Searching the World for Public Health Challengesmeme81
Promoting Health Equity A Resource to Help Communities Address
Social Determinants of Health
Cover art is based on original art by Chris Ree developed for the Literacy for Environmental Justice/Youth Envision Good Neighbor program, which addresses links between food security and the activities of
transnational tobacco companies in low-income communities and communities of color in San Francisco. In partnership with city government, community-based organizations, and others, Good Neighbor provides incentives to inner-city retailers to increase their stocks of fresh and nutritious foods and to reduce tobacco
and alcohol advertising in their stores (see Case Study # 6 on page 24. Adapted and used with permission.).
Promoting Health Equity A Resource to Help Communities Address
Social Determinants of Health
Laura K. Brennan Ramirez, PhD, MPH Transtria L.L.C.
Elizabeth A. Baker, PhD, MPH Saint Louis University School of Public Health
Marilyn Metzler, RN Centers for Disease Control and Prevention
This document is published in partnership with the Social Determinants of Health
Work Group at the Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services.
Suggested Citation Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.
For More Information E-mail: [email protected] Mail: Community Health and Program Services Branch
Division of Adult and Community Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention 4770 Buford Highway, Mail Stop K–30 Atlanta, GA 30041
E-mail: [email protected] Mail: Laura Brennan Ramirez, Transtria L.L.C.
6514 Lansdowne Avenue Saint Louis, MO 63109
Online: This publication is available at http://www.cdc.gov/nccdphp/dach/chaps and http://www.transtria.com.
Acknowledgements The authors would like to thank the following people for their valuable contributions to the publication of this resource: the workshop participants (listed on page 5), Lynda Andersen, Ellen Barnidge, Adam Becker, Joe Benitez, Julie Claus, Sandy Ciske, Tonie Covelli, Gail Gentling, Wayne Giles, Melissa Hall, Donna Higgins, Bethany Young Holt, Jim Holt, Bill Jenkins, Margaret Kaniewski, Joe Karolczak, Leandris Liburd, Jim Mercy, Eveliz Metellus, Amanda Navarro, Geraldine Perry, Amy Schulz, Eduardo Simoes, Kristine Suozzi and Karen Voetsch. A special thanks to Innovative Graphic Services for the design and layout of this book.
This resource was developed with support from: > National Center for Chronic Disease Prevention and Health Promotion
Division of Adult and Community Health Prevention Research Centers Community Health and Program Services Branch
> National Center for Injury Prevention and Control
Web site addresses of nonfederal organizations are provided solely as a service to our readers. Provision of an address does not constitute an endorsement of an organization by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of other organizations’ web pages.
Table of Contents Introduction p.4
Chapter One: Achieving Health Equity p.6 What is health equity? p.6 How do social determinants influence health? p.10 Learning from doing p.11
Chapter Two: Communities Working to Achieve Health Equity p.12 Background: The Social Determinants of Disparities in Health Forum p.12 Small-scale program and policy initiatives p.14
Case Study 1: Project Brotherhood p.14 Case Study 2: Poder Es Salud (Power for Health) p.16 Case Study 3: Project BRAVE: Building and Revitalizing an Anti-Violence Environment p.18
Traditional public health program and policy initiatives p.20 Case Study 4: Healthy Eating and Exercising to Reduce Diabetes p.20 Case Study 5: Taking Action: The Boston Public Health Commision’s Efforts to Undo Racism p.22 Case Study 6: The Community Action Model to Address Disparities in Health p.24
Large-scale program and policy initiatives p.26 Case Study 7: New Deal for Communities p.26 Case Study 8: From Neurons to King County Neighborhoods p.28 Case Study 9: The Delta Health Center p.30
Chapter Three: Developing a Social Determinants of Health Inequities Initiative in Your Community p.32–89
Section 1: Creating Your Partnership to Address Social Determinants of Health p.34 Section 2: Focusing Your Partnership on Social Determinants of Health p.42 Section 3: Building Capacity to Address Social Determinants of Health p.54 Section 4: Selecting Your Approach to Create Change p.58 Section 5: Moving to Action p.76 Section 6: Assessing Your Progress p.82 Section 7: Maintaining Momentum p.88
Chapter Four: Closing Thoughts p.90
Tables Table 1.1: Examples of Health Disparities by Racial/Ethnic Group or by Socioeconomic Status p.7 Table 1.2: Social Determinants by Populations p.8 Table 3.1: Applying Assessment Methods to Different Types of Social Determinants p.47
Figures Figure 1.1: Pathways from Social Determinants to Health p.10 Figure 1.2: Growing Communities: Social Determinants, Behavior, and Health p.11 Figure 3.1: Phases of a Social Determinants of Health Initiative p.33
Suggested Readings and Resources p.92
Introduction This workbook is for public health practitioners and partners interested in addressing social determinants of health in order to promote health and achieve health equity. In its 1988 landmark report, and again in 2003 in an updated report,1, 2 the Institute of Medicine defined public health as “what we as a society do to collectively assure the conditions in which people can be healthy.”
Early efforts to describe the relationship between these conditions and health or health outcomes focused on factors such as water and air quality and food safety.3
More recent public health efforts, particularly in the past decade, have identified a broader array of conditions affecting health, including community design, housing, employment, access to health care, access to healthy foods, environmental pollutants, and occupational safety.4
The link between social determinants of health, including social, economic, and environmental conditions, and health outcomes is widely recognized in the public health literature. Moreover, it is increasingly understood that inequitable distribution of these conditions across various populations is a significant contributor to persistent and pervasive health disparities.5
One effort to address these conditions and subsequent health disparities is the development of national guidelines, Healthy People 2010 (HP 2010). Developed by the U.S. Department of Health and Human Services, HP 2010 has the vision of “healthy people living in healthy communities” and identifies two major goals: increasing the quality and years of healthy life and eliminating health disparities. To achieve this vision, HP 2010 acknowledges “that communities, States, and national organizations will need to take a multidisciplinary approach to achieving health equity — an approach that involves improving health, education, housing, labor, justice, transportation, agriculture, and the environment, as well as data collection itself” (p.16). To be successful, this approach requires community-, policy-, and system-level changes that combine social, organizational, environmental, economic, and policy strategies along with individual behavioral change and clinical services.6 The approach also requires developing partnerships with groups that traditionally may not have been part of public health initiatives, including community organizations and representatives from government, academia, business, and civil society.
This workbook was created to encourage and support the development of new and the expansion of existing, initiatives and partnerships to address the social determinants of health inequities. Content is drawn from Social Determinants of Disparities in Health: Learning from Doing, a forum sponsored by the U.S. Centers for Disease Control and Prevention in October 2003. Forum participants included representatives from community organizations, academic settings, and public health practice who have experience developing, implementing, and evaluating interventions to address conditions contributing to health inequities. The workbook reflects 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, poor quality of life, racism, sex discrimination, and low socioeconomic conditions are the major risk factors for ill health and health inequalities… conditions such as polluted environments, inadequate housing, absence of mass transportation, lack of educational and employment opportunities, and unsafe working conditions are implicated in producing inequitable health outcomes. These systematic, avoidable disadvantages are interconnected, cumulative, intergenerational, and associated with lower capacity for full participation in society….Great social costs arise from these inequities, including threats to economic development, democracy, and the social health of the nation.”7
knowledge, public health, medicine, social work, sociology, psychology, urban planning, community economic development, environmental sciences, and housing. It is designed for a wide range of users interested in developing initiatives to increase health equity in their communities. The workbook builds on existing resources and highlights lessons learned by communities working toward this end. Readers are provided with information and tools from these efforts to develop, implement, and evaluate interventions that address social determinants of health equity.
We hope you will join us in learning from doing.
Participants October 28–29, 2003 Social Determinants of Disparities in Health: Learning From Doing
Alex Allen Community Planning & Research Isles, Inc. Trenton, NJ
Alma Avila San Francisco Department of Public Health San Francisco, CA
Elizabeth Baker Saint Louis University Saint Louis, MO
Adam Becker Tulane University New Orleans, LA
Rajiv Bhatia San Francisco Department of Public Health San Francisco, CA
Judy Bigby Brigham and Women’s Hospital Boston, MA
Angela Glover Blackwell PolicyLink Oakland, CA
Laura Brennan Ramirez Transtria LLC Saint Louis, MO
Gregory Button University of Michigan School of Public Health Ann Arbor, MI
Cleo Caldwell University of Michigan School of Public Health Ann Arbor, MI
Sandy Ciske Public Health - Seattle & King County Seattle, WA
Stephanie Farquhar School of Community Health Portland, OR
Stephen B. Fawcett University of Kansas Lawrence, KS
Barbara Ferrer Boston Public Health Commission Boston, MA
Nick Freudenberg Hunter College New York, NY
Sandro Galea New York Academy of Medicine New York, NY
H. Jack Geiger City University of New York Medical School New York, NY
Gail Gentling Minnesota Department of Health Saint Paul, MN
Virginia Bales Harris Centers for Disease Control and Prevention Atlanta, GA
Kathryn Horsley Public Health – Seattle & King County Seattle, WA
Ken Judge University of Glasgow Glasgow, United Kingdom
Margaret Kaniewski Centers for Disease Control and Prevention Atlanta, GA
James Krieger Public Health - Seattle and King County Seattle, WA
Alicia Lara The California Endowment Woodland Hills, CA
Susana Hennessey Lavery San Francisco Department of Public Health San Francisco, CA
E. Yvonne Lewis Faith Access to Community Economic Development Flint, MI
Marilyn Metzler Centers for Disease Control and Prevention Atlanta, GA
Yvonne Michael Oregon Health and Sciences University Portland, OR
Linda Rae Murray Project Brotherhood/Woodlawn Health Center Chicago, IL
Ann-Gel Palermo Mount Sinai School of Medicine New York, NY
Jayne Parry University of Birmingham Birmingham, United Kingdom
Jim Randels Project Director, Students at the Center New Orleans, LA
William J. Ridella Detroit Health Department Detroit, MI
Amy Schulz University of Michigan Ann Arbor, MI
Eduardo Simoes Centers for Disease Control and Prevention Atlanta, GA
Mele Lau Smith San Francisco Department of Public Health San Francisco, CA
Kristine Suozzi Bernalillo County Office of Environment Health Albuquerque, NM
Bonnie Thomas Project Brotherhood/Woodlawn Health Center Chicago, IL
Susan Tortolero Science Center at Houston School of Public Health Houston, TX
Junious Williams Urban Strategies Council Oakland, CA
Mildred Williamson Project Brotherhood/Woodlawn Health Center Chicago, IL
1 Achieving Health Equity What is health equity? A basic principle of public health is that all people have a right to health.8 Differences in the incidence and prevalence of health conditions and health status between groups are commonly referred to as health disparities (see Table 1.1).9 Most health disparities affect groups marginalized 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 (e.g., healthy food, good housing, good education, safe neighborhoods, freedom from racism and other forms of discrimination) that support health (see Table 1.2). Health disparities are referred to as health inequities when they are the result of the systematic and unjust distribution of these critical conditions. Health equity, then, as understood in public health literature and practice, 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.”10 “Social determinants of health are life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life.”11
Table 1.1: Examples of Health Disparities by Racial/Ethnic Group or by Socioeconomic Status
Infant mortality Infant mortality increases as mother’s level of education decreases. In 2004, the mortality rate for infants of mothers with less than 12 years of education was 1.5 times higher than for infants of mothers with 13 or more years of education.12,13
Cancer deaths In 2004, the overall cancer death rate was 1.2 times higher among African Americans than among Whites.12,13
Diabetes As of 2005, Native Hawaiians or other Pacific Islanders (15.4%), American Indians/Alaska Natives (13.6%), African Americans (11.3%), Hispanics/Latinos (9.8%) were all significantly more likely to have been diagnosed with diabetes compared to their White counterparts (7%).14
HIV/AIDS African Americans, who comprise approximately 12% of the US population, accounted for half of the HIV/AIDS cases diagnosed between 2001 and 2004.12 In addition, African Americans were almost 9 times more likely to die of AIDS compared to Whites in 2004.12,13
Tooth decay Between 2001 and 2004, more than twice as many children (2–5 years) from poor families experienced a greater number of untreated dental caries than children from non-poor families. Of those children living below 100% of poverty level, Mexican American children (35%) and African American children (26%) were more likely to experience untreated dental caries than White children (20%).12,13
Injury In 2004, American Indian or Alaska Native males between 15–24 years of age were 1.2 times more likely to die from a motor vehicle-related injury and 1.6 times more likely to die from suicide compared to White males of the same age.12,13
Table 1.2: Social Determinants by Populations*
• 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 at least a bachelor’s degree. In addition, Asian American and Hispanic adults (75% and 68%, respectively) were less likely to have visited a doctor or
Access to care other health professional in the past year compared to White adults (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 least once in the past 12 months compared to Whites.12
• 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 income more than twice the poverty level.12
• Residents of nonmetropolitan areas are more likely to be uninsured or covered by Medicaid and less likely to have private insurance coverage than residents of metropolitan areas.12
• As of December 2007, the unemployment rate varied substantially by racial/ethnic group (4% among Whites, 6% among Hispanics/Latinos, and 9%
Employment among African Americans) and by age and gender (4.5% among adult men, 4.9% among adult women, and 15.4% among teenagers).16
• In 2007, African Americans and Hispanics/Latinos were more likely to be unemployed compared to their White counterparts.16 Further, adults with less than a high school education were 3 times more likely to be unemployed than those with a bachelor’s degree.16
• Since the Elementary and Secondary Education Act first passed Congress in 1965, the federal government has spent more than $321 billion (in 2002 dollars) to help educate disadvantaged children. Yet nearly 40 years later, only 33% of fourth-graders are proficient readers at grade level.17
While the reading performance of most racial/ethnic groups has improved over the past 15 years, minority children and children from low-income families are significantly more likely to have a below basic reading level.18
• According to the National Assessment of Adult Literacy, African American, Hispanic/Latino, and American Indian/Alaska Native adults were significantly more likely to have below basic health literacy compared to their White and Asian/Pacific Islander counterparts. Hispanic/Latino adults had the lowest average health literacy score compared to adults in other racial/ethnic groups.19
• The high school dropout rates for Whites, African Americans, and Hispanics/Latinos have generally declined between 1972 and 2005. However, as of 2005, Hispanics/Latinos and African Americans were significantly more likely to have dropped out of high school (22% and 10%, respectively) compared to Whites (6%).20
Table 1.2: Social Determinants by Populations (continued)*
Access to resources
• 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. African American male students (19.8%) were significantly less likely to be asked to show proof of age than were White (36.6%) or Hispanic (53.5%) male students.23,24
• Low socioeconomic status (SES) is associated with an increased risk for many diseases, including cardiovascular disease, arthritis, diabetes, chronic respiratory diseases, and cervical cancer as well as for frequent mental distress.15
• The real median earnings of both men and women who worked full time decreased between 2005 and 2006 (1.1% and 1.2% change, respectively), with women earning only 77% as much as men.25
• In 2005, American Indians or Alaska Natives were 1.5 times more likely and African Americans were 1.3 times more likely to die from residential fires and burns than Whites.26
• Homeless people are diverse with single men comprising 51% of the homeless population, followed by families with children (30%), single women (17%) and unaccompanied youth (2%). The homeless population also varies by race and ethnicity: 42% African-Americans, 39% Whites, 13% Hispanics/ Latinos, 4% American Indians or Native Americans and 2% Asian Americans. An average of 16% of homeless people are considered mentally ill; 26% are substance abusers.27
• Rural residents must travel greater distances than urban residents to reach health care delivery sites.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 compared to 24.5% of Whites.29
• Low-income minorities spend more time traveling to work and other daily destinations than do low-income Whites because they have fewer private vehicles and use public transit and car pools more frequently.29
*Social inequities and social determinants refer to the same resources (e.g., health care, education, housing) but social inequities reflect the differential distribution of these resources by population and by group.
How do social determinants influence health? Multiple models describing how social determinants influence health outcomes have been proposed.30–40
Although differences in the models exist, some fairly consistent elements and pathways have emerged. The model presented here contains many of these elements and pathways and focuses on the distribution of social determinants (see Figure 1.1). As the model shows, social determinants of health broadly include both societal conditions and psychosocial factors, such as opportunities for employment, access to health care, hopefulness, and freedom from racism. These determinants can affect individual and community health directly, through an independent influence or an interaction with other determinants, or indirectly, through their influence on health-promoting behaviors by, for example, determining whether a person has access to healthy food or a safe environment in which to exercise.
Policies and other interventions influence the availability and distribution of these social determinants to different socialgroups,includingthosedefinedbysocioeconomic status, race/ethnicity, sexual orientation, sex, disability status, and geographic location. Principles of social justice influence these multiple interactions and the resulting health outcomes: inequitable distribution of social determinants contributes to health disparities and health inequity, whereas equitable distribution of social determinants contributes to health equity. Appreciation of how societal conditions, health behaviors, and access to health care affect health outcomes can increase understanding about what is needed to move toward health equity.
Figure 1.1: Pathways from Social Determinants to Health
Figure adapted from Blue Cross and Blue Shield of Minnesota Foundation, http://www.bcbsmnfoundation.org/ objects/Tier_4/mbc2_determinants_charts.pdf and Anderson et al, 2003.38,39
Learning from doing Chapter 2 of this workbook contains examples of community initiatives that have addressed inequities in the social determinants of health either directly or indirectly through more traditional public health efforts. These examples identify skills and approaches important to developing and implementing programs and policies to reduce inequities in social determinants of health and in health outcomes. After you have seen how other communities have addressed these inequities, Chapter 3 will describe how to develop initiatives to reduce inequities in your community.
Figure 1.2: Growing Communities: Social Determinants, Behavior, and Health
Figure adapted from Anderson et al, 2003; Marmoetal, 1999; and Wilkinson et al, 2003.39–41
2Communities Working toAchieve Health Equity Background: The Social Determinants of Disparities in Health Forum The Social Determinants of Disparities in Health: Learning from Doing forum included the presentation and discussion of nine community initiatives that address inequities in the social determinants of health. The forum was intended to allow participants to share their ideas and experiences with ongoing projects and to use these ideas and experiences as a basis for future research and practice. Information from each of the community initiatives is presented here as described by presenters at the forum. These initiatives are examples of what’s being done in varying contexts to address a broad range of health and social issues. They were divided into three groups for the panel presentations at the forum, even though most of them shared characteristics with initiatives presented in the other categories. The three categories were: > Small-scale program and policy initiatives These are local initiatives that either focus directly on social determinants of health or address them through more traditional health promotion or disease prevention projects. See case studies 1–3. > Traditional public health program and policy initiatives These initiatives illustrate how efforts to address social determinants of health can be incorporated into traditional public health programs, processes, and organizational structures. See case studies 4–6. > Large-scale program and policy initiatives The first two community initiatives in this group are attempting to directly reduce inequities in social determinants of health caused by factors such as poverty, racism, or an unhealthful physical environment. The third is a historical perspective that provides inspiration and evidence for a multifaceted health care system. See case studies 7–9.
1 C A S E S T U D Y
Project Brotherhood Who we are: A black men’s clinic at Woodlawn Health Center, Chicago, Illinois.
What we want to achieve: Project Brotherhood seeks to: 1) create a safe, respectful, male-friendly place where a wide range of health and social issues confronting black men can be addressed; and 2) expand the range of health services for black men beyond those provided through the traditional medical model.
What we are doing: Project Brotherhood was formed by a black physician from Woodlawn Health Center and a nurse-epidemiologist from the Trauma Department at Cook County Hospital who were interested in better addressing the health needs of black men. Partnering with a black social science researcher, they conducted focus groups with black men to learn about their experiences with the health care system, and met with other black staff at the clinic. As a result of this research, Project Brotherhood uses the following strategic approaches:
> Offers free health care, makes appointments optional, and provides evening clinic hours to make health care more accessible to black men.
> Offers health seminars and courses specifically for black men.
> Employs a barber who gives 30–35 free haircuts per week and who received health education training to be a health advocate for black men who cannot be reached by clinic staff.
> Provides fatherhood classes to help black men become more effectively involved in the lives of their children.
> Discourages violence among the next generation of black men by producing “County Kids,” a comic book that teaches children how to deal with conflict without resorting to violence.
> Builds a culturally competent workforce able to create a safe, respectful, male-friendly environment and to overcome mistrust in black communities toward the traditional health care system.
> Organizes physician participation in support group discussions to promote understanding between providers and patients.
How we will know we are making a difference: In January 1999, Project Brotherhood averaged 4 medical visits and 8 group participants per week. By September 2005, the average grew to 27 medical visits and 35 group participants per week, plus 14 haircuts per clinic session. The no-show rate for Project Brotherhood medical visits averages 30% per clinic session compared to a no-show rate of 41% at the main health …