Social Determinants of Health
The socio-ecological model, first proposed in the 1970s by Urie Bronfenbreener (see Figure 1), describes the real-world model in which multiple, overlapping factors influence the health of an individual. While the individual may be responsible for making lifestyle choices that determine health status, the ability to make these choices and changes is also dependent on the environment that extends beyond the individual.
These “social determinants” of health include the prevailing culture, the physical environment, the schools, the workplace and other organizations, health care institutions, and public policy. If there are only fast-food restaurants or convenience stores in a neighborhood, or if fear of crime is so rampant that people stay indoors and away from playgrounds, or if there are no sidewalks to access schools, then community residents are less likely to have access to nutritious foods and exercise that are essential components of good health.
Social determinants of health are recognized in the health promotion and disease prevention goals set by the U.S. Department of Health and Human Services’ Healthy People 2020, which includes as a primary objective the development of “social and physical environments that promote good health for all.” Here is where local governments have a vital role. Three broad areas of involvement are logical extensions of the public interest responsibility of local government:
- Local elected officials represent the best interests of the residents.
- Good health is related to improved quality of life and, therefore, to economic health.
- Local governments provide opportunities to address public policy issues that foster improved health in the community by incentivizing best practices, regulating potentially harmful or illegal behaviors, and reducing barriers to improved health.
Representing Residents’ Broad Interests
A renewed interest in local government participation in community health planning has been fostered in two primary ways. First, changes in the Internal Revenue Service (IRS) code driven by the Patient Protection and Affordable Care Act now require nonprofit hospitals “to conduct a community health needs assessment (CHNA) every three years and adopt an implementation strategy to meet the community health needs identified.”
Second, public health agencies across the nation are engaging in a process of accreditation, part of which requires these agencies to take a hard look at their operations within the larger community and how, in the context of the socio-ecological model, community partners can engage to achieve the common goal of improved health outcomes.
“It’s not our job.”
Think again. In cities like Decatur, Georgia; Birmingham, Michigan; and Warwick Township, Pennsylvania—all ICMA Life, Well Run featured communities—leaders have recognized the direct connection between economic and resident health. Local governments are increasingly engaged in planning for improved community health, often as part of broad coalitions that include health providers, public health, and civic and social service organizations.
The impetus is clear: Awareness is growing that health is not just a matter of access to medical care—though prevention and treatment are assuredly factors in good health–but also a function of the broader environment that affects the individual.
In thousands of communities across the nation, community health needs assessments and health improvement planning are under way. Local governments are increasingly expected to accept a leadership role in the process.
Public health accreditation efforts require broad participation of the community, including input from policymakers. The IRS requirement is that “the community health needs assessment must take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health.”
Elected officials and public managers bring expertise through their knowledge of the residents and neighborhoods they represent. Through strategic policy making, they can carry out their public interest responsibility to make improvements or reduce risks that can positively impact health.
The Centers for Disease Control (CDC) also urges participation of local government leaders. Among the best practices recommended to reduce obesity is that “local government is an active member of at least one coalition or partnership that aims for environmental and policy change to promote active living and/or healthy eating.”
An Economic Issue
Good health is an economic issue. Figure 2, based on data from the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation’s County Health Rankings, illustrates the undeniable relationship between health factors and health outcomes rankings across each of the nation’s counties.
“Health Factors” rankings are based on three major types of measures: 1) social and economic issues, including measures of education, employment, income, family and social support, and community safety; 2) clinical care, including access to care and quality of care; and 3) individual health behaviors.
“Health Outcomes” rankings refer to measures of length of life and quality of life. County Health Rankings is a free and valuable resource that provides, on an annual basis, data that can help communities monitor their progress in health and related factors.
The socio-ecological model, as interpreted in Figure 2, stands as a reminder to local governments that everything is connected. Educational attainment, which affects poverty, is a primary predictor of good health and a fundamental component of job creation.
Jobs not only reduce poverty, but they also affect health care infrastructure and access to care, which affect quality of life. A measure of quality of life is good health. Figure 2 also provides strong evidence that healthy communities and economically vibrant communities are often one and the same.
Public Policy and Healthy Choices
Local leaders clearly have a role in crafting policy that impacts individual choices and local health concerns. In fact, some public managers recommend that in any policy-making checklist, resident health should be a decision factor.
There are dozens of ways local government decisions can impact health. This article provides a list of functional areas of opportunity that comes from community health improvement plans around the country and from the CDC report, Recommended Community Strategies and Measurements to Prevent Obesity in the United States—a report in which ICMA local government representatives participated in 2009.
There are other ways to effect change, but this list provides a starting point for thinking about health outcomes in relation to local government policy decisions.
- Decisions that affect the number of stores that sell alcohol.
- Consideration of open space to provide active play areas in high-density neighborhoods.
- Building permits that require safe play spaces and open areas for children.
- Encouragement of mixed-used development.
- Pedestrian, non-motorized vehicle spaces.
Law Enforcement and Safety
- Law enforcement compliance checks at stores and restaurants that sell alcohol and tobacco.
- Law enforcement compliance checks on child safety seats and seatbelt use.
- New construction inspections that consider safety and environmental hazards.
- Sidewalks and safe crosswalks that encourage walking and biking.
- Access routes to schools that allow and encourage walking and biking.
- Inspection and efforts to reduce substandard housing.
- Controlling crime to make people feel safe to be outside.
- Control of toxic/hazardous waste dumping and emissions.
- Monitoring water quality.
- Limiting the number of septic tanks.
- Grant funding for enhanced water treatment and monitoring.
- Establishment of recycling programs to reduce landfills.
- Enforcement of landfill rules.
Revenue and Taxation
- Tax incentives for grocery stores and markets to reduce food deserts.
- Free or low-cost space to encourage farmers’ markets on public property to provide an outlet for farmers and fresh vegetables for residents.
- Seeking grant opportunities for water enhancements, parks, natural areas, bike trails, and analysis of the community’s “walkability.”
Parks and Recreation
- Sufficient parks and active playgrounds and adequate sidewalks to provide access within a half mile from all homes to encourage exercise.
- Healthy foods in vending/food service areas in government-operated venues.
- Policies that allow public use of school recreation facilities after-hours through cooperative agreements.
- Programs that engage all ages in physical activity.
- No smoking allowed in parks.
Regulation and Licensure
- Healthy food standards for schools, daycare centers.
- Establishment of no-smoking areas.
- No alcohol community events.
- Planning for terrorism, infectious disease outbreaks, and natural disasters.
- Emergency response for incidents and accidents.
Internal HR Issues
- Tobacco-free policies.
- Wellness incentives for employees.
- Access to healthy snacks, foods at work.
Tourism/Resident Quality of Life
- Creating hiking trails, even within the city.
- Becoming a bike-friendly community.
- Establishing access points to rivers, lakes, streams for non-motorized boats.
- Conversion of abandoned railroad beds to walking/biking paths.
- Historical walking tours.
- Using cemetery green space for walking/biking.
- Improved signage that promotes recreation opportunities.
- Sharing information.
- Setting an example.
Ultimately, some local governments may shy away from involvement in conducting health assessments or health planning because they already have enough issues on the table or fear political pushback, but smart cities and counties are on the bandwagon.
Engagement with public health to achieve common goals can benefit residents, business and industry, and local governments as they collaborate to build healthier and more economically vibrant communities. For best practice recommendations, visit the website at http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/index.htm#ag.