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Citizenship Health – Addressing the social determinants to build a Culture of Health

By Dr. Gina Weisblat, faculty, Department of Family and Community Medicine and director of education for service, Northeast Ohio Medical University


Gina Weisblat

If there were only one truth, you couldn’t paint a hundred canvases on the same theme.
-Pablo Picasso, 1966

LeShon’s Story (From urban Ohio)
Our memories and experiences shape our behavior and our responses to the world. Leshon comes from a background that is similar to that of his peers. His father was not engaged (a few rare visits over his lifetime), and his mother had to attend to him as well as to multiple other siblings.

Surviving poverty and growing up in an unforgiving, depleted environment delays children in their cognitive and emotional development. When this occurs in successive generations, the impact is multiplied, and whole family histories are written with very low rates of success. LeShon was lucky. He found a way out early, a pathway that allowed him to build a foundation for each tomorrow he faced in his world. “College didn’t come up in my house. It was if you did not finish high school you were going to the service, that type of thing. And so education was never that highly stressed. My mom dropped out of high school and got her GED. My grandma, I’m not even sure if she finished high school. And so those type of things just never came up. But I can tell you one thing: going to college is the best way to start to make change.”

poster board photoToday
Each generation of learners has its own metamorphosis. Stakeholders shepherd this journey by converting student potential through their transfer of scholarship, by providing pathways for the independent acquisition of knowledge and skill, and by instilling a life-long love of learning. These processes draw upon the enlightenment of the progenitors who came before them. As educators, health professionals and community members, we are entrusted with our nation’s greatest asset, our young people’s human capital and motivation. As such, we are always striving to improve the functionality of the tools in our daily operations, and advance the best practices of theory, pedagogy and methodology of learning. Past research has taught us that we must incorporate the context of the local ecology, and understand the learner‘s existing assets and potential for growth, in order to provide a fertile environment for sustainable learning. This must be done in a supportive community, yet with an appreciation for and application of external constraints and expectations (e.g. standardized testing). Incorporating the community into the classroom and providing the necessary social connectedness and support can give our future leaders the opportunity to grow to be the next generation of healthcare providers, or today’s version of Martin Luther King and Albert Einstein. But those endeavors require stepping outside of the comfort zone, sometimes failing, and not always being 100% certain of the outcome.

Citizenship Health

Diagram 1: Weisblat Model (2017) Pillars of Citizenship Health

Citizenship Health as a Solution
Citizenship Health (Weisblat, 2017) is the collaborative practice of people to effectively understand and address the social determinants of health (SDoH) in order to participate responsibly in building a culture of health for all. The four pillars of Citizenship Health can be seen in the diagram below. Citizen participation is a process which provides individuals and communities an opportunity to influence internal and external decisions for a person and their pathway and gain the support of the collective. Citizenship Health is operationalized by relating individual efforts to the larger well-being of the community. Active Citizenship Health begins and is grounded in our everyday lives by the choices we make minute to minute, and is bound to the anchors of our context in many ways. For this reason, SDoH are more important than traditionally defined mechanisms of improving health outcomes, and refocusing dollars on the SDoH will end in better economic and community-responsible driven healthcare systems.

Enacting Citizenship Health in our Community Today
Methods for encouraging youth participation in the future must be driven by youth interest. The Health Profession Affinity Community (HPAC) program empowers local youth to become community health entrepreneurs as they advance themselves toward higher education and ultimately to the health professions. They are encouraged to identify and act upon their health concerns in their communities, which are recognized as powerful and resourceful contexts for health and growth. They adopt a newfound role of healthcare champion in their community and they engage their community as a vital partner in the process. HPAC identifies public health concerns like obesity, type II diabetes, food insecurity, mental health and bullying, and develops grassroots programs with local assets to address them. Those programs include:

  • public service announcements about mental health and obesity filmed with mobile phones, edited on school-based computers, and distributed on YouTube,
  • “iron chef” competitions situated in “food deserts” and using healthy food options available in and donated by local convenience stores serving these communities, and
  • near-peer mentoring programs to support students with and without disabilities to navigate the psychosocial stresses of middle school and the transition to high school.

poster boardOver the past five years, HPACs addressed hundreds of local public health concerns with an array of local resources. Those resources include donations, health professionals providing their time and talents, and undergraduate and graduate students mentoring younger students.

Fast forward 5 years. LeShon has struggled to pay his bills, and find peace between the strain of home and a life that may set him apart in some ways from his community. However, LeShon believes his current success at a top Ivy League institution and his choice to pursue primary care, with a plan to serve under-resourced communities, is due to his experience in HPAC. HPAC continues to support him in college as a paid mentor in the summer programs, and assisting with his Community Health Worker certification. In his first year, he only had an old phone to help him achieve his schoolwork. The HPAC program helped him acquire a computer. LeShon has stayed connected to this Citizenship Health effort; helping him to succeed in this phase of his life, easing internal community tensions and providing mentorship is an example of Citizenship Health at its best.

Education is a fundamental determinant of health (e.g. quitting smoking and finishing high school have the same impact on life expectancy). The 21st century provides us with a tremendous opportunity to build on new assets (e.g., easy access to information) and to redirect our supply and natural talent to an ever-changing landscape. Each pillar of Citizenship Health can be seen in the Health Professions Affinity Community (HPAC) program, the Community Health Worker programs (see e-commons), the Health Scholars’ program and others that are operationalized under this banner and employed by the Ohio Alliance (OA).

poster boardOhio Alliance
As Co-Director with Dr. Erik Porfeli, from The Ohio State University, our visionis to shape health professions by creating a national community-focused agenda to modernize the healthcare education system and emphasize the individual’s role in caring for our own health and the health of our community. Community and university resources are combined to grow and sustain a diverse and innovative pipeline to health professions pathways. The goal was (and still is) to build an academically competent, diverse healthcare workforce, promoting community health and economic development across the nation, beginning in Ohio with the expertise and leadership of The Sullivan Alliance. Our approach to advancing the health, life success, and economic prosperity of underserved communities:

  • casts diversity, health maintenance, and life success as ongoing and interacting processes rather than simply outcomes to achieve;
  • recognizes that health and life success source from the same social determinants and are deeply rooted and reinforced on person, family, community, and regional levels;
  • provides developmentally-sensitive, interprofessional training and community engagement opportunities
  • emphasizes sustainability by finding existing community resources (social, cultural, economic and human capital), and combining them synergistically with university resources
  • encourages and trains students to become active agents of community health improvement
  • fosters a continuum of peer role modeling and mentorship with more advanced students serving as role models and mentors to less advanced students
  • empowers communities to develop recruitment and training programs to prepare their citizens to become a part of the future health care workforce and
  • casts students from distressed communities bound for and progressing through healthcare training programs as a precious resource because of their community and cultural knowledge that must be shared with all students within healthcare training programs.

studentsTo make this work possible, we have developed partnerships across the state to employ AmeriCorps members (Who are also CHWs) to support this vision. Our external funders work with us as champions to fulfill our goals with real actions: Serve Ohio, The Health Path Foundation, Interact for Health, The Cleveland Foundation, The Saint Luke’s Foundation, HRSA HCOP, State of Ohio Community Connectors, Rapids, 21st Century, Ohio Colleges of Medicine Government Resource Center. Additionally, we have key partnerships with the Family Medicine Education Consortium, Area Health Education Centers, Veteran’s Administration, Metro Hospital, University Hospital, Dayton Children’s Hospital, Ohio Community Health Centers, Harvest Time Evangelical Ministries, START SOLE, Teaching Ties, Neighborhood Centers Association, Cleveland Metropolitan Schools, Cleveland Police to mention a few. Ultimately, our work has yielded over 400 partnerships across the state of Ohio, we serve 2,000 students and they reach an estimated 20,000 Ohioans and many others to create a health and diverse eco-system across. Diverse youth of our communities have become the social entrepreneurs and ambassadors of transformation by operationalizing community programs to address all of our determinants of health.

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