REACH U.S. in Action: Inspiring Hope, Rewarding Courage

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

I am writing this foreword just days after returning from the 20th International Union for Health Promotion and Education World Conference on Health Promotion in Geneva, Switzerland (July 11-15, 2010). The primary goals of the conference were to "build bridges between sustainable development and health promotion, the outreach of health in all policies, and the transfer of knowledge with long-term impact" (http://www.iuhpe.org). More than 2200 health promoters from 123 countries and all continents contemplated how we might achieve health equity and sustainable development in a global environment of overtaxed natural resources, struggling political economies, and competing ideologies about the way forward. Notable speakers from around the world described the interconnectedness between how we use the finite resources of the planet; policies governing globalization; social, political, and economic inequality within and between nation-states; and the people's health. Promising strategies were showcased, and provocative conversations reframing more traditional approaches to protecting the public's health were presented. Translate this broad thinking to the community level, and we see a snapshot of the day-to-day realities, experience, leadership, and community-based participatory approaches of Racial and Ethnic Approaches to Community Health Across the United States (REACH U.S.) in eliminating racial and ethnic health disparities.

This special issue of the Journal of Family and Community Health provides a much needed collection of community voices describing how they are working to transform their social environments-one victory at a time-to improve health outcomes in communities that are disproportionately affected by preventable premature death and treatable disability. In preparing the reader for this special issue, I first of all situate the work of REACH U.S. in the global movement to reduce health inequalities through attention to the social determinants of health. I describe how the REACH experience in addressing the social determinants of health reflects a familiar clash of interests of people at the nexus of industry (including art), politics, and science. In these articles, we discover through detailed case studies how local communities resolved some of these competing interests. At the end, I briefly broach the issue of culture as a social determinant of health, and how community health workers have been vital resources in eliminating health disparities as both cultural translators and frontline advocates for health equity.

It is important to light a lamp while protesting against the darkness. - East India saying

Since 2007, the REACH U.S. program has addressed the social determinants of health in their efforts to eliminate disparities in cardiovascular disease, diabetes, breast and cervical cancer, infant mortality, asthma, immunizations, hepatitis, and tuberculosis. Building upon the successes of REACH 2010, which tended toward more long-lasting protective interventions, clinical interventions, and counseling and education,1 REACH U.S. is concerned with improving the social environment in which opportunities for health and health-promoting behaviors are supported. The social environment in this instance refers to the place or context, that is, neighborhoods, workplaces, regions, or state where people live, and the health effects derived from these contexts. According to Kawachi et al,

a contextual effect relates to the broader political, cultural, or institutional context, for example the presence or absence of features that are intrinsic to places, such as infrastructural resources, economic policies of states, social and public support programmes. Contextual effects can also include influences of cultural background, such as the ethnic, religious, and linguistic make up of communities, as well as certain ecological or environmental influences.2

The social environment is integral to the social determinants of health.

The basic reason to be concerned with the social determinants of health is the growing empirical evidence that we cannot eliminate racial and ethnic health disparities without attending to the political, economic, social, educational, and cultural factors that undermine disadvantaged communities. There is a large and growing literature documenting the association between living conditions and health dating back to antiquity. The 2008 release of the report of the World Health Organization's (WHO's) Commission on the Social Determinants of Health, "Closing the Gap in a Generation," has invigorated longstanding dialogues and debates around the globe about the responsibility and necessity of public health and medicine to confront the social determinants.3 Established in 2005, the WHO Commission on the Social Determinants of Health was charged "to bring together evidence on what can be done to achieve better and more fairly distributed health worldwide, and to promote a global movement to achieve this" (http://www.who.int/social_determinants/th-ecommission/). They define the social determinants of health in the following way:

The Commission takes a holistic view of social determinants of health. The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives-their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities-and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a "natural" phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.3

The landmark report of the Commission has been exceedingly helpful to us in further legitimizing and energizing the necessity to think and act at the level of social institutions while taking "an open approach to evidence," that is, not being limited to evidence derived from randomized controlled trials for which there is none at this time.4 Being able to disentangle the complex systems that define the social determinants, identify measures and methods of inquiry that will satisfy the many stakeholders who must be mobilized to address the social determinants of health, and reconcile philosophical and political differences about social justice and health equity, is unlikely in the short term.5-9 Neither can we afford to wait until we have perfect information to act in light of the increasing burden of health disparities between and among racial and ethnic communities in the United States.

Why treat people without changing what makes them sick? (Poster Caption - http://www.who.int/social_determinants/en/)

In May 2008, the National Association of Chronic Disease Directors (NACDD) in collaboration with the CDC convened a National Expert Panel on Social Determinants of Health Equity to provide input on accelerating public health efforts to achieve health equity. The panel included recognized experts in the social determinants of health from academia, foundations, state and local health departments, health policy advocates, and representatives from CDC programs (eg, human immunodeficiency virus, injury, environmental health, global health, and chronic disease prevention and health promotion). Panelists were asked, "what is the public health role in responding to the social determinants of health?" Responses included renouncing all forms of social exclusion, building economic justice, improving neighborhood environments, and strengthening community and resident participation in public health planning and decision-making. The benefits associated with greater community participation are the following:

Social and community networks influence health by providing support, helping members secure access to resources needed for health, and creating avenues for solving societal problems. These networks and supportive relationships are linked to good health and also to the development of social and political power that can be used to positively influence neighborhood conditions and opportunities. The public health field must listen and respond to the authentic voices of communities that experience the greatest inequities in order to support the development of local capacity and strengthening of community networks to act on their own behalf to improve conditions for health. Participation in basic decisions that affect their lives by members of low income and communities of color is vital for developing effective strategies to eliminate health inequities.10^(p18)

Community engagement and community building are hallmarks of the REACH program.

The CDC, through the Division of Adult and Community Health, has launched several new initiatives since the expert panel report was released. For example, a social context module has been available since 2009 for use by state and local contributors to CDC's Behavioral Risk Factor Surveillance System. We continue to add practice-based evidence to the literature such as this special issue of the Journal of Family and Community Health. We are conducting training programs in person and via Webinar on the workbook "Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health." In collaboration with the Health Equity Council of NACDD, we are identifying training needs related to social determinants for the public health workforce in state health departments. Most recently, we are developing a national communications campaign to raise public awareness about the relationship between the social environment and health.

Even as we move deliberately in this direction, we recognize that for some stakeholders in community health, confronting social, economic, and political power structures that can either improve or retard community health has been, and continues to be, controversial in the context of public health practice. However, REACH U.S. has demonstrated that organized and determined multisector community coalitions can successfully improve the stock of material resources in communities with a large proportion of racial and ethnic minority residents that supports chronic disease prevention and health promotion. We are learning from REACH U.S. how to mobilize community resources, identify common goals across influential sectors, and create a shared vision to achieve healthy communities with a large proportion of racial and ethnic minorities. Articles from the REACH U.S. grantees featured in this special issue of the Journal of Family and Community Health describe the fortitude among community residents needed to change policies and other systemic barriers to health in racial and ethnic communities. These communities have achieved impressive policy, systems, and environmental changes in large urban centers as well as in rural and remote communities. The processes of change implemented in these communities have not only been responsive to the sociopolitical context but also to the historical and cultural realities of the peoples involved.

"The imperative is to define what is right and do it."

US Congresswoman Barbara Jordan

(http://womenshistory.about.com/od/quotes/a/Barbara_jordan.htm)

Looking ahead, there are many conceptual and measurement challenges to resolve in the interest of documenting the health impact of these efforts. In addition, there are other issues of concern as we continue to work from a socioecological framework. For example, over the last decade, the role of culture and the necessity of practitioners being "culturally competent" has achieved wide acceptance as a critical competence in the elimination of health care disparities. Cultural competency is not well defined in the literature, but reflects the ability of health care practitioners to communicate effectively with patients from diverse backgrounds and prescribe care plans that (as much as possible) mesh with the beliefs, practices, and social circumstances of the patient. At this point, there is insufficient evidence in the literature to support the effectiveness of cultural competence in achieving desired health outcomes (http://www.thecommunityguide.org/social/ccc.html). However, this is not to suggest that cultural competence is not effective, but points to the need for more ongoing, rigorous evaluations of programs that provide training in cultural competency to the clinical and public health workforce and their impact. In the REACH program, cultural competency is not limited to interactions within the health care system, but is extended into community-based programs.

Culture, in some discussions, is also included as a social determinant of health.11-13 Anthropologists are particularly sensitive to the challenges associated with defining "culture" in contemporary multiethnic communities, and applying our cultural understandings in the practice of public health. There is also cause to be concerned about misappropriating "culture" when making attributions about disparities in health among diverse ethnic communities in the United States.13 In other words, there may not be any causal relationship between the cultural beliefs and practices of a community and the health disparities experienced by that community.

According to Janes,11^(p261) "the transnational flows of people and ideas that are part and parcel of globalization, the legacies of colonialism and, in consequence, a need to take power into account, have rendered older ideas of culture-as a relatively homogeneous set of understandings shared among a group of socially interacting people-conceptually obsolete." This is not to suggest that culture is not real, or to negate its association with health and disease.12,14,15 Indeed, much of ethnic identity (a by-product of culture) is predicated on "an individual's sense of identification with a particular ethnic group and its beliefs, values, norms, and history."16^(p278) Medical anthropologists17 add that "cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even personality." Culture in this context is "not a single variable but rather comprises multiple variables, affecting all aspects of experience. Culture is inseparable from economic, political, religious, psychological, and biological conditions."17^(p292) So, how we synthesize and apply concepts of culture in a population-based approach is an enormous challenge.

If our policy, systems, and environmental changes are to support opportunities for healthier communities, that is, making the healthy choice the easy choice, to what extent does "culture" factor into the process of achieving the desired health outcome? A fair and full discussion of this question is beyond the scope of this foreword. However, there are 3 areas associated with culture that are important to address within the framework of the social determinants of health: (1) the community's history in the United States and in the locale where the program to eliminate health disparities is focused, (2) health-related attitudes, beliefs, and behaviors of residents shaped in response to this history and the current socioeconomic and sociopolitical circumstances of the community, and (3) how the community perceives its resilience to misfortune and power to pursue and achieve social change. No single answer to the question of how culture determines health outcomes will emerge from this inquiry, but the respect afforded the community by investing time in learning about who they are, what are their aspirations for the community, and what adds to their quality of life is a powerful indication of cultural competency in a truly community-based participatory approach. Learning how lifestyles, health-related behaviors, residential and employment patterns, religious and political beliefs, civic engagement, and other sociocultural phenomena developed over time is important in gaining and sustaining community leadership and engagement, the process of setting priorities for action, and identifying targets and strategies for policy, systems, and environmental change.

One of the hallmarks of the REACH program has been its attention to culture and history. A prominent feature of REACH to ensure cultural competence has been the engagement of community health workers and promotors whose utilization has also been endorsed as a means of targeting the persistent health disparities that plague our current health care system.18 Community health workers have been instrumental in public health practice in the United States for more than 50 years.19 These individuals are typically members of the target community and are able to build trusting and collaborative relationships with community members and institutions.20 A national survey of community health workers conducted in 1998 identified 7 core roles: "cultural mediation, informal counseling and social support, providing culturally appropriate health education, advocating for individual and community needs, assuring that people get services they need, building community capacity, and providing direct services."21,22 Articles in this special issue highlight the role of community health workers as cultural translators and change agents in REACH communities. They have been effective in implementing chronic disease self-management interventions,23,24 increasing access to quality health care among persons feeling alienated from the system because of language and other barriers and building community capacity for health promotion19-all elements of a health promoting social environment.

The mission of REACH U.S. is to lead an innovative and transdisciplinary public health movement that eliminates health disparities and achieves health equity. There is much work ahead before we achieve our vision of optimal health for all in a just, fair, and equitable world, but the demonstrated commitment and tenacity of the REACH grantees inspires hope and courage to continue. I applaud the REACH communities for what they have championed to allow these stories to be told.

-Leandris C. Liburd, PhD, MPH, MA

Chief of the Community Health and

and Equity Branch at the CDC,

Atlanta, Georgia

REFERENCE