BLUEWEST INSTITUTE

OF BUSINESS STUDIES & HEALTH SCIENCES

MANAGEMENT OF COMMUNITY CONCERNS

Addressing Social Concerns/Determinants of Health and Development

 WHAT ARE SOCIAL CONCERNS/DETERMINANTS OF HEALTH

AND DEVELOPMENT?
 WHY MANAGE/ADDRESS SOCIAL
CONCERNS/DETERMINANTS?
 WHO SHOULD ADDRESS SOCIAL DETERMINANTS?
 WHEN SHOULD YOU ADDRESS SOCIAL DETERMINANTS?
 HOW DO YOU ADDRESS SOCIAL DETERMINANTS O F HEALTH
AND DEVELOPMENT IN YOUR COMMUNITY?

WHAT ARE SOCIAL DETERMINA NTS OF HEALTH

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

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

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

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

Many of the social determinants listed below are specific forms of or contributors to these three
categories. At a community level, it may be difficult to influence income inequality directly, but a
non-governmental or community-based organization may be able to approach it through addressing a
particular issue. A small organization may be able to have more effect on social connectedness and
the sense of efficacy, since collective action can influence both social ties and the experience of
changing communities and systems.
The World Health Organization, in its publication The Solid Facts, recognizes the need to break these
factors down into more manageable pieces. It lists ten factors that affect health and life expectancy,
and advocates addressing each within a comprehensive program of social protection that addresses all
of them within a society. These ten factors are:

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

The factors listed below are, in most cases, more specific than the three broader determinants
discussed above. In addressing social determinants, however, keep in mind these broader factors, and
gear programs and policies toward influencing them at whatever level you can, given the resources
and scope of your organization.
As listed above, there are modifiable factors that can greatly influence community members’ health
and quality of life. Let’s look at a video that describes some of these factors:

The social determinants of a particular community health or development issue may be unique to a
particular community or group, or may be part of the larger society. People from different immigrant
cultures, different social classes, or with different levels of education might experience the same issue
very differently because of different social factors.
There are three major ways in which social determinants may affect specific populations. These can
also be viewed as levers – points of intervention – that can be used to address those social
determinants and lessen their effects.
1. Differences in exposure. Certain population groups, because of economics, geography, or other
factors, may be more likely than others to encounter particular health risks. People in poverty, for
example, are likely to be exposed to higher levels of stress, economic uncertainty, and unhealthy
conditions than their wealthier countrymen.
A specific example: in developing, or even middle-income, countries, poor rural villages may get all
their water – for drinking, washing, waste disposal, and other uses – from a single, above-ground
source, such as a lake or stream. In that case, the villagers are far more apt to be exposed to water-
borne diseases and pollutants than wealthier neighbors who can afford to buy bottled water or drill a
well.

2. Differences in vulnerability. Because of their poverty, their exposure to stress and uncertainty, or
other factors, those same population groups might find themselves more vulnerable than others to
health problems. The inability to pay for regular health care or medical treatment increases the
possibility of chronic illness. In the example of the village above, poor nutrition, as a result of
poverty, could increase villagers’ vulnerability to water-borne disease, as would the inability to
organize to finance a village well.
3. Differences in consequences. Differences in wealth, social standing, connectedness, and other
factors can lead to very different outcomes where health issues are concerned. For a middle- or upper-
class family in many countries, a minor health problem – missing a few days of work, paying a
modest sum for treatment – might be just an annoyance. For a poor family, it might be the difference
between a roof over their heads and homelessness, or between children attending school and dropping
out to go to work. Discrimination, high stress levels, employment conditions, and other factors can
result in disparities in health and health care among different groups.
There are a number of social factors to address to improve conditions for health and development.
Some of the more common factors to be addressed are:
ECONOMIC FACTORS.
The unemployment rate, for example, has a great influence on such issues as domestic violence,
substance abuse, depression, or physical illness. Economic inequality affects people’s stress levels,
exposure to violence and toxins, educational prospects, access to services, high-risk behavior, and
mortality rates.
SOCIAL INCLUSION.
Social connectedness and the cohesion of the community have been shown to have a direct
relationship to good health and lower mortality rates. These factors can also encourage civic
participation in changing conditions that affect group goals.
EDUCATION.
More education means not only better jobs and more affluence, but also a greater sense of control
over one’s life. People with more education have more choices in health, housing, careers, and other
areas that affect the quality of their lives.
RACIAL OR ETHNIC BIAS.
Social exclusion can be the result of prejudice, which results in different access to health care,
education, or other services.
SOCIAL NORMS OF ACCEPTANCE OF PARTICULAR BEHAVIORS
OR PRACTICES.
Smoking, or even alcohol abuse, may be an accepted part of the culture of a community. In that case,
many more people will adopt it than in a community where it is frowned upon.
CULTURAL FACTORS.
There are many elements of culture that might have a bearing on social inclusion, efficacy, and
income inequality.

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

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

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

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

 Attitudes toward mainstream culture can influence everything from medical care to whether or not
high school students can attend dances. This, in turn, affects the type and amount of health care
received, the sense of connectedness within a community, and many other factors.
  Language barriers can cut people off from health care and other services, make it difficult for them to
find and keep decent jobs, and affect their children’s education.

THE INFLUENCE OF MASS MEDIA.

The media, particularly television, can send powerful messages about community health and
development. In the 1950s in the U.S., smoking was portrayed in movies, magazines, and TV as
glamorous and sophisticated. Now, there are no TV ads for cigarettes, virtually no one in the movies
smokes, and anti-smoking messages are everywhere. These conditions both reflect and are partially
responsible for the fact that fewer than 25% of adults in the U.S. now smoke.
The media can help or hinder other efforts to improve health (through programming that shows
people exercising as a matter of course, for instance, or that shows the same people eating fatty fast
food or drinking too much). They can also, similarly, encourage or discourage tolerance for others,
push a political agenda, or condone or condemn such behavior as solving disputes with violence and
engaging in unsafe sex.
POLITICS.
It is probably fair to say that all community issues are political to some degree. If a factory is
poisoning town wells with its effluent, for example, local officials are faced with the choice of not
dealing with the actual cause of the problem (the dumping of waste) and endangering citizens’ health,
or addressing the dumping and endangering citizens’ jobs. Politicians with larger constituencies,
using poll data, may pander to what they perceive as people’s selfishness and prejudice, passing
legislation or instituting policies that discriminate against one group or another, or fly in the face of
the public interest. Even honest differences of political opinion – over whether the government should
be responsible for providing social services or not, for instance – can have enormous consequences in
the community.
LIVING CONDITIONS.
Run-down or inadequate housing, dangerous streets, noise, and blighted neighborhoods all have their
effects on those who experience them every day, as do manicured landscapes and calm environments.
The stress of living in a difficult situation carries over into many other areas of life.
GEOGRAPHY.
Location may have a great deal to do with whether people receive services or not. In developing
countries, children from isolated villages in the mountains or on the seacoast may have no
opportunity for school or medical care, for instance. In the U.S., as mentioned earlier, access to
medical care and other services may depend on the availability of transportation. In urban areas, that
access may have a lot to do with the neighborhood in which the services are located: another gang’s
turf or a neighborhood perceived as hostile may be as effective in denying services as if they didn’t
exist at all.

WHY ADDRESS SOCIAL D ETERMINANTS OF

HEALTH AND DEVELOPME NT?
Reasons for addressing the social determinants of an issue include:
If you want to solve or prevent a problem for the long term, you have to deal with its root
causes.
If you address the root causes, you’re more likely to successfully address the issue for the short
term as well. To cure a disease, you have to treat more than the symptoms – but you usually have to
treat the symptoms, too. Dealing with social determinants will not only resolve the issue over the long
term, but will make alleviating the current effects of the issue possible also.
To eliminate cholera, one of the most important steps is to provide people with clean drinking water.
During the London cholera epidemic of 1854, John Snow, a physician, mapped the houses where the
disease struck. He learned that many of the stricken were drawing water from a pump that tapped a
filthy part of the Thames River, because conventional wisdom said it was better than the piped water
also available to them – which actually came from a cleaner area. He was able to close the pump and
substitute piped for pumped water, almost immediately ending the outbreak. Snow’s insights about
the social determinants of cholera, along with the later work of others, eventually helped to eliminate
the disease as a threat in most of the developed world. But they also served to stop the 1854 epidemic.

WHO SHOULD ADDRESS S OCIAL DETERMINANTS

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

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

WHEN SHOULD YOU ADDR ESS SOCIAL

DETERMINANTS OF COMM UNITY HEALTH AND
DEVELOPMENT?
You should always look at the social factors that play a role in community issues, but there are some
times when analysis of those factors is particularly important.
  When it’s clear that simply focusing on the issue isn’t enough. As cities have found again and
again, all the enforcement in the world won’t really stop youth violence. There has to be a change in
the culture that creates that violence.

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

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

HOW DO YOU ADDRES S SOCIAL DETERMINANT S OF

COMMUNITY HEALTH AND DEVELOPMENT?
Now that you’re convinced that addressing the social factors that cause or influence community
health and development issues is important, how do you go about doing so? There are really two parts
to addressing social determinants. The first is identifying how various social factors affect the issue
you’re concerned with, and the second is developing and implementing an action plan based on an
understanding of how, and from what angle, to approach them successfully in order to change the
way the issue plays out in the community and, ultimately, resolve the problem.
IDENTIFYING SOCIAL DETERMINANTS
The issue you’re dealing with may be obvious, but it’s likely that all of its social determinants are not.
There may be local customs that seem so obvious to the folks you’re working with that they don’t
consider them worth mentioning, even though they may control a great deal of the community’s
functioning. If they’re unique to that community or region, and you’re not a native, you’ll have to
learn about them if you have any hope of changing conditions. In other cases, social factors may have
to be traced through several layers of the society before you reach the point where they originate and
can be influenced. The way to find out about these and other social determinants is to do a
community assessment.
Assess the community to find the social determinants of your issue. The purpose of community
assessment is largely to assess the community for needs and assets, but the strategies it proposes are
equally useful in searching for social determinants of health and development.

 Start by talking to people:

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

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

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

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

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

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

 Make sure your information is accurate.

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

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

ADDRESSING SOCIAL DETERMINANTS

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

 Economic inequality
 Social connectedness
 A sense of efficacy

The lower people’s economic levels, the less connected they are to others – through family, social
groups and organizations, faith communities, etc.; the less convinced they are of their ability to
control their situations and their lives, the greater the likelihood that they’ll experience more health
problems than those in the society who fare better in those categories.
And as we’ve also discussed, particular individuals or populations are most likely to be disadvantaged
by health problems because of:

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

These characteristics feed each other in a cycle of poverty and powerlessness. An effective
intervention has to break that cycle by understanding the social determinants behind it and changing
them and the conditions that they cause in a truly profound way.
You can develop interventions that can reduce people’s exposure to, their vulnerability to, and their
consequences from health problems, and that can also encourage gains in economic equality, social
connectedness, and efficacy. By doing so, you can help people not only improve their health and that
of their children, but move up the ladder of economic and social status, thus cementing their gains,
and securing them for the next generation.
This may seem like an impossible task. How can you change a society? It’s hard for governments and
even harder for most NGOs and community-based organizations, given the limits on their resources.
Major social change often takes not a single type of intervention, but an all-out assault on a number of
social factors over a long period of time. Unless you’re a high government official, or have access to
unlimited funds, you’re probably not planning anything that broad . . . and you don’t have to.
Rather than trying to concentrate on the huge issues, you can intervene in the environmental and
policy conditions that reflect social determinants and that can more easily affect differences in
exposure, vulnerability, and consequences. In the process of addressing these types of issues, the
folks you’re concerned with can learn much of what they need to change their position in society.
Environmental here refers not just to the natural environment, but to the total environment of the
people in question. That includes the built environment – buildings, roads, power sources, farms, etc.
– as well as the social environment – culture, social rules and norms, government, business,
education, economics, etc.. The term “environment” here encompasses all the natural and human
physical, social, economic, and political structures that surround people’s lives.

Environmental and policy conditions include:

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

Helping people gain knowledge and skills can be an intervention in itself, or be part of a broader
intervention that nonetheless provides participants with tools to safeguard or improve their health and
their lives. Some community development programs, for example, include literacy classes as part of
the support they provide. With literacy, participants gain skills that allow them to continue and
expand the community development activities they’ve begun, or to get jobs that will better serve them
and their families. Literacy also gives people who’ve typically been powerless a means to power over
their lives by helping them understand the forces working on them (not to mention the terms of
contracts and other papers to which they’re asked to agree), and take action on their own behalf.
Providing knowledge of specific health issues and practices can have a dramatic effect on the health
of a community. Safe sex practices, for instance, can cut down on the incidence of HIV infection, and
information about the treatment of infant diarrhea can drastically reduce infant mortality.
In both these examples, addressing a specific issue serves to address efficacy, and, in the case of
literacy training, economic inequality as well. Depending on how programs are structured, most can
also address social connectedness, either by bringing a community or population group together to
work on an issue, or by creating a community among those involved (in literacy classes, for
example.)

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

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

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

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

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

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

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

An intervention to decrease or prevent exposure to hazards can take any one of several forms. A self-
help program to dig a well or use filters to obtain clean water, channel sewage, grow food without
pesticides or chemical fertilizers, eliminate VOCs (volatile organic compounds, often-toxic chemicals
– used in glues, dyes, paint, and solvents – that vaporize at room temperature and can affect the health
of many people) in a building, or clean up a neighborhood can not only improve health conditions,
but increase participants’ sense of efficacy as well.
A different approach might involve advocacy for government assistance or services – drilling a well,
installing a sewer system, establishing a health clinic, instituting public transportation, etc. – or to
pass or prevent laws that affect exposure to health risks. These actions would speak to both social
connectedness (community organizing brings communities or groups together to apply pressure and
advocate effectively) and participants’ sense of efficacy.
A third possibility that also addresses both social connectedness and efficacy might involve an
initiative to change the behavior of – or prosecute – a corporation or other party responsible for
pollution, unsafe workplace practices, illegal dumping, shoddy and dangerous construction, selling
harmful products, or other potential hazards.

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

Changing or instituting policy is generally a matter of advocacy. It’s important because policies can,
and do, affect all three of the differences – in exposure, vulnerability, and consequences – that create
less healthy conditions for populations at risk.
An initiative aimed at policy change can start at any level. It may begin with government, with the
realization by legislators, other elected or appointed officials, or an agency that some sizeable group
of citizens is in danger of, or already suffering from, disparities in health. It may begin with an NGO
or grassroots organization that works with (or is composed of) that group. Or it may begin with the
people themselves, who have simply come to the end of their patience with their situation.
Policy change is often difficult, but, in the long run, it can be the most effective means of improving
health and development outcomes, because it can lead to real social change. The ideal intervention
would be one that either originates with, or involves those who will benefit from the change in
question, since that gives them control over what happens to them.

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

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

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

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

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

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

Capacity-building involves helping local people gain the skills and knowledge – and establish or
strengthen the community organizations and institutions – necessary to allow them to take action and
control their own fate. That may entail direct training, using resources like the Community Tool Box,
and a certain amount of “on-the-job training”. There’s no substitute for experience in health and
community development, although having some background before you’re thrown into it is certainly
helpful.
At some point – earlier is usually better than later, and from the beginning is often best – local people
have to be directly involved in planning and carrying out strategies for improving their situation.
Taking on responsibility and leadership positions builds both a sense of efficacy and connectedness in
the local population, and also puts their future where it belongs – in their own hands.

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

Partners can be NGOs or community health or development organizations, government agencies,

corporations, academic institutions, faith communities – any party that is generally respected, has
some clout, and can function as an honest broker.

As is perhaps obvious from the discussion directly above, an important goal of addressing social
determinants is strengthening the ability of the community to sustain the changes that an intervention
brings about. If a population is malnourished, giving them food is only a temporary solution: helping
them to develop self-sufficient and sustainable farming practices, or training them for necessary and
available work, on the other hand, can be permanent ones.
Another important goal is to take on tasks that can actually be accomplished. A local entrepreneur,
owner of a large and flourishing tire business, a real estate development firm, and several other
successful ventures, was asked how he got to the position he was in. His answer was simple: “Crawl,
walk, run.” He started small, with something he knew he could handle. When he succeeded at that, he
used it as a base to take on something a bit more challenging, consolidated his gains again when he
succeeded at that, and just kept going.
Social change often works the same way. Success breeds success, and you’re far more likely to be
successful if you attempt something that’s challenging but doable. Once you accomplish it, you have
a foundation from which to address the next issue, or the next level of issues. Communities never lack
the most important resource – people, and their intelligence and determination – but they may lack
the material resources that allow them to attempt overall social change – change that entails
addressing several social factors and levels of power – all at once. They can do it, however, if they
take it one step at a time.
The last bit of how-to in this section will be familiar to regular Tool Box users. You have to keep
taking that one step at a time again and again and again for as far into the future as you want your
community to exist. Addressing social determinants of health and development isn’t a one-time thing.
People have to maintain their gains and their healthy practices, and teach the next generation what
they’ve learned about creating a healthy community, so that it will continue to be one.

IN SUMMARY
“Social determinants” of health and development issues are the social factors that determine or
influence the issues. Most fall into the three categories of economic inequality, social connectedness,
and sense of efficacy. By understanding and addressing these social factors, you can increase your
chances of resolving issues over the long term by getting at their root causes.
It makes sense to use a participatory approach to analyze and address social determinants of health
and development issues. By including those who know the history and context of the issue, and by
subjecting it to analysis from many minds and perspectives, you’re more likely to arrive at a thorough
understanding of it. This kind of analysis is especially effective when it’s clear that simply putting a
Band-Aid on the symptoms of the issue isn’t enough, and that you have to employ a long-term
strategy in order to address it effectively. Such a strategy may incorporate advocacy for a change in
law or policy and leadership training, as well as community-based actions.
A community assessment will help you understand what the social determinants are in a particular
case. By asking the right questions to determine community reality – Who is affected and how? What
are the patterns in who is affected, who is opposed to action, what are the interests at stake? What are
the costs of action and inaction, and who will pay them? – and talking to those affected and others
who may already know what the social determinants are in the situation, you can create a complete
picture of the issue.
Using that picture, you can address the social factors in order to reduce the population’s exposure to,
vulnerability to, and consequences from the issue at hand. The best approach is usually through
environmental and policy conditions, rather than through attempting to change social factors – which
can be far-reaching and ingrained in the culture of the society – all at once. Work toward incremental,
sustainable change, help local people learn the skills to take over and continue the effort themselves,
and make sure the effort continues indefinitely, and you’ll ultimately be successful in developing a
healthy community.