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PED0010.1177/1757975913501006CommentaryC. Blanchard et al.
Commentary Learning from communities in the USA and England to promote equity and address the social determinants of health Claire Blanchard1, Martin Gibbs2, Ginder Narle3 and Chris Brookes4
Abstract: This commentary contextualises and documents the process of a twinning learning exchange between the US Racial and Ethnic Approaches to Community Health initiative and the Communities for Health initiative in England to enable the transfer and adaptation of ideas for similar communityfocused initiatives in various contexts globally. The multi-partner twinning exchange built on and shared knowledge around community health promotion interventions, targeting ‘marginalised’ populations and focused on addressing the social determinants of health to effectively reduce health inequalities. This commentary presents the methodology of the exchange; provides key themes, outcomes and lessons learnt that arose from discussions and the experience; and provides insights, considerations and recommendations for adaptation. Finally, it highlights the importance of such exchanges in the current global context and the need for their replication and adaptation. These experiences contribute to building the evidence base on successful interventions and identifying strategies that work for improving health outcomes and reducing health inequalities. They strengthen the need for all governments to address the social determinants of health as a priority whilst providing insights to inform successful policy. (Global Health Promotion, 2013; 20 Supp. 4: 104–112). Keywords: social determinants of health (SDH), inequalities, learning exchange, cross-learning, noncommmunicable diseases, communities Transforming the health of communities requires development of the social determinants of health and the built environment, where people live, work and play and prevention across a full spectrum of factors influencing the lifespan of individuals and communities as the thread of the social fabric. (Mona Fouad)
Introduction This summary commentary contextualises and documents the process of a twinning learning exchange between the US Racial and Ethnic Approaches to Community Health initiative (REACH USi) and the Communities for Health (C4Hii) initiative in England. 1. 2. 3. 4.
For an in-depth analysis of the exchange see Blanchard et al. (1). The purpose was to enable the transfer and adaptation of ideas for similar community-focused initiatives in various contexts globally, a dimension often overlooked and yet essential to health promotion efforts. The multi-partner twinning exchange built on and shared knowledge around community health promotion interventions, targeting ‘marginalised’ populations and focused on addressing the social determinants of health (SDH) to effectively reduce health inequalities. These efforts were inspired and informed by major recent global efforts (2–6) and are part of the International Union for Health Promotion and Education’s (IUHPE) priority area of action for
International Union for Health Promotion and Education (IUHPE), St Denis cedex, France. Health Inequalities and Inclusion Health, Department of Health (DH), London, UK. Learning for Public Health West Midlands (LPHWM), Sandwell Primary Care Trust, West Bromwich, UK. Health Action Partnership International (HAPI), London, UK.
Correspondence to: Claire Blanchard, IUHPE, 42 bvd de la Libération, 93203 St Denis cedex, France. Email: [email protected] Global Health Promotion 1757-9759; Vol 20 Supp. 4: 104–112; 501006 Copyright © The Author(s) 2013, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913501006 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on March 25, 2015
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2011–2016 on the social determinants of health. The innovative and successful partnership between the US Centers for Disease Control and Prevention (CDC), the IUHPE, the Department of Health (DH) of England, Health Action Partnership International (HAPI), and more recently Learning for Public Health West Midlands (LPHWM), enabled this exchange to happen.
competent and linguistically appropriate health-care services (e.g. prenatal care) by incorporating community health workers and youths in advocating for health, and utilizing community-driven assessments to drive change (11). During the time of the twinning exchange, there were more than 50 CDC-funded REACH communities working to eliminate health disparities across the country.
Historical context
Methodology
Launched in 2005, C4H was a new approach to unlock the energy within communities to make changes to their lifestyle that would enable them to improve their health, and support individuals to live healthier lives. Local authorities across England delivered a range of activities to engage communities in their own health and develop their capacity to support individual behavioural change for healthier lifestyles, build partnerships between organisations and communities; and develop innovative practices for community-based health improvement. The programme was innovative in providing health funding to local authorities and in allowing local communities to identify their own priorities for action. It demonstrated how local authorities are able to take a leading role, working with their local partners and communities, to address the health needs of their population and tackle health inequalities. The REACH US programme began in 1999 as the cornerstone of the CDC’s efforts to eliminate racial and ethnic health disparities in the United States. The various REACH US partners use community-based, participatory approaches to address health disparities across a wide range of health priority areas. Data from the REACH US Risk Factor Survey demonstrate that residents in most of the minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for and burden of disease compared with the general populations living in the same metropolitan area, county, or state (7). REACH communities have successfully employed policy, systems and environmental change strategies to address the social determinants of health, and through these actions have begun to close the gap in health disparities (8–10). They have also demonstrated change in the conditions that contribute to health, such as access to culturally
The idea of a learning exchange developed from a visit by the CDC to the DH in 2008 and a lengthy exploratory phase to figure out how to best adapt the exchange to both political environments. A scan of community programmes focused on addressing health inequalities in England identified the C4H as a good match for the REACH US programme, recognising that there were two significant differences: 1. The REACH programme had a greater focus on ethnicity and the C4H programme focused more on socio-economic status and health outcomes; 2. There is a stronger tradition of ‘community activism’ in the US, compared to local government intervention in England. Community profiles informed the identification of suitable REACH US and C4H communities for twinning. This process was driven by two initial questions (‘What learning would the community like to achieve through the proposed exchange?’ and ‘What have the communities already learnt from their work that they can start sharing with others?’), and selection was based on a set of criteria under three headings: Community by geography, Health challenge and Programme activity. To provide a systematic process to help guide participants in the exchange visits, a semi-structured framework was developed with help from leading global experts in health inequalities. The framework was a useful checklist of areas to explore through the exchange. A glossary of common understanding of the terms for the initiative was also developed. The first site visits were made in November 2011 to the US. The experience of community representatives led to the identification of four major themes which informed a second set of site visits by US colleagues in England in June 2012. IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
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Table 1 provides an overview of the methodological stages, detailed steps and lessons learnt from the present efforts. Throughout the planning, implementation and evaluation phases of the twinning exchange, CDC, IUHPE, and C4H colleagues and other experts collaborated to generate key areas for learning and developed a framework to guide participants in the analysis of the exchange. As it was important to facilitate learning across communities, CDC technical staff and C4H key actors accompanied community partners on both ‘legs’ of the visit, providing background, technical assistance and guidance to the exchanges.
Insights and recommendations for adaptation – learning from experience The twinning learning exchange described here was conducted in two high income countries and thus as shaped by very specific circumstances. For adaptation to other environments, it is important to understand the situation of this context. Some insights from the present experience to bear in mind when embarking on such efforts: 1. This sort of initiative can be time-consuming for all participants. 2. Flexibility in project methodology, expectations and budget is key to making these efforts happen. 3. A good working team with a positive, openminded and asset-focused approach was an essential ingredient for success. Clear roles and responsibilities as well as a focal point and overall coordinator are important to maintain momentum.
Considerations for adaptation For adaptation of these efforts, it is important to consider potential facilitators, barriers, contexts, circumstances and available resources (financial, human and others). For example, adaptation to other country settings may need to take potentially favourable (open-minded multi-sectorally oriented officials, engagement and enthusiasm, etc...) and impeding (corrupt officials or local authorities that do not have the flexibility of facilitating or supporting such exchanges, cost and ease of
transportation, time required to conduct an exchange, etc...) factors into consideration. With some important reports of decreased inequalities in low and middle income countries in Latin America (12), it would be extremely valuable to have a similar twinning or even a tripartite exchange between countries like Argentina, Brazil and Mexico and/or others outside the region to identify whether some of the learnings from the present exchange are shared by other countries and their community efforts.
Innovation through partnership The essential ingredients for the success of this exchange were the leadership, dedication and flexibility in design and implementation to respond to the constantly evolving political contexts of the partners that initiated these efforts in 2008; the active engagement and participation of all appropriate stakeholders and global experts at key steps under the leadership of a small manageable and nimble working project team; and the support of various partner institutions over the years. This is exactly the kind of partnership the IUHPE is keen to foster and engage in as it not only re-iterates health promotion concepts but fully embraces them and puts them into practice starting from within.
Key themes and lessons learnt arising from discussions during the twinning exchange visits 1. Political context and power distribution: the importance of the political context in the initial advocacy for, design, development, implementation, evaluation and sustainability of community interventions was consistently highlighted. It was also evident that addressing the power distribution as a major health determinant needed to start within the health sector and with widespread and truly participatory approaches; 2. Community engagement: the key role of community engagement and the dedicated participation of communities contributed to the success and sustainability of interventions. This was evident throughout the programme and shared by represented communities. Using a community assets-based approach was identified as a key factor in developing a culture of
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Budgeting the exchange
Preparing documentation to provide a systematic process to help guide participants in the exchange visits
Gathering information on various communities/ community programmes to take part in the exchange 1. Develop a semi-structured framework, with help from leading global experts in health inequalities, to provide a systematic process to help guide participants in the exchange visits. The framework developed for the described efforts was neither comprehensive nor exhaustive, but rather provided a useful checklist of areas to explore through the exchange; 2. Guide efforts by developing a glossary of common understanding of the terms for the initiative. 1. Following preparatory work, develop a budget to enable the exchange.
1. Engage in open dialogue between stakeholders, establish a truly participatory culture and dynamic for partnership and define how to best adapt the exchange to cultural, social and environmental contexts as well as the political climates of interested countries; 2. Get insight into and understand the cultural, social and environmental contexts of interested countries; 3. Get insights into and understand the current political climate and policy functioning in interested countries. 1. Scan community programmes focused on addressing health inequities in each country wanting to take part in the exchange; 2. Agree on selection criteria to inform the selection of community programmes to take part; 3. Perform a matching exercise of candidate community programmes between each country to select programme(s) to take part in learning exchange. 1. Agree on information and collect community profiles to inform twinning (this does not need to be limited to twinning); 2. Analyse community profiles and twin communities from country A to communities from country B.
Exploratory phase
Identifying community programmes to participate in exchange
Steps
Methodological stage
Table 1. Methodology, lessons learnt and insights for adaptation.
It was extremely important to keep expectations clear and to adapt them according to the available budget for the exchange. It is important to note that the Centers for Disease Control and Prevention provided financial support to enable both sets of site visits.
It was helpful to set up a small drafting team that then sought input from a broader project team and then leading global experts in the field. Leading global experts were more likely to respond if contacted by a known person.
This requires central coordination to facilitate the process and an in-country person to collect profiles. Communities were more likely to respond if contacted by a known person.
This requires every stakeholder’s engagement, and central coordination to facilitate the process and collection and as a focal point for the project.
This can be a lengthy process but requires flexibility to ensure all stakeholders are on board and have a supportive context enabling them to fully engage in the efforts.
Insights for adaptation
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Steps 1. Once twinning has been conducted, plan, organise and hold a first set of site visits in country A as well as debrief meetings immediately after and a few weeks after the visits; 2. Draft and share a report of the first set of site visits to continue the dialogue and inform the second set of site visits; 3. Plan, organise and hold a second set of site visits in country B as well as debrief meetings immediately after and a few weeks after the visits; 4. Draft and share a report of the second set of site visits. 1. Report on key discussion themes, lessons learnt, and insights to inform policy and practice; 2. Share learnings broadly as part of a wide-reaching dissemination activity.
Methodological stage
Planning and organising the visits
Analysis and reporting
Table 1. (Continued)
In retrospect, it would have been more effective and less resource intensive to collect additional information to inform a more in-depth qualitative comparative analysis for final reporting in addition to the final exchange report. This could be done at various of the earlier stages of the initiative (e.g. when collecting community profiles, when organising site visits with various community projects...).
It was extremely helpful to have an in-country contact coordinating logistical arrangements and various visits as well as central coordination of the overall process. In addition, each community hosting visits was responsible for making arrangements to meet with various projects, community efforts and key stakeholders.
Insights for adaptation
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ownership, pride and long-term sustainability of the lifestyle and environmental changes introduced into the community; 3. Information intelligence: the crucial need to have effective information systems and intelligence, not only to access consistent and comparable data collected across various communities and settings but also to strengthen the evidence for investing in programmes and the evaluation process to highlight health improvement outcomes, was made evident; 4. Collaborative work: the exchange also emphasised the very central role that partnerships and collaborative work played in community interventions, and specifically the very innovative nature of these unconventional alliances based on trust, often outside the health sector with community stakeholders such as firemen and football clubs. There have been examples of the different forms of partnerships: • Partnerships formed due to one partner funding the other, through a contractual relationship, to deliver a programme of work (sleeping partner); • Partnerships through joint ownership, resource and decision making. 5. Champions and leaders: very often the leaders and champions were members of the communities, dedicated to improving the health of their communities by working with health and social care professionals; 6. A holistic approach: holistic and upstream asset approaches adopted and shared by many of the community interventions that participated in the twinning exchange to promote health and wellbeing across a full spectrum of factors influencing the lifespan of individuals and communities as a whole as opposed to traditionally biomedical approaches to disease prevention, were shared; 7. Sustainability challenge: communities face similar challenges, including that of the sustainability of community interventions beyond political cycles when attempting longterm change and improved health outcomes whilst having to be accountable for short-term changes as conditions for continued support; 8. Funding mechanisms and governance: differences in funding mechanisms and governance (from community activism in the US leveraging donor
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support versus the English government commissioning of specific interventions led by local authorities) very much defined the driving force of community interventions and served as a key determinant of true and sustained engagement and leadership; 9. Key markers of success: successful community interventions shared the following markers of success: they were community-driven, actionoriented and centred on negotiated collaboration; they acknowledged history; engaged with communities at various levels; comprised comprehensive evaluation and reporting and informed an iterative process of improved practice. Many of these themes reinforced health promotion concepts. Community efforts were clearly driven by health promotion and equity principles such as community empowerment and engagement, truly participatory approaches, capacity building, consideration and aspiration to address and improve broader environments as opposed to focusing on specific diseases, and a genuine concern for sustainability, long-term health and well-being improvements.
Outcomes and lessons learnt The initiative was welcomed and supported by all communities and stakeholders, all of whom remain dedicated to ensuring efforts are continued and sustained. Mona Fouad, MD, MPH (Director of the Minority Health & Health Disparities Center, University of Alabama at Birmingham, who sits on the National Advisory Council of the National Institute of Minority Health and Disparities of the NIH) commented on the effort: This learning exchange is one of the most innovative and productive collaborations currently underway. A collaboration to understand the impact of fundamental health care reforms happening in both countries; to see first hand the different models that both countries have designed through the years to balance access, quality and cost; and most importantly, to develop new and more comprehensive frameworks that go deeper into understanding the root causes of health inequities and open new frontiers for the creation of transformative solutions to sustainable development of individuals and society.[...] On IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
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behalf of the University of Alabama at Birmingham REACH US, I want to commend the visionary work of the leaders who conceived this learning exchange. The community representatives and partners agreed on the importance of capitalising on the momentum and keeping in touch and connected around key thematic areas; sharing information about key events, updates, highlights and testimonies of how the exchange has informed change; contributing to ongoing efforts and collaborations initially through electronic communications to be facilitated by IUHPE and LPHWM and, in the longer term, through the creation of an online social network with buy-in from all partners. It is hoped that the project outcomes and lessons learnt will enable both US and English communities to develop more robust health components and strengthen the social determinants of health (SDH) dimension of their programmes. Though it is too early to assess what communities are doing differently since the exchange, efforts to stay connected are specifically focused on capturing these changes, improvements and potential resulting outcomes. Some immediate outcomes of the exchange and its planning process included: 1. Creation of a network of practitioners dedicated to improving their communities and the conditions in which community members are born, grow, live, work and age beyond health and well-being towards sustainable and equitable environments and societies; 2. Strengthening of existing partnerships and the creation of new alliances/collaborations fostering continued exchanges as well as new projects (e.g. establishment of a Staffordshirewide health inequalities partnership centre; and collaboration and fundraising around Sustainable Smart Cities efforts); and 3. Coordination of and/or participation in planned events to share lessons learnt, encourage similar adapted exchanges, continue sharing and continue growing the network of practitioners.
reporting and dissemination, efforts towards staying connected, and strategy recommendations to influence health promotion policy and practice.
A broad dissemination strategy A comprehensive dissemination strategy is being implemented, with the aim to be as wide reaching as possible with visibility on a number of the partners’ websites, communities’ websites/blogs and other related web resources, publications in peer-reviewed journals, and presentations at and contributions to key events.
A network of community stakeholders To provide a platform for sustained and continued exchange the IUHPE and LPHWM are exploring the possibility of creating a social network with buy-in from all partners. In the shorter term, the IUHPE and LPHWM are committed to facilitating an electronic exchange of this informal network of community stakeholders. Since the final set of site visits, the communication flow has been ongoing and is guiding the development of the social network proposed to start with a focus on the: 1. Economic downturn and impact on social inequalities: assessing the impact of the financial challenges on inequities in health and demonstrating association between social welfare spending and mortality (in England, in the US and globally); 2. Development of an international online live bibliography on the social determinants of health and health inequities structured in a first instance around the key themes that arose from the learning exchange; 3. Review of the research piece once in-depth analysis has been conducted and the paper drafted to ensure it accurately reflects the experiences of the communities that participated in the exchange; and 4. Connection with other networks (e.g. healthy cities).
Next steps
A more in-depth qualitative report on the twinning exchange
There is a strong focus on sharing learnings with other communities across the world through
A more in-depth qualitative piece (13) on this initiative to capture the key learnings, identify
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implications for local, national and global levels, as well as lessons learnt and strategies to address health disparities that work (at both practical and strategic levels) and provide insights to inform policy and practice was developed.
Influencing policy and practice One of the main aims of the exchange was to inform and influence policy and practice. The project stakeholders plan to: 1. Utilise key contacts of communities and partners to influence policy and practice nationally and globally; 2. Develop key messages for different audiences (communities, local authorities, policy and decision makers, global field, practitioners, academics) as a resource for advocacy efforts; and 3. Integrate these efforts into broader IUHPE advocacy efforts; using the recommendations of the in-depth qualitative report (1).
A session at a key global event The key learnings of the exchange have also played a central role in and informed a sub-plenary organised by the IUHPE Global Working Group on the Social Determinants of Health, on the occasion of the 21st IUHPE World Conference on Health Promotion – Best Investments for Health (http:// www.iuhpeconference.net/en/index.php) in Pattaya, Thailand on 25–29 August 2013. The sub-plenary was shaped as a panel of key global experts from high, middle and low income settings to discuss and challenge some key issues and priorities for the global SDH agenda.
A global context urging for equitable and sustainable efforts – replicating and adapting the twinning exchange model Recent evidence around potential impacts of the economic downturn and welfare reforms in England (14) indicates that a significant increase in inequalities is to be expected. Tackling inequalities in the long term will be reliant on upstream
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interventions (15), often more difficult to explain to decision makers who are not familiar with tackling population health and inequalities. However, this by no means negates the need for downstream efforts. Evidence does also show that environmental approaches, including SDH initiatives, are costeffective and should be prioritised for sustainable and wider health and well-being improvements (16). As the global financial crisis continues and the impact of the economic downturn on inequalities is already being documented (14), there is an opportunity to review what is meant by public health for the 21st Century (17) and explore a new paradigm with central concepts of sustainability, equity and assets towards addressing the ‘dis-eases’ of our societies and communities (18). As Einstein said, ‘We can’t solve problems by using the same kind of thinking we used when we created them’ (19). Now more than ever, efforts such as the REACH US and C4H learning exchange and the importance of multiplying and adapting these sorts of exchanges globally seem essential. These experiences contribute to building the evidence base on successful interventions and identifying strategies that work for improving health outcomes and reducing health inequalities. They only strengthen the need for all governments to address the social determinants of health as a priority whilst providing insights to inform successful policy. Conflict of interest None declared.
Funding The initiative described in this commentary was supported by the International Union for Health Promotion and Education (IUHPE) and the US Centers for Disease Control and Prevention (CDC) and has received financial support from the United States Centers for Disease Control and Prevention (CDC), an Agency of the Department of Health and Human Services, under Cooperative Agreement Number CDC RFA DP07-708 on Building Capacity of Developing Countries to Prevent non-Communicable Diseases. The content of this commentary is solely the responsibility of the authors and does not necessarily represent the official views of CDC.
Notes i.
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More information about the Communities for health programme can be found at http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_107093
References 1. Blanchard C, Narle G, Gibbs M, Ruddock C, Grady M, Brookes C, et al. Improving policy and practice to promote equity and social justice – A qualitative comparative analysis between England and the US. Glob Health Promot. 2013; DOI:10.1177/ 1757975913509658. 2. International Union for Health Promotion and Education. Key Messages from the International Union for Health Promotion and Education on the Social Determinants of Health. Saint-Denis, France: IUHPE; 2012. http://iuhpe.org/images/IUHPE/ Advocacy/IUHPEKeyMessages_SDH.pdf (accessed 31 December, 2013). 3. WHO Commission on Social Determinants of Health (CSDH). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the WHO Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. http://whqlibdoc. who.int/publications/2008/9789241563703_eng.pdf (accessed 10 August 2013). 4. World Health Organization. Rio Political Declaration on Social Determinants of Health – World Conference on Social Determinants of Health. Rio di Janeiro, Brazil: WHO; 2011. http://www.who.int/entity/ sdhconference/declaration/Rio_political_declaration. pdf (accessed 10 August 2013). 5. Marmot M, Atkinson T, Bell J, Black C, Broadfoot P, Cumberlege J, et al. Fair Society, Healthy Lives: The Marmot Review. 2010. http://www. instituteofhealthequity.org/projects/fair-societyhealthy-lives-the-marmot-review/fair-societyhealthy-lives-full-report (accessed 10 August 2013). 6. World Health Organization. A Review of Social Determinants of Health and the Health Divide for the WHO European Regional Office. Geneva, Switzerland: WHO; 2012. http://www.instituteofhealthequity.org/ projects/who-european-review (accessed 10 August 2013). 7. Liao Y, Bang D, Cosgrove S, Dulin R, Harris Z, Taylor A, et al. Surveillance of health status in minority communities – Racial and ethnic approaches to community health across the U.S. (REACH U.S.) risk factor survey, United States, 2009. MMWR Surveill Summ. 2011; 60(6): 1–44. 8. Golub M, Charlop M, Groisman-Perelstein AE, Ruddock C, Calman N. Got low-fat milk? How a community-based coalition changed school milk policy in New York City. Fam Community Health. 2011; 34 Suppl 1: S44–S53.
9. Lewis LB, Galloway–Gilliam L, Flynn G, Nomachi J, Keener LC, Sloane DC. Transforming the urban food desert from the grassroots up: A model for community change. Fam Community Health. 2011; 34(Suppl 1): S92–S101. 10. McCloskey J, Tollestrup K, Sanders M. A community integration approach to social determinants of health in New Mexico. Fam Community Health. 2011; 34 (Suppl 1): S79–S91. 11. Buckner-Brown J, Tucker P, Rivera M, Cosgrove S, Coleman JL, Penson A, et al. Racial and ethnic approaches to community health: Reducing health disparities by addressing social determinants of health. Fam Community Health. 2011; 34(Suppl 1): S12–S22. 12. Lustig N, Lopez-Calva LF, Ortiz-Juarez E. Declining Inequality in Latin America in the 2000s: The Cases of Argentina, Brazil, and Mexico. CGD Working Paper 307. Washington, DC: Center for Global Development. h t t p : / / w w w. c g d e v. o r g / c o n t e n t / p u b l i c a t i o n s / detail/1426568 (accessed 10 August 2013). 13. Hopkins T, Grady M, Gibbs M, Ruddock C, Blanchard C, Narle G, et al. A learning exchange between the USA and England: Racial and Ethnic Approaches to Community Health (REACH) & Communities for Health (C4H) – A qualitative analysis. Saint-Denis, France: IUHPE; 2012. http:// www.iuhpe.org/uploaded/Activities/Scientific_ Affairs/CDC/TwinningExchangeUSREACH&C4HE ngland_AQualitativeAnalysis.pdf (accessed 10 August 2013). 14. UCL Institute of Health Equity, for the London Health Inequalities Network. The impact of the economic downturn and the welfare reforms on health inequalities in London; UCL IHE; 2012. http:// w w w. i n s t i t u t e o f h e a l t h e q u i t y. o r g / p r o j e c t s / demographics-finance-and-policy-london-2011-15effects-on-housing-employment-and-income-andstrategies-to-reduce-health-inequalities (accessed 10 August 2013). 15. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community. 2013; 67(2):190–193. 16. Chokshi DA, Farley TA. The cost-effectiveness of environmental approaches to disease prevention. N Engl J Med. 2012; 367: 295-297. 17. Lang T, Rayner G. Ecological public health: The 21st century’s big idea? Br Med J. 2012; 345: e5466. http://www.bmj.com/content/345/bmj.e5466 (accessed 10 August 2013). 18. Hanlon P, Carlisle S, Hannah M, Lyon A. The Future Public Health. Buckingham, UK: Open University Press; 2012. 19. Albert Einstein. http://www.brainyquote.com/quotes/ quotes/a/alberteins385842.html (accessed 10 August 2013).
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PED0010.1177/1757975913501006CommentaryC. Blanchard et al.
Commentary Learning from communities in the USA and England to promote equity and address the social determinants of health Claire Blanchard1, Martin Gibbs2, Ginder Narle3 and Chris Brookes4
Abstract: This commentary contextualises and documents the process of a twinning learning exchange between the US Racial and Ethnic Approaches to Community Health initiative and the Communities for Health initiative in England to enable the transfer and adaptation of ideas for similar communityfocused initiatives in various contexts globally. The multi-partner twinning exchange built on and shared knowledge around community health promotion interventions, targeting ‘marginalised’ populations and focused on addressing the social determinants of health to effectively reduce health inequalities. This commentary presents the methodology of the exchange; provides key themes, outcomes and lessons learnt that arose from discussions and the experience; and provides insights, considerations and recommendations for adaptation. Finally, it highlights the importance of such exchanges in the current global context and the need for their replication and adaptation. These experiences contribute to building the evidence base on successful interventions and identifying strategies that work for improving health outcomes and reducing health inequalities. They strengthen the need for all governments to address the social determinants of health as a priority whilst providing insights to inform successful policy. (Global Health Promotion, 2013; 20 Supp. 4: 104–112). Keywords: social determinants of health (SDH), inequalities, learning exchange, cross-learning, noncommmunicable diseases, communities Transforming the health of communities requires development of the social determinants of health and the built environment, where people live, work and play and prevention across a full spectrum of factors influencing the lifespan of individuals and communities as the thread of the social fabric. (Mona Fouad)
Introduction This summary commentary contextualises and documents the process of a twinning learning exchange between the US Racial and Ethnic Approaches to Community Health initiative (REACH USi) and the Communities for Health (C4Hii) initiative in England. 1. 2. 3. 4.
For an in-depth analysis of the exchange see Blanchard et al. (1). The purpose was to enable the transfer and adaptation of ideas for similar community-focused initiatives in various contexts globally, a dimension often overlooked and yet essential to health promotion efforts. The multi-partner twinning exchange built on and shared knowledge around community health promotion interventions, targeting ‘marginalised’ populations and focused on addressing the social determinants of health (SDH) to effectively reduce health inequalities. These efforts were inspired and informed by major recent global efforts (2–6) and are part of the International Union for Health Promotion and Education’s (IUHPE) priority area of action for
International Union for Health Promotion and Education (IUHPE), St Denis cedex, France. Health Inequalities and Inclusion Health, Department of Health (DH), London, UK. Learning for Public Health West Midlands (LPHWM), Sandwell Primary Care Trust, West Bromwich, UK. Health Action Partnership International (HAPI), London, UK.
Correspondence to: Claire Blanchard, IUHPE, 42 bvd de la Libération, 93203 St Denis cedex, France. Email: [email protected] Global Health Promotion 1757-9759; Vol 20 Supp. 4: 104–112; 501006 Copyright © The Author(s) 2013, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913501006 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on March 25, 2015
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2011–2016 on the social determinants of health. The innovative and successful partnership between the US Centers for Disease Control and Prevention (CDC), the IUHPE, the Department of Health (DH) of England, Health Action Partnership International (HAPI), and more recently Learning for Public Health West Midlands (LPHWM), enabled this exchange to happen.
competent and linguistically appropriate health-care services (e.g. prenatal care) by incorporating community health workers and youths in advocating for health, and utilizing community-driven assessments to drive change (11). During the time of the twinning exchange, there were more than 50 CDC-funded REACH communities working to eliminate health disparities across the country.
Historical context
Methodology
Launched in 2005, C4H was a new approach to unlock the energy within communities to make changes to their lifestyle that would enable them to improve their health, and support individuals to live healthier lives. Local authorities across England delivered a range of activities to engage communities in their own health and develop their capacity to support individual behavioural change for healthier lifestyles, build partnerships between organisations and communities; and develop innovative practices for community-based health improvement. The programme was innovative in providing health funding to local authorities and in allowing local communities to identify their own priorities for action. It demonstrated how local authorities are able to take a leading role, working with their local partners and communities, to address the health needs of their population and tackle health inequalities. The REACH US programme began in 1999 as the cornerstone of the CDC’s efforts to eliminate racial and ethnic health disparities in the United States. The various REACH US partners use community-based, participatory approaches to address health disparities across a wide range of health priority areas. Data from the REACH US Risk Factor Survey demonstrate that residents in most of the minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for and burden of disease compared with the general populations living in the same metropolitan area, county, or state (7). REACH communities have successfully employed policy, systems and environmental change strategies to address the social determinants of health, and through these actions have begun to close the gap in health disparities (8–10). They have also demonstrated change in the conditions that contribute to health, such as access to culturally
The idea of a learning exchange developed from a visit by the CDC to the DH in 2008 and a lengthy exploratory phase to figure out how to best adapt the exchange to both political environments. A scan of community programmes focused on addressing health inequalities in England identified the C4H as a good match for the REACH US programme, recognising that there were two significant differences: 1. The REACH programme had a greater focus on ethnicity and the C4H programme focused more on socio-economic status and health outcomes; 2. There is a stronger tradition of ‘community activism’ in the US, compared to local government intervention in England. Community profiles informed the identification of suitable REACH US and C4H communities for twinning. This process was driven by two initial questions (‘What learning would the community like to achieve through the proposed exchange?’ and ‘What have the communities already learnt from their work that they can start sharing with others?’), and selection was based on a set of criteria under three headings: Community by geography, Health challenge and Programme activity. To provide a systematic process to help guide participants in the exchange visits, a semi-structured framework was developed with help from leading global experts in health inequalities. The framework was a useful checklist of areas to explore through the exchange. A glossary of common understanding of the terms for the initiative was also developed. The first site visits were made in November 2011 to the US. The experience of community representatives led to the identification of four major themes which informed a second set of site visits by US colleagues in England in June 2012. IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
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Table 1 provides an overview of the methodological stages, detailed steps and lessons learnt from the present efforts. Throughout the planning, implementation and evaluation phases of the twinning exchange, CDC, IUHPE, and C4H colleagues and other experts collaborated to generate key areas for learning and developed a framework to guide participants in the analysis of the exchange. As it was important to facilitate learning across communities, CDC technical staff and C4H key actors accompanied community partners on both ‘legs’ of the visit, providing background, technical assistance and guidance to the exchanges.
Insights and recommendations for adaptation – learning from experience The twinning learning exchange described here was conducted in two high income countries and thus as shaped by very specific circumstances. For adaptation to other environments, it is important to understand the situation of this context. Some insights from the present experience to bear in mind when embarking on such efforts: 1. This sort of initiative can be time-consuming for all participants. 2. Flexibility in project methodology, expectations and budget is key to making these efforts happen. 3. A good working team with a positive, openminded and asset-focused approach was an essential ingredient for success. Clear roles and responsibilities as well as a focal point and overall coordinator are important to maintain momentum.
Considerations for adaptation For adaptation of these efforts, it is important to consider potential facilitators, barriers, contexts, circumstances and available resources (financial, human and others). For example, adaptation to other country settings may need to take potentially favourable (open-minded multi-sectorally oriented officials, engagement and enthusiasm, etc...) and impeding (corrupt officials or local authorities that do not have the flexibility of facilitating or supporting such exchanges, cost and ease of
transportation, time required to conduct an exchange, etc...) factors into consideration. With some important reports of decreased inequalities in low and middle income countries in Latin America (12), it would be extremely valuable to have a similar twinning or even a tripartite exchange between countries like Argentina, Brazil and Mexico and/or others outside the region to identify whether some of the learnings from the present exchange are shared by other countries and their community efforts.
Innovation through partnership The essential ingredients for the success of this exchange were the leadership, dedication and flexibility in design and implementation to respond to the constantly evolving political contexts of the partners that initiated these efforts in 2008; the active engagement and participation of all appropriate stakeholders and global experts at key steps under the leadership of a small manageable and nimble working project team; and the support of various partner institutions over the years. This is exactly the kind of partnership the IUHPE is keen to foster and engage in as it not only re-iterates health promotion concepts but fully embraces them and puts them into practice starting from within.
Key themes and lessons learnt arising from discussions during the twinning exchange visits 1. Political context and power distribution: the importance of the political context in the initial advocacy for, design, development, implementation, evaluation and sustainability of community interventions was consistently highlighted. It was also evident that addressing the power distribution as a major health determinant needed to start within the health sector and with widespread and truly participatory approaches; 2. Community engagement: the key role of community engagement and the dedicated participation of communities contributed to the success and sustainability of interventions. This was evident throughout the programme and shared by represented communities. Using a community assets-based approach was identified as a key factor in developing a culture of
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Budgeting the exchange
Preparing documentation to provide a systematic process to help guide participants in the exchange visits
Gathering information on various communities/ community programmes to take part in the exchange 1. Develop a semi-structured framework, with help from leading global experts in health inequalities, to provide a systematic process to help guide participants in the exchange visits. The framework developed for the described efforts was neither comprehensive nor exhaustive, but rather provided a useful checklist of areas to explore through the exchange; 2. Guide efforts by developing a glossary of common understanding of the terms for the initiative. 1. Following preparatory work, develop a budget to enable the exchange.
1. Engage in open dialogue between stakeholders, establish a truly participatory culture and dynamic for partnership and define how to best adapt the exchange to cultural, social and environmental contexts as well as the political climates of interested countries; 2. Get insight into and understand the cultural, social and environmental contexts of interested countries; 3. Get insights into and understand the current political climate and policy functioning in interested countries. 1. Scan community programmes focused on addressing health inequities in each country wanting to take part in the exchange; 2. Agree on selection criteria to inform the selection of community programmes to take part; 3. Perform a matching exercise of candidate community programmes between each country to select programme(s) to take part in learning exchange. 1. Agree on information and collect community profiles to inform twinning (this does not need to be limited to twinning); 2. Analyse community profiles and twin communities from country A to communities from country B.
Exploratory phase
Identifying community programmes to participate in exchange
Steps
Methodological stage
Table 1. Methodology, lessons learnt and insights for adaptation.
It was extremely important to keep expectations clear and to adapt them according to the available budget for the exchange. It is important to note that the Centers for Disease Control and Prevention provided financial support to enable both sets of site visits.
It was helpful to set up a small drafting team that then sought input from a broader project team and then leading global experts in the field. Leading global experts were more likely to respond if contacted by a known person.
This requires central coordination to facilitate the process and an in-country person to collect profiles. Communities were more likely to respond if contacted by a known person.
This requires every stakeholder’s engagement, and central coordination to facilitate the process and collection and as a focal point for the project.
This can be a lengthy process but requires flexibility to ensure all stakeholders are on board and have a supportive context enabling them to fully engage in the efforts.
Insights for adaptation
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Steps 1. Once twinning has been conducted, plan, organise and hold a first set of site visits in country A as well as debrief meetings immediately after and a few weeks after the visits; 2. Draft and share a report of the first set of site visits to continue the dialogue and inform the second set of site visits; 3. Plan, organise and hold a second set of site visits in country B as well as debrief meetings immediately after and a few weeks after the visits; 4. Draft and share a report of the second set of site visits. 1. Report on key discussion themes, lessons learnt, and insights to inform policy and practice; 2. Share learnings broadly as part of a wide-reaching dissemination activity.
Methodological stage
Planning and organising the visits
Analysis and reporting
Table 1. (Continued)
In retrospect, it would have been more effective and less resource intensive to collect additional information to inform a more in-depth qualitative comparative analysis for final reporting in addition to the final exchange report. This could be done at various of the earlier stages of the initiative (e.g. when collecting community profiles, when organising site visits with various community projects...).
It was extremely helpful to have an in-country contact coordinating logistical arrangements and various visits as well as central coordination of the overall process. In addition, each community hosting visits was responsible for making arrangements to meet with various projects, community efforts and key stakeholders.
Insights for adaptation
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ownership, pride and long-term sustainability of the lifestyle and environmental changes introduced into the community; 3. Information intelligence: the crucial need to have effective information systems and intelligence, not only to access consistent and comparable data collected across various communities and settings but also to strengthen the evidence for investing in programmes and the evaluation process to highlight health improvement outcomes, was made evident; 4. Collaborative work: the exchange also emphasised the very central role that partnerships and collaborative work played in community interventions, and specifically the very innovative nature of these unconventional alliances based on trust, often outside the health sector with community stakeholders such as firemen and football clubs. There have been examples of the different forms of partnerships: • Partnerships formed due to one partner funding the other, through a contractual relationship, to deliver a programme of work (sleeping partner); • Partnerships through joint ownership, resource and decision making. 5. Champions and leaders: very often the leaders and champions were members of the communities, dedicated to improving the health of their communities by working with health and social care professionals; 6. A holistic approach: holistic and upstream asset approaches adopted and shared by many of the community interventions that participated in the twinning exchange to promote health and wellbeing across a full spectrum of factors influencing the lifespan of individuals and communities as a whole as opposed to traditionally biomedical approaches to disease prevention, were shared; 7. Sustainability challenge: communities face similar challenges, including that of the sustainability of community interventions beyond political cycles when attempting longterm change and improved health outcomes whilst having to be accountable for short-term changes as conditions for continued support; 8. Funding mechanisms and governance: differences in funding mechanisms and governance (from community activism in the US leveraging donor
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support versus the English government commissioning of specific interventions led by local authorities) very much defined the driving force of community interventions and served as a key determinant of true and sustained engagement and leadership; 9. Key markers of success: successful community interventions shared the following markers of success: they were community-driven, actionoriented and centred on negotiated collaboration; they acknowledged history; engaged with communities at various levels; comprised comprehensive evaluation and reporting and informed an iterative process of improved practice. Many of these themes reinforced health promotion concepts. Community efforts were clearly driven by health promotion and equity principles such as community empowerment and engagement, truly participatory approaches, capacity building, consideration and aspiration to address and improve broader environments as opposed to focusing on specific diseases, and a genuine concern for sustainability, long-term health and well-being improvements.
Outcomes and lessons learnt The initiative was welcomed and supported by all communities and stakeholders, all of whom remain dedicated to ensuring efforts are continued and sustained. Mona Fouad, MD, MPH (Director of the Minority Health & Health Disparities Center, University of Alabama at Birmingham, who sits on the National Advisory Council of the National Institute of Minority Health and Disparities of the NIH) commented on the effort: This learning exchange is one of the most innovative and productive collaborations currently underway. A collaboration to understand the impact of fundamental health care reforms happening in both countries; to see first hand the different models that both countries have designed through the years to balance access, quality and cost; and most importantly, to develop new and more comprehensive frameworks that go deeper into understanding the root causes of health inequities and open new frontiers for the creation of transformative solutions to sustainable development of individuals and society.[...] On IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
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behalf of the University of Alabama at Birmingham REACH US, I want to commend the visionary work of the leaders who conceived this learning exchange. The community representatives and partners agreed on the importance of capitalising on the momentum and keeping in touch and connected around key thematic areas; sharing information about key events, updates, highlights and testimonies of how the exchange has informed change; contributing to ongoing efforts and collaborations initially through electronic communications to be facilitated by IUHPE and LPHWM and, in the longer term, through the creation of an online social network with buy-in from all partners. It is hoped that the project outcomes and lessons learnt will enable both US and English communities to develop more robust health components and strengthen the social determinants of health (SDH) dimension of their programmes. Though it is too early to assess what communities are doing differently since the exchange, efforts to stay connected are specifically focused on capturing these changes, improvements and potential resulting outcomes. Some immediate outcomes of the exchange and its planning process included: 1. Creation of a network of practitioners dedicated to improving their communities and the conditions in which community members are born, grow, live, work and age beyond health and well-being towards sustainable and equitable environments and societies; 2. Strengthening of existing partnerships and the creation of new alliances/collaborations fostering continued exchanges as well as new projects (e.g. establishment of a Staffordshirewide health inequalities partnership centre; and collaboration and fundraising around Sustainable Smart Cities efforts); and 3. Coordination of and/or participation in planned events to share lessons learnt, encourage similar adapted exchanges, continue sharing and continue growing the network of practitioners.
reporting and dissemination, efforts towards staying connected, and strategy recommendations to influence health promotion policy and practice.
A broad dissemination strategy A comprehensive dissemination strategy is being implemented, with the aim to be as wide reaching as possible with visibility on a number of the partners’ websites, communities’ websites/blogs and other related web resources, publications in peer-reviewed journals, and presentations at and contributions to key events.
A network of community stakeholders To provide a platform for sustained and continued exchange the IUHPE and LPHWM are exploring the possibility of creating a social network with buy-in from all partners. In the shorter term, the IUHPE and LPHWM are committed to facilitating an electronic exchange of this informal network of community stakeholders. Since the final set of site visits, the communication flow has been ongoing and is guiding the development of the social network proposed to start with a focus on the: 1. Economic downturn and impact on social inequalities: assessing the impact of the financial challenges on inequities in health and demonstrating association between social welfare spending and mortality (in England, in the US and globally); 2. Development of an international online live bibliography on the social determinants of health and health inequities structured in a first instance around the key themes that arose from the learning exchange; 3. Review of the research piece once in-depth analysis has been conducted and the paper drafted to ensure it accurately reflects the experiences of the communities that participated in the exchange; and 4. Connection with other networks (e.g. healthy cities).
Next steps
A more in-depth qualitative report on the twinning exchange
There is a strong focus on sharing learnings with other communities across the world through
A more in-depth qualitative piece (13) on this initiative to capture the key learnings, identify
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implications for local, national and global levels, as well as lessons learnt and strategies to address health disparities that work (at both practical and strategic levels) and provide insights to inform policy and practice was developed.
Influencing policy and practice One of the main aims of the exchange was to inform and influence policy and practice. The project stakeholders plan to: 1. Utilise key contacts of communities and partners to influence policy and practice nationally and globally; 2. Develop key messages for different audiences (communities, local authorities, policy and decision makers, global field, practitioners, academics) as a resource for advocacy efforts; and 3. Integrate these efforts into broader IUHPE advocacy efforts; using the recommendations of the in-depth qualitative report (1).
A session at a key global event The key learnings of the exchange have also played a central role in and informed a sub-plenary organised by the IUHPE Global Working Group on the Social Determinants of Health, on the occasion of the 21st IUHPE World Conference on Health Promotion – Best Investments for Health (http:// www.iuhpeconference.net/en/index.php) in Pattaya, Thailand on 25–29 August 2013. The sub-plenary was shaped as a panel of key global experts from high, middle and low income settings to discuss and challenge some key issues and priorities for the global SDH agenda.
A global context urging for equitable and sustainable efforts – replicating and adapting the twinning exchange model Recent evidence around potential impacts of the economic downturn and welfare reforms in England (14) indicates that a significant increase in inequalities is to be expected. Tackling inequalities in the long term will be reliant on upstream
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interventions (15), often more difficult to explain to decision makers who are not familiar with tackling population health and inequalities. However, this by no means negates the need for downstream efforts. Evidence does also show that environmental approaches, including SDH initiatives, are costeffective and should be prioritised for sustainable and wider health and well-being improvements (16). As the global financial crisis continues and the impact of the economic downturn on inequalities is already being documented (14), there is an opportunity to review what is meant by public health for the 21st Century (17) and explore a new paradigm with central concepts of sustainability, equity and assets towards addressing the ‘dis-eases’ of our societies and communities (18). As Einstein said, ‘We can’t solve problems by using the same kind of thinking we used when we created them’ (19). Now more than ever, efforts such as the REACH US and C4H learning exchange and the importance of multiplying and adapting these sorts of exchanges globally seem essential. These experiences contribute to building the evidence base on successful interventions and identifying strategies that work for improving health outcomes and reducing health inequalities. They only strengthen the need for all governments to address the social determinants of health as a priority whilst providing insights to inform successful policy. Conflict of interest None declared.
Funding The initiative described in this commentary was supported by the International Union for Health Promotion and Education (IUHPE) and the US Centers for Disease Control and Prevention (CDC) and has received financial support from the United States Centers for Disease Control and Prevention (CDC), an Agency of the Department of Health and Human Services, under Cooperative Agreement Number CDC RFA DP07-708 on Building Capacity of Developing Countries to Prevent non-Communicable Diseases. The content of this commentary is solely the responsibility of the authors and does not necessarily represent the official views of CDC.
Notes i.
More information about the REACH US programme can be found at http://www.cdc.gov/reach/ communities/index.htm IUHPE – Global Health Promotion Vol. 20, Supp. 4 2013
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More information about the Communities for health programme can be found at http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_107093
References 1. Blanchard C, Narle G, Gibbs M, Ruddock C, Grady M, Brookes C, et al. Improving policy and practice to promote equity and social justice – A qualitative comparative analysis between England and the US. Glob Health Promot. 2013; DOI:10.1177/ 1757975913509658. 2. International Union for Health Promotion and Education. Key Messages from the International Union for Health Promotion and Education on the Social Determinants of Health. Saint-Denis, France: IUHPE; 2012. http://iuhpe.org/images/IUHPE/ Advocacy/IUHPEKeyMessages_SDH.pdf (accessed 31 December, 2013). 3. WHO Commission on Social Determinants of Health (CSDH). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the WHO Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. http://whqlibdoc. who.int/publications/2008/9789241563703_eng.pdf (accessed 10 August 2013). 4. World Health Organization. Rio Political Declaration on Social Determinants of Health – World Conference on Social Determinants of Health. Rio di Janeiro, Brazil: WHO; 2011. http://www.who.int/entity/ sdhconference/declaration/Rio_political_declaration. pdf (accessed 10 August 2013). 5. Marmot M, Atkinson T, Bell J, Black C, Broadfoot P, Cumberlege J, et al. Fair Society, Healthy Lives: The Marmot Review. 2010. http://www. instituteofhealthequity.org/projects/fair-societyhealthy-lives-the-marmot-review/fair-societyhealthy-lives-full-report (accessed 10 August 2013). 6. World Health Organization. A Review of Social Determinants of Health and the Health Divide for the WHO European Regional Office. Geneva, Switzerland: WHO; 2012. http://www.instituteofhealthequity.org/ projects/who-european-review (accessed 10 August 2013). 7. Liao Y, Bang D, Cosgrove S, Dulin R, Harris Z, Taylor A, et al. Surveillance of health status in minority communities – Racial and ethnic approaches to community health across the U.S. (REACH U.S.) risk factor survey, United States, 2009. MMWR Surveill Summ. 2011; 60(6): 1–44. 8. Golub M, Charlop M, Groisman-Perelstein AE, Ruddock C, Calman N. Got low-fat milk? How a community-based coalition changed school milk policy in New York City. Fam Community Health. 2011; 34 Suppl 1: S44–S53.
9. Lewis LB, Galloway–Gilliam L, Flynn G, Nomachi J, Keener LC, Sloane DC. Transforming the urban food desert from the grassroots up: A model for community change. Fam Community Health. 2011; 34(Suppl 1): S92–S101. 10. McCloskey J, Tollestrup K, Sanders M. A community integration approach to social determinants of health in New Mexico. Fam Community Health. 2011; 34 (Suppl 1): S79–S91. 11. Buckner-Brown J, Tucker P, Rivera M, Cosgrove S, Coleman JL, Penson A, et al. Racial and ethnic approaches to community health: Reducing health disparities by addressing social determinants of health. Fam Community Health. 2011; 34(Suppl 1): S12–S22. 12. Lustig N, Lopez-Calva LF, Ortiz-Juarez E. Declining Inequality in Latin America in the 2000s: The Cases of Argentina, Brazil, and Mexico. CGD Working Paper 307. Washington, DC: Center for Global Development. h t t p : / / w w w. c g d e v. o r g / c o n t e n t / p u b l i c a t i o n s / detail/1426568 (accessed 10 August 2013). 13. Hopkins T, Grady M, Gibbs M, Ruddock C, Blanchard C, Narle G, et al. A learning exchange between the USA and England: Racial and Ethnic Approaches to Community Health (REACH) & Communities for Health (C4H) – A qualitative analysis. Saint-Denis, France: IUHPE; 2012. http:// www.iuhpe.org/uploaded/Activities/Scientific_ Affairs/CDC/TwinningExchangeUSREACH&C4HE ngland_AQualitativeAnalysis.pdf (accessed 10 August 2013). 14. UCL Institute of Health Equity, for the London Health Inequalities Network. The impact of the economic downturn and the welfare reforms on health inequalities in London; UCL IHE; 2012. http:// w w w. i n s t i t u t e o f h e a l t h e q u i t y. o r g / p r o j e c t s / demographics-finance-and-policy-london-2011-15effects-on-housing-employment-and-income-andstrategies-to-reduce-health-inequalities (accessed 10 August 2013). 15. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community. 2013; 67(2):190–193. 16. Chokshi DA, Farley TA. The cost-effectiveness of environmental approaches to disease prevention. N Engl J Med. 2012; 367: 295-297. 17. Lang T, Rayner G. Ecological public health: The 21st century’s big idea? Br Med J. 2012; 345: e5466. http://www.bmj.com/content/345/bmj.e5466 (accessed 10 August 2013). 18. Hanlon P, Carlisle S, Hannah M, Lyon A. The Future Public Health. Buckingham, UK: Open University Press; 2012. 19. Albert Einstein. http://www.brainyquote.com/quotes/ quotes/a/alberteins385842.html (accessed 10 August 2013).
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