How Are You Going to Pivot? - Part III: Community & Health Ecology

It takes a village. To many, this may sound like an outdated cliché. However, the phrase is

overwhelmingly accurate when it comes to affecting individual and population level health,

well-being, and quality of life.

Most of us are familiar with the natural science concept of ecology, wherein living

organisms interact with each other and their environment. In much the same way, people

exist in relationship with a variety of entities which in turn shape human behavior. So, what

are the entities where individuals relate and make up their own ecology? First, there are

interpersonal networks composed of family, friends, coworkers and other social groups.

Second, there are organizations such as schools, workplaces and places of worship. Third,

there are communities, where people are born and raised, where they eat and sleep, and

where and how they live, work, play and pray. Lastly, there are the government institutions

at the national, state and local level that establish public policy.

In short, everyone exists within a unique social and environmental context. To add to this

mix, everyone has a distinct set of beliefs, attitudes, information and skills to interpret and

interact with every level of their ecology.

What lends a great deal of complexity to this ecological model is the overlay of the Social

Determinants of Health (SDoH). These are a host of behavioral, socioeconomic and

environmental factors which greatly affect health, well-being and quality of life such as

health behaviors (smoking, diet/exercise), economic stability (employment/income),

education (literacy, higher education), the neighborhood and physical environment

(housing, air/water quality), food (hunger, affordable/healthy options), the community and

social context (social integration and support), and the health care system

(coverage/access/quality). Deficits in these areas may often arise because of systemic

bias attributed “race”, ethnicity, class, identity, ability, religion, gender and sexual

orientation.

To what degree do these behavioral, socioeconomic and environmental factors impact

health outcomes on a population level? Medical care alone is estimated to account for

only 10-20 percent of the modifiable contributors to healthy outcomes. The remaining 80

to 90 percent has been attributed to SDoH [1].

With the considerable contribution of SDoH to health outcomes, we must surmise that

one’s ability to make healthy lifestyle choices is often dependent on the knowledge,

resources and opportunities conferred by one’s behavioral, socioeconomic, and

environmental context. Given that this interaction between people and their environment

impacts health so profoundly, a more precise label for this system is warranted. I would

submit “health ecology” as a worthy phrase.If we are to adequately address individual and population health issues that are prevalent in our culture, we must leverage the inherent power of the entities that shape health behavior outside the brick-and-mortar walls of the health care system. To that end, patient care should be devised with collective action that encourages pro-health standards and practices.

The community is a logical place to start given its storied track record. Community health

initiatives have been a fixture in the United States for more than 70 years. The attendant

community health workers (CHWs) have worked in a variety of settings and have been

increasingly recognized as an essential part of the health workforce. CHWs share life

experience with the people they serve and have firsthand knowledge of the drivers and

sequelae of health inequity. They often provide a critical link between marginalized

communities and health care and public health services. Several studies have

demonstrated that CHWs can improve the management of chronic conditions, increase

access to preventive care, improve patients' experience of care, and reduce health care

costs. CHWs can also advance health equity by addressing social needs and advocating

for systems and policy change [2].

In short, medical interventions that work in tandem with community partnerships produce

a more comprehensive approach to behavior change [1]. A consistent first step in this

quest will require assessing environmental and social needs at a level of intake within the

medical care system and subsequently linking affected individuals with appropriate

community agencies. For example, coupling those with deficits in the areas of housing,

transportation, food, health care access and personal safety can bring expertise, allies,

and resources to address complex issues such as poor nutrition, inadequate sleep,

substance abuse, physical inactivity, smoking and social isolation. These are the very

factors that are responsible for a significant portion of chronic conditions burden in the

United States. As my former colleagues at Kaiser Permanente were fond of saying, “make

the right thing easy to do”. To meet this end, a village is required indeed.

Peter Sepsis, MS, MPH

References

[1} Social Determinants of Health 101 for Health Care: Five Plus Five. Discussion Paper.

National Academy of Medicine. Magnan, Sanne. 2017. October 9

[2] Community Health Worker Integration with and Effectiveness in Health Care and Public

Health in the United States. A Review. Annual Review of Public Health. 2023. Apr 3:44:363-

381.