The case for place-based community health improvement

Or why your current amalgamation of programming isn’t improving community-level health measures

As healthcare delivery organizations continue to explore outcomes-based community health improvement strategies, it’s sensible to pursue one focused on “place.”

Places present the parameters for healthy decision making. The social determinants of health (WHO: the social and economic environment, the physical environment, and the person’s individual characteristics and behaviors) are heavily dependent on the concept of place.

We spend all of our time in places both in the real and abstract senses. There are two components instrumental to place in the pursuit of health improvement: the degrees to which it is 1) health supporting and 2) builds community.

Why place? The most successful behavior interventions and population health management efforts cannot be sustained if the environments (read: places) where individuals spend their time don’t support healthy living. Making healthy choices isn’t a problem when willpower and motivation are present; the difficulty comes when those personal resources are low — a tidal process nearly every individual experiences daily. Places of work, schools, and even religious institutions are beginning to offer more and more aggressive health improvement programming and, in the process, are creating health-supporting environments. Meanwhile the most important places — the home, the neighborhood, and increasingly online — remain on the sideline despite public health, hospital, and community foundation efforts.

Health occurs “out there,” outside the purview of a provider, outside the walls of even the most community-focused hospital. The vast majority of Americans — even those with chronic ailments — spend a fraction of their year under the care of a provider. While some may identify this lack of connection to the healthcare system as a problem, it actually represents an opportunity to shift health creation to the places where individuals spend their time, which, in fact, is where it should be. It behooves community health improvement initiatives to help people make the vast majority of their year healthier.

Places also happen to be where we gather, an important concept affecting both health creation and community building. The study of social dynamics has long held that individuals are influenced by each other’s behaviors and gathering is a prerequisite to the existence of community. Noteworthy programs such as Weight Watchers and Alcoholics Anonymous have leveraged both in building successful health improvement programming.

Why not an explicit focus on physical health? Because the physical manifestation of health problems are often signals of root causes. Hospitals, public health agencies, local governments, and community foundations have been working on health improvement initiatives for at least two decades and have little in quantifiable improvements to show for it. Middling attempts at a consumer-centered marketing frame of health have not achieved the widespread acceptance necessary to create impact. In the busyness of American culture, health is commonly the the “to do” left uncompleted on the “to do” list.

That busyness is as much to blame for declining health indicators as a poor diet or a lack of exercise. Declining social ties, lack of access to healthy foods, decreasing levels of spirituality, stressful workplaces, financial struggles, poor education, high rates of crime, strained family relations, among many others, are all contributors to declining health status.

The truth, often, is that physical health issues are the outcome of a complex concoction of life’s realities. But health is life; without it, none of the enjoyment that comes from being alive is possible. While the message of “health is life” isn’t likely to evoke action in the wider population — a struggle experienced by hordes of self-development strategies — it’s mandatory of a competent health improvement strategy to find a frame that resonates to encompass the essence of a “health is life” message.

Improving outcome measures like obesity rates, high blood pressure, managed diabetes, etc. through behavior change intervention is fundamentally arriving at the problem too far downstream. Those programs and interventions are necessary, to be sure, but that work becomes the focus of population health management and clinical interventions.

The future of health improvement will be based upon reimbursement and the preservation of revenue, not the work within a community benefit scope. The importance of behavior change programming can’t be left to volunteers, right place/right time programming, and an underfunded community benefit strategy. Today it requires — and the industry is coming to terms with this notion — the same level of professionalism, individualization, and reimbursement as traditional medical care to counteract the factors responsible for poor health.

Just because there are so many contributors to unhealthy living and the identified problem is deliberately defined with grandiose scale doesn’t mean a community health improvement strategy should microscopically focus on improving physical health indicators. It means the approach to community health improvement should match the magnitude and individualization of the situation. It also means that healthcare delivery systems must ask for their limited community health improvement dollars to do more. That approach is to become a catalyst for creating health supporting places.

Why a catalytic role? There are three reasons to pursue a catalytic community health improvement strategy:

• The magnitude of the unhealth problem; if the definition is limited to physical health indicators the problem is massive; it only grows with the addition of the factors encompassing whole-person wellness.
• The traditional consumer’s cognitive connection between health and healthcare providers. Providers can provide a respected connection to health improvement opportunities in the community.
• The unique role a local hospital plays in a local community. Few, if any, corporatized organizations continue to hold special stature in local communities than “our hospital.”

The magnitude of unhealthiness — both at a national and local level in this country — is too tall a problem to expect that even the combined financial budgets of hospital community health improvement programming, local government initiatives, public health agency efforts, and community foundation grant making strategies to address.

Combine those monies in a catalytic effort with the (much more important) non-financial resources of community and neighborhood development and a recipe for true, impactful upstream change begins to appear. In short, to rival the causes of unhealth, health improvement is in need of a solution that scales: where the audience grows disproportionately compared to production costs.

This means working with households, schools, and businesses as well as local governments, spiritual institutions, and non-profit organizations to catalyze the creation of health supporting and community building environments. Individuals spend their time in an abundance of places and the extent to which their real and abstract characteristics support health and build community are varied.

What does it look like? Healthcare delivery organizations should pursue a place based health improvement strategy because places:

• provide the necessary scaling opportunity;
• can be crafted to be health supporting; and
• are where individuals gather as groups to build community.

First, a conversation about scale. In a limited pilot, a program called Healthy Lakewood (Colorado) shows great promise in improving individual activation. In this scenario, activation is defined as the knowledge, skills, and confidence essential to managing one’s health. The evidence is clear that improved activation leads to improved health outcomes. The success of Healthy Lakewood is based upon the following tenets:

• People are in need of supportive conversation more than they are in need of instruction.
• Health education must be paired with an activation opportunity.
• Change must be self-directed (but can be co-created).

The Healthy Lakewood program adopted a co-creation mindset: improvement driven by the individual and assisted by a supportive health guide. This community-centric model relies upon the organizational competencies of three Lakewood partners: St. Anthony Hospital, City of Lakewood Recreation Department, and the Consortium for Older Adult Wellness and connected participants to additional community services through self-management skill building and action planning.

The pilot results and growing demand for additional implementations of the Healthy Lakewood model are useful guides in the decision to expand the strategy. Given the number of people that would benefit from the program, however, the resource constraint of health coaching becomes apparent. Healthcare delivery organizations do not have, and will not have, the resources required to provide the level of assistance necessary to the number of potential participants required to create movement in population health measures.

But places do.

The true value of the Healthy Lakewood program lies in peer-to-peer conversations of support; not in the expertise of a certain class of professionals or license holders. While healthcare system investment is required to prove efficacy in initial implementations, future investment should trend toward creating and sustaining a peer-to-peer health improvement support model. This is possible given the learnings from Healthy Lakewood.

That same recipe of supportive conversation, activation, and self-direction (+ co-creation) can be applied in numerous settings to begin improving the “places” where individuals spend their time, to develop and redevelop (social dynamics and physical spaces) environments that support healthy living and behavior change interventions. Neighborhoods, workplaces, and places of worship (and Rotary Clubs, after-school programs, and yes, even the local pub, among others) hold additional value in this new community health improvement paradigm because they are essential to the creation of social capital.

The concept of social capital, defined simply as “sense of community,” is explored in Robert Putnam’s seminal work “Bowling Alone: The Collapse and Revival of American Community.” Putnam charts the decline of social capital since World War II and explores potential causes of Americans’ increasing engagement with private life at the expense of civic activities. His writings provide evidence that each generation since the pre-World War II generation has become less socially inclined; a certain problem given that communities with high levels of social capital are more successful while those with poor levels suffer social ills. While not as easily to chart, each generation since World War-II has become increasingly unhealthier, too.

The connection to health becomes clear when Putnam begins to provide the causes of declining social capital: increased television viewing (the average American now watches more than four hours of TV daily), busier families (dual-earning households, growth in youth activities, etc.), and urban sprawl (commute times, reduction in walkable urbanism, big back yards as opposed to front porches). These factors account for declining leisure time and are contributors in creating the perception of busier lives. A perceived lack of time is a major reason not to partake in health creating activities like praying, socializing, relaxation, or exercise. Levels of civic engagement and health status are linked, if only by the same causes.

Combine this reality with the steady societal transition away from a physical labor-intensive workforce, the emergence of processed foods, and an increasing reliance on modern medicine and it’s no wonder former U.S. Surgeon General Regina Benjamin remarked, “We are the last of the accidentally well.” No longer the happy consequence it once was, the pursuit of health has become a choice, rather, an amalgamation of choices. Catalyzing places to support community building in the pursuit of creating social capital is important not only because of social dynamics’ influence on individual decision making, but because community building also leads groups to improve the places where they spend their time.

Community building social capital strategies have been pursued as a means of increasing local civic engagement for a number of decades. The shortcoming of such strategies, often termed “healthy community initiatives,” has been a simple misframing of the opportunity. While health is always a component of these initiatives — along with education, economic opportunity, environmental sustainability, among others — it’s treated as one pillar rather than the overarching feature it should be.

Health is life. A person that is economically secure, educated, and lives in a safe environment is likely to be healthy. If by improved group activation neighborhoods, workplaces, and churches become more health supporting these opportunities become attainable and healthy communities will emerge. Creating places that support healthy living is different than creating healthy communities, it prioritizes the pursuit of health as an end over a means. The two approaches are similar in desire; an effort to create places supportive of healthy living can be informed by the work of those pursuing creating healthy communities. Jo Anne Schneider produced a report for the Annie E. Casey Foundation titled “The Role of Social Capital in Building Healthy Communities.” She writes in the introduction:

… fostering communities where residents have a sense of ownership for the neighborhood as a whole, as well as shared responsibility to other members, requires a complex mix of investment in individuals and institutions combined with measures to build trust and strengthen already existing social networks. Establishing healthy communities also requires that communities develop trusting connections with citywide institutions, markets, and policymakers to ensure that the neighborhood receives the resources that it needs, and that families have a bridge between their local communities and the wider society to achieve their goals.

Before healthcare delivery asks individuals to think about health differently, the industry must truly acknowledge that health is more than just the absence of disease. A reframed “health is living” concept is, at face value, important to most. If it is not important to the individual, it must become so before health improvement can commence. And that is the key to future messaging: the pursuit of health (wellness) is an individually defined undertaking. Surely every person can be encouraged to make healthier decisions but every person is also already pursuing some activities that are health creating. At the individual level, it is about recognizing what those are and doing more of them. The folly is in the expectation that a single message or approach will resonate with everyone. That is an unrealistic expectation in any setting.

The intriguing idea is this: a reframed concept of health — ”health is living” — can resonate with individuals, businesses, governments, organizations, churches, schools — places — because the presence or absence of health affects everyone. A strategy to create places that support healthy living and build social capital is the approach healthy communities initiatives should undertake.

That is the opportunity. It’s a partnership strategy to create and promote health supporting and community building “places.” It’s not about doing the work, rather, it’s about leading the work; launch the ship rather than sail it. Given the unique leadership position hospitals hold within the local community and the impetus provided by the foundations of community health improvement, pursuing a place-based strategy is the first step in ensuring healthy living becomes a way of life.

Putting it into practice

A few ideas:

• Peer-to-Peer health improvement support/training as described in the Healthy Lakewood example; an organization like Centura would develop, train, and maintain the model through a network of community partners.
• A self-management, activation, and organization training program for individuals to take leadership and ownership in the pursuit of place development by employing the three tenets of Healthy Lakewood
• Leverage the Community Health Needs Assessment and Implementation Plan processes to create an ongoing and sustained community leadership conversation around a reframing of health, acknowledging the importance of place and the four broadly defined categories of physical, social, mental, and spiritual. This group should be empowered to lobby for impactful change efforts.
• An accelerator would provide assistance to individuals and groups wishing to advance place-based-building projects such as expertise in data and analytics, community connections, project planning, capital, access to experts, among others.