Professional Documents
Culture Documents
I
n the mid-1990s, the independent national Task groups, and social networks.
Force on Community Preventive Services (the Despite the recognition that changes in social condi-
Task Force) was created under the auspices of tions can change patterns of health and illness,5–9
the Department of Health and Human Services to systematic integration of this information into models
summarize what is known about the effectiveness of of public health is limited, as is systematic exploration
community-based interventions to improve population of interventions that might improve social conditions
health outcomes.2 The Task Force wanted to examine and health. In developing its Guide to Community Preven-
broad social determinants of health from an ecologic tive Services (the Community Guide), the Task Force
perspective— one that recognized the connection be- developed a conceptual model (Figure 1) that links
tween health and sustainable human, cultural, eco- social environmental interventions to health outcomes.
nomic, and social activities.3 Communities interact with In this introduction, we describe the analytic thinking
resources in the social and physical environments over underlying this conceptual framework. In the accom-
broad periods of time. Understanding patterns of panying article10 we illustrate use of this framework for
health or disease requires a focus not only on personal selecting interventions to be evaluated in systematic
reviews of the social environment and health for the
behaviors and biologic traits but also on characteristics
Community Guide.
of the social and physical environments that shape
human experience and offer or limit opportunities for
health.
The Community Guide’s Social Environment and
Health Model
The model shown in Figure 1 was developed by the
From the Division of Prevention Research and Analytic Methods,
Epidemiology Program Office, Centers for Disease Control and Task Force and a multidisciplinary team consisting of
Prevention (Anderson), Atlanta, Georgia; the Task Force on Com- the authors and consultants. We identified aspects of
munity Preventive Services and University of Illinois, Chicago, School the social environment known to influence health,
of Public Health (Scrimshaw), Chicago, Illinois; the Task Force on
Community Preventive Services and Columbia University (Fullilove), designed models to capture these relationships, synthe-
New York, New York; and the Task Force on Community Preventive sized and revised our models, and reached consensus
Services, Los Angeles Department of Health Services, and School of on the model shown in Figure 1.
Public Health, University of California, Los Angeles (Fielding), Los
Angeles, California The fundamental premise of the Community Guide’s
Address correspondence to: Laurie M. Anderson, PhD, MPH, model is that access to societal resources determines commu-
Community Guide Branch, Centers for Disease Control and Preven- nity health outcomes.11 Standard of living, culture and
tion, 4770 Buford Highway, MS-K73, Atlanta GA 30341. E-mail:
LAA1@cdc.gov. history, social institutions, built environments, political
The names and affiliation of the Task Force members are listed at structures, economic systems, and technology are all
the front of this supplement and at www.thecommunityguide.org. societal resources that a population draws upon to
Address reprint requests to: Community Guide Branch, Centers
for Disease Control and Prevention, 4770 Buford Highway, MS K-73, sustain health. Patterns of exposure to risk vary among
Atlanta GA 30341. Website: communityguide@cdc.gov. socioeconomic groups and are associated with a funda-
mental access to resources.11 Prosperity, whether at the • community development and employment opportu-
community, family, or personal level, provides re- nities29 –33;
sources such as knowledge, money, power, and pres- • prevailing community norms, customs, and process-
tige, which can be used to avoid or buffer exposure to es34 –37;
health risks. Poverty, however, with all of its attendant • social cohesion, civic engagement, and collective
burdens, also powerfully influences health status. An efficacy38 – 41; and
impoverished social environment is a potential source • health promotion, disease and injury prevention, and
of stressors (e.g., high-crime neighborhood or job healthcare opportunities.42– 45
scarcity) as well as resources (e.g., after-school pro-
These six observable conditions are intermediate
grams or homeless shelters).12–14
indicators along a pathway from root determinants of
The degree to which equity and social justice exist in
health to community health outcomes. Using these
a society is reflected in the distribution of resources
community conditions as general categories for inter-
within the population.15–17 Macroeconomic research
vention, we identified approximately 200 community-
shows us that, in addition to economic prosperity,
based interventions to promote health-enhancing so-
equality in the distribution of wealth is a characteristic
cial environments (Table 1), from which the first three
of societies that improves average population health
topics for systematic review were selected (this process
status and reduces health disparities.18,19
is described in more detail elsewhere in this supple-
As illustrated in our model, the following conditions
ment10). Our first three systematic reviews of commu-
in the social environment are associated with health
nity interventions, presented in this supplement (early
outcomes:
childhood development programs,46 affordable and
• neighborhood living conditions20 –24; safe housing,47 and access to culturally competent
• opportunities for learning and developing capaci- healthcare systems48), are examples of using social
ty25–28; resources to improve health.
Social Conditions as Risk and Protective Factors evaluate trends, correlate conditions with health out-
The social conditions illustrated in the Community Guide’s comes, evaluate health and social programs, and inform
social environment and health model are quantifiable policy decisions. High-risk or protective social conditions
and offer a means, using epidemiologic methods, to can be identified with available community-level data
(e.g., on education, housing, employment, and highlight which resources are most needed by the
crime). For example, data on the number of young community (e.g., quality early childhood develop-
children within census tracts in conjunction with ment centers, family health services, and after-school
high proportions of female-headed households can programs).