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Section 17. Addressing Social Determinants of Health in Your Community

Learn about how to address social determinants of health in your community initiative.



What broader factors determine whether people in a community are healthy? What accounts for differences in health outcomes among people in different groups, communities, and countries?

The health of a community – and its people – is dependent on a number of social, political, economic, and environmental conditions.

Social determinants of health refer to access to power, money, and resources and the conditions of daily life that affect health and well being for groups of people (Solar, Irwin, WHO 2010). These conditions support or limit the health of a community or a population. Health disparities or inequalities occur when there are differences in conditions—where people are born, live, work, and play—across different groups. For instance, racial/ethnic minorities experience poorer health when they are more:

  • exposed to hazards through poor housing and working conditions
  • vulnerable due to poor education and limited resources
  • likely to have adverse consequences due to lack of adequate services


In 2008, the Commission on Social Determinants of Health published its final report, Closing the Gap: Health Equity Through Action on the Social Determinants of Health. The report reminds us: “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… Achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it.”

Throughout the world, there are efforts to address social determinants of health. For instance, in the United States, the health objectives for the nation include the goal of create social and physical environments that promote good health for all by addressing social determinants of health (Healthy People, 2020). Globally, the Rio Political Declaration on Social Determinants (2011) reaffirmed the global commitment to take action on social determinants of health. Key action areas include improving governance, community participation, attention to health inequities, and monitoring progress.

To achieve this vision will require a whole community approach in which different sectors—health, education, housing, labor, justice, transportation, agriculture, and the environment—all work together to assure conditions for health. To be successful, this approach requires changes at the levels of individuals, relationships, communities, and broader systems. It requires environmental, economic, and policy strategies along with individual behavioral change and health services. The approach also requires developing partnerships among different groups including public health, community organizations, education, government, business, and civil society.

Health equity and health disparities. A basic principle of public health is that all people have a right to health. Health disparities refer to differences in the existence and frequency of health conditions and health status among groups. Most health disparities affect groups that have been marginalized or excluded 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 that support health and well being; for instance, healthy food, good housing, good education, safe neighborhoods, and freedom from racism and other forms of discrimination. Health disparities are referred to as health inequities when they are the result of the systematic and unjust distribution of these critical conditions.

Health inequities are “avoidable inequalities in health between groups of people within countries and between countries” (World Health Organization, 2010). Health equity, then, 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.”

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What do we mean by developing an initiative to address social determinants of health?

Many communities embark on initiatives aimed at improving the health of citizens. Generally, they are intended to change individual behavior by offering opportunities and information that make it easier for people to quit smoking, get more exercise, eat healthier foods, or obtain health screenings for various diseases. Although these efforts can certainly lead to good outcomes, they often don’t address the social determinants that are at least partially responsible for positive or negative health conditions.

In this section, we’re presenting ideas from a report of the U.S. Centers for Disease Control and Prevention on how to assess and address important social determinants of health in your community. The model promotes inclusiveness, community participation, careful assessment and planning, implementation, evaluation, and maintenance of effort. In other words, it is in many ways similar to the other models for community health and development in this chapter. The major difference is that it suggests how to influence health and health-related issues by addressing their social determinants.

This model also aims to promote health equity, since that is the ultimate goal. In most communities and most societies, some people have better access to health care and health resources and live in healthier environments than others. As a result, they are generally healthier and longer-lived than those with fewer advantages. In many cases, these differences are caused, at least partially, by social conditions – income, education, discrimination, politics, and geography – rather than by genes or luck.

When conditions for health are unequal, these are health inequalities. When these conditions are unjustly distributed, the result is health inequity. By effectively addressing the social determinants of health, we can create a healthier community, and improve the quality of life for all.

Why develop a social determinants of health initiative in your community?

  • Such initiatives use a participatory process that involves all sectors of the community. Involvement by individuals, groups, and organizations from all backgrounds and sectors of the community leads to community ownership. When affected groups are involved in the planning, implementation, and evaluation, the effort can best meet the needs of the community.
  • Aiming at social determinants gets at the root causes of inequity. Social determinants, such as income inequality, underlie many different problems in health and development. You can address their results, but unless you address the determinants directly, your effort isn’t likely to have long-term effects.
  • A social determinants effort addresses social change through the development of greater equity. Greater equity in societies has been shown to lead to longer life expectancy for everyone, and makes for greater peace and stability by lessening resentment and strengthening social ties.
  • It helps create community partnerships that can endure, and be directed to other issues as well. The base of community collaboration and leadership that’s built through this effort can carry over to build community resources and address other concerns.
  • A social determinants effort uses the knowledge of those most affected, as well as that of others in the community. It takes advantage of the accumulated wisdom of the community.
  • Such an effort educates the community about health inequity and its consequences. Many citizens, even some in the partnership that coordinate the effort, may not be aware of the level and consequences of health inequity in the community. By drawing attention to and explaining these issues, the initiative can help the community to understand and deal with them whenever and in whatever forms they arise.
  • As a result, a social determinants initiative can help to create a fairer, more equitable community that deals with discrimination and other equity issues. Once the community understands social determinants and the results of inequity, and sees how dealing with these factors can improve the quality of life, it may be more willing to address persistent barriers to equity, such as discrimination, that it has been unable of or unwilling to address before.
  • A participatory effort can build new community leadership. By including in the partnership people who might not normally be in such a position, the effort can encourage new leadership, and prepare the community to continue efforts into the next generation.


How to take action to address social determinants of health

The link between social determinants of health -- including social, economic, and environmental conditions -- and health outcomes is widely recognized in public health. It is increasingly understood that inequitable distribution of these conditions across various populations is a significant contributor to widespread and persistent health disparities.

So... you understand social determinants of health (SDOH) and their relationship to health outcomes and health equity. And you see ways that social determinants can be changed in your community to improve health and the quality of life for everyone. How do you go about making those changes?

What follows is step-by-step guidance for implementing an initiative to do just that. Be aware that these steps are only a guideline. All communities are different, and what works well in one might not work in another. Although these steps are arranged in the order they might logically be taken, in some cases it might make more sense to change the order, or to act on more than one step at a time.

Some parts of the guideline are important in all cases, however. The formation of a partnership that incorporates people from all sectors of the community – particularly those who experience inequity in health and other areas – is crucial if the process is to lead to long-term social change. Focusing on SDOH, as well as careful planning and evaluation are also necessary.

Perhaps most important is maintaining and building on successes. Too many initiatives founder after their initial success because everyone thinks the problem is solved, and that the changes will ride on their own momentum indefinitely. A neglected house will eventually fall down, and a neglected initiative will do the same, only much more quickly. With that caution in mind, let’s get to work.

The Figure below (from the CDC Report) outlines seven phases and related steps in addressing social determinants of health in your community. By clicking on the phase, you can skip to ideas and resources for implementing related steps.


Figure: CDC Phases of a Social Determinants of Health Initiative

CDC Phases of a Social Determinants of Health Initiative chart


Phase 1: Create or Enhance Your Partnership

The foundation for a successful initiative is the development of a multi-sector partnership. This alliance is responsible for conceiving, planning, implementing, evaluating, and maintaining the effort over time. A partnership is an intentional relationship between two or more parties (individuals, groups, or organizations) committed to pursuing an agenda or goal of mutual benefit. It is essential to build partnerships to address social determinants of health because no one group, whether health care providers, public health practitioners, community organizations, or community members, can accomplish the many tasks required for changing social, economic, and environmental conditions that affects health. Partnerships are necessary to:

  • Increase understanding of a community’s needs and assets.
  • Improve public policies and health systems.
  • Engage new issues without having sole responsibility for addressing them.
  • Develop widespread public support for issues or actions.
  • Share or develop the necessary resources for taking action and problem solving.
  • Minimize duplication of effort and services.
  • Recruit participants from diverse backgrounds and with diverse experiences.
  • Promote community-wide change through multiple approaches.
  • Gaining community members’ trust in a broad-based coalition of partners.

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. You may choose to work within existing partnerships that have helpful knowledge and experience. Existing groups, however, 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.

Listening to the voices of people and organizations in the community who experience inequitable distribution of resources can help to build a strong partnership to address social determinants. This can be strengthened by ties to diverse groups in your community and involvement of relevant sectors of your community (e.g., government, education, business, public services, faith, funding agencies). To identify who should be involved, it helps to consider how your community is defined.

Define your community. A community is essentially a group of people who have something in common and who see themselves, or are seen by others, as part of that group. It’s most often thought of as a geographic area – a neighborhood, a town, a city, or a village, for example. Shared experience can also define a community including:

  • Socio-economic status or class. This affects people’s efficacy or ability to have influence in their environment.
  • Employment, trade or profession. Some jobs may expose workers to unhealthy conditions that lead to community health issues.
  • Ethnicity or race. Patterns of discrimination are often directed toward particular groups.
  • Culture. This may be related to geography, racial or ethnic heritage, or religion. It involves a particular way of seeing the world, and, often, particular practices that go with that view.
  • Particular groups, such as women, who may be socially excluded from equal access to resources and opportunity.

Once you’ve clarified the physical and/or social boundaries of the community you’re working with, it will be easier to determine who from that community needs to be involved.

Determine who should be included in the partnership. Start with those who are obvious and/or who have the largest networks, and ask them to help you identify others. Be sure that your initial group is diverse enough, and that you have enough knowledge of the community, so that no one will be left out and resentful. Some people you ask may choose not to participate, and some groups may go unrepresented no matter how hard you try, but it’s important to make a serious and sincere effort to involve everyone.

Those who might be included, depending on the initiative, are:

  • Those directly affected by health disparities and inequity and its social determinants.
  • Local government officials, including those concerned with health and well being.
  • Health workers and organizations (e.g., those in hospitals, clinics).
  • Human service organizations, especially those that serve the population of concern.
  • The business community.
  • Environmental groups or agencies.
  • Community advocates and advocacy organizations.
  • Educators at all levels.
  • Faith communities.
  • Funding agencies and foundations.
  • Interested individuals, particularly those who might have needed experience, skills, or relationships.

The people and groups identified should reflect the diversity of the community, including gender, race, ethnicity, age, income, sexual preference, and other dimensions of social exclusion.

Contact potential partners and convince them to participate. Once you’ve identified some of the individuals and groups needed to make up the partnership, you have to recruit them. In general, the best way to do this is personally, face to face. For individuals, that may mean sharing a meal together or meeting with several people in a group. For larger groups and organizations, talking to a regular gathering of the board and/or staff might be the best approach, perhaps after meeting with the director or board chair. As you bring people on board, you can ask them to recruit others that they know.

In general, people are more likely to respond to those whom they know and trust. If you can engage a few particularly respected individuals, others will become interested because they trust those people’s judgment. Once you’ve signed up a core group, it’s more likely that the rest of the members will fall into place.

Choose a facilitator. Your partnership will need someone to run meetings, help to resolve conflicts, and generally hold things together. This could be a partnership member or, if the partnership has the resources and the need, someone hired from outside the community. In either case, it should probably be someone who is seen as neutral (having no bias toward or against one group or another), fair, ethical, open to new ideas, and flexible. The facilitator might be only that, or might be seen, both within and outside the partnership, as the leader of the initiative. If so, that person should be collaborative, encouraging and safeguarding the partnership’s participatory process, and facilitating problem solving.

Establish guiding principles for the partnership. What are the principles the partnership is firmly committed to, regardless of what the initiative chooses to address and how it chooses to address it? A collaborative process? Treating every person and idea respectfully, even when there’s disagreement? A focus on social determinants? The basic principles, if they’re worked out and recorded at the beginning, will make the work easier down the road. They’ll provide the foundation for the vision and mission statements that come later, and they’ll also provide the framework within which the partnership will operate, reminding members what they’re there for, and structuring how they treat one another. Guiding principles provide security for partnership members: the principles show that they’re all on the same track, and that no one will be abused or disadvantaged by the process. (See Tool #1 below for examples of guiding principles.)

Phase 2: Focus Your Partnership on Social Determinants

This step is about assessing community resources and challenges. If the purpose of an assessment is to identify a particular health condition and treat it, the assessment will take a different shape than it will if its focus is to identify the social determinants underlying that condition. An assessment that emphasizes social determinants will prepare the partnership to make changes that aim at the root causes of the condition, and thereby diminish or eliminate it.

Assess social determinants. Your first decision here is to consider what you want to assess. You have a choice in how to approach your assessment:

  • You may start with disparities in health, such as high rates of infant mortality among some groups, and try to determine what social determinants influence them.
  • You may start with major social determinants, such as income inequality or education levels, and consider how they affect health.

Remember that social determinants can have either positive or negative effects on health. Discrimination and poverty generally have negative effects; by contrast, a healthy environment and good educational opportunities usually have a positive influence. You may choose to address social determinants by eliminating (moderating) negative factors or by increasing (strengthening) positive factors.

Identifying social determinants is an exercise in critical thinking. What are the real conditions or issues that influence health in the community? Are there of environmental health threats, and, if so, whom do they most affect? Why? Are the adverse affects concentrated in geographic areas, and, if so, how did that come to happen? (Are more low-income people exposed to environmental health threats because polluting industries are intentionally located in low-income areas, for example?) Are there economic and political factors that influence those conditions or issues? (E.g., Does a polluting industry – a coal mine, a paper mill – also provide many of the jobs in the community?)

There is rarely a simple casual relationship between particular social determinants, such as inequality and social exclusion, and particular health issues. It can take some detective work and very careful analysis to determine the multiple and inter-related contributors to a health or social problem.


  • Survey community partners and others to determine concerns, needs and resources in the community. If you’ve assembled a truly representative group, partnership members and the networks they’re connected to should be the best sources of information about the real concerns of the community. They may interpret health much more broadly than public health officials or medical professionals do; for instance, as related to poor economic conditions and housing. They may also have knowledge of assets and resources that aren’t immediately apparent to those from outside the community or neighborhood.
  • Think about the types of information that will be useful for understanding your community. A combination of the many available information sources may provide the most nearly 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. To the extent possible, it may be useful to examine community-level indicators (e.g., infant mortality, injuries) data by race, income, or other characteristics to better understand how social determinants could be influencing health disparities in your community. Some examples: the National Health and Nutrition Examination Survey data (NHANES), National Health Interview Survey data (NHIS), and National Vital Statistics System data (NVSS).
    • 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) and Community Health Status Indicators (CHSI).
    • 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 area). Multiple useful resources are available on the Web; for instance, Data Set Directory of Social Determinants of Health at the Local Level, as well as through the U.S. Census.

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 cardiovascular diseases and diabetes (and obesity) and lower rates of fruit and vegetable consumption in areas with fewer grocery stores. These findings might lead your partners to consider developing farmer’ markets and access to fresh fruits and vegetables through community markets.

  • Determine what information you need to collect to better understand your community.
    • Review of existing data sources. Public records and archival data – census figures, data from public health and other research studies, community reports, housing authority data, welfare records, employment records, etc. This category also includes information related to laws, regulations, local bylaws, budget data, and other such information.
    • Surveys and results of previous surveys.
    • Brainstorming with the partnership and community groups.
    • Qualitative interviews and focus groups. Individual and group interviews with community residents, giving their subjective answers to a series of carefully thought out, open-ended questions about the community.
    • PhotoVoice. An audio and photographic view of the community by members of the population of concern.
    • Community observations and audits. Observing various aspects or areas of the community is a way to understand community members’ lives and the circumstances in which they live them, as well as how they interact with one another. Community audits are formal observations of how well various services are working and how responsive government and other sectors are to community needs.
    • Concept mapping. This is a general method that can be used to help individuals or groups to describe their ideas about a topic in a pictorial form.
    • Health Impact Assessment. A Health Impact Assessment (HIA) is a study of the impact on community health of a planned project, development, or action on the part of government or some other party that conducts operations on a large scale – a major corporation, real estate developer, transportation company, etc.
    • Appreciative inquiry. Appreciative inquiry (AI) is a change strategy that identifies existing strengths (rather than problems) in a community, group, or system and then actively builds on these strengths to envision and plan for a desired outcome.

Surveys, interviews, focus groups and other methods give you insight into community members’ perceptions and what they know and think about various conditions and issues. Existing data sources, such as archival records and observation, provide a portrait of the community in its current condition.

  • Develop a work plan for the assessment that identifies tasks to accomplish, partner roles and responsibilities, and a time frame for completion. A work plan should encompass:
    • The information to be collected and the questions you want to answer.
    • Your data-gathering resources. That includes people, expertise and skills, funds (at least some of those people may have to be paid, equipment and supplies may have to be bought), computer time, etc. You may be able to expand your ability to gather data by using help from outside the partnership.
    • How you’ll find the answers to your questions (data sources and data-gathering methods.)
    • Who will examine what data sources.
    • A flexible timeline for reporting back to the partnership.
  • Collect and organize information so it can be shared with all partners, community organizations, and community members. Focus on the data that are most useful to your partnership, and try to organize information in relevant ways – by question, by population, by geographic area, by particular conditions – and present it in appropriate forms – written reports, charts, slide shows – so that it can be understood by everyone, no matter how they learn best. You might want to compare your data and reports with those of other communities.
  • With information gathered and summarized, partners can prioritize issues to address. Deciding on priorities should involve all partners, so that everyone’s concerns are addressed. Some questions to consider:
    • Which social determinants, such as exposure to hazards and stress through poor housing, affect the most people or have the greatest influence in the community? Why?
    • Which determinants seem to influence which conditions? Which affect the largest number of health conditions and social issues?
    • Which have the greatest effect on equity?
    • Which are feasible to address with the resources available? Perhaps you can’t address climate change on a global scale, but you may be able to affect local air pollution or surface temperature, for example.
  • There are four basic principles or lessons learned that others who have conducted community assessments have found helpful in guiding this process:
    • 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.
    • 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 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 program or intervention, and determining a baseline to assess the progress you are making toward achieving your desired outcomes.

Develop a vision and mission. Clear vision and mission statements are crucial to the success of any initiative. It is particularly important for them to be developed through a participatory process, and that you take whatever time is necessary to craft wording that everyone can support. The time taken for this process will be well worth it for its contribution to the cohesion and focus of the partnership.

Your partnership’s vision -- such as “health for all” or “safe and caring communities” -- is what you want the community to look like when everything you hope to accomplish has been achieved.

Your partnership’s mission statement includes the essential “why” (e.g., “Achieving health for all…” and essential “what” (e.g., through policy advocacy and collaborative action”). It is focuses the effort to realize the vision. In simplest terms, your mission statement describes the essential work of your initiative.

Your vision and mission statements should be as short and to the point as possible. They should fit together: carrying out the mission should lead to fulfillment of the vision. (See Chapter 8, Section 2, Proclaiming Your Dream: Developing Vision and Mission Statements.)

Identify and prioritize goals and objectives. An initiative planning model can be very useful as you identify your goals, objectives, and action steps. 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 ultimate 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.

Combined into a model or framework, 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, you may decide to focus on one specific determinant (e.g., housing, racism) within an initiative or specific health outcomes, such as asthma or heart disease, and the social determinants that influence them.

Your goal is the long-term outcome your partnership is striving toward. Objectives are the stops along the road that lead toward that goal. If, for instance, your goal is providing access to healthy food for everyone, an objective might be to persuade at least one merchant in each neighborhood to devote a certain amount more shelf space to affordable fruits and vegetables within the next six months.

In identifying and prioritizing objectives, an important consideration is to set up your partnership for success at the beginning. Early objectives should be challenging enough so that meeting them takes work, but reachable enough so that the chances of success are great. If the first objectives are met, later setbacks won’t feel too difficult to overcome. If the partnership starts off with failure, partners may get discouraged, and the effort could wither.

Phase 3: Build Community Capacity to Address Social Determinants

“Community capacity” refers to the resources, infrastructures, relationships, and operations that enable a community to create change and improvement.

Assess community capacity. Assessing community capacity involves identifying existing community strengths that can be mobilized to address social determinants; those economic and environmental conditions affecting health equity. In general, you should look at the places (e.g., parks, libraries) and organizations where assets are found. These will likely be located in different sectors of the community: education, health care, business, housing, transport, faith-based groups, social services, civic/volunteer groups, local government, and non-governmental organizations. 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, trust).

Build community capacity. Once people and organizations in the community have a common understanding of social determinants, they can work to improve the conditions that affect the health of all its 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 community health efforts. One way to do this is to start with existing social groups such as those in schools, workplaces, 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. These are critical to the meaningful participation of individuals in group projects. Participation of these groups can enhance current and future collaboration.
  • Identify existing social ties and relationships and use them to assure participation of people and organizations. Share information and work to build unity and solidarity among community members most affected and social groups.
  • Identify useful assets of people and organizations in the community. These assets may include experience with the issue and its consequences or the ability to facilitate meetings or mobilize people and efforts. It may involve the ability to provide funding, space, and other necessities for carrying out the project. These may also involve spiritual assets such as compassion.
  • Conduct regular conversations to share information with community members and engage them in making decisions through consensus-based and collaborative processes. Build on existing social networks such as the social ties already found in workplaces, schools, place of worship, cultural organizations. 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 and that they understand its assets and needs. They need to be able to 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.

Phase 4: Select Your Approach to Create Change

Now it’s time to develop interventions to address social determinants of health. These may include programs or policy initiatives intended to move your community closer to your vision. There are a number of approaches you might use. In general, they are complementary; using them in some combination increases the likelihood that changes will lead to the desired goal.

This step describes six approaches or strategies for 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 your situation, what your partnership wants to accomplish, and how well the strategies fit your situation. 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.

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. It can be useful in creating a partnership to increase community-wide support for addressing specific health inequities and their root causes.

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 inequities. It also helps individuals and groups identify specific social determinants or structural factors 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 (e.g., among different ethnic groups) that lessen the ability to create change.

Methods used to raise consciousness typically generate discussion by asking individuals to share their experiences. This can be done in listening sessions presenting hypothetical vignettes or situations. This can be done by 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?”

Community (locality) development. Community development is a set of processes or efforts to create community change at the local level. It involves strengthening social ties, increasing awareness of issues affecting the community, and enhancing community member participation in addressing these issues.

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 all work in this field should be participatory, community development is unique in that those who experience the problem are the leaders in addressing it. Those most affected by health inequity and the social determinants that lead to it are in control of changing the situation. This approach is in accordance with the Ottawa Charter, a 1986 document drafted by the World Health Organization at a meeting in Ottawa, Canada, that lays out the basis for a SDOH approach.

Community development seeks to enhance or establish a group of individuals who work together to create changes in health or the social determinants of health. In community development approaches, capacity building is paramount: the goal is to use the community’s capabilities and strengths to increase community control. As this suggests, the process of community problem solving is seen as the process of health promotion. Building and using existing capacities for problem solving can improve health equity, both directly and indirectly.

This approach may sound similar to community capacity building. But, community development specifically seeks to establish and enhance the power of those most affected by inequity, rather than just creating enhanced community capacity for planning or program implementation.

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. This goes beyond other partnership-building activities described earlier, such as inviting stakeholders, identifying social and health inequities in the community, deciding on a shared vision and mission. This approach may be particularly 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.

In community development efforts, community members lead the initiative. Others, such as public health practitioners, researchers, and community organizers, can assist community members by supporting group processes for problem solving and consensus building. It is important to ensure that the models and processes suggested by outsiders 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 efforts 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 designed by others.

Social action. Social action is an approach that focuses on altering social relationships and/or resources available to address health inequities. 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.

Social action may use a continuum of direct action tactics from requesting accountability to public demonstrations.

Social action can be used to help raise awareness of issues and to increase community participation in efforts to address them. For instance, it can be especially useful at the beginning of change efforts since media attention can help get people’s attention when other approaches have failed. Although this strategy can help define and bring attention to a problem, it does not necessarily identify effective solutions.

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). 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 influence public opinion, it is often useful to organize media coverage of the event and ensure that public officials are aware of it.

Health promotion. Health promotion refers to the process of people working together to create conditions that improve health and well being for all members of the community or prevent illness through changes in environments, lifestyle, and behavior. It 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. 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.

In the Global South where many people live in extreme poverty, health promotion efforts often focus on social determinants. For instance, they may work to assure access to primary education, the availability of clean water, and sanitation, or social protection for the poor.

Within community settings, it is not unusual for organizations and individuals to want to focus on the behavioral determinants of health such as healthy nutrition or physical activity. However, even when the effort focuses on a particular health or risk behavior, it is useful to incorporate program elements that address social determinants. 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 improvement in health outcomes.

Health promotion efforts may attempt to improve health by creating change at the level of individuals, relationships, organizations, community, or society. For example, an intervention aimed at altering individuals’ knowledge, skills, attitudes, or behaviors might include educating community members on the benefits of physical activity. Because the costs of exercise facilities might constitute a barrier for many people, your health promotion effort might address social determinants by working with a local recreational facility to lower fees for those who cannot afford them. Similarly, your efforts to improve healthy nutrition might work with local 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, it is important to:

  • Consider the amount and quality of the existing social ties among individuals and organizations and how new social ties or relationships can be created and supported.
  • Consider the physical or built environment, including:
    • The availability of safe neighborhoods and sidewalks in good repair for walking.
    • Access to affordable recreational facilities such as gyms and soccer fields.
    • Access to grocery stores with affordable fresh fruits and vegetables.
  • Consider the availability of resources (e.g., transportation, jobs, housing, and 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 in the environment.

Media advocacy. Media advocacy refers to the strategic use of print, broadcast, and social media to encourage social, economic, or environmental change. It is an excellent way to reach large populations and capture the attention of decision makers who influence policy. Mass media campaigns reach people through newspapers, radio, television, and other means (e.g., Facebook, Twitter, billboards, posters, brochures). Historically, mass media campaigns in public health have focused on encouraging individual behavior change such as reducing tobacco use or underage drinking. Alternatively, media advocacy can be designed to influence change in norms, policies, and collective responses by the community to inequities.

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 also address broader social, economic, and environmental conditions. This type of media advocacy helps to reframe public health concerns as the result of community rather than individual causes. This can help initiate collective community responses to create change. Media campaigns are most useful when high visibility is desired and public debate or discussion is useful in reframing the issue to focus on broader social change.

Begin planning a media campaign by referring to your partnership’s vision and mission. Decide on the goals and objectives of your media campaign and identify the main audience for the message such as the general public or elected and appointed officials.

Once you have chosen your audience, invite media representatives to become involved with the planning, implementation, and evaluation of your media campaign. In addition, consider the most appropriate media outlet – given your audience – for delivering your message and make sure that a representative of that medium is included in your partnership. 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.

Next, plan your message. Identify the community health 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 and screenings, you may want to direct your media campaign toward local decision makers, health planners, and other influential individuals or organizations in the community. Messages may emphasize increased funding for health screenings, expansion of existing transportation or service routes, improved hours of operation, or other changes assure access to health services in the community.

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 outlets you have chosen.
  • Piggyback onto breaking news by highlighting local stories related to health and social issues.

(See Tool #2 for an outline of how to run a media campaign and references to more detailed Tool Box information.)

Policy and environmental change. Achieving community-level improvement in health and health equity typically requires changes in policies and environmental conditions. This requires 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. Your partnership may focus on changes in policy (e.g., zoning regulations, tax policies, and worksite or school policies) and other conditions that affect health (e.g., equal access to education, employment, recreation facilities, and healthy food).

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, businesses and corporations, 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, or combining state taxes for education and distributing them across districts to assure fair access to public education).

The environment includes physical facilities (e.g., roads, sanitation, schools, parks) and structural and cultural amenities (e.g., benches, streetlights, recycling bins, public art). It also includes the social environment – economic and social conditions. Changing the environment requires informed decision making about urban design, land use, transportation, and political and social systems and their relationships to health outcomes.

Changing policy and/or the environment is useful when you want to promote health and health equity. People and organizations in the community may consider using policy change to affect whole groups of people. Policy changes can be designed to regulate the behavior of individuals (e.g., smoking bans), organizations (e.g., flex-time policies in workplaces), or communities (e.g., housing codes for minimizing exposure to hazards). 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 public plazas with signage communicating the history and culture of the community.

Your partners can be active players in the policy-making process by educating decision makers about how changes to policy or the environment can promote health equity. For example, they can provide current data on health and social determinants, information about existing policies, or examples of policies that have worked well in other communities. They can also help by identifying key decision makers to contact based on their interest in the issue or their position on certain decision-making bodies (e.g., committees, boards).

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). It can help unit voices and actions to create change, and assist local organizations in finding resources and support for their work. 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, early childhood development).

If you’re a tax-exempt U.S. organization receiving government funds, you may be legally constrained from certain kinds of lobbying or political activity. Be sure to find out. You can also get more information from the CDC.

Selecting your approach. Which approach or combination of approaches to addressing social determinants is right for your effort? Here are some factors to consider as you make that decision:

  • 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 change at community or organizational levels.
  • The political and social buy-in of the community.
  • The relative success or failure of similar approaches in the past.

Mold your approach to your situation – your resources, knowledge and experience of partners, community history, etc. Don’t be afraid to modify an approach, or to try something new if you have good reason to think it might work. If you settle on a combination of approaches, think about the advantages and disadvantages of using them at the same time or in sequence – resources needed, one approach paving the way for the next, etc. The important thing is that the group agrees on the best way to proceed.

Document your decision-making process to help 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.

Phase 5: Move to Action

Now it’s time to get moving, by creating and carrying out a plan to reach your goals.

Assemble a planning team. This may include members of the partnership, as well as others recruited for their experience, perspective, special skills, or expertise. Be sure to include people from the groups most affected by the social determinants addressed by the initiative. After the planning group has been organized, it should meet to determine what action steps are necessary. Once these steps have been developed, agree on specific roles and responsibilities for partners and devise a timeline for all action steps. (See Chapter 18, Section 2, Participatory Approaches to Planning Community Intervention.)

Develop your 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. An action plan will help keep you on track toward achieving your goals and tell the community that you’re making progress. Keep in mind, however, that you may need to modify your action plan to meet changing conditions in your community over time. To be effective, an action plan should include the following key elements:

  • Your partnership’s goals and objectives.
  • Who is responsible for which activities.
  • The time frame for completion of activities.
  • How you will assess progress.
  • How you will assess impacts and outcomes.

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 (who will do what) for each action step.
  • Provides a timeline and deadlines for completion of the action steps.
  • Outlines what resources – both existing and needed – will be necessary to successfully implement each action step, including finances, staff, space, and equipment.
  • 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.

Implement your plan. This is it – the point where you actually put all your planning into effect. Some helpful guidelines include:

Coordination is crucial for successful implementation. You can’t do something as complicated as running an initiative without a person or small group keeping track of everything and making sure that the appropriate things get done at the appropriate times.

  • Anticipate challenges; consider how to address them before they happen. Challenges might include:
    • Maintaining effective communication. The effort must assure that partners and other group members are communicating effectively with one another and the community, and that everyone gets both general information about the effort and whatever specific information he or she needs. Because your partnership will likely include groups that do not normally work together, clear and respectful communication is essential. (See Chapter 15, Section 4, Promoting Internal Communication for more on communication.)
    • Dealing with conflict among partnership members – turf issues, jealousy, disputes over funding, differences of opinion about strategy, perceived or real power imbalances, etc. Conflict and power imbalances, if handled well, can lead to enhanced collaboration and understanding about how differences in power can influence health.
    • 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 partners’ unrealistic expectations about the amount of their time the initiative will consume, the timing and magnitude of results, funding that they expect will come their way, etc. (Setting numerous achievable short-term goals can help task-oriented partners deal with the inefficiencies of process related to collaborative action.)
    • Resolving conflicts between partners’ roles in the effort and their obligations to their own organizations – time conflicts, competition for funding or positions, etc.

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. Other problems your partnership may need to address include members’ perception that the partnership threatens their autonomy, disagreement about community needs, and conflicts over funding decisions. Other potential challenges include 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 or mediator.

Phase 6: Document and Share Your Work

From the beginning of your effort, you should also be evaluating your work, both to document it for your partnership, your community, and others who might want to try something similar, and to find out where you need to make changes in order to be as effective as possible. That means you have to keep careful records of everything you do, and of all that happens as part of the initiative.

There are three areas to evaluate:

  • Process. Your initiative most likely used key processes to advance its effort—for instance, assessing community assets and needs, collaborative planning, and implementation of the activities. What did you do to form and run the effort? Did everything go as planned? Were there unintended or unforeseen actions or consequences, and how did they affect the effort?
  • Impact. What did you actually do: that is, how close did you come to meeting your objectives? (Did you serve or have an effect on the number of people you planned for? Did you do what you intended to do – conduct the proposed number of actions, arrange the planned number of media events, make contact with the intended policy makers?)
  • Outcomes. What were the ultimate results of what you did? Did the social determinants you aimed at change in the ways you’d hoped? Did your work bring the community closer to your vision of a healthy community for all?

Evaluate your efforts. Your evaluation should be organized at the very beginning of the initiative, so that you’ll record information about the formation of the partnership and the first stages of planning as they happen. The first step is to formulate evaluation questions that reflect what you want the evaluation to tell you. Then, you should structure the evaluation, using the form, tools, and methods that will best answer the questions you have chosen. An important element is the participatory nature of the evaluation, as well as of the rest of the process. To the extent possible, partners should be involved in formulating evaluation questions, choosing methods, taking part in the evaluation, analyzing the results, determining adjustments to be made, and presenting what you’ve learned to the community.

Some evaluation questions you might want to answer:

  • How well is your partnership working? This is about process. How did you put the partnership together? Were you able to get all the key people, groups, and sectors involved? How well have partners worked together? How good was your communication? What about the partnership has worked well? What were major challenges? Were they overcome, and how? If not, what were the results? How would you deal with them in the future?
  • How has the partnership related to the community? What resources have been helpful? What is still needed?
  • How well has your action plan worked? Did you do what you initially planned? If you made changes along the way, what were they and why did you make them? If there were unintended changes, what caused them? (Common causes are delays in funding or hiring, difficulties in obtaining space, and emergencies that make it difficult or impossible to carry out certain parts of the plan, such as a key person falling ill.)
  • Are your partners making progress toward their goals (outcome evaluation) and objectives (impact evaluation)? Review records, meeting minutes, etc. to document what people actually did to make things happen.
  • If you were starting this whole process over, what would you do differently?
  • What were the intended consequences of your actions?
  • What were the unintended consequences (positive or negative)?

Link your evaluation to your community assessment and action plan. This may seem obvious, but it is sometimes difficult to remember that all of these elements of the initiative should fit together. Your action plan should address issues and their social determinants identified by your community assessment, and your evaluation should tell you how well it did so. Formulate objectives as milestones along the road to achieving long-term goals, and help partners and community members understand that realizing the overall vision is a long process. Their expectations have to be aimed at attaining milestones, rather than quickly reaching the end of the journey.

Carefully record what you do. This will enable others to reproduce what works in the initiative and know what to expect if they take the same actions you’ve taken.

Share your work. Your initiative should communicate the findings and lessons learned to others in the field. You should share general information with others – for instance, about what was effective and what wasn’t, how your process worked, ways to increase participation, the outcomes, and how long things take to accomplish. Some communication methods you can use include:

  • Newsletters
  • Presentations to the community at large and to various organizations
  • Internet sites, listservs
  • Social media (Facebook, Twitter)
  • Media stories and press conferences
  • Presentations at conferences
  • Informal networks, word of mouth
  • Flyers/brochures

Phase 7: Maintain Momentum

No matter how successful your initial efforts have been, you’re not done yet. To effect real social change, which is, after all, what changing social determinants is about, you have to keep at it for the long term.

Remain flexible and dynamic. Dynamic organizations continually change, both in response to changes in the environment and to incorporate new and better methods and approaches. Organizations, initiatives, and movements that aren’t dynamic are dead. No matter how good your work is, it can always be better. Never be afraid to test out new ideas or to abandon old truths and traditions if they don’t work anymore. It’s the best way to keep your work fresh, and to make sure that everyone maintains enthusiasm for it. 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 ultimately accomplish its goals. Some ways to keep flexible and dynamic:

  • Continue to monitor changes in the community and broader environment such as changes in population, political trends, health information and possibilities, etc., and adjust accordingly.
  • Continue to monitor and evaluate your work, and adjust as needed.
  • Add new partners as old ones leave for other jobs or localities or retire; add new partners as circumstances change (new organizations that should be involved, for example, or individuals with valuable skills).
  • Change methods, approaches, and process as you gain more insight into what you’re doing.

Change is often difficult for people. 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.

Combat fatigue and burnout. Social change is hard work. It often involves dealing with injustice and human tragedy on a daily basis, and its results may be slow in coming. People and organizations get tired, and the temptation to quit can grow strong. It’s important to recognize the possibility of fatigue and burnout, and to make sure to address them in various ways.

  • Be aware of community history. Some partners and community members may have made several past attempts to create changes in community health or in social, economic, and environmental conditions, and may feel that their energy and efforts were in vain.
  • Continue to strive for maximum participation and diversity.

Barbara Corey, the longtime former coordinator of the North Quabbin Community Coalition in Massachusetts (USA), constantly sent postcards to Coalition and task force members, thanking them for their work. Whenever she had a spare moment, she’d write a note to someone she’d met with, or who had played an important (or even not so important) role in a community effort. The result was that people kept volunteering and remained connected, both to the Coalition itself and to its goals and ideals.

Sustain the partnership and the work. The work of addressing social determinants can be a long process. Funders get tired just as partners do, and the community may also lose interest in the partnership. If you’re going to realize your vision, you have to find ways to keep the work going. Some important ideas for sustainability:

  • Develop a formal organizational structure when the group is ready. Two possibilities:
    • 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. This 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, and foster new community leadership.
  • Develop a strong sense of group identity.
  • 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.

It’s easy, once routines are established, to let things slide. In fact, for a community change effort to be successful, it has to maintain its momentum indefinitely. It must be sustained for as long as it takes for the ideas, processes, and practices to be integrated into the community. There was a time when fire departments, police departments, and public libraries were new and radical ideas. Now, their presence is the norm in many parts of the world. Until social and health equity become the norm, until all of us are healthy, our job is not done.

In Summary

Addressing social determinants is an important strategy for working toward healthier and more just communities. This cross-cutting approach is more comprehensive than narrower efforts to address particular categorical health issues such as preventing violence, diabetes, or infant mortality. By working together to modify the differential exposures, vulnerabilities, and consequences that produce disparities, we can help to assure conditions for health and well being for all.


We encourage the reproduction of this material, but ask that you credit the Community Tool Box:

Adapted from **Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Social Determinants of Health Workgroup at the Centers for Disease Control, U.S. Department of Health and Human Services.

Laura K. Brennan Ramirez, PhD, MPH
Elizabeth A. Baker, PhD, MPH
Marilyn Metzler, RN
Stephen Fawcett, Edits/additional contributions
Phil Rabinowitz, Edits/additional contributions

Online Resources

Action: SDH: an electronic discussion platform, which aims to stimulate debate and share experiences of improving health equity through addressing the social determinants of health.

Actively Addressing Systemic Racism Using a Behavioral Community Approach - a journal article from Behavior and Social Issues.

Can Hospitals Heal America's Communities? from Democracy Collaborative illuminates the possibilities of hospitals and health systems healing America’s communities and explores how “all in for mission” is the emerging healthcare model.

Chapter 16: Behavioral Community Approaches in the "Introduction to Community Psychology" outlines how large, complicated problems can be broken down into smaller ones, the importance of studying and bringing about change in observable behaviors, and how behavioral approaches are used in Community Psychology.

City of Baltimore Health Commissioner, Leana Wen - In this video, APHA TV sits down with the City of Baltimore Health Commissioner, Leana Wen, to discuss how the city is improving community health by addressing the underlying social determinants of health.

DETERMINE: An EU Consortium for Action on the Socio-Economic Determinants of Health. This Portal is a tool to promote health equity amongst different socio-economic groups. Here, you can find information on policies and interventions to promote health equity within and between countries via the socio-economic determinants of health.

Equity, social determinants, and public health programmes edited by Erik Blas and Anand Sivasankara Kurup. World Health Organization Department of Ethics, Equity, Trade and Human Rights and Priority Public Health Conditions Knowledge Network of the Commission on Social Determinants of Health.

Essentials of SDH Online Course. Open to all audiences, this 10-hour fully automated, self-directed online course is offered in both English and Spanish, and includes a Portable Offline Version.

BALLE's field guide, The Future of Health is Local, gives health care providers actionable tools and examples on how to align the non-clinical assets of their organizations – such as procurement, employment, and investment – with local economic development strategies to improve human health and revitalize local communities.

Getting to Equity in Obesity Prevention Toolkit - This toolkit from the Council on Black Health addresses the need to include an equity component in the planning and implementation of policy, systems, and environmental change approaches (PSE) undertaken to curb adverse trends in obesity and related health consequences. is a website with a set of strategic practices that health departments can apply to more meaningfully and comprehensively advance health equity.

Health Equity Animated: Equity vs. Equality from the Center for Prevention in Minnesota explores the difference between the needs of various communities, and how addressing those specific needs requires specific solutions.

Health Equity in Healthy People 2030 provides tools for action to help individuals, organizations, and communities committed to improving health and well-being advance health equity.

Healthy Neighborhoods Study, based in Boston, is the largest resident-driven, participatory action research project in the US about neighborhood change processes, like gentrification and climate change, and their impact on health.

Healthy People, 2020. Social determinants of health.

This ColorCode “Housing Is Health Care” podcast delves into how housing — and today’s housing crisis — intersects with health. It also explores how racial discrimination has played a part in causing this crisis, as well as present-day housing segregation on Long Island.

Infographic: The ABC of SDH is a free poster-size infographic for all audiences.

The Lazy Person's Guide to Saving the World is from the United Nations and features 17 sustainable development goals to transform our world.

No Justice, No Peace of Mind and Body: The Health Impacts of Housing Insecurity for Black Women from The Nonprofit Quarterly.

Pew Charitable Trusts provides an article about holistic approaches made by partnerships to promote healthy birth outcomes.

Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health by Laura K. Brennan Ramirez, PhD, MPH; Elizabeth A. Baker, PhD, MPH; Marilyn Metzler, RN. Social Determinants of Health Workgroup at the Centers for Disease Control, U.S. Department of Health and Human Services.

The Research Methods Knowledge Base is a wide-ranging compendium of information on research methods.

Rio Political Declaration on Social Determinants of Health (2011).

SDH-Net Virtual Learning Platform is open to all audiences but especially helpful to researchers. This platform offers online and classroom-based courses, methodological documents, repository, infographic, and guides.

SDH Repository of Resources contains over 250 SDH resources including audio, video, pictures, and documents in English, Spanish, and Portuguese.

Seven Vital Conditions for Health and Well-Being is a useful framework for conceptualizing holistic well-being and the conditions that give rise to it, as well as identifying levers for community change and improvement.

Social Determinants of Health is a video from the World Health Organization (WHO).

Social Determinants of Health (SDOH) Training Plan from the TRAIN Learning Network provides over a dozen hours of training over the foundational concepts and their applications to various issues.

Social Determinants of Health and Older Adults covers new resources made available by specifically focusing on the health of older adults.

Social Determinants of Health in Rural Communities Toolkit by the Rural Health Information Hub organizes evidence-based models and resources to support the implementation of programs that address the social determinants of health (SDOH) in rural communities across the United States.

The Sustainable Development Goals Guide is a preliminary guide on how to "get started" with implementing the Sustainable Development Goals.

Transformational Community Engagement to Advance Health Equity is a report with case studies from the Robert Wood Johnson Foundation.

What is Healthy Equity? This three-minute motion graphic video explains how social, economic, and environmental conditions can create health inequities and how these inequities can affect health disparities.

What is Privilege? A video from BFMP at Buzzfeed.

Why Community Power Is Fundamental to Advancing Racial and Health Equity from the National Academy of Medicine.

Working Upstream: Skills for Social Change - a resource guide for developing a course on advocacy for public health.

Print Resources

Commission on Social Determinants of Health. Closing the Gap: Health Equity Through Action on the Social Determinants of Health, Final Report of the Commission on Social Determinants of health. Geneva, World Health Organization, 2008.

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

Poland, Blake, Koch, Andrew, Graham, Heather, Syed, Saddaf. (2008). Addressing the Determinants of Health Together: A Resource Guide for Hospital-Community Collaboration. Dalla Lana School of Public Health, University of Toronto.

Poland, Blake, Krupa, Gene, McCall, Douglas. (2009). Settings for Health Promotion: An Analytic Framework to Guide Intervention Design and Implemenation. Health Promotion Practice.

Ramirez, Laura K. Brennan, PhD, Baker, Elizabeth A., MPH, PhD, Metzler, Marilyn, RN. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Social Determinants of Health Workgroup at the Centers for Disease Control and Prevention. Department of Health and Human Services.

Solar, Orielle, Irwin, Alec. (2010). A conceptual framework for action on the social determinants of health. Social Determinants of health Discussion Paper 2 (Policy and Practice). World Health Organization: Geneva.