[Community drivers of health are] the circumstance in which we are

born, grow up, live, work and age, and the systems put in place to deal
with illness. 1
Evidence-based suggestions for communicating about drivers of health: 2
o Use one compelling fact per message
o Include solutions when identifying problems
o Appeal to the idea of personal responsibility
o Focus on the general population, not specific groups
o Prime audiences with messages they already believe, before introducing new
ideas
o Specific examples compel audiences
Phrases to use when communicating about drivers of health:
o Make the healthy choice, the easiest choice
o Health is the product of a patients total environment
o Opportunities for health begin before people need medical care. They begin in
schools, work places and neighborhoods.
o Everyone can have a fair change for good health
o Enabling people to choose the right path
o Providing the tools people need to make better health decisions
Phrases to avoid when communicating about drivers of health:
o Insured/uninsured
o Inequalities, equality, equal
o Disparities

The length and quality of life is primarily influenced by social, physical,

and economic environments. Only a small portion of health (15-20%) can
be contributed to clinical care. 3,4,5,6
To create social and physical environments that promote good health for all it is
important to address access to educational, economic and job opportunities, access
to health care services, and the quality of education and job training. 7
Studies suggest that improving community drivers of health will impact population
health significantly more than advances in medical care. 8,9,10
A national survey of physicians found that 85 percent believe community drivers of
health impact their patients health just as much as medical care. 11
Preventing health problems requires providing people with information and creating
environments that support healthy responses to that information. 12
o Informing people about healthy behaviors is not enough. We need to focus on
the environment that influences health decisions, instead of relying on
individual behaviors to achieve health.
- For example, educating people on the importance of eating fruits and
vegetables will have little impact on dietary habits if people lack accessible
and affordable places to purchase fresh produce. 13
o Multiple Risk Factor Intervention Trial 14
- 12,000 men at high risk for heart disease
- Half of the men were instructed to reduce their risk by changing their diet,
taking high-blood pressure medication, ceasing to smoke and reporting
frequently to the health clinic
- The other half did not receive any information on these health behaviors
- After six years, the men who were told how to reduce their risk were no
healthier than the other men. Why? Nothing was done to change the
environment or make healthier choices more accessible to those men.
o Changing the environment to be more conducive to making healthy choices
has dramatic effects, relying on individual behavior does not.
o When people are equipped with the tools they need to make healthy choices,
they feel empowered to do so.

Engaging a variety of stakeholders

The Sonoma County Department of Health Services in California is currently
implementing a community health program that focuses on education, health
systems and income. The initiative was developed due to the risk of a hospital
leaving the county. Not only has the program allowed the hospital to stay open, it
also forged partnerships between a variety of stakeholders in the community.

Creating cross-sectorial partnerships:

Health in All Policies: A Guide for State and Local Governments was a partnership
between the American Public Health Association, the Public Health Institute and the
California Department of Public Health focusing on job creation and economic
stability and educational attainment. The program emphasized collaboration across
sectors when addressing community drivers of health. Specifically, public health
organizations can support organizations outside the realm of health by offering health
messaging to help meet the organizations goals.
Example: Partner with parks and recreation departments to promote exercise,
benefits of green spaces and other health benefits that encourage the use of their
facilities.

Giving community members a voice in health policy:

GetInvolved is an online toolkit available to government agencies to facilitate
community engagement. Tools include online forums, surveys and polls to
streamline community feedback and opinions about health policies, etc.

Stakeholders: Emphasize that addressing these drivers of health

benefits the interests of many stakeholders in the community.
o When speaking to members of other sectors of the community, frame health
messages into ideas that benefit the priorities of these sectors rather than
simply emphasizing the need the address community drivers of health.
o Use phrases that appeal to a variety of sectors: health and well being,
community resilience, sustainability 15
o Example: For government workers concerned about the economy, discuss
addressing education, the economy and access to health care as creating a
vibrant community and economy.

Community members: Transportation is an issue for some residents of

Alamance County. Social media is a viable option to engage residents
who cannot be physically present at public meetings, etc.
o Promote community engagement by demonstrating a clear vision for the
future of the community, situating efforts to address community drivers of
health within that vision.

Stakeholder engagement may include:

o
o
o
o
o
o
o
o

One-on-one discussions
Community workshops, meetings, forums, listening sessions, or focus groups
Webinars with a discussion feature
Teleconferences
Formal or informal advisory groups
Public input periods at government meetings or hearings
Invitations for written input
Social media or other uses of online communications 16

Investments in education are investments in health. 17

Evidence-based research
o Research shows that people with higher levels of education and adequate
income experience lower risks for several illnesses and an increased life
expectancy. 18,19,20
o The health of students significantly impacts school attendance, academic
performance and dropout rates. 21,22
o Individuals with more education are healthier than individuals with less
education, even when they have equal access to health care. According to
Kaiser Permanente, 69 percent of adults with a college degree report having
very good or excellent health. Among adults who do not have a high school
diploma, that percentage drops to 32 percent. 23

Interventions addressing education

Educating parents to obtain skilled jobs
o A study of Kanas children revealed that those living in households without a
high school graduate experienced health problems at four times the rate of
children living in a household with an adult college graduate.24 Considering
these study results, the Ready-To-Work program was created to forge
partnerships between businesses, public health organizations and community
colleges to help increase working wages and education levels. Specifically,
the program helps people pursue higher education at technical and
community colleges. Compared to the control group, program participants
had higher wages and longer employment lengths. 25
Educating children for economic stability in adulthood
o Research shows that by the age of 27, children who attended a part-time
preschool earn 60 percent more than their peers who did not attend
preschool. Early childhood education programs (i.e. intensive preschool
programs for low-income children) have been shown to be cost-effective. 26

Economic well-being is one of the most critical determinants of health;

living in poverty is associated with significantly worse health outcomes
across all races and ethnicities and in every state and community. 27
Evidence-based research
o Unemployment has been linked with poor physical, mental and emotional
health. 28
o The relative strength of the economy and economic opportunities directly
influence health through financial resources, job benefits (i.e. health insurance),
access to health care and potentially hazardous work environments and poor
working conditions. 29

Interventions addressing the economy

Empowering women with economic knowledge
o Understanding that poverty is linked with poor health, the Contra Costa County
Public Health Department started a program to help women understand the
process of income tax and how to apply for tax credit.
o The health department advanced the health of women and their children by
addressing economic concerns. Program participants report understanding the
impact of money on health and how to handle money.

Hospitals recognize that if they help improve community access to

health care, preventive care, and healthy lifestyle behaviors, they have
the ability to significantly reduce the incidence of chronic diseases and
reduce unnecessary inpatient admissions and ED visits. 30
Evidence-based research

o In addition to basic address to primary care, there is a need to improve health

literacy. Health literacy is the ability to access and understand health
information and health services in order to make educated health decisions.31

Interventions addressing access to health care

Linking low-income families with health resources
o Health Leads focuses on expanding the impact of health clinics to link patients
with non-medical resources they need to be healthy. Doctors recommend
related resources such as housing, healthier food, etc. and volunteers link
patients with those critical resources. This program allows primary care
physicians to consider community drivers of health as a component of patient
care.
Connecting at-risk individuals to diabetes care
o Targeting an area with a diabetes rate double the national rate, Rush University
Medial Center partnered with a number of health organizations and nonprofits
to conduct diabetes screenings and connect residents to local physicians
along with other health resources.
o A majority of the local population could not afford to see a doctor when they
were sick and struggled with language barriers, but as a result of the program,
more than 1,000 residents have been linked with a health care provider. The
program also offers educational programs and healthy cooking
demonstrations tailored toward diabetes patients. 32

Health Systems Learning Group

With support from the Robert Wood Johnson Foundation
They are working to identify best practices for hospitals nationwide to help improve
population health through community collaborations. In the future, they plan to track the
return on investment of preventative programs and their effect on hospital readmissions.

Healthy People 2020: Social Determinants of Health

Provides a comprehensive list of national, state and local-level interventions addressing
community drivers of health outcomes. Interventions are classified by the specific
determinant they address (i.e. education, economy).

Managing Population Health: The Role of the Hospital

Offers strategies for hospitals to address population health. Case studies are included as
supporting evidence.

Institute for Alternative Futures

Leveraging the social determinants of health
Outlines evidence for focusing on community drivers of health outcomes and lists current
and upcoming trends for community health. Also includes several case studies of prior
interventions focusing on community drivers of health.

Virginia Commonwealth University Center on Society and Health

Details the relationship between education and health. Offers an evidence-based argument
for the need to strengthen education as a means to improve population health.

Commission on Social Determinants of Health. 2008. 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: World Health Organization.
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
2
Robert Wood Johnson Foundation. 2010. A new way to talk about the social determinants of health.
http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023
4

McGinnis, J. M., Williams-Russo, P., & Knickman, J. A. 2002. The case for more active policy attention to health promotion.
Health Affairs, 21(2), 83.
5
Robert Wood Johnson Foundation, Commission to Build a Healthier America. 2012. What drives health.
http://www.commissiononhealth.org/WhatDrivesHealth.aspx
6
Williams., et al. 2008. Moving upstream: How interventions that address the social determinants of health can improve health
and reduce disparities. Journal of Public Health Management Practice Supplement.
http://www.ncbi.nlm.nih.gov/pubmed/18843244
7
Healthy People 2020. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
8
Braveman, Egerter & Mockenhaupt. 2011. Broadening the focus: The need to address the social determinants of health.
American Journal of Preventive Medicine.
9
Bottle, Gnani, Saxena, Aylin, Mainous & Majeed. 2008. Association between quality of primary care and hospitalization for
coronary heart disease in England: National cross-sectional study. Journal of General Internal Medicine.
10
Raphael, 2006. Social determinants of health: An overview of concepts and issues.
11
Institute for Alternative Futures, 2012. Community health centers leveraging the social determinants of health.
http://www.altfutures.org/pubs/leveragingSDH/IAF-CHCsLeveragingSDH.pdf
12
National Prevention, Health Promotion, and Public Health Council, 2014 Annual Status Report.
http://www.surgeongeneral.gov/priorities/prevention/2014-npc-status-report.pdf
13
Centers for Disease Control and Prevention. 2008. Promoting Health Equity: A Resource to Help Communities Address Social
Determinants of Health. http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/SDOHworkbook.pdf
14
Journal of the American Medical Association, 1982. Multiple risk factor intervention trial.
15
Institute for Alternative Futures. 2012. http://www.altfutures.org/pubs/leveragingSDH/IAF-CHCsLeveragingSDH.pdf
16
Rudolph et al. 2013. Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA:
American Public Health Association and Public Health Institute. http://www.phi.org/resources/?resource=hiapguide
17
Virginia Commonwealth University Center on Society and Health. http://www.societyhealth.vcu.edu/
18
Chang & Romero. 2008. Present, engaged & accounted for: The critical importance of addressing chronic absence in the early
grades. New York: National Center for Children in Poverty.
19
Jackson, Vann, Kotch, Pahel & Lee. 2011. Impact of poor oral health on childrens school attendance and performance.
American Journal of Public Health.
20
Olshansky, et al. 2012. Differences in life expectancy due to race and educational differences are widening, and many may not
catch up. Health Affairs.
21
Philip R. Lee Institute for Health Policy Studies. 2009.
http://www.calendow.org/uploadedFiles/Publications/By_Topic/Access/General/Critical Connection between Student.pdf
22
Baltimore Education Research Consortium. 2011
23
Virginia Commonwealth University Center on Society and Health. http://www.societyhealth.vcu.edu/
24
Childrens Health in All Policies. 2010.
http://www.naccho.org/toolbox/_toolbox/Children%27s_Health_in_All_Policies_A_Workbook__1.pdf
25
Childrens Health in All Policies. 2010.
http://www.naccho.org/toolbox/_toolbox/Children%27s_Health_in_All_Policies_A_Workbook__1.pdf
26
RAND Corporation. 1998. Investing in our children: What we know and dont know about the costs and benefits of
early childhood interventions. http://www.rand.org/content/dam/rand/pubs/monograph_reports/1998/MR898.pdf
27
Adler, N. E., & Newman, K., 2002. Pathways and policies. Health Affairs.
28
Dooley, D., Fielding, J., & Levi, L. 1996. Health and unemployment. Annual Review of Public Health.
29
Kaplan, G. A. 2009. The poor pay more: Povertys high cost to health. Robert Wood Johnson Foundation.
30
American Hospital Association. 2012. Managing Population Health: The role of the hospital.
http://www.hpoe.org/resources/hpoehretaha-guides/805
31

Healthy People 2020. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health

American Hospital Association. 2012. Managing Population Health: The role of the hospital.
http://www.hpoe.org/resources/hpoehretaha-guides/805
32