HEALTH PROMOTION 1

Health Promotion through Collaboration

Kelly Klarich

St. Mary’s University of Minnesota

Schools of Graduate & Professional Programs

In partial fulfillment of the requirements for

HS698 Capstone

Jerry Lovrien, MHA

May 1, 2023

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Table of Contents

Chapter One: Introduction..........................................................................................................3

Purpose ..........................................................................................................................3

Significance....................................................................................................................3

Scope...............................................................................................................................6

Terms..............................................................................................................................7

Chapter Two: Literature Review................................................................................................8

Health Indicators.............................................................................................................8

Critical Influences/Social determinants of Health..........................................................9

........................................................................................................................................

Partnerships.....................................................................................................................12

Healthcare Organizations & Policies..............................................................................13

Chapter Three: Conclusion.........................................................................................................15

Recommendations...........................................................................................................15

........................................................................................................................................

Lessons Learned.............................................................................................................17

........................................................................................................................................

Further Research.............................................................................................................18

Summary.........................................................................................................................19

References...................................................................................................................................20

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Health Promotion

Chapter One: Introduction

Purpose

Healthcare can only go so far in controlling the health of a patient or population due to

social, economic, environmental and behavioral determinants such as economic stability,

education, food sources, environmental impacts and the individual choices people make with

respect to their health. As a result of these influences not in the control of the healthcare system

is it realistic to think that healthcare organizations can impact the over-all health of a population

group on their own? The purpose of this paper is to examine the social determinants impacting

the health of individuals not easily controlled by a healthcare organization and develop

recommendations for ways to improve the health of American’s collaboratively with other

partners.

Significance

According to the Center for Medicare & Medicaid Services (CMS) “ U.S. spending for

healthcare rose nearly 3.6 percent, reaching $2.9 trillion or $9,255 per person in 2013” (Centers

for Disease Control and Prevention. 2015a. para.2). The U.S. compared to all other countries

spends a larger percent of its gross domestic product (GDP) on healthcare (Yesalis, 2012, p 3).

According to the Commonwealth Fund the U.S. spent 17.1 percent of its GDP on healthcare

spending, and was the only country studied which spent more on healthcare spending than social

service spending (Squires and Anderson, 2015). Figure 1 below demonstrates the healthcare

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spending in comparison to social spending as compared to eleven countries. American’s were

also noted for having the highest out-of-pocket expenses, with a quarter of individuals

experiencing cost-related health care access issues (Morrison, 2015). Although, American’s are

spending more on healthcare the Commonwealth Fund cited the U.S. as underperforming in

many health measures such as cost, quality, value, and consumer responsiveness compared to

those same eleven countries (Morrison, 2015, para.7).

Figure 1 Health and Social Care Spending as a Percentage of GDP (Squires and Anderson,

2015). Adapted from “U. S. Health Care from a Global Perspective: Spending, Use of Services,

Prices, and Health in 13 Countries” by Squires, D., Anderson, C. 2015. The Commonwealth

Fund. October 2015. Copyright 2015 by The Commonwealth Fund.

For decades there have been many initiatives implemented with a goal of improving the

overall health of individuals and reducing healthcare costs, most geared directly at curing

individuals from disease once they become sick and most driven by healthcare organizations or

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third party payers. Many of the efforts associated to reducing costs are directly passed along to

healthcare providers and patients holding them accountable to reduce spending and absorb costs,

while also holding providers responsible to increase quality with little impact of improving the

health of the overall population if the other determinants of health are not improved as well.

Healthy People 2020 recently high-lighted the importance of health starting in homes,

schools, workplaces, neighborhoods, and communities, and that to truly impact the over-all

health of an individual there must be a shared responsibility, one that takes into account all

determinants of health to include social determinants (2015, para.1 & 2). It seems as though a

stronger call to action by healthcare leaders and leaders in other governmental and social sectors

focusing on increasing the national spending allocated to population wide approaches to

improving health from 5 percent to a more proportional rate with the 95 percent spent on medical

care will have the greatest impact to the overall health of a population (McGinnis, Williams, and

Knickman, 2002, p.78).

As health systems navigate the changing landscape, so too are pediatric healthcare

leaders interested in how best to prevent the onset of illness by investing in the right programs to

address the determinants of health. As a pediatric healthcare leader I am particularly interested in

the work the Children’s Association is doing to support the health paradigm shift and to better

understand the overall landscape. In the fall of 2014 the Children’s Hospital Association began

collaborating with other industry leaders to define the impacts of health determinants on the

pediatric population. Figure 2 illustrates the associations break down by percentage by

determinants of health for the pediatric population.

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Figure 2 Determinants of Health (Children’s Hospital Association, 2015). Adapted from

Children’s Hospital Association. (2015, March 15). Creating Health. Retrieved from

https://www.childrenshospitals.org/issues-and-advocacy/population-health/fact-sheets/childrens-

hospitals-creating-health

Scope

As a result of the limited research on the impact of social determinants of health for the

pediatric population the scope of this research will be focused on obtaining a better

understanding of the social, environmental and behavioral determinants of health to inform

leaders of the most effective approaches to improving the overall health of a population by

identifying health indicators, understanding the social determinants, critical health influences,

structures, methods and approaches to achieving health promotion through partnerships,

collaborations, and policies.

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As healthcare leaders we have an obligation to take an active role in health promotion

and are well positioned with the necessary skills and knowledge of health behaviors, genetic

make-up, and designing medical health-directed approaches to influence social determinants of

health, we just need to know where to focus our limited resources to achieve the greatest impact.

Terms

Health promotion. The term Healthy People defined as “any combination of health

education and related organizational, political, and economic interventions designed to facilitate

behavioral and environmental changes conducive to health” (Koh et al., 2011).

Social determinants. Conditions in the environment that impact health, functioning, and

quality of life outcomes and risks (Healthy People, 2015).

Health determinants. Factors that influence an individual and a population’s health (Shi

& Singh, 2013, p.34).

Structural approaches. “Modifications to the physical, social, political, and economic

environment in which people make health-related decisions” (Lieberman, Golden, and

Earp, 2013).

Health disparities. The Health Services Research Information Center defines health

disparities as “differences in access to or availability of facilities and services” (HSRIC,

2014).

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Chapter Two: Literature Review

The evidence is mounting on the impact of social circumstances and determinants.

Inequalities have clearly been identified as health risks as have other critical influencers. “The

WHO Commission on Social Determinants of Health claims the vast majority of inequalities in

health are avoidable (2015b, p.4).” WHO also noted the importance of family affluences as an

important predictor of health.

If leaders are to impact overall population health, understanding the impacts of social

determinants impacting society’s ability to make good choices is a good place to start.

Understanding the determinants that impact health can better position leaders to make

appropriate changes in policies and spending to have the greatest impact on health promotion

while reducing or redistributing government spending. This chapter will explore indictors of

health, critical influences of health, social determinants, structural approaches to health,

partnerships, healthcare organizations ability to influence change, and examples of how policies

can improve the overall health of a population.

Health Indicators

Using the medical model an indicator of health is the absence of illness or disease (Shi &

Singh, 2013, p. 30). The Society for Academic Emergency Medicine (SAEM) indicates health as

“a state of physical and mental well-being that facilitates the achievement of individual and

societal goals (Shi & Singh, 2013, p. 30). Recent scientific evidence suggests that an individual’s

health is an outcome resulting from various health determinants. The determinants or factors

impacting the health of an individual or population are comprised of genetic make-up, individual

behaviors, medical practice, social, economic, and environmental factors based on the choices

that people make in response to options they have (Koh, Peotrowski, Jumanyika, Fielding, 2011,

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p. 552 & Shi & Singh, 2013, p.34 & McGinnis et al., 2002, p. 78). The choices people make can

be impacted significantly by social economics restricting an individual’s options. Health is

influenced by multiple factors. Understanding the impact or influence of social determinants on

an individual’s health can help guide leaders and help with planning and priorities of healthy

initiatives.

Critical Influences/Social determinants of Health

As indicated above there are many influences that impact the health of individuals. This

report is focused primarily on those social circumstances or determinants that impact health.

Education, employment, income disparities, poverty, housing, crime, and social cohesion are all

very powerful influences in health with the most consistent predictor being cited as the level of

education (McGinnis et al., 2002, p. 80). Gender, ethnicity, age, and disability are also social

differences which can impact health of individuals (WHO, 2015b, p.5).

According to Healthy People, social determinants are conditions in the environment that

impact health, functioning, and quality of life outcomes and risks (2015, para. 4). Social

determinants are further broken down into three sub-types, social, economic, and physical

(Healthy People, 2015, para. 4). Examples of social determinants include safe and affordable

housing, access to education, public safety, healthy foods, emergency and health services, and

toxin-free environments (Healthy People, 2015, para. 5).

The scope, design, implementation and effectiveness of structural approaches to

improving people’s health by keeping them free from disease and chronic conditions which

require healthcare services requires intervention in the physical, social, political, and economic

environment and requires decision making of individuals in an effort to provide these structural

changes (Lieberman, Golden, and Earp, 2013, p. 520). Below are examples of a few influences

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and social determinants that can impact the health of individuals and some specific examples of

conditions these social determinants have on the population.

Education and poverty level. According to the National Center for Health Statistics,

individuals with higher levels of education have death rates 2.5 times lower than persons with

lower education levels as they are more likely to seek healthcare services sooner and are more

likely to take preventative measures in an effort to keep from getting sick such as becoming

vaccinated (1998). Individuals who live in poverty are 6 percent more likely to have a higher

mortality rate than those individuals who do not do to the inability to obtain healthcare, seek

preventative services, purchase necessary prescriptions, become vaccinated or eat healthy

(McGinnis et al., 2002, p. 80). “In general, cost may restrict families from adopting healthy

behaviors such as eating fruit and vegetables and participating in fee-based physical activities

causing inadequate access to health resources and leading to obesity, which is associated to co-

morbidities such as cardiovascular disease such as heart attacks and diabetes (Curie, et al., 2012,

p.6). The lack of distribution of wealth or socioeconomics creates health inequalities which may

be causing poorer health in the most vulnerable populations influencing their ability to achieve

optimal health and quality of life associated to healthy living.

Physical environment. The physical environment such as the places we live and work

also can impact an individual’s health status. A lack of grocery stores with healthy food choices

in low-income neighborhoods and pricing on healthy food options can be linked to obesity and

associated diseases. Toxic agents such as lead in paint, smoke, etc, found in the environment and

in the food and water supplies can have a profound impact on mortality and morbidity rates,

particularly cardiovascular, pulmonary disease, and cancers and blood disorders. According to

the Johnson, Hayes, Brown, Hoo, & Ethier, lung cancer was the leading cause of cancer deaths,

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accounting for 27% of all cancer deaths in 2011 and can be attributed to behavioral risks and or

environmental factors related to tobacco smoke (2014, p.8). Foodborne illnesses such as

Salmonella and E.coli have also increased during the past three years to a rate of 1.15 cases per

100,000 individuals impacting the health of individuals (Johnson et al., 2014, p.4).

Housing and crime. Having safe neighborhoods where people can be active and free

from harm can greatly reduce the likelihood of obesity, which according to the World Health

Organization (2014a) “Childhood obesity is one of the most serious public health challenges of

the 21st century” (para. 1). Estimates indicate the frequency of obese children has increased two

to five times in developed countries and up to four times in developing countries between 1980

and 1990 (Flynn et al., 2006, para. 1). “Obesity is a major contributor to cardiovascular disease,

diabetes, and several types of cancer (Frieden et al., 2010, p.357; CDC, 2014c).

Although many factors shape an individual’s health, 40 percent of deaths are caused by

behavioral patterns that could be modified by preventative interventions if health equalities could

be managed (McGinnis et al., 2002, p. 78). Behavioral patterns such as dietary and physical

activity leading to obesity, unprotected sexual intercourse leading to disease, and substance

abuse such as tobacco usage results in nearly 900,000 deaths in the U.S. each year, resulting in

the single biggest influencer of health across all determinants (McGinnis et al., 2002, p. 80).

While behavioral patterns have been identified as a major impact to health, the focus of this

report is on the social determinants impacting health status, which may also have an impact on

the choices individuals make impacting their overall health. Understanding how and where all of

these determinants of health intersect to impact the overall health of the population will require

advances through partnerships from all sectors.

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Partnerships

Many recent health initiatives were defined and executed as a result of coordinated

efforts at the federal level through partnerships with governmental, public health, private and

other health and human service networks through a Healthy People initiative who’s focus was to

“promote a stronger legacy for a healthier nation” by promoting a shared societal responsibility

for change (Koh, Peotrowski, Jumanyika, Fielding, 2011). Structural approaches such as policy

changes, price modifications, redesign of community environments, changing social norms

through resource redistribution and empowering individuals and communities to make healthier

choices are not new to public health but are grounded in social and health behaviors and will

require data, resources, and education across all spectrums of the social, environmental, and

political structures to improve the health of the population (Lieberman et. al., 2013). Healthcare

organizations and leaders have a role to play in becoming stronger partners in influencing

changes that impact the social determinants of health.

Healthcare Organizations

As leaders of healthcare organizations the goal of improving the overall health of the

population seems somewhat of a daunting task. Healthcare organization’s strategy efforts have

historically focused on advances in technology and evidence-based care related to treating sick

patients. A shift in the paradigm has given-way to new responsibilities for healthcare

organizations. A stronger concentration on health-directed structural initiatives impacting

particular health issues and changes in the environment, in an effort to reduce the social

determinants associated to health risk, have entered the strategic plans for health organizations.

Finding ways to educate others on the health risks associated to environmental factors such as

smoke-free environments, bike lanes, restrictions on sugar-sweetened beverages, expanded

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insurance coverage on preventative screening, and implementing “opt-out” testing to drive

increased compliance could have a profound effect on changing health behaviors and outcomes

(Lieberman et. al., 2013). Healthcare organizations are starting to adopt new ways to partner with

organizations to provide exercise memberships to their own employees and are promoting other

organizations to do so as well to promote a healthy living style. Pediatric organizations in

collaboration with community partners, schools, and others have started to educate parents and

children on the importance of the 5-2-1-0 tool as a way to bring awareness to nutrition and

physical activity to reduce the likelihood of diseases later in life as a result of obesity and

improper eating. The tools suggests eating five fruits and vegetables or more, cutting screen time

to two hours or less a day, participating in at least one hour of moderate physical activity and

restricting sugary beverage intake to zero (Foundation for Healthy Communities, 2015).

The value of the data collected at healthcare organizations to improve care across the care

continuum can facilitate the creation of health equality policies and can help in identification of

access and quality issues related to social determinants of health (Shi & Singh, 2013, p.46).

Interoperability of data to ensure information crosses the care continuum and is shared with

federal and state data repositories or databases is vital to the cross-functional partnerships of the

Healthy People initiative and other organizations focused on the social, environmental, and

behavioral determinants of health.

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Health Policies

The data collected from public health and healthcare organizations is just one of many

tools and efforts in place to help leaders think more broadly about public and community health

policies. According to the CDC, The ATSDR Brownfield/Land Reuse Action Model is a great

tool for community leaders aimed at encouraging people at the local level to design their

communities with health, community, land and environment, and buildings and infrastructure in

mind to promote wellness and improved access, to increased health benefits (2015b). The CDC

also maintains a chronic disease policy tracking database to inform lawmakers from each state of

policies related to chronic disease prevention and health promotion, many of which were

developed to improve access to healthy food choices, improving physical activity and public

transportation (2015b).

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The Health in All Policies collaborative is another resource that has taken an active role

in integrating and articulating health considerations across various sectors into policies. The

collaboration is designed to help identify gaps in achieving health equity and provides ways to

achieve the National Prevention Strategy and Healthy People 2020 goals by creating a call to

action across the country (2015b). These examples are just a few of the many resources being

developed at the federal and state level to help influencers and lawmakers improve the number of

Americans who are healthy through efforts to increase healthy and safe community

environments, eliminate health disparities, empower individuals, and build preventative medical

and community services to promote health. Policies aimed at creating a tobacco free

environment, preventing drug abuse and excessive alcohol use, eating healthy and creating an

active living style, improving mental and emotional well-being, reducing sexually transmitted

disease and creating safe environments will all help reduce the social determinants impacting the

overall population’s health.

Summary

This chapter explored the indictors of health, critical influences and social determinants,

structural approaches, partnerships, healthcare organizations role in influencing change, and

examples of how policies can improve the overall health of a population. Chapter three will

focus on recommendations for healthcare leaders and others related to impacting social

determinants of population health.

Chapter Three: Recommendations

Tackling the increasingly high cost of health care without regard to social, environmental,

and behavioral changes seems a little overwhelming and more than healthcare organizations can

accomplish without partnerships and collaboration with public health, government officials, large

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corporations, local communities and individuals, as it requires changing American’s social

values. Educating American’s on the importance of changing social inequalities impacting health

and influencing individual health behaviors is essential and will require changing where tax

dollars are spent and may be difficult to accomplish, as elected government officials and strong

lobbyist by big agencies such as tobacco companies and other strongly funded special interest

groups may not always place the health of society before individual agendas, and individuals

require health literacy and increased access to services in order to change their behaviors.

According to Koh, The U.S. needs to broaden healthier public policies and private sector

practices outside the public health domain, similar to recent policy changes such as the smoke-

free community buildings change in an effort to reduce chronic cardiovascular and pulmonary

diseases (2011). Koh also recommended establishing new collaborations between healthcare

organizations, education, transportation, community design, food and agriculture, housing, and

social services similar to the Healthy People 2020 collaboration (2011). In partnership with

health leaders, these groups can provide health education geared towards changes to the physical,

social, political, and economic environments to improve health. They can also help create a

stronger emphasis and focus on preventative interventions related to behavioral patterns in an

effort to influence the choices individuals make, while shifting individual habits and social

norms. “Our environments cultivate our communities, and our communities nurture our health

(Ramirez, Baker, Metzler, 2008).” Figure 3 illustrates the impact of social determinants and

inequities on our health.

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Figure 3 Growing Communities: Social Determinants, Behavior, and Health (Ramirez, Baker,

Metzler, 2008). Adapted from “Promoting Health Equity” by Ramirez, Baker, Metzler, Atlanta:

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,

2008.

Collectively, the data gathered by healthcare organizations and public health agencies can

be used to study the impact of social, environmental, and behavioral changes and can be used to

help educate local and federal government officials on the adoption of new policy changes to

food environments, like reducing the costs of healthy food choices namely fruits and vegetables

and shifting those costs to non-healthy food choices such as taxing sugary drinks and junk food

which could have a positive impact on consumer choices and improve nutrition while reducing

the impact on obesity (Frieden et al., 2010, p.357).

Lessons Learned

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Healthcare and public health organizations, government officials, and other corporate

sectors have begun to realize that shifting the health paradigm might be better served by

investing more time and resources on social, environmental and behavioral determinants rather

than on controlling healthcare spending as roughly 80% of the overall health of an individual is a

result of non-healthcare determinants (Magnan et al., 2012). Figure 4 below illustrates the

breakdown of population health by social determinants. This new realization is a result of

improved data and research. Through initiatives such as the Healthy People 2020, researchers

have determined that behavioral modifications may be the single most effective way to improve

health and reduce healthcare spending, even greater than focusing on social determinants.

Figure 4 Social Determinants of Health (Magnan et al., 2012). Adapted from Achieving

Accountability for Health and Health Care. Retrieved from Accountable-Health-Communities-

White-Paper.pdf

Making environmental modifications like placing fruits and vegetables rather than

candies and sweets by check out registers in stores, and cafeterias and eliminating sugary drinks

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in vending machines in schools and family-centered businesses could significantly change

individual choices and empower them to make good decisions. Raising taxes on junk food,

alcoholic beverages and soda and shifting the dollars to making healthy food more affordable

and available to vulnerable populations will promote healthy behaviors. People want to make

good choices but unfortunately do to social injustices are unable to make healthy choices.

Healthcare organizations can actively influence and educate policy makers by providing

health related information on the impact of social determinants to health indicators. Health

leaders may have little control over structural changes such as vending machine modifications or

income redistribution but may be able through education to help policy makers understand the

impacts of policies on health promotion efforts and the causes of chronic disease as it relates to

social, environmental, and behavioral determinants. The role of healthcare organizations today

can and should be focused on health literacy, health prevention, policy advocacy for vulnerable

populations, community involvement in an effort to better understand the barriers to healthy

living, and improvement of access to health services and education.

Further Research

As a pediatric healthcare leader my concern is the limited studies specific to the pediatric

population and the effects of social and behavioral influences on the long-term health of our

youth population. The choices we make as individuals are learned at a very young age, as are our

social values. Why hasn’t a stronger emphasis been placed on education and funding to support

additional research and programs geared at changing behavioral choices and improving access to

healthy food choices and physical activity for people in our most vulnerable populations?

Secondly, the studies researched have failed to provide adequate criteria or tools for measuring

the exact cause and effect related to each change making it very difficult to really understand

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what one effort had the largest impact on improving the overall health of the population. This

inability to identify which change had the greatest impact may result in excess spending in an

area that had little impact.

Summary

The health of an individual or population is determined by a person’s physical, mental,

and social well-being, not just the absence of being free from disease. To examine improve the

health of an individual or population requires more than just looking at the medical determinants

impacting health. The goal of this research and better understand the social determinants

impacting the health of individuals not easily controlled by a healthcare organization and

develop recommendations for ways to improve the health of American’s collaboratively with

other partners. As healthcare leaders our role is to inform, motivate and partner with community

leaders, public, private, and governmental agencies to promote healthy living by advancing

policies and spending on complex social, environmental, and behavioral forces impacting health

promotion. We, as healthcare leaders have an important role to play in collecting and sharing

data, influencing decision makers, partnering with communities, schools, and businesses to

improve health literacy, expanding access to quality medical care, controlling costs, and

empowering individuals to adopt healthy behaviors. Understanding the determinants that impact

health and collaborating with others is essential in establishing a healthier population.

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