Addressing Health Disparities Is a Place-Based Issue

Collaborative place-based approaches to improving population health and addressing health disparities are gaining momentum. There is strong rationale for prioritizing the premise that addressing health disparities is a placed-based issue, where improving community conditions could make a difference in improving health outcomes.^1,2 An equitable approach to building healthy communities requires place-based approaches that involve the community and stakeholders. Place is characterized by structural resources such as schools, hospitals, recreational facilities, retail outlets, and housing. Healthier places have health-promoting environments such as parks, safe walking spaces, maintained homes, full-service food stores, and environmental protection. Based on the strength of available evidence, there are policy initiatives that are feasible and sustainable for improving health in a community setting. Such initiatives could lead to

1. improved economic opportunity with better access to good jobs;

2. higher quality schools at the kindergarten through to 12th grade level that enhance access to college;

3. more open green space, maintained sidewalks, and effective community policing;

4. local businesses promoting healthier food options; and

5. available health care that addresses risk behaviors, acute illness, preventive measures, and management of chronic diseases.

Place-based interventions take time to become established, implemented, and sustained. Even though the research is still in a nascent stage, gaps in our knowledge demonstrate that it is currently impossible to provide a single model for powerful, feasible, and sustainable place-based initiatives that guarantees improved community health outcomes with any certainty. Part of the challenge is the varied planning and evaluation processes, and limited studies with long-term evaluation outcomes tied to improved health conditions. We can say that certain key elements play an important role in successful approaches. On the strength of the available evidence, we suggest that place-based initiatives should incorporate the approaches listed in Table 1.

TABLE 1—

Suggested Approaches for Place-Based Initiatives

Equitable Approaches	Key Elements and Drivers for Change
Establishing an inclusive participatory community-based strategy as the basis for action, planning, and implementation	A shared sense of urgency for improved health and well-being
	Interventions and resources that are aligned toward common goals
	Shared goals and clear long-term vision
	Establishment of clear governance structure and responsibilities
	Engagement of a wide range of stakeholders that includes influential champions, community advocates, and strong leadership
	Engaging institutional, civic, and natural leaders that reflect the demographic diversity of the community
	Community empowerment and building local community capacity for engagement
Developing and implementing a plan of action that includes ecological multilevel approaches to address conditions that influence health and health disparities	Approaches that incorporates the context and culture, community strengths, resources, and strategies tailored to local circumstances and needs
	An integration of geospatial data that provide a rich level of detail about the physical environment of a defined geographical area
	Multilevel interventions that consider the inclusion of some universal sets of health, social, and related services and supports needed to improve families, with consideration for members with special needs
Creating a framework for evaluation of health outcomes, program effectiveness, and continuous improvement	Clearly defined and shared outcomes, measurement, and tracking systems of value to the community
	Individual data that survey community members on self-reported health status, substance use prevalence, physical activity, and other health behaviors; use of administrative data collected for other reasons that ascertain rates of chronic disease (e.g., asthma), prevalence of diseases (e.g., sexually transmitted infections), hospitalizations, violence-related events, injuries, and area mortality, can be used to evaluate the health of a neighborhood
	Realistic evaluation methodologies such as time series to take advantage of external events such as implementation of health reform
Adopting a plan for continuous, responsive, and meaningful communication between community and stakeholders	More effective communication to ensure that service providers and service systems can be more attuned to the concerns and more responsive to the needs of communities
	Continuous learning and establishment of cycles of continuous improvement for maximum effectiveness

STRATEGIES

Various terms have been offered to characterize and define place-based interventions for addressing health disparities and improving population health. These include community health development, sustainable community initiatives, collective impact programs, and neighborhood revitalization initiatives.^3,4 In place-based approaches, community and stakeholder agencies collaborate to address health and contextual factors influencing social well-being of a population within a defined geographic location. We use the term placed-based interventions to refer to approaches for improving health in a geographic location that aligns the community members, businesses, institutions, and other relevant stakeholders in a collaborative and participatory process. Multilevel intervention strategies are often employed to address issues that impact health, mitigating the health needs and poorer outcomes experienced by residents in that defined community. The geographic location of the intervention is not limited to a neighborhood and could be a school or workplace environment.

EARLY INTERVENTIONS

Strategies for implementing place-based interventions have emerged from experiences with improving health among rural populations and American Indian tribes. These early community-responsive practices, as they were called, were groups of academic and nonacademic health centers that assumed a larger than ordinary share of the responsibility for safeguarding the health of the community by providing public health measures to serve the needs of a defined population.⁵ In the 1950s, an area-based approach was implemented on the Navajo Indian reservation to improve the health and well-being of the tribe. The tribal health committee was the primary decision-maker in this health improvement effort. This model involved careful documentation of the health problems in the community using demographic and epidemiological surveys, analyses of patient care utilization, and nutrition studies. Navajo community health workers assisted with providing interpretation of medical problems and care coordination.⁶ Other early place-based interventions include a tuberculosis eradication project that evolved into a community-oriented primary care program in a rural Appalachian community in the 1960s, and a neighborhood health center established in East Harlem, New York, by the Tenants Council to improve housing and health needs for the community.⁷

NEW MODELS

Collective impact and collective efficacy is an emerging place-based intervention model embraced as the mechanism for creating change on a larger scale. This model emphasizes cross-sector collaboration and shared efforts to address complex community problems by aligning public and private partnerships while fully engaging residents. The concept of collective efficacy involves the ability of community residents (and their advocates) to leverage resources and effectively respond to related health concerns for the collective benefit. This approach is often contrasted with the more familiar traditional approach where discrete evidence-based interventions are implemented to address a particular disease or social issue.⁸

A number of large-scale, place-based interventions have been profiled as examples demonstrating collective impact characteristics to revitalize distressed communities and break the cycle of poverty. One example is the Harlem Children’s Zone that aimed to improve the lives of New York City’s poor children and has grown into a 97-block community-service project that includes Promise Academy charter schools, social services, parenting classes, and after-school programs (http://www.hcz.org). The Strive Partnership of Cincinnati and Strive Together National Cradle-to-Career Network, committed to improving educational outcomes for every child in the region and involving a voluntary partnership of hundreds of organizations, helps communities across the United States implement collective impact initiatives (http://www.strivenetwork.org). The Magnolia Place Community Initiative is a large-scale initiative involving more than 70 community organizations, schools, businesses, and local government agencies working to improve the health, educational, social and economic outcomes of the 35 000 children living in the 500-block Magnolia catchment area in Los Angeles, California (http://www.policylink.org/focus-areas/promiseneighborhoods-institute). Finally, Promise Neighborhoods, based on the example of the Harlem Children’s Zone, is a competitive program of the US Department of Education targeted at children and families in disadvantaged areas, which now serves more than 50 communities (http://www2.ed.gov/programs/promiseneighborhoods/index.html). Metrics of success or outcomes to validate the investments in these programs in addressing health and health disparities will be invaluable.

Not all places or communities may need the same type of place-based approach. A collective impact approach may be justified in communities with entrenched social problems, but other communities may benefit from other strategies. The research shows that there are limits to collective efficacy and collective impact approaches. In neighborhoods with extreme deterioration—such as high levels of crime, territoriality, uninhabitable boarded-up vacant buildings, and trash and litter on the street—the willingness of neighbors to help for the common good (collective efficacy) was found to have an adverse impact on social relationships and opportunities to engage in healthful behaviors.⁹ Immigrant ethnic enclaves also represent a different type of challenge with mixed evidence of how strong social networks could facilitate place-based approaches to improve health despite limited financial resources.¹⁰

When it comes to identifying the powerful levers of community-level, place-based approaches, we are still at a relatively early stage in our understanding of the processes that work and the mechanisms under which improved health outcomes can occur. When it comes to understanding interventions that work across the life course, it may also be unrealistic to expect that a single scheme will ever be able to determine the elements that influence complex multiple determinants of disease and health disparities. Our understanding of place-based approaches is continuously evolving, and this serves as an opportunity for collaborative continuous learning.