Section 5. Addressing Social Determinants of Health and Development

Learn how to address broader social factors, such as income inequality or social exclusion that lead to or influence health and development outcomes.

 

 

"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...an ethical imperative. Social injustice is killing people on a grand scale." -excerpt from the 2008 World Health Organization Commission on Social Determinants of Health Final Report Executive Summary

What are social determinants of health and development?

“Social determinants” refer to broader social factors, such as income inequality or social exclusion, that lead to or influence health and development outcomes. In Section 4 of this chapter, for instance, a development worker in Mexico tells of realizing that one of the major causes of malnutrition in the area where he was working was not that there simply wasn’t enough food. Sharecropping farmers were able to grow enough to feed their families, but had to borrow seed from the landowner to plant their crops. The terms of the loan were that, for every liter of maize borrowed at planting time, three liters had to be repaid from the harvest. With this high interest rate, peasants went deeper and deeper into debt, and had to use more of their crop each year to pay the landowner. Without power, group solidarity, and influence, the farmers were unable to create conditions that assured the health and well-being of their families.

There is a great deal of research on the social determinants of health. Most of it points to three overarching factors:

• Income inequality. Once a country has reached the point of development where most deaths come not from infectious diseases (tuberculosis, dysentery, cholera, malaria, flu, pneumonia, etc.), but from chronic diseases (heart disease, diabetes, cancer), the economic and social equality within the society is a greater determinant of death rates and average lifespan than the country’s position with regard to others. The United States, for instance, lags behind Japan, Sweden, Canada, and many other less affluent countries in the life expectancy of its citizens. The difference seems to be the size of the gap between the most and least affluent segments of the society.

• Social connectedness. Many studies indicate that “belonging” – whether to a large extended family, a network of friends, a social or volunteer organization, or a faith community – is related to longer life and better health, as well as to community participation.

• Sense of personal or collective efficacy. This refers to people’s sense of control over their lives. People with a higher sense or stronger history of efficacy tend to live longer, maintain better health, and participate more vigorously in civic life.

Many of the social determinants listed below are specific forms of or contributors to these three categories. At a community level, it may be difficult to influence income inequality directly, but a non-governmental or community-based organization may be able to approach it through addressing a particular issue. A small organization may be able to have more effect on social connectedness and the sense of efficacy, since collective action can influence both social ties and the experience of changing communities and systems.

The World Health Organization, in its publication The Solid Facts, recognizes the need to break these factors down into more manageable pieces. It lists ten factors that affect health and life expectancy, and advocates addressing each within a comprehensive program of social protection that addresses all of them within a society. These ten factors are:

• The social gradient (extent of equity or the difference in wealth and opportunity between those with the most and those with the least)
• Stress
• Early life experience
• Social exclusion (the opposite of social connectedness)
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transport

The factors listed below are, in most cases, more specific than the three broader determinants discussed above. In addressing social determinants, however, keep in mind these broader factors, and gear programs and policies toward influencing them at whatever level you can, given the resources and scope of your organization.

The social determinants of a particular community health or development issue may be unique to a particular community or group, or may be part of the larger society. People from different immigrant cultures, different social classes, or with different levels of education might experience the same issue very differently because of different social factors.

There are three major ways in which social determinants may affect specific populations. These can also be viewed as levers – points of intervention – that can be used to address those social determinants and lessen their effects.

1.  Differences in exposure. Certain population groups, because of economics, geography, or other factors, may be more likely than others to encounter particular health risks. People in poverty, for example, are likely to be exposed to higher levels of stress, economic uncertainty, and unhealthy conditions than their wealthier countrymen.

A specific example: in developing, or even middle-income, countries, poor rural villages may get all their water – for drinking, washing, waste disposal, and other uses – from a single, above-ground source, such as a lake or stream. In that case, the villagers are far more apt to be exposed to water-borne diseases and pollutants than wealthier neighbors who can afford to buy bottled water or drill a well.

2.  Differences in vulnerability. Because of their poverty, their exposure to stress and uncertainty, or other factors, those same population groups might find themselves more vulnerable than others to health problems. The inability to pay for regular health care or medical treatment increases the possibility of chronic illness. In the example of the village above, poor nutrition, as a result of poverty, could increase villagers’ vulnerability to water-borne disease, as would the inability to organize to finance a village well.

3.  Differences in consequences. Differences in wealth, social standing, connectedness, and other factors can lead to very different outcomes where health issues are concerned. For a middle- or upper-class family in many countries, a minor health problem – missing a few days of work, paying a modest sum for treatment – might be just an annoyance. For a poor family, it might be the difference between a roof over their heads and homelessness, or between children attending school and dropping out to go to work. Discrimination, high stress levels, employment conditions, and other factors can result in disparities in health and health care among different groups.

There are a number of social factors to address to improve conditions for health and development. Some of the more common factors to be addressed are:

Economic factors.

The unemployment rate, for example, has a great influence on such issues as domestic violence, substance use, depression, or physical illness. Economic inequality affects people’s stress levels, exposure to violence and toxins, educational prospects, access to services, high-risk behavior, and mortality rates.

Social inclusion.

Social connectedness and the cohesion of the community have been shown to have a direct relationship to good health and lower mortality rates. These factors can also encourage civic participation in changing conditions that affect group goals.

Education.

More education means not only better jobs and more affluence, but also a greater sense of control over one’s life. People with more education have more choices in health, housing, careers, and other areas that affect the quality of their lives.

Racial or ethnic bias.

Social exclusion can be the result of prejudice, which results in different access to health care, education, or other services.

Social norms of acceptance of particular behaviors or practices.

Smoking, or even alcohol abuse, may be an accepted part of the culture of a community. In that case, many more people will adopt it than in a community where it is frowned upon.

Cultural factors.

There are many elements of culture that might have a bearing on social inclusion, efficacy, and income inequality.

• Gender roles in different cultures may lead to differences in opportunities for men and women, and to disparities in nutrition, health, education, and life opportunities for their children as well.

• Food preferences in different cultures may have profound health effects. For centuries, for instance, the Japanese ate a diet consisting largely of rice, vegetables, and fish, and, at least partly as a result, experienced fewer heart health problems than the meat-and-potato eaters in the United States.

In many cases, people only one generation removed from rural poverty – as typified by many Eastern European immigrants to the U.S. in the early 20th century – may eat more fat because being able to eat fatty foods, such as meat, symbolizes wealth in peasant cultures. Many turn-of-the-20th-century immigrants to the U. S. – the grandparents of contemporary Americans – thought fat children were healthy children, because fat children clearly get enough to eat, as opposed to going hungry. Starvation was a real danger in the time and place of their childhoods.

• Religion can have profound effects on both health and development issues.

• Attitudes toward mainstream culture can influence everything from medical care to whether or not high school students can attend dances. This, in turn, affects the type and amount of health care received, the sense of connectedness within a community, and many other factors.

• Language barriers can cut people off from health care and other services, make it difficult for them to find and keep decent jobs, and affect their children’s education.

The influence of mass media.

The media, particularly television, can send powerful messages about community health and development. In the 1950s in the U.S., smoking was portrayed in movies, magazines, and TV as glamorous and sophisticated. Now, there are no TV ads for cigarettes, virtually no one in the movies smokes, and anti-smoking messages are everywhere. These conditions both reflect and are partially responsible for the fact that fewer than 25% of adults in the U.S. now smoke.

The media can help or hinder other efforts to improve health (through programming that shows people exercising as a matter of course, for instance, or that shows the same people eating fatty fast food or drinking too much). They can also, similarly, encourage or discourage tolerance for others, push a political agenda, or condone or condemn such behavior as solving disputes with violence and engaging in unsafe sex.

Politics.

It is probably fair to say that all community issues are political to some degree. If a factory is poisoning town wells with its effluent, for example, local officials are faced with the choice of not dealing with the actual cause of the problem (the dumping of waste) and endangering citizens’ health, or addressing the dumping and endangering citizens’ jobs. Politicians with larger constituencies, using poll data, may pander to what they perceive as people’s selfishness and prejudice, passing legislation or instituting policies that discriminate against one group or another, or fly in the face of the public interest. Even honest differences of political opinion – over whether the government should be responsible for providing social services or not, for instance – can have enormous consequences in the community.

Living conditions.

Run-down or inadequate housing, dangerous streets, noise, and blighted neighborhoods all have their effects on those who experience them every day, as do manicured landscapes and calm environments. The stress of living in a difficult situation carries over into many other areas of life.

Geography.

Location may have a great deal to do with whether people receive services or not. In developing countries, children from isolated villages in the mountains or on the seacoast may have no opportunity for school or medical care, for instance. In the U.S., as mentioned earlier, access to medical care and other services may depend on the availability of transportation. In urban areas, that access may have a lot to do with the neighborhood in which the services are located: another gang’s turf or a neighborhood perceived as hostile may be as effective in denying services as if they didn’t exist at all.

Why address social determinants of health and development?

 

Reasons for addressing the social determinants of an issue include:

If you want to solve or prevent a problem for the long term, you have to deal with its root causes.

If you address the root causes, you’re more likely to successfully address the issue for the short term as well. To cure a disease, you have to treat more than the symptoms – but you usually have to treat the symptoms, too. Dealing with social determinants will not only resolve the issue over the long term, but will make alleviating the current effects of the issue possible also.

To eliminate cholera, one of the most important steps is to provide people with clean drinking water. During the London cholera epidemic of 1854, John Snow, a physician, mapped the houses where the disease struck. He learned that many of the stricken were drawing water from a pump that tapped a filthy part of the Thames River, because conventional wisdom said it was better than the piped water also available to them – which actually came from a cleaner area. He was able to close the pump and substitute piped for pumped water, almost immediately ending the outbreak. Snow’s insights about the social determinants of cholera, along with the later work of others, eventually helped to eliminate the disease as a threat in most of the developed world. But they also served to stop the 1854 epidemic.

Who should address social determinants of community health and development?

The Community Tool Box advocates for participatory approaches to planning and, in this case, for a participatory approach to analysis and intervention as well. The presence of members of the groups affected by the issue will ensure that everyone knows its full context and history, as well as what various segments of the community might be willing and unwilling to do about it. Those who should be involved include:

• Those directly affected by, or at risk for, a particular health condition or community development issue.
• Policy makers, legislators, officials, or others who can affect the issue.
• Human services staff, administrators, and others (such as police officers, teachers, and coalition members) who are responsible for dealing with the issue at hand.
• Respected local figures, including advocates, clergy, and others in the community to whom people turn for support.
• Members of groups that may be asked to change or sacrifice or take action in order to address the issue. Employers, landlords and other property owners, health and human service workers, police, and teachers all might fall into this category.

When should you address social determinants of community health and development?

You should always look at the social factors that play a role in community issues, but there are some times when analysis of those factors is particularly important.

• When it’s clear that simply focusing on the issue isn’t enough. As cities have found again and again, all the enforcement in the world won’t really stop youth violence. There has to be a change in the culture that creates that violence.

In the late 1960s, Philadelphia was a city of gangs. One night in 1969 in North Philadelphia, there were five shootings in a one-square-block area. The neighborhood was crawling with police who were apparently powerless to stop the string of attempted revenge killings (“attempted” only because only three of the shootings were fatal). What eventually succeeded, a couple of years later, was a peacemaking effort that involved the gang leaders and that addressed the social issues that lay behind the existence of gangs and violence in the neighborhood: the isolation and alienation of black youth from the society at large, the lack of jobs, and the irrelevance of school to kids whose main concern was getting home alive. Gang members formed entrepreneurial businesses – making films, developing clothing lines – and school became relevant because education was necessary to run a business successfully. Community violence lessened as truces were signed and hope for a reasonable life grew.

• When you’re advocating for legislation, policy change, or funding to address a community issue. The legislation, policy, or funding – and therefore your advocacy – should address the underlying causes of the problem you’re trying to solve, as well as its symptoms. Otherwise, you’ll be dealing with the symptoms forever.
• When you’re trying to demonstrate that fundamental change is needed. Change is difficult for everyone. Trying to get a whole community to change its attitudes and/or behavior is even more difficult. Being able to explain clearly how the changes are related to positive results can make things easier.
• When you’re looking for long-term solutions to long-term problems. Long-term solutions are impossible without taking into account the root causes of the problems you want to solve. Analyzing the social determinants of those problems makes it possible to address them, and come to real, permanent solutions.
• When your focus is on community wellness and prevention. Whether you’re trying to guard against a disease or debilitating condition, or trying to create a healthy community, you have to look at the issue as a whole in order to be successful. You can’t lower your blood pressure, for instance, without adjusting your diet, exercise, stress levels, and daily activities, all of which may be governed, to some extent, by social as well as personal factors. By the same token, you can’t alter racial tensions in a community without somehow addressing all the history that led to those tensions, the preconceptions and misconceptions on both sides, personal experiences, the attitudes of community officials and police, the racial prejudice endemic in the society, etc.

How do you address social determinants of community health and development?

Now that you’re convinced that addressing the social factors that cause or influence community health and development issues is important, how do you go about doing so? There are really two parts to addressing social determinants. The first is identifying how various social factors affect the issue you’re concerned with, and the second is developing and implementing an action plan based on an understanding of how, and from what angle, to approach them successfully in order to change the way the issue plays out in the community and, ultimately, resolve the problem.

Identifying social determinants

The issue you’re dealing with may be obvious, but it’s likely that all of its social determinants are not. There may be local customs that seem so obvious to the folks you’re working with that they don’t consider them worth mentioning, even though they may control a great deal of the community’s functioning. If they’re unique to that community or region, and you’re not a native, you’ll have to learn about them if you have any hope of changing conditions. In other cases, social factors may have to be traced through several layers of the society before you reach the point where they originate and can be influenced. The way to find out about these and other social determinants is to do a community assessment.

Assess the community to find the social determinants of your issue. The purpose of community assessment is largely to assess the community for needs and assets, but the strategies it proposes are equally useful in searching for social determinants of health and development.

• Start by talking to people:
• Community leaders
• Members of the group most affected by the issue
• Government officials
• Staff and volunteers of non-governmental health and community development organizations (NGO’s)
• Community activists and organizers
• Anyone who has a stake in the issue you are trying to address

If there are conflicting factions or “sides” involved in the issue, it’s important to hear from all of them. Even if you’re clear about who’s in the right, or about what needs to happen in order for the issue to be resolved, understanding all points of view can tell you a great deal about the social factors that underlie the situation in the community.

You can hear what people have to say in various ways:

• Individual interviews
• Group interviews
• Focus groups
• Community meetings
• Informal conversations
• Listening and observation at gatherings held for other purposes
• Learning as much as you can about community history. Social determinants of health and development often run deep and go back generations.

The Battle of Montaperti was fought between the Italian cities of Florence and Siena, then independent republics, in 1260. In the 21st century, a sports contest between the two, whether on the high school or professional level, often spurs a cry of “Remember Montaperti” by the Sienese – the victors 750 years ago.

Apply critical thinking principles to analyze the results of the assessment. Very briefly, these include:

• Make sure your information is accurate.
• Consider the reliability of your sources.
• Examine and challenge your own and others’ assumptions and biases.
• Identify the interests being served or ignored.
• Ask the right questions. This could also be considered a principle of critical thinking, and dovetails with the “But why?” technique. Some of the questions you might want to ask are:
• Whom does the issue affect?
• What do those affected have in common? Class? Race or ethnicity? Gender? Physical characteristics? Geographical origin or location? Behavior or personal practices? Lifestyle? Education? Employment? Personal history? Culture? Interests? Other characteristics?
• What is the history of the issue in the community? When did it become an issue? What else was happening at the time, both in the community and in the society at large?
• Who stands to gain, and who stands to lose – socially, economically, or politically – if nothing changes?
• Who stands to gain, and who stands to lose if changes are made? Is there a win-win option, where everyone benefits?
• Who has the power to create change in this situation? What are reasons they may or may not do so?
• Where is the issue centered, geographically and socially?
• Are there economic aspects to the issue? What would it cost to change the situation or to leave it as it is, and who would bear the cost in either case?

The “But why?” technique is actually quite simple. Once you have the answer to an initial question, you follow up the answer with “But why?” The answer to that question gets another “But why?” until you get as far as you can go. At that point, you have an answer that identifies the root of the problem, and therefore implies a solution.

Addressing social determinants

As we’ve discussed, most social determinants come down to:

• Economic inequality
• Social connectedness
• A sense of efficacy

The lower people’s economic levels, the less connected they are to others – through family, social groups and organizations, faith communities, etc.; the less convinced they are of their ability to control their situations and their lives, the greater the likelihood that they’ll experience more health problems than those in the society who fare better in those categories.

And as we’ve also discussed, particular individuals or populations are most likely to be disadvantaged by health problems because of:

• Differences between them and others in the society in the level of their exposure to those problems.
• Differences in their vulnerability to those problems.
• Differences in the consequences to them of those problems.

These characteristics feed each other in a cycle of poverty and powerlessness. An effective intervention has to break that cycle by understanding the social determinants behind it and changing them and the conditions that they cause in a truly profound way.

You can develop interventions that can reduce people’s exposure to, their vulnerability to, and their consequences from health problems, and that can also encourage gains in economic equality, social connectedness, and efficacy. By doing so, you can help people not only improve their health and that of their children, but move up the ladder of economic and social status, thus cementing their gains, and securing them for the next generation.

This may seem like an impossible task. How can you change a society? It’s hard for governments and even harder for most NGOs and community-based organizations, given the limits on their resources. Major social change often takes not a single type of intervention, but an all-out assault on a number of social factors over a long period of time. Unless you’re a high government official, or have access to unlimited funds, you’re probably not planning anything that broad . . . and you don’t have to.

Rather than trying to concentrate on the huge issues, you can intervene in the environmental and policy conditions that reflect social determinants and that can more easily affect differences in exposure, vulnerability, and consequences. In the process of addressing these types of issues, the folks you’re concerned with can learn much of what they need to change their position in society.

Environmental here refers not just to the natural environment, but to the total environment of the people in question. That includes the built environment – buildings, roads, power sources, farms, etc. – as well as the social environment – culture, social rules and norms, government, business, education, economics, etc.. The term “environment” here encompasses all the natural and human physical, social, economic, and political structures that surround people’s lives.

Environmental and policy conditions include:

• Knowledge and skills. Individual and group knowledge and experience affect the availability of resources for supporting health and well-being. A villager who understands how to advocate with the government for clean drinking water, for instance, can greatly enhance the health prospects of his community.

Helping people gain knowledge and skills can be an intervention in itself, or be part of a broader intervention that nonetheless provides participants with tools to safeguard or improve their health and their lives. Some community development programs, for example, include literacy classes as part of the support they provide. With literacy, participants gain skills that allow them to continue and expand the community development activities they’ve begun, or to get jobs that will better serve them and their families. Literacy also gives people who’ve typically been powerless a means to power over their lives by helping them understand the forces working on them (not to mention the terms of contracts and other papers to which they’re asked to agree), and take action on their own behalf.

Providing knowledge of specific health issues and practices can have a dramatic effect on the health of a community. Safe sex practices, for instance, can cut down on the incidence of HIV infection, and information about the treatment of infant diarrhea can drastically reduce infant mortality.

In both these examples, addressing a specific issue serves to address efficacy, and, in the case of literacy training, economic inequality as well. Depending on how programs are structured, most can also address social connectedness, either by bringing a community or population group together to work on an issue, or by creating a community among those involved (in literacy classes, for example.)

• Support within and between groups. Emotional support from family and friends, such as for the stress of difficult work or family situations, helps us cope with situations that cannot be easily changed. Links with other groups, such as faith communities or non-governmental organizations (NGOs), can provide access to goods and services. Just as important, joining with other groups to work for increased resources and better health conditions can permanently improve the quality of community life.

Again, an intervention to connect people or groups with others may stand alone, or may be integrated into a larger concept. A government agency might encourage groups to combine across ethnic or geographic lines in order to receive funding or training for health and community development projects. In a situation where the government is perceived as withholding support, a group of villages without access to health care, for instance, might come together to petition the government for a centrally located health clinic that would be easily reachable for all of them. Groups like this represent the most fundamental kind of community organizing, which brings groups and communities together to advocate for their interests and to take control of what happens to them.

• Barriers to, access to, and opportunities for resources and services. Some social groups, such as women or ethnic minorities, face discrimination and other barriers in gaining access to education, jobs, and basic services. The quality and availability of even basic education and health services are unfairly distributed among social groups.

In cases where education, jobs, services, and other necessities are unequally distributed, the appropriate action may be to organize the community, as above, to demand equal treatment; to use the court system to try to gain access and opportunity; or to attempt to address the issue locally, using available community assets and the initiative of local people. If the initiative comes from the government, it might create programs that remove or address barriers to opportunities and services, such as discrimination, unaffordable expense, geographic isolation, lack of transportation, illiteracy, and lack of job skills.

• Consequences of Actions. Research has long shown that people are more apt to take or continue action if it rewards them with goods, peer approval, pleasure, status, satisfaction, or the desired results than if it punishes them with high costs, disapproval, misery, loss of status, dissatisfaction, or frustration. If gaining access to health care or to healthy goods or practices is difficult, slow, and tedious, and often ends in failure, it won’t be long before people stop trying.

A possible remedy here is, as above, to improve access and break down barriers to access to goods and services, thus making the attempt to obtain them less frustrating and more likely to be repeated. Strategies might include providing transportation to and from existing services or distribution points, locating new services closer to where they’re needed, or lessening bureaucratic requirements. If the intervention involves action by participants, actions should be planned in small steps, so that people can easily experience success, at least at the beginning. A series of small successes is more likely to develop a sense of efficacy and keep people moving ahead than a grand failure.

• Exposure to or protection from hazards. Contact with environmental hazards – polluted water, toxic substances or dangerous practices in the workplace, endemic diseases such as malaria, widespread violence – increase risk for disease or injury. By the same token, actions taken to reduce or eliminate those hazards – drilling a new well, instituting protective workplace safety procedures, disease eradication campaigns, negotiating a peace treaty – work to make disease or injury less probable.

An intervention to decrease or prevent exposure to hazards can take any one of several forms. A self-help program to dig a well or use filters to obtain clean water, channel sewage, grow food without pesticides or chemical fertilizers, eliminate VOCs (volatile organic compounds, often-toxic chemicals – used in glues, dyes, paint, and solvents – that vaporize at room temperature and can affect the health of many people) in a building, or clean up a neighborhood can not only improve health conditions, but increase participants’ sense of efficacy as well.

A different approach might involve advocacy for government assistance or services – drilling a well, installing a sewer system, establishing a health clinic, instituting public transportation, etc. – or to pass or prevent laws that affect exposure to health risks. These actions would speak to both social connectedness (community organizing brings communities or groups together to apply pressure and advocate effectively) and participants’ sense of efficacy.

A third possibility that also addresses both social connectedness and efficacy might involve an initiative to change the behavior of – or prosecute – a corporation or other party responsible for pollution, unsafe workplace practices, illegal dumping, shoddy and dangerous construction, selling harmful products, or other potential hazards.

• Policies. Policies that affect community health and development may be formal or informal, and may be those of governmental or non-governmental bodies (e.g., corporations, institutions, foundations, professional associations). They may relate to the provision of goods and services (e.g., clean water, adequate food, health care, education, housing) or to regulations and their enforcement (e.g., environmental and drug laws, welfare rules, trade regulations, non-discrimination laws in employment and education.) Public policies often mirror a community’s or society’s norms (the unspoken rules of “how things should be”), and, as a result, are often a direct reflection of social determinants.

Changing or instituting policy is generally a matter of advocacy. It’s important because policies can, and do, affect all three of the differences – in exposure, vulnerability, and consequences – that create less healthy conditions for populations at risk.

An initiative aimed at policy change can start at any level. It may begin with government, with the realization by legislators, other elected or appointed officials, or an agency that some sizeable group of citizens is in danger of, or already suffering from, disparities in health. It may begin with an NGO or grassroots organization that works with (or is composed of) that group. Or it may begin with the people themselves, who have simply come to the end of their patience with their situation.

Policy change is often difficult, but, in the long run, it can be the most effective means of improving health and development outcomes, because it can lead to real social change. The ideal intervention would be one that either originates with, or involves those who will benefit from the change in question, since that gives them control over what happens to them.

Several principles, assumptions, and values help guide collaborative action to create conditions that promote health and development. These include:

• Priority issues and strategies for collaborative action are best determined by people most affected by the concern. This can enhance community efficacy and empowerment, and is also most likely to address the issues most important to those involved.

• Since health and development outcomes are caused by multiple and interrelated factors at multiple levels, single interventions are likely to be insufficient. This suggests the importance of comprehensive interventions that address environmental and policy conditions at all levels.

Multi-pronged, multi-faceted interventions are the ideal, and are, in general, necessary to create real and permanent social change. The reality for small organizations, however, is that such interventions may not be possible, because of limited resources and geographic and/or political isolation. There are at least two ways to deal with this reality: One is to form a coalition, pulling in other organizations – including national and international NGOs and even the government where possible – to mount a collaborative effort on many fronts. The second is to develop a long-range strategic plan that takes as its base the saying of the Chinese philosopher Lao Tzu, “The longest journey begins with a single step.” That involves starting with a single issue in order to tackle something manageable and achieve a success that will energize and empower those affected. Then you can go on to the next issue and the next, always maintaining and consolidating gains as you go. In this way, you can end up with an effort that addresses the full range of social determinants, without exceeding your capacity at the beginning. It may take a while, but your chances of creating real change are better if you take it step by step, as long as you don’t lose sight of the goal.

• Collaborative efforts must bring about change in multiple sectors and systems. (This requires leadership to engage groups with different interests, such as those in business or education, to share resources and responsibilities in common purpose.

Again, depending on your resources, even a coalition or other collaborative body might have to take this one step at a time.

• The aim of support organizations is to build capacity so that local people can take action over time and across issues.

Capacity-building involves helping local people gain the skills and knowledge – and establish or strengthen the community organizations and institutions – necessary to allow them to take action and control their own fate. That may entail direct training, using resources like the Community Tool Box, and a certain amount of “on-the-job training”. There’s no substitute for experience in health and community development, although having some background before you’re thrown into it is certainly helpful.

At some point – earlier is usually better than later, and from the beginning is often best – local people have to be directly involved in planning and carrying out strategies for improving their situation. Taking on responsibility and leadership positions builds both a sense of efficacy and connectedness in the local population, and also puts their future where it belongs – in their own hands.

• Health and development efforts should involve collaborative partners as catalysts for change. (Partners must convene conversations that lead to addressing the issue, broker relationships, and develop resources for those doing the work of changing communities and systems.)

Partners can be NGOs or community health or development organizations, government agencies, corporations, academic institutions, faith communities – any party that is generally respected, has some clout, and can function as an honest broker.

As is perhaps obvious from the discussion directly above, an important goal of addressing social determinants is strengthening the ability of the community to sustain the changes that an intervention brings about. If a population is malnourished, giving them food is only a temporary solution: helping them to develop self-sufficient and sustainable farming practices, or training them for necessary and available work, on the other hand, can be permanent ones.

Another important goal is to take on tasks that can actually be accomplished. A local entrepreneur, owner of a large and flourishing tire business, a real estate development firm, and several other successful ventures, was asked how he got to the position he was in. His answer was simple: “Crawl, walk, run.” He started small, with something he knew he could handle. When he succeeded at that, he used it as a base to take on something a bit more challenging, consolidated his gains again when he succeeded at that, and just kept going.

Social change often works the same way. Success breeds success, and you’re far more likely to be successful if you attempt something that’s challenging but doable. Once you accomplish it, you have a foundation from which to address the next issue, or the next level of issues. Communities never lack the most important resource – people, and their intelligence and determination – but they may lack the material resources that allow them to attempt overall social change – change that entails addressing several social factors and levels of power – all at once. They can do it, however, if they take it one step at a time.

The last bit of how-to in this section will be familiar to regular Tool Box users. You have to keep taking that one step at a time again and again and again for as far into the future as you want your community to exist. Addressing social determinants of health and development isn’t a one-time thing. People have to maintain their gains and their healthy practices, and teach the next generation what they’ve learned about creating a healthy community, so that it will continue to be one.

In Summary

“Social determinants” of health and development issues are the social factors that determine or influence the issues. Most fall into the three categories of economic inequality, social connectedness, and sense of efficacy. By understanding and addressing these social factors, you can increase your chances of resolving issues over the long term by getting at their root causes.

It makes sense to use a participatory approach to analyze and address social determinants of health and development issues. By including those who know the history and context of the issue, and by subjecting it to analysis from many minds and perspectives, you’re more likely to arrive at a thorough understanding of it. This kind of analysis is especially effective when it’s clear that simply putting a Band-Aid on the symptoms of the issue isn’t enough, and that you have to employ a long-term strategy in order to address it effectively. Such a strategy may incorporate advocacy for a change in law or policy and leadership training, as well as community-based actions.

A community assessment will help you understand what the social determinants are in a particular case. By asking the right questions to determine community reality – Who is affected and how? What are the patterns in who is affected, who is opposed to action, what are the interests at stake? What are the costs of action and inaction, and who will pay them? – and talking to those affected and others who may already know what the social determinants are in the situation, you can create a complete picture of the issue.

Using that picture, you can address the social factors in order to reduce the population’s exposure to, vulnerability to, and consequences from the issue at hand. The best approach is usually through environmental and policy conditions, rather than through attempting to change social factors – which can be far-reaching and ingrained in the culture of the society – all at once. Work toward incremental, sustainable change, help local people learn the skills to take over and continue the effort themselves, and make sure the effort continues indefinitely, and you’ll ultimately be successful in developing a healthy community.