Transcript Changing Risk Behaviors

The Sociocultural Environment and
Health:
Systematic Reviews of
Community Interventions
Sociocultural Review Team
Laurie Anderson CDC Community Guide
Mindy Fullilove
Columbia University
Susan Scrimshaw University of Illinois Chicago
Jonathan Fielding Los Angeles County DHS
Jacques Normand National Institutes of Health
Ruth Sanchez-Way Substance Abuse and Mental
Health Services Administration
A Tool for Informed Decision-Making
The Community Guide provides a set of evidence-based
recommendations for public health action to improve
community health.
The Community Guide summarizes what is known about the
effectiveness and feasibility of community-based health
interventions by conducting systematic reviews of the
intervention literature.
Community Guide Reviews
Environmental Influences
• Sociocultural Environment
• Physical Environment
Risk Behaviors
Specific Conditions
• Tobacco Use
• Alcohol Abuse/Misuse
• Other Substance Abuse
• Poor Nutrition
• Inadequate Physical Activity
• Unhealthy Sexual Behaviors
• Vaccine Preventable Disease
• Pregnancy Outcomes
• Violence
• Motor Vehicle Injuries
• Depression
• Cancer
• Diabetes
• Oral Health
www.thecommunityguide.org
Community Interventions to Promote
Health-Enhancing Social Environments
The sociocultural environment exerts a fundamental
influence on health at the neighborhood, community,
and societal level.
The Sociocultural Environment reviews in the Guide
will include evaluations and recommendations on
interventions to reduce health inequalities through
modifying the social environment.
SOCIOCULTURAL DETERMINANTS:
SOCIAL RESOURCES AND THEIR DISTRIBUTION
IMPACT HEALTH
Social Resources
Standard of living
Culture and history
Social institutions
Built environments
Political structures
Economic systems
Technology
Physical
Environment
Equity &
Social Justice
(Resource Distribution)
COMMUNITY
HEALTH
Social Resources and their Distribution
Adequate social resources are prerequisite
to maintaining a supportive social
environment for health.
Equity and social justice are quintessential
to health. They are conditions that
characterize the distribution of resources
among the population.
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Neighborhood Living Conditions
Community Development
and Employment Opportunities
Civic Engagement & Participation
in Decision-Making
Community Customs,
Norms and Processes
Opportunities for Learning and
Developing Capacity
Health Promotion, Prevention
and Care Opportunities
OUTCOME
COMMUNITY
HEALTH
Intermediate Outcomes
Between root social determinants and health
outcomes are observable community conditions
amenable to intervention programs:
neighborhood living conditions, school and work
opportunities, community norms, neighborhood
cohesion, available health and social services
These are quantifiable conditions and thus offer a
means to account for why communities with few
social resources experience poorer health.
SOCIOCULTURAL ENVIRONMENT FRAMEWORK
Determinants
EQUITY AND
SOCIAL
JUSTICE
Intermediate Outcomes
Neighborhood Living Conditions
Community Development
and Employment Opportunities
SOCIAL
RESOURCES
Standard of living
Culture and history
Social institutions
Built environments
Political structures
Economic systems
Technology
PHYSICAL
ENVIRONMENT
Natural Resources
Civic Engagement & Participation
Health Outcome
in Decision-Making
Community Customs,
Norms and Processes
Opportunities for Learning and
Developing Capacity
Health Promotion, Prevention
and Care Opportunities
HEALTHIER
COMMUNITIES
Priority Interventions for Health Enhancing
Social Environments
RANKED BY POTENTIAL IMPACT ON IMPROVING COMMUNITY HEALTH
1
Child development programs (Head Start, Healthy Start, etc.).
2
Adequate public investment in education.
3
“Living wages” to move working families above poverty.
4
Access to quality health care for all ages.
5
Mixed income housing to decrease segregation by socioeconomic status.
6
Programs to reintegrate stigmatized populations.
7
Parenting classes in schools, churches, health agencies, etc.
8
Neighborhood schools as site of numerous community support programs.
9
Family-focused, one-stop health and human services centers.
10 Adequate health benefits with employment.
Completed Systematic Reviews
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Neighborhood
Living
Conditions
Mixed-income
housing
developments.
Rental voucher
subsidies which
allow families choice
in residential
location.
Opportunities for
Learning and
Developing Capacity
Health Promotion
Prevention and Care
Opportunities
Culturally competent
Publicly funded,
health care systems:
center-based,
-interpreters and
comprehensive early
bilingual staff
childhood
development programs -cultural diversity
for low-income
training for providers
children,
-linguistically and
3-5 years of age.
culturally appropriate
health information
-ethnic specific services
Early Childhood Development Programs
Recommendations from the Task Force on Community Preventive Services regarding community interventions to promote
health-enhancing social environments.
Task Force
recommendation
Outcomes
Key findings (reported as standard effect size or
percentage point change)
Early Childhood Development Programs
Strongly recommended
based on improvements
in children’s cognitive
outcomes
Academic achievement and IQ scores,
grade retention, placement in special education,
school readiness.
Cognitive outcomes: median effect size for academic achievement was +0.35, for
IQ +0.43, for retention in grade -21% (-2% to -25%), special education placement
-12% (-6% to -23%), and for school readiness +0.34. (12 studies)
Insufficient evidence*
for these outcomes
Behavioral assessments of child’s social
interaction; social risks: teen pregnancy, teen
fatherhood, high school drop-out,
unemployment, use of social services,
delinquency, arrests, incarceration.
Social outcomes: median effect size for assessments of child’s social competence
+0.38, for social risks -0.41. (5 studies)
Child health screening, preventive services,
dental care.
Child health screening: receipt of health screenings tests +44%, dental exam
within past year +61%. (1 study)
Parental educational attainment, mother or father
employed, access to health services.
Family outcomes: mother high school graduate +4%, father high school graduate
+3%, family income above poverty +7.4%, mother working +21.6%, father
working +5.8%, not receiving public assistance +16%, health screening for
siblings of Head Start students +11%. (2 studies)
* Evidence may be judged to be insufficient for one or more of the following reasons: limitations in design or execution of the studies, too few studies,
inconsistent findings across studies, or effect size not large enough.
Affordable Housing in Mixed-SES Neighborhoods
Recommendations from the Task Force on Community Preventive Services regarding community interventions to promote
health-enhancing social environments.
Task Force
recommendation
Outcomes
Key findings (reported as standard effect size or
percentage point change)
Tenant-Based Rental Assistance Programs
Recommended based on
lessened victimization
Experience of victimization: crime against
person (mugged, beaten or assaulted, stabbed or
shot) and property. Neighborhood murder rate.
Social disorder: public drinking, public drug use,
seeing person carrying weapon, hearing gunfire.
Neighborhood safety: median effect size for household member victimized -6%
(+6% to -22%), neighborhood murder rate -52%, social disorder -15.5% (-3% to
-89%). (6 studies)
Insufficient evidence*
for these outcomes
Substandard housing conditions that pose
health and safety risks.
Housing quality: presence of peeling paint -53%, inadequate plumbing -28%,
rodent infestation -34%, broken or no locks on door to unit -42%. (1 study)
Behavioral problems in school, behavioral
problems at home, delinquent acts, arrests for
violent crime, arrests for property crime.
Youth risks: median effect size for youth behavioral problems -7.8% (-7% to
-8.5%). (3 studies)
Self-reported symptoms of depression and
anxiety by household head. Self-rated health
status as good or excellent compared to fair or
poor. Child needing medical attention for
accidents or asthma, child use of preventive
services.
Psychological and physical morbidity: median effect size for symptoms of
depression and anxiety -8% (-6.5% to -9.5%), self-rated health status as good or
excellent +11.5% (+9% to +11.5%), child requiring acute medical attention
-4.5% (-6% to 0%), child use of preventive care was -5.5% (-7% to -4%).
(2 studies)
* Evidence may be judged to be insufficient for one or more of the following reasons: limitations in design or execution of the studies, too few studies,
inconsistent findings across studies, or effect size not large enough.
Access to Culturally Competent Health Care
Access to culturally competent health care
•Diversity training
•Culturally accommodating settings
•Interpreter services
•Culturally appropriate health education materials
•Diverse staffing
•Insufficient number of evaluation studies to draw
conclusions about intervention effectiveness
For Further Information
•Morbidity and Mortality Weekly Report on
Community Guide Sociocultural Environment
reviews coming in November 2001
•Reviews will be published in the American
Journal of Preventive Medicine in Fall 2002
•Community Guide website: www.thecommunityguide.org