AF4Q is improving the way health care is delivered, paid for, and received in 16 communities across the country. Recently, these communities have started to examine what happens outside of hospital and clinic walls—what happens in the community that impacts health. Bridging the gap between the medical system and population health is a problem fraught with challenges, but AF4Q communities, composed of multi-stakeholder partnerships, are experts at bringing people together to solve tough problems.

Learn more about AF4Q's work in population health.

What happens when you combine information on the social determinants of health with disease data? You get the Coalition for a Livable Future’s unique web-based mapping tool, called the Regional Equity Atlas 2.0. The Equity Atlas maps four chronic diseases (obesity, asthma, cardiovascular disease, and diabetes) and “healthy eating, active living”—or a person’s ability to make healthy lifestyle and behavioral choices. Data about disease came from the leader of the Aligning Forces for Quality initiative in Oregon, the Oregon Health Care Quality Corporation (Q Corp). The mapping tool allows users to overlay disease incidence rates with social factors like walkability of neighborhoods and access to grocery stores. This information can be used to assess how well different populations across the four-county Portland metro region can access key resources necessary for advancing their health and well-being.

The combination of this valuable information can help inform policymakers and support varied programs to improve health along all its dimensions. For example, urban planners may use the atlas to plan for roadways, bike paths, and bus routes to improve flow and accessibility.

“Many of the important factors that determine health are not within the health care system but are a combination of where we live, work, and recreate,” said Mylia Christensen, executive director of Q Corp.

Learn more about the Oregon AF4Q Alliance here.

Until recently, debates over health disparities were bounded by what’s been called an individual, bio-medical model that focuses almost exclusively on the roles of health care, medical technologies, and individual behaviors in shaping health outcomes. The social determinants of health equity framework offers a model for understanding health inequities. The social determinants of health are the conditions in which people are born, grow, live, work, and age, including the health system. This framework understands political and economic structures that offer advantages to some and disadvantages to others to be a root cause of different health outcomes both within and between populations.

P² Collaborative of Western New York (P² Collaborative), the leader of the Aligning Forces for Quality Alliance in Western New York, initiated a series of Community Conversations to bring community members together to take action on social determinants of health. This program gives residents the opportunity to initiate improvement projects and make their neighborhoods more healthy, livable, and safe. P² Collaborative provided local health and determinants of health data, and then residents identified priorities for change. One neighborhood addressed the inability to access fresh fruits and vegetables by creating a van service to get to the grocery store more easily. Another neighborhood fixed bus shelters and outdoor lights, creating a safer environment. These positive changes are just the beginning in improving social determinants of health in Western New York.

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