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Section 17. Addressing Social Determinants of Health in Your Community

Example #1: Creating Healthy Child Development at the Mitumba Informal Settlement, Nairobi, Kenya

Mary Amuyunzu- Nyamongo, African Institute for Health and Development

Urban informal settlements, more commonly referred to as “slums,” are home to almost one billion people globally, including one-third of those living in cities in developing regions. Such settlements provide some of the harshest conditions found in any collective living arrangement due to overcrowding, poor sanitation, and minimal access to essential resources. These conditions also result in stigmatization, social isolation, and discrimination. In Africa, people in urban settlements experience more morbidity and mortality than rural residents and have less access to health services. Children are hit hardest by these conditions, with under-five mortality 35% higher among children in Nairobi settlements than among children in rural Kenya.

Mitumba, a Kiswahili term meaning “second hand” or “used,” is a Nairobi settlement of approximately 18,000 people established in 1992. Mitumba is smaller than other Nairobi settlements and consequently has received little attention or support from governmental or other organizations. In 2006, the African Institute for Health & Development (AIHD), with support from the U.S. Centers for Disease Control and Prevention, established a partnership with residents of Mitumba to undertake a pilot project to promote healthy child development. AIHD is a Nairobi-based non-governmental organization (NGO) with multidisciplinary staff including anthropologists, sociologists, economists, and education specialists established in 2004 to conduct research, training, and advocacy on health and development issues.

The goal of the Mitumba project is to facilitate empowerment processes with mothers of under-five children to improve health; these include increased access to health information, safety, and early child development opportunities. The project follows general principles of community-based participatory research (CBPR), fully engaging mothers of under-five children, community health workers, and community leaders throughout the entire project period. CBPR goes beyond simply educating people, which usually involves interventions imposed on communities by outsiders, to an approach inspired by the Brazilian community organizer Paulo Freire. In his 1968 work, Pedagogy of the Oppressed, Freire describes a process which actively involves community members and organizations in developing the capacity to improve their own political and economic circumstances, as well as their health and well-being. Communities are encouraged to take control of their situations and to collectively improve them through cycles of planning, action, and evaluative reflection. The rationale here is that the beneficiaries must drive the improvement and promotion of their own health with effective and sustainable strategies if significant long-term change is to take place.

To help all residents and AIHD gain clarity about living conditions in Mitumba, a 10-day social mapping project was conducted with youth and adults to understand community resources and boundaries. Mothers took part in surveys and focus group discussions to identify community conditions and norms affecting maternal and child health. In interviews, key informants provided insight into community issues and challenges. Participatory processes informed the design of the questionnaires as well as efforts to assure respondents of confidentiality.

The findings revealed that Mitumba has three narrow roads passable by car during non-rainy seasons, six narrow paths for foot traffic, four churches, one school, and no health facilities. Housing structures are small and crowded: in 68% of the households, 3 to 5 people share a single 10' _ 10' room for both cooking and sleeping; only occasionally does the living space include a toilet. Most houses are made of metal sheeting and plastic, and have dirt floors. Water, available from community taps, is purchased at high prices and is mostly unclean because the vendors who supply the water use low quality pipes. Toilets, constructed by landlords, are shared by large numbers of people, poorly maintained, and often full. Children are not allowed to use them because of these conditions and because the holes are too big, creating safety concerns. Consequently, most children eliminate their waste on the open ground, causing serious sanitation problems. The sole community school in Mitumba has six classrooms, none of which has doors, windows, desks or books. The nearby city council school does not accept children from settlements. Some children attend private schools but most families cannot afford the fees.

Some 65% of the mothers in Mitumba have received primary education and 35% a secondary education. Most residents engage in casual labor in industrial areas or construction sites. Women work in nearby wealthy households, although more than half were unemployed at the time of the baseline study. Poor economic conditions limit access to safe, affordable child care when mothers work or run errands. Young children (0–3 years) are usually left with neighbors who are not obligated to feed or clean them; older children (3–5 years) are usually left outside of the locked house. Children are often seen looking for food, loitering around neighboring houses, or sleeping on the ground when their mothers are away. Mothers reported that the major concerns facing young children include lack of food (20%) and diseases (42%), including malaria, respiratory infections, and diarrhea and vomiting. Due to lack of access to health services and limited economic resources, mothers stated that when their children are sick they frequently rely on chemists (pharmacies) and drug vendors who often sell inadequate or inappropriate remedies. Thus, 20% of households reported at least one child having died.

With this information, organizers held a consensus-building forum with mothers to identify and prioritize their needs and to enable them to think of homegrown, practical approaches they could adopt and implement without stretching their scarce resources. The community decided upon three initiatives: establishing a day care center (the core project), soliciting support for the community school, and working with youth to enhance their ongoing activities and to open new horizons for them. Together, these initiatives support the overall goal of improved child health while also increasing skills and capacities among various groups in the community.

For example, the mothers stated that they wanted their children nurtured in a home environment staffed by older mothers with experience and training in child care and development. They identified two such mothers from the community, potential locations, and determined how much they could afford per child. The community members and AIHD jointly planned the intervention. They included a signed memorandum of understanding that defined roles and responsibilities for each group, in order to develop commitment and to safeguard against potential misunderstandings. They constructed the day care by refurbishing and expanding an existing facility.

The floors were cemented, fences added, and walls painted with bright colors and murals of story book characters. Fifteen mothers attended a training session to learn how to make toys and other items needed for the center. Additional sessions focused on nutrition, developmental needs and health and safety issues. Within a few weeks, the day care center reached full capacity, with 20 children, and the partnership began discussing the development of additional centers.

Additional Activities

Community members also stressed the importance of education for the growth of individuals, communities, and the nation at large. Current educational conditions in Mitumba make it difficult for the children to learn and thus fully participate in the world. During meetings with community members, the school chairman, and teachers, the partnership identified the need to: construct a fence around the school to ensure safety; obtain access to desks, textbooks, and writing materials; secure windows and doors; and pipe water in for personal hygiene and food preparation. The group developed a proposal to seek city council sponsorship.

Another serious problem in Mitumba is the lack of employment for youth which contributes to alcoholism, drug abuse, prostitution, and single parenthood. Using an approach similar to that adopted by the mothers, a partnership was established with

Tuff Gong, a community youth group in existence since 2004 that has been involved in environmental cleanliness, HIV and AIDS education, and football activities. Members started monthly cleanups but no longer have the equipment necessary to continue, and the partnership is seeking funds to support their activities. Evaluation activities for the pilot phase of the Mitumba project include review of the registers used to record implementation activities, before and after photography, periodic informal discussions with the community members, and end-of-project surveys.

 

(Lightly edited from “Community Interventions on Social Determinants of Health: Focusing the Evidence,” by Marilyn Metzler, Mary Amuyunzu-Nyamongo, Alok Mukhopadhyay, and Ligia de Salazar. In McQueen, D and C. Jones C, editors. Global Perspectives on Health Promotion Effectiveness. New York: Springer, 2007.)

Example #2: Addressing Social Determinants of Health in Baltimore

Baltimore Health Commissioner Leana Wen tells how the city is improving community health by addressing the underlying social determinants of health.

 

Example #3: Rolling Hills Apartments: Weaving Together Opportunities for Healthier Lives for a Diverse Immigrant Community

Photo of Rolling Hills Apartments

Twin Cities LISC, a local community development financial institution, has partnered with local organizations and city agencies to create quality affordable housing with improved healthcare access, including constructing a Federally Qualified Health Center. LISC also employed community health advocates to weave together the isolated health-related efforts in the neighborhood of focus into a cohesive health agenda. More specifically, they connect and help support existing efforts, identify and help address gaps, and facilitate the conversations and activities that sustain collaboration.

Learn how social determinants of health are being addressed to build healthier lives for immigrants in St. Paul, Minnesota in this Community Close-Up from the Building Healthy Places Network.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #4: Community Development 2.0—Collective Impact Focuses a Neighborhood Strategy for Health

The East Bay Asian Local Development Corporation (EBALDC) has built health into its strategic plan, and in the neighborhood revitalization work of The San Pablo Collaborative (SPARC), convened by EBALDC, health is the first priority. The San Pablo Area Revitalization Corridor neighborhood that stretches between downtown Oakland and Emeryville is considered to be one of the poorest and most disadvantaged areas of Oakland, California. Life expectancy in this area is up to 20 years lower than the neighboring area, Oakland Hills. SPARC works tirelessly to address the physical, social and economic factors-“social determinants”- that shape residents’ health in the San Pablo Avenue Corridor. SPARC partners work collectively in order to create an overall healthier environment for residents throughout the neighborhood. The California Hotel has been successfully preserved as affordable housing and a grocery store has been brought to this long abandoned neighborhood.

Learn how social determinants of health are being addressed to build healthier lives for the most disadvantaged areas of Oakland, California in this Community Close-Up from the Building Healthy Places Network.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #5: Community Health and Literacy Center, South Philadelphia, PA: A Hospital Partners with a City to Develop a Health, Literacy and Recreation Hub

Photo of South Philly Community Health and Literacy Center

Learn how social determinants of health are being addressed to build healthier lives by building a new, shared facility that would better serve the diverse residents of South Philly in this Community Close-Up from the Building Healthy Places Network.

 

Example #6: Columbia Parc at the Bayou District-New Orleans, LA: Holistic Redevelopment to Bring Lasting Change to a Distressed Neighborhood

Image of Columbia Park at the Bayou.

Learn how social determinants of health are being addressed to build healthier lives, where mixed income housing, new schools, and a sustaining economic anchor completely transformed a once-struggling neighborhood in post-Katrina New Orleans in this Community Close-Up from the Building Healthy Places Network.

 

Example #7: Mobilizing to Overcome the ‘Geography of Inequality’ in St. Louis: For the Sake of All

In St. Louis, being born in zip code 63105 or zip code 63106 can make all the difference in the path your life takes, including how long you live. That was one of the main findings from the For Sake of All project report released in May 2014. What it highlights is deep structural and systemic changes that need to happen. Learn more about this initiative, and view GIS maps they created to better understand and communicate disparities in place here.

For the Sake of It All logo.

 

Example #8: The Brandywine Center: In Pennsylvania, Wealthy County’s Poorer Residents Get A Healthy Place To Live

Although Chester County, Pennsylvania, has been considered one of the richest counties in the country, seven percent of its half-million residents live in poverty. Coatesville, a city of 13,000 people, is one such low-income pocket. To combat this problem, the Brandywine Health Foundation (BHF) constructed the Brandywine Center, a community hub. The four-story building houses health and dental services on the first floor, behavioral care on the fourth, and 24 units of affordable senior housing on the two middle floors. The BHF is committed to working toward both improved neighborhood conditions and improved health in this low-income community.

Photo of Brandywine Center.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #9: Community Health And Literacy Center: A Health, Literacy & Recreation Hub

The Community Health and Literacy Center, formed out of a collaboration between the Children’s Hospital of Philadelphia (CHOP) and the City as unexpected partners, worked together to bring a neglected neighborhood both improved access to health care and health, promoting recreation and literacy opportunities.

The center, which opened in the spring of 2016, is a first-of-its-kind hospital-city partnership. The project includes a CHOP pediatric clinic; a full-service community health center run by the city’s department of public health; a branch of the Free Library of Philadelphia; and a modern recreation center with a playground and green space, run by the city’s Department of Parks and Recreation. It offers welcoming outdoor space for the neighborhood and an indoor community meeting space. The location has excellent public transit access, with a subway stop on site. CHOP and the city are working to integrate services and programming as a way to have more of an impact on improving population health.

Photo of proposed community center.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #10: Vita Health & Wellness District: Health at the Center of a Neighborhood Transformation

The Vita Health & Wellness District project was established through a partnership between the Stamford housing authority and Stamford hospital to revitalize an impoverished inner city area, in Stamford Connecticut, into a mixed-income community with expanded neighborhood services centered around a sustainable urban farm. Addressing the social determinants of health provide a framework for managing the neighborhood transformation in ways that would support and strengthen the existing community.

The Vita project is a great example of how a hospital can fulfill the Affordable Care Act’s mandate to engage its community by partnering to address the social determinants of health. The project also demonstrates how a forward-thinking community development organization can effectively partner with the health sector to pursue comprehensive community revitalization that could not have been achieved otherwise. These are still early days in what promises to be a fruitful and long-lasting partnership.

Image of the community gardening.

Read more about the Vita Health & Wellness District project on the Building Healthy Places Network blog.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #11: Revitalizing People and Place with a Healthy Food Hub Origin

Photo of woman in grocery store.

Following the devastation of Hurricane Katrina in New Orleans, the founders of what became Broad Community Connections (BCC) began to attend community meetings, and investigate with their fellow community members how to rebuild a city in disarray. These discussions highlighted many of the problems that many central New Orleans resident had faced even before the storm, including but not limited to economic disadvantage, community disinvestment, health disparities, and lack of access to many needed goods and services. BCC was designed to revitalize Broad Street, a commercial thoroughfare running through the heart of the city and to connect several of the central city neighborhoods.

Founded in 2008, BCC set its sights on improving health and improving economic vitality in the area. Ultimately, the ReFresh project provided a high-quality grocery store to a low-income food desert and created a multi-faceted hub to improve healthy food access and local food systems, foster community connectivity, support youth development, and anchor economic development.

Read more about the ReFresh project in New Orleans on the Building Healthy Places Network blog.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #12: Under One Roof: Health Care and Social Services in the Same Place

The Chicanos Por La Causa (CPLC) is the largest community development corporation based in Arizona. CPLC is committed to building stronger, healthier communities as a lead advocate, coalition builder, and direct service provider. CPLC helps more than 200,000 people through programs in four areas–housing, economic development, education, and health and human services. CPLC recognizes that the needs of the families it serves are complex as a family rarely approaches the CDC with only one need. As a result, CPLC sought to establish cross-sector partnerships that would more effectively and holistically meet the needs of families.

Read more about CPLC on Rooflines - The Shelterforce Blog, from the National Housing Institute.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #13: Boston Children’s Hospital Community Asthma Initiative

The Community Asthma Initiative (CAI), an initiative of Boston Children’s Hospital, began addressing health disparities in Boston neighborhoods impacted by asthma in 2005. CAI provides an enhanced model of care, which includes asthma education and home visits for families with children ages 2–18 living in the Greater Boston area that were previously treated in the Emergency Department (ED) or hospitalized as a result of asthma. CAI works with partners and coalitions to address asthma health disparities by implementing changes in policies at the local and state levels. As of June 2014 there were reductions in the number of children with ED visits, hospitalizations, missed school days, and missed work days for parents.

Read more about the Community Asthma Initiative from the National Forum on Hospitals, Health Systems & Population Health.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #14: Columbia Gorge Hears From Everyone on Health: A Deeper Look

The Columbia Gorge is a vast rural area characterized by extremes. Near the coffeehouses and boutiques of affluent neighborhoods are remote towns in which residents live in poverty and the nearest doctor’s office may be an hour away. To combat these disparities, the governor of Oregon signed into law a new system for managing federal dollars for the medical needs of low-income residents by dividing and creating action plans for each of the 16 divisions of Oregon, ultimately shaping policy and improving health.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #15: Louisville’s Focus on Health Equity: A Deeper Look

In Louisville generational disparities are caused by many other systemic issues besides proximity to health care services including education, employment, air quality, housing, access to healthy food and various resources, etc. The city’s efforts in aiming to right historical wrongs and improve the lives of many Louisville families led the Louisville to be recognized as an RWJF Culture of Health Prize winner. Members from all of Louisville’s sectors including but not limited to the arts, business, health, education, law enforcement and social service have come together to lessen health disparities and neighborhood violence and to make the city’s health resources accessible to everyone.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #16: Manchester’s Weaving Health into the Community’s Fabric: A Deeper Look

Manchester’s community leaders are facing a very tough challenge: Restoring health and well-being throughout Manchester’s neighborhoods, which are plagued by poverty, violence, homelessness and the effects of the opioid epidemic that has brought negative attention to Manchester and other nearby cities. Manchester’s health promotion efforts focus on the creation and restoration of communities with an emphasis on strong support networks.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #17: Miami’s Goal of Health for All: A Deeper Look

Miami is facing pressing social and health risks, as 20% of Dade County’s residents live below the federal poverty line, including 1 in 3 children. Over 30% of the population is uninsured, 60% of adults are overweight or obese, and many neighborhoods lack access to affordable healthy food or safe parks. In 2003 the Consortium for a Healthier Miami-Dade County was formed to improve the overall health of the county. The consortium partnered with 160 organizations to focus on and target factors that impact health.

Contributed by Lia Thompson, University of Kansas, Community Tool Box Intern.

 

Example #18: Use of Photovoice by the Roma Community in Seville, Spain

In this interview with Daniela Miranda, doctoral student at the Universidad de Sevilla, we learn about the use of Photovoice among a disenfranchised, marginalized group of Roma neighbors in Seville, Spain. The Roma community comprises the largest ethnic minority in Spain and Europe. The Roma community experiences disproportionate social marginalization and discrimination manifested in high unemployment rates and poor health outcomes. The Roma neighbors used photos as a tool for action to help them communicate poor living conditions.