More and more research shows that how long you live may be determined by where you live – down to the zip code level. The cumulative impact of years of exposure to factors such as violence, lack of walkable paths, food deserts and economic insecurity can reduce a person’s life-span by as much as 16 years compared to someone who lives only a zip code away. But whether you’re a concerned citizen, a journalist wanting to cover these issues, or a public health department, it’s hard to know how to change these factors. Taking action can feel overwhelming. Where do you start? How do you do it?
So it is no surprise that an audience-packed 2-hour session at the 2012 America Public Health Association (APHA) conference was on just that topic: how to take action to change deeply-rooted social determinants of health. Speakers from three different communities shared the solutions they had found and offered tips for “moving from measuring inequalities, to taking action.”
Tips from Toledo
Identify Your Target
The first speaker, Kate Sommerfeld, from United Way of Toledo, Ohio, talked about the specific steps that her community has taken to impact the social determinants of health. Their first step was to focus on what’s important to them locally. For Toledo, their primary target was high school graduation rates. Their graduation rates are only approximately 63% – with half that rate for African-American and Latino males. High school graduation rates, while not a “be-all or end-all,” are a hot button issue for that local community and are felt to be a key determinant for life-long health and economic security.
Frame The Discussion
The second key to their approach was working together – often the “make or break” part of the process. But for them, how an issue is framed is crucial. Their group uses an image of a kid coming to school dragging heavy bags of hunger, homelessness, and domestic violence. Their message is that addressing these issues together is a way of supporting schools. If you go into a school to try to implement a public health initiative, it’s important to speak the language of education. Their local community has a high level of food insecurity, which became a priority for service providers, who implemented a summer feeding program for kids. Another coordinated new program was dental care for kids, which was provided in the schools.
Go To The People Affected
Another of their lessons-learned is that of “looking outward.” In the past, their approach was to look at rankings on a variety of measures, then getting motivated by poor results to create interventions. Their new approach is to go to the communities at risk and ask community members what their goals and priorities are, and how they feel an issue can be best addressed.
Understand Your Partners
Constituent relationship management is another factor in success. What is the corporate social responsibility? Is it hunger? Is it early literacy? Once you can define a topic, they found they could bring partners in and support them through the process.
Doctors’ roles, Ms. Sommerfeld felt, are important to understand, especially physicians’ roles in early literacy and social-emotional development. Their group sent handy bullet-point reminders on issues that doctors can assess in a child’s visit, even in the zero-to-one age range, as well as a list for doctors to use as referral resources.
Unify Your Message
Ms. Sommerfeld’s tips for other groups included creating a common vision, finding a group to drive the coordination between partners, and providing evidence-based approaches to further goals. She emphasized that collective action and impact is much greater than each individual program alone.
Care in Kansas City
Embrace Bad News
The next speakers were Joe Reardon, Mayor of Kansas City, Kansas, and Joe Connor, their county director of public health, and Caitlin McMurty, an analyst with Mayor Reardon’s office. Mayor Reardon spoke first about their experiences mobilizing the public sector. Kansas City has a population of about 150,000 people and they recently combined into a unified government of city and county (Wyandotte County). One of their first combined initiatives years ago was to “grow the economy,” which Mr. Reardon felt they have successfully done. But, as Mr. Reardon pointed out, just as this engine of economic growth is occurring, his office got the bad news about their health rankings. How bad was it? They were “dead last” – 105 out of 105 counties in health measures. Typically, he noted, elected officials don’t like bad news and rankings. In general the advice is to “run away” because it is “too hard, and it will have to involve too many people.” Instead, Mr. Reardon said he made a choice to “embrace bad news” as a way of motivating change.
An Informed Politician Is An Effective Politician
Mr. Reardon said he was surprised that the numbers could be so bad because they have a large health IT industry, as well as a major medical center, the University of Kansas Medical Center. It was at this point that he learned about the social determinants of health. Joe Connor, director of public health, pointed out that one of the challenges they had to overcome initially was teaching the difference between health, and healthcare. The mayor said that he understood then “my agenda had to change.” He said that he felt that, instead of just growing jobs, he had to “lift up the community.”
Mr. Reardon found that their key steps were to get people to speak to each other, and to de-politicize the process. Mr. Reardon said that he was surprised to find that the community “got it,” that these were long-standing issues, and that they were aware that things needed to change. He said that immediate action became one of their most important priorities. They defined five strategic areas right out of the gate on which they wanted to take action. Their first success was to pass a complete streets ordinance.
Action Breeds Momentum
In response to this success, a foundation offered to pay for a complete assessment and the creation of a master-plan for trails and sidewalks. A local college went out and assessed every single sidewalk. He also gave an example of how, once a road in their most-neglected neighborhood was renovated with sidewalks, the local minister of a church right next to the road called his office to say that they would like to begin a walking program and would the mayor attend the kick-off? Mayor Reardon said that having the project as a collaboration meant that the community wanted to use it to improve health right away: “There is a momentum that is created.” Their next initiative was addressing access to fruit and vegetables. Their newest chain of groceries stores that opened in their urban corridor has been very successful, and actually sells more fruits and vegetables than in other neighborhoods.
People Can Agree On Health
Mr. Reardon said that one of the surprises to him was that when an issue is framed as a social determinant of health, the political battles that are often a part of tackling these issues “go away.” For example, local districts used to fight about sidewalks as soon as the topic was introduced. Framing an issue as a public health inequality can overcome political battles, especially when inequities are pointed out.
Even When You’re Moving Fast, Stay On Message
Joe Connor, director of public health, then talked about how their whole process was “very organic. We just jumped off a cliff.” In their community, the health department “needed to be the convener.” But he also emphasized that they needed to move beyond assessment. “We’ve been assessed to death.” Their pivotal report made a difference because “it put it all in one place,” and was statistically valid. He added that their message needed to be consistent, including emphasizing that major health centers and the closing or opening of hospitals does not change the overall underlying health of the community. Policy development was key. His approach was to look for “opportunities that make a difference.” He noted that their community had gone through a 10-month planning process, and so, when an influx of money appeared from their casinos, they were able to direct the funds effectively and rapidly.
Take Public Health Skills To Other Areas
Caitlin McMurty, an analyst with the mayor’s office, shared an experience about useful ways to intervene. One day, by chance, she went by a county commissioners’ meeting, and found that the topic of discussion was community gardens. But instead of discussing the health benefits of these gardens, the commissioners’ discussion centered around noises, smells, and the increased costs associated with buying back land from investors. She spoke up to the developers and business members present at this meeting and asked about where health was in this discussion. She shared with the meeting their area’s own food desert statistics, and then volunteered to work with the committee. She emphasized that the type of research she did around this issue “is what we do best.” She said that when participants are willing to spearhead a community process, and write a white paper, it can change the nature and outcome of a discussion.
Affecting Change in Alameda
Make The Link To Health
The last speaker, Alexandra Desautels, was from the Alameda County Department of Health. Alameda County ranks in the middle of the road in terms of health rankings. However, when they look at the sub-county level, the differences between a child of the same race and age from the Oakland Hills, compared to a child from West Oakland, show a 15 year gap in life expectancy. Their goal is to obliterate these differences. She spoke about policy creation around health equity and noted that sometimes an official will ask, “Excuse me, can you tell me why the health department is involved in this?” She said her reply is that their goal is to work so that “everyone in their county can be healthy, not just some people.” In their work, they have shown that people going through foreclosure miss more medical appointments and make other trade-off with their health. Economic inequalities are also tied to neighborhood level issues.
Multi-Task Your Approach
Ms. Desautels said they think about their efforts as working in “both the portrait and the landscape modes.” They work with people one-on-one, and they also work with the larger community in mind.
For example, one-on-one, they are coordinating with a local agency to teach consumers how to read and understand some of the obscure marketing around the more predatory banking practices.
On a larger scale, their director wrote an Op-Ed article about how the banking issue is a health issue. Their department also affects larger changes by policy, for which she gave several examples.
One of their newer initiatives is the Prosperity Project. The department learned that 41% of county residents do not have access to banking services and, those who don’t are 2-3 times more likely to go without food or medicines. Payday loans are highly concentrated in poorer neighborhoods. Because of these issues, her group is working on a responsible banking policy. Community Reinvestment Acts (CRAs) require banks to reinvest in the community, but the data on how and where this occurs is quite difficult, if not impossible, to penetrate. Her group is pushing to pass an ordinance for the data to be shared at the census tract level. They want to be able to see where the investment occurs. Then they want to partner with the bank to see that the money is being invested in the areas that need it most, and to have a say in how to get maximum benefits to the community, such as more money into reserve funding for products like lower-cost payday loans.
Look Within For Impact
In other examples, Ms. Desautels said they discovered that their own Alameda truancy policies required families to go to court, and that many of the truancy cases involve children missing school because of issues around managing chronic diseases. They are linking case managers to these cases and are working with the code enforcement department to try to shift toward a more preventive approach. They have also identified point people within other departments to work with them on health-related topics, such as an identified trained code-enforcement agent to be on call for problems when a child with asthma is living in mold-infested housing. Finally, they are working with the regional transportation authority on the health impact of raising bus fares.
She also emphasized that they feel it is important to recognize and address emerging issues as they occur. They field requests from community groups and other government agencies. They provide a health equity impact tool to help interested groups assess questions around health equity impacts.
Tackling the social determinants of health can be tough. But as Ms. Desaultner said in her closing remarks, “If it wasn’t controversial, it wouldn’t be important.” These three very different communities’ experiences show some striking commonalities around communication, policy, and strong, multi-faceted approaches. And they demonstrate the dramatic success that can occur when using social determinants of health in a holistic approach.