It still takes a village: Advocating healthy living medicine for communities through social justice action.

Countless individuals in the United States continue to experience effects related to the coronavirus disease 2019 (COVID-19) pandemic, such as job/business instability, the breaking down of school systems, isolation, and negative health consequences. There are, however, certain populations and communities that continue to be disproportionately affected, resulting in severe health outcomes, decreased quality of life, and alarmingly high death rates. These populations typically live in historically excluded communities and identify as persons of color. To advance health equity in these communities, healthy living (HL) strategies are paramount. In fact HL Medicine - getting sufficient physical activity, practicing good nutrition, maintaining a healthy body weight, and not smoking, can be a viable solution. Applying these concepts, particularly the promotion of physical activity, through community collaboration can advance the goals of social justice action.

Introduction

After almost two years of coronavirus disease 2019 (COVID-19) related morbidity and mortality, compounded by the multifarious effects of racism on health, addressing root causes of these problems has taken a reinvigorated and justified prominence, presently viewed as a dire concern and top priority. , There is a universal call for answers, with organizations on local, national, and international levels working to find effective health solutions for individuals in need. Countless individuals in the United States (US) continue to experience pandemic related effects such as job/business instability, the breaking down of school systems, isolation, and negative health consequences.2., 3., 4. There are, however, certain populations and communities that continue to be disproportionately affected, resulting in severe health outcomes, decreased quality of life (QoL), and alarmingly high death rates. , , A great number of these populations identify as persons of color, live in historically excluded communities, and are at greater risk of being exposed to natural and man-made disasters because of their limited resources. ,

To advance health equity in these communities, healthy living (HL) strategies are of paramount importance. With the above-mentioned factors contributing to chronic disease for so many, HL Medicine (HLM) - getting sufficient physical activity, practicing good nutrition, maintaining a healthy body weight, and not smoking, is a necessary solution. Applying these concepts through social justice action is essential to help to improve the lives of underrepresented individuals living in underserved communities. This paper examines the role of social justice action and racial equality in advancing HLM in the US.

Physiological and psychosocial health risks for historically marginalized communities

Epidemiological studies have consistently demonstrated troubling trends of poor national health and more concerning observations of disinvested communities disproportionally impacted by largely preventable chronic health conditions. , Black and Hispanic populations commonly live in these communities , and their rates of hypertension, hypercholesterolemia, smoking, obesity, and metabolic disorders have been found to more prevalent compared to non-Hispanic White individuals. Although complex, these observations can largely be attributed to long term health and social inequities which have contributed to suboptimal lifestyle behaviors such as low PA levels, high sedentary times,13, 14, 15 consumption of calorically dense and sugary foods, and using tobacco products, all which significantly increase the risk of developing CVD, metabolic syndrome, diabetes, pulmonary disease, and cognitive dysfunction.16, 17, 18 Indigenous and Pacific Islander communities are also economically and socially marginalized and suffer negative health outcomes, being more than twice as likely (3.3 and 2.6 respectively) to die from COVID-19 related complications as Whites. Additionally, a disturbing surge in anti-Asian racism due to misinformation concerning the spread of the COVID -19 virus has resulted in devastating effects on health in this pan-ethnic population. Although Asian subgroups have their own unique health challenges, as an aggregate population they have experienced a 35% increase in excess deaths in the first seven months of the pandemic, 60% higher hospitalization, and a 50% higher positive test rate than Whites.

Psychosocial factors like stress, depression and low socioeconomic status are associated with CVD risk. Individuals earning less than $35,000 per year who also reported stress and depression symptoms had a 48% higher risk of developing CVD and a 33% increased risk for all-cause mortality. Structural, interpersonal, and institutional racism in a variety of environments can take a negative toll on mental and physical health. In the US, African Americans suffer extreme amounts of overt and subtle racist treatment, from subtle microaggressions to high instances of murder and violence at the hands of law enforcement and others who rarely receive justice for their crimes. , , , , , The anxiety of one's personal safety, in addition to meeting their basic needs is a reality that Black citizens and other people of color must negotiate daily.

Community defined

In creating and implementing successful HLM initiatives, collaborations with community members are elemental. Community is often geographically defined. Community change researchers Chavis and Lee argue that community does not simply encompass location, but “both a feeling and set of relationships among people”. Our best approach adopts definitions created by diverse groups themselves, as self-definition and self-naming are traditions in communities of color used to empower and as “a tool to rename and redefine individual and collective identity”. Of 118 interviewed individuals from various US locations, core elements of community determined were: 1) physical location (77%); 2) persons who share a common interest (58%); 3) those who participate in joint action or activities (50%); 4) sharing social ties and/or relationships (50%); and 5) differences or diversity (24%). This multilayered definition requires us to understand how groups interact and solve problems together. From here on we will use the term ‘community’ to refer to any group sharing something in common, often geographical location, race and/or ethnicity, history, culture, and/or concerns.

Effects of systemic racism on community

The health of American communities and neighborhoods is directly connected to our nation's history of exclusion, racism, and intolerance. Although legal segregation has been eliminated for decades, clear inequities to access for certain populations persist, which has a strong correlation to a range of chronic diseases like diabetes, CVD, obesity, and poor mental health. , , , As a method to keep US racialized groups marginalized, segregation was prominently deployed in the discriminatory practice of redlining (i.e., the denying of financial services such as loans or insurance to low income and communities of color). The far-reaching consequences of this historical practice can be associated with modern-day higher prevalence of concentrated poverty, insecurity, illness, and social vulnerability. When banks and other organizations discourage lending in a particular community, residents are often unable to maintain properties, which fall into disrepair. , Companies leave when neighborhoods deteriorate, taking with them much needed tax monies that are allocated for revitalization and programming. Disinvested communities typically have schools that are underfunded, which severely limits student learning opportunities and outcomes. , Additionally, under-resourced hospitals and healthcare facilities may provide substandard care, or force residents to travel outside of their neighborhoods to receive adequate preventive and rehabilitative services, as has been painfully obvious in the availability of treatment and testing for COVID-19.

The Mapping Inequality digital humanities project is a collaborative effort between researchers at the University of Richmond, Virginia Tech, the University of Maryland, and John Hopkins University. , The map illustrated in Fig. 1 , from 1935 to 1940, details how the Home-Owners Loan Corporation, a now defunct federal agency, classified neighborhoods nationwide in terms of perceived desirability and loan risk levels. The historical consequences of labeling certain areas valuable based on the race/ethnicity of its inhabitants have had long standing consequences affecting previously mentioned health outcomes as well as fertility and birth rates, incomes, and overall QoL. ,

Fig. 1

Map of neighborhood desirability and loan risk across the United States.

The city of Chicago is an excellent example of how the current pandemic has demonstrated racial inequity for different communities. The Illinois department of public health analyzed the relationship between zip codes, COVID-19 cases, and COVID-19 related deaths, finding that communities on the West and South sides of Chicago had higher cases and deaths related to COVID-19. These communities, which are predominantly African American, also demonstrate higher rates of cardiac related deaths, stroke related deaths, asthma, hypertension, diabetes, obesity, and smoking. The census data listed in Table 1 reveals the sharp contrast of demographic and health outcomes between two Chicago near Westside neighborhoods separated by one major street. ,

Table 1

Chicago census data from two westside neighborhoods.

Category	Census Tract 2431(Between Damen and Wood, Kinzie and Chicago Avenue)	Census Tract 2804(Between Damen and Ashland, Kinzie and Washington Blvd)
Population	2274 (0.1 Square Mile)	1585 (0.2 Square Mile)
Life Expectancy	85.6	69.8
Median Household Income	$110,385	$39,544
Below the Poverty Line	7%	36.8%
Bachelor's Degree or Higher	64.1%	21.7%
Women who gave birth between 15 and 50 years old	5.2%	2.4%

As evidenced above and across the US, many communities that were once subjected to redlining, a practice ending only 48 years ago with the 1968 Fair Housing Act, are currently at risk for experiencing shorter life spans of as much as 30 years compared to other neighborhoods in the same city. What we have presented to this point confirms the challenges countless communities face in achieving a culture of HL. We advocate for the consideration of a HLM approach, with an emphasis on increasing physical activity (PA) to begin to work toward a health equity focus that improves the well-being of community residents nationwide.

The promise of HLM

HLM is very deliberate in its pragmatic approach, which honors the variability of one's lived experiences and is centered in a willingness to meet people where they are in terms of location, attitude, and level of health. This is the opposite of traditional healthcare models that simply treat disease from a secondary or tertiary standard of care, often limited to medical facilities. In a two-way dialogue where both participants and practitioners share experiences and resources, HLM strategies can help one move toward understanding and adopting a healthier lifestyle. Effective HLM practices work to normalize a “culture of healthy living” where being active and healthy eating becomes an easy choice. For many living in a community where there are very little health promoting services and environments, a consideration to meet the standard PA guidelines of 150 min (about 2 and a half hours) per week may be unrealistic. Bigger issues pertaining to survival are often at the forefront of community members' needs. Promoting incremental increases in PA offers a non-judgmental, achievable benchmark, reinforcing that all types of movement are important and useful, and any movement toward HL may increase health benefits , This mindset may appeal to community members who do not have access to big box gyms or community recreation centers. Activities such as walking and dancing, which do not require equipment, can be performed by those with varying levels of fitness. HLM can advance social justice in its flexibility of the effort needed to be successful and its accessibility. Activities that promote ‘moving more sitting less’ can be performed almost anywhere. One's living room or yard, the breakroom at work, or church all provide an environment to be active. In this way, HLM offers culturally informed consideration. Further, HLM champions community collaboration among diverse groups – government and healthcare organizations, educational institutions and individuals. , Collectively advocating HLM encourages interaction which may result in teamwork, empathy and understanding.

PA to advance HLM

Numerous investigative efforts have established the efficacy of PA interventions in reducing the risk of developing chronic health conditions and slowing their progression or even reversing physiologic impairments in the presence of chronic disease. , However, these interventions have not translated well in clinical or community settings due to insurance, financial and transportation barriers experienced by underserved community members. More sobering is knowing that these barriers inhibit individuals from exploiting the powerful and protective effects of healthy living against morbidities.

A large majority of research studies implementing PA interventions do so by selecting structured activities (e.g., treadmill walking, cycling, resistance exercise using machines, etc.) which may not be easily accessible or even culturally accepted by ethnic groups, especially older adults. A growing body of literature has raised awareness of racial/ethnic cultural perceptions and preferences related to the broad scope of PA and their influence on PA behavior.41, 42, 43 This is particularly true in older adults and specifically older Black and Hispanic adults. For instance, older black women have reported placing greater emphasis on taking care of family members and friends before tending to their own needs, which may negatively impact the time and energy available to engage in regular, structured PA. Previous focus group work in older Hispanic adults examining perceptions and attitudes toward PA revealed common experiences of being raised in communities that discouraged older adults from performing structured exercise regimens that would cause one to perspire. Furthermore, women reported that it was considered culturally unacceptable for girls to exercise and participate in sports during childhood as well as across the lifespan. An experience that may also be shared by older Black women. Understanding, identifying, and finding solutions to overcome these unique, culturally specific PA barriers should be an integral component of PA counseling sessions.

The process of culturally tailoring PA programs requires a recognition of a group's shared history, cultural values, social norms, beliefs, and behaviors to effectively promote PA adoption. Special emphasis is placed on addressing these areas and providing education/clarification on what the term PA represents, as it is commonly interpreted as structured, traditional exercise (e.g., walking, jogging, weightlifting). Clarifying this term will facilitate the participants' ability to report activities that they enjoy or commonly engage in (e.g., dancing, playing with grandchildren, housework, etc.) as a part of or independent of their cultural background. For example, dancing is tightly woven into the Hispanic culture and is considered culturally acceptable for all ages and sexes. This form of PA has been found to facilitate improvements in cognitive function as well as functional capacity. , Thus, emphasizing that movement at moderate to vigorous efforts relative to the person's functional capacity, rather than mode of activity, facilitates health related improvements. Taking on this approach to providing PA guidance may therefore play an integral role in lowering the risk of developing chronic health conditions or improving the management of chronic diseases in underserved community members.

Examples of healthy communities in action

Cardiac Rehabilitation(CR) at the University of Illinois Chicago

Contemporary CR programs provide supervised exercise training, opportunities for dietary interventions, diabetes management and smoking cessation with the goal of reducing risk of secondary events, improving cardiorespiratory fitness, healthspan and quality of life. Despite the well documented benefits of this service, enrollment rates are disparagingly low. Although there are many barriers to participating in CR, cost sharing responsibilities and travel time/distance pose prominent limitations. Therefore, many patients attending CR attend at a facility near their place of residence.

The University of Illinois at Chicago's CR Program is physically located in an area that largely serves minority populations that live in communities that have limited access to physically active spaces and have high rates of violent crimes which makes walking in their neighborhood an impractical PA recommendation. As practitioners who serve these patients, we develop empathy by recognizing and appreciating our professional and personal privilege that shelters us from these often-daily experiences. In recognition of this unfortunate barrier to PA, practitioners delivering CR have open, one-on-one discussions with participants regarding their experience living in their community to consciously tailor PA recommendations to be performed on non-CR days. In addition to promoting health related improvements through PA, it may also contribute to the participants' perception of being able to take control of their health and make a positive change. A seemingly simple observation but particularly meaningful for individuals who may have previously felt that HL was not an option.

(Re)Present! Wellness Program

As a community, Black women and girls work against significant challenges concerning their health, with higher levels of obesity and overweight than any other racial or gender group. , Maternal mortality rates are highest among Black women, , and doctors and other medical personnel often underestimate and undertreat Black women's pain, resulting in misdiagnosis and poorer health outcomes. The mental health of Black girls ages 13–19 is at an all-time crisis level due in part to disproportionate disciplinary actions subjected upon them compared to White girls. , Research centered on Black Women and girls' health supports that culturally informed and responsive interventions and programs are needed. The (Re) Present! Wellness Program was created in 2016 as a PA centered initiative created by Dr. Grenita Hall and Chicago Public School principal Sydney Golliday to improve the health and wellness of Black women and girls.

Program goals include fostering participants' positive attitudes about physical activity, cultivating positive body image and self-esteem, and (re)presenting ideas of identity and self-efficacy. These goals support evidence that positive body image and high levels of self-esteem yield higher levels of participation in physical activity.

(Re)Present! employs resiliency practices and culture-centered knowledge to develop and nurture the belief that self-care is a necessity. In doing so, motivating images and opportunities are promoted for Black women and girls to see vitality, good health, and PA as normal, functional parts of their everyday lives. (Re) Present! also prioritizes collective and individual psychosocial needs and collaborates with organizations that center Black women and girls' health concerns like Black Girls Run (https://blackgirlsrun.com/), GirlTrek (https://www.girltrek.org/), and Therapy for Black Girls (https://therapyforblackgirls.com/).

My Very Own Library/Literacy For All

Many historically excluded communities suffer from its members having low levels of literacy. Risks from low literacy include challenges understanding basic health information, poorer management of chronic illnesses and conditions, and less likelihood of accessing preventive services. , The first step to eliminating low literacy of communities is to improve family literacy. Family literacy is defined as “home literacy activities that provide literacy skill building activities opportunities for young children while enhancing literacy skill development for all family members”. Literacy rich homes provide better home school communication, which results in students who are happier, healthier, and better prepared for the work force. , The My Very Own Library Program at the University of Chicago creates home libraries for students and families, working within six states and serving 50,000 students. This project seeks to get 100 books into the homes of students from Pre-Kindergarten to 8th grade over the course of ten years (10 books a year for every school in the program). Parents in the program receive tools to encourage reading and writing for students at home and at school. Educators receive classroom supplies, technology, and funding to gain additional training in supporting student language and literacy skills.

Future directions/solutions

What is needed to create healthy solutions for US communities? Many advocate that less talk and more action is preferable, while others champion evidence-based processes that take time. Community based participatory research (CBPR) satisfies both. CBPR is an ethical collaborative approach to research involving community members, researchers, and service organizations to achieve health equity through social justice action. Also known as Participatory Action Research, CBPR aspires to encompass the following qualities: 1) Recognizes community as a unit of identity; 2) Builds on strengths and resources within the community; 3) Integrates and achieves a balance between knowledge generation and intervention for the mutual benefit of all partners; 4) Involves a long-term process and commitment to sustainability; 5) Openly addresses issues of race, ethnicity, racism, and social class, and embodies “cultural humility”. Table 2 below details four community action models that have been successful in improving the health of US communities in the past 10 years.66., 67., 68.

Table 2

Community action models.

Community Model	Overview	Methods	Why use?	Contact Information
Community Readiness Model	Assesses the degree to which a community is ready to act concerning a specific issue. Determined by community efforts, knowledge, leadership, climate, and resources.	1) Assessment tool (36 Interview questions 2) Score and develop strategies based on community level of readiness	1) Efficient, inexpensive, user-friendly 2) Promotes community recognition/ownership 3) Culturally informed	www.ruralhealthinfo.org/toolkits/health-promotion/2/program-models/community-readiness
Healthy Cities, Healthy Communities	Loosely defined strategy that encourages community members and elected officials to work together in creating healthier communities.	No step-by-step format, may use any participatory process, if it results in a community wide, multi-level plan	Offers a comprehensive view on health that includes peace, sustainable resources, social justice	ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/healthy-cities-healthy-communities/main
IOM's Community Health Improvement Process (CHIP)	Community health framework with performance monitoring component. Focuses on process, not content.	Two cycle processes:First: Assess and analyze community to identify pressing issue(s)Second:1) Analyze issue(s), evaluate available resources 2) Develops long term strategic plan and short-term goals 3) Identify accountability and measurable indicators for success	1) Takes community perspective 2) Inclusive/ Participatory 3) Promotes equity as a key component	ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/chip/main
CDC's Community Health Improvement (CHI)	Unites healthcare, public/ other stake holders to improve community health	Focuses on intervention in four action areas – socioeconomic factors, physical environment, health behaviors, clinical care	Community Health Improvement Navigator – offers community stakeholders vetted tools for successful community interventions	www.cdc.gov/chinav/index.html

Numerous health and government organizations are also making a commitment to improve the health of communities through social justice action. Trinity Health Systems, one of the largest not-for-profit, Catholic healthcare systems in the US, practices equitable action with their two signature programs. The Community Investing Program offers low interest loans to community partners who positively influence social factors that improve health outcomes in underserved neighborhoods, investing 37.2 million dollars to 29 non-for-profits in 2021. Additionally, the Community Health Institute was established in 2008 and offers grants to community-based organizations that work to improve community health. The Centers for Disease Control (CDC), the primary health protection agency in the US, works to “understand the intersection of racism and health, and take action”. Under this pretense, the CDC has allocated $300 million dollars to assist the efforts of community workers to prevent and manage COVID-19 among populations and communities most adversely affected by the pandemic. The CDC's Racial and Ethnic Approaches to Community Health, is a national program that funds culturally informed interventions and programs that address health issues among under-resourced populations. The REACH program recipients include health departments, universities, tribal and community organizations.

Conclusion

As we create and think about viable solutions, a holistic lens must be implored. Our positionality as practitioners, researchers and students must begin with the fundamental truth that we are also members of a community. We have skills, resources, and ideas regarding our lives, and those in the neighborhoods and cities we serve are no different. Addressing our own biases and being mindful of how our work and lives affect members of other communities is key. It is then we can offer our skills as actively engaged partners to help fix broken systems that keep certain groups from living their best, healthful lives. Working effectively across differences will require doing away with outdated narratives guiding our thinking and thus our actions.

COI/Disclosures

None.