A Local Structure for Social Determinants of Health

The World Health Organization defines social determinants of health as

“…conditions in which people are born, grow, live, work and age, including the health system…shaped by the distribution of money, power and resources at global, national and local levels.”

The international organization has launched a commendable commission, sponsored a world conference, and provided overarching recommendations for reducing inequities in these conditions. Consider the WHO overarching recommendations:

1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money, and resources
3. Measure and understand the problem and assess the impact of action

Each of these recommendations is explained in further detail on the WHO site. I do not disagree with the principles described. Yet, it may be difficult for local communities to translate the recommendations and themes into a locally applicable framework. I propose  a locally applicable framework comprised of 3 considerations on which to structure institutional innovations and individual interventions.

Social Determinants of Health are functions of a local community’s governance of its Institutions, Environmental Factors, and Common Threads in Self-Governance.

Institutions

Humans engage in complex systems, even complex adaptive systems. Stated simply, people will not do better just because they know better or the opportunity is available. In order to address individual health, we will need to change the rules of the game rather than continually attempting to educate and appeal to the better nature of the players (For a primer on complex systems, see this BOHO Interactive video).

Institutions are the chess boards upon which each of us execute our lives. Institutions have an ability to force our behavior through a complex interaction between rules, social conformity, and individually created meaning. Local communities must measure and manage these institutions for the progress, justice and altruism supporting the health and wellbeing of citizens. Consider the primary institutions as follows: Faith, Family, Education, Entrepreneurship, and Health.

FAITH. Regardless of the diverse implementations of faith, they share a common expectation of a brighter future. Faith communities support citizens to believe in a future despite past failures or predictions based on the past. Consider that identified faith communities are a local community’s first partners toward sustainable change.

FAMILY. The WHO gives primacy to the role of child development in the advancement of communities. Families provide the tools and techniques for evaluating relationships, social role definition, and work ethic. Local communities will do well to communicate a productivity focus supporting a family-level test bed for safe, sustainable risk and education that increases the potential for larger community success.

EDUCATION. Local communities must move beyond education as a simple requirement and provision of schools. They must offer insight into the process and mechanics of teaching, learning, and self-development integrating a new culture of creativity as an institutional innovation. Structure the process as a family interaction. Expand the interaction from child-centered to family-engaging. Re-envision education as a control system, and abandon the assembly-line model.

ENTREPRENEURSHIP. Expand the notion of employment, work, and wealth creation. It is important to engage and ensure fairness among employers. Also, local communities must, whether the employer base exists or not, promote the habits, perspective, and discipline that convert ideas into capital. Empower citizens to create products, connect to markets, and package individual expertise.

HEALTH. Expand the notion of health services to include the practice wisdom of the medical and mental health professions. Engage other institutions in education to structure health promoting environments and activities. The WHO supports exploration of the impact of environment, stress, nutrition. Local communities can effectively add relationship patterns, roles and affiliations, beauty and personal care (i.e. nail salons), and perceptions of self to the determinants of physical and mental development and holistic well-being.

Environmental Factors

In order for institutions to flourish and achieve individual intervention, local communities will need to attend to the basic requirements of community participation: Housing, Transportation, Recreation, Emergency Services, and Safety (From Violence).

Housing is a basic provision of healthy communities. As the WHO recognizes, quality housing means clean water and sanitation. For local communities, it also means community spaces and integration with institutions. For example, in an eldercare independent living high rise, provide medical, college/certification, reunions, meditation, and inventor services in the building.

Transportation can be especially concerning in rural communities. Even in larger communities, transportation must involve a combination of private sector and public sector solutions. Examine the excess capacity and willingness to engage represented in institutions. For example, faith communities may be willing to run transportation services within certain communities if liability concerns could be worked out.

Recreation includes public spaces, but also private spaces. Local community planners would do well to engage with studies that support porches, outdoor gardens, terraces and patios. These structures support the health of the community (Evans & Wells, 2003). An example may be a competitive neighborhood grant sponsored by the local government in cooperation with a private sector home improvement store. The grant could propose to provide half of the funding needed to add a garden, a front porch, or re-pave sidewalk.

Emergency Services today is inextricably connected to disaster services in the minds of many citizens. Of course, a preparedness, triage, and contingency plan must be in place and market. Local communities will do well to also consider family, block, and neighborhood disaster planning support as well. Support these plans within the institutions rather than just printing brochures. For example, offer a community award for the school or faith community that registers or renews the most family emergency contact lists, fire escape plans, or other preparedness concerns.

Public safety does not always have to be active public safety interventions. Programs like community policing and “officer in residence” have not been reviewed to be panacea as a lone intervention. Yet, neighbors in such programs report a sense of safety. Moreover, officers in such arrangements report engaging with citizens in new and productive ways. Another idea may be connecting police professionals in homeowner’s association or other community meetings to discuss strategies or citizen concerns.

Common Threads in Self-Governance (CTSG)

CTSG is just a quick way to express that element of complex adaptive systems that motivates the individual to action. The adage suggests, “you can lead a horse to water, but you can’t make it drink.” Local governments can create institutions and environments that are fair, progressive, just, and altruistic, but this does not mean that those same principles are successfully communicated to the public. Certainly, even effective communication does not mean that the principles are adopted and practiced by the population.

Local communities can move another step toward effective communication of principles by transparently revealing mechanisms, choice models, and interrelatedness.

Mechanisms refer to the real processes of community progress. Essentially, it is community asset building as an institutional process ensuring access to information, relationships, and the means of production (e.g. co-ops, incubators, pre-screened health services, and more). Transparent sharing of mechanisms would result in a greater potential to match need, ideas, and personal assets with excess capacity, mentoring, and capital translation. Community wealth clearinghouses like community-wealth.org are examples of open access to information. Aunt Bertha in Austin, Texas is an example of a services matching idea. Technologies like lulu.com are examples of the means of production.

Choice Models refer to a new way of providing information. Consider the decision points that an individual citizen considers along the process of action. As well, consider the social influences that attend every decision point. Build the information and social influence model into institutions and increase the potential for the individual citizen’s choice to be influenced toward a more sustainable choice. For example, engage faith communities in health eating seminars including private sector businesses to cater events. Provide leaders with information on healthy diet and lifestyle knowing that these leaders influence citizens through lectures, modeling, after-service dinners, bake sales, and other events.

Interrelatedness refers to the core experience of complex systems. One event impacts the larger system in some way. Use marketing and public service channels as well as institutional information sharing (based on choice models) to regularly communicate the interrelatedness of citizens. For example, present a scenario in a public service announcement that tells the story of what results from one citizen neglecting to recycle or vaccinate. Focus the story on the impact of one citizen’s choice on the available choice and well-being of other individual citizens.

You are welcome, WHO. 🙂

Bibliography

Aunt Bertha: http://www.auntbertha.com/about

BOHO Interactive, http://youtu.be/bN2N7gqAax0

Community Wealth: http://community-wealth.org/

Evans, G.W. and Wells, N.M. (2003). Housing and Mental Health: A Review of the Evidence and a Methodological and Conceptual Critique. Social Issues, 59(3). 475-500.

World Health Organization: http://www.who.int/social_determinants/en/