Using a Health in All Policies Approach to Address Social Determinants of Sexually Transmitted Disease Inequities in the Context of Community Change and Redevelopment

Abstract

Objectives

We used a Health in All Policies (HiAP) framework to determine what data, policy, and community efficacy opportunities exist for improving sexual health and reducing sexually transmitted diseases (STDs) in an area surrounding an Army base undergoing redevelopment in Atlanta, Georgia.

Methods

We conducted a literature review, consulted with experts, mapped social determinants in the community, conducted key informant interviews with community leaders to explore policy solutions, used Photovoice with community members to identify neighborhood assets, and shared data with all stakeholder groups to solicit engagement for next steps.

Results

We identified the following HiAP-relevant determinants of STD inequities in the literature: education, employment, male incarceration, drug and alcohol marketing, and social capital. Quantitative data confirmed challenges in education, employment, and male incarceration in the area. Interviews identified policy opportunities such as educational funding ratios, Community Hire Agreements, code and law enforcement, addiction and mental health resources, lighting for safety, and a nonemergency public safety number. Photovoice participants identified community assets to protect including family-owned businesses, green spaces, gathering places, public transportation resources, historical sites, and architectural elements. Stakeholder feedback provided numerous opportunities for next steps.

Conclusions

This study contributes to the HiAP literature by providing an innovative mixed-methods design that locates social determinants of STDs within a geographic context, identifies policy solutions from local leaders, highlights community assets through the lens of place attachment, and engages stakeholders in identifying next steps. Findings from this study could inform other redevelopments, community-based studies of STDs, and HiAP efforts.

Incidence of sexually transmitted diseases (STDs) is associated with socioeconomic status, race/ethnicity, poverty, and substance abuse in the United States.^1–8 Rates of Chlamydia, gonorrhea, syphilis, and human immunodeficiency virus/acquired immunodeficiency syndrome among black people range from 5.4 to 17.8 times the rates among white people.⁹ Lack of resources and inequity of resource distribution are associated with risky sexual behavior, lack of health care, and rising STD rates.¹⁰ High STD rates have also been associated with deteriorated neighborhoods and alcohol outlet density.^11–13

Some of the highest incidences of Chlamydia, gonorrhea, and syphilis in the Atlanta, Georgia, area are located in the neighborhoods surrounding the 488-acre Fort McPherson Army base. For 2008, in the ZIP codes surrounding the base, rates for all three STDs combined ranged from 1,407 to 1,966 per 100,000 population, placing these rates in the top third of STD rates for the Atlanta area. In 2007, this area also had the second-highest rate of home foreclosures in the nation.¹⁴ In September 2011, the base ceased to function as a military installation, through the U.S. Department of Defense's Base Realignment and Closure program. Land redevelopment has the potential to impact the health and wellness not only of the new residents, but of the surrounding communities as well.

In 2011, the National Network of Public Health Institutes engaged the Georgia Health Policy Center, through a cooperative agreement with the Centers for Disease Control and Prevention, in a Health in All Policies (HiAP) approach to addressing STDs in the area surrounding Fort McPherson. HiAP is a concept that strengthens the link between health and policies from other sectors such as housing, transportation, education, employment, and land use to create an environment that enables people to lead healthy lives.¹⁵ Many complex problems shape access to opportunities and resources for health, and many of these problems are not the responsibility of any single sector. HiAP is a collaborative approach to improve health and reduce disparities through coordinated policy efforts.¹⁶ As Marmot wrote, “Action on the social determinants of health … will have the broader aim of improving the circumstances in which people live and work.”¹⁷ Examples of HiAP efforts include agricultural policies that enhance the consumption of fruit and vegetables, transportation policies that promote physical activity, and land-use policies that support access to a variety of health-promoting resources. HiAP approaches to improve health and reduce disparities have been explored by the World Health Organization, the European Union, Australia, Finland, and other countries.¹⁶

We are not aware of any prior HiAP approaches specifically designed to address sexual health and STDs; thus, this study establishes a new application of the HiAP concept. The purpose of this study was to use a HiAP framework to answer the following question: What data, policy, and community efficacy opportunities exist for improving sexual health and reducing STDs in the area surrounding Fort McPherson? This question addresses the need for data to inform policy while also recognizing the importance of community involvement in selecting policy options that could enhance community assets and achieve health benefits for the community when those policies are implemented. This study contributes to the HiAP literature by providing an innovative mixed-methods design that locates publicly available data on the social determinants of STDs within a geographic context and identifies policy solutions and community assets to address those challenges.

METHODS

We used a HiAP approach to frame the entire study. Figure 1 provides an overview of the mixed-methods design.

Figure 1.

A Health in All Policies approach to addressing and improving the social determinants of community health: a mixed-methods design

^aFarley TA. Sexually transmitted diseases in the Southeastern United States: location, race, and social context. Sex Transm Dis 2006;33(7 Suppl):S58-64.

^bRiley RB. Attachment to the ordinary landscape. In: Altman I, Low SM, editors. Place attachment. Human behavior and environment: advances in theory and research, volume 12. New York: Plemum Press; 1992. p. 13-35.

^cAltman I, Low SM. Place attachment: a conceptual inquiry. In: Altman I, Low SM, editors. Place attachment. Human behavior and environment: advances in theory and research, volume 12. New York: Plemum Press; 1992. p. 1-12.

Literature review and consultation with subject-matter experts

Baker and colleagues state, “A … challenge faced by those working to address social determinants of health inequities is determining where to focus their efforts.”¹⁸ A literature review explored the social determinants of STD inequities to assess where other sectors could influence sexual health equity. This literature was succinctly captured in a conceptual model by Farley, who proposed a model of 13 predictor variables from a variety of different sectors that explain elevated rates of STDs in African Americans.¹⁹ The research team used a HiAP perspective to focus on five factors from the Farley model that involve sectors outside health in which policy change might influence the social determinants of STDs. These factors include education, employment, drug and alcohol marketing, male incarceration, and social capital.

As Farley described, these five factors are associated with STDs in the following ways. Education's health-protective effects occur directly and through its impact on employment and income.¹⁹ Employment can increase individuals' access to health insurance, as well as provide meaningful engagement in society. Research has shown that when people are not sufficiently employed or engaged in meaningful activity, risk-taking behaviors can increase, including those that could result in STDs.²⁰ Farley reports that when individuals—particularly men—perceive no opportunity to engage in the legal economy, they may engage in illicit drug and alcohol marketing. Drug and alcohol availability and use have been shown to be positively correlated with STDs.¹⁹ Such illicit activity can lead to incarceration. The incarceration rate might influence STDs by creating an imbalance in male-female ratios. Kilmarx et al.⁴ found that syphilis incidence, for example, is higher in counties with lower ratios of males to females and in counties with greater concentrations of female-headed households. Social capital is also an important factor for understanding STDs. When neighbors watch out for each other and social connections are encouraged through formal and informal relationships, many times illegal activities (e.g., drug use and risk-taking behavior) can be curbed.²¹

Seven consultations with different subject-matter experts (SMEs) were conducted to further expand upon the findings in the literature. SMEs were selected to provide additional context on other STD studies and crime prevention efforts in the area, the broader context of STD and health equity efforts nationwide, and a deeper understanding of research on the complex topic of social capital.

Place-attachment theory was offered by one SME group as a place- and assets-based approach to social capital and community efficacy. Riley defined place attachment as “an affective relationship between people and the landscape that goes beyond cognition, preference, or judgment.”²² Altman and Low described place attachment as being created and maintained through interactions with the environment, including interconnections among biological, environmental, psychological, and sociocultural processes.²³ Place attachment relates to financial investment in the community, social cohesion, and a low fear of crime.

Findings from the literature review and consultations with SMEs, including the Farley model and place-attachment theory, further informed the three methods used to answer the three-part research question.

Quantitative data and mapping

What data opportunities exist for improving sexual health and reducing STDs in the area surrounding Fort McPherson? We assessed quantitative data that represented the social determinants of STDs, as identified in the Farley model. We gave priority to data that were relevant, actionable, and publicly available to enhance relevance to community members in tracking community challenges over time and identifying opportunities for action.

The process for determining indicators was to:

1. Develop, from the literature and SME interviews, a broad list of social and environmental variables for which there is credible evidence of a correlation with STD rates;

2. Exclude determinants not amenable to influence through policy, systems, or environmental change, or where change would likely have unacceptable adverse effects;

3. Exclude variables for which data specific to the project area could not be obtained by the public at a ZIP-code or census-tract level;

4. Identify specific measurements for these variables as evidenced in the literature; and

5. Seek reasonable proxy variables where data for the original indicator were unavailable.

Data were spatially mapped with the Fort McPherson property circled, indicating a 1.5-mile buffer from the base perimeter. This buffer was selected to capture at least a portion of the four high-STD ZIP-code areas that surround the base and to overlap with a range of policymaking jurisdictions—public safety, education, city council, neighborhood planning units, and other governmental sectors.

Interviews

Key informants were used to identify potential policy opportunities to address the social determinants of STDs in the area surrounding Fort McPherson. Key informants were selected based on their experience with and their ability to speak to potential policy options within the five components of focus in the Farley model: education, employment, male incarceration, drug and alcohol marketing, and social capital. For example, because the Farley model documented education as a social determinant of STDs and sexual health, the project team sought to interview an expert in education. Key informant interviews were conducted with 20 individuals representing the following sectors: education, finance, housing, indigent defense, prisoner reentry, faith community, community-based organizations, academia, and the Georgia Legislature. Most interviews were conducted in person, although some were conducted by phone to accommodate scheduling.

Photovoice

We sought community efficacy opportunities for improving sexual health and reducing STDs in the area surrounding Fort McPherson. In this study, we defined community efficacy as the capacity, interest, and willingness of community members to influence the redevelopment process. Photovoice is a community-based participatory research technique where participants are asked to represent their community or point of view by taking photographs, discussing them together, and developing narratives to go with their photos. This technique has been shown to build community efficacy in addressing problems.²⁴ We used a purposive non-probability sampling strategy to ensure that the six community members who participated in the Photovoice activity were representative of a range of people from the community. Participants met seven times in three months. These meetings were guided by the place-attachment theoretical perspective to engage community members in documenting the assets in their community that they felt attached to and wished to protect. An emphasis on the longstanding pride in the neighborhoods surrounding Fort McPherson can help both community members and policy makers “recognize the importance of the preservation of a people in a place, the preservation of a community, the preservation of places that people are proud to call home.”²⁵

Although some findings involved non-health sectors other than the five sectors of interest identified by the components of the Farley model, many findings were consistent with these components and further informed ways to address the underlying determinants of STDs through community efficacy.

Further detail on methods can be found at http://aysps.gsu.edu/ghpc/6094.html. Once data from all three methods were collected, analyzed, and triangulated, they were shared with stakeholders, including SMEs, key informants, and community members. The presentation allowed stakeholders to provide feedback and recommendations on opportunities for communication, partnership, research, and practice in a variety of areas.

RESULTS

Results are organized according to the five social determinants, with a sub-categorization of findings for each research question and its corresponding methodology. All potential policy opportunities listed hereafter were offered by the key informants who were familiar with the community and Farley model policy-related industries who were interviewed as part of this study.

Education

Quantitative data opportunities.

In a ranking of high school graduation rates in the relevant city and county school systems, the schools located near Fort McPherson fell into the lower fifth overall, with graduation rates for 2010 ranging from 64% to 81%.

A study on school funding equity gave Georgia an overall student finance grade in the range of C– to C+, and also found that weighted, per-pupil funding was greater in wealthy school districts in the state than in poor districts.²⁶ States use a number of adjustment formulas to allocate additional funding. One common formula that Georgia does not employ takes into account local income levels in determining allocation levels. This formula could address the enhanced student needs in schools around Fort McPherson.

Policy opportunities.

Suggested policy opportunities included increasing the ratio of social workers to students based on the needs of the student populations by school, rather than a per-student social worker formula that is the same for each school, regardless of need.

Employment

Quantitative data opportunities.

Most census tracts surrounding the base have a deficit of jobs relative to residents; although, there is an exception to the east of the base where there is an industrial area with a few large manufacturing operations and little housing stock (Figure 2).

Figure 2.

Number of jobs per resident aged 18–65 years, by census tract, in areas surrounding Fort McPherson: Atlanta, Georgia, 2009^a

^aThe map was created by the authors using data from: Census Bureau (US). 2009 American Community Survey, 5-year estimates [cited 2013 Jul 3]. Available from: URL: http://www.census.gov/acs/www/data_documentation/2009_5yr_data

Policy opportunities.

One opportunity would be to focus on living wage and wealth building within the local community. Community hire agreements (CHAs) would encourage new businesses associated with the redevelopment to hire locally.

Community efficacy opportunities identified through Photovoice (photo not shown).

Many participants spoke with pride about the “heyday” in southwest Atlanta, when businesses such as restaurants, clubs, and shops were thriving and several were black-owned family businesses. Recently, the area has been affected by economic divestment. Participants felt that the base closing may further impact small businesses.

Drug and alcohol marketing

Policy opportunities.

Even the best-designed policy will be ineffective at combating negative drug and alcohol influences in a community if there are insufficient enforcement mechanisms in place. Strict enforcement of city codes, such as those regulating the presence of environmental contaminants and those that target owners of vacant and abandoned homes and unsightly junk lots, could help create an environment that is less conducive to drug and alcohol presence and use. Consistently enforcing criminal laws to address problems such as commercial sex work could also help.

Male incarceration

Quantitative data opportunities.

The areas around Fort McPherson show the highest concentrations in the city of male residents on parole as of fall 2011 (Figure 3). The most serious offense for more than one-quarter of these male parolees is nonviolent and drug-related.

Figure 3.

Number of male residents on parole per total residents in areas surrounding Fort McPherson: Atlanta, Georgia, 2011^a

^aThe map was created by the authors using data from: Georgia Department of Corrections. Parolee database [cited 2011 Oct 24]. Available from: URL: http://www.pap.state.ga.us/paroleedatabase

Policy opportunities.

Several opportunities could help curb offenses, including providing Fort McPherson's residents with enhanced access to addiction and mental health treatment resources, providing a diversion into addiction treatment programs for minor drug offenses, and including provisions in CHAs so that they do not permit discrimination based on criminal records, particularly for minor offenses.

Social capital

Policy opportunities.

Several opportunities exist to advance social capital, including increasing the number and scope of gathering places; developing joint use agreements, where multiple community groups use the same location as a meeting space (e.g., schools, churches, and activity centers can also be used for clubs and neighborhood groups); and making the cost of access to community institutions such as recreation centers, which provide after-school activities, affordable to a greater percentage of the local population.

Community efficacy opportunities.

Churches could be used as gathering places for the community (Figure 4). Additionally, parks, tree cover, and green space could be used to build social connections and promote quality of life (Figure 5).

Figure 4.

Mother, Son, Holy Ghost by Joshua Peltier: “If you want to have a thriving, healthy community, you need to have a place where people can gather. The church is that haven. For many, it is the rock of the community that connects the people.”^a

^aPhotoVoice photo data, title, and caption provided by community researcher, documenting community assets for the neighborhoods surrounding Fort McPherson in Atlanta, Georgia, that could influence the social determinants of sexually transmitted disease inequities, such as social capital.

Figure 5.

The Road Less Traveled, by Dianese Howard: “Protecting our natural assets is key to the quality of life in our neighborhood. Having a tranquil spot that is devoid of the hustle and bustle of development.”^a

^aPhotoVoice photo data, title, and caption provided by community researcher, documenting community assets for the neighborhoods surrounding Fort McPherson in Atlanta, Georgia, that could influence the social determinants of sexually transmitted disease inequities, such as social capital.

Policy opportunities.

One person said, “A lot of people in these communities are depressed, and they don't even know it.” Increasing access to mental health services and providing enhanced resources for victims of violence could help these people.

Additional suggestions concern safety, including ensuring that all streets and other community spaces have adequate lighting, and providing a non-emergency (e.g., 311) number so that people have the ability to communicate with police and city officials about potential problems before they escalate to crisis level. Doing so increases the feeling of efficacy, community, and personal safety, and fosters neighborhood cohesion.

Figure 6 contains recommendations for next steps that were identified by stakeholders. Recommendations are organized around the key components of Farley's model and also include research opportunities and ways to improve the relationships between people and both natural and built environments.

Figure 6.

Opportunities for addressing the social determinants of STD inequities for the area surrounding Fort McPherson in Atlanta, Georgia: summary of qualitative data from stakeholder meetings, October 2001

STD = sexually transmitted disease

BRAC = Base Closure and Realignment Commission

DISCUSSION

Addressing social determinants of health inequities provides public health an opportunity to understand the context in which disparities exist and persist. Public health discourse has primarily focused on social determinants as an explanation for disparities, leaving us challenged with how to change and impact these determinants, particularly ones that are beyond the health sector. Public health, as a broad field, is also challenged in how to motivate action on these determinants when the problems identified often appear daunting. HiAP is an approach that specifically targets policy opportunities in sectors outside of health with a solutions-focused lens, concentrating on fundamental causes.²⁷ Findings from this study confirm that HiAP can be one of the tools public health is searching for to apply to a specific health outcome such as STDs, and it can be used from a stakeholder engagement perspective as well.^28,29 The use of conceptual -models that identify social determinants for a particular health outcome, which can then be narrowed from a HiAP lens, and the use of place-attachment theory as a framework for approaching place-based community engagement, offer further refinements in this operationalization of a HiAP approach.

Inequities

Assessments of social determinants data confirmed findings in the literature that these challenges coexist in the same geographic location as areas of high STD rates. Utilization of publicly available, relevant, and actionable data not only can be informational, it can be an opportunity. Initial stakeholder reactions to the data included confirmation of their assumptions and responses that the problems seemed overwhelming. However, when these data were further woven with the findings on policy opportunities and visual documentation of the assets of their community, stakeholders were motivated to identify additional solutions and to take action.

Next steps for the Georgia Health Policy research team include responding to requests to share findings with groups that can mobilize action, such as the Community Engagement committee of the Local Redevelopment Authority, which could inform redevelopment decisions relating to CHAs, green space preservation, and place-attachment branding, and the Atlanta City Council, which could inform decisions related to lighting and code enforcement, among others. Efforts will be made to publicize the findings and engage other sectors as well.

Limitations

Limitations of this study included those inherent to a case study, which is that it presents an opportunity to deeply understand one case but offers limited perspective on the characteristics that may be unique and, therefore, not representative of other cases. It is also not known to what degree the proposed changes, if implemented, might improve sexual health or reduce STDs. The underlying premise of HiAP efforts is that they offer an opportunity to improve population health and reduce disparities. Additional research is needed to track and quantify any potential changes. Research on what is known that works in policy and how that evidence can shape the discourse of this redevelopment is also needed.

CONCLUSIONS

This study addressed the social determinants of STD inequities by using a HiAP approach while acknowledging the critical role of place attachment. The unique combination of methods proved useful to operationalize HiAP, yielding meaningful data to document challenges, highlight assets, and explore policy opportunities while simultaneously engaging stakeholders in dialogue regarding next steps.

Using HiAP to address social determinant and health issues identified by this case study could improve overall health as well as sexual health. Publicly available data can be used to track changes in STD rates and social determinants over time. Changes addressing the fundamental causes of STDs may occur over an extended period of time. Plans for tracking changes should maximize design elements for ongoing natural experiments, and special care should be taken to track length of residency in the area to address potential confounding from displacement of current community members.³⁰

Findings from this study could inform other redevelopments, community-based studies of STDs, and HiAP efforts. As more HiAP efforts are used and tracked, the field will continue to refine its methodologies and assess its outcomes.