Assignment: Personal Perspective – Disparities and Determinants of Health

Health disparities and the social determinants of health can be influenced by many factors, some obvious and some you may never have considered until now. What does health equity mean to you? What can be done to improve the health of vulnerable populations in your community, nationally, and even globally?

To prepare for this Application Assignment, review your Learning Resources and the Discussion posts from your classmates this week. Think about your community, and particularly the vulnerable populations and their health risks, as you answer the questions in this week’s application. Find at least two additional resources to add information to your application. One resource should be from a recent (last 5 years) peer-reviewed journal (from the Walden University Library). For suggestions to help with your search, visit the Library

http://library.waldenu.edu/908.htm.

The other additional resource should be from an online source with “.edu”, “.org”, or “.gov” in the web address to ensure you are accessing a reliable resource.

To complete this Application Assignment, write a 2- to 3-page paper that discusses how health equity and the social determinants of health, as described in this week’s Learning Resources, relate to a racial, ethnic, or geographic group of your choice. In your paper, answer the following questions:

What does health equity mean to you? What is the impact of health equity from the perspective of a health care professional?
What racial, ethnic, or geographic population are you basing this application on? What types of issues related to health equity are reported in the population you selected for this application?
How does your definition of health equity and diversity relate to Walden’s mission of social justice?

Instruction:

Be sure to support your work with specific citations from this week’s Learning Resources and additional scholarly sources, as required.

Resources:

Resources for files below:

https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/SDOH-workbook
https://class.waldenu.edu/bbcswebdav/institution/USW1/201830_05/BS_HLST/HLTH_3115_WC/artifacts/USW1_HLTH_3115_Week2-WHO_Social_Determinants_health_exec_summary
Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2137064/

https://www.cdc.gov/obesity/data/adult.html

https://www.cdc.gov/nchs/

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;

08.

For More Information
E-mail: ccdinfo@cdc.gov.
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
47

Buford Highway, Mail Stop K–

Atlanta, GA 300

E-mail: laura@transtria.com
Mail: Laura Brennan Ramirez, Transtria L.L.C.

Lansdowne Avenue
Saint Louis, MO 6310

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

Participants p.

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.

Case Study 3: Project BRAVE: Building and Revitalizing an Anti-Violence
Environment p.

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.

Case Study 6: The Community Action Model to Address Disparities
in Health p.

Large-scale program and policy initiatives p.

Case Study 7: New Deal for Communities p.26
Case Study 8: From Neurons to King County Neighborhoods p.

Case Study 9: The Delta Health Center p.30

Chapter Three: Developing a Social Determinants of Health
Inequities Initiative in Your Community p.32–

Section 1: Creating Your Partnership to Address Social Determinants
of Health p.

Section 2: Focusing Your Partnership on Social Determinants of Health p.

Section 3: Building Capacity to Address Social Determinants of Health p.

Section 4: Selecting Your Approach to Create Change p.

Section 5: Moving to Action p.

Section 6: Assessing Your Progress p.

Section 7: Maintaining Momentum p.

Chapter Four: Closing Thoughts p.90

Tables
Table 1.1: Examples of Health Disparities by Racial/Ethnic Group
or by Socioeconomic Status p.

Table 1.2: Social Determinants by Populations p.8
Table 3.1: Applying Assessment Methods to Different Types
of Social Determinants p.

Figures
Figure 1.1: Pathways from Social Determinants to Health p.10
Figure 1.2: Growing Communities: Social Determinants, Behavior,
and Health p.

Figure 3.1: Phases of a Social Determinants of Health Initiative p.3

Suggested Readings and Resources p.

References p.

106

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%).

• 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

Insurance
coverage

• 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

Education

• Since the Elementary and Secondary Education Act first passed Congress in 1965, the federal government has spent more than $3

billion (in
2002 dollars) to help educate disadvantaged children. Yet nearly

years later, only 33% of fourth-graders are proficient readers at grade level.

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.

• The high school dropout rates for Whites, African Americans, and Hispanics/Latinos have generally declined between 19

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

Income

• 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.

Housing

• 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.

Transportation

• 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.

• 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 and Anderson et al, 2003.38,

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.

1313

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–

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 clinic. To meet the
growing needs, additional staff time has been secured and Project Brotherhood
clinic hours have been extended. As of 2007, Project Brotherhood has provided
service to over 13,000 people since opening.

Summing up:
By providing a health services environment designed specifically for black
men where they are respected, heard, and empowered, Project Brotherhood is
helping to reduce the health disparities experienced by black men.

How to reach us:
Mildred Williamson
Project Brotherhood
(773) 753-55

ProjectBrotherhood@hotmail.com
http://www.projectbrotherhood.net

What we are learning:

When our patients learn that the health care providers at Project Brotherhood share an interest in many
issues that affect them, they gain a sense of social support that becomes a powerful dynamic. Knowing that
they 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 black
professionals as well as black high school and college students.

C A S E

2S T U D Y Poder es Salud (Power for Health) 42 Who we are: We are a partnership of the Latino Network, the Emmanuel Community General Services, the Community Capacitation Center of the
Multnomah County Health Department, the School of Community Health at Portland State University, the Department of Public Health and
Preventive Medicine at the Oregon Health and Science University, and several community and faith-based groups.

What we want to achieve:
To address social determinants of health and reduce health disparities in black and Latino communities in Multnomah County, Oregon, by
increasing social capital, which is a resource available to all members of a community through durable social networks for the purpose of
facilitating the achievement of community goals and health outcomes.

What we are doing:
Our project proposes that health inequities are shaped by fundamental social determinants, including racial discrimination, social exclusion, and
poverty. The project, which uses existing resources to enhance residents’ access to social and economic resources, explores how racially and
ethnically dissimilar communities can use existing social capital to change community conditions.

We rely on three strategies to address social determinants of health:

> We use community-based participatory research to support cross-cultural partnerships in which partners share resources and
decision-making power.

> We use popular education, which means teaching through a process of mutual learning and analysis (emphasizing that students
need to be active in the learning process and should be considered agents of change rather than receptacles of knowledge) to
identify important community health issues and their social determinants, to identify useful expertise among community members,
and to develop the community leadership necessary to take action.

> We select community health workers (CHWs) and provide them with specialized training in leadership, local politics, governance
structure, advocacy, community organizing, popular education, and health.

We elected to work with five groups: three black faith-based communities, the Comunidad Cristiana (a Latino coalition of five evangelical
congregations) and a geographically defined Latino community consisting of four apartment complexes. This decision to work with relatively
small groups (40–

107

members) helped the steering committee and CHWs address issues of specific concern in these communities instead
of broader issues common to all Latino and black community members. In an ongoing process, CHWs use popular education to identify
health issues in their communities and to design projects to respond to those issues. Projects have included forming a public safety committee,
organizing a community health fair, establishing a diabetes support and information group, and a homework club, and a photovoice project
that provides community members with cameras to document community problems and strengths. The photovoice project led community
members to develop a campaign to address trash problems and other environmental health issues.

How we will know we are making a difference:
To determine whether opportunities for building skills, increasing knowledge, and
sharing decision making will increase social capital, we administered a baseline
survey to 170 adults randomly selected from the communities to assess social
capital, general health, and health-related quality of life. We also conducted
in-depth interviews with selected community members to help us determine how
the development and function of social capital in black communities differs from
that in Latino communities. Follow-up surveys showed significant improvements in
social support, self-rated health and mental health among community members
that participated in the interventions with Community Health Workers who use
popular education.

Summing up:
The data described above were reviewed to identify and prioritize the concerns
of participating communities. We found that popular education is an effective
tool to encourage members of different communities to talk about and begin
to address their unique and common health concerns. Our challenge is to
better understand how a person’s health is affected by social, economic, and
political contexts.

How to reach us:
Stephanie A. Farquhar, PhD
Portland State University
(503) 725-51

farquhar@pdx.edu 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 capital
differ. We embrace these differences and are working with both groups to identify opportunities for
cross-cultural collaboration.
Building trust between members of different demographic groups is difficult but essential work. A specific
challenge of working across cultures is the language barrier. Popular education, which uses role-playing and
other creative learning methods, can help provide a common language and reduce potential divisiveness of
language barriers.

C A S E

3S T U D Y Project BRAVE: Building and Revitalizing an Anti-Violence Environment

Who we are:
Project BRAVE is a school-based intervention developed by Students at the Center, a school-based organization; the Crescent City Peace
Alliance, a community-based organization; and a researcher and students from Tulane University School of Public Health to reduce youth
violence in New Orleans, Louisiana.

What we want to achieve:
To reduce the social determinants of violence by changing learning and teaching methods in elementary, middle, and high schools.

What we are doing:
Project BRAVE classes begin with a “story circle,” where small groups of students tell stories about violence they have experienced or seen. After
sharing these stories orally, the students write them down and edit them. In our pilot, a public health researcher helped the students critically
analyze their experiences and identify the social determinants of violence in their community. This analysis, based on a technique known as
“conscientization” or raising critical awareness, involved a number of steps over several weeks. Relevant themes that emerged during this process
included the importance of attending school and increasing the level of social support among students. Participating students came to see
themselves as agents of change in the school and in the community with the ability to motivate others to implement solutions to violence. A final
theme was that heightened awareness of violence could help prevent it in the future. Artists worked with students to translate their stories into a play
that communicated the importance of reducing youth violence to neighborhood members, organizations, and other key stakeholders who might
have a role in addressing such violence. Their play, “Inhaling Brutality, Exhaling Peace,” told a student’s story about a murder witnessed at a local
park. One of the performances was conducted in the neighborhood next to the park where the events in the story took place. The discussion that
followed led some neighbors to express shock at what was happening in their neighborhood park and to begin organizing community efforts to
prevent further violence.

How we will know we are making a difference:
At the end of the semester, project team members tape-recorded group interviews
with students, analyzed and coded the content of the interviews, and used these
data to identify various themes related to social determinants of violence (e.g.,
school attendance, social support, self-perceptions as change agents). Interest
in the Project BRAVE class has led to an increase in school attendance, an
important social determinant of violence and community health. Future evaluation
efforts will include school and community surveys to measure change in student-
related variables, such as school attachment and social support, and community-
level variables, such as collective efficacy and community empowerment. Finally,
we will monitor longer-term outcomes such as crime rates, to assess the project’s
impact on the overall community.

Summing up:
Project BRAVE builds on existing relationships among schools, community
members, community-based organizations, and local researchers to support
already-established opportunities for students to share their experiences and to
participate in community change to reduce violence.

Post–Hurricane Katrina update:
Despite the devastation of schools and neighborhoods caused by Hurricane
Katrina, the work of Project BRAVE is being continued by Students at the Center.
The group is teaching writing classes at McMain Secondary School and in the
Douglass community using BRAVE materials and methods, working to publish
a collection of student writing on violence, and participating in many efforts to
“watchdog” the rebuilding process as it pertains to public schools. Many young
people are working to improve education as New Orleans rebuilds.

How to reach us:
Jim Randels
Students at the Center (SAC)
(504) 982-03

jimrandelssac@earthlink.net

What we are learning:

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

C A S E

4S T U D Y Healthy Eating and Exercising to Reduce Diabetes 45
Who we are:
The East Side Village Health Worker Partnership (ESVHWP) is a community-based participatory research effort formed to understand and
address social determinants of women’s health on Detroit’s 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 a
program 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 risk
for diabetes. The project is built upon the recognition that social and economic policies as well as social and physical environments contribute to
the 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 or
delay 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.

How we will know we are making a difference:
We have conducted both process and outcome evaluations. We used
evaluation results from the first training session to modify the training program
for subsequent training sessions. We have also tracked participation and sales
volume at mini-markets, both to document the demand for fresh produce and
to allow the project coordinator to tailor the quantity and types of products to
be offered at future markets. We joined forces with another community initiative
to expand the mini-markets and food demonstrations and to conduct a more
extensive evaluation.

Summing up:
Healthy Eating and Exercising to Reduce Diabetes (HEED) emerged within the
context of an ongoing partnership that had built capacity through collaborative
work. These partners worked to develop an analysis of diabetes risk that placed
health in the context of their particular community environments. From this analysis,
they were able to address barriers to the management of diabetes within their
communities. Such partnerships offer a great opportunity for dialogue that
increases understanding of diverse perspectives and can provide a foundation
for addressing social and environmental factors that affect health. More recent
activities from the HEED project include impacting local policies in order to
address structural and environmental issues that limit access to healthy food.

How to reach us:
Amy Schulz, PhD
University of Michigan
(734) 647-0221
ajschulz@umich.edu

What we are learning:

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

> Community initiatives to address health issues or their social determinants are largely dependent on local funding
sources 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 and
other stakeholders that these disparities are caused in part by inequities in the social determinants of health.

C A S E
S T U D Y

Taking Action:
The Boston Public Health Commission’s

Efforts to Undo Racism
Who we are:
The Boston Public Health Commission (BPHC) in partnership with city agencies, health care organizations, community-based organizations,
and community members.

What we want to achieve:
To determine how a large public health organization can recreate itself to incorporate an anti-racist agenda.

What we have done:
The elimination of racial and ethnic health disparities was determined to be one of our priority areas in response to data showing that blacks in
Boston fare significantly worse than whites on 15 of 20 measures of health. Our efforts to understand and eliminate the impact of racism on health
are based on the following principles: 1) race is a social and political construct that establishes and maintains white privilege; 2) understanding
the role of racism in perpetuating disparities in health requires a common language and contextual framework; and 3) undoing institutional racism
requires participatory approaches placing leadership and decision making in the hands of those being served. We focus on lack of equal
opportunity, discrimination, and race-related differences in exposure to health risks as well as instituting quality-improvement initiatives within the
health care system by adopting three main strategies:

> Promote a non-racist work environment. Activities include training BPHC staff and managers, creating executive positions to
coordinate these efforts, reviewing and adapting policies and practices to eliminate discrimination, increasing effectiveness in
handling complaints about racism, increasing staff diversity, creating performance measures to assess progress in addressing
racism, and establishing standards for culturally appropriate materials and compliance mechanisms.

> Build partnerships. Activities include training community leaders, employing coalition members, conducting community assessments
to document the effects of racism on residents, and sponsoring workshops for community residents.

> Refocus external activities. We formed the “Task Force to Eliminate Racial Disparities in Health,” which includes hospital CEOs;
community health center directors; community coalition chairs and representatives from health plans, businesses, and higher
education. The Boston mayor also established a hospital working group to improve the assessment of health disparities, workforce
diversity, cultural competence training, and hospital participation in community-based efforts by linking funding to the REACH
2010/Boston Healthy Start Coalition’s outreach and education activities.

How we will know we are making a difference:
Project staff are tracking the impact of efforts to make targeted policy changes.
Since its beginning, the BPHC Disparities Project has reached over 6,

100

people
across Boston through education, training, and planning activities focused
on understanding and addressing health disparities. A city-wide blueprint
for addressing racial and ethnic health disparities has been developed and,
in 2006, the Mayor of Boston was awarded the U.S. Department of Health
and Human Services Director’s Award in recognition of his leadership on the
project. In 2007, BPHC received a REACH US (Racial and Ethnic Approaches
to Community Health) cooperative agreement award from CDC to establish a
learning collaborative to share this work with other communities.

Summing up:
The first step in addressing institutional racism is the collection and use of
appropriate health disparity data to engage key leaders and encourage
community members, health care providers, and elected officials to address
health disparities and develop concrete plans for eliminating them. Implementing
the BPHC Taking Action initiative has required shifting existing personnel and
financial resources as well as identifying new funding sources. Fortunately, we
have been able to do both because of the commitment of political leaders and
the strength of community coalitions.

How to reach us:
Meghan Patterson
Boston Public Health Commission
(617) 534-26

MPatterson@BPHC.org
www.BPHC.org/disparities

What we are learning:

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

6
C A S E
S T U D Y

The Community Action Model to
Address Disparities in Health

Who we are:
San Francisco Tobacco Free Project (SFTFP) of the Community Health Promotion and Prevention section of the San Francisco Department of
Public Health and local community-based organizations.

What we want to achieve:
We have two primary goals: 1) to mobilize community members and agencies to change environmental factors that promote economic and
environmental inequalities; and 2) to provide a framework for community members to acquire the skills and resources to investigate the health
of their community, and then plan, implement, and evaluate actions that change the environment to promote and improve health.

What we have done:
We designed the Community Action Model (CAM) to increase community and organizational capacity to address the social determinants of
health associated with tobacco-related illness. A key component of CAM is helping community members (advocates) identify underlying social,
economic, and environmental forces that create health inequities using the following process:

> Skill-based training. Train 5–15 advocates in the CAM process, discuss issues of concern, and choose a focus area that has
meaning to the community.

> Action research. Define, design, and implement a community diagnosis to find root causes of community concerns and discover
resources to overcome them.

> Analysis. Analyze the results of the diagnosis and prepare findings.

> Organizing. Select, plan, and implement an action to address the issues of concern.

> Implementation. Enforce and maintain the action to ensure that the appropriate groups will sustain the community’s efforts.

Since 1996, SFTFP has implemented the CAM model by funding community-based organizations (CBOs) to work with community
advocates to carry out the process above. SFTFP has funded

projects, and the following are examples of successful actions
accomplished by CBOs:

> San Francisco School Board policies to ban
tobacco food subsidiary products.

> Tenant-driven smoke-free policies in multi-unit
housing complexes.

> City-wide ban on tobacco ads.

> Enforcement of local and national laws
prohibiting bidi tobacco product and cigar
use by youth.

> A Good Neighbor program to promote inner
city access to healthy alternatives to tobacco
food subsidiary products. (See poster on inside
front cover of this workbook).

How we will know we are making a difference:
We are conducting evaluations to determine whether funded projects have
completed the five CAM steps, met the criteria for action (i.e., is achievable,
has potential for sustainability, and compels people to change the community
for the well-being of all), and increased the capacity of advocates/agencies
to participate in the CAM process. Preliminary findings suggest that 30 of the
projects implemented action plans that met the criteria and 28 of them successfully
accomplished the proposed actions themselves. Future evaluations will address
long-term sustainability of projects and identification of factors that contribute to a
project’s success.

Summing up:
CAM is designed to enhance individual and organizational capacity to address
social determinants of health through policy interventions. Helping the community
members most affected by health disparities to develop the skills to change
social structures underlying health inequities is an important first step. Although
we have focused on tobacco-related issues, the skills and capacities developed
by participants in the projects we have funded can also be used to address
other health issues affecting communities.

How to reach us:
Susana Hennessey Lavery
San Francisco Department of Public Health
(415) 581-2446
susana.hennessey-lavery@sfdph.org
http://sftfc.globalink.org

What we are learning:

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

> Projects to make health-related environmental changes require sustained funding and can be labor
intensive, 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 control
may 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 sustainable

and 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 demonstrate a history of or interest in activism,
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.

47 7
C A S E
S T U D Y

New Deal for Communities

Who we are:
Partnerships between community members, community and voluntary organizations, local authorities, businesses, and the United Kingdom government.

What we want to achieve:
To reduce health inequities by restructuring local socioeconomic environments.

What we are doing:
We designed the National Strategy for Neighborhood Renewal (NSNR) to reduce social inequities through the development of healthy
communities and neighborhoods. A key element of the NSNR was the New Deal for Communities (NDC) initiative, an area-based regeneration
initiative being implemented in 39 of the most deprived communities in the United Kingdom. The initiative supports intensive regeneration of
neighborhoods through partnerships among local people, community and voluntary organizations, local authorities, businesses, and government
agencies. Each NDC partnership has developed a plan focused on one of four key areas determined to be barriers to lasting change in deprived
neighborhoods: unemployment, poor health, crime, and low education levels. They are attempting to overcome these barriers by improving the
physical environment; improving neighborhood management; improving local services; creating better facilities for arts, sports, and leisure activities;
building the local community’s capacity to take action on health-related goals; tackling disadvantages resulting from racial discrimination; and
encouraging enterprise to support economic development.

How we will know we are making a difference:
The NDC has a formal evaluation plan that includes the collection of baseline
and follow-up data, though the vast scope of the project makes formal
evaluation an extremely complex process. Evaluation activities will focus on
three main processes to assess how the initiatives impact health, including how
direct or indirect actions contribute to health improvement; how the process of
selecting communities for participation impacts health, either negatively, due to
identification as a community in need, or positively, due to recognition of unmet
needs; and how this approach influences health by increasing the capacity
of community members to participate in health enhancing activities. Interim
evaluation results, which vary by neighborhood, show increased satisfaction
with the neighborhood as a place to live; significant improvements in crime
and fear of crime; community elected Boards to oversee neighborhood
regeneration activities (average voter turnout 23%); improvements in youth
educational attainment and in school retention; and modest improvements in
self-rated health.

Summing up:
There is a great deal to learn about the effectiveness of interventions that seek
to modify the macro-socioeconomic environment, though we do know that
the active participation of affected community members in all stages of such
interventions is essential to their success. Also, the longer the interval between
an intervention and an anticipated change in a group’s health status, the greater
the likelihood that the evaluation will fail to capture an effect.

How to reach us:
Jayne Parry
University of Birmingham
+44 (0)121 414 31

j.m.parry.1@bham.ac.uk
http://www.neighbourhood.gov.uk/page.asp?id=617

What we are learning:

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 with
community 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 financial
investment over 10 years; 4) strong national leadership; 5) expert and administrative engagement and
support; 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) lack
of support for health care practitioners engaging in community work; 3) reliance on expert consultants,
which, without transfer of skills, minimizes the ability to build community capacity; 4) inexperienced and
overworked staff; and 5) conflicts between community groups.

8
C A S E
S T U D Y

From Neurons to King County
Neighborhoods

Who we are:
Public Health – Seattle & King County, local and state governments, human services and child advocacy organizations, community residents,
and other early childhood development stakeholders.

What we want to achieve:
To develop a coordinated policy agenda that will strengthen early childhood environments and complement existing efforts focused on families
and individuals. Our ultimate goal is to create “universal access” to environments that support healthy development, school readiness, and
success in school.

What we are doing:
We designed a policy-oriented intervention to enhance early childhood environments in King County, Washington. The intervention involves the
following five steps:

> Develop partnerships with early childhood development stakeholders to discuss current and proposed policies to support early
childhood development.

> Build a common knowledge base by developing a document that describes “what we know” about policies that support early
childhood development.

> Develop policy recommendations in 14 areas by working with stakeholders to compare existing governmental policies with
proposed policies.

> Organize support for proposed policy changes through community meetings to disseminate and discuss the policy agenda.

> Monitor the 14 governmental policies on the agenda, report progress to stakeholders on a regular basis, and identify
opportunities for action.

How we will know we are making a difference:
We will formally monitor and periodically report to stakeholders on the status
of the policies. We conducted interviews to assess stakeholder knowledge
on each of the policy areas. The results of these interviews helped us identify
opportunities for action (e.g., to help move people out of poverty, stakeholders
can advocate for income assistance by enrolling all eligible families in Earned
Income Tax Credit/Temporary Assistance for Needy Families/Social Security
benefits) as well as the need for more coordinated partner and community support
before a proposed policy change could be attempted. The outcome goals of
partnerships are also used as a basis for assessment activities. For example, after
we selected school readiness as an outcome goal, we conducted a population-
based assessment of school readiness among King County kindergarten
children in three school districts. The resulting data has been used to mobilize
community engagement, funding and action particularly in one neighborhood in
King County. We are in the process of conducting a second assessment in these
school districts and will have the baseline data against which to compare and
track improvement in school readiness.

Summing up:
We are in the process of developing strategies to promote local, county, and state
policies that support environments conducive to early childhood development,
school readiness, and success in school. However, ensuring that all American
children grow up in such environments will require the ongoing commitment and
cooperation of all partners in this endeavor.

How to reach us:
Sandy Ciske, Regional Health Officer
Public Health – Seattle & King County
(206) 263-86

sandra.ciske@kingcounty.gov

What we are learning:

It is difficult to keep partners engaged long enough for them to become fully informed participants in
building a policy agenda to support childhood development and to keep them focused on the environment
rather than on individuals or families as the unit of change. Although people say they want to change
conditions in their community, they may lose interest in the proposed policy agenda before it can be
implemented, because the changes necessary can seem daunting and the benefits of such changes
seem 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 services
and programs.

9
C A S E
S T U D Y

The Delta Health Center
Mound Bayou, Mississippi

A Historical Case Study
Who we are:
The Delta Health Center, located in Mound Bayou, Mississippi, was created in 19

following a year of intensive work to establish 10 local community
health associations. These local associations, which modeled themselves on black churches and offered public health and nursing services, eventually
merged to form the North Bolivar County Health Council, which became chartered as a community development corporation.

What we wanted to achieve:
To develop a health center that provided primary medical services and to change social determinants of health by helping the local community to organize,
articulate their health-related needs, and act to meet those needs.

What we did:
In addition to providing medical, dental, and nursing care, the health center offered the following services:

> Environmental services. Activities included digging a protected well, building sanitary privies, repairing and screening housing, and establishing
rodent and pest control.

> Nutritional services. Activities included obtaining money for an emergency food distribution program and developing the North Bolivar County
Farm Cooperative, in which 1,000 families worked to grow vegetables instead of cotton, sharing the harvest and selling the surplus in local markets.

> Transportation services. Activities included creating and operating a bus transportation system that linked the contact centers of the 10
community health association centers to the Delta Health Center.

> Educational services. Activities included training community members as medical secretaries, medical librarians, nursing aides, and community
health workers/educators/organizers; establishing a General Educational Development certificate program under the credentialing umbrella of
a local black community college; operating a college preparatory program; operating a public health sanitarian program; and establishing the
Office of Education within the Delta Health Center to assist community members with applications to colleges and to medical, nursing, and other
professional schools. Within the first eight years, this program produced seven physicians, five doctors in the clinical sciences, two environmental
engineers, more than twelve registered nurses, and six social workers.

> Financial services. Activities included establishing a bank branch in Mound Bayou, where local black community members were hired as
tellers and supervisors and racial discrimination in mortgage lending was decreased, which led to the construction of new housing and an
increase in home ownership; hiring a part-time lawyer to apply for federal and state housing; and establishing economic and community
development programs.

In addition, we worked to reduce the social isolation of poor and rural communities by establishing summer internships for students as well as Head start,
teen guidance, and counseling interventions.

How we knew we were making a difference:
The success of our efforts has been reflected in the personal commitment of those who
received services from the Delta Health Center and then returned to join the Center staff
in various positions, including as executive directors, physicians, and nurses.

Summing up:
Community health centers can partner with local communities to function as
multidisciplinary community institutions that address a wide range of factors affecting
health outcomes. The Delta Health Center, originally sponsored by Tufts Medical
School, is now owned and operated by a nonprofit community board in Mound
Bayou, Mississippi, and serves parts of three counties in the Mississippi Delta.

How to reach us:
Seymour Mitchell, Executive Director
Delta Health Center
(662) 741-21

http://www.tecinfo.com/~dhc1/history.html

What we learned:

After initially resisting many Delta Health Center activities, the state government, state and local medical
societies, and other Mississippi resources ultimately cooperated with the Center; some poverty-alleviating
interventions led to conflict within the black community because they were perceived as threatening to
middle class community members and institutions; and many Center activities fostered important attitudinal
and opportunity changes among community members (e.g., educational interventions led to higher levels of
educational aspiration and achievement). The Delta Health Center can serve as a model for other federally
qualified health centers attempting to increase community capacity to improve the social determinants
of health.

Developing a
Social Determinants of

Health Inequities Initiative
in Your

Community

This chapter provides guidelines you can adapt to develop a social determinants of health
initiative in your community. As you prepare your initiative, engaging multiple sectors of the
community and encouraging active participation in collaborative processes are critical
to improving the conditions for health. These processes involve personal and professional
commitments to build trust, accept responsibility, listen to new or opposing perspectives, and
maintain authenticity.

> Section 1 of this chapter discusses how to enlist participation from members of
your community to create partnerships and build capacity.

> Section 2 provides methods for assessing social determinants of health and
developing a shared vision for community change.

> Section 3 describes processes for building community capacity to address social
determinants as part of your shared mission and vision.

> Section 4 offers approaches useful for focusing your initiative on social
determinants of health inequities.

> Section 5 describes how to develop and implement an action plan for your initiative.
> Section 6 discusses how to assess your initiative’s progress, make adjustments as

needed, and share your results with others.
> Section 7 provides recommendations for how to maintain your initiative’s

momentum over time.

Sections 1–7 are presented in sequential order, but the framework for developing your initiative
illustrates how the information presented in these sections forms a cumulative knowledge base
or process for achieving health equity (see Figure 3.1). This framework recognizes that the
information presented in each step may be useful to change social determinants of health
inequities, whether you are forming a partnership, developing goals and objectives for a
program, or evaluating why a program was or was not successful in your community. 332

Each section provides information, tools, and processes that you can
incorporate into your ongoing work or use to start a new initiative.
Some of these resources are provided in call-out boxes as follows:

> Moving Forward
Includes thoughts and recommendations from others
engaged in this work.

> Forum Spotlight
Presents work from the community initiatives described
in Chapter 2.

> Example from the Field
Provides an example adapted from multiple initiatives of how
these resources have been applied in diabetes prevention.

> Perspectives
Offer insights from experts in the field.

Finally, this chapter presents information and resources that can be used to
produce change, whether you are creating a new partnership, transforming
an existing partnership, or working on organizational change to address
social determinants of health.

Figure 3.1: Phases of a Social Determinants of Health Initiative

Figure adapted from Brownson et al, 2003 and Green et al, 1991.51,

S E C T I O N 1

Creating Your Partnership to Address
Social Determinants of Health

Because social relationships are complex and have varying effects
on different members of a community, establishing a broad-based
collaborative partnership is fundamental to addressing the social
determinants of health inequities. Partnerships can be described
both by their structure (the number and types of groups that form
the partnership) and by the methods and processes of collaboration
they use (the ways partners work together to create change and
the degree to which all partners are engaged in the partnership’s
activities).

This section describes how to create a partnership to
address social determinants of health within your community.

Developing the structure and collaborative
processes for your partnership
A partnership is a purposive relationship between two or more
parties (individuals, groups, or organizations) committed to pursuing
an agenda or goal of mutual benefit.54 Partnerships are formed for
many reasons, including to help members of the partnership learn
and adopt new skills, gain access to necessary resources, share
financial risks and benefits, exchange viewpoints with a broad range
of individuals and organizations from the community, and respond
to the changing needs of a community.53 It is essential to build
partnerships to address social determinants of health because no

one group, be it health care providers, public health practitioners,
or community members, can accomplish the many tasks required for
changing social, economic, and environmental conditions that impact
health. Partnerships are necessary in order to:

> Pool information.

> Increase understanding of a community’s needs and assets.

> Improve public policies and health systems.

> Engage new issues without having sole responsibility for
managing or developing them.

> Develop widespread public support for issues or actions.

> Share or develop the necessary resources for action and
problem solving.

> Minimize duplication of effort and services.

> Recruit participants from diverse backgrounds and with
diverse experiences.

> Promote community-wide change through the use of multiple
approaches proposed by representatives from different sectors
of the community.

> Improve your chances of making meaningful changes in community
conditions by gaining community members’ trust in a broad-based
coalition of partners.53–

The first step toward creating a successful partnership is to assemble a group
of interested community members and organizations to discuss ideas and
concerns for the community. In doing so, it is important to recognize that
individuals and groups might already be gathering in your community. You
may choose to work within existing partnerships to minimize the burden put
on them by asking them to join yet another group. These existing partnerships
may have helpful knowledge and experience. However, although existing
groups are important, they may not address the social determinants of health
or include people or organizations from the community who can inform
initiatives to address social determinants. Therefore, you might wish to invite
others to join your efforts, particularly those who have insight into or experience
harm from the political, social, economic, and environmental conditions in
your community.55–

Listening to the voices of people and organizations in the community who
experience inequitable distribution of social, economic, and environmental
resources can help to build a strong partnership to address social determinants of
health inequities. Together with other members of your community, you can identify
these important nontraditional partners by making a list of the relevant sectors
of your community (e.g., government, education, business, public services, faith,
funding agencies) and ensuring that your partnership includes representatives
from each of these sectors as well as other community members. To effectively
identify those who may be interested in the work of your partnership, it may first
be necessary to consider how your community is defined.

PERSPECTIVES — Community
Yvonne Lewis: Faith Access to Community Economic Development; Flint, Michigan (Participant in Learning From Doing forum)

Involving the community into the decision-making process is critical
for ensuring that decisions concerning community health are just and
right for all, not only those in charge. People in communities know what
their problems are, and researchers can learn from the experiences of
community members by talking with them rather than talking about them.

Communities have been defined or characterized in a number of ways,
including as groups of people who live in a particular geographic area,
have some level of social interaction, share a sense of belonging, or share
common political and social responsibilities.60–65 Each community has its
own set of structures and norms that govern interactions among its members.
A person may be part of many overlapping communities, some of which
influence access to social resources more than others. Thus, someone living
in a geographically defined community that is economically depressed might
have less access to affordable healthy food options (e.g., grocery stores or
supermarkets) and medical care (e.g., hospitals or clinics) than someone living
in a more prosperous area, even though this individual may have a relatively
high personal income.

The following questions can help you think about how to define your
community: Who does the community include? Who does it not include?
Does the community have definite geographic boundaries? Are there
social or cultural ties that link community members? What are some shared
characteristics of the community? (See “Example from the Field: Building
Community Partnerships.”)

Once your partners have been gathered, consider ways to meaningfully
involve this diverse group of community leaders (e.g., businesspersons, clergy,

Correcting inequities requires knowledge of how systems work. For
example, communities need to understand how the legislature decides to
allocate money. Then they can ask questions of the folks saying, “please
vote for me,” and work to achieve things that will make a difference in
their communities.

health care providers) and community members. This may include informal as
well as formal strategies. For example, it is often useful to have an informal
meeting at a restaurant. Informal activities such as “ice breakers” can encourage
members to get to know each other and enable them to learn how to work
across inherent power differences within the group.66, 67 It can also be useful
to choose a neutral facilitator or facilitators to help keep the group focused
and moving forward. A facilitator recognizes that a group can accomplish
more than one person alone because of the varying skills and talents of group
members as well as different norms, cultures, and processes of your partners.
A facilitator can encourage all partners to take part in the group and help the
group address conflict when it arises.

An important formal strategy is to establish guiding principles for partnership
interaction. These principles can include how partners agree to interact within
the partnership and how information is shared within the partnership and with
those outside the group. Some principles to consider are listed in “Moving
Forward: Partnership Principles.” You and your partners can use these to guide
the development of your own principles. Once agreed on by all partners,
your principles can be posted at meetings and referred to when necessary. To
sustain the partnership, it is useful to revisit and modify your principles as new
partners join your group.

ExAMPLE FROM THE FIELD

Building Community

Partnerships

A local public health agency has just received funding for a community-
based initiative to address diabetes, a growing community health concern.
Evidence suggests that at least 10%–15% of adults in this community have
diabetes (note: this does not include people with undiagnosed diabetes)
and this number continues to rise. Local hospitals report an increase over the
past year in the number of people coming to their emergency departments
seeking care for uncontrolled diabetes, including high blood glucose levels,
foot infections, high blood pressure, and vision problems. Doctors advise
the patients to eat healthy, be physically active, and take their medications.
However, many of these individuals lack access to medications or health
insurance. In addition, living conditions, such as inadequate housing or
homelessness, lack of resources or places to purchase healthy foods, and
an absence of employment opportunities, make it difficult to eat healthy
or be physically active. For these reasons, the agency decided it was
important to focus on the social determinants contributing to diabetes and
overall health. To get started, agency representatives began within their
own organization and listed partners as follows:

> Someone with community health assessment experience.

> An epidemiologist.

> Someone who knows about health surveillance.

> Someone with community outreach experience.

> Someone with health education experience.

Next, they identified potential partners in their community, including:

> Nurses, doctors, or other health care providers, particularly those
who treat people with diabetes.

> Hospital and health clinic administrators.

> Individuals from volunteer agencies.

> Representatives from local businesses (e.g., pharmacies, recreational
facilities, and grocery stores).

> Representatives from local homeless shelters and food pantries.

> Faith-based organization leaders and members.

> Local media representatives.

> Policy makers and local government officials.

> Community members who know the history of the community,
including those with diabetes and those who care for people
with diabetes.

> Local school administrators.

> Funding agency representatives.

MOVING FORWARD
Sample Partnership Principles
Convene a meeting with your partners to agree on a set of principles for
all members to adhere to during meetings and other interactions. These
principles are based on the premise that all members seek, as a partnership,
to create initiatives that build on the unique strengths and assets of the local
community. To do so, all partners agree to respect the beliefs and cultural
norms of others and to build trust and mutual respect to ensure that programs
will be maintained and enhanced over time. The following principles may
help to start your discussion:

We are committed to equity, collective decisions, and collective action.

> Knowledge originates and resides in all members of a group.

> All partners are encouraged to participate in all phases of the process.

> Information is shared among all partners.

> Differences in interpretation are addressed with respect for all partners.

> Efforts are made to ensure that the language used is heard and
understood by all partners.

> Partners will recognize and honor that each partner brings different
assets and different needs to the partnership.

We are committed to high-quality, ethical initiatives.

> We are committed to ensuring that no harm, including emotional
and physical harm, is done to anyone affected by the initiative.

> We are committed to full and total disclosure of all information
related to risk.

> Informed consent protects the initiative partners and participants
as well as the affected community.

> Confidentiality will be maintained.

> Partners agree to act in a manner that is respectful to other partners, to
the community, and to the organizations they represent.

> Partners will obtain appropriate human subjects review or approval
prior to the collection of qualitative or quantitative data.

> Partners will obtain approval from the partnership to use data or
publish findings.

We are committed to addressing social inequities that affect health,
including those that constrain the meaningful participation of individuals
and communities in the decision-making process.

> We are committed to processes that foster inclusion and will work
against all forms of exclusion, such as racism, sexism, or homophobia.

> We are committed to ensuring all partners have an opportunity to
participate in local governance, such as membership on city councils
or school boards.

We will maximize opportunities for learning within the local community
and associated organizations.

> We encourage shared leadership (i.e., decision making, meeting
facilitation, direction and management of the partnership).

> We encourage shared input into the development, implementation,
evaluation, and dissemination of partnership initiatives.

> We will actively seek financial and other resources that can benefit
the community. This includes working with local partners to develop
applications for funding.

Assessing partnership resources and building capacity
It is helpful to take an inventory of the individual, organizational, and structural > Does your partnership speak with a unified voice?
resources that influence your partnership’s capacity to carry out its activities. > Do several individuals help with day-to-day operations?
When considering your partnership’s capacity, it is useful to ask your partners > Do you have shared leadership?
the following questions: > Do leaders have the skills necessary to facilitate a meeting? Do you share
> What is the demographic makeup of the partnership (e.g., gender, race/

ethnicity, religion, age)? Is there a variety of groups within your partnership?
Who is missing? How will this influence your ability to create change in

your community?

> Do all partners feel they have a voice? Are all opinions and ideas
taken into consideration and respected?

> Are meetings held in a place and at a time that encourages
participation by multiple groups within your community?

information from the meeting with those who were and were not present
(e.g., minutes)?

> Do current leaders know how to mentor new leaders?
> Do members trust the partnership leader?
> Does your partnership influence events outside your group?
> Does your partnership have physical space and other resources (e.g.,

facilities, equipment, supplies) for day-to-day activities?

> Have you and your partners clearly described what you want to do? ExAMPLE FROM THE FIELD
> Do you have processes in place for shared decision making?

Identifying Partnership Assets

> Do you have processes in place for managing conflict when it arises?
(See “Anticipating challenges” on page 79) To identify partnership assets, the community partnership to address the social

determinants of diabetes decided to engage partners in the following discussion:
PERSPECTIVES — Funding > Who are the individuals, organizations, and institutions that make up this

Alicia Lara: California Endowment; Woodland Hills, California partnership? Are people with diabetes involved?
(Participant in Learning From Doing forum) > Do our partners represent the people living in this community in their race/

ethnicity? Gender? Income? Education? Age? Ability status? Sexual orientation? For funders, the two most important elements in improving the
> What individual and organizational assets do partners bring to the table? These social determinants of health at the community level are achieving

might include, for example, the capacity to provide health services; relationships balance between individual and social responsibility for health and
to policy makers, health care administrators, or the media; connections to
understanding the power dynamics of community interventions.
other important sectors, such as social services, education, jobs, or housing;
Funders should be prepared to:

community organizing skills; office experience; research or evaluation skills;
> Ensure that the projects they support strive to achieve a
places to meet; and resources such as computers or copy machines.
balance between individual and group responsibility.

> Have we established communication and decision-making processes? > Support changing the power dynamic by helping community
> What is currently being done to prevent the onset of diabetes in our community? based organizations access and manage resources.

What is being done to address the diagnosis and management of diabetes? > Accept that creating sustainable change in a community
What is being done to address social determinants that contribute to
requires a long-term commitment from funders.

diabetes? Who is doing this? Can we partner with them?
> Learn to work collaboratively with other funders.

Building partnership capacity
Responses to these questions will help point to areas where the partnership is
doing well and areas that need improvement. This inventory can lead to changes
in where and how often the partners meet, how long meetings should last, decision-
making processes, conflict-management strategies, and the roles and responsibilities of
individual partners.

In addition to your partnership principles, it is important to create and agree upon ground
rules for running partnership meetings. Ground rules are a set of standards for group
behavior that establish a safe and comfortable environment and may include sharing
information, respecting others’ opinions, refraining from dominating the discussion,
correcting misperceptions and maintaining confidentiality. For further information
and assistance with creating partnerships, see “Moving Forward: Partnership
Meetings” below.

MOVING FORWARD
Partnership Meetings

> Convene your partners to discuss a proposed agenda.
> Build social time into your gatherings for networking or just getting to

know each other.
> Prepare an invitation with a catchy slogan and reading materials to

attract community members to the discussion.
> Consider inviting a neutral facilitator for the discussion.
> Agree upon, post, and revisit as needed a set of ground rules for

the meeting.
> Develop, post, and revisit as needed a set of principles to guide

the partnership.
> Meet on a regular basis with a clear purpose; start and end meetings

on time.
> Define roles and responsibilities for all partners (e.g., appoint someone

to take notes and prepare meeting minutes).
> Preserve shared leadership and responsibility by delegating meaningful

tasks to small groups or subcommittees and devising realistic timelines.
Form active committees that allow partners to be involved in issues of
concern to them.

> Prepare to engage partners using multiple methods of communication
(e.g., oral, written, pictorial) to ensure that people understand information
and feel comfortable expressing themselves.

> Avoid conversations about strategies for addressing problems until you
have jointly defined the nature of the problems.

> Create an atmosphere in which participants feel comfortable expressing
contradictory opinions.

> Focus on common ground but don’t be afraid to address conflicts.

> Be prepared to deal with conflict as it arises. (See Section 5 for more

information on conflict resolution)

> Prepare meeting summaries and share them with all partners.

> Establish consensus on the financial responsibilities of members and

develop a budget for the partnership.
> Build relationships with elected officials and other key community leaders

to gain support for the partnership.
> Ensure consistent and clear communication among all partners. Consider

creating a newsletter to keep everyone informed.
> Seek technical assistance and support if resources are needed from

outside the partnership. This may include recruiting people with needed

skills to become members of the partnership or asking outsiders to help

(but not necessarily join) the partnership.

> Recognize hard work and dedication through celebrations and

fun activities.

Your partnership will likely include a wide range of individuals and groups (e.g., members,
researchers, health care professionals, counselors, educators, community activists, community
planners), so you may want to consider dividing partners into smaller, more focused subgroups
to enable the partnership to function more efficiently (e.g., finance committee, executive
committee, youth committee, senior committee). The structure of the partnership should specify
how these committees are to coordinate their efforts with the entire partnership. For example,
you may decide to have committees report to the larger group on a regular basis.

Establishing strong relationships among partners and ensuring that each partner has clear
roles and responsibilities are essential to the success of your partnership. Carefully consider
whom to invite into a partnership, how information is to be shared, and how inherent power
structures already operate within the partnership. As you move toward defining which social
determinants of health you want to focus on and the approaches you want to use, you may
need to consider adding new partners to enhance the group’s resources and capacity.
Highlighting the benefits of participation for each member of the partnership and ensuring
that the partnership is structured in a way that maximizes these benefits for each partner are
also important.

PERSPECTIVES — Research
Susan Tortolero: University of Texas Health Science Center; Houston, Texas
(Participant in Learning From Doing forum)

Academic and public health researchers need to adapt training, evaluation, and research
approaches to support and develop the relatively new field of social determinants
intervention research. For example:

> Public health models that hold individuals solely responsible for their poor health need
to begin incorporating systemic factors that affect health, such as racism and poverty.

> Developers of interventions to address social determinants of health need to conduct
appropriate evaluations of the interventions and publish the results to build a scientific
basis for this work.

> Researchers and community partners need to be trained in conducting community-
based participatory research. Training should include leadership, participation in
the policy-making process, communication skills, community organizing skills, and
quantitative and qualitative methods for data collection and analysis.

> Academic institutions need to be more flexible in supporting this type of research
and sharing resources with the community.

FORuM SPOTLIGHT
How to Use Partnership Capacity to
Enhance Programming

The following example illustrates how existing partnership
resources were used to develop a social determinants of health
initiative and how partnership capacity was strengthened as
part of the initiative.

The East Side Village Health Worker Partnership (ESVHWP),
established in 1996, conducts community-based participatory
research to understand and address social determinants of
women’s health (see pages 20-21). The ESVHWP is guided
by a steering committee made up of representatives from
community-based organizations and academic institutions, as
well as health care providers and community members known
as Village Health Workers (VHWs). The steering committee
decided to focus on diabetes in women residing in Detroit’s
east side, because the Detroit VHWs deal with diabetes in
their own lives and the lives of their friends, families, coworkers
and community members. Given the benefits of having an
existing partnership (e.g., people with a working relationship,
resources, skills, and experiences), the VHWs were able to
develop the Healthy Eating and Exercising in Detroit (HEED)
initiative. As the ESVHWP members worked together to
develop, implement, and sustain the HEED project, the VHWs
were also able to attract individuals with other resources, skills,
and experiences to enhance their capacity to reach community
members and influence their behavior.

S E C T I O N 2

Focusing Your Partnership on
Social Determinants of Health

With your partners around the table and principles and ground rules
established, you are now ready to identify and discuss the social
determinants of health inequities in your community.

Assessing social determinants of health
The first step in assessing social determinants of health is to conduct
a community assessment. Community assessments are important
for several reasons. First, an assessment can provide insight into the
community context and ensure that interventions will be designed,
planned, and carried out in a way that maximizes benefits to the
community. Partnerships can use assessments to make decisions about
where to focus resources and interventions. A community assessment

also helps to ensure that all members of a partnership understand
of the relationship between the social determinants and the health
behaviors or outcomes of interest. Information from a community
assessment can encourage others in the community to provide
support or resources for the intervention efforts. Lastly, a community
assessment can be used to understand where your partnership is
starting and what kinds of things you want to track along the way
in order to determine how your efforts are contributing to change. A
community assessment is considered more comprehensive than the
more traditional “needs assessment” because it assesses not only the
challenges and needs of the community but also the resources and
strengths of the community.

There are many ways to identify and assess social determinants of health. Your
partnership can choose one or several, depending on the interests and skills of
your partnership members and on resource availability. Below are a series of
steps to consider as you conduct your community assessment.

1. Consider what you and your partners want to assess.
In some communities, it may be helpful to gather support for addressing social
determinants by identifying the leading causes of morbidity (sickness) and
mortality (deaths) for the community. Partners can then assess the extent to
which the social determinants influence morbidity and mortality, as illustrated
in Chapters 1 and 2. Other communities may choose to identify the social
determinants first and then examine the extent to which each contributes to causes
of morbidity and mortality. Both approaches can be helpful for narrowing in
on your partnership’s priority areas. Remember, some social determinants have
a direct impact on health whereas others influence health through behaviors
or psychosocial factors (see Figure 1.1 on page 10). In addition, some social
determinants can have a positive influence on health (e.g., support, resources)
whereas others have a negative influence. Lastly, once your partnership has
chosen a priority area, it may be useful to reflect with community members on
current and past programs that have been conducted to address this area, if any
(e.g., policy development, environmental change, social marketing campaigns,
education programs). Once an inventory has been created, document what
about these prior efforts did or did not work, what challenges were faced, what
was not addressed in previous approaches, and whether efforts worked for the
entire community or only for specific populations.51,70

2. Talk to other community partners and members who
represent the population or communities of interest.
From these conversations, try to determine perceptions of the needs,
resources, and challenges in the community. These individuals may be
interested in collaborating on the community assessment and cultivating a
working relationship to support intervention planning, implementation, and
evaluation activities.

3. Think about the types of information that will be useful
for understanding your community.
There are multiple sources of information that can be assessed. The community
initiatives presented in Chapter 2 suggest that a combination of information
sources may provide the most complete perspective of the community. In
general, it is useful to consider sources in the scientific literature as well as
local, state, and national Web-based data systems. The following existing
sources of information may be of use:

> Morbidity/mortality. Numerous data systems are available to evaluate
the rates of morbidity (sickness) and mortality (deaths) within your
community. To the extent possible, it may be useful to examine these data
by race, income, or other characteristics to better understand how social
determinants could be influencing health disparities in your community. For
example, you can view the National Health and Nutrition Examination
Survey data (NHANES, http://www.cdc.gov/nchs/nhanes.htm),
National Health Interview Survey data (NHIS, http://www.cdc.gov/
nchs/nhis.htm), and National Vital Statistics System data (NVSS, http://
www.cdc.gov/nchs/nvss.htm).

> Behavioral factors. Various groups in your community might have different
rates of health-related risk behaviors. Even if you wish to focus on the
social determinants of health, it may be useful to have information about
health-related behaviors among different groups in your community.

These data may be important in understanding the extent to which social
determinants influence health behaviors and health outcomes. For example,
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, available Spring 2008).

> Social indicator data. A number of sources can give information on
various social, economic, and environmental conditions in your community,
including employment, education, housing, transportation, and parks and
recreation. It may be useful to have a researcher or other partner familiar
with how to access and work with such data (through Web sites or other
sources). The benefit of these data is that they provide information about
places or communities on a wide variety of indicators. For example, these
data sources may provide information on employment (e.g., job growth,
discrimination, affirmative action policies), housing (e.g., residential
patterns, costs, mortgage lending practices), environmental hazards
(e.g., air quality, hazardous waste), and education (e.g., graduation
rates, dropout rates, literacy rates) as well as individual-level information
(e.g., percent of families living below poverty in your county). Multiple
useful resources are available on the Web at http://www.cdc.gov/
dhdsp/library/data_set_directory/pdfs/data_set_directory (data
set directory of social determinants of health at the local level).

Each of the data sources described above may be helpful for determining
the best starting point to understand how social determinants contribute to
health disparities in your community. By reflecting on them together you may
gain a better sense of the specific social determinants you want to address.
For example, your community may have high rates of morbidity and mortality
associated with high rates of obesity (e.g., cardiovascular disease, diabetes)
and lower rates of fruit and vegetable consumption in areas with fewer
grocery stores. These findings might lead your partners to consider developing
community produce markets.

4. Determine what information you need to collect to better
understand your community.
The community initiatives presented in Chapter 2 suggest that a combination
of assessment methods works best. Your partnership may find existing sources
of information useful, but there may be limited existing data sources that
can provide insight into the resources, services, and other types of support
in your community. You may want to gather additional information before
deciding, but this can be costly and time consuming. In this case, guidance
from someone with research experience will increase the quality of the data
and the likelihood of getting the information your partners are seeking. Below
are some methods your partners might want to consider when gathering data
for your community. Community asset mapping may also be helpful and is
discussed on page 55.

> Review of existing data sources. One aspect of community assessment
is an assessment of existing resources and programs. This includes an
assessment of policies, programs, services, and resources of community
agencies and organizations to assess interaction among these groups,
duplication, overlap, gaps, emerging issues, and new resources. It may
be helpful to list the existing sectors of your community and the specific
agencies or individuals your partners consider important in each area.
These might include health care, policy makers, social service agencies,
civic and neighborhood associations, educational institutions, businesses,
faith-based organizations, community members, and media representatives.
Identify the resources that each entity can contribute, including personal
skills such as counseling or public speaking, funding, meeting space,
equipment, supplies, programs, publicity, tools, or information. Describe
how these entities and resources can have a meaningful impact on your
partnership’s area of interest. Finally, identify strategies for recruiting
entities that are not already part of your community partnership (i.e.,
determine what might motivate them to get involved). It may also be useful
to identify how, or if, various sectors contribute to the social determinants
that influence health. For example, there may be institutional policies that

influence who gets hired or city policies that influence whether or not
certain businesses decide to provide services in a particular area.

> Survey data. Several data sources have public use instruments that can
be used within your community. Your partners may want to use these
instruments to gather information about morbidity, mortality, behavioral risk
factors, psychosocial factors, and social determinants. These data may be
available through the Centers for Disease Control and Prevention (http://
www.cdc.gov) and include BRFSS, the Youth Risk Behavior Surveillance
System and the Global Youth Tobacco Survey, among others. Alternately,
you may want to collect survey data that is not typically part of existing
data sources. For example, it may be important to assess your community
capacity for engaging in change efforts (e.g., civic engagement,
organizational belonging, interorganizational networks, and community
values). Several researchers have considered ways to capture these
characteristics and have made tools and instruments available (e.g.,
http://ctb.ku.edu and http://wonder.cdc.gov).

There are also various
instruments for assessing experiences of racism and discrimination and
socioeconomic status that may be useful.72–

> Brainstorming. Brainstorming is a way of generating ideas from a group
of individuals. You may want to ask members of your partnership to list
the social determinants they think have a significant impact on the health
of their community. You can do this verbally, asking people to discuss or
call out the concerns in their community, or visually, asking individuals or
groups to create posters or collages that picture the health concerns in
their community. The benefit of this process is that you can learn about
community perceptions of what is most important. If your partnership
represents a small group of individuals within your community, you may
need to get input from other community members and organizations in
order to capture the range of issues most important to the entire community.

> Qualitative interviews or focus groups. Qualitative interviews, or guided
discussions, can occur with individuals or with groups. Such interviews
allow you to ask specific questions about social determinants of health,
including current or historic experiences. Developing an interview guide
with an outline of questions and probes (follow-up or clarifying questions) to
be asked of each individual or group will increase the quality and amount
of information gathered from participants. One benefit of this method is
that it allows you to obtain more in-depth information than you might from
a brainstorming process while still providing a community perspective.
You can also identify additional groups in your community and ensure
that individuals from each of these groups are interviewed, allowing for a
wider range of perspectives than you might get from brainstorming.75,76

> Photovoice. Photovoice is a way of conducting a community assessment
through still photographs or video. The photography may be conducted by
members of the community or by outsiders. Typically, the images collected
are used to generate dialogue among community members or community
agencies about the conditions in the community.

> Community observation and audits. Community audits are tools that can
be used to systematically track various social and physical structures as well
as individual behaviors in a geographic location. Audits may, for example,
be checklists that indicate whether there are sidewalks or streetlights in a
particular location. Audits can also be used to identify the presence or
absence of merchants who sell fruits and vegetables as opposed to snack
foods and alcohol. Alternately, audits can be used to assess the number of
vacant lots, playgrounds (with and without equipment), or graffiti. Community
audits may be used with geographic information systems software to create
maps indicating the presence or absence of various structures in different
areas. Printed poster-sized maps and pushpins can also be used to indicate
the presence or absence of various structures.78–

> Concept mapping. Concept mapping is a process that uses complex
qualitative data to engage participants in the definition and measurement
of key determinants. In addition, it provides participants with the opportunity
to develop conceptual frameworks of how the determinants relate to each
other and to health and behavior. Concept mapping includes six overall

steps: preparation (select a group of participants and determine focus),
group brainstorming to generate statements, structuring statements through
a sorting process to create clusters, representation of the statements/
clusters using a map, interpretation of the maps and utilization of the
maps. This process is considered particularly appropriate for obtaining
information regarding group-level definitions and perceptions as opposed
to individual conceptualizations.82–

> Health impact assessment (HIA): HIA is a combination of procedures,
methods, and tools by which the potential impact of a policy, program,
or project on the health of a population can be assessed. It is similar to
an environmental impact assessment, though the emphasis with HIA is the
impact on humans rather than the environment. HIA can range from simple,
fairly easy-to-conduct analyses to more in-depth, complex analyses. HIA is a
broad concept often interpreted in different ways by different users, but there
are common elements that can provide a framework for common action
among multiple users. Some of these common elements include: social
impact assessment, epidemiological assessment, retrospective evaluation of
community interventions, health inequalities impact assessment, and hazard
mapping. While retrospective analyses are possible, HIA is considered most
effective when used prospectively, or before deciding upon and implementing
a course of action.

> Appreciative inquiry. (AI) AI is a change strategy that identifies
existing strengths in a community, group, or system and then actively
builds on these strengths to improve a situation. AI often begins by
asking such questions as “What is working well here?” and “Why is
this working well?” Rather than focusing on problems, AI uses positive
words, stories, and images to describe conditions that currently exist
and then positively describes conditions the group would like to create.
Steps in the process often include discovery, visioning, designing,
and creating/sustaining. Capturing and enhancing positive aspects
can access untapped potential, which can then be directed toward
positive change.86

Table 3.1: Applying Assessment Methods to Different Types of Social Determinants

Method Context Example measures

Review of existing data

Social

> Crime rates.
> Housing patterns.
> Law enforcement policies.

Economic
> Poverty rates.
> Local tax dollars spent on health, education, transportation, etc.
> Policies on government spending.

Environment
> Land-use policies (e.g., commercial, residential, parks).
> Industry standards (e.g., pollutants).
> Maintenance policies and procedures (e.g., trash, playground equipment).

Surveys, qualitative
interviews, focus groups,
appreciative inquiry,
concept mapping

Social
> Perception of racism and discrimination.
> Perception of a sense of community.
> Feeling safe from interpersonal crime.

Economic
> Perception of job availability.
> Perception of local businesses’ financial contributions to the community.
> Attitude toward policies on public spending.

Environment
> Knowledge of environmental hazards in the community (e.g., pollution, illegal dumping).
> Perception of access to places and resources to maintain health.
> Attitude toward policies related to the environment (e.g., pollutants).

Brainstorming

Social
Economic
Environment

> Community list of priority concerns.
> Perception of strengths and weaknesses of previous efforts to address concerns.
> Identification of innovative ways to address concerns.

Photovoice

Social
Economic
Environment

> Pictures of people, places, or events that can be used to describe or tell a story
about the community, such as:
• People talking or greeting one another; people arguing or acting hostile to

one another.
• Closed schools or businesses, building remodeling, or construction.
• Trees, art or cultural decoration; abandoned cars or litter.

Community audits

Social
Economic
Environment

> Documentation (e.g., checklists, inventories) of observations of people, places,
equipment, maintenance, or aesthetics in the community environment, such as:
• People engaging in physical activities; people driving in cars.
• Absence of grocery stores, supermarkets, and produce markets; presence of

fast food restaurants and convience stores.
• Parks with paved, marked, multi-use trails; playgrounds with broken swings

or rusty equipment.

Health impact
assessment

Social
Economic
Environment

> Existing evidence: published reviews, gray literature, and views and opinions of
people and organizations affected by the issue.

> Identification of health relevance of a policy or project of interest.
> Estimation of the size of health impact of the policy or project of interest.
> Identification of key health issues and concerns.

MOVING FORWARD
Identifying Social Determinants of Health

> Ask partners to think 20–25 years into the future and imagine
how they would like life to be different in their community.

> Invite outside speakers who can help inform the partnership
about social determinants of health and how they contribute
to health inequities in the community.

> Take a walking tour of different areas of the community
and ask partners to take pictures that represent conditions
or social determinants they would like to address in the
community.

5. Develop a work plan that identifies tasks to accomplish,
partner roles and responsibilities, and a time frame
for completion.
It is often helpful to lay out a specific plan for conducting the community
assessment that includes:

> The information to be collected and the questions you hope to answer.
This will help the individuals collecting the data to be sure that what they
are collecting will be useful. For example, the partnership may want to
know morbidity and mortality rates in general or by certain population
subgroups (e.g., race/ethnicity, age).

> The potential data sources to examine for this information (See Step 4
for data sources).

> The individuals responsible for exploring these data sources.

> A timeline for completion and reporting back to the partnership
that is flexible.

6. Collect and organize information so it can be
shared with all partners, community organizations,
and community members.
Develop a table of indicators related to various diseases, behaviors,
psychosocial factors, social determinants, and any other relevant information
that was gathered about your community. The Internet and other technologies
have made information easier to access than ever before. However, it is
important to focus on the data that are most useful to your partnership and to
present these data in ways that allow all partners to understand the relationship
between social determinants and health. Consider comparing the information
your partners have gathered with that collected for other communities or
counties or the state or nation as a whole (e.g., high school dropout rates,
median income among various groups, percentage of population below
poverty, unemployment rates, business census data indicating changes
in the number of grocery stores in your community). This comparison can
help identify high-priority considerations for your community relative to other
communities. It is easy to be overwhelmed by too much data. If possible, have
someone who is familiar with accessing and summarizing data help you in
this effort. Remember that some people are better able to process data when
it is presented visually in maps, graphs, and, to a lesser extent, tables.* It
may also be useful to consider pros and cons of more simple data collection
and methods (e.g., counting the number of vacant lots and indicating their
location by putting pushpins on a map) versus more complex and costly data
collection and methods (e.g., extensive community audits and geographic
information systems software).

* For maps, the data must be geographically referenced so they can be
displayed with mapping software.

7. With information gathered and summarized, partners
can prioritize issues to address.
After you have completed your community assessment, ask partners to
decide on the most important issues to address first. This may be done in
partnership meetings or through meetings with various community agencies
and organizations. Alternately, it may make sense to hold a community
forum to present your findings. A community forum is an opportunity to bring
together individual community members, partnership members, agency
representatives, elected officials, and other interested and influential groups to
present the findings from the assessment and move toward prioritization and
intervention development. The methods used should incorporate the process
the community members and organizations have used for decision making in
the past. Regardless of the mechanism chosen, it may be useful to consider the
following in your discussion of priorities:

> Which determinants affect the largest number of people in your community?

> Which determinants are most important to your community?

> Why are these determinants important to your community?

> Which determinants have the greatest positive or negative impact
on the health of the community?

> Which determinants are easiest to change?

> Which determinants are your partners most willing to work to change?

> What is the expertise of your partners?

> What are the barriers to addressing these determinants?

> What resources are available to address these determinants?

There are four basic principles or lessons learned that others who have
conducted community assessments have found helpful in guiding discussions:

> No matter how much time is available to the partnership, there will never
be enough time to examine everything.

> Make intentional and open choices about what to assess and what not
to assess.

> Be clear about the purposes of the assessment. Make choices about
the methods you will use, what information will be shared, who the
information will be shared with, and how it will be communicated.

> Be sure the assessment promotes the interests of the community members
and that findings are not used against them.

Once you have conducted your community assessment, this information
can be helpful in determining priority areas to focus on, setting goals and
objectives for your intervention (see page 52), and determining a baseline to
assess the progress you are making toward achieving your desired outcomes
(see page 82).

Identifying a vision and mission for the partnership
Increasing agreement to focus on the social determinants, psychosocial
factors, health behaviors, and health outcomes of interest is part of the process
of building partnership cohesiveness. Partners can begin to define a general
direction for the partnership through a decision-making process that gives all
participants an active role in creating a shared vision and mission. Because
social determinants of health inequities may not be the primary focus of your
partnership, you may need to remind your partners about ways in which social
determinants affect their ability to improve the health of the community.

To address the social determinants of health inequities, you may need to
challenge partners to identify larger, system-level concerns.67 As covered in
the previous section, try to hear from a range of people and organizations
and create a balance between groups already involved and those new to the

ExAMPLE FROM THE FIELD
Assessing Social Determinants of Inequities in Diabetes
Once they had invited key partners to meet, the public health agency
identified some questions to help focus the discussion on the social
determinants of diabetes. These included:

> According to statistics, diabetes is a significant problem in this
community. Do you agree? Why? Why not?

> How has diabetes affected this community? Please identify
specific examples.

> Are some community members more likely to get diabetes than
others? Why? Why not?

> Are some community members with diabetes able to manage their diabetes
better than others? Why? Why not?

> Does the history of this community influence who gets diabetes and
how it affects their lives? How?

> Do the values of this community influence who gets diabetes and
how it affects their lives? How?

> What other factors influence who get diabetes and how it affects
their lives?

discussion. Remember to work from the list of determinants, factors, behaviors,
and outcomes already generated (see page 52).

If you attempt to change the social determinants of health within a community
by working within an existing organization, you may find that the organization
has already defined a vision or mission that does not include social determinants
of health. If so, you can either build on what exists by highlighting additional
actions that could address social determinants of health inequities or suggest
modifying the vision to better meet the needs of people and organizations in
the partnership.

Please see the “Suggested Readings and Resources” section for references
on assessing social determinants of health and writing a shared vision and
mission statement for your partnership.

> What characteristics of this community support people who have
diabetes?

> What are the obstacles to preventing, treating, or managing diabetes
for people in this community?

> What are the social, economic, and environmental conditions that
influence the prevention, treatment, or management of diabetes in
this community?

> Do other communities in this area experience the same problems
with diabetes? Why or why not?

> Do the other communities work with this community to address
diabetes? If so, how?

> What are the most common problems faced by people with diabetes
in this community?

> How do these problems relate to other challenges faced by
community members?

ExAMPLE FROM THE FIELD
Creating a Mission and a Vision67

After the partners met and agreed on some key social, economic, and
environmental concerns related to diabetes to address in their community,
they were ready to discuss their mission and vision. They organized their
discussion using the following questions:

> What are the three most important social determinants of diabetes in
our community?
• Partners used a group process in which participants wrote down

what they thought were the most important social determinants
related to diabetes. The meeting facilitator then asked each
person to read one of these determinants out loud. The
determinants were written on an easel or large piece of paper
taped on the wall so that the group could see the list. Once
everyone had had an opportunity to add one determinant to the
list, the facilitator went around the group again, asking people to
add any determinants that had not yet been listed.
• Of the determinants listed, the group was asked to identify

the top priorities for the community. Partners were asked to
pick and rank the three determinants they thought were most
important from the list generated. Then the participants stated
their top three determinants, and the facilitator indicated their
votes with stickers (i.e., blue sticker for #1, red sticker for #2,

and green sticker for #3). By doing this, the group was able
to see which determinants most people thought had the highest
priority.
• The group was asked to decide which of the determinants with

greatest priority could be more readily changed in the short term
and which of the would require long-term initiatives. The facilitator
then asked each partner to rank the determinants, this time by the
ability to create change, identifying those that could be changed
in the short term and those that can be changed in the long term.
A different color scheme was used to identify the changeability
rankings (i.e., purple for short-term change, and orange for long-
term change).

> What does this partnership need to look like in order to address these

priority social determinants of diabetes? Do others need to be invited to

join the effort?

> What does our community need more of and less of to reduce inequities
in social determinants that impact who gets diabetes and how it affects
their lives?

> How will our community look different if these social determinants of

diabetes are addressed? What can be done in 1 year? 5 years?
10 years? 20 years?

Identifying and prioritizing goals and objectives
Goals and objectives can help you stay focused on activities that enable
you to achieve your mission and vision.70,

Goals are defined as the long-
term outcomes that you hope to achieve. Objectives are concise, time- and
action-specific, measurable statements that describe how a goal will be
reached. Objectives specify what needs to occur, the time it will take to
achieve the desired result, the specific approaches you will use to address
your determinants, and how much of a change you anticipate will be required

to reach your goal. Typically, numerous objectives must be accomplished to
achieve your goal.

Each objective may also require multiple action steps. To identify and prioritize
goals, objectives, and action steps, you can revisit your partnership’s vision
and mission. Specific goals, objectives, and action steps can be derived from
these consensus-driven statements.

An initiative planning model70,79 can be very useful as you organize your
goals, objectives, and action steps and prioritize your objectives. This model
can be used to inform your planning process by guiding your community to
understand current needs and to plan for the future. To develop an initiative
planning model, outline your overall long-term goal and a series of objectives
that will help move you toward achieving this goal. These objectives can be
used to identify the specific action steps necessary to create change and
benchmarks to determine your progress. In developing this model, be sure to
include who will be responsible for each action step and the time frame for
the steps completion.

ExAMPLE FROM THE FIELD

Combined into a model, these goals, objectives, and action steps provide the
sequence of necessary actions. From this information, you and your partners
can prioritize activities according to the timeline laid out in the plan. For
example, community awareness and support may be needed before you can
secure resources to create structural changes.

In addressing social determinants of health inequities, you may decide to
focus on one specific determinant (e.g., housing, racism) within an initiative or
specific health outcomes and the social determinants that influence them.

S E C T I O N 3

Building Capacity to Address
Social Determinants of Health

Assessing community capacity
“Community capacity,” as used in this workbook, refers to the
resources, infrastructures, relationships, and operations that enable
a community to create change. Using and increasing community
capacity, also often referred to as the “assets” of a community, is an
essential step in improving the health of community members.63,88,89

Assessing community capacity helps you think about existing
community strengths that can be mobilized to address social,
economic, and environmental conditions affecting health inequities.
In general, you should look at the places (e.g., parks, libraries) and
organizations (e.g., education, health care, faith-based groups,
social services, volunteer groups, businesses, local government, law
enforcement) in various sectors of the community. It is also important
to identify the nature of the relationships across these sectors (e.g.,
norms, values), with the community (e.g., civic participation), and
among various subgroups within the community (e.g., distribution
of power and authority, trust, identity).81,82 For more information on
assessing and mapping community assets, see “Moving Forward:
Mapping Community Assets” (page 55).

MOVING FORWARD
Mapping Community Assets68

> Begin by defining community assets so that everyone understands what resources

are already available in the community. These can include people, organizations,

or places and their associated resources (e.g., knowledge, skills, meeting space).

> Discuss the importance of identifying community assets, including how these

assets can help move a project forward even when funding is limited or

unavailable. Community members feel a greater sense of control over their lives

and their communities when involved in the process, and efforts are likely to last

longer when they use existing resources.

> Work with partners to identify the purpose(s) for creating an inventory of

community assets, because you may not know what resources you have in your

community. For example, community members’ talents might be underutilized,

so you may have to find alternative ways to encourage a sense of pride and

ownership or build trusting relationships.

> Outline a process for collecting information, including what will be collected

(e.g., historical information; demographic information; awareness of social

determinants; information on social, economic, and environmental conditions;

infrastructures; facilities); how the information will be collected (e.g., telephone

interviews, group discussions or brainstorming, face-to-face interviews); what and

how many people, organizations, and places will be inventoried; how long it

will take to collect the information; how much it will cost; and how you will use

the information once it has been collected.

> Decide on roles and responsibilities for conducting the inventory, including who will

lead, who will collect and store the information, and who will analyze and

present information to the partners.

> Develop and pilot test interview questions with your partners to make sure you

are capturing all the information you need.

> Develop a map of your community’s assets such as parks and community centers

in one of several ways: find a large street map and mark assets with a dot, tag,

or pushpin (maybe color coded by type); use a computer software program

(e.g., geographical information systems); or draw your own map to illustrate the

locations of various assets.

> Use the map to identify places in the community with and without resources. This

information will be helpful as you think about what locations are in greatest need

and what resources are available in or around them.

ExAMPLE FROM THE FIELD
Mapping Community Assets68

To map community assets, the community partnership to address social
determinants of diabetes discussed the following questions and came up
with some ideas for each question:

What are the relevant skills, capacities, and experiences of community
members and organizations that can help address the social
determinants of diabetes? (Make a note of those not included
among your partners).

> Health care environment (e.g., hospitals, clinics, insurance
companies, pharmacies)?

> Food environment (e.g., produce markets, quick shops,
fast food restaurants)?

> Active living environment (e.g., sidewalks, parks, recreation centers)?

> Community services (e.g., employment assistance, housing, transportation)?

> Other public institutions (e.g., schools, libraries)?

> Private businesses?

> Nonprofit organizations?

> Community or neighborhood organizations?

How can these skills, capacities and experiences be used to address
the social determinants of diabetes? Some examples include changes
in environments, policies, and practices, such as:

> Doctors, nurses, and support staff from a local clinic could donate time
in the evenings or weekends to ensure those without health insurance
have an opportunity to access health care services.

> Community members could educate other community members about
the harmful effects of fast food, including the lack of nutrition, the large
serving sizes, and the unhealthy preparation of the food.

> Local parks and recreation departments could build or maintain parks,
playgrounds, or greenways to support active living.

> Housing officials could create programs to offer more subsidized
housing to people with low income.

> Schools could provide information to students through health
education classes on places to access healthy foods (e.g., produce
markets, restaurants) and to be physically active (e.g., parks,
community recreation centers) and encourage students to share the
information with their family members.

> Small retail businesses could receive tax incentives for selling and
advertising healthy food alternatives.

> Nonprofit organizations could work with local media to inform
members within the community and those in surrounding communities
about the significant impact of diabetes on community members’ health.

> Community groups could provide support to those with language
barriers or low literacy levels to ensure that health information is
received by all members of the community.

What skills, capacities, and experiences are missing?

> Multilingual individuals.

> Media personnel.

> Evaluators.

> Individuals with knowledge of the community’s history.

> Community role models.

> Policy makers.

Building community capacity
One of the most important capacities to develop is a shared language
and common understanding of how social determinants influence health.
Once people and organizations in the community have a common
understanding, they can work to improve the conditions that affect the health
of community members.

Much of the work to increase community capacity relies on processes
that you will develop working in and with your community. The following
recommendations provide some guidance for developing these processes.

> Encourage broad community participation in planning, organizing
and implementing projects. One way to do this is to start with existing
social groups such as those in schools, work sites, service organizations,
volunteer organizations, and places of worship. Individuals within these
groups often share a sense of belonging with other group members and
have some trust in the processes that the group uses to reach its goals —
both of which are critical to the enthusiastic participation of individuals in
group projects. Experiences with these groups can be stepping stones to
future collaboration.

> Identify existing social relationships and use them to solicit participation
from other people and organizations, share information, build unity and
solidarity among community members, and open doors for individuals
and groups.

> Identify useful assets of people and organizations in the community.
These assets may include experience with strategic planning, the
ability to facilitate meetings or mobilize people and efforts, or the
ability to provide funding, space, and other necessities for carrying
out the project.

> Conduct regular conversations to share information with community
members and engage them in making decisions through consensus-
based, collaborative processes. Build on existing social networks such
as workplaces, schools, place of worship, and clubs and keep all
community voices involved by attempting to address everyone’s interests
and needs.

Ensure that your group’s leaders are representative of the community, that they
understand its needs, and that they can engage all community representatives
in identifying problems and devising solutions that will have broad support.
You should also establish mechanisms to ensure that leadership roles and
responsibilities are widely shared. These may include mentoring new leaders
or creating bylaws that require periodic changes in leadership. Attempt
to understand how the beliefs, perspectives, and histories of people and
organizations in the community influence their willingness to participate in
efforts to change community conditions and encourage them to consider
alternative ways of thinking.

Please see the “Suggested Readings and Resources” section for more
information on assessing and building partnerships and community capacity
and on establishing goals and objectives for your partnership.

S E C T I O N 4

Selecting Your Approach

Once your partnership has developed a mission and vision, assessed
partnership and community capacities, identified needed resources,
and decided on goals and objectives, you are ready to develop
interventions to address social determinants of health programs or
policy initiatives intended to move your community closer to your
vision. You may use a wide variety of approaches. These include
raising awareness or increasing knowledge of social determinants
of health inequities and their influence on health, building skills
and capacities to change a social determinant or its influence on
health; or altering social, economic, or environmental conditions
through policies and infrastructure changes. These approaches are
complementary; using them in combination increases the likelihood
that changes will lead to the desired goal. In other words, although
raising awareness and building capacity are critical, it is likely that
changes in skills and policies and infrastructures will also be required
to alter health inequities. Similarly, changes in skills, policies, and
infrastructures are less likely to occur without increased awareness
and capacity.

to Create Change
Section 2 suggested that different approaches can be used to create
the changes specified in your objectives. Section 4 describes six
approaches to changing community conditions that others have found
useful: consciousness raising, community development, social action,
health promotion, media advocacy, and policy change. The best
approach depends on what your partnership wants to accomplish
and your comfort level with the strategies used in each approach. In
some cases, the decision to incorporate certain approaches may be
partially determined by funding guidelines or other restrictions based
on work already occurring in your community or organization. The
following descriptions of these approaches will help you select those
that best meet the needs of your partnership.

Consciousness raising
What is consciousness raising?
Consciousness raising is a process through which people come together to
discuss the relationship between individual or group experiences or concerns
and the social or structural factors that influence them.90–92

Consciousness raising can be useful both in creating a coalition or partnership
and in working with an existing partnership to increase community-wide support
for addressing specific inequities in the social determinants of health.

When do you use consciousness raising?
This approach is useful for ensuring that both “insiders” and “outsiders” develop
a common understanding of issues and concerns, stimulating discussion and
motivating partners to address the issues and concerns. Consciousness raising is
a good approach when some people in a group do not see or understand how
social and structural factors influence health. It also helps individuals and groups
identify specific social determinants or structural factors that influence current
inequities to develop goals and objectives for change. In addition, this approach
can help the partnership frame issues in ways that bring groups together for
action rather than creating factions that lessen the ability to create change.

How do you use consciousness raising?
Some methods used to raise consciousness include generating discussion by
asking individuals to share their experiences, presenting hypothetical vignettes,
having the group discuss responses to a picture or photograph, or reading a
story or poem. Encourage critical reflection by asking individuals to describe
what they saw or heard as the major issue, followed by asking “but why does
this happen?” or “why is this the situation?”

ExAMPLE FROM THE FIELD
Selecting Your Approach to Create Change
The community partnership to address social determinants of diabetes inequities
decided it would be useful to generate deeper understanding of the social
determinants, as opposed to individual determinants, of diabetes. They looked
in the local newspaper and found a story about a homeless person who had
recently died at a nearby shelter due to complications from diabetes. They
copied this story and shared it with the members of the partnership. Next, they
had a partnership member facilitate a discussion focused on gaining a better
understanding of how this could happen in their community. This generated a list
of key factors associated with diabetes among people with limited resources.

List of key factors associated with diabetes among people with limited resources
> Lack of access to healthy food (e.g., not enough money to buy healthy food,

fast food is available and cheap, food pantries and soup kitchens cannot
afford to provide fresh fruits and vegetables).

> Lack of places or time to exercise.
> Limited access to health care and inability to afford medications,

cultural factors associated with seeking health services and late diagnosis.
> Chronic stressors (e.g., family, living conditions, employment status).

The facilitator then asked the group to focus on the social determinants, or root
causes, of these factors and diabetes through addressing the question, “but
why does this situation exist?” This led to the reasons listed below.

“But why does this situation exist?”
> Lack of good jobs for those with limited education or no previous

job experience.

> Many neighborhoods lack grocery stores that provide affordable fresh

fruits and vegetables.

> New development has increased the cost of housing over the past few

years, causing many people to become homeless or to move away from
their neighborhoods;. these moves may prevent people from accessing
public transportation to get to health clinics or jobs.

> Feelings of discouragement and that “the system” (e.g., health care providers,
employers, policy makers) doesn’t care what happens to people who are
“down and out.”

FORuM SPOTLIGHT
Consciousness raising
The following example illustrates how consciousness raising was used to
draw attention to community problems.

This New Orleans school- and neighborhood-based intervention is working
to reduce violence and its social determinants as experienced by youth
(see pages 18-19). Teachers worked with 15 students to write stories about
violence in their lives or in their community. A local actor worked with
the students to turn their stories into monologues. The actor and students

then added movement and sound (e.g., poetry, rap music) to the
monologues to create a living backdrop meant to evoke the locations
of violent events. They developed a list of people and organizations to
invite to their performance and held the performance at a local park.
Following the performance, the students and attendees talked about
how violence was affecting the teens’ lives and discussed strategies for
reducing violence.

Community development (sometimes called locality development)

What is community development?
Community development is a set of processes or efforts to create community
change at the local level through strengthening social ties, increasing awareness
of issues affecting the community, and enhancing community member participation
in addressing these issues.90–92 With respect to the social determinants of health
inequities, this involves bringing together individuals affected by a particular health
inequity so they can cultivate a shared group identity and develop a specific set
of processes for addressing their common purpose. Though it is important for all
work in this field to engage partners to determine processes, define problems, and
identify approaches for change, community development is unique in that those who
experience the problem are the leaders. The focus is on using existing and new
individual and community capacities to increase control over the events that occur
in the community.

Community development seeks to enhance or establish a group of individuals who
share a common purpose: the desire to increase their abilities to work together to
create changes in health or the social determinants of health. With other change
strategies, the focus may be on implementing a particular health education program
or policy or environmental change, and capacity building is seen as important but
secondary to these outcomes. In community development approaches, the goal is to
use the community capacities and strengths to increase community control.

As stated in the Ottawa Charter, a document produced by the World Health
Organization’s first International Conference on Health Promotion in response
to growing expectations for more comprehensive, ecological approaches to
public health:

“To reach a state of complete physical, mental, and social well-being, an individual
or group must be able to identify and to realize aspirations, to satisfy needs, and to
change or cope with the environment… People cannot achieve their fullest health
potential unless they are able to take control of those things that determine their
health. At the heart of this process is [communities taking] ownership and control of
their own endeavors and destinies.

As this suggests, setting priorities, making decisions, and planning strategies are some
of the main health promotion action areas; the process of problem solving is seen as
health promoting in and of itself. Building and using existing capacities for problem
solving can directly and indirectly improve health equity.

This approach may sound similar to community capacity building. These strategies
share several common characteristics. However, the processes and outcomes may
look very different. Community development seeks to establish an empowered group
of individuals who share a common purpose as the primary outcome through which
changes in social determinants of health inequities are created. Capacity building
may involve processes that increase funding, enhance skills, or make other types of
improvements but do not necessarily build on and enhance the power of those most
affected by the inequity.

When do you use community development?
Community development may be useful when you first develop a partnership or
later when the partnership has accomplished other goals. The process encourages
partners to develop a shared group identity that relies on understanding, trust,
acceptance of differences, and cohesive relationships, in addition to the partnership-
building activities described in Section 1 (e.g., inviting stakeholders, identifying social
and health inequities in the community, deciding on a shared vision and mission).
Community development is useful because it can enhance the processes by which
community partners work together to define their concerns. It can also motivate
partners to act on behalf of their mutual interests.90 This approach may be useful
when an existing partnership decides to use a more participatory approach as
opposed to one that relies on public health or other experts taking the lead.

How do you use community development?
Community members should take the lead roles in community development efforts.
Others, such as public health practitioners, researchers, and community organizers,
can assist community members by presenting processes for facilitating meetings,
problem solving, and consensus building. It is important to ensure that the models
and processes suggested can be modified by community members as needed.
It also could be helpful to engage community members in consciousness-raising
processes before, or as part of, community development to increase their awareness
of the social determinants of health.

In addition to representatives from the community, partnerships should include
community agencies or organizations that will be asked to help implement change.
Organizations are more likely to take part in changing social determinants of health
if they have been included in the discussions and have worked with the community
from the start, rather than just being asked to implement a solution.

MOVING FORWARD
Community Development Meeting Preparation

Preparing to gather:

> Clarify the purpose of the meeting. This is important so you can clearly
articulate the purpose to others who may be interested in working
with you.

> Start by inviting community members affected by the social
determinants of health in your community.

> Invite key people, including those who know about, work in, or are
affected by the social determinants of health (e.g., transportation,
education, economic development) in your community.

> Select a time, day, and place to meet that fits into the schedules of
a majority of community members and representatives of community-
based and other, more formal organizations.

> Create a clear agenda for the meeting. Ask individuals as you invite
them if there is something in particular they want addressed during this
first meeting.

> Ensure that everyone’s specific needs are met (e.g., childcare,
transportation, interpreters) so they can participate actively.

Facilitating discussion:

> Establish roles for ensuring that the group functions smoothly, including
a neutral facilitator, note taker, and timekeeper.

> Ask participants to introduce themselves.

> Establish ground rules for the meeting.

> Agree upon and post the vision and mission statements for your group.

> Establish clear decision-making processes that encourage everyone to
participate in the discussion.

> Conduct meetings in an organized fashion:

• Review minutes or proceedings from the previous meeting.

• Assess progress members have made in carrying out assignments
from the previous meeting.

• Determine items to be addressed at the current meeting and set
priorities for discussion.

• Reserve time on the agenda for information sharing and discussion
of key topics.

After the gathering:

> Share handouts, minutes, and task assignments with all members,
including those who were unable to attend the meeting.

FORuM SPOTLIGHT

Community Development

A small group of community members decided that they wanted to improve
health in their community. They realized that to do so they needed to enhance
their own capacities to define the key issues in their community and increase
their collective ability to create solutions. The small group invited several
community members and leaders (e.g., pastors from churches) to work with
them to learn together how to identify health problems that threatened the
community (e.g., diabetes, cardiovascular disease) and to create solutions.
They spent a good deal of time talking about the underlying social,
economic, and environmental problems contributing to these community
health concerns. The group worked together to learn different ways of
defining health and a healthy community. For example, participants were
asked to respond to the following questions:

> What do you know about health?

> What does health mean to you?

> What are the causes of good health and poor health?

The group then met with other community leaders to identify strengths and
needs in the community and create a list of specific goals and solutions. These
processes helped people already involved feel even more committed; it also
engaged some of those who were not originally interested. Committees were
formed to carry out the tasks identified. Some of the key social determinants
identified were lack of health insurance and lack of jobs and employment
security. Solutions identified included creating a formal cooperative that
provided members with health insurance, small business loans, and job
opportunities. Overall, those who participated felt they had contributed in a
meaningful way, learning new skills and using existing skills, so that they were
able to take the lead in creating change.

Social action
What is social action?
Social action is an approach that focuses on altering social relationships or
resources.90–92 This strategy spotlights how social factors can affect people’s
health and how inequities in the social determinants of health can be
influenced. Social action often includes activities that explicitly highlight an
issue. For example, a group of community members might join together to light
a candle for each person in their community injured by an alcohol-impaired
driver in the past five years as a way to encourage the enforcement of laws
that prohibit driving while under the influence of alcohol.

When do you use social action?
Social action can be used to help raise awareness of issues and to increase
community participation in efforts to address them. It can be especially useful
at the beginning of change efforts; later in the process, social action can
sometimes get people’s attention when other approaches have failed. Though
this strategy can help define and bring attention to a problem, it does not
necessarily identify effective solutions.

How do you use social action?
Health practitioners can take part in social action in a variety of ways. For
example, they can provide current, relevant information and data to help
develop the messages conveyed through social action activities. They can
also help identify appropriate audiences for a particular message (e.g.,
an elected official, the public at large). Health practitioners can assist the
partnership in determining how to convey the message from the data to the
audience in a way that will capture its attention. This is usually a public action
involving a large number of people. Because the intent of social action is to
make a public statement, it is often useful to organize media coverage of the
event and ensure that public officials are aware of it.

ExAMPLE FROM THE FIELD

Social Action

The partnership to address diabetes wanted to show community members
the number of people affected by diabetes in their community and how
social determinants influenced these peoples’ lives. They decided to hold
a march with people carrying body bags, each representing a person in
their community who died from diabetes at an early age because they
didn’t have access to resources to prevent or limit the impact of diabetes.

These individuals were followed by a group suffering from or representing
those living with diabetes who lacked the resources to take care of their
health. Another group followed, carrying posters highlighting the social
determinants associated with diabetes, including statistics about funding
for education, unemployment rates, health insurance rates, housing, and
access to affordable places to eat healthy foods or exercise.

Health promotion
What is health promotion?
Health promotion refers to activities designed to help people improve their
health or prevent illness through changes in environments, lifestyle, and
behavior.52 Health promotion includes efforts to reach individuals or families,
activities in the workplace to reach employees, and community initiatives
focused on larger populations. Traditionally, health promotion in the United
States has focused on changing individual knowledge, attitudes, and skills
to encourage particular behaviors. These promotional, informational, and
skill-based messages are often conveyed in individual participants’ homes, at
schools or in the medical providers’ offices; communicated through campaigns
(e.g., distribution of generic, targeted or tailored information); or transmitted at
community sites (e.g., health fairs). Health promotion efforts may also include
organizational, policy, or environmental changes that facilitate positive
health outcomes. These health promotion efforts are more likely to address
social determinants of health, such as increased access to quality fruits and
vegetables through development of community gardens or reduced exposure
to environmental toxins through policies supporting improved air quality.

When do you incorporate changes in social determinants to enhance
your health promotion programs?
Within community settings, it is not unusual for organizations and individuals
to want to focus on the behavioral determinants of health and well-being.
However, even when the partnership is interested in addressing a particular
health or risk behavior, it is possible to address social determinants of health
equity. It is useful to incorporate program elements that address social
determinants in order to create desired behavior changes. For example,
educating people about the health benefits of eating fruits and vegetables is
important. However, people must have access to affordable produce if they
are to incorporate it into their diets. Thus, increasing access to affordable food
(the social determinant), in conjunction with knowledge and skill development,
is more likely to create the desired change in behavior and thus the change
in health outcomes.

How can social determinants be incorporated into your health
promotion efforts?
Health promotion efforts may attempt to improve health by creating individual,
social, organizational, community, or governmental changes. For example,
individual change efforts could focus on altering knowledge, skills, attitudes, or
behaviors. Such an intervention might include working to educate community
members on the benefits of exercise. An examination of the social determinants
that influence this behavior might uncover a number of barriers to exercise,
such as a lack of recreational facilities or the requirement of fees or an annual
membership to use those that are available. Your health promotion effort
might incorporate attention to social determinants by working with a local
recreational facility to create a sliding scale for fees or alternative payment
plans for those who cannot afford the usual fees or arrangements. Similarly,
your efforts to improve dietary patterns might include not only information
and skill-building activities but also working with local government officials to
increase access to healthy food options through tax and zoning policies that
encourage the development of full-service grocery stores in neighborhoods
where they are lacking.

When working to incorporate changes in social determinants into health
promotion programs, especially programs in communities that experience
multiple disadvantages (e.g., residential segregation due to race, ethnicity,
and income), it is important to:

> Consider the quality of the existing social ties among individuals and
organizations and how new social ties can be created and supported.

> Consider the physical or built environment, including:
• Access to grocery stores with affordable fresh fruits and vegetables.
• The availability of safe neighborhoods and sidewalks in good

repair for walking.
• Access to affordable facilities such as gyms and pools.

> Consider the availability of resources (e.g., transportation, jobs,
housing, schools).

> Work with partner organizations to provide opportunities for economic
development, including healthy jobs with livable wages.

> Enhance cultural competency among health educators and increase
access to interpretive services.

> Use participatory approaches to work with community members and
different sectors of the community to create these changes.

FORuM SPOTLIGHT
Health Promotion Approach that Incorporates Social Determinants

The following example illustrates how social determinants were incorporated
into a more traditional health promotion effort.

In 1998, a group of health professionals at the Cook County Health
Department in Chicago opened a walk-in clinic to address the health needs
of black men (see pages 14-15). These professionals recognized the need
to address health in the context of men’s lives in the community. The clinic
provided free health services; expanded after-hours care; provided fare
cards for public transportation to the clinic and to job interviews; provided
technical assistance on preparing résumés and interviewing for jobs; and
offered fatherhood and parenting courses, a manhood development
course, social support discussion groups and youth initiatives for sexual
health education. The health professionals also developed community
outreach strategies to encourage black men in the community to visit the

clinic. Once at the clinic, this connection was reinforced by a predominantly
black male staff, physicians who participated in support group discussions,
and courses and programs tailored to black male adult and youth cultures.
This project demonstrates how health promotion efforts can be effective by
increasing access to health care and by reducing barriers that reinforce
social inequities, including:

> Cost of health care.

> Lack of trust for medical staff who do not understand the social context
(e.g., lack of similarities with clients, including appearance, language,
history, or culture).

> Flexibile in appointment times.

> Assistance with obtaining employment and social support.

Media advocacy
What is media advocacy?
Media advocacy is the strategic use of media coverage to encourage social,
economic, or environmental change.

Media coverage is an excellent
approach for reaching large populations and capturing the attention of
decision makers who influence policy. Mass media campaigns reach people
through newspapers, radio, television, and other means (e.g., billboards,
posters, brochures, e-mail alerts). Historically, mass media campaigns in public
health have focused on encouraging individual behavior change. Alternatively,
media advocacy can be designed to influence norms, policies, and collective
responses by the community.

When do you incorporate social determinants into your media advocacy?
Mass media campaigns have been used to increase public understanding
of specific health issues, such as how individuals can change their own or
their loved ones’ behavior to improve health outcomes. To address social
determinants of health, it is important to shift the focus to help the public
understand how health outcomes are influenced by broader social, economic,
and environmental conditions. This type of media advocacy campaign can
help reframe certain public health concerns as the result of community rather
than individual causes or problems. This can help initiate collective community
responses to create change. Media campaigns are most useful when high
visibility is desired and debate or discussion is useful in reframing the issue and
providing support for initiatives to create social or organizational change.

How do you use media advocacy?
Begin by referring to your partnership’s vision and mission. Decide on the goals
and objectives of your media campaign and identify your main audience.

Once you have chosen your audience, invite media representatives to
become involved with the planning, implementation, and evaluation of your
media campaign if they are not already part of the partnership. In addition,
consider the most appropriate media outlet for delivering your message (e.g.,
newspaper, radio) and make sure that a representative of that medium is
included in your partnership.

Next, plan your message. Identify the problem and offer solutions. Consider
how to frame the problem and the solution to attract the interest of your
audience and ensure the message is culturally sensitive. For example, if your
objective is to increase access to health care through improved transportation
opportunities, you may want to direct your media campaign toward local
decision makers, transportation planners, and other influential individuals or
organizations in the community. Messages may emphasize increased funding
for public transportation, expansion of existing transportation infrastructure or
service routes, improved hours of operation, or other changes to transportation
opportunities in the community.

Decide on the best media outlet to use based on your audience. Media
outlets may include television (PSAs, news, public affairs, popular culture,
paid advertising), newspapers (editorials), radio, billboards, interactive media
(chat rooms, bulletin boards, Web sites), or public information forums (news
releases, special events, town meetings). In addition to discrete media spots,
the message must be part of an ongoing community dialogue to be effective.
This can be done through letters to the editor, editorials, and public hearings
or community meetings.

Be sure to frame your message in a way that moves the focus for change
away from individual behavior and toward social, economic, or environmental
conditions. Work with local media representatives to learn how to develop
a marketable story, create sound bites, and determine who will be the
public spokesperson.

Additional points to keep in mind:
> Messages should be simple and clear. State the issue and why the

intended audience should be concerned. Provide potential solutions,
be powerful and compelling, and speak directly to your audience.

> Be sure your data are accurate, up-to-date, and easy to understand.

> Develop a media list and become familiar with local media. Find out
which reporters cover which issues. Think about the audience each
media outlet (e.g., newspaper, radio station) reaches.

> Work with media specialists so that your message is in the proper format
for the media outlet you have chosen.

> Piggyback onto breaking news by highlighting local stories related
to health and social issues.

FORuM SPOTLIGHT —
Use of Media Advocacy to Influence Policy
The following example illustrates how media advocacy was used to influence
policy changes.

In 2002, the Girls After School Academy (GASA), a program primarily serving African
American girls aged 8-18 years, received a grant from the San Francisco Department of
Public Health Tobacco Free Project to implement a smoke-free policy at the Sunnydale
Housing Project (see pages 24-25). Sunnydale Housing is a 767-unit public housing
project made up of 91 buildings and has been described as the largest, most isolated,
and most underserved public housing development in San Francisco.92 Approximately
70% of the community members are African American. Seven girls in GASA were recruited
as youth advocates to research, develop, and advocate for a smoke-free policy for one
of the Sunnydale buildings. After comprehensive training, the youth advocates:

> Developed a pamphlet on the harmful effects of tobacco, which included
the focused targeting of African Americans by the tobacco industry.

> Conducted a survey of tenants to assess the level of interest in developing
smoke-free areas at Sunnydale.

> Created a petition and collected signatures to support smoke-free buildings
in Sunnydale.

> Worked with the tenants to pass an initiative to phase in a smoke-free policy.

PERSPECTIVES The Media
Gregory V. Button: University of Michigan; Ann Arbor,
Michigan (Participant in Learning From Doing forum)

To ensure that the media will provide the coverage needed
to advance the public health message from one that places
sole responsibility for health on the individual to one that also
questions how social factors affect health, it is important to:

> Have a clear message.
> Be armed with facts, not just assertions.
> Be prepared to discuss the solution as well as

the problem.
> Build all of the elements of a good news story

into presentations.
> Be tenacious and willing to undergo repeated

rejection to get the message to the public.

ExAMPLE FROM THE FIELD
Media Advocacy
The community partners discussed a newspaper article about a person with
diabetes who had died at a local homeless shelter. The article highlighted the
person’s life as an individual but didn’t mention any of the broader social issues
that influence who gets diabetes, such as high rates of diabetes among African
Americans and Hispanics or high school graduation rates or health literacy
levels among people with diabetes. The partnership had been exploring these
issues and decided to work with local media outlets, particularly radio and local
television stations, to encourage the community to consider the ways these issues
influenced the health of their community. Their main goal was to shift attitudes
away from “what is wrong with these people” to the social challenges faced
by people with or at risk for diabetes and how a lack of choices and access
to resources can makes their diabetes worse. They started by considering the
following: many community members may be concerned about their own health
and the health of those they care about, but they may not really understand the
health of other people, saying it is a choice not to be healthy. Some, such as those
who work in social service agencies, may want support for their clients so they can
be healthier and more effective at getting jobs, finding housing, or participating
in the community in other ways. Some employers said they didn’t want to hire
people with diabetes because they missed too much work and because it raised
the cost of insurance premiums. Once these different responses to diabetes were
identified, different messages were created to reach different audiences.

What are the key messages that we want to convey?
What local data support these claims?

> Message 1: Save our Community!
Data: African Americans in our state are five times more likely to have
diabetes than whites.

Report or Web site: Centers for Disease Control and Prevention,
http://www.cdc.gov/diabetes/statistics/prev/state/index.htm

Year published: 2005

Data Source: State-specific Estimates of Diagnosed Diabetes Among Adults

Years data were collected: 1994–2004

> Message 2: Stay in School, Stay Healthy
Data: High school graduation rates are lower among African Americans
than whites (10% of African Americans and 6% of whites in the U.S. do not
complete high school reducing their chances for meaningful employment,
which limits their ability to buy healthy foods or live in adequate housing, as
well as limiting understanding of health issues).

Report or Web site: Kids Count, http://www.kidscount.org/sld/databook.jsp

Year published: 2004

Data source: National Center for Education Statistics, Dropout Rates

in the United States, 2000

Year data were collected: 2000

What is the right media outlet?

> Who do we want to hear our message?
• Policy makers — city council, county and state legislatures.
• Employers.
• School administrators.
•Grocery and convenience store owners.
•Neighborhood organization leaders.
•Community members.

> What media outlets does our intended audience use?
• Radio — soft rock, public radio, R&B stations, classical stations,

gospel stations.
• TV — nightly local news.
•Newspaper — local newspaper — living section, business section.
•Other — shopping cart placards, billboards.

Policy and environmental change
To achieve community-wide changes in health equity, community members can
engage in decision-making processes within their community. This may require
learning new skills or strategies to gain active participation of people and
organizations in the community and key decision makers from different sectors.
Local decision makers include elected and appointed officials, institutional
or organizational leaders, and other individuals or groups involved in policy
making in your community.
Using this approach, your partnership may focus on policy initiatives (e.g.,
zoning regulations, tax policies, worksite or school policies) or changes to the
built environment (e.g., creating equitable access to affordable transportation,
education, employment, recreation facilities, healthy food).

According to the Institute of Medicine, public health agencies
and community coalitions have a special role to play in policy

development and implementation. “[They] must raise crucial
questions that no one else raises; initiate communication with

all affected parties, including the public-at-large; consider long-
range issues in addition to crises; plan ahead as well as react;

speak on behalf of persons and groups who have difficulty
being heard in the process; build bridges between fragmented

concerns; and strive for fairness and balance.” (pg. 45)2

What is policy and environmental change?
A policy is a plan or course of action intended to influence and determine
decisions, actions, and rules or regulations that govern our collective daily
life.

Policies can be created and enforced by organizations, communities,
or the government at local, state, or federal levels. One purpose of creating
new or changing existing policies is to change the social determinants that
influence health equity (e.g., tax incentives for the food service industry to
provide healthy foods, combine state taxes for education and distribute
across districts to ensure equitable access to public education).
Changes to the environment include facilities (e.g., buildings, roads, schools,
parks), amenities (e.g., benches, trash bins, streetlights), cultural or artistic
events or enhancements (e.g., statues, festivals, murals) ), and social support
and networks (e.g., block groups, charettes, community forums). Changing the

environment requires informed decision making about urban design, land
use, transportation , and political and social services and systems and their
relationships to health outcomes.

When do you use policy and environmental change?
This approach is useful when you want to create or change existing policies
or environments to promote health equity. People and organizations in the
community may consider using policy change to affect groups of people
instead of or in addition to individual-level strategies (e.g., brochures, posters).
Policy changes can be designed to regulate the behavior of individuals (e.g.,
smoking bans), organizations (e.g., flex-time), or communities (e.g., housing
codes for maintaining rental property). Policy changes can also affect the
built environment, such as zoning related to new grocery stores or fast food
restaurants, maintenance of sidewalks and streetscapes, or architectural design
features such as neighborhood signage addressing the history and culture of
the community.
How do you use policy and environmental change?
Health practitioners, researchers, and other people and organizations in the
community can be active players in the policy-making process by educating
decision makers about how changes to policy or the environments can
promote health equity. For example, your partners can provide current health
or social determinants data, information about existing policies, examples of
policies that have worked well in other communities, or other information on
an issue as it is experienced by your community. Your partners can also help
by developing a list of key decision makers to contact based on their interest in
the issue or their position on certain decision-making bodies (e.g., committees,
boards). See “Moving Forward: Ways to Support Policy Change” (page 72)
for more ideas on how to engage in policy-change work.
Your partnership may also consider engaging in policy change by connecting
to larger organizations that can help define concerns and develop potential
solutions. A well-structured, well-positioned organization can support policy
change by defining a problem that affects many individuals or communities
(e.g., consumer legislation, air quality), and it can also help unite voices and
actions to create change. Larger organizations can also work with local
organizations to obtain support to implement these strategies. Some groups
may work directly on health-related topics (e.g., land-use policies to increase
parks and greenways), whereas others may work on policies that influence
the social determinants of health even if they are not explicitly focused on
health (e.g., housing, air quality).

NOTE: If your partnership is considering policy-change strategies, be aware that most organizations that receive public funds or have 501(c)3 status cannot participate in lobbying activities. Lobbying activities include letter or phone campaigns, petition drives, promoting
a position on a specific legislation, or endorsing a position to a legislator. These rules are updated regularly. For more information, go to AR-12 at http://www.cdc.gov/od/pgo/funding/ARs.htm.

If your partnership receives public funds, many activities are allowed that support policy change. You can provide current data or other educational information on an issue as it is experienced in your community. You can also help by developing a list of legislators to
contact based on their interest in the issue or their position on certain legislative committees. See “Moving Forward: Ways to Support Policy Change” (page 72) for more ideas on how to engage in policy-change work.

PERSPECTIVES — The Role of Policy in Community Matters

Angela Glover Blackwell: President, PolicyLink Institute, Oakland, CA
Keynote Address, Social Determinants of Health Disparities:
Learning from Doing, Atlanta, GA, October 28, 2003

“Across America, people are creatively solving local problems by taking
advantage of the wisdom of those who are working for change at the
community level as well as that of those working for change at the policy
level. The experiences and wisdom of people working at the local level are
integral to solving problems in ways that are meaningful and sustainable.

There has been an explosion of exciting activities in local communities that
cross lines of race, class, and profession; people are organizing, building
networks, and finding solutions to problems within their communities that will
ultimately lead to an improved quality of life for all community members.
However, it is impossible to talk about quality of life without considering
the need for policies to improve overall public health and to reduce health
disparities among different segments of the population.

A major factor in reducing health disparities is recognizing how place
matters – i.e., how where a person lives is associated with disparities in
disease incidence, mortality rates and other health indicators. The physical,
social, and economic environments of a community, including air and water
quality, housing conditions, and access to resources and services, determine
the daily advantages or disadvantages community members face in trying
to survive and prosper. For example, someone who lives in an environment
of concentrated poverty will likely have little or no access to full-service
grocery stores with fresh produce, limited access to transportation (personal
or public) to get to a store, a clinic, or a health center, and few community
health programs in local public schools. One’s address should not determine
one’s destiny.

We have many exciting examples of how community members can produce
meaningful improvements in their community by analyzing strengths and
problems, recognizing opportunities, overcoming differences, and working
together as a disciplined team of community partners.

To create needed changes, we must use approaches that encourage
cooperation among public health professionals, community partners (e.g.,
transportation, parks and recreation, policy makers, businesses, schools),
and the community members they serve. Community members offer practical

experience in solving real-life problems, while public health professionals
bring a different perspective and a theoretical basis for changing community
conditions: both sets of assets are vital to community-based efforts to improve
factors affecting the health of community members. To overcome what
may seem like intractable problems, we must work together to strengthen
existing organizations or build new institutions to create new standards and
expectations for community life. By building coalitions, community members
and public health officials can gain the strength and breadth of support
necessary to address issues whose ultimate solution can best be achieved
through policy change. The key to success for these coalitions is realizing that
community members must be full partners.

Multiple strategies are needed to improve quality of life in our communities.
Key among these must be strategies that emphasize policy development
designed to help local communities achieve local level change. Why policy
development? Local, state, and federal policies influence the way society
organizes its resources, conducts its business, and expresses its values. In a
democracy, all people have a right to participate meaningfully in policy making.
The use of successful local projects to inform policy agendas acknowledges
the authenticity of a community-centered approach to change.

Everyone benefits when communities are organized, responsive to local needs,
supportive of residents input to policy change, and active in creating policies
to protect community members from harmful conditions. Establishment of these
conditions will not only help improve community health, but communities that
do so will become stronger, because their members will have the information
and skills needed to sustain such gains.

Unfortunately, significant barriers have existed and communities of color and
low-income communities have frequently been excluded from discussions of
the health-related policies that affect them. The development of successful
health-related policies depends on the participation of a broad, representative
coalition of community members so that the policies created represent the
needs or experiences of all community members.

Public health can support the use of innovative approaches with communities,
to improve the health and quality of life. To create a strong, healthy, and
equitable world, we must identify and replicate successful community-based
projects that harness our collective wisdom and experience.”

MOVING FORWARD
Ways to Support Policy Change
> Provide current local statistics on health issues of concern to increase

awareness of the problem.
> Work with community groups to develop simple, to-the-point

statements about the issue and specific strategies to implement that
can be shared with decision makers and the media.

> Provide a list of local decision makers with contact and
background information.

> Assist community groups with setting up times to meet local
decision makers.

> Build community capacity to communicate with decision makers by
building partnerships with other groups that have similar interests.

> Translate academic and policy reports for use by public health
practitioners and community groups to make them locally relevant.

> Work with community groups to develop an agenda for action at the
local, state, or national level.

FORuM SPOTLIGHT
Recruiting Partners to Work for Policy Change
The following example illustrates how advocacy was used to develop a policy agenda.

Public Health – Seattle & King County (PHSKC) designed an intervention to bring attention
to environmental policies focused on families and individuals (see pages 28–29). Through
a coordinated policy agenda and strengthened advocacy, partners focused on building
public will to address the environmental factors that shape the lives of young children. The
ultimate goal was to create universal access to environments that support school readiness
and other indicators of healthy child development. PHSKC produced a 75-page child
development resource to engage partners in discussions of issues considered crucial for
healthy childhood development (e.g., nurturing relationships, family resources, child care,
neighborhood, access to early interventions). Approximately 60 partners were asked to
read the resource before meeting to generate policy recommendations for healthy early

childhood environments. Obtaining additional support for these policy changes from

communities in King County is one of the group’s next steps.

PERSPECTIVES — Policy
Jim Kreiger: Public Health – Seattle & King County;
Seattle, Washington

To make change on a large, community scale, public health
needs to influence changes at the policy level. Suggestions
for ways to accomplish this include:

> Assess the situation and consider policy
implications up front.

> Bring the issue to policy makers’ attention.
> Provide the technical background policy makers need

in a clear and concise manner.
> Mobilize constituencies to ensure genuine participation

and power sharing by all groups involved.

Selecting your approach
Your partnership may feel overwhelmed by the wide range of ways to address the
social determinants of health inequities in your community. Consider this an asset
rather than a barrier, because it allows you to try a variety of approaches to find out
what works best for your partnership and your community. If possible, use multiple
approaches to increase the likelihood of reaching different groups in your community.
There is no right or wrong approach, but there are several factors that might influence
your decision about which approach to use to achieve your goals and objectives.
These include:

> The experience and expertise of your partners.

> The nature of the social determinants you plan to address.

> The availability of financial and other resources.

> Funding restrictions or guidelines for the initiative.

> The existence of policies that are not being enforced.

> Whether you are working to create community change or organizational change.

> The political and social buy-in of the community.

> The relative success or failure of similar approaches in the past.

FORuM SPOTLIGHT
The Use of Multiple Approaches
The following example illustrates how multiple approaches can be used to
address the same issue.

The Boston Public Health Commission (BPHC), the city’s health department, has
identified the elimination of racial and ethnic disparities in health as one of its top
priorities (see pages 22–23). An analysis of routinely collected health outcomes
demonstrated that black community members in Boston fared significantly worse
than white community members on 15 of 20 measures. BPHC determined that the
most effective strategies for addressing disparities would focus on understanding and
eliminating the impact of racism on health. Health inequities are associated with a
variety of factors, including unfair environmental exposures, unequal access to care,
and bias or discrimination by health care providers. Interventions were designed to

Although these factors can help guide your decision-making process, it is important to
trust the intuition and experience of your partners, particularly the community members.
Your partners could decide it is time for a new and different approach. They could
also suggest that you modify one of the suggested approaches or choose another
alternative. For many issues, it might be necessary to use more than one approach to
create the changes desired. In such cases, it may be useful to determine the benefits
and challenges of implementing these approaches simultaneously or sequentially.
You may want to consider, for instance, the resources required, the extent to which
one approach lays the groundwork for the other, and the readiness of the community
to engage in these approaches. The important thing is that the group agrees on the
best way to proceed. Some additional questions that might help you determine the
best next step for you are found in “Example from the Field: Selecting Your Approach”
(page 74).

Document your decision-making process to develop support for the selected approach.

Remember to consider new partners who can support your use of different approaches.

Be willing to modify your approach as you track your successes and challenges.

This is the learning-from-doing model. Several sources of information on these
approaches are available in the “Suggested Readings and Resources” section.

be population-based, with an emphasis on improving access to care, linking clients
to social services, and addressing institutional policies and norms considered racist.
To address these factors, BPHC selected multiple approaches, including:

> Promoting an anti-racist work environment by establishing an internal team to
guide ongoing anti-racism dialogues (consciousness raising).

> Creating a position in the executive office to coordinate the BPHC’s
anti-racism work (policy change).

> Documenting and disseminating information on racial disparities
(media advocacy).

> Redirecting funds to support initiatives that addressed documented racial
disparities (policy change).

ExAMPLE FROM THE FIELD
Selecting Your Approach
The community partnership to address diabetes knew it wanted to focus
on social determinants, but partners were not sure where to begin or how
to proceed. The following questions were useful in helping them decide
what to do:

Which of the approaches described in Section 4 are particularly appealing?
> One of our objectives was to increase community awareness of social

determinants of diabetes inequities. Media advocacy seems like a
good way to do this.

> We like the idea of health promotion programs.
> Maybe we could work on policy-level issues — a good amount of this

requires changes in policies.

What is the benefit of using the media advocacy approach?
> Media advocacy would be good to start with, because until we

increase awareness, we won’t have the support to make other kinds
of changes.

> Media advocacy might also help us get more people interested,
broadening the range of ideas and support we can use to make other
kinds of changes.

What are the potential drawbacks to using this approach right now?
> Support is nice, but it doesn’t really change the things we need to

change. It may be okay if we start there but commit to move beyond
just getting support.

What social determinants of diabetes do we plan to address in our
community? What approaches seem to have a “good fit” with the
outcomes we hope to achieve?

> We really need to work on increasing access to affordable, healthy
food and places to be active; improving housing and health care; and
increasing jobs. Media advocacy doesn’t really do much for us in this area.

> Maybe media advocacy will mobilize support from people on the
local business council, and maybe businesses will see that influencing
social determinants of diabetes among all community members,
not just their employees, is in their best interest and then work with
us to develop ways to increase jobs for people living with or at risk
for diabetes.

Consider the experiences, resources, and other supports that exist in the
partnership. Do they help us with one approach rather than another?
Consider any funding restrictions we might have.

> We have some help from the local newspapers and some people
who know radio personalities.

> We need to get local businesses involved and probably someone
from the local hospital, housing coalition, and food pantries.

> We have a limited budget for this, and media advocacy would fit
within the guidelines for how we can and cannot use the money.
We might want to check with the funding agency to be certain.

Finally, work with the group to prioritize the approaches so you can
allocate your resources according to your priorities.

S E C T I O N 5

At this stage, you have formed your partnership, developed a common
understanding of the social determinants of health inequities in your
community, reached a consensus on your partnership’s mission and
structures for working together, inventoried partnership and community
capacities, identified goals and objectives, and selected one or
more approaches that best meet the needs of your community. You
are now ready to learn from doing by developing and implementing
an action plan. In addition to discussing how to form an action plan,
this section describes how to anticipate possible barriers to fulfilling
your plan.

Getting started

Developing an action plan
An action plan describes the specific steps necessary to meet clearly
defined goals and objectives. Begin to develop an action plan as soon
as your partnership’s vision, goals, objectives, and approaches have
been determined. The initiative planning model described at the end
of Section 2 (page 53) provides an outline of the components to
include in your action plan.

Moving to Action

An action plan is important not only to keep your partnership on track
toward meeting its goals but also to demonstrate to community members
and other stakeholders that you are making tangible progress toward
improving social, economic, and environmental conditions. Keep
in mind, however, that you may need to modify your action plan to
meet changing conditions in your community over time. An action plan
should not be viewed as a static document. To be effective, an action
plan should include the following key elements:

> Your partnership’s goals and objectives.

> Who is responsible for the completion of activities.

> The time frame for completion of activities.

> How you will assess progress.

> How you will assess impacts and outcomes.

Before writing your action plan, you will need to organize a planning group,
which should include people and organizations in the community that you
identified when creating your partnership. Some of these groups or individuals
may be part of your existing partnership, whereas others may be invited because
they bring a different perspective or experience. After the planning group has
been organized it should meet to determine what action steps are necessary.
Once these steps have been developed, assign specific roles and responsibilities
to partners and devise a timeline for all action steps. A good action plan:

> Describes each action step clearly and specifically. The plan should be easy
to understand and in a format useful to all partners.

> Assigns responsibilities for each action step. This determination should
be made following a group discussion about who should be responsible
for what.

> Provides a timeline for completion of the action steps. The group will need
to estimate the time needed for each action step and be sure the times are
reasonable for everyone involved. Some steps will need to be completed
before others can begin. Be sure to identify this in your action plan.

> Outlines what resources will be necessary to successfully implement each
action step, including finances, staff, space, and equipment. The group will
need to identify existing resources first and then determine whether additional
resources will be required. You might want to create a mini action plan for
obtaining additional resources.

> Includes a list of other community members who may be potential collaborators
and involves them in your project as necessary. This may also help increase
community awareness of your project.

MOVING FORWARD
Developing Your Action Plan67,69

When developing an action plan, ask partnership members the following
questions and incorporate their agreed-upon answers into your plan:

> What is the purpose of this action plan?

> Why do we think the plan is achievable?

> How does the plan address our partnership’s goals and objectives?

> How will we know if we are achieving our objectives?

> What are the specific action steps?

> Who is responsible for each action step?

> When will the action steps take place? Will they be completed
by a specific date, or will they be ongoing?

> Who else in the community should know about or can help with
the plan?

> What resources (e.g., money, space) are necessary to implement
the plan?

> What resources does the planning group have now to complete the
action steps?

> What additional resources are needed? Where and how will these
resources be obtained?

MOVING FORWARD
Implementing Your Action Plan67,69

> Review the action plan: is it complete, clear, and current?

> Follow through with action steps.

> Does the action plan reflect the goals and objectives as well as the
roles and responsibilities of all partners?

> If volunteer or paid staff are required, is there a plan to train them?
Do they have clear roles and responsibilities?

> Discuss the plan and the activities with all partners to ensure the
timeline and roles are realistic for everyone.

> Work to identify potential barriers and challenges and strategies
to address them.

> Check in with all partners during the implementation process to see
whether the partnership is making progress.

> Refine the action plan as necessary.

> Discuss the possibility of unanticipated challenges the partners
may encounter while attempting to implement the action plan, and
document discussions.

> Keep partners informed about progress.

> Keep track of what has been accomplished whether it is what was
intended, and, if not, what changes should be made to the plan.

> Celebrate small and large accomplishments.

Continually monitor your group’s progress toward completing the action plan.
Once an action plan has been formulated that meets the criteria above, revise
it as needed to maximize your chances for success. Meet regularly and use
the set of questions in “Developing an action plan” (page 76) as the basis for
a status report to be discussed at your meetings. The group can acknowledge
and celebrate what has been completed, assess challenges, and revise the
action plan accordingly.

Implementing your action plan
As you move from the planning stage to the action stage, be sure that all
partners have a copy of the action plan and understand their roles and
responsibilities. Your first step in implementing your action plan is to obtain
the resources identified as necessary for moving forward. Make sure these
resources are in place before you begin to implement your action plan. Also,
be sure that your group has a backup plan in case promised resources are not
provided or in case additional resources become necessary.

Carrying out your plan may be challenging at times, and progress may
sometimes be difficult to recognize. Take time to appreciate what has been
accomplished and to publicly recognize what people have contributed.
Doing so will help reenergize your group and strengthen relationships among
group members.

Anticipating challenges
Any partnership working to change conditions within a community should
expect to face challenges of various sorts and should, as much as possible,
develop strategies for addressing potential problems before they occur. The
following are challenges you may encounter in working with your partners.66,96

> Maintaining effective communication. One challenge is to ensure that
group members are communicating effectively with one another. It is
important when addressing social determinants of health inequities to
invite groups that historically have not been part of public health initia
tives. Based on different experiences, some groups may use language
that other groups in your partnership have trouble understanding, and
each group will come into the partnership with different expectations
and priorities. It is important to work together to develop a common
vocabulary and to reassure the members of the partnership that
differences actually make the partnership stronger.

> Dealing with conflict among partnership members. Conflict is inevitable
and is not necessarily a bad thing if handled well. Conflict due to power
imbalances within the community or among members of the partnership is
important to address openly and honestly. These imbalances may become
apparent as the group forms or during consciousness raising when
partners are discovering and discussing issues of concern. Although
recognition of such imbalances can create tension and discomfort
among partnership members, you can use the tension to your advantage
by discussing differences in access to social resources among various
groups in your community and the potential implications of these differences.

> Adhering to partnership principles. If this is a problem, review each
principle and determine challenges to adherence. Post the principles
at each partnership meeting and review and revise them as needed.

> Addressing unrealistic expectations of various partners. Partners may
become impatient or dissatisfied with the direction of the partnership or
the time it takes to make decisions and implement actions. For example,
some people find the community development approach frustrating due
to the focus on process rather than on tasks. You may need to remind
them that the focus on process is an effort to promote participation of all
partners and build trust among them, thus improving your partnership’s
chances of accomplishing its goals. As noted earlier, including short-term
achievable action steps in your action plan should help reduce the
frustration of partners eager for immediate change and give them a
sense of accomplishment that will help them stay in the partnership for
the long haul. You should continuously monitor the energy level of the
partnership and allow opportunities for members to shift the direction
of the partnership as needed.

> Resolving conflicts between partners’ roles and responsibilities within
the partnership and their roles and responsibilities within the community,
their organizations, or their home environments. For example, if a
partnership is developed to reduce infant mortality rates in the
community and a local foundation decides to grant money to a single
organization, the partnership may be at risk due to the potential
for competition among partnership members established by the grant
opportunity. Even if the organization that receives the grant money is
successful in reducing infant mortality rates, community partnerships
could feel negative impacts due to unresolved conflicts. It is important
that the partnership develop mechanisms to overcome such tensions
and promote understanding among members of the community.

You can help prevent conflicts from damaging the partnership by encouraging
members to openly discuss actual or potential conflicts, modifying the action
plan if necessary and feasible and ensuring that community members help
define the actions most appropriate for their communities. This will help the
members better understand and respect the roles their partners have outside
of the partnership. Also, it is important to recognize that representatives from
agencies and organizations are often limited by their organizational roles or
policies. For example, agencies or organizations that receive public funding
may be prohibited from participating in certain policy activities. However, even
those agencies can play some role in policy change (see page 70). Working
collaboratively to determine the most appropriate role for each partner will
strengthen the overall process and improve outcomes.

Other problems your partnership may need to address include members’
perception that the partnership threatens their autonomy, disagreement about
community needs, conflicts over funding decisions, lack of consensus about
membership criteria or coalition structure, lack of leadership, competing
interests, and failure to include relevant constituencies.

To overcome these problems, the members of the partnership must work
together to identify expected challenges, prepare for unexpected challenges,
agree to disagree, and create strategies to overcome both expected and
unexpected challenges. If challenges prohibit progress of the partnership, it
may be useful to seek assistance from an outside consultant.

Please see “Suggested Readings and Resources” for more information on
coping with challenges and resolving conflict.

S E C T I O N 6

Assessing Your Progress

It is important to incorporate ways to assess or track the steps your
partners make from the beginning of your efforts. This process
is a bit like drawing a map of the efforts your partners will make
to reach your goals and objectives. In Section 2, your began this
process by creating and implementing your community assessment.
The findings from your assessment were used to determine your
priorities, goals, and objectives and actions to be taken. The next
steps involve documenting the progress your partnership has made
toward meeting these goals and objectives. It is valuable to record
intended and unintended actions taken by the partnership as well
as intended and unintended consequences of those actions. A
responsive initiative will likely change the action plan many times in
the course of doing its work, so it is necessary to provide evidence
of the barriers or challenges that led to these changes and how the
partnership adapted to improve the initiative. By tracking its progress
this way, your partnership will be able to see whether the initiative has
met its goals and objectives. Although each initiative is unique, the
information your partners collect can help the partnership determine
whether the action plan has been successful or a new plan will need
to be developed. Information your partners collect on this initiative
can provide information for others engaged in similar work, and your
partners can share this information with people and organizations in
the community who are interested in your progress.

All partners should be actively involved in tracking your
progress,69,96,

which should include steps to define the questions
to address, collect and track information, assess and interpret
findings, and report findings to others.

Evaluating your efforts
Even with the best intentions, your efforts to track your partners’
decision making processes; the challenges that emerged; and
notes, pictures, or recorded conversations about the initiative
aren’t helpful unless you organize and annotate (i.e., interpret
and make notes on items) so you can remember how each
item relates to your progress. Evaluation questions, tools, and
methods help you track your progress and organize the information
you collect. Identifying and organizing the evaluation at the
beginning of your initiative can ensure that the right questions
are asked and the answers are documented along the way. The
nature and complexity of your initiative will help determine the
types of evaluation your partnership chooses. In general, the tools
and methods described in Section 2 on community assessment are
the same tools and methods that can be used to track progress
throughout your initiative. However, when evaluating your initiative,
there are several questions your partners may want to consider.
Some of these questions follow along with some tools and methods
your partners might want to use to help answer them.

> How is your partnership working?

One of the first things to consider is how to evaluate the processes used to
develop and carry out your initiative. This involves examining the processes
used within the partnership itself. To assess your partnership, your partners
should discuss what to document, with whom the information should be
shared, and how it is to be used. For example, your partners might want to
document satisfaction with what has been accomplished to gauge continued
interest in participating in the project. It might also be useful to document the
extent to which partners feel they have been involved in decision making and
their comfort with conflict management strategies. Partners may also choose
to review the minutes from meetings to ensure that activities are being carried
out as agreed upon by the group. The accomplishments and challenges
documented will help guide future partnership initiatives. This learning-from
doing approach can strengthen and maintain your partnership by reinforcing
accomplishments and revising or eliminating what isn’t working so that
all partners feel they are making a meaningful contribution to the project.
“Moving Forward: Evaluating Your Process” (page 84) provides specific
questions to consider as you evaluate your partnership. In addition, many
resources exist to guide the development and implementation of partnership
evaluation plans. For more detailed information about designing and
conducting evaluations of partnerships, see “Evaluation” in the “Suggested
Readings and Resources” section.71

MOVING FORWARD
Evaluating Your Process
Partnership

> What about your partnership works well (e.g., decision making,
conflict management, leadership, ability to move forward, location,
time of meetings, length of meetings, balance of tasks, time for
social interaction)?

> What about your partnership has not worked well?

> How can you make the partnership work better?

Community capacity
> Has your partnership successfully reached out to the community? How?

> What has been challenging about assessing community strengths?

> What resources have been helpful?

> What resources are still needed? Are these resources available
within the community? Are there costs associated with securing them?

> How well has your action plan worked?

The next consideration is the extent to which your partnership has
implemented the action plan as intended. Explore changes that have been
made and document why these changes were considered appropriate
(referred to as “process evaluation”). For example, your partners may
have decided to use a media advocacy approach and work with a
particular radio station. After several months of planning your media
events, the person your partners have been working with at the station let
them know that she was moving to another city. In such a case, you could
begin working with a new contact person or use a different media outlet
(e.g., another radio station, a local newspaper). Another example based
on the media advocacy approach is to ask community members to listen
to the media messages created and determine whether they understood
the messages as intended. Community members might recommend
changes that could enhance your ability to get your message across. By
tracking these types of changes and their rationales, your partners can
document choices, allowing them to recognize the types of things that
facilitate or hinder their momentum.

> Are your partners making progress toward their goals and objectives?

It is also useful to document the extent to which your partners are
accomplishing their objectives (referred to as “impact evaluation”) and
goals (referred to as “outcome evaluation”). Below are some questions
to consider as part of your evaluation process:

•What was your intention? What did partners hope to accomplish?
Your partners can answer these questions by recording and
reviewing meeting minutes and referring to the mission statement,
goals, and objectives.

•What did the partnership do to accomplish these goals and
objectives? To answer this, your partners might again review your
meeting minutes or notes. Other strategies include documenting
stories and conversations with other partners and keeping any
photographs, illustrations, or records of media coverage or speaking
engagements that highlight the social and economic determinants of
health inequities that your partnership has chosen to address.

• If the partnership were starting the initiative over, what would your
partners do the same or differently? To help answer this, keep a
record of discussions among partners about the process and
action steps carried out. It may also be helpful to ask people who
took part in the process what they thought worked well and what
they would like to see done differently in the future. These questions
can be asked through a questionnaire or a group discussion. Be
prepared to review your goals and objectives and make changes
as needed.

•What were some of the intended consequences of your actions? The
intended consequences are the changes in the objectives and goals
the partnership laid out. In terms of your initiative, this might involve
tracking the programs and policy or environmental changes planned
and implemented by your partners, any money generated for these
initiatives, and any changes that have occurred as a result of your
activities, including changes in employment opportunities; changes
in structures, such as new sidewalks, community centers, or grocery
stores; and changes in people’s behaviors, such as increased physical
activity or increased use of preventive screening.

•What were some of the unintended consequences of your actions?
It is also important to document unexpected changes, including
changes in your partnership, your objectives, or your goals and out
comes. For example, partners may record new partnerships or
initiatives that have formed or a change in how the media portrays
community health issues in response to your initiative (e.g., more
focused on social responsibility as opposed to individual
responsibility). In some instances, it may be the change in the
action plan that enables you to reach the goals or objectives
(i.e., creating change in one or more social determinants).

Linking your evaluation to your community
assessment and action plan
To answer many of these questions, partners need to have considered
what they hoped to accomplish through the partnership (mission and vision),
where it started (community assessment), and where partners wanted to
go (goals and objectives). Therefore, it is important to link your evaluation
activities to the specific data collected as part of your community assessment,
including indicators of behavior; health; and economic, environmental,
and social status in your community (i.e., the data you collected and
assessed in Section 2). To track changes in your activities as well as
social determinants of health, you can include aggregate assessments
of individuals (e.g., community-based surveys, existing surveillance data)
and systemic social, economic, and environmental assessments. These
indicators provide the opportunity to not only identify areas for change and
illuminate trends (e.g., to develop appropriate new initiatives) but also
evaluate the impact of your current initiative (i.e., whether you are
reaching your objectives). Although many community groups can access
these data through public use data sets to see whether these changes are
significant, you may consider obtaining technical assistance from local
organizations with evaluation expertise or from researchers at local colleges
or universities. Such technical assistance can also be useful if your partnership
chooses or your funding guidelines require you to link your activities and
community indicators of change to health outcomes.

In addition, partners can discuss the information gathered in surveys, interviews,
or meeting minutes (i.e., the data you collected and assessed, as discussed in
Section 2). Whereas existing indicators can help to track changes in health
and social determinants of health over time, feedback from the community
(positive and negative responses) can provide insight into how the changes
have affected the community and pinpoint specific activities that worked well
and those that did not.

It is important to note that most changes in social determinants of health take
time. Moreover, it is often difficult to pinpoint a single action or initiative that
caused a change in social determinants of health. Rather, it is likely that many
different initiatives and actions will act together or synergistically to create
changes. It is, therefore, very important to:
> Develop appropriate expectations among your partners and

community members.

> Track what you have done so others who may follow will know the
cumulative effect of the various steps you took.

> Identify small, short-term milestones on the road to achieving your
long-term goal. See the “Suggested Readings and Resources” section.

ExAMPLE FROM THE FIELD

Sharing your work
Some of the products of your work should be shared only among your group’s
partners. These confidential work products can include:

> Strategies to improve or change goals, objectives, or the action plan.
> Plans to address barriers or conflict within the partnership.
> Methods to rally more support for the project.

Information shared among partners should remain confidential unless all
partners agree otherwise. A lot of information, however, is appropriate
to share with all community members and with other groups engaged in
efforts similar to yours. Such information sharing among groups is vital to the
success of local, regional, or national efforts to eliminate health disparities.
This workbook, in fact, is largely the product of information sharing by
participants in the “Learning from Doing” forum. Your partnership can share

FORuM SPOTLIGHT
Evaluation Strategies
This example illustrates how an evaluation plan was developed to track
outcomes for a very comprehensive initiative.

The New Deal for Communities initiative is an area-based regeneration
initiative being implemented in 39 of the most deprived communities in
England (see pages 26–27). The initiative supports the intensive regeneration
of neighborhoods through the creation of partnerships between local people,
community and voluntary organizations, local health authorities, businesses,
and government agencies. Each community receives financial support to
address a number of key issues, including those related to community health
and the social determinants of health. Action plans include:

> Addressing worklessness (i.e., unemployment or underemployment).

> Improving health.

> Reducing crime.

> Improving educational achievement.

information with the community and with others interested in addressing the
social determinants of health inequitiesin a variety of ways. These include:

> Newsletters.
> Community forums.
> Internet outlets such as Web sites or chat rooms.
> Local newspapers, professional journals, or magazines.
> Local, state and national conferences.
> Informal networks, such as those that operate through libraries, schools,

colleges or universities, parks or recreation centers, faith-based
organizations, small businesses, and word of mouth.

> Flyers distributed in various ways, including door-to-door, at meetings, and
at tables set up in public locations such as supermarkets or on sidewalks.69

Evaluation of the impact of this multifaceted policy program is complex and
guided by theory-driven evaluation strategies, evaluation findings from other
effective approaches, and experiential evidence from the community. This
evidence can be documented and incorporated into frameworks, such as
individual or organizational theories of change (i.e., reflecting readiness to
change and processes of change). Participants are asked to articulate how
and why they think the actions they are taking will lead to the outcomes
they desire (i.e., pathways of change). Participants’ responses begin to define
the types of data needed to establish whether the pathways are being
followed and whether expected short- and intermediate-term outcomes are
being achieved.

S E C T I O N 7

Maintaining Momentum
Eliminating inequities in the social determinants of health will likely
require long-term commitment and the use of several approaches.
With a variety of approaches, community partnerships allow their
individual members to become involved in ways that work best for
them. In addition, by mixing and phasing in various approaches,
different partners can be engaged and energized at different
times. Your partnership should consider flexibility one of the most
important characteristics of its process. A willingness to adapt (e.g.,
to abandon strategies that don’t work and to try new unconventional
strategies) will help your group sustain its work over time and ulti
mately accomplish its goals.

To maintain momentum, your partnership will need to be responsive
to changes in social, economic, and environmental conditions
and in the needs of community members. This responsiveness
may involve changes in the configuration and focus of the
partnership. Making changes can be challenging, in part because
long-time members may feel their concerns are being minimized as
the partnership incorporates new perspectives.

To keep from losing valuable partners during periods of transition,
you may need to make a special effort to convince them of both
the importance of modifying the group’s focus and their continued
value to the group, rather than allowing them to feel they are being
replaced. It can also be helpful to create subcommittees through
which some members of your group engage in new ventures while
others continue to carry out ongoing activities and to focus on
building and maintaining relationships during group meetings. The
latter is particularly important as new members join the group.

Community fatigue is a challenge that all long-term partnerships must
address to maintain momentum and keep the partnership healthy
and strong. The capacity of your partnership to be flexible and

respond effectively to transitions can help minimize the fatigue
of partners and community members. However, you may also
encounter exhaustion and burnout in partners who have been
engaged in community work for a long time. An understanding of
community history is essential to sustaining your partnership and your
initiatives over time. Some partners and community members may
have made several past attempts to create change in the health of
or social, economic, and environmental conditions in the community
with varying degrees of success. Because of barriers they might have
encountered during these attempts, these individuals may feel that
their energy and efforts were in vain.

To keep energy and enthusiasm high, continue to encourage
participation by all partners and ensure their perceived ownership
of partnership activities. Be sure that each partner has realistic
roles and responsibilities so that no individual or organization feels
overburdened. In addition to attempting relatively ambitious long-
term actions, try to develop easily completed, shorter-term activities
that can be expected to produce “small wins” that will keep the
partners motivated and optimistic. You can also anticipate and
plan for training and resources needed in your partnership or the
community to enable you to accomplish your initiative.

The information presented in Chapter 3, Section 1, applies to the
establishment of an informal partnership. At some point, however, members
may decide to formalize the partnership and may require legal advice to
helpdeterminethemostappropriateorganizationalstructure(see“Moving
Forward: Maintaining and Sustaining Your Partnership” on page 89).
This could lead you and your partners to consider hiring management
and administrative staff to assist with planning, implementation, and
evaluation activities. Hiring paid staff may require additional funding as
well as other resources, such as office space and equipment.

In summary, keeping your partnership and the initiatives you sponsor alive and
thriving requires your group to be flexible in its response to changing conditions
without losing its capacity to harness the collective expertise its members

MOVING FORWARD
Maintaining and Sustaining Your Partnership
Maintaining Your Partnership

> Develop a formal organizational structure when you are ready.
The following are examples of types of organizations and possible
advantages of structuring your partnership in each way:

have gained working together. Remember to celebrate your partnership’s
accomplishments and to recognize the contributions of each member.

• A government-sanctioned organization. Structuring your partnership
as an organization that has been authorized by executive or
legislative action of state or local government might increase your
group’s credibility in the community and could give it the legal
authority and fiscal status to conduct certain activities.

• A community network or coalition. This form of organizational
structure may allow you to more accurately identify community
needs and to gain greater community support for your group’s
activities. In addition, structuring your group in this way could
allow you the flexibility to engage in a variety of activities without
being restricted by any one organization’s rules and regulations.
If your group is organized in this fashion, it might be useful to have
a memorandum of understanding that outlines the expectations of
each partner. It can also be helpful to establish bylaws for more
formal partner interactions.

> Create local awareness of and support for the partnership.

> Bring in new partners.

> Ensure that all members are participating in partnership activities.

> Encourage shared leadership and decision making.

> Develop a strong sense of group identity.

Sustaining Your Partnership’s Initiative
> Increase community awareness and understanding of the initiative.

> Help partners develop the skills and resources necessary to carry out
the initiative.

> Build the initiative on existing efforts when possible.

> Identify potential funding opportunities, such as grants from
government agencies or foundations. If you are part of a non-
incorporated coalition, you may need to find a fiscal agent or
partner that will permit you to access these funding streams.

> Reflect on mission, goals, and objectives to determine
necessary changes.

> Revisit your partnership principles often and revise them as necessary.

> Change strategies as necessary and appropriate.

Closing Thoughts

Since the Social Determinants of Health Disparities: Learning From Doing forum in October
2003, the community initiatives presented in Chapter 2 have evolved and new lessons learned
have emerged. The information presented in this workbook provides only a snapshot of the
impressive efforts that have taken place in our example communities and elsewhere. One of
the best ways to understand the process of developing social determinants of health initiatives
is through regular, ongoing observation of those engaged in these initiatives; here we have
provided only a glimpse of their efforts.

We recognize that there are many other promising interventions, tools and resources
in communities across the globe. As we begin to work with new partners across different
sectors of the community, we can learn from alternative approaches to influencing the social,
economic, and environmental conditions that influence health. For example, we can find
meaningful interventions in public policy (e.g., educational policies that ensure equal access
to educational opportunities regardless of student residence), economic development (e.g.,
microfinance, individual development accounts), or information technology (e.g., computer
and Internet connectivity support).

As noted earlier, most communities have long histories of improving conditions that, in the
long run, also improve health and minimize health disparities. There seems to be growing
appreciation of such initiatives for their potential public health impact. Such initiatives provide
public health agencies and community organizations with potential new partners. Community
initiatives bring interested citizens, local knowledge, and other resources to such efforts. Public
health agencies and community organizations can bring an emphasis on addressing health
disparities, evaluation strategies, and other resources.

As the breadth of local initiatives addressing health disparities grows, so does the depth.
Many communities are developing multicomponent initiatives with the understanding that many
factors affect health. For example, job training programs can have a positive health effect
for participants through increased self-esteem and income from a new or better job. There
is growing understanding in some communities that job training programs are most likely to
be successful when combined with other initiatives, such as financial literacy programs, job
creation programs, and improved primary and secondary education programs 490

These complex initiatives require time and substantial effort to build sustainable
partnerships, share resources, develop systems of communication, and minimize
the competitive environment many organizations have been exposed to in order
to acquire funding.

It is by sharing challenges and successes in the efforts to change social
determinants that communities can learn from each other how to work
to achieve health equity. Each initiative brings new information about
strategies that can be used to improve social determinants of health. We
hope that you will join the many others working toward health equity, some
of whose efforts we have highlighted in this workbook, so we can all learn
by doing.

Tell us your story about the work your community is doing to achieve health
equity. You may email us at CCDinfo@cdc.gov, attention social determinants of
health. Include your contact information in your email if you would like a reply.

Suggested Readings and Resources
Chapter 1: Achieving Health Equity

Health Equity

Braveman P, Gruskin S. Defining equity in health. Journal of
Epidemiology and Community Health 2003;57:254–258.

Braveman P. Monitoring equity in health and healthcare. Journal of
Health Population and Nutrition 2003;21(3):181–192 .

Commission on social determinants of health. Achieving health
equity: from root causes to fair outcomes. Interim statement. London
(UK): Commission on Social Determinants of Health, World Health
Organization; 2007. http://www.who.int/social_determinants/
resources /interim_statement/en/index.html.

Dahlgren G, Whitehead M. Policies and Strategies to Promote Equity
in Health. Copenhagen: World Health Organization; 1992.

Evans T, Whitehead M, Diderichsen F, Abbas B, Wirth M, editors.
Challenging Inequities in Health: From Ethics to Action. Oxford and
New York: Oxford University Press; 2001.

Flournoy R, Bell J, Bell JD, Blackwell AG, Colmenar R, Fox R, et al.
Regional Development and Physical Activity: Issues and Strategies
for Promoting Health Equity. Oakland, CA: PolicyLink; 2002.

Kosny A, Ennis G. The social determinants of health: equity across
the lifespan. Proceedings of Made to Measure: Designing Research,
Policy and Action Approaches to Eliminate Gender Inequality,
National Symposium; 1999 Oct 3–6; Halifax, Nova Scotia.

Rifkin SB. A framework linking community empowerment and health
equity: it is a matter of CHOICE. Journal of Health Population
and Nutrition 2003;21(3):168–180.

Health Inequalities

Daniels N, Kennedy B, Kawachi I. Is Inequality Bad for Our Health?
Boston: Beacon Press; 2000.

Ibrahim SA. Eliminating health inequalities. American Journal of Public
Health 2003;93(10):1618.

Raphael D. Health inequities in the United States: prospects and

solutions. Journal of Public Health Policy 2000;21(4):394–425.

Singh GK. Area deprivation and widening inequalities in US mortality,
1969–1998. American Journal of Public Health 2003;93(7):1137–1143.

Woodward A, Kawachi I. Why reduce health inequalities? Journal of
Epidemiology and Community Health 2000;54(12):923–929.

Health Disparities

Applied Research Center. Closing the Gap: Solutions to Race-Based
Health Disparities. Oakland, CA: Arc Publications; 2005.

Artazcoz L, Benach J, Borrell C, Cortes I. Unemployment and mental
health: understanding the interactions among gender, family roles, and
social class. American Journal of Public Health 2004;94(1):82–88.

Davis R, Cohen L, Mikkelsen, L. Strengthening Communities: A Prevention
Framework for Eliminating Disparities. Oakland, CA: Prevention
Institute; 2003.

Hillmeier MM, Lynch J, Harper S, Casper M. Measuring contextual

characteristics for community health. Health Services Research

2003;38(6 pt 2):1645–1717.

James SA. Social determinants of health: Implications for intervening on
racial and ethnic health disparities. Proceedings of the Minority Health
Conference; 2002 Mar 1; University of North Carolina.

James SA. Confronting the moral economy of US racial/ethnic health
disparities. American Journal of Public Health 2003;93(2):189.

Johnson JC, Smith NH. Health and social issues associated with racial,
ethnic, and cultural disparities. Generations 2002;Fall:25–32.

Keppel K, Pamuk E, Lynch J, Carter-Pokras O, Kim I, Mays V, et al.
Methodological issues in measuring health disparities. Vital and
Health Statistics. Series 2, Data Evaluation and Methods Research
2005;2(141):1–22.

Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism,
sexism and social class: implications for studies of health, disease
and well-being. American Journal of Preventive Medicine 1993;9
(6 Suppl):82–122.

LaVeist T, editor. Race, Ethnicity and Health: A Public Health Reader.
San Francisco: Jossey-Bass; 2002.

Levy BS, Sidel VW. Social Injustice and Public Health. New York:
Oxford University Press; 2005.

Livingston IL. Praeger Handbook of Black American Health: Policies
and Issues Behind Disparities in Health. 2nd edition. Westport, CT:
Praeger Publishers; 2004.

Mays VM, Yancey AK, Cochran SD, Weber M, Fielding JF.
Heterogeneity of health disparities among African American,
Hispanic, and Asian American women: unrecognized influences
of sexual orientation. American Journal of Public Health
2002;92(4):632–639.

Mikkelsen L, Cohen L, Bhattacharyy K, Valenzuela I, Davis R, Gantz T.
Eliminating Health Disparities: The Role of Primary Prevention.
Oakland, CA: Prevention Institute; 2002.

National Institutes of Health. NIH Addressing Health Disparities: The
NIH Program of Action. Available at http://healthdisparities.nih.gov/
whatare.html.

PolicyLink. Reducing Health Disparities Through a Focus on Communities.
Oakland, CA: PolicyLink; 2002.

The Prevention Institute. Health for All: California’s Strategic Approach
to Eliminating Racial and Ethnic Health Disparities. Oakland, CA:
California Campaign to Eliminate Racial and Ethnic Disparities in
Health; 2003.

Provider’s Guide to Quality and Culture. A Resource for Providing High
Quality, Culturally Competent Services to Multi-Ethnic Populations.
Available at http://erc.msh.org/mainpage.cfm?file=1.0.htm& module
=provider&language=English.

Redmond L J, Bowman BA, Mensah GA, compilers. Health Disparities:
A Selected Bibliography from the National Center for Chronic Disease
Prevention and Health Promotion. January 2000–January 2005.
Atlanta, GA: Centers for Disease Control and Prevention; 2005.

Schulz AJ, Israel BA, Parker EA, Lockett M, Hills Y, Wills R. The East Side
Village Worker Partnership: integrating research with action to reduce
health disparities. Public Health Reports 2001;116(6):548–557.

Williams DR, Collins C. US socioeconomic and racial differences

in health: patterns and explanations. Annual Review Sociology

1995;21:349–386.

Defining Social Determinants

Barnett E, Casper M. A definition of “social environment.” American

Journal of Public Health 2001;91(3):465.

Berkman LF, Kawachi IE. Social Epidemiology. New York: Oxford

University Press; 2000.

James SA. Social determinants of health: implications for intervening on
racial and ethnic health disparities. Proceedings of the Minority Health
Conference; 2002 March 1; University of North Carolina.

Krieger N. A glossary for social epidemiology. Journal of Epidemiology
and Community Health 2001;55(10):693–700.

Marmot M. Introduction. In: Marmot M, Wilkinson R, editors. Social
Determinants of Health. Oxford: Oxford University Press; 1999:1–16.

Miringhoff M, Miringhoff, ML. The Social Health of the Nation.

New York: Oxford University Press; 1999.

Queensland Health. Integrating Public Health Practices: A Position

Statement on Community Capacity Development and the Social

Determinants of Health for Public Health Services. Queensland
Government; 2003. Available at http://www.health.qld.gov.au/

phs/Documents/shpu/20426 .

Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts.
Copenhagen: World Health Organization; 2003.

World Health Organization. Action on the social determinants
of health: Learning from previous experiences. Proceedings of the
First Meeting of the Commission on Social Determinants of Health;
2005 Mar; Geneva. Available at http://www.who.int/social_
determinants/strategy/CSDH_socialdet_backgrounder .

Examples of Social Determinants

Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE. The Community
Guide’s model for linking the social environment to health. American
Journal of Preventive Medicine 2003;24(3 Suppl):12–20.

Baker E, Williams D, Kelly C, Nanney MS, Vo H, Barnidge E, et al.
Access, income and racial composition: dietary patterns aren’t just
a personal choice. Proceedings of the American Public Health
Association Meeting; 2003 Nov; San Francisco.

Berkman L, Kawachi I. Social Epidemiology. New York: Oxford

University Press; 2000.

Davis R, Cook D, Cohen L, Baxi S. A community resilience approach
to reducing ethnic and racial disparities in health. American Journal
of Public Health 2005;95(12):2168–2173.

Evans RG, Barer ML, Marmor TR. Why are Some People Healthy and
Others Not: The Determinants of Health of Populations. New York:
Aldine de Gruyter; 1994.

Findley SE, Irigoyen M, See D, Sanchez M, Chen S, Sternfels P, et al.
Community-provider partnerships to reduce immunization
disparities: field report from northern Manhattan. American
Journal of Public Health 2003;93(7):1041–1044.

Flournoy R, Yen I. The Influence of Community Factors on Health:
An Annotated Bibliography. Oakland, CA: PolicyLink; 2004.

Gunn SWA, Mansourian PB, Davies AM, Piel A, Sayers B. Understanding
the Global Dimensions of Health. New York: Springer; 2005.

James SA. Social determinants of health: implications for intervening on
racial and ethnic health disparities. Proceedings of the Minority Health
Conference; 2002 Mar 1; University of North Carolina.

Kawachi I, Kennedy BP. Health and social cohesion: why care about
income inequality? BMJ. 1997;314:1037–1040.

Kingsley GT. Housing, health, and the neighborhood context. American
Journal of Preventive Medicine 2003;24(3 Suppl):6–7.

Krieger J, Allen C, Cheadle A, Ciske S, Schier JK, Senturia K, et al. Using
community-based participatory research to address social
determinants of health: lessons learned from Seattle Partners for
Healthy Communities. Health Education and Behavior
2002;29(3):361–382.

Krieger N. A glossary for social epidemiology. Journal of Epidemiology
and Community Health 2001;55(10):693–700.

Link BG, Phelan J. Social conditions as fundamental causes of disease.
Journal of Health and Social Behavior 1995;Spec No:80–95.

Marmot M. Introduction. In: Marmot M, Wilkinson, R, editors. Social
Determinants of Health. Oxford: Oxford University Press; 1999:1–16.

Needle RH, Trotter RT, Singer M, Bates C, Page B, Metzger D, et al.
Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority
communities: an approach for timely community interventions.
American Journal of Public Health 2003;93(6):970–979.

Ramos IN, May M, Ramos KS. Environmental health training of
promotoras in colonias along the Texas-Mexico border. American
Journal of Public Health 2001;91(4):568–570.

Raphael D. Addressing social determinants of health in Canada:
bridging the gap between research findings and public policy.
Policy Options 2003;35–40.

REACH 2010. Atlanta: National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention.
Available at http://www.cdc.gov/reach2010.

Schulz A, Northridge ME. Social determinants of health: implications for
environmental health promotion. Health Education and Behavior
2004;31(4):455–471.

Schulz AJ, Parker EA, Israel BA, Allen A, DeCarlo M, Lockett M.
Addressing social determinants of health through community-based
participatory research: The East Side Village Health Worker Partnership.
Health Education and Behavior 2002;29(3):326–341.

Singh GK. Area deprivation and widening inequalities in US mortality,
1969-1998. American Journal of Public Health 2003;93(7):1137–1143.

Singh GK, Miller BA, Hankey BF. Changing area socioeconomic
patterns in U.S. cancer mortality, 1950–1998: Part II – Lung and
colorectal cancers. Journal of the National Cancer Institute
2002;94(12):916–925.

Singh GK, Siahpush M. Increasing inequalities in all-cause and
cardiovascular mortality among US adults aged 25–64 years by
area socioeconomic status, 1969–1998. International Journal of
Epidemiology 2002;31(3):600–613.

Syme L. Social determinants of health: the community as an empowered
partner. Preventing Chronic Disease 2004;1(1):1-5.

Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts.
Copenhagen: World Health Organization; 2003.

Williams DR, Collins C. US socioeconomic and racial differences in
health: Patterns and explanations. Annual Review of Sociology
1995;21:349–386.

Health Impact Assessment

Harris-Roxas B, Simpson S, Harris L. Equity-Focused Health Impact
Assessment: A Literature Review. Sydney: Centre for Health
Equity Training Research and Evaluation; 2004. Available at
http://chetre.med.unsw.edu.au/files/Harris-Roxas_B_(2004)_
Equity_Focused_HIA .

IMPACT: International Health Impact Consortium. Liverpool, England:
Department of Public Health at the University of Liverpool; 2001.
Available at http://www.ihia.org.uk.

Mindell J, Boltong A. Supporting health impact assessment in practice.
Public Health 2005;119(4):246–252.

National Institute for Health and Clinical Excellence. London: National
Institute for Health and Clinical Excellence; 2006. Health Impact
Assessment Gateway. Available at http://www.publichealth.
nice.org.uk/page.aspx?o=HIAGateway.

World Health Organization. Health Impact Assessment. Geneva: World
Health Organization; 2006. Available at http://www.who.int/hia/en.

Inequalities by Race

Cutting H, Themba-Nixon M. Talking the Walk: A Communications
Guide for Racial Justice. San Francisco: We Interrupt This
Message; 2003.

Glover-Blackwell A, Kwoh S, Pastor M. Searching for the Uncommon
Ground: New Dimensions on Race in America. New York: W.W.
Norton & Company, Inc; 2002.

James SA. Confronting the moral economy of US racial/ethnic health
disparities. American Journal of Public Health 2003;93(2):189.

Jones CP. Levels of racism: a theoretic framework and a gardener’s tale.
American Journal of Public Health 2000;90(8):1212–1215.

Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism
and social class: implications for studies of health, disease and
well-being. American Journal of Preventive Medicine 1993;9
(6 Suppl):82–122.

LaVeist T, editor. Race, Ethnicity and Health: A Public Health Reader.
San Francisco: Jossey-Bass; 2002.

Massey DS, Denton NA. American Apartheid: Segregation and the Making
of the Underclass. Cambridge, MA: Harvard University Press; 1993.

One America In the 21st Century: The President’s Initiative on Race.
Washington, DC: White House: 1998.

Williams DR. Race, socioeconomic status, and health: the added effects
of racism and discrimination. Annals of the New York Academy
of Sciences 1999;896:173–188.

Williams DR, Collins C. US socioeconomic and racial differences in
health: patterns and explanations. Annual Review of Sociology 1995;
21:349–386.

Community

Fellin P. Understanding American communities. In: Rothman J, Erlich J
L, Tropman J E. Strategies of Community Organization. Itasca, IL:
Peacock; 1995.

Hunter A. The loss of community: an empirical test through replication.
American Sociology Review 1975;40(5):537–552.

Israel BA, Checkoway B, Schulz A, Zimmerman M. Health education
and community empowerment: conceptualizing and measuring
perceptions of individual, organizational and community control.
Health Education Quarterly 1994;21(2);149–170.

Israel BA, Eng E, Schulz AJ, Parker EA, editors. Methods in Community-
Based Participatory Research for Health. San Francisco: John Wiley &
Sons; 2005.

McKnight JL. Redefining community. Social Policy 1992; Fall-Winter: 56–62.

Minkler M, Wallerstein N. Community Based Participatory Research for
Health San Francisco: Jossey-Bass; 2003.

Patrick DL, Wickizer TM. Community and health. In: Amick IBJ, Levine S,
Tarlov AR, Chapman Walsh D, editors. Society and Health. New
York: Oxford University Press; 1995:46–92.

Steuart GW. Social and cultural perspectives: community intervention
and mental health. Health Education Quarterly 1993;20(1 Suppl):
S99–S111.

Public Health

Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public
Health. New York: Oxford University Press; 2003.

Hofrichter R, editor. Tackling health inequities through public health
practice: a handbook for action. The National Association of County
and City Health Officials. 2006.

Institute of Medicine. The Future of the Public’s Health in the 21st Century.

Washington, DC: The National Academies Press; 2003.

Stokols D. Translating social ecological theory into guidelines for
community health promotion. American Journal of Health Promotion
1996;10(4):282–298.

Tarlov A, St. Peter R. Introduction. In: Tarlov A, St. Peter R, editors.
The Society and Population Health Reader: A State and Community
Perspective. New York: New Press; 2000:ix–xxv.

Chapter 2: Communities Working to Achieve Health Equity

Becker AB, Randels J, Theodore D. Project BRAVE: Engaging youth
as agents of change in a youth violence prevention project.
Community Youth Development Journal 2005 Fall; Available at
www.cydjournal.org/contents.html.

Geiger HJ. Community-oriented primary care: a path to community
development. American Journal of Public Health 2002;92:1713–1716.

Michael YL, Farquar SA, Wiggins N, Green MK. Findings from a
community-based participatory prevention research intervention
designed to increase social capital in Latino and African American
communities. Journal of Immigrant and Minority Health In press.

Office of the Deputy Prime Minister. Research report 17. New deal
for communities 2001-2005: an interim evaluation. Sheffield
Hallam University; 2006 November. Available at
http://www.neighbourhood.gov.uk/publications.asp?did=1625.

Chapter 3: Developing a Social Determinants of Health
Inequities Initiative in Your Community

Assessing Social Determinants

Amick BC, Levine S, Tarlov AR, Chapman Walsh D. Society and Health.
New York: Oxford University Press; 1995.

Berkman LF, Kawachi IE. Social Epidemiology. New York: Oxford
University Press; 2000.

Centers for Disease Control and Prevention. Data Set Directory of Social
Determinants of Health at the Local Level. Atlanta: Centers for Disease
Control and Prevention. Available at http://www.cdc.gov/cvh/
library/data_set_directory/index.htm.

Corin E. The cultural frame: context and meaning in construction of
health. In: Society and Health. New York: Oxford University Press;
1995:272–303.

Davis R, Cook D, Cohen L, Baxi S. A community resilience approach
to reducing ethnic and racial disparities in health. American Journal of
Public Health 2005;95(12);2168–2173.

Flournoy R, Yen I. The Influence of Community Factors on Health: An
Annotated Bibliography. Oakland, CA: PolicyLink; 2004.

James SA. Social determinants of health: implications for intervening on
racial and ethnic health disparities. Proceedings of the Minority Health
Conference; 2002 Mar 1; University of North Carolina.

Labonte R. How Our Programs Affect Population Health Determinants:
A Workbook for Better Planning and Accountability. Regina,
Saskatchewan, Canada: Health Canada; 2003.

Marmot M. Introduction. In: Marmot M, Wilkinson R, editors. Social
Determinants of Health. Oxford: Oxford University Press; 1999:1–16.

Miringoff M, Miringhoff ML. The Social Health of the Nation. New York:
Oxford University Press; 1999.

Miringoff ML. Toward a national standard of social health: the need for
progress in social indicators. American Journal of Orthopsychiatry
1995;65(4):462–467.

Raphael D. Addressing social determinants of health in Canada:
bridging the gap between research findings and public policy.
Policy Options 2003;24(3):35–40.

Raphael D. Barriers to addressing the societal determinants of health:
public health units and poverty in Ontario, Canada. Health Promotion
International 2003;18(4):397–405.

Syme L. Social determinants of health: the community as an empowered
partner. Preventing Chronic Disease 2004;1(1):1-5.

Weissman E, editor. Using Performance Monitoring to Improve
Community Health: Conceptual Framework and Community
Experience. Washington, DC: National Academy Press; 1996.

Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts.
Copenhagen: World Health Organization; 2003.
97

Partnerships

Alter C, Hage J. Organizations Working Together. Newbury Park, CA:
Sage Publications, Inc.; 1992.

Baker EA, Homan S, Schonhoff R, Kreuter M. Principles of practice for
academic/practice/community research partnerships. American
Journal of Preventive Medicine 1999;16(3 Suppl):86–93.

Berkowitz B. Collaboration for health improvement: models for state,
community and academic partnerships. Journal of Public Health
Management and Practice 2000;6(1):67–72.

Clark NM, Community/practice/academic partnerships in public

health. American Journal of Preventive Medicine 1999;16(3

Suppl):18–19.

Cohen L, Aboelata MJ, Gantz T,Van Wert J. Collaboration Math:

Enhancing the Effectiveness of Multidisciplinary Collaboration.

Oakland, CA: Prevention Institute; 2003.

Gamm LD. Advancing community health through community health
partnerships. Journal of Healthcare Management 1998;43(1):51–66.

Green L, Daniel M, Novick L. Partnerships and coalitions for community
based research. Public Health Reports 2001;116(1 Suppl):20–30.

Israel BA, Lichtenstein R, Lantz P, McGranaghan R, Allen A, Guzman
JR, et al. The Detroit Community-Academic Urban Research Center:
development, implementation, and evaluation. Journal of Public Health
Management Practice 2001;7(5):1–19.

Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based
research: assessing partnership approaches to improve public health.
Annual Review of Public Health 1998;19:173–202.

Johnson K, Grossman W, Cassidy A. Collaborating to Improve
Community Health: Workbook and Guide to Best Practices in
Creating Healthier Communities and Populations. San Francisco:
Jossey-Bass; 1997.

Lantz PM, Vruell-Fuentes E, Israel BA, Softley D, Guzman R. Can
communities and academia work together on public health research?
Evaluation results from a community-based participatory research
partnership in Detroit. Journal of Urban Health 2001;78(3):495–507.

Lasker R. Promoting collaborations that improve health. Proceedings of
the Community-Campus Partnerships for Health’s 4th Annual
Conference The New York Academy of Medicine Division of Public
Health; Apr-May 2000; New York.

The Lewin Group, Inc. Communities Sustain Public Health Improvement
Through Organized Partnership Structures. Battle Creek, MI:
W.K. Kellogg Foundation; 2004.

Mattessich PW, Murray-Close M, Monsey BR. Collaboration: What
Makes it Work. Saint Paul: Wilder Publishing Center; 2001.

Metzler MM, Higgins DL, Beeker CG, Freudenberg N, Lantz PM,
Senturia K, et al. Addressing urban health in Detroit, New York
City and Seattle through community-based participatory research
partnerships. American Journal of Public Health 2003;93(5):803–811.

Nelson JC, Rashid H, Galvin VG, Essien JD, Levine LM. Public/private
partners: key factors in creating a strategic alliance for community
health. American Journal of Preventive Medicine 1999;16(3 Suppl):
94–102.

Richter D, Gimarc J, Preston G, Williams A. Implementing community-
campus partnerships in South Carolina: collaborative efforts to
improve public health. Public Health Reports 2003;118:387–391.

Roussos ST, Fawcett SB. A review of collaborative partnerships as a
strategy for improving community health. Annual Review of Public
Health 2000; 21:369–402.

Schulz AJ, Israel BA, Parker EA, Lockett M, Hill Y, Wills R. The East Side
Village Worker Partnership: integrating research with action to reduce
health disparities. Public Health Reports 2001;116(6):548–557.

Seifer SD, Krauer P. Toward a policy agenda for community-campus
partnerships. Education for Health 2001;14(2):156-162.

Sullivan M, Kone A, Senturia KD, Chrisman NJ, Ciske SJ, Krieger JW.
Researcher and researched-community perspectives: toward bridging
the gap. Health Education and Behavior 2001;28(2):130-149.

Syme L. Social determinants of health: the community as an empowered
partner. Preventing Chronic Disease 2004;1(1):1-5.

Turning Point: Collaborating for a New Century in Public Health.
Seattle: The Robert Wood Johnson Foundation. Available
at http://turningpointprogram.org/Pages/New_TP_brochure .

Community-Based Participatory Research

Green L, Daniel M, Novick L. Partnerships and coalitions for community
based research. Public Health Reports 2001;116(1 Suppl):20–30.

Israel BA, Eng E, Schulz AJ, Parker E, editors. Methods in Community-
Based Participatory Research for Health. San Francisco: John Wiley
& Sons; 2005.

Lantz PM, Viruell-Fuentes E, Israel BA, Softley D, Guzman R. Can
communities and academia work together on public health research?
Evaluation results from a community-based participatory research
partnership in Detroit. Journal of Urban Health 2001;78(3):495–507.

Metzler MM, Higgins DL, Beeker CG, Frudenberg N, Lantz M, Senturia K,
et al. Addressing urban health in Detroit, New York City and Seattle
through community-based participatory research partnerships.
American Journal of Public Health 2003;93(5):803–811.

Minkler M, Wallerstein N. Community Based Participatory Research for
Health. San Francisco: Jossey-Bass; 2003.

Schulz AJ, Parker EA, Israel BA, Allen A, Decarlo M, Locckett M.
Addressing social determinants of health through community-based
participatory research: the East Side Village Health Worker
Partnership. Health Education and Behavior 2002;29(3):326–341.

Community Coalitions

Butterfoss F. Coalition Effectiveness Inventory Self Assessment Tool.

Charleston, SC: Center for Pediatric Research, Center for Health

Promotion; 1998.

Butterfoss F, Goodman R, Wandersman A. Community coalitions
for prevention and health promotion: factors predicting satisfaction,
participation and planning. Health Education Quarterly 1996;23:
65–79.

Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for
prevention and health promotion. Health Education Research 1993;
8(3):315–330.

Cohen L, Baer N, Sattenwhite P. Developing effective coalitions: an
eight step guide. In: Wurzbach ME, editor. Community Health
Education and Promotion: A Guide to Program Design and Evaluation.
2nd edition. Gaithersburg, MD: Aspen Publishers, Inc.; 2002:144–161.

Cohen L, Gould J. The Tension of Turf: Making it Work for the Coalition.
Oakland, CA: Prevention Institute; 2003.

Feighery E, Rogers T. Building and Maintaining Effective Coalitions. Palo
Alto, CA: Stanford Health Promotion Resource Center; 1990.

Green L, Daniel M, Novick L. Partnerships and coalitions for community
based research. Public Health Reports 2001;116(1 Suppl):20–30.

Kegler MC, Steckler A, McLeroy K, Malek SH. Factors that contribute
to effective community health promotion coalitions: a study of 10
Project ASSIST coalitions in North Carolina. Health Education and
Behavior 1998;25(3):338–353.

Wolff T, Kaye G. From the Ground Up! A Workbook on Coalition

Building and Community Development. Amherst, MA: AHEC/

Community Partners; 1997.

Community Capacity

Aspen Institute. Measuring Community Capacity Building: A Workbook
in Progress for Rural Communities. Queenstown, MD: Aspen Institute:
Rural Economic Policy Program; 1996. Available at
http://www.aspeninstitute.org/bookdetails.asp?i=59&d=60.

Chavis D, Wandersman A. Sense of community in the urban
environment: a catalyst for participation and community development.
American Journal of Community Psychology 1990;18:55–81.

Cottrell, L. The competent community. In: Kaplan BH, Wilson RN,

Leighton AH. Further Explorations in Social Psychiatry. New York:

Basic Books; 1976.

Easterling D, Gallagher K, Drisko J, Johnson T. Promoting Health by
Building Community Capacity: Evidence and Implications for
Grantmakers. Denver: Colorado Trust; 1998. Available at
http://www.coltrust.org/repository/publications/pdfs/ComCapEvid .

Fawcett S, Francisco V, Hyra D. Building healthy communities. In: Tarlov
AR, St. Peter RF. The society and population health reader. New York:
New Press; 2000:75–96.

Freudenberg N, Eng E, Flay B, Parcel G, Rogers T, Wallerstein N.
Strengthening individual and community capacity to prevent disease
and promote health: in search of relevant theories and principles.
Health Education Quarterly 1995;22(3):290–306.

Goodman RM, Speers MA, McLeroy K, Fawcett S, Kegler M, Parker
E, et al. Identifying and defining the dimensions of community capacity
to provide a basis for measurement. Health Education and Behavior
1998;25(3):258–278.

Kretzmann JP, McKnight JL. A Guide to Capacity Inventories: Mobilizing
the Community Skills of Local Residents. Chicago: ACTA Publications;
1997.

Lasker RD, Weiss ES. Broadening participation in community problem
solving: a multidisciplinary model to support collaborative practice
and research. Journal of Urban Health 2003;80(1):14-60.

McLeroy K. Community capacity: What is it? How do we measure it?
And what is the role of the prevention centers and the CDC?
Proceedings of the Sixth Annual Prevention Centers Conference —
Centers for Disease Control and Prevention, National Center for
Chronic Disease Control and Prevention; Feb 1996; Atlanta.

Norton B, McLeroy K, Burdine JN, Felix MRJ, Dorsey AM. Community
capacity: concept, theory and methods. In: DiClemente RJ, Crosby
RA, Kegler MC. Emerging Theories in Health Promotion Practice and
Research. San Francisco: Jossey-Bass; 2002:194-227.

Poole DL. Building community capacity to promote social and public
health: challenges for universities. Health and Social Work 1997;
22(3):163–170.

Rifkin SB. A framework linking community empowerment and health
equity: it is a matter of CHOICE. Journal of Health, Population
and Nutrition 2003;21(3):168–180.

Queensland Health. Integrating Public Health Practices: A Position
Statement on Community Capacity Development and the Social
Determinants of Health for Public Health Services. Queensland,
Australia: Queensland Government; 2003. Available at
http://www.health.qld.gov.au/phs/Documents/shpu/20426 .

100

Consciousness Raising

Freire P. Pedagogy of the Oppressed. New York: Continuum

Publishing Corporation; 1970.

Community Development

Dewar T. A Guide to Evaluating Asset-Based Community Development:
Lessons, Challenges and Opportunities. Chicago: ACTA
Publications; 1997.

Garkovich L. Local organizations and leadership in community
development. In: Christenson JA, Robinson JW. Community
Development in Perspective. Ames, Iowa: State University Press; 1989.

Hope A, Timmell S. Training for Transformation: A Handbook for
Community Workers. Volumes 1–4. London: ITDG Publishing; 1995.

Kingsley GT, McNeely JB, Gibson JO. Community Building: Coming
of Age. Washington, DC: Development Training Institute and the
Urban Institute; 1997.

Kretzmann JP, McKnight JL. Building Communities from the Inside Out: A
Path Toward Finding and Mobilizing a Community’s Assets. Chicago:
ACTA Publications; 1993.

Kretzmann JP, McKnight JL. A Guide to Mapping and Mobilizing the
Economic Capacities of Local Residents. Chicago: ACTA Publishing; 1996.

Kretzmann JP, McKnight JL. A Guide to Mapping Consumer Expenditures
and Mobilizing Consumer Expenditure Capacities. Chicago: ACTA
Publications; 1996.

Kretzmann JP, McKnight JL. A Guide to Mapping Local Business Assets
and Mobilizing Local Business Capacities. Chicago: ACTA
Publications; 1996.

Kretzmann JP, McKnight JL. A Guide to Creating a Neighborhood
Information Exchange: Building Communities by Connecting Local
Skills and Knowledge. Chicago: ACTA Publications; 1998.

Mattessich P, Monsey B. Community Building: What Makes it Work?
Saint Paul: Wilder Publishing Center; 1997.

Minkler M, Wallerstein N. Improving health through community
organization and community building. In: Minkler M. Community
Organizing and Community Building for Health. New Brunswick, NJ:
Rutgers University Press; 1997:30–52.

Minkler M, Wallerstein N. Improving health through community
organization and community building. In: Glanz K, Lewis FM, Rimer,
BK, editors. Health Behavior and Health Education. San Francisco:
Jossey-Bass; 1997:241–269.

Community and Social Health Indicators

Centers for Disease Control and Prevention. Data Set Directory of Social
Determinants of Health at the Local Level. Atlanta: National Center for
Chronic Disease Prevention and Health Promotion, Cardiovascular
Health. Available at http://www.cdc.gov/cvh/library/data_set_
directory/index.htm.

Childstats.gov. American Children: Key National Indicators of Well-Being.
Washington DC: Federal Interagency Forum on Child and Family
Statistics. America’s Children: Key National Indicators of Well-Being.
Available at http://childstats.gov.

Communityindicators.net. Available at http://www.communityindicators.net.

Communityphind.net. Baltimore MD: Public Health Indicators and
National Data; 2005. Available at http://www.communityphind.net.

Emerine D, Feldman E. Active Living and Social Equity: Creating Healthy
Communities for All Residents: A Guide for Local Governments.
Washington, DC: International City/County Management
Association: 2005. Available at http://bookstore.icma.org/obs/
showdetl.cfm?&DID=7&Product_ID=1247Active.

Global Equity Gauge Alliance. Monitoring Health Inequalities and
Promoting Equity Within and Between Societies. Available at
http://www.gega.org.za.

101

Kingsley GT. Building and Operating Neighborhood Indicator Systems:
A Guidebook. Washington, DC: The Urban Institute; 1999.

KnowledgePlex.org. Washington, DC: Fannie Mae Foundation; 2006.
Available from: http://www.knowledgeplex.org.

Miringhoff M, Miringhoff ML. The Social Health of the Nation.
New York: Oxford University Press; 1999.

Miringoff ML. Toward a national standard of social health: the need
for progress in social indicators. American Journal of Orthopsychiatry
1995;65(4):462–467.

Mohan J, Barnard S, Jones K , Twigg L. Social capital, place and health:
creating, validating and applying small-area indicators in the
modelling of health outcomes. Wetherby, Yorkshire: National Institute
for Health and Clinical Excellence; 2004.

Urban.org. Democratizing Information. Washington, DC: The Urban

Institute National Neighborhood Indicators Project. Available at

http://www.urban.org/nnip.

Community Organizing

Bobo KA, Max S, Kendall, J. Organizing for Social Change: Midwest
Academy Manual for Activists. Santa Ana, CA: Seven Locks Press; 2001.

Hunter D, Bailey A, Taylor B. The Art of Facilitation: How to Create
Group Synergy. Cambridge, MA: Fisher Books; 1995.

Kahn S. Organizing: A Guide for Grassroots Leaders. Revised edition.
Washington, DC: National Association of Social Workers Press; 1991.

Kahn S. How People Get Power. Revised edition. Washington, DC:

National Association of Social Workers Press; 1994.

Rothman J. Three models of community organization practice. In: Cox F,
Erlich JR, Rothman J, Tropman J. Strategies of Community Organization:
Macro Practice. Itasca, IL: Peacock Publishers Inc; 1970:20–35.

Stoecker R. Crossing Development-Organizing Divide: A Report on the
Toledo Community Organizing Training and Technical Assistance
Program. Toledo, OH: Toledo Community Foundation, University of
Toledo Urban Affairs Center; 2001.

Warren RB. The Neighborhood Organizer’s Handbook. Notre Dame,
IN: University of Notre Dame Press; 1977.

Social Action

Economos CD, Brownson RC, DeAngelis MA, Foerster SB, Foreman CT,
Gregson J, et al. What lessons have been learned from other
attempts to guide social change? Nutrition Reviews 2001;
59(3 Pt 2):S40–S56; discussion S57–S65.

Kahn S. How People Get Power. Revised edition. Washington, DC:

National Association of Social Workers Press; 1994.

Scott JC. Domination and the Arts of Resistance. New Haven, CT: Yale
University Press; 1990.

Shaw R. The Activist’s Handbook: A Primer. Updated edition. Berkeley:
University of California Press; 2001.

Speeter G. Power: A Repossession Manual – Organizing Strategies for
Citizens. Amherst, MA: University of Massachusetts at Amherst; 1978.

Social Capital

Harwood Group. Public Capital: The Dynamic System that Makes
Public Life Work. Bethesda, MD: The Kettering Foundation; 1996.

National Civic League. The Civic Index: Measuring Your Community’s
Civic Health. Denver, CO: National Civic League; 1999.

Saguaro Seminar. The Social Capital Community Benchmark Survey:
Executive Summary. Cambridge, MA: John F. Kennedy School of
Government, Harvard University; 2001.

Sampson RJ, Raudenbusch SW, Earls F. Neighborhoods and violent
crime: a multilevel study of collective efficacy. Science. 1997;
277(15):918–924.

102

Van Kemenade S. Social Capital as a Health Determinant: How Is it
Defined? Ottawa, Ontario, Canada: Health Canada; 2002.

Health Promotion

Adler NE, Newman K. Socioeconomic disparities in health, pathways
and policies. Health Affairs 2002;21(2):60–76.

Anderson LM, Fielding JE, Fullilove MT, Scrimshaw SC, Carande-Kulis
VG. Methods for conducting systematic reviews of the evidence of
effectiveness and economic efficiency of interventions to promote
healthy social environments. American Journal of Preventive Medicine
2003;24(3 Suppl):25–31.

Butterfoss FD, Goodman RM, Wandersman A. Community coalitions
for prevention and health promotion: factors predicting satisfaction,
participation and planning. Health Education Quarterly 1996;23:
65–79.

Davis R, Cook D, Cohen L, Baxi S. A community resilience approach
to reducing ethnic and racial disparities in health. American Journal of
Public Health 2005;95(12);2168–2173.

Findley SE, Irigoyen M, See D, Sanchez M, Chen S, Sternfels P, et al.
Community-provider partnerships to reduce immunization disparities:
field report from northern Manhattan. American Journal of Public
Health 2003;93(7):1041–1044.

Israel BA. Social networks and social support: implications for natural
helper and community level interventions. Health Education Quarterly
1985;12(1):65–80.

Johnson K, Grossman W, Cassidy A. Collaborating to Improve

Community Health: Workbook and Guide to Best Practices in
Creating Healthier Communities and Populations. San Francisco:

Jossey-Bass; 1997.

Kaye G, Wolff T. From the Ground Up: A Workbook on Coalition
Building and Community Development. Amherst, MA: AHEC/

Community Partners, Inc; 1997.

Littlefield D, Robison C, Engelbrecht L, Gonzales B, Hutcheson H.
Mobilizing women for minority health and social justice in California.
American Journal of Public Health 2002;92(4):576–579.

Metzler M, Higgins D, Beeker CG, Freudenberg NL, Paula M, Viruell-
Fuentes EA, et al. Addressing urban health in Detroit, New York
City and Seattle through community-based participatory research
partnerships. American Journal of Public Health 2003;93(5):803–811.

Morland K, Wing S, Diez Roux A, Poole C. Neighborhood
characteristics associated with the location of food stores and
food service places. American Journal of Preventive Medicine
2002;22(1):23–29.

Morland K, Wing S, Diez Roux A. The contextual effect of the local food
environment on residents’ diets: the atherosclerosis risk in communities
study. American Journal of Public Health 2002;92(11):1761–1768.

Needle R, Trotter R, Singer M, Bates C, Page JB, Metzger D, et al.
Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority
communities: an approach for timely community interventions.
American Journal of Public Health 2003.93(6):970–980.

Norris T. The Community Indicators Handbook: Redefining Progress.
Boulder, CO: Tyler Norris Associations; 1997.

Provan K, Nakama L, Veazie MA, Teufel-Shone NI, Huddleston C.
Building community capacity around chronic disease services through
a collaborative inter-organizational network. Health Education and
Behavior 2003;30(6):646–662.

Ramos IN, May M, Ramos KS. Environmental health training of
promotoras in colonias along the Texas-Mexico border. American
Journal of Public Health 2001;91(4):568–570.

103

Stokols D. Translating social ecological theory into guidelines for
community health promotion. American Journal of Health Promotion
1996;10(4):282–298.

Community-Wide Media Advocacy

Altman DG, Balcazar FE, Fawcett SB, Seekins T, Young JQ. Public
Health Advocacy: Creating Community Change to Improve Health. Palo
Alto, CA: Stanford Center for Research in Disease Prevention; 1994.

Bryant C, Forthofer M, McCormack Brown K, McDermott R.

Community-based prevention marketing. American Journal of

Health Behavior 2000;24(1):61–68.

Goldman KD, Zasloff KD. Tools of the trade: media do’s and don’ts.
SOPHE News and Views 1994; 6–7.

Kansiss P. Making Local News. Chicago: University of Chicago

Press; 1991.

Kickbusch I. Action on Health Promotion: Approaches to Advocacy and
Implementation. Copenhagen: World Health Organization; 1989.

National Cancer Institute. Media Strategies for Smoking Control:

Guidelines. Bethesda, MD: National Cancer Institute; 1988.

Olien CN, Tichenor PJ, Donahue GA. Media coverage in social

movements. In: Salmon CT, editor. Information Campaigns:

Balancing Social Values and Social Change. Newbury Park:

Sage Publications;1989:139–163.

Perschuk M, Wilbur P. Media Advocacy: Reframing Public Debate.

Washington, DC: The Benton Foundation; 1991.

Ryan, C. Prime Time Activism. Boston: South End Press; 1991.

Wallack L. Mass Media and Health Promotion: Promise, Problems,
Challenges. Mass Communication and Public Health: Complexities
and Conflicts. Newbury Park, CA: Sage Publications: 1990.

Wallack L. Two approaches to health promotion. World Health Forum.
1990;11(2):143–154; discussion 155–164.

Wallack L. Media advocacy: a strategy for empowering people and
communities. Journal of Public Health Policy 1994;15(4):420–436.

Wallack L, Dorfman L, Jerniagan D, Themba M. Media Advocacy
and Public Health: Power for Prevention. Newbury Park, CA: Sage
Publications;1993.

Whitman A. Changing the Media’s Perspective on Public Health.
Lawrence, KS: University of Kansas; 1999. Available at
http://ctb.ku.edu/tools/en/section_1276.htm.

Structural Change (Policy and Built Environment)

Aboelata M. The Built Environment and Health. Oakland, CA:

Prevention Institute; 2004.

Acosta C. Improving public health through advocacy policy. Oakland,
CA: Public Health Institute; 2003.

Alinsky SD. Rules for Radicals. New York: Random House; 1989.

Brenner M. Political economy and health. In: Amick BC, Levine S, Tarlov
AR, Chapman Walsh D. Society and Health. New York: Oxford
University Press; 1995:211–245.

Flournoy R. Regional Development and Physical Activity: Issues and
Strategies for Promoting Health Equity. Oakland, CA: PolicyLink; 2002.

Frank LD, Engelke PO, Schmid TL. Health and Community Design: The
Impact of the Built Environment on Physical Activity. Washington, DC:
Island Press; 2003.

Northridge ME, Sclar ED, Biswas P. Sorting out the connections
between the built environment and health: a conceptual framework
for navigating pathways and planning healthy cities. Journal of Urban
Health 2003;80(4):556–568.

Speeter GL. Power: A Repossession Manual – Organizing Strategies for
Citizens. Amherst, MA: University of Massachusetts at Amherst; 1978.

104

Evaluation

Eng E, Parker E. Measuring community competence in the Mississippi
Delta: the interface between program evaluation and empowerment.
Health Education Quarterly 1994;21(2):199–220.

Fawcett SB, Paine-Andrews A, Francisco VT, Schultz JA, Richter KP, Lewis
RK, et al. Empowering community health initiatives through evaluation.
In: Fetterman DM, Kaftarian SJ, Wandersman A. Empowerment
Evaluation: Knowledge and Tools for Self-Assessment and
Accountability. Thousand Oaks, CA: Sage Publications; 1996.

Fetterman D. Steps of empowerment evaluation: from California to Cape
Town. Evaluation and Program Planning 1997;17(3):305–313.

Fetterman DM, Kaftarian SJ, Wandersman A. Empowerment Evaluation:
Knowledge and Tools for Self-Assessment and Accountability.
Thousand Oaks, CA: Sage; 1996.

Kegler MC, Twiss JM, Look V. Assessing community change at multiple
Levels: the genesis of an evaluation framework for the California
Healthy Cities Project. Health Education and Behavior 2000;
27(6):760–779.

Kreuter M, Lezin N, Young L. Evaluating community-based collaborative
mechanisms: implications for practitioners. Health Promotion Practice
2000;1(1):49–63.

Additional Resources

Beverly SG, Moore A, Schreiner M. A framework of asset-accumulation
stages and strategies. Journal of Family and Economic Issues
2003;24(2):143–156.

Bhatia R, Katz M. Estimation of health benefits from a local living wage
ordinance. American Journal of Public Health 2001;91(9):1398–1402.

CGAP.org. Washington, DC: Consultative Groups to Assist the Poor;
2003. Available at http://www.cgap.org/index.html.

Microfinancegateway.org. Washington, DC: Consultative Group to Assist
the Poor; 2006. Available at http://www.microfinancegateway.org.

Schreiner M. A Framework for Financial Benefit-Cost Analysis of
Individual Development Accounts at the Experimental Site of the
American Dream Demonstration. Saint Louis, MO: Research Design,
Center for Social Development, Washington University; 2000.

Schreiner M, Sherraden M. Drop-out from individual development
accounts: prediction and prevention. Financial Services Review
2005;14(1):37–54.

Schreiner M, Sherraden M, Clancy M, Johnson E, Curley J, Zhan M,
et al. Asset accumulation by low-resource people: evidence
from individual development accounts. In: Blanton JL, Williams A,
Rhine SLW, editors. Changing Financial Markets and Community
Development. Proceedings of the Federal Reserve System Community
Affairs Research Conference; Richmond, VA: Federal Reserve Bank of
Richmond; 2001:183–216.

Vonderlack R, Schreiner. Women, microfinance, and savings: lessons
and proposals. Development in Practice 2002;12(5):602–612.

105

References
1. Institute of Medicine. The Future of the Public’s Health in the 21st Century.

Washington, DC: The National Academies Press; 2003.

2. Institute of Medicine. The Future of Public Health. Washington, DC: National
Academies Press; 1988.

3.Nadakavlikaren A. Our Global Environment: A Health Perspective. 5th edition.
Prospect Heights, IL: Waveland Press, Inc.; 2000.

4.Berkman L, Kawachi I. Social Epidemiology. New York: Oxford University
Press; 2000.

5.Braveman P, Gruskin S. Defining equity in health. Journal of Epidemiology and
Community Health 2003;57:254–258.

6.Baker E, Metzler M, Galea S. Addressing social determinants of health
inequities: learning from doing. American Journal of Public Health
2005;95(4):553–555.

7. National Association of County and City Health Officials Health and Social
Justice Committee. Creating Health Equity Through Social Justice. National
Association of County and City Health Officials. Available at http://archive.
naccho.org/documents/healthsocialjusticepaper5 .

8.Mann J, Gruskin S, Grodin M, Annas G. Health and Human Rights: A Reader.
New York: Routledge; 1999.

9.Braveman P. Health disparities and health equity: concepts and
measurement. Annual Review of Public Health 2006;27:167–194.

10. Whitehead M, Dahlgren G. Levelling Up (Part 1): A Discussion Paper on
Concepts and Principles for Tackling Social Inequities in Health. World
Health Organization. Available at http://www.euro.who.int/document/
e89383 .

11. James S. Social determinants of health: implications for intervening on
racial and ethnic health disparities. Paper presented at: Minority Health
Conference, 2002; University of North Carolina.

12. National Center for Health Statistics. Health, United States, 2007 With
Chartbook on Trends in the Health of Americans. Hyattsville, MD: U.S.
Department of Health and Human Services, Centers for Disease Control
and Prevention; 2007.

13. National Center for Health Statistics. Health, United States, 2006 With
Chartbook on Trends in the Health of Americans. Hyattsville, MD: U.S.
Department of Health and Human Services, Centers for Disease Control
and Prevention; 2006.

14. Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults:
national health interview survey, 2005. National Center for Health Statistics.
Vital Health Statistics 2006;10(232). Available at http://www.cdc.gov/
nchs/nhis.htm.

15. Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults:
national health interview survey, 2006. National Center for Health Statistics.
Vital Health Statistics 2007;10(235). Available at http://www.cdc.gov/
nchs/nhis.htm.

16. United States Bureau of Labor Statistics. Labor Force Statistics from the
Current Population Survey. United States Department of Labor. Available
at http://data.bls.gov/cgi-bin/surveymost?ln.

17. Lee J, Grigg W, Donahue P. The Nation’s Report Card: Reading 2007.
Washington DC: United States Department of Education, Institute of
Education Sciences, National Center for Education Statistics; 2007.
Available at http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid= 2007496.

106

18. United States Department of Education. National Assessment of Educational
Progress: 1992, 1994, 1998, 2000, 2002, 2003, 2005, and 2007
Reading Assessments. Washington DC: United States Department of
Education, Institute of Education Sciences, National Center for Education
Statistics. Available at http://nationsreportcard.gov/reading_2007/ data.asp.

19. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s
Adults: Results From the 2003 National Assessment of Adult Literacy (NCES
2006–483). Washington, DC: U.S. Department of Education, National
Center for Education Statistics; 2006.

20. Laird J, DeBell M, Kienzl G, Chapman C. Dropout Rates in the United States:
2005. Washington DC: United States Department of Education, Institute of
Education Sciences, National Center for Education Statistics; 2007.
Available at http://nces.ed.gov/fastfacts/display.asp?id-16.

21. Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics
associated with the location of food stores and food service places.
American Journal of Preventive Medicine 2002;22(1):23–29.

22. Baker E, Schootman M, Barnidge E, Kelly C. Access to foods that enable
individuals to adhere to dietary guidelines: the role of race and poverty.
Preventing Chronic Disease 2006;3(3):1–11.

23. Centers for Disease Control and Prevention. Tobacco Information and
Prevention Source: Minors’ Access to Tobacco Fact Sheet. National Center
for Chronic Disease Prevention and Health Promotion. Available at
http://www.cdc.gov/tobacco/sgr/sgr_2000/factsheets/
factsheet_minor.htm.

24. Centers for Disease Control and Prevention. Tobacco use, access,
and exposure to tobacco in media among middle and high school
students, United States, 2004. Morbidity and Mortality Weekly Report
2005;54(21):297-301.

25. DeNavas-Walt C, Proctor BD, Smith J. Income, Poverty, and Health Insurance
Coverage in the United States, 2006. Washington DC: United States
Census Bureau; 2007.

26. Centers for Disease Control and Prevention. WISQARS Injury Mortality
Reports, 2005. Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control. Available at www.cdc.gov/
ncipc/wisqars.

27. National Coalition for the Homeless. How Many People Experience
Homelessness? National Coalition for the Homeless; 2007. Available at
http://www.nationalhomeless.org/publications/index.html.

28. Agency for Healthcare Research and Quality. Health Care Disparities in Rural
Areas: Selected Findings from the 2004 National Healthcare Disparities
Report. Rockville, MD: Agency for Healthcare Research and Quality; 2005.
Available at http://www.ahrq.gov/research/ruraldis/ruraldis par.htm.

29. Battelle. Travel Patterns of People of Color. Washington, DC: U.S. Department
of Transportation, Federal Highway Administration; 2000. 2010. Volume II.
Conference Edition. Washington, DC: U.S. Department of Health and
Human Services; 2000.

31. Solar O, Irwin A. Towards a Conceptual Framework for Analysis and Action
on the Social Determinants of Health. Available at http://ftp.who.int/
eip/commision/Cairo/Meeting/CSDH%20Doc%202%20-%20
Conceptual%20framework .

32. Schulz A, Northridge M. Social determinants of health: implications
for environmental health promotion. Health Education & Behavior
2004;31(4):455–471.

33. Lynch J, Kaplan G. Socioeconomic position. In: Berkman L, Kawachi I, editors.
Social Epidemiology. New York: Oxford University Press; 2000.

107

34. Hertzman C, Power C, Matthews S, Manor O. Using an interactive
framework of society and lifecourse to explain self-rated health in early
adulthood. Social Science in Medicine 1999;53:1575–1585.

35. Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M. Challenging
Inequities in Health: From Ethics to Action. New York: Oxford University
Press; 2001.

36. Evans RG, Barer ML, Marmor TF. Why are Some People Healthy and Others
Not? The Determinants of Health of Populations. New York: Aldine de
Gruyter; 1994.

37. Dahlgren G, Whitehead M. Policies and Strategies to Promote Social Equity
and Health. World Health Organization. Available at http://whqlibdoc.
who.int/euro/-1993/EUR_ICP_RPD414(2) .

38. Blue Cross and Blue Shield of Minnesota Foundation. Determinants and
Critical Pathways Charts. Blue Cross and Blue Shield of Minnesota
Foundation. Available at: http://www.bcbsmnfoundation.org/
objects/Tier_4/mbc2_determinants_charts .

39. Anderson L, Scrimshaw S, Fullilove M, Fiedling J. The Community Guide’s
model for linking the social environment to health. American Journal of
Preventive Medicine 2003;24(3S):12–20.

40. Marmot M, Wilkinson R. Social Determinants of Health. New York:
Oxford University Press; 2005.

41. Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts.
Copenhagan: World Health Organization; 2003.

42. Farquhar S, Michael Y, Wiggins N. Building on leadership and social capital
to create change in 2 urban communities. American Journal of Public
Health 2005;95(4):596–601.

43. Michael YL, Farquar SA, Wiggins N, Green MK. Findings from a community-
based participatory prevention research intervention designed to increase
social capital in Latino and African American communities. Journal of
Immigrant and Minority Health. In press.

44. Becker A, Randels J, Theodore D. Project BRAVE: Engaging youth as
agents of change in a youth violence prevention project. Community Youth
Development 2005;Fall:39–52.

45. Schulz A, Zenk S, Odoms-Young A, Hollis-Neely T, Nwankwo R, Lockett M.
Healthy eating and exercise to reduce diabetes: exploring the potential
of social determinants of health, frameworks within the context of community-
based participatory diabetes prevention. American Journal of Public Health
2005;95(4):645–651.

46. Lavery S, Smith M, Esparza A, Hrushow A, Moore M. The community action
model: a community-driven model designed to address disparities in health.
American Journal of Public Health 2005;95(4):611–616.

47. Parry J, Judge K. Tackling the wider determinants of health disparities in
England: a model for evaluating the new deal for communities Regeneration
Initiative. American Journal of Public Health 2005;95(4):626–632.

48. Office of the Deputy Prime Minister. Research report 17. New deal for
communities 2001-2005: an interim evaluation. Sheffield Hallam University;
2006. Available at http://www.neighbourhood.gov.uk/ publications.
asp?did=1625.

49. Horsley K, Ciske S. From neurons to King County neighborhoods:
partnering to promote policies based on the science of early childhood
development. American Journal of Public Health 2005;95(4):562–567.

50. Geiger H. Community-oriented primary care: A path to community
development. American Journal of Public Health 2002;92(11):1713– 1716.

108

51. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health.
New York: Oxford University Press; 2003.

52. Green LW, Kreuter MW. Health Promotion Planning: An Educational and
Environmental Approach. Mountain View, CA: Mayfield Publishing
Company; 1991.

53. Alter C, Hage J. Organizations Working Together. Newbury Park, CA:
Sage Publications, Inc.; 1992.

54. Nelson J, Rashid H, Galvin V, Essien J, Levine L. Public/private partners: key
factors in creating a strategic alliance for community health. American
Journal of Preventive Medicine 1999;16(3 Suppl):94–102.

55. Berkowitz B. Collaboration for health improvement: models for state,
community and academic partnerships. Journal of Public Health
Management and Practice 2000;6(1):67–72.

56. Butterfoss F, Goodman R, Wandersman A. Community coalitions for prevention
and health promotion: factors predicting satisfaction, participation and
planning. Health Education Quarterly 1996;23(1):65–79.

57. Green L, Daniel M, Novick L. Partnerships and coalitions for community based
research. Public Health Reports 2001;116(1 Suppl):20–30.

58. Lasker R. Promoting collaborations that improve health. Paper presented at:
Community-Campus Partnerships for Health’s 4th Annual Conference,
2000; New York.

59. Roussos S, Fawcett S. A review of collaborative partnerships as a strategy for
improving community health. Annual Review of Public Health 2000;21:
369–402.

60. MacQueen K, McLellan E, Metzger D, Kegeles S, Strauss R, Scotti R,
et al. What is community? An evidence-based definition for participatory
public health. American Journal of Public Health 2001;91(12):1929–1938.

61. Hunter A. The loss of community: an empirical test through replication.
American Sociology Review 1975;40(5):537–552.

62. Fellin P. Understanding American Communities. In: Rothman J, Erlich JL,
Tropman JE, editors. Strategies of Community Organization. 5th edition.
Itasca, IL: Peacock; 1995.

63. Eng E, Parker E. Measuring community competence in the mississippi delta:
the interface between program evaluation and empowerment. Health
Education Quarterly 1994;21(2):199–220.

64. Israel BA, Checkoway B, Schulz A, Zimmerman M. Health education and
community empowerment: conceptualizing and measuring perceptions of
individual, organizational, and community control. Health Education
Quarterly 1994;21(2):149–170.

65. McKnight JL. Redefining community. Social Policy 1992;23(2):56–62.

66. Feighery E, Rogers T. Building and Maintaining Effective Coalitions.
2nd edition. Palo Alto, CA: Stanford Health Promotion Resource Center; 1990.

67. Kaye G, Wolff T. From the Ground Up: A Workbook On Coalition Building
and Community Development. Amherst, MA: AHEC/Community Partners,
Inc.; 2002.

68. Kretzmann JP, McKnight JL. Building Communities from the Inside Out: A Path
Toward Finding and Mobilizing a Community’s Assets. Evanston, IL: ACTA
Publications; 1993.

69. Johnson K, Grossman W, Cassidy A. Collaborating to Improve Community
Health: Workbook and Guide to Best Practices in Creating Healthier
Communities and Populations. San Francisco: Jossey-Bass; 1996.

70. Timmreck T. Planning, Program Development, and Evaluation: A
Handbook for Health Promotion, Aging, and Health Services. Boston:
Jones and Bartlett; 1995.

109

71. Granner ML, Sharpe PA. Evaluating community coalition characteristics
and functioning: a summary of measurement tools. Health Education
Resources 2004;19(5):514–532.

72. Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences
of discrimination: validity and reliability of a self-report measure for
population health research on racism and health. Social Science Medicine
2005;61(7):1576–1596.

73. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale.
American Journal of Public Health 2000;90(8):1212–1215.

74. Williams D, Collins C. US socioeconomic and racial differences in health:
patterns and explanations. In: LaVeist T, editors. Race, Ethnicity and Health.
San Francisco: Jossey-Bass; 2003:391–431.

75. Ulin P, Robinson E, Tolley E. Qualitative Methods in Public Health: A
Field Guide for Applied Research. San Francisco: Family Health
International; 2005.

76. Krueger R. Focus groups: A practical guide for applied research. 2nd
Edition. Thousand Oaks, CA: Sage Publications; 1994.

77. Wang C, Burris MA. Photovoice: concept, methodology, and use for
participatory needs assessment. Health Education and Behavior
1997;24(3):369–387.

78. Baker E, Schootman M, Barnidge E, Kelly C. The role of race and poverty
in access to foods that enable individuals to adhere to dietary guidelines.
Preventing Chronic Disease 2006;3(3):1–11.

79. Brownson R, Hoehner C, Brennan L, Cook R, Elliott M, McMullen K. Reliability
of two instruments for auditing the environment for physical activity. Journal of
Physical Activity and Health 2004;1:189–207.

80. Pikora T, Bull F, Jamrozik K, Knuiman M, Giles-Corti B, Donovan R. Developing
a reliable audit instrument to measure the physical environment for physical
activity. American Journal of Preventive Medicine 2002;23(3):187.

81. Sampson R, Raudenbush S. Systematic social observation of public spaces:
a new look at disorder in urban neighborhoods. American Journal of
Sociology 1999;105(3):603–651.

82. Trochim WMK. An introduction to concept mapping for planning and
evaluation. Evaluation and Program Planning 1989;12:87–110.

83. Trochim W, Cook J, Setze R. Using concept mapping to develop a
conceptual framework of staff’s views of a supported employment program
for individuals with severe mental illnesses. Journal of Consulting and Clinical
Psychology 1994;62(4):766–775.

84. Johnsen J, Biegel D, Shafran R. Concept mapping in mental health: uses and
adaptations. Evaluation & Program Planning 2000;23(1):67–75.

85. Kemm J, Parry J, Palmer S. Health Impact Assessment: Concepts, Theory,
Techniques and Applications. Oxford: Oxford University Press; 2004.

86. Barrett F, Fry R. Appreciative Inquiry: A Positive Approach to Building
Cooperative Capacity. Chagrin Falls, OH: Taos Institute Publications; 2005.

87. The Synergy Project. APDIME Toolkit: Resources for HIV/AIDS Program,
Version 2.0 Managers. Social and Scientific Systems, Inc. Available at
http://www.synergyaids.com/APDIME/index.htm.

88. Goodman R, Speers M, McLeroy K, Fawcett S, Kegler M, Parker E, et al.
Identifying and defining the dimensions of community capacity to
provide a basis for measurement. Health Education and Behavior
1998;25(3):258–278.

110

89. Cottrell L. The competent community. In: Kaplan B, Wilson R, Leighton A,
editors. Further Explorations in Social Psychiatry. New York: Basic Books; 1976.

90. Minkler M, Wallerstein N. Improving health through community organization
and community building: a health education perspective. In: Minkler M,
editors. Community Organizing and Community Building for Health. New
Brunswick, NJ: Rutgers University Press; 2002:30–67.

91. Rothman J. Three models of community organization practice. In: Cox F,
Erlich J, Rothman J, Tropman J, editors. Strategies of Community
Organization: Macro Practice. Itasca, IL: Peacock Publishers Inc;
1970:20–35.

92. Speeter G. Power: A Repossession Manual – Organizing Strategies for
Citizens. Amherst, MA: University of Massachusetts at Amherst; 1978.

93. First International Conference on Health Promotion. The Ottawa Charter
for Health Promotion. First International Conference on Health Promotion.
Available at http://www.who.int/healthpromotion/conferences/previous/
ottawa/en/index.html.

94. Wallack L, Dorfman L, Jernigan D, Makani T. Media Advocacy and Public
Health: Power for Prevention. Newbury Park, CA: SAGE Publications; 1993.

95. Harrington C, Estes C. Health Policy. 4th Edition. Boston: Jones & Bartlett
Publishers; 2004.

96. Kreuter M, Lezin N, Young L. Evaluating community-based collaborative
mechanisms: implications for practitioners. Health Promotion Practice
2000;1(1):49–63.

97. Dewar T. A Guide to Evaluating Asset-Based Community Development:
Lessons, Challenges and Opportunities. Evanston, IL: ACTA Publications; 1997.

98. The Lewin Group I. Communities Sustain Public Health Improvement Through
Organized Partnership Structures. Battle Creek, MI: W.K. Kellogg
Foundation; 2004.

111

Closing
the gap
in a
generation
Health equity through action on
the social determinants of health

Commission on Social Determinants of Health FINAL REPORT | EXECUTIVE SUMMARY

264; fax: +41 22 791
4857; e-mail: bookorders@who.int). Requests
for permission to reproduce or translate
WHO publications – whether for sale or
for noncommercial distribution – should
be addressed to WHO Press at the above
address (fax: +41 22 791 4806;
e-mail: permissions@who.int).

Disclaimer

This publication contains the collective views
of the Commission on Social Determinants
of Health and does not necessarily represent
the decisions or the stated policy of the
World Health Organization. The designations
employed and the presentation of the material
in this publication do not imply the expression
of any opinion whatsoever on the part of the
World Health Organization concerning the legal
status of any country, territory, city, or area or
of its authorities, or concerning the delimitation

of its frontiers or boundaries. Dotted lines
on maps represent approximate border lines
for which there may not yet be full agreement.

The mention of specific companies or of
certain manufacturers’ products does not
imply that they are endorsed or recommended
by the World Health Organization in preference
to others of a similar nature that are not
mentioned. Errors and omissions excepted,
the names of proprietary products are
distinguished by initial capital letters.

All reasonable precautions have been taken
by the World Health Organization to verify
the information contained in this publication.
However, the published material is being
distributed without warranty of any kind, either
expressed or implied. The responsibility for the
interpretation and use of the material lies with
the reader. In no event shall the World Health
Organization be liable for damages arising
from its use.

WHO/IER/CSDH/08.

Photos

WHO/Marko Kokic; Rotary Images/Alyce Henson; WHO/Christopher Black;
WHO/Chris De Bode; WHO/Jonathan Perugia; WHO/EURO
Specific photo-credits can be obtained from WHO.

The Commission
calls for closing
the health gap
in a generation
Social justice is a matter of life and death. It affects the
way people live, their consequent chance of illness, and
their risk of premature death. We watch in wonder as
life expectancy and good health continue to increase in
parts of the world and in alarm as they fail to improve
in others. A girl born today can expect to live for more
than 80 years if she is born in some countries – but less
than 45 years if she is born in others. Within countries
there are dramatic differences in health that are closely
linked with degrees of social disadvantage. Differences
of this magnitude, within and between countries, simply
should never happen.

These inequities in health, avoidable health inequalities,
arise because of the circumstances in which people
grow, live, work, and age, and the systems put in place
to deal with illness. The conditions in which people live
and die are, in turn, shaped by political, social, and
economic forces.

Social and economic policies have a determining
impact on whether a child can grow and develop to
its full potential and live a flourishing life, or whether
its life will be blighted. Increasingly the nature of the
health problems rich and poor countries have to solve
are converging. The development of a society, rich or
poor, can be judged by the quality of its population’s
health, how fairly health is distributed across the social
spectrum, and the degree of protection provided from
disadvantage as a result of ill-health.

In the spirit of social justice, the Commission on Social
Determinants of Health was set up by the World Health
Organization (WHO) in 2005 to marshal the evidence
on what can be done to promote health equity, and to
foster a global movement to achieve it.

As the Commission has done its work, several
countries and agencies have become partners seeking
to frame policies and programmes, across the whole
of society, that influence the social determinants of
health and improve health equity. These countries and
partners are in the forefront of a global movement.

The Commission calls on the WHO and all
governments to lead global action on the social
determinants of health with the aim of achieving
health equity. It is essential that governments, civil
society, WHO, and other global organizations now
come together in taking action to improve the lives of
the world’s citizens. Achieving health equity within a
generation is achievable, it is the right thing to do, and
now is the right time to do it.

A new global
agenda for
health equity
Our children have dramatically different life chances depending on where
they were born. In Japan or Sweden they can expect to live more than
80 years; in Brazil, 72 years; India, 63 years; and in one of several African
countries, fewer than 50 years. And within countries, the differences in life
chances are dramatic and are seen worldwide. The poorest of the poor
have high levels of illness and premature mortality. But poor health is not
confined to those worst off. In countries at all levels of income, health and
illness follow a social gradient: the lower the socioeconomic position, the
worse the health.
It does not have to be this way and it is not right that it should be like
this. Where systematic differences in health are judged to be avoidable by
reasonable action they are, quite simply, unfair. It is this that we label health
inequity. Putting right these inequities – the huge and remediable differences
in health between and within countries – is a matter of social justice.
Reducing health inequities is, for the Commission on Social Determinants
of Health (hereafter, the Commission), an ethical imperative. Social injustice
is killing people on a grand scale.

The social determinants of
health and health equity
The Commission, created to marshal the evidence on what
can be done to promote health equity and to foster a global
movement to achieve it, is a global collaboration of policy-
makers, researchers, and civil society led by Commissioners with
a unique blend of political, academic, and advocacy experience.
Importantly, the focus of attention embraces countries at all
levels of income and development: the global South and North.
Health equity is an issue within all our countries and is affected
significantly by the global economic and political system.

The Commission takes a holistic view of social determinants
of health. The poor health of the poor, the social gradient
in health within countries, and the marked health inequities
between countries are caused by the unequal distribution of
power, income, goods, and services, globally and nationally, the
consequent unfairness in the immediate, visible circumstances
of peoples lives – their access to health care, schools, and
education, their conditions of work and leisure, their homes,
communities, towns, or cities – and their chances of leading a
flourishing life. This unequal distribution of health-damaging
experiences is not in any sense a ‘natural’ phenomenon but is
the result of a toxic combination of poor social policies and
programmes, unfair economic arrangements, and bad politics.
Together, the structural determinants and conditions of daily life
constitute the social determinants of health and are responsible
for a major part of health inequities between and within
countries.

The global community can put this right but it will take
urgent and sustained action, globally, nationally, and locally.
Deep inequities in the distribution of power and economic
arrangements, globally, are of key relevance to health equity.
This in no way implies ignoring other levels of action. There is
a great deal that national and local governments can do; and the
Commission has been impressed by the force of civil society
and local movements that both provide immediate local help
and push governments to change.

And of course climate change has profound implications for
the global system – how it affects the way of life and health of
individuals and the planet. We need to bring the two agendas of
health equity and climate change together. Our core concerns
with health equity must be part of the global community
balancing the needs of social and economic development of
the whole global population, health equity, and the urgency of
dealing with climate change.

A new approach to development
The Commission’s work embodies a new approach to
development. Health and health equity may not be the aim
of all social policies but they will be a fundamental result.
Take the central policy importance given to economic
growth: Economic growth is without question important,
particularly for poor countries, as it gives the opportunity to
provide resources to invest in improvement of the lives of their
population. But growth by itself, without appropriate social
policies to ensure reasonable fairness in the way its benefits are
distributed, brings little benefit to health equity.

Traditionally, society has looked to the health sector to
deal with its concerns about health and disease. Certainly,
maldistribution of health care – not delivering care to those
who most need it – is one of the social determinants of
health. But the high burden of illness responsible for appalling
premature loss of life arises in large part because of the
conditions in which people are born, grow, live, work, and
age. In their turn, poor and unequal living conditions are the
consequence of poor social policies and programmes, unfair
economic arrangements, and bad politics. Action on the social
determinants of health must involve the whole of government,
civil society and local communities, business, global fora, and
international agencies. Policies and programmes must embrace
all the key sectors of society not just the health sector. That said,
the minister of health and the supporting ministry are critical
to global change. They can champion a social determinants
of health approach at the highest level of society, they can
demonstrate effectiveness through good practice, and they can
support other ministries in creating policies that promote health
equity. The World Health Organization (WHO), as the global
body for health, must do the same on the world stage.

Closing the health gap in a generation
The Commission calls for closing the health gap in a
generation. It is an aspiration not a prediction. Dramatic
improvements in health, globally and within countries, have
occurred in the last 30 years. We are optimistic: the knowledge
exists to make a huge difference to people’s life chances and
hence to provide marked improvements in health equity. We
are realistic: action must start now. The material for developing
solutions to the gross inequities between and within countries is
in the Report of this Commission.

COMMISSION ON SOCIAL DETERMINANTS OF HEALTH | FINAL REPORT – EXECUTIVE SUMMARY

Three principles of action

1 Improve the conditions of daily life – the circumstances in
which people are born, grow, live, work, and age.

2 Tackle the inequitable distribution of power, money, and
resources – the structural drivers of those conditions of
daily life – globally, nationally, and locally.

3 Measure the problem, evaluate action, expand the
knowledge base, develop a workforce that is trained in the
social determinants of health, and raise public awareness
about the social determinants of health.

The Commission’s
overarching
recommendations

Improve Daily Living Conditions
Improve the well-being of girls and women and the circumstances in which their children are born, put major
emphasis on early child development and education for girls and boys, improve living and working conditions and
create social protection policy supportive of all, and create conditions for a flourishing older life. Policies to achieve
these goals will involve civil society, governments, and global institutions.

Tackle the Inequitable Distribution
of Power, Money, and Resources
In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities –
such as those between men and women – in the way society is organized. This requires a strong public sector that
is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it
requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and
for people across society to agree public interests and reinvest in the value of collective action. In a globalized world,
the need for governance dedicated to equity applies equally from the community level to global institutions.

Measure and Understand the Problem
and Assess the Impact of Action
Acknowledging that there is a problem, and ensuring that health inequity is measured – within countries and
globally – is a vital platform for action. National governments and international organizations, supported by WHO,
should set up national and global health equity surveillance systems for routine monitoring of health inequity and the
social determinants of health and should evaluate the health equity impact of policy and action. Creating the
organizational space and capacity to act effectively on health inequity requires investment in training of policy-makers
and health practitioners and public understanding of social determinants of health. It also requires a stronger focus on
social determinants in public health research.

These three principles of action are embodied in the three
overarching recommendations above. The remainder of the
Executive Summary and the Commission’s Final Report is
structured according to these three principles.

1. Improve Daily
Living Conditions
The inequities in how society is organized mean that the freedom to
lead a flourishing life and to enjoy good health is unequally distributed
between and within societies. This inequity is seen in the conditions of
early childhood and schooling, the nature of employment and working
conditions, the physical form of the built environment, and the quality of
the natural environment in which people reside. Depending on the nature
of these environments, different groups will have different experiences
of material conditions, psychosocial support, and behavioural options,
which make them more or less vulnerable to poor health. Social
stratification likewise determines differential access to and utilization of
health care, with consequences for the inequitable promotion of health
and well-being, disease prevention, and illness recovery and survival.

CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

Equity from the start

What must be done

A comprehensive approach to the early years in life
requires policy coherence, commitment, and leadership
at the international and national level. It also requires a
comprehensive package of ECD and education programmes
and services for all children worldwide.

Commit to and implement a comprehensive approach
to early life, building on existing child survival
programmes and extending interventions in early life
to include social/emotional and language/cognitive
development.

• Set up an interagency mechanism to ensure policy
coherence for early child development such that, across
agencies, a comprehensive approach to early child
development is acted on.

• Make sure that all children, mothers, and other caregivers
are covered by a comprehensive package of quality early
child development programmes and services, regardless of
ability to pay.

Expand the provision and scope of education to
include the principles of early child development
(physical, social/emotional, and language/cognitive
development).

• Provide quality compulsory primary and secondary
education for all boys and girls, regardless of ability to pay.
Identify and address the barriers to girls and boys enrolling
and staying in school and abolish user fees for primary
school.

Early child development (ECD) – including the physical,
social/emotional, and language/cognitive domains – has a
determining influence on subsequent life chances and health
through skills development, education, and occupational
opportunities. Through these mechanisms, and directly, early
childhood influences subsequent risk of obesity, malnutrition,
mental health problems, heart disease, and criminality. At
least 200 million children globally are not achieving their full
development potential. This has huge implications for their
health and for society at large.

Evidence for action
Investment in the early years provides one of the greatest
potentials to reduce health inequities within a generation.
Experiences in early childhood (defined as prenatal
development to eight years of age), and in early and later
education, lay critical foundations for the entire lifecourse.
The science of ECD shows that brain development is highly
sensitive to external influences in early childhood, with lifelong
effects. Good nutrition is crucial and begins in utero with

adequately nourished mothers. Mothers and children need a
continuum of care from pre-pregnancy, through pregnancy
and childbirth, to the early days and years of life. Children
need safe, healthy, supporting, nurturing, caring, and responsive
living environments. Preschool educational programmes and
schools, as part of the wider environment that contributes to
the development of children, can have a vital role in building
children’s capabilities. A more comprehensive approach to early
life is needed, building on existing child survival programmes
and extending interventions in early life to include social/
emotional and language/cognitive development.

Effects of combined nutritional supplementation and psychosocial stimulation on stunted children in a
2-year intervention study in Jamaicaa.

105

Baseline 6 mo 12 mo 16 mo 24 mo

a Mean development scores (DQ) of stunted groups adjusted for initial age and score compared with a
non-stunted group adjusted for age only, using Griffiths Mental Development Scales modified for Jamaica.
Reprinted, with permission of the publisher, from Grantham-McGregor et al. (1991).

Non-stunte

Supplemented

and stimulated

Supplemented

Control

Stimulated

IMPROVE DAILY LIVING CONDITIONS

Healthy Places Healthy People

What must be done

Communities and neighbourhoods that ensure access to
basic goods, that are socially cohesive, that are designed
to promote good physical and psychological well-being and
that are protective of the natural environment are essential for
health equity.

Place health and health equity at the heart of urban
governance and planning.

• Manage urban development to ensure greater availability of
affordable housing; invest in urban slum upgrading including,
as a priority, provision of water and sanitation, electricity, and
paved streets for all households regardless of ability to pay.

• Ensure urban planning promotes healthy and safe
behaviours equitably, through investment in active transport,
retail planning to manage access to unhealthy foods, and
through good environmental design and regulatory controls,
including control of the number of alcohol outlets.

Promote health equity between rural and urban areas
through sustained investment in rural development,
addressing the exclusionary policies and processes
that lead to rural poverty, landlessness, and
displacement of people from their homes.

• Counter the inequitable consequences of urban growth
through action that addresses rural land tenure and rights
and ensures rural livelihoods that support healthy living,
adequate investment in rural infrastructure, and policies that
support rural-to-urban migrants.

Ensure that economic and social policy responses to
climate change and other environmental degradation
take into account health equity.

Where people live affects their health and chances of leading
flourishing lives. The year 2007 saw, for the first time, the
majority of human beings living in urban settings. Almost 1
billion live in slums.

Evidence for action
Infectious diseases and undernutrition will continue in
particular regions and groups around the world. However,
urbanization is reshaping population health problems,
particularly among the urban poor, towards non-communicable
diseases, accidental and violent injuries, and deaths and impact
from ecological disaster.

The daily conditions in which people live have a strong
influence on health equity. Access to quality housing and
shelter and clean water and sanitation are human rights and
basic needs for healthy living. Growing car dependence, land-
use change to facilitate car use, and increased inconvenience of
non-motorized modes of travel, have knock-on effects on local
air quality, greenhouse gas emission, and physical inactivity. The
planning and design of urban environments has a major impact
on health equity through its influence on behaviour and safety.

The balance of rural and urban dwelling varies enormously
across areas: from less than 10% urban in Burundi and Uganda
to 100% or close to it in Belgium, Hong Kong Special
Administrative Region, Kuwait, and Singapore. Policies

and investment patterns reflecting the urban-led growth
paradigm have seen rural communities worldwide, including
Indigenous Peoples, suffer from progressive underinvestment
in infrastructure and amenities, with disproportionate levels of
poverty and poor living conditions, contributing in part to out-
migration to unfamiliar urban centres.

The current model of urbanization poses significant
environmental challenges, particularly climate change – the
impact of which is greater in low-income countries and among
vulnerable subpopulations. At present, greenhouse gas emissions
are determined mainly by consumption patterns in cities of
the developed world. Transport and buildings contribute 21%
to CO2 emissions, agricultural activity accounts for about one
fifth. And yet crop yields depend in large part on prevailing
climate conditions. The disruption and depletion of the climate
system and the task of reducing global health inequities go
hand in hand.

CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

COMMISSION ON SOCIAL DETERMINANTS OF HEALTH | FINAL REPORT – EXECUTIVE SUMMARY

IMPROVE DAILY LIVING CONDITIONS

Fair Employment and
Decent Work

What must be done

Through the assurance of fair employment and decent
working conditions, government, employers, and workers
can help eradicate poverty, alleviate social inequities, reduce
exposure to physical and psychosocial hazards, and enhance
opportunities for health and well-being. And, of course, a
healthy workforce is good for productivity.

Make full and fair employment and decent work a
central goal of national and international social and
economic policy-making.

• Full and fair employment and decent work should be made
a shared objective of international institutions and a central
part of national policy agendas and development strategies,
with strengthened representation of workers in the creation
of policy, legislation, and programmes relating to employment
and work.

Achieving health equity requires safe, secure, and fairly
paid work, year-round work opportunities, and healthy
work–life balance for all.

• Provide quality work for men and women with a living
wage that takes into account the real and current cost of
healthy living.

• Protect all workers. International agencies should support
countries to implement core labour standards for formal and
informal workers; to develop policies to ensure a balanced
work–home life; and to reduce the negative effects of
insecurity among workers in precarious work arrangements.

Improve the working conditions for all workers to
reduce their exposure to material hazards, work-
related stress, and health-damaging behaviours.

Employment and working conditions have powerful effects on
health equity. When these are good, they can provide financial
security, social status, personal development, social relations
and self-esteem, and protection from physical and psychosocial
hazards. Action to improve employment and work must be
global, national, and local.

Evidence for action
Work is the area where many of the important influences
on health are played out. This includes both employment
conditions and the nature of work itself. A flexible workforce
is seen as good for economic competitiveness but brings
with it effects on health. Evidence indicates that mortality
is significantly higher among temporary workers compared
to permanent workers. Poor mental health outcomes are
associated with precarious employment (e.g. non-fixed term
temporary contracts, being employed with no contract, and
part-time work). Workers who perceive work insecurity
experience significant adverse effects on their physical and
mental health.

The conditions of work also affect health and health equity.
Adverse working conditions can expose individuals to a range
of physical health hazards and tend to cluster in lower-status
occupations. Improved working conditions in high-income
countries, hard won over many years of organized action and
regulation, are sorely lacking in many middle- and low-income
countries. Stress at work is associated with a 50% excess risk
of coronary heart disease, and there is consistent evidence that
high job demand, low control, and effort-reward imbalance are
risk factors for mental and physical health problems.

8
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

Permanent

Fixed term
temporary

Non-fixed term
temporary

No contract

0
5
10

Men Women

Pe
rc

en
t

Prevalence of poor mental health among manual workers in Spain by type of contract.

Source: Artazcoz et al., 2005

0
10
20
30

100

1997 2002 2007

World
Central & South East Europe
East Asia
South East Asia & Pacific
South Asia
Latin America & Caribbean
Middle East
North Africa
Sub-Saharan Africa

Regional variation in the percentage of people in work living on US$ 2/day or less.

Pe
rc
en
t

2007 figures are preliminary estimates.
Reprinted, with permission of the author, from ILO (2008).

IMPROVE DAILY LIVING CONDITIONS

Social Protection
Across the Lifecourse

What must be done

Reducing the health gap in a generation requires that
governments build systems that allow a healthy standard of
living below which nobody should fall due to circumstances
beyond his or her control. Social protection schemes can
be instrumental in realizing developmental goals, rather than
being dependent on achieving these goals – they can be
efficient ways to reduce poverty, and local economies can
benefit.

Establish and strengthen universal comprehensive
social protection policies that support a level of income
sufficient for healthy living for all.

• Progressively increase the generosity of social protection
systems towards a level that is sufficient for healthy living.

• Ensure that social protection systems include those
normally excluded: those in precarious work, including
informal work and household or care work.

All people need social protection across the lifecourse, as young
children, in working life, and in old age. People also need
protection in case of specific shocks, such as illness, disability,
and loss of income or work.

Evidence for action
Low living standards are a powerful determinant of health
inequity. They influence lifelong trajectories, among others
through their effects on ECD. Child poverty and transmission
of poverty from generation to generation are major obstacles
to improving population health and reducing health inequity.
Four out of five people worldwide lack the back-up of basic
social security coverage.

Redistributive welfare systems, in combination with the extent
to which people can make a healthy living on the labour
market, influence poverty levels. Generous universal social
protection systems are associated with better population health,
including lower excess mortality among the old and lower
mortality levels among socially disadvantaged groups. Budgets
for social protection tend to be larger, and perhaps more

sustainable, in countries with universal protection systems;
poverty and income inequality tend to be smaller in these
countries compared to countries with systems that target
the poor.

Extending social protection to all people, within countries and
globally, will be a major step towards securing health equity
within a generation. This includes extending social protection
to those in precarious work, including informal work, and
household or care work. This is critical for poor countries
in which the majority of people work in the informal
sector, as well as for women, because family responsibilities
often preclude them from accruing adequate benefits under
contributory social protection schemes. While limited
institutional infrastructure and financial capacity remains an
important barrier in many countries, experience across the
world shows that it is feasible to start creating social protection
systems, even in low-income countries.

10
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

11
IMPROVE DAILY LIVING CONDITIONS

USA

0 10 20 30 40 50 60 70 80 90 100

110

5
10
15
20
25

Family policy
generosity %

Po
ve

rty
%

Total family policy generosity and child poverty in 20 countries, circa 2000.

Net benefit generosity of transfers as a percentage of an average net production worker’s
wage. The poverty line is 50% of median equivalized disposable income.
AUS = Australia; AUT = Austria; BEL = Belgium; CAN = Canada; FIN = Finland; FRA = France;
GER = Germany; IRE = Ireland; ITA = Italy; NET = the Netherlands; NOR = Norway;
SWE = Sweden; SWI = Switzerland; UK = the United Kingdom; USA = the United States
of America. Reprinted, with permission of the publisher, from Lundberg et al. (2007).

AUS

IRE

UK CAN

ITA

GER
FRA

BEL

FIN
SWE

NOR

AUT

NET
SWI

Universal Health Care

What must be done

Build health-care systems based on principles of
equity, disease prevention, and health promotion.

• Build quality health-care services with universal coverage,
focusing on Primary Health Care.

• Strengthen public sector leadership in equitable health-
care systems financing, ensuring universal access to care
regardless of ability to pay.

Build and strengthen the health workforce, and expand
capabilities to act on the social determinants of health.

• Invest in national health workforces, balancing rural and
urban health-worker density.

• Act to redress the health brain drain, focusing on
investment in increased health human resources and training
and bilateral agreements to regulate gains and losses.

Access to and utilization of health care is vital to good and
equitable health. The health-care system is itself a social
determinant of health, influenced by and influencing the effect
of other social determinants. Gender, education, occupation,
income, ethnicity, and place of residence are all closely linked
to people’s access to, experiences of, and benefits from health
care. Leaders in health care have an important stewardship role
across all branches of society to ensure that policies and actions
in other sectors improve health equity.

Evidence for action
Without health care, many of the opportunities for
fundamental health improvement are lost. With partial
health-care systems, or systems with inequitable provision,
opportunities for universal health as a matter of social
justice are lost. These are core issues for all countries.
More pressingly, for low-income countries, accessible and
appropriately designed and managed health-care systems will
contribute significantly to the achievement of the Millennium
Development Goals (MDGs). Without them, the chances of
meeting the MDGs are greatly weakened. Yet health-care
systems are appallingly weak in many countries, with massive
inequity in provision, access, and use between rich and poor.

The Commission considers health care a common good, not
a market commodity. Virtually all high-income countries
organize their health-care systems around the principle of
universal coverage (combining health financing and provision).
Universal coverage requires that everyone within a country
can access the same range of (good quality) services according
to needs and preferences, regardless of income level, social
status, or residency, and that people are empowered to use these
services. It extends the same scope of benefits to the whole
population. There is no sound argument that other countries,
including the poorest, should not aspire to universal health-care
coverage, given adequate support over the long term.

The Commission advocates financing the health-care system
through general taxation and/or mandatory universal insurance.
Public health-care spending has been found to be redistributive
in country after country. The evidence is compellingly in
favour of a publicly funded health-care system. In particular,
it is vital to minimize out-of-pocket spending on health care.
The policy imposition of user fees for health care in low- and
middle-income countries has led to an overall reduction in
utilization and worsening health outcomes. Upwards of 100
million people are pushed into poverty each year through
catastrophic household health costs. This is unacceptable.

Health-care systems have better health outcomes when built
on Primary Health Care (PHC) – that is, both the PHC model
that emphasizes locally appropriate action across the range
of social determinants, where prevention and promotion are
in balance with investment in curative interventions, and an
emphasis on the primary level of care with adequate referral to
higher levels of care.

In all countries, but most pressingly in the poorest and
those experiencing brain-drain losses, adequate numbers
of appropriately skilled health workers at the local level are
fundamental to extending coverage and improving the quality
of care. Investment in training and retaining health-care
workers is vital to the required growth of health-care systems.
This involves global attention to the flows of health personnel
as much as national and local attention to investment and skills
development. Medical and health practitioners – from WHO
to the local clinic – have powerful voices in society’s ideas of
and decisions about health. They bear witness to the ethical
imperative, just as much as the efficiency value, of acting more
coherently through the health-care system on the social causes
of poor health.

12
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

13
IMPROVE DAILY LIVING CONDITIONS

Lowest
economic
quintile

Highest
economic
quintile

0
10
20
30
60
50
40
70
80
90
100

Antenatal
care

Oral
rehydration

therapy

Full
immun-
ization

Medical
treatment

of ARI

Attended
delivery

Medical
treatment

of diarrhoea

Medical
treatment
of fever

Use of
modern
contra-
ceptives
(women

)

Pe
rc

en
ta

ge
o

f p
op

ul
at

io
n

gr
ou

p
co

ve
re

Use of basic maternal and child health services by lowest and highest economic quintiles, 50+ countries.

Reprinted, with permission of the publisher, from Gwatkin, Wagstaff & Yazbeck (2005).

60.3

91.6

71.2

57.0

39.8
34.5

63.5
58.9

34.1

83.7

27.6

47.6 48.2

26.8

18.7

37.2

2. Tackle the Inequitable
Distribution of Power,
Money, and Resources
Inequity in the conditions of daily living is shaped by deeper social
structures and processes. The inequity is systematic, produced
by social norms, policies, and practices that tolerate or actually
promote unfair distribution of and access to power, wealth, and
other necessary social resources.

14
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

15
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

Health Equity in All Policies,
Systems, and Programmes

What must be done

Place responsibility for action on health and health
equity at the highest level of government, and ensure
its coherent consideration across all policies.

• Make health and health equity corporate issues for the
whole of government, supported by the head of state,
by establishing health equity as a marker of government
performance.

• Assess the impact of all policies and programmes on
health and health equity, building towards coherence in all
government action.

Adopt a social determinants framework across the
policy and programmatic functions of the ministry
of health and strengthen its stewardship role in
supporting a social determinants approach across
government.

• The health sector itself is a good place to start building
supports and structures that encourage action on the
social determinants of health and health equity. This requires
strong leadership from the minister of health, with support
from WHO.

Every aspect of government and the economy has the potential
to affect health and health equity – finance, education,
housing, employment, transport, and health, just to name six.
Coherent action across government, at all levels, is essential for
improvement of health equity.

Evidence for action
Different government policies, depending on their nature,
can either improve or worsen health and health equity. Urban
planning, for example, that produces sprawling neighbourhoods
with little affordable housing, few local amenities, and irregular
unaffordable public transport does little to promote good
health for all. Good public policy can provide health benefits
immediately and in the future.

Policy coherence is crucial – this means that different
government departments’ policies complement rather than
contradict each other in relation to the production of health
and health equity. For example, trade policy that actively
encourages the unfettered production, trade, and consumption

of foods high in fats and sugars to the detriment of fruit and
vegetable production is contradictory to health policy, which
recommends relatively little consumption of high-fat, high-
sugar foods and increased consumption of fruit and vegetables.
Intersectoral action (ISA) for health – coordinated policy and
action among health and non-health sectors – can be a key
strategy to achieve this.

Reaching beyond government to involve civil society and
the voluntary and private sectors is a vital step towards action
for health equity. The increased incorporation of community
engagement and social participation in policy processes helps to
ensure fair decision-making on health equity issues. And health
is a rallying point for different sectors and actors – whether it
is a local community designing a health plan for themselves
(Dar es Salaam, United Republic of Tanzania’s Healthy City
Programme) or involving the entire community including local
government in designing spaces that encourage walking and
cycling (Healthy by Design, Victoria, Australia).

Making health and health equity a shared value across sectors is
a politically challenging strategy but one that is needed globally.

16
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

17
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

94-95 95-96 96-97 97-98
0

5
10
15
20
25
30
35
40

Year

In
ju

ry
ra

te
p

er
1

00
,0

Changes in bicycle-related head and other injuries in Canadian provinces with and without mandatory
helmet legislation.

Legislation introduced across provinces between 1995 and 1997.
Reprinted, with permission of the publisher, from Macpherson et al. (2002).

‘Other’ injury rate,
legislation provinces

Head injury rate,
legislation provinces

Head injury rate,
no legislation provinces

‘Other’ injury rate,
no legislation provinces

Fair Financing

What must be done

Strengthen public finance for action on the social
determinants of health.

• Build national capacity for progressive taxation and
assess potential for new national and global public finance
mechanisms.

Increase international finance for health equity,
and coordinate increased finance through a social
determinants of health action framework.

• Honour existing commitments by increasing global aid to
the 0.7% of GDP commitment, and expand the Multilateral
Debt Relief Initiative; enhance action on health equity by
developing a coherent social determinants of health focus in
existing frameworks such as the Poverty Reduction Strategy
Paper.

Fairly allocate government resources for action on the
social determinants of health.

• Establish mechanisms to finance cross-government action
on social determinants of health, and to allocate finance fairly
between geographical regions and social groups.

Public finance to fund action across the social determinants of
health is fundamental to welfare and to health equity.

Evidence for action
For countries at all levels of economic development, increasing
public finance to fund action across the social determinants
of health – from child development and education, through
living and working conditions, to health care – is fundamental
to welfare and health equity. Evidence shows that the
socioeconomic development of rich countries was strongly
supported by publicly financed infrastructure and progressively
universal public services. The emphasis on public finance,
given the marked failure of markets to supply vital goods and
services equitably, implies strong public sector leadership and
adequate public expenditure. This in turn implies progressive
taxation – evidence shows that modest levels of redistribution
have considerably greater impact on poverty reduction than
economic growth alone. And, in the case of poorer countries, it
implies much greater international financial assistance.

Low-income countries often have relatively weak direct tax
institutions and mechanisms and a majority of the workforce
operating in the informal sector. They have relied in many cases
on indirect taxes such as trade tariffs for government income.
Economic agreements between rich and poor countries that
require tariff reduction can reduce available domestic revenue
in low-income countries before alternative streams of finance
have been established. Strengthened progressive tax capacity
is an important source of public finance and a necessary
prerequisite of any further tariff-cutting agreements. At the
same time, measures to combat the use of offshore financial
centres to reduce unethical avoidance of national tax regimes
could provide resources for development at least comparable
to those made available through new taxes. As globalization
increases interdependence among countries, the argument for
global approaches to taxation becomes stronger.

Aid is important. While the evidence suggests that it can and
does promote economic growth, and can contribute more
directly to better health, the view of the Commission is
that aid’s primary value is as a mechanism for the reasonable
distribution of resources in the common endeavour of social
development. But the volume of aid is appallingly low. It is low
in absolute terms (both generic and health specific); relative
to wealth in donor countries; relative to the commitment
to a level of aid approximating 0.7% of their gross domestic
product (GDP) made by donors in 1969; and relative to the
amounts required for sustainable impact on the MDGs. A
step-shift increase is required. Independent of increased aid, the
Commission urges wider and deeper debt relief.

The quality of aid must be improved too – following the Paris
agreement – focusing on better coordination among donors
and stronger alignment with recipient development plans.
Donors should consider channelling most of their aid through
a single multilateral mechanism, while poverty reduction
planning at the national and local levels in recipient countries
would benefit from adopting a social determinants of health
framework to create coherent, cross-sectoral financing. Such
a framework could help to improve the accountability of
recipient countries in demonstrating how aid is allocated, and
what impact it has. In particular, recipient governments should
strengthen their capacity and accountability to allocate available
public finance equitably across regions and among population
groups.

18
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

19
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

19
61

19
62

19
63

19
64

19
65

19
66

19
67

19
68

19
69

19
70

19
71

19
72

19
74

19
75

19
77

19
78

19
79

19
80

19
82

19
83

19
84

19
85

19
86

19
87

19
88

19
89

19
90

19
91

19
92

19
93

19
94

19
95

19
96

19
97

19
98

19
99

20
00

20
01

20
02

80
70
110

130

160

170

180

210

260

230

270
1961=100

Years

Pe
rc
en
t

The growing gap: per capita aid from donor countries relative to per capita wealth, 1960–2000.

Reprinted, with permission of the publisher, from Randel, German & Ewing (2004).

GNP per Cap

ODA per CapGNI per capita in
2002: $28,500

GNI per capita in
1960: $11,303

Aid per capita in
1960: $61

Aid per capita in
2002: $67

Market Responsibility

What must be done

Institutionalize consideration of health and health
equity impact in national and international economic
agreements and policy-making.

• Institutionalize and strengthen technical capacities in health
equity impact assessment of all international and national
economic agreements.

• Strengthen representation of health actors in domestic and
international economic policy negotiations.

Reinforce the primary role of the state in the provision
of basic services essential to health (such as water/
sanitation) and the regulation of goods and services
with a major impact on health (such as tobacco,
alcohol, and food).

Markets bring health benefits in the form of new technologies,
goods and services, and improved standard of living. But the
marketplace can also generate negative conditions for health
in the form of economic inequalities, resource depletion,
environmental pollution, unhealthy working conditions, and
the circulation of dangerous and unhealthy goods.

Evidence for action
Health is not a tradable commodity. It is a matter of rights
and a public sector duty. As such, resources for health must
be equitable and universal. There are three linked issues. First,
experience shows that commercialization of vital social goods
such as education and health care produces health inequity.
Provision of such vital social goods must be governed by the
public sector, rather than being left to markets. Second, there
needs to be public sector leadership in effective national and
international regulation of products, activities, and conditions
that damage health or lead to health inequities. These together
mean that, third, competent, regular health equity impact
assessment of all policy-making and market regulation should
be institutionalized nationally and internationally.

The Commission views certain goods and services as
basic human and societal needs – access to clean water, for
example, and health care. Such goods and services must be
made available universally regardless of ability to pay. In such
instances, therefore, it is the public sector rather than the
marketplace that underwrites adequate supply and access.

With respect both to ensuring the provision of goods and
services vital to health and well-being – for example, water,
health care, and decent working conditions – and controlling
the circulation of health-damaging commodities (for example,
tobacco and alcohol), public sector leadership needs to be
robust. Conditions of labour and working conditions are – in
many countries, rich and poor – all too often inequitable,
exploitative, unhealthy, and dangerous. The vital importance of
good labour and work to a healthy population and a healthy
economy demands public sector leadership in ensuring
progressive fulfilment of global labour standards while also
ensuring support to the growth of micro-level enterprises.
Global governance mechanisms – such as the Framework
Convention on Tobacco Control – are required with increasing
urgency as market integration expands and accelerates
circulation of and access to health-damaging commodities.
Processed foods and alcohol are two prime candidates for
stronger global, regional, and national regulatory controls.

In recent decades, under globalization, market integration has
increased. This is manifested in new production arrangements,
including significant changes in labour, employment, and
working conditions, expanding areas of international and global
economic agreements, and accelerating commercialization of
goods and services – some of them undoubtedly beneficial
for health, some of them disastrous. The Commission urges
that caution be applied by participating countries in the
consideration of new global, regional, and bilateral economic
– trade and investment – policy commitments. Before such

20
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

21
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

0
1
3
2
4
6
5
7
8
9
10

Consumption (kl/month)

Ac
tu

al
Ta

rif
fs

(R
an

d/
kl

)

Johannesburg water pricing. The existing subsidy structure (thin line) favours richer consumers (and allows
over-use), while the ideal tariff structure (thick line) favours adequate subsidized supply to poorer consumers
with disincentives for higher use.

hh = households.
Reprinted, with permission of the author, from GKN (2007).

Johannesburg

Ideal for hh
of 10

1 11 21 31 41 51 61 71 81 91 101

commitments are made, understanding the impact of the
existing framework of agreements on health, the social
determinants of health, and health equity is vital. Further,
assessment of health impacts over time suggests strongly
that flexibility, allowing signatory countries to modify their
commitment to international agreements if there is adverse
impact on health or health equity, should be established at the
outset, with transparent criteria for triggering modification.

Public sector leadership does not displace the responsibilities
and capacities of other actors: civil society and the private
sector. Private sector actors are influential, and have the power
to do much for global health equity. To date, though, initiatives
such as those under corporate social responsibility have shown
limited evidence of real impact. Corporate social responsibility
may be a valuable way forward, but evidence is needed to
demonstrate this. Corporate accountability may well be a
stronger basis on which to build a responsible and collaborative
relationship between the private sector and public interest.

Gender Equity

What must be done

Gender inequities are unfair; they are also ineffective and
inefficient. By supporting gender equity, governments,
donors, international organizations, and civil society can
improve the lives of millions of girls and women and their
families.

Address gender biases in the structures of society – in
laws and their enforcement, in the way organizations
are run and interventions designed, and the way in
which a country’s economic performance is measured.

• Create and enforce legislation that promotes gender equity
and makes discrimination on the basis of sex illegal.

• Strengthen gender mainstreaming by creating and
financing a gender equity unit within the central administration
of governments and international institutions.

• Include the economic contribution of housework, care
work, and voluntary work in national accounts.

Develop and finance policies and programmes that
close gaps in education and skills, and that support
female economic participation.

• Invest in formal and vocational education and training,
guarantee pay-equity by law, ensure equal opportunity for
employment at all levels, and set up family-friendly policies.

Increase investment in sexual and reproductive health
services and programmes, building to universal
coverage and rights.

Reducing the health gap in a generation is only possible if
the lives of girls and women – about half of humanity – are
improved and gender inequities are addressed. Empowerment
of women is key to achieving fair distribution of health.

Evidence for action
Gender inequities are pervasive in all societies. Gender biases in
power, resources, entitlements, norms and values, and the way
in which organizations are structured and programmes are run
damage the health of millions of girls and women. The position
of women in society is also associated with child health and
survival – of boys and girls. Gender inequities influence health
through, among other routes, discriminatory feeding patterns,
violence against women, lack of decision-making power, and
unfair divisions of work, leisure, and possibilities of improving
one’s life.

Gender inequities are socially generated and therefore can
be changed. While the position of women has improved
dramatically over the last century in many countries, progress
has been uneven and many challenges remain. Women earn
less then men, even for equivalent work; girls and women
lag behind in education and employment opportunities.
Maternal mortality and morbidity remain high in many
countries, and reproductive health services remain hugely
inequitably distributed within and between countries.
The intergenerational effects of gender inequity make the
imperative to act even stronger. Acting now, to improve gender
equity and empower women, is critical for reducing the health
gap in a generation.

22
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

23
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

Nominal wages for women are significantly lower than for men.

4 countries in the

Middle

East and North Africa

6 countries in East Asia
and Pacific

22 industrialized countries

10 countries in transition

8 countries in Latin
America and Caribbean

4 countries in
sub-Saharan Africa

0 20

81
80
80
76
73
70

40 60 80 100

Proportion of women’s wages to men’s wages outside of agriculture

Reprinted, with permission of the author, from UNICEF (2006).

Political Empowerment –
Inclusion and Voice

What must be done

Empower all groups in society through fair
representation in decision-making about how society
operates, particularly in relation to its effect on health
equity, and create and maintain a socially inclusive
framework for policy-making.

• Strengthen political and legal systems to protect human
rights, assure legal identity and support the needs and claims
of marginalized groups, particularly Indigenous Peoples.

• Ensure the fair representation and participation of
individuals and communities in health decision-making as an
integral feature of the right to health.

Enable civil society to organize and act in a manner
that promotes and realizes the political and social
rights affecting health equity.

Being included in the society in which one lives is vital to
the material, psychosocial, and political empowerment that
underpins social well-being and equitable health.

Evidence for action
The right to the conditions necessary to achieve the highest
attainable standard of health is universal. The risk of these rights
being violated is the result of entrenched structural inequities.

Social inequity manifests across various intersecting social
categories such as class, education, gender, age, ethnicity,
disability, and geography. It signals not simply difference but
hierarchy, and reflects deep inequities in the wealth, power,
and prestige of different people and communities. People who
are already disenfranchised are further disadvantaged with
respect to their health – having the freedom to participate
in economic, social, political, and cultural relationships
has intrinsic value. Inclusion, agency, and control are each
important for social development, health, and well-being.
And restricted participation results in deprivation of human
capabilities, setting the context for inequities in, for example,
education, employment, and access to biomedical and technical
advances.

Any serious effort to reduce health inequities will involve
changing the distribution of power within society and global
regions, empowering individuals and groups to represent
strongly and effectively their needs and interests and, in so
doing, to challenge and change the unfair and steeply graded
distribution of social resources (the conditions for health) to
which all, as citizens, have claims and rights.

Changes in power relationships can take place at various
levels, from the ‘micro’ level of individuals, households, or
communities to the ‘macro’ sphere of structural relations
among economic, social, and political actors and institutions.
While the empowerment of social groups through their
representation in policy-related agenda-setting and decision-
making is critical to realize a comprehensive set of rights and
ensure the fair distribution of essential material and social
goods among population groups, so too is empowerment for
action through bottom-up, grassroots approaches. Struggles
against the injustices encountered by the most disadvantaged in
society, and the process of organizing these people, builds local
people’s leadership. It can be empowering. It gives people a
greater sense of control over their lives and future.

Community or civil society action on health inequities cannot
be separated from the responsibility of the state to guarantee a
comprehensive set of rights and ensure the fair distribution of
essential material and social goods among population groups.
Top-down and bottom-up approaches are equally vital.

24
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

25
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

Age-adjusted mortality among men and women of the Republic of Korea
by educational attainment, 1993–1997.

University

High

Middle

Elementary

0
1
2
3
4
5
6
Men Women

Ra
te

ra
tio

Source: Son et al., 2002

Good Global Governance

What must be done

Make health equity a global development goal, and
adopt a social determinants of health framework to
strengthen multilateral action on development.

• The United Nations, through WHO and the Economic
and Social Council, to adopt health equity as a core global
development goal and use a social determinants of health
indicators framework to monitor progress.

• The United Nations to establish multilateral working
groups on thematic social determinants of health – initially
early child development, gender equity, employment and
working conditions, health-care systems, and participatory
governance.

Strengthen WHO leadership in global action on the
social determinants of health, institutionalizing social
determinants of health as a guiding principle across
WHO departments and country programmes.

Dramatic differences in the health and life chances of peoples
around the world reflect imbalance in the power and prosperity
of nations. The undoubted benefits of globalization remain
profoundly unequally distributed.

Evidence for action
The post-war period has seen massive growth. But growth
in global wealth and knowledge has not translated into
increased global health equity. Rather than convergence,
with poorer countries catching up to the Organisation for
Economic Cooperation and Development, the latter period of
globalization (after 1980) has seen winners and losers among
the world’s countries, with particularly alarming stagnation
and reversal in life expectancy at birth in sub-Saharan Africa
and some of the former Soviet Union countries. Progress in
global economic growth and health equity made between 1960
and 1980 has been significantly dampened in the subsequent

period (1980-2005), as global economic policy influence hit
hard at social sector spending and social development. Also
associated with the second (post-1980) phase of globalization,
the world has seen significant increase in, and regularity of,
financial crises, proliferating conflicts, and forced and voluntary
migration.

Through the recognition, under globalization, of common
interests and interdependent futures, it is imperative that the
international community re-commits to a multilateral system
in which all countries, rich and poor, engage with an equitable
voice. It is only through such a system of global governance,
placing fairness in health at the heart of the development
agenda and genuine equality of influence at the heart of its
decision-making, that coherent attention to global health
equity is possible.

26
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

27
TACKLE THE INEQUITABLE DISTRIBUTION OF POWER, MONEY, AND RESOURCES

Trend in the dispersion measure of mortality (DMM) for life expectancy at birth, 1950–2000.

0
1
2
3
4
5
6
7

Period

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995
–55 –60 –65 –70 –75 –80 –85 –90 –95 –2000

DM
M

(y
ea

rs
)

Reprinted, with permission of the publisher, from Moser, Shkolnikov & Leon (2005).

3. Measure and
Understand the
Problem and Assess
the Impact of Action
The world is changing fast and often it is unclear the impact that social,
economic, and political change will have on health in general and on
health inequities within countries or across the globe in particular. Action
on the social determinants of health will be more effective if basic data
systems, including vital registration and routine monitoring of health
inequity and the social determinants of health, are in place and there are
mechanisms to ensure that the data can be understood and applied to
develop more effective policies, systems, and programmes. Education
and training in social determinants of health are vital.

28
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

MEASURE AND UNDERSTAND THE PROBLEM AND ASSESS THE IMPACT OF ACTION

The Social Determinants of
Health: Monitoring, Research,
and Training

What must be done

There is enough evidence on the social determinants of
health to act now. Governments, supported by international
organizations, can make action on the social determinants of
health even more effective by improving local, national, and
international monitoring, research, and training infrastructures.

Ensure that routine monitoring systems for health
equity and the social determinants of health are in
place, locally, nationally, and internationally.

• Ensure that all children are registered at birth without
financial cost to the household.

• Establish national and global health equity surveillance
systems with routine collection of data on social determinants
and health inequity.

Invest in generating and sharing new evidence on the
ways in which social determinants influence population
health and health equity and on the effectiveness of
measures to reduce health inequities through action on
social determinants.

• Create a dedicated budget for generation and global
sharing of evidence on social determinants of health and
health equity.

Provide training on the social determinants of health
to policy actors, stakeholders, and practitioners and
invest in raising public awareness.

• Incorporate the social determinants of health into medical
and health training, and improve social determinants of health
literacy more widely. Train policy-makers and planners in the
use of health equity impact assessment.

• Strengthen capacity within WHO to support action on the
social determinants of health.

No data often means no recognition of the problem. Good
evidence on levels of health and its distribution, and on the
social determinants of health, is essential for understanding
the scale of the problem, assessing the effects of actions, and
monitoring progress.

Evidence for action
Experience shows that countries without basic data on
mortality and morbidity by socioeconomic indicators have
difficulties moving forward on the health equity agenda.
Countries with the worst health problems, including countries
in conflict, have the least good data. Many countries do not
even have basic systems to register all births and deaths. Failing
birth registration systems have major implications for child
health and developmental outcomes.

The evidence base on health inequity, the social determinants
of health, and what works to improve them needs further
strengthening. Unfortunately, most health research funding
remains overwhelmingly biomedically focused. Also, much

research remains gender biased. Traditional hierarchies
of evidence (which put randomized controlled trials and
laboratory experiments at the top) generally do not work for
research on the social determinants of health. Rather, evidence
needs to be judged on fitness for purpose – that is, does it
convincingly answer the question asked.

Evidence is only one part of what swings policy decisions –
political will and institutional capacity are important too. Policy
actors need to understand what affects population health and
how the gradient operates. Action on the social determinants
of health also requires capacity building among practitioners,
including the incorporation of teaching on social determinants
of health into the curricula of health and medical personnel.

30
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

COMMISSION ON SOCIAL DETERMINANTS OF HEALTH | FINAL REPORT – EXECUTIVE SUMMARY

Unregistered births (in thousands) in 2003 by region and level of development.

Region Births Unregistered children, n (%)

World 133 028 48 276 (36%)

Sub-Saharan Africa 26 879 14 751 (55%)

Middle East and North Africa 9790 1543 (16%)

South Asia 37 099 23 395 (63%)

East Asia and Pacific 31 616 5901 (19%)

Latin America and Caribbean 11 567 1787 (15%)

CEE/CIS and Baltic States 5250 1218 (23%)

Industrialized countries 10 827 218 (2%)

Developing countries 119 973 48 147 (40%)

Least developed countries 27 819 19 682 (71%)

CEE = Central and Eastern Europe; CIS = Commonwealth of Independent States.

Source: UNICEF, 2005

MEASURE AND UNDERSTAND THE PROBLEM AND ASSESS THE IMPACT OF ACTION

Actors
Above, we set out the key actions
called for in the recommendations.
Here, we describe those on whom
effective action depends. The role
of governments through public
sector action is fundamental to
health equity. But the role is not
government’s alone. Rather, it is
through the democratic processes
of civil society participation and
public policy-making, supported
at the regional and global levels,
backed by the research on what
works for health equity, and with
the collaboration of private actors,
that real action for health equity is
possible.

Multilateral agencies
An overarching Commission recommendation is the need
for intersectoral coherence – in policy-making and action
– to enhance effective action on the social determinants of
health and achieve improvements in health equity. Multilateral
specialist and financing agencies can do much to strengthen
their collective impact on the social determinants of health and
health equity, including:

• Coherence in global monitoring and action: Adopt health equity
as a fundamental shared goal, and use a common global
framework of indicators to monitor development progress;
and collaborate in multi-agency thematic working groups
for coherent social determinants of health action.

• Coherent and accountable financing: Ensure that increases in
aid and debt relief support coherent social determinants
of health policy-making and action among recipient
governments, using health equity and social determinants of
health performance indicators as core conditions of recipient
accountability.

• Improved participation of UN Member States in global governance:
Support equitable participation of Member States and other
stakeholders in global policy-making fora.

WHO
WHO is the mandated leader in global health. It is time to
enhance WHO’s leadership role through the agenda for action
on the social determinants of health and global health equity.
This involves a range of actions, including:

• Policy coherence globally and nationally: Adopt a stewardship
role supporting social determinants of health capacity-
building and policy coherence across partner agencies in the
multilateral system; strengthen technical capacity globally
and among Member States for representation of public
health in all major multilateral fora; and support Member
States in developing mechanisms for coherent policy and
ISA for social determinants of health.

• Measurement and evaluation: Support goal-setting on health
equity and monitoring progress on health equity between
and within countries as a core developmental objective;
support the establishment of national health equity
surveillance systems in Member States, and build necessary
technical capacities in countries; support Member States in
development and use of health equity impact assessment
tools and other health equity-related tools such as a national
equity gauge; and convene a regular global meeting as part
of a periodic review of the global situation.

• Enhancing WHO capacity: Build internal social determinants
of health capacity across the WHO, from headquarters,
through the Regional Offices, to Country Programmes.

National and local government
Underpinning action on the social determinants of health
and health equity is an empowered public sector, based
on principles of justice, participation, and intersectoral
collaboration. This will require strengthening of the core
functions of government and public institutions, nationally
and sub-nationally, particularly in relation to policy coherence,
participatory governance, planning, regulation development
and enforcement, and standard-setting. It also depends on
strong leadership and stewardship from the ministry of health,
supported by WHO. Government actions include:

• Policy coherence across government: Place responsibility for
action on health and health equity at the highest level of
government, and ensure its coherent consideration across
all ministerial and departmental policy-making. Ministers
of health can help bring about global change – they will be
pivotal in helping to create buy-in by the head of state and
from other ministries.

• Strengthening action for equity: Commit to progressive
building of universal health-care services; establish a central
gender unit to promote gender equity across government
policy-making; improve rural livelihoods, infrastructure
investment, and services; upgrade slums and strengthen
locally participatory health urban planning; invest in full
employment and decent labour policy and programmes;
invest in ECD; build towards universal provision in vital
social determinants of health services and programmes
regardless of ability to pay, supported by a universal
programme of social protection; and establish a national
framework for regulatory control over health-damaging
commodities.

32
CLOSING THE GAP IN A GENERATION EXECUTIVE SUMMARY

• Finance: Streamline incoming international finance (aid,
debt relief) through a social determinants of health action
framework, with transparent accountability; strengthen
revenue through improved progressive domestic taxation;
and collaborate with other Member States in the
development of regional and/or global proposals for new
sources of international public finance.

• Measurement, evaluation, and training: Build towards universal
birth registration; set cross-government performance
indicators for health equity through the establishment of a
national health equity surveillance system; build capacity to
use health equity impact assessment as a standard protocol in
all major policy-making; ensure training of practitioners and
policy-makers on the social determinants of health; and raise
public awareness of the social determinants of health.

Civil society
Being included in the society in which one lives is vital to the
material, psychosocial, and political aspects of empowerment
that underpin social well-being and equitable health. As
community members, grassroots advocates, service and
programme providers, and performance monitors, civil society
actors from the global to the local level constitute a vital
bridge between policies and plans and the reality of change
and improvement in the lives of all. Helping to organize and
promote diverse voices across different communities, civil
society can be a powerful champion of health equity. Many
of the actions listed above will be, at least in part, the result
of pressure and encouragement from civil society; many of
the milestones towards health equity in a generation will be
marked – achieved or missed – by the attentive observation of
civil society actors. Civil society can play an important role in
actions on the social determinants of health through:

• Participation in policy, planning, programmes, and evaluation:
Participate in social determinants of health policy-making,
planning, programme delivery, and evaluation from the
global level, through national intersectoral fora, to the local
level of needs assessments, service delivery, and support; and
monitor service quality, equity, and impact.

• Monitoring performance: Monitor, and report and campaign
on, specific social determinants of health, such as
upgrading of and services in slums, formal and non-formal
employment conditions, child labour, indigenous rights,
gender equity, health and education services, corporate
activities, trade agreements, and environmental protection.

Private sector
The private sector has a profound impact on health and well-
being. Where the Commission reasserts the vital role of public
sector leadership in acting for health equity, this does not imply
a relegation of the importance of private sector activities. It
does, though, imply the need for recognition of potentially
adverse impacts, and the need for responsibility in regulation
with regard to those impacts. Alongside controlling undesirable
effects on health and health equity, the vitality of the private
sector has much to offer that could enhance health and well-
being. Actions include:

• Strengthening accountability: Recognize and respond
accountably to international agreements, standards, and
codes of employment practice; ensure employment and
working conditions are fair for men and women; reduce
and eradicate child labour, and ensure compliance with
occupational health and safety standards; support educational
and vocational training opportunities as part of employment
conditions, with special emphasis on opportunities for
women; and ensure private sector activities and services
(such as production and patenting of life-saving medicines,
provision of health insurance schemes) contribute to and do
not undermine health equity.

• Investing in research: Commit to research and development in
treatment for neglected diseases and diseases of poverty, and
share knowledge in areas (such as pharmaceuticals patents)
with life-saving potential.

Research institutions
Knowledge – of what the health situation is, globally, regionally,
nationally, and locally; of what can be done about that
situation; and of what works effectively to alter health inequity
through the social determinants of health – is at the heart
of the Commission and underpins all its recommendations.
Research is needed. But more than simply academic exercises,
research is needed to generate new understanding and to
disseminate that understanding in practical accessible ways to
all the partners listed above. Research on and knowledge of
the social determinants of health and ways to act for health
equity will rely on continuing commitments among academics
and practitioners, but it will rely on new methodologies
too – recognizing and utilizing a range of types of evidence,
recognizing gender bias in research processes, and recognizing
the added value of globally expanded Knowledge Networks
and communities. Actions in this field of actors include:

• Generating and disseminating social determinants of health
knowledge: Ensure research funding is allocated to social
determinants of health work; support the global health
observatory and multilateral, national, and local cross-
sectoral working through development and testing of social
determinants of health indicators and intervention impact
evaluation; establish and expand virtual networks and
clearing houses organized on the principles of open access,
managed to enhance accessibility from sites in all high-,
middle-, and low-income settings; contribute to reversal of
the brain drain from low- and middle-income countries;
and address and remove gender biases in research teams,
proposals, designs, practices, and reports.

33
ACTORS

Is closing the
health gap in
a generation
feasible?
This question – is closing the health gap in a generation feasible – has two
clear answers. If we continue as we are, there is no chance at all. If there
is a genuine desire to change, if there is a vision to create a better and
fairer world where people’s life chances and their health will no longer be
blighted by the accident of where they happen to be born, the colour of
their skin, or the lack of opportunities afforded to their parents, then the
answer is: we could go a long way towards it.

Action can be taken, as we show throughout the report. But coherent
action must be fashioned across the determinants – across the fields of
action set out above – rooting out structural inequity as much as ensuring
more immediate well-being. To achieve this will take changes starting at
the beginning of life and acting through the whole lifecourse. In calling to
close the gap in a generation we do not imagine that the social gradient in
health within countries, or the dramatic differences between countries, will
be abolished in 30 years. But the evidence, produced in the Final Report,
both on the speed with which health can improve and the means needed
to achieve change, encourage us that significant closing of the gap is
indeed achievable.

This is a long-term agenda, requiring investment starting now, with
major changes in social policies, economic arrangements, and political
action. At the centre of this action should be the empowerment of
people, communities, and countries that currently do not have their fair
share. The knowledge and the means to change are at hand and are
brought together in this report. What is needed now is the political will to
implement these eminently difficult but feasible changes. Not to act will
be seen, in decades to come, as failure on a grand scale to accept the
responsibility that rests on all our shoulders.

Reducing health inequities
is, for the Commission on
Social Determinants of
Health, an ethical imperative.
Social injustice is killing
people on a grand scale.

www.who.int/social_determinants

<< /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Gray Gamma 2.2) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.2 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages false /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.1000 /ColorConversionStrategy /UseDeviceIndependentColorForImages /DoThumbnails false /EmbedAllFonts false /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo false /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo false /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Remove /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 100 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 100 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >>
/ColorImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >>
/JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >>
/JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >>
/AntiAliasGrayImages false
/CropGrayImages true
/GrayImageMinResolution 150
/GrayImageMinResolutionPolicy /OK
/DownsampleGrayImages true
/GrayImageDownsampleType /Bicubic
/GrayImageResolution 100
/GrayImageDepth -1
/GrayImageMinDownsampleDepth 2
/GrayImageDownsampleThreshold 1.50000
/EncodeGrayImages true
/GrayImageFilter /DCTEncode
/AutoFilterGrayImages true
/GrayImageAutoFilterStrategy /JPEG
/GrayACSImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >>
/GrayImageDict << /QFactor 1.30 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >>
/JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >>
/JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 10 >>
/AntiAliasMonoImages false
/CropMonoImages true
/MonoImageMinResolution 300
/MonoImageMinResolutionPolicy /OK
/DownsampleMonoImages true
/MonoImageDownsampleType /Bicubic
/MonoImageResolution 200
/MonoImageDepth -1
/MonoImageDownsampleThreshold 1.16500
/EncodeMonoImages true
/MonoImageFilter /CCITTFaxEncode
/MonoImageDict << /K -1 >>
/AllowPSXObjects true
/CheckCompliance [
/None
]
/PDFX1aCheck false
/PDFX3Check false
/PDFXCompliantPDFOnly false
/PDFXNoTrimBoxError true
/PDFXTrimBoxToMediaBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXSetBleedBoxToMediaBox true
/PDFXBleedBoxToTrimBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXOutputIntentProfile (None)
/PDFXOutputConditionIdentifier ()
/PDFXOutputCondition ()
/PDFXRegistryName ()
/PDFXTrapped /False
/Description << /CHS
/CHT
/DAN
/DEU
/ESP
/FRA
/ITA
/JPN
/KOR
/NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken die zijn geoptimaliseerd voor weergave op een beeldscherm, e-mail en internet. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.)
/NOR
/PTB
/SUO
/SVE
/ENU (Use these settings to create Adobe PDF documents best suited for on-screen display, e-mail, and the Internet. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)
/ENG ()
>>
/Namespace [
(Adobe)
(Common)
(1.0)
]
/OtherNamespaces [
<< /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >>
<< /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /ConvertToRGB /DestinationProfileName (sRGB IEC61966-2.1) /DestinationProfileSelector /UseName /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >>
/FormElements false
/GenerateStructure false
/IncludeBookmarks false
/IncludeHyperlinks false
/IncludeInteractive false
/IncludeLayers false
/IncludeProfiles true
/MultimediaHandling /UseObjectSettings
/Namespace [
(Adobe)
(CreativeSuite)
(2.0)
]
/PDFXOutputIntentProfileSelector /NA
/PreserveEditing false
/UntaggedCMYKHandling /UseDocumentProfile
/UntaggedRGBHandling /UseDocumentProfile
/UseDocumentBleed false
>>
]
>> setdistillerparams
<< /HWResolution [200 200] /PageSize [612.000 792.000] >> setpagedevice