Health Promotion and Health Equity

Introduction

Local boards of health (LBOH) are responsible for protecting the public's health by providing the 10 Essential Public Health Services outlined by the Centers for Disease Control and Prevention (CDC). One of these essential services is to communicate effectively to inform and educate people about health, factors that influence it, and how to improve it. According to the World Health Organization (WHO), health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions. Health equity is a framework for addressing the social and environmental factors that contribute to negative health outcomes in specific segments of the population. This training will detail what is meant by health and health equity. It will also outline health promotion strategies that LBOH can use when planning and implementing interventions that support the health and well-being of all individuals and families in their community.

Companion trainings include:

Learning Objectives

After completing this training, you will be able to:

 

Healthy People Initiative

The Centers for Disease Control and Prevention (CDC)'s Healthy People initiative provides science-based national goals and objectives with ten-year targets. The initiative is designed to guide national health promotion efforts with the goal of improving the health of all people in the United States.

Healthy People 2020 (HP 2020) has four overarching goals:

  1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
  2. Achieve health equity, eliminate disparities, and improve the health of all groups
  3. Create social and physical environments that promote good health for all
  4. Promote quality of life, healthy development, and healthy behaviors across all life stages

HP 2030 has been released. It is the fifth iteration of the Healthy People initiative and builds on knowledge gained over the past four decades. You can learn more by visiting the Additional Resources (last page of this training).

Leading Health Indicators

To reach these goals nationally, every ten years the CDC identifies leading health indicators (LHI) to communicate high-priority health issues and actions that can be taken to address them. The LHI serve as measure of the nation's health.

HP 2020 Topics  

The HP 2020 LHI can be categorized into 12 topics:

  1. Access to Health Services
  2. Clinical Preventive Services
  3. Environmental Quality
  4. Injury and Violence
  5. Maternal, Infant, and Child Health
  6. Mental Health
  7. Nutrition, Physical Activity, and Obesity
  8. Oral Health
  9. Reproductive and Sexual Health
  10. Social Determinants
  11. Substance Abuse
  12. Tobacco

 

 

It is important to note that the goals of the Healthy People initiative can't be reached without multi-sector collaboration and community partnerships.

 

How do you define your community? Who are your community partners?


Map of Massachusetts

Be sure to think about your community in a broad sense.

Community can be defined by geography, institution type, population characteristics (i.e., race, sexual orientation, religion, culture), or other factors that members have in common.

Community partners might include other government departments or agencies, non-profit or faith-based groups, businesses, health care organizations, and academic institutions.

 

 

 Complete the knowledge check below. Note: this is unscored so you will see a group quiz score of 0/0.

   

 

What is Health?

The WHO defines health as a state of complete physical, mental, and social well-being; not merely the absence of disease or infirmity.

Health is determined by many things:

  1. Social and economic factors
  2. Physical environment
  3. Health care
  4. Health behaviors
  5. Genes and biology

The 2017 Massachusetts State Health Assessment illustrates that genes, biology, and health care represent only a small percent of what makes us healthy (20%). Social and economic factors have a much greater impact (40%).

 

What makes us healthy?

Social Determinants of Health

Social determinants of health are economic and social conditions that influence the health of people and communities. These conditions are shaped by the amount of money, power, and resources that people have access to. Oftentimes, they are also influenced by policies, institutions, and systems created by people with access to money, power, and resources.

The result is not everyone experiences the same opportunities for good health. Where you live, work, and play is a strong dictator of your health and well-being (individual, family, or community).

Before moving on, see if you can list economic and social conditions that can influence health.


The following are some examples:

  • Access to good schools and affordable professional education
  • Being able to find and keep a job
  • The type of work a person does
  • Access to public transportation
  • Having enough food, or being able to buy nutritious food
  • Stable housing
  • A safe community that has open spaces, parks, and other recreational areas
  • Social supports
  • Freedom from discrimination and bias

 

 

The Massachusetts Department of Public Health (MDPH) has grouped social determinants of health into six categories:

  1. Built Environment
  2. Education
  3. Employment
  4. Housing
  5. Social Environment
  6. Violence

 

MA Six Social Determinants of Health Categories

By identifying and prioritizing these categories, MDPH is aiming to transform inequitable policies, cultural norms, and structural barriers so that all people will have the same opportunity to be healthy, regardless of race, ethnicity, income, ability, sexual orientation, gender identity, age, or zip code.

Public Health 3.0

Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure (PH 3.0) is a report that addresses the need to focus on the social determinants of health as a way of creating lasting health improvements for everyone. PH 3.0 is a new model that calls for local public health agencies to move beyond traditional roles and to engage multiple sectors and community partners to generate collective impact and achieve health equity.

Important Quotes

"We have made great strides in the last several years to expand health care coverage and access to medical care and preventive services, but these successes have not yet brought everyone in America to an equitable level of improved health. Today, a person's zip code is a stronger determinant of health than their genetic code.......In order to solve the fundamental challenges of population health, we must address the full range of factors that influence a person's overall health and well-being."

 "Public health is what we do together as a society to ensure the conditions in which everyone can be healthy......When we build a complete infrastructure of healthy communities, we can begin to close the gaps in health due to race or ethnicity, gender identity or sexual orientation, zip code or income."

-- Karen B. DeSalvo, Assistant Secretary for Health (acting), U.S. Department of Health and Human Services, PH 3.0

 

 

What is Health Equity?

Healthy People 2000 (HP 2000) and 2010 (HP 2010) included goals that focused on health disparities. HP 2000 aimed to reduce health disparities among Americans and HP 2010 aimed to eliminate, not just reduce, those health disparities.

For the first time in the initiative's history, HP 2030 includes an emphasis on health literacy and this is is reflected in foundational principles and overarching goals.

In September 2020, a revised version of the 10 Essential Public Health Services (EPHS) was released to address the dramatic shift in the public health landscape since they were initially released 25 years prior.

To achieve equity, the EPHS actively promote policies, systems, and overall community conditions that enable optimal health for all and seek to remove systemic and structural barriers that have resulted in health inequities. Such barriers include poverty, racism, gender discrimination, ableism, and other forms of oppression. Everyone should have a fair and just opportunity to achieve optimal health and well-being

10 EPHS

The following definitions are from the San Francisco State University Health Equity Institute.

Health Equity

Attainment of the highest level of health for all people

Health Inequities

Differences in health that are avoidable, unfair, and unjust

Health Disparities

Differences in health outcomes among groups of people

Health equity means ensuring all people have full and equitable access to opportunities that allow them to lead healthy lives. This requires a commitment on the professional and health department level to:

The MDPH Health Equity Workgroup, which includes both MDPH staff and community stakeholders, has expanded the definition of health equity to include both the process and the outcome of addressing disparities by considering the social determinants of health.

This establishes health equity as not just an ideal state where everyone has the same access to, and quality of, care or health outcomes. Rather, it is also the ongoing process of assessing and improving of systems in order to eliminate the inequities that result in, or perpetuate, disparities.

Inequities involve the social drivers as well as the systemic factors (i.e., policies) that result in health and other disparities among populations.

Example - Infant Mortality

The infant mortality goal of HP 2020 is 6 deaths per 1,000 live births.

The 2017 Massachusetts State Health Assessment reports that Massachusetts achieved a 2.6% annual decline in the infant mortality rate from 2005 to 2014 and currently has the lowest rate of all of the states in the nation.

Yet, racial and ethnic disparities still persist.

 

Infant Mortality Rate by Race/Ethnicity in MA, 2014

Race/Ethnicity

Infant Mortality Rate (per 1,000 live births) in 2014

Asian, non-Hispanic

2.9

White, non-Hispanic

3.4

Hispanic

5.0

Black, non-Hispanic

7.3

 

MA Communities with the Highest Infant Mortality Rate, 2014

Town

Infant Mortality Rate (per 1,000 live births) in 2014

Fitchburg

9.9

Chelsea

8.5

Worcester

7.4

 

Before moving on, think about what causes these disparities in infant mortality rate. Would you consider these inequities? Now consider what steps we can take to achieve health equity.


According to the 2017 Massachusetts State Health Assessment, "disparities in infant mortality rate result from differential developmental pathways shaped by early life experiences and cumulative wear and tear on the body as an individual is exposed to repeated or chronic stress over time."

Repeated or chronic stressors such as poor/unstable housing, environmental hazards in the community or on the job, limited access to nourishing food, discrimination, or no access to adequate health insurance and/or health care can be contributing factors to a higher infant mortality rate.

The disparities in the infant mortality rate in Massachusetts do constitute an inequity because the outcomes vary by racial/ethnic category and by geographic location. Even when individual health behaviors like smoking and alcohol consumption rates for pregnant women are considered, the infant mortality rate for some groups remain high, indicating that the outcomes may be a result of their environment, which is both unjust and preventable.

In order to achieve health equity, women's exposure to risk factors must be addressed not only during pregnancy, but over their life course. Doing so must take into account all of the social determinants that impact a woman's ability to be healthy, stay healthy, and help her child be and stay healthy

 

 

Health Promotion for Everyday Practice

As you can see, there are many factors that influence the health and health behaviors of individuals and communities.

There are several models and theories that can be used to better understand and explain health behaviors and influences. The information gathered from these models and theories can better inform and guide the planning, implementation, and effectiveness of interventions aimed at improving health.

Models and Theories

The Rural Health Information Hub (RHIhub) has identified and described five theories and models that most health promotion and disease prevention programs incorporate:

  1. Ecological Models (highlight people's interactions with their physical and sociocultural environments)
  2. Health Belief Model (explains and predicts individual changes in behavior based on individual beliefs)
  3. Social Cognitive Theory (provides opportunities for social support through instilling expectations, self-efficacy, and other reinforcements to achieve behavior change)
  4. Stages of Change/Transtheoretical Model (explains an individual's readiness to change their behavior in six stages - (1) pre-contemplation (2) contemplation (3) preparation (4) action (5) maintenance and (6) termination)
  5. Theory of Reasoned Action/Planned Behavior (suggests a person's health behavior is determined by their intention to perform a behavior with their intention predicted by attitude and subjective norms)

Further information about these five theories and models can be found in Additional Resources (last page of this training).

It is important to note that no one model works for every situation.

More Important Quotes

"The 'art and science' of health promotion is not an either/or situation; it is about both the application of good judgment and the availability of relevant knowledge. Good judgment requires more and varied experience, and the relevant knowledge requires applied research that can be directly transferred into practice."

"A key future challenge for health promotion is to develop a cadre of professionals that are able to bridge the gap between theory and practice, and who are trained in the application of the 'art and science' in a range of contexts, including in fragile populations, and in using new communication technologies."

-- Glenn Laverack, author, "The Challenge of the 'Art and Science' of Health Promotion"

 

Strategies

In addition to models and theories, there are also many strategies that can assist you in integrating health promotion and disease prevention perspectives into everyday practice. Three commonly used strategies outlined by RHIhub are:

1. Health Communication

2. Health Education

3. Policy, Systems, and Environmental Change

1. Health Communication

The CDC defines health communication as the study and use of communication strategies to inform and influence individual decisions that enhance health.

Health communication refers to verbal and written strategies used to influence and empower individuals, populations, and communities to make healthier choices.

Health communication can play a powerful role in working toward health equity. Start by identifying your target population (communities within communities) and tailor communications to their specific needs. Involving members of those communities in the process is also a vital key to success.

Think about an intervention you have been involved with. How did you communicate your message? What did you consider during the planning stages of the intervention?


Common ways to communicate include radio, television, newspapers, flyers, posters, brochures, websites, and social media. Understanding where different members of the community get their information is key (i.e., senior centers, hair salons, Spanish-speaking radio programs).

When planning, be very clear about your communication goal, and be sure you understand your target audience. The information must be relevant and clear to members of your target audience. Make sure they have access to the communication avenues you selected.

Engaging representatives from the target community, or working with coalitions that have representation from the community, to craft the communication plan will increase the chances for success.

 

Two posters - one in english and one in spanish  

2. Health Education

The WHO defines health education as any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.

Health education activities present information to target populations on particular health topics, including health benefits and threats they may face, and provide participants with tools to build capacity and support behavior change in an appropriate setting. Health education activities include lectures, courses, webinars, workshops, and classes.

The Massachusetts Health Promotion Clearinghouse offers free health promotion materials for Massachusetts residents, health care providers, and social service providers. These free materials, which are offered in multiple languages and address diverse community needs, can be used as a part of your health communication and health education efforts.

3. Policy, Systems, and Environmental Change

In order to maximize health promotion efforts, policies, systems, and environments must be supportive of health. This includes considering the social determinants of health in the target community, and making sure that healthy choices are readily available and accessible in that community.

As an example, the Bay Area Regional Health Inequities Initiative developed a conceptual framework that illustrates the connection between social inequalities and health. The framework focuses attention on upstream efforts that address social and institutional inequities and living conditions, rather than downstream ones such as risk behaviors.

 

A public health framework for reducing health inequities

 

In 2014, Massachusetts was the first state to declare opioids a public health emergency. It was declared a nationwide public health emergency in 2017. Think about how you could use the three health promotion strategies to address the opioid epidemic in your community.


Start by gathering data. On mass.gov, you can find current opioid statistics, prescription drop box locations, and information about overdose prevention and Naloxone access. You can also find links to free communication and education materials on opioid overdose prevention, including posters (in multiple languages), magnets, brochures, and fact sheet packets.

Think about the social determinants of health, and how you can adopt policies or make changes to the system or environment. You might offer a needle exchange and/or drug take-back program in your community. You could also deliver overdose prevention training, supply Naloxone, or educate patients, providers, and the general public about the epidemic.

The next section will explain how to get started with your health promotion activities, and how to put your plan into action.

 

 

 

 

Health Promotion Planning and Action

Health promotion works best when there is a thoughtful planning and implementation process.

Getting Started

In the planning phase, you should:

  1. Identify the problem
  2. Define the at-risk population
  3. Collect data

Identify the Problem

The planning process should begin by identifying the problem. In other words, what is the issue and what effect is it having on the community?

Ask these types of questions:

  • What's wrong?
  • What can be done about it?
  • Are there treatments or interventions available?
  • Is it preventable?
  • Who is most affected?
  • Are there disparities or inequities?
  • What are some underlying factors and root causes that must be considered and addressed?
  • Is the problem specific to a geographic area, age, culture, or other demographic?
  • What are the consequences if the problem is not addressed?
  • Who can you partner with to ensure the plan addresses the problem in a community-appropriate way (i.e., community-based agencies, community groups, health institutions, academic institutions, business community)
  • Who in the community is already working on this problem?

Define the At-Risk Population

Once the problem is identified, you should figure out who is at risk and why.

Ask these types of questions:

  • Where do they live?
  • What are the values, attitudes, beliefs, customs, and current behaviors that impact the problem (both positively and negatively)?
  • What is their level of awareness of the problem?
  • What are their values, attitudes, beliefs, habits, and current behaviors?
  • How and where do they get their health information?
  • What barriers to making the desired change do this population face?
  • How can we get members of this population involved in the process? Who are the change leaders in that community?

Collect Data

Once the problem and at-risk population have been identified, the next step is to learn as much as possible about the problem. Be sure to collect data and other information from a variety of reliable sources.

Reliable sources include:

  • Government agencies (federal, state, and local)
  • Health statistic portals (government and non-government)
  • Hospital community health assessments
  • Community partners, community groups, and community members interested in participating in the planning, implementation. and evaluation process


Note: Wikipedia, tweets, and personal websites or blogs are not reliable sources of data.

 

 

Action Plan

After completing the planning phase, it is time to put your plan into action. Remember, if you want to increase your chances for success and work toward health equity, then you must include members of the community you are focusing on in all aspects of the process.

Print or save this Action Planning template, developed by Health Resources in Action (HRiA), which can help you turn your vision into a concrete plan.

The template outlines seven elements that should be part of any action plan:

  1. Goal
  2. Objectives
  3. Strategies (or action steps)
  4. Partners/persons responsible
  5. Timeline
  6. Outcome indicators
  7. Monitoring/evaluation approach

Do your health promotion activities include other elements?


There is no right or wrong answer. Your plan may just address these seven key elements, or your population, partners, and/or goals may choose to add more.

Additional elements may include available resources, potential barriers, or expected challenges.

Your template might ask questions like:

  • What are you looking to improve?
  • What are you going to change to get there?
  • How will you measure your progress?
  • How will you build on the findings?

Don't forget to include a strategy for monitoring/evaluation to assess if your plan worked.

A quality improvement tool called Plan-Do-Study-Act (PDSA) allows for a rapid quality improvement process. Its four steps include assessing/identifying areas for improvement (plan), selecting one small change you can implement quickly (do), monitoring the change for a specified time and reviewing the impact (study), and deciding whether to keep, modify, or abandon the change (act). This PDSA cycle can be repeated for multiple changes.

 

Complete the knowledge check below. Note: this is unscored so you will see a group quiz score of 0/0.

   

 

Moving Forward

The vision and mission of the MDPH is to support health equity for all people in the Commonwealth.

According to the 2017 Massachusetts State Health Assessment, "the good news is that because most health inequities result from socially-determined structural inequities, change is possible. We can begin to improve health for a whole community when systems and structures, such as structural racism or gender bias, are acknowledged and explicitly addressed. By transforming inequitable policies, cultural norms, and structural barriers, we can move towards a Commonwealth where all people have the same opportunities to be healthy, regardless of race, ethnicity, income, ability, sexual orientation, gender identity, or age."

MDPH mission and vision supported by data and focusing on determinants and disparities.

As you are working to promote health in your community, how can you also support health equity?


Asking the right questions in the planning phase, and ensuring your action plan includes the necessary elements for success, including evaluation, will support health equity.

Other ways include:

  1. Focusing on the social determinants of health, and striving to eliminate health disparities
  2. Engaging the community in all parts of the process
  3. Using relevant, timely data
  4. Acknowledging historical and current injustices, and ensuring your plan does not further such practices

 

Local Community in Action

The Communities That Care Coalition (CTC) was formed in 2002 in Franklin County, MA, when a group of community members came together to address alcohol, tobacco, and other drug use among local youth.

The vision of the CTC is that Franklin County and the North Quabbin region be a place where young people are able to reach their full potential and thrive with ongoing and coordinated support from schools, parents, and the community.

word cloud

The CTC uses data about the status of local young people to identify needs and measure the success of their programs.

With a robust set of diverse community partners, the CTC has:

After the public release of data from the 2016 Teen Health Survey, the CTC adopted a new goal to "increase health equity in Franklin County and the North Quabbin region, specifically in our coalition's priority areas."

Since the report was released, the CTC has been exploring ways to incorporate racial justice into its coalition culture, goals, and plans. To support this, the CTC decided to add a racial justice workgroup to its current organizational structure. The scope for this new workgroup is currently being developed.

  

Conclusion and Additional Resources

Congratulations! You have completed the training.

Print or save this Job Aid (PDF) that summarizes the key points.

Review the Learning Objectives

You are now able to:

If you feel you need additional exposure to this material, you may repeat the training or refer back to any of the pages at any time.

Additional Resources

If you would like further information about this topic, please consult the following websites and materials.

Health Equity

Health Promotion

Post-test and Certificate of Completion

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