareessentialtothesuccessofyourpartnership.Carefullyconsiderwhomtoinviteintoapartnership,howinformationistobeshared,andhowinherentpowerstructuresalreadyoperatewithinthepartnership.Asyoumovetowarddefiningwhichsocialdeterminantsofhealthyouwanttofocusonandtheapproachesyouwanttouse,youmayneed toconsider adding newpartners toenhance thegroups resourcesand capacity.Highlightingthebenefitsofparticipationforeachmemberofthepartnershipandensuringthatthepartnershipisstructuredinawaythatmaximizesthesebenefitsforeachpartnerarealsoimportant.66

PERSPECTIVESResearchSusanTortolero:University of Texas Health Science Center; Houston, Texas(Participant in Learning From Doing forum)

Academicandpublichealthresearchersneedtoadapttraining,evaluation,andresearchapproaches to support and develop the relatively new field of social determinantsinterventionresearch.Forexample:

>Publichealthmodelsthatholdindividualssolelyresponsiblefortheirpoorhealthneedtobeginincorporatingsystemicfactorsthataffecthealth,suchasracismandpoverty.

>Developersofinterventionstoaddresssocialdeterminantsofhealthneedtoconductappropriateevaluationsoftheinterventionsandpublishtheresultstobuildascientificbasisforthiswork.

>Researchersandcommunitypartnersneedtobetrainedinconductingcommunity-basedparticipatoryresearch.Trainingshouldincludeleadership,participationinthepolicy-makingprocess,communicationskills,communityorganizingskills,andquantitativeandqualitativemethodsfordatacollectionandanalysis.

>Academicinstitutionsneedtobemoreflexibleinsupportingthistypeofresearchandsharingresourceswiththecommunity.

FORUMSPOTLIGHT

HowtoUsePartnershipCapacitytoEnhanceProgramming

The following example illustrates how existing partnershipresources were used to develop a social determinants of healthinitiative and how partnership capacity was strengthened aspart of the initiative.

TheEastSideVillageHealthWorkerPartnership(ESVHWP),establishedin1996,conductscommunity-basedparticipatoryresearch to understand andaddress social determinants ofwomenshealth(seepages20-21).TheESVHWPisguidedby a steering committee made up of representatives fromcommunity-basedorganizationsandacademicinstitutions,aswellashealthcareprovidersandcommunitymembersknownasVillage Health Workers (VHWs). Thesteering committeedecidedtofocuson diabetes inwomenresiding inDetroitseastside,because theDetroit VHWsdealwith diabetes intheirownlivesand thelivesoftheirfriends,families,coworkersand community members. Given the benefits of having anexistingpartnership(e.g.,peoplewithaworkingrelationship,resources,skills,and experiences), theVHWs were able todeveloptheHealthyEatingandExercisinginDetroit(HEED)initiative. As the ESVHWP members worked together todevelop,implement,andsustaintheHEEDproject,theVHWswerealsoabletoattractindividualswithotherresources,skills,

andexperiencestoenhancetheircapacitytoreachcommunitymembersandinfluencetheirbehavior.

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S E C T I O N 2 FocusingYourPartnershiponSocialDeterminantsofHealth

Withyourpartnersaroundthetableandprinciplesandgroundrulesestablished,youarenowreadytoidentifyanddiscussthesocialdeterminantsofhealthinequitiesinyourcommunity.

Assessingsocialdeterminantsofhealth

Thefirststepinassessingsocialdeterminantsofhealthistoconducta community assessment. Community assessments are importantforseveralreasons.First,anassessmentcanprovideinsightintothecommunitycontextand ensure thatinterventionswill bedesigned,planned,andcarriedoutinawaythatmaximizesbenefitstothecommunity.Partnershipscanuseassessmentstomakedecisionsaboutwheretofocusresourcesandinterventions.Acommunityassessment

alsohelpsto ensurethatallmembersof apartnershipunderstandoftherelationshipbetweenthesocialdeterminantsandthehealthbehaviors or outcomes of interest. Information from a communityassessment can encourage others in the community to providesupportorresourcesfortheinterventionefforts.Lastly,acommunityassessment canbe used to understandwhereyour partnership isstartingandwhatkindsofthingsyouwanttotrackalongthewayinordertodeterminehowyoureffortsarecontributingtochange.Acommunityassessmentisconsideredmorecomprehensivethanthemoretraditionalneedsassessmentbecauseitassessesnotonlythechallengesandneedsofthecommunitybutalsotheresourcesand

strengthsofthecommunity.

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Therearemanywaystoidentifyandassesssocialdeterminantsofhealth.Yourpartnershipcanchooseoneorseveral,dependingontheinterestsandskillsofyourpartnershipmembersandonresourceavailability.Belowareaseriesofstepstoconsiderasyouconductyourcommunityassessment.

1.Considerwhatyouandyourpartnerswanttoassess.

Insomecommunities,itmaybehelpfultogathersupportforaddressingsocialdeterminants by identifying the leading causes of morbidity (sickness) andmortality (deaths) for the community. Partners can thenassess the extent towhich thesocial determinantsinfluencemorbidityandmortality, asillustratedinChapters 1 and2. Othercommunitiesmay choose to identifythe socialdeterminantsfirstandthenexaminetheextenttowhicheachcontributestocausesofmorbidityandmortality.Both approachescanbehelpfulfornarrowinginonyourpartnershipspriorityareas.Remember,somesocialdeterminantshaveadirectimpactonhealthwhereasothersinfluencehealththroughbehaviorsorpsychosocialfactors(seeFigure1.1onpage10).Inaddition,somesocialdeterminantscanhaveapositiveinfluenceonhealth(e.g.,support,resources)whereasothers have anegative influence. Lastly, once yourpartnership haschosenapriorityarea,itmaybeusefultoreflectwithcommunitymembersoncurrentandpastprogramsthathavebeenconductedtoaddressthisarea,ifany(e.g.,policydevelopment,environmentalchange,socialmarketingcampaigns,

educationprograms).Onceaninventoryhas been created,documentwhatabouttheseprioreffortsdidordidnotwork,whatchallengeswerefaced,whatwasnotaddressedinpreviousapproaches,andwhethereffortsworkedfortheentirecommunityoronlyforspecificpopulations.51,70

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2.Talktoothercommunitypartnersandmemberswhorepresentthepopulationorcommunitiesofinterest.

From these conversations, try to determine perceptions of the needs,resources, and challenges in the community. These individuals may beinterested in collaborating on the community assessment and cultivating a

working relationship to support intervention planning, implementation, andevaluationactivities.

3.Thinkaboutthetypesofinformationthatwillbeusefulforunderstandingyourcommunity.

Therearemultiplesourcesofinformationthatcanbeassessed.ThecommunityinitiativespresentedinChapter2suggestthatacombinationofinformationsourcesmay provide themostcomplete perspectiveof thecommunity. Ingeneral,it isusefultoconsidersources inthescientificliteratureas wellaslocal,state,and national Web-baseddatasystems. Thefollowingexisting

sourcesofinformationmaybeofuse:>Morbidity/mortality. Numerousdatasystemsareavailabletoevaluate

the rates of morbidity (sickness) and mortality (deaths) within yourcommunity.Totheextentpossible,itmaybeusefultoexaminethesedatabyrace,income,orothercharacteristicstobetterunderstandhowsocialdeterminantscouldbeinfluencinghealthdisparitiesinyourcommunity.Forexample,youcanviewtheNationalHealthandNutritionExaminationSurvey data (NHANES, http://www.cdc.gov/nchs/nhanes.htm),NationalHealth InterviewSurvey data (NHIS, http://www.cdc.gov/nchs/nhis.htm),andNationalVitalStatisticsSystemdata(NVSS,http://

www.cdc.gov/nchs/nvss.htm).>Behavioral factors. Variousgroupsinyourcommunitymighthavedifferent

ratesofhealth-relatedriskbehaviors.Even ifyou wish tofocuson thesocialdeterminantsofhealth,itmaybeusefultohaveinformationabouthealth-related behaviors among different groups in your community.

Thesedatamaybeimportantinunderstandingtheextenttowhichsocialdeterminantsinfluencehealthbehaviorsandhealthoutcomes.Forexample,you can visit the Behavioral Risk Factor Surveillance System (BRFSS,http://www.cdc.gov/brfss) and Community Health Status Indicators(CHSI,http://communityhealth.hhs.gov,availableSpring2008).

>Social indicator data. A number of sourcescan give informationonvarioussocial,economic,andenvironmentalconditionsinyourcommunity,includingemployment,education,housing,transportation,andparksandrecreation.Itmaybeusefultohavearesearcherorotherpartnerfamiliarwithhowtoaccessandworkwithsuchdata(throughWebsitesorothersources).Thebenefitofthesedataisthattheyprovideinformationaboutplacesorcommunitiesonawidevarietyofindicators.Forexample,thesedatasourcesmayprovideinformationonemployment(e.g.,jobgrowth,discrimination, affirmative action policies), housing (e.g., residentialpatterns, costs, mortgage lending practices), environmental hazards(e.g., air quality, hazardous waste), and education (e.g., graduation

rates,dropoutrates,literacyrates)aswellasindividual-levelinformation(e.g.,percentoffamilieslivingbelowpovertyinyour county).Multipleuseful resources are available on the Web at http://www.cdc.gov/dhdsp/library/data_set_directory/pdfs/data_set_directory.pdf (datasetdirectoryofsocialdeterminantsofhealthatthelocallevel).

Eachof thedatasourcesdescribedabovemaybehelpfulfordeterminingthebeststartingpoi

sdoh workbook

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