We need to change the way we do public health in the United States. Although we spend more than every other industrialized nation on health care, we continue to experience worse trends in health outcomes such as life expectancy, infant mortality, and obesity than our peers.1 A large cause of this discrepancy is spending on health care at the expense of investments in the social determinants of health. Social determinants of health are social and economic conditions in the environments in which people live, such as safe housing and transportation, that drive the majority of health outcomes that we experience.
For too long we have made the mistake of not recognizing the power of prioritizing public health investments in the social determinants of health. Now, the World Health Organization and Healthy People 2020 are among many health authorities championing the social determinants of health as fundamental for health. Public health opinion leaders have highlighted the importance of maintaining consistency in our understanding of these determinants.2,3 They caution that current efforts focused on providing individual services and support are important, but they do not fully address the upstream factors that ultimately impact the health of entire communities.4 It is also particularly important, as we change our focus to addressing social determinants of health, that we do not make the mistake of leaving the community's voice out of this process.
Experience teaches us that we need to change the kinds of investments we make, as well as the individuals and groups driving the investments. Rather than dictating the priorities and nature of spending in our communities, public health leaders must start by listening to the communities they wish to serve and let community members lead. In this spirit, the Association for State and Territorial Health Officials (ASTHO) has named Building Healthy and Resilient Communities as its national President's Challenge for the next 2 years.5 This challenge focuses, in part, on engaging health officials to mobilize community-led, place-based initiatives.
An example that highlights the importance of community-led efforts is the work happening in Rhode Island's Health Equity Zones (HEZs), which are community-led collaboratives that bring together community members and local organizations from diverse fields to pursue shared goals. One story that demonstrates the impact of this initiative in local communities is the development of a Green and Complete Streets Ordinance in Central Falls, Rhode Island. The community members and partners from the Pawtucket and Central Falls HEZ identified the importance of ensuring that streets that were accessible for pedestrians, motorists, and bicyclists and safe for users of all ages and abilities as a priority. They partnered with the city planning office to advocate for and develop a Green and Complete Streets Ordinance, the first of its kind in the Northeast. Through this work, the members and organizations of the HEZ helped shape transformational change that will have lasting implications for the health and safety of residents.
The Athens Land Trust (ALT) is a nonprofit organization in Athens, Georgia, dedicated to using community land for community interests. One of the trust's key activities is to increase community food production and access to healthy food.6 After identifying this goal, ALT worked with community members to address food access and unemployment through community development efforts that bring about sustainable change. The trust worked first with a local school and then with an apartment complex for low-income senior citizens to take advantage of underutilized land for community gardens. ALT also offers free agriculture and business training for low-income residents and supports the Young Urban Farmers Program, which provides technical training in farming and gardening to youth.
Importantly, ALT also works to address lack of home ownership in the community, which was identified as a community need.6 The trust provides access to housing at affordable, below-market prices for individuals and families who earn no more than 80% of the area median income. While the trust owns the land, the community member owns the home under a 99-year ground lease, which provides the owner with security; ownership is also transferrable to family members. If the home is ever sold, the terms of agreement are such that the home must remain affordable and be sold to lower-income individuals. The terms also ensure that the homeowner has some share in the appreciation of the home whenever it is sold. Initiatives such as this give community members opportunity to build wealth and free them from cycles of poverty. In addition, this initiative provides access to safe, affordable housing—a foundational requirement for health. Investments such as this, which address upstream determinants of health while keeping community priorities at the forefront, represent the future of public health.
Who Is the Community?
The term “community” can sometimes be hard to define in the context of public health and health policy. It is not uncommon for different people to have different ideas of what “community” refers to.7 The community can be thought of as “a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings.”7(p1932) For the ASTHO President's Challenge, we consider community to be people or groups who live, learn, work, and play in the neighborhoods or area of interest. Community refers to people and organizations that have lived experience within a location and are personally invested in seeing that area flourish. Thus, examples of community members can include a family, a local business, a school, or a religious leader.
The Spectrum of Community Leadership
Community collaboration and community consultation are often confused with a truly community-led process. Community consultation involves getting feedback from community members at some point in the process of investing resources or developing activities but ultimately not letting community members have the last word on deciding which priorities to set and what actions to take. Community collaboration entails involving the community throughout the entire process of defining goals and priorities and developing and implementing an action plan. Collaboration between public health leaders, policy makers, and community members is necessary but not sufficient for a community-led process. The missing piece in the community collaboration model is ensuring that the power dynamics of the relationship put the community in the driver's seat. Community leadership refers to letting the community ultimately decide what initiatives get prioritized and supporting the community in its chosen priorities.
Community-Led Initiatives: A Catalyst for Healthy and Resilient Communities
The community-led approach is important for several reasons: this approach ensures that community health investments appropriately match the lived experience of those residing in the community. It is easy to have well-intentioned projects and investments that are misaligned with the needs of the community. Second, community-led processes build community development capacity. For example, when the Pawtucket and Central Falls HEZ brought community partners together to decide on community priorities, it conducted a needs assessment process and developed an infrastructure for convening its partners that they will continue to address community priorities moving forward. Finally, community-led work that involves community members organizing toward shared goals builds resiliency, or the ability to “bounce forward” from adversity, by fostering social capital, community pride, and local communication channels.
Barriers to Community Leadership
Community leadership in addressing the social determinants of health first requires policy makers and public health leaders to change their organizational cultures and shared understanding around what it means to have authentic community engagement. Like any cultural change, this can be a long and challenging process. This approach requires public health professionals and their community partners to adopt new practices and systems. Historical and relational factors between public health professionals and community members, such as mistrust and lack of communication, often need to be addressed. From the community's perspective, asking the community to lead in the work of addressing social determinants of health may pose challenges such as finding the right leaders, finding space and time to meet, and getting compensated and valued for the time that this work takes. In addition, traditional grant funding mechanisms geared at addressing social determinants of health can be prescriptive and can result in the stifling of community voice and flexibility.
The First Step to Community-Led Work
While community-led work can be difficult to achieve, taking steps toward this ideal is essential. For organizations that have not conducted significant community engagement, a good first step is being intentional about building relationships with community members. This means having conversations with trusted community leaders in different fields such as education, the faith community, and local business and developing a good working relationship and understanding of each other's goals and objectives. Multiple frameworks exist for engaging community members and working toward community-led initiatives.8 Key aspects of any successful framework include relationship building, transparency, clear communication, and effective goal setting.
ASTHO invites state and local health officials and national public health leaders to lead the way in catalyzing community-led, place-based initiatives. Much of the public health leadership for community-based work must occur at the local level. However, the encouragement and active support of state leaders are very important to community-led initiatives. These bring recognition to their work, help overcome obstacles, and can assist in efforts to expand and leverage resources. State leaders are also well poised to bring about policy change and facilitate cross-sector partnerships and investments in community-led work. They can often provide the needed leadership to allow existing funding to be used in different ways that support community-led efforts. They can also develop state-based mechanisms to guide and support local communities in identifying and developing evidence-based approaches and identifying new resources to support their work. Finally, they can support local policy changes and ultimately take these kinds of efforts to scale by expanding and enacting these successful local policy “experiments” at the state level. This work is not limited to health officials. It will take leadership and support from diverse stakeholders, including business leaders, to make public health more community-centered.
For those new to community-led public health, this challenge will require reflection and intentionality to change default practices. It will also entail using existing resources in different ways. We encourage you to learn more about how to engage in community-led work and share your experiences with others through the ASTHO President's Challenge.5 The health of our nation depends on communities leading the way.
1. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024–1039.
2. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008.
3. Healthy People.gov. Social determinants of health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
. Published January 2019. Accessed January 31, 2019.
4. Castrucci Brian, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Aff. 2019. doi:10.1377/hblog20190115.234942.
5. Association of State and Territorial Health Officials. 2019 ASTHO President's Challenge. http://www.astho.org/ASTHO-Presidents-Challenge/2019
. Published 2018. Accessed January 31, 2019.
6. Athens Land Trust. Affordable housing. https://athenslandtrust.org/our-work/affordable-housing/
. Published January 2019. Accessed January 31, 2019.
7. MacQueen KM, McLellan E, Metzger DS, et al. What is community? An evidence-based definition for participatory public health. Am J Public Health. 2001;91(12):1929–1938.
8. National Collaborating Centre for Determinants of Health. A Guide to Community Engagement Frameworks for Action on the Social Determinants of Health and Health Equity. Antigonish, NS, Canada: National Collaborating Centre for Determinants of Health; 2013.