Lesson 21 · Actions to promote and improve health
Applying the SDGs I: what other communities did, and what transfers
Every community that has improved its own health did something specific, in a specific place, with specific people. The question this lesson answers is which parts of that were about the place and which parts would work anywhere — because copying a program without its mechanism is how good ideas fail in new towns.
A program improved children's health in one town. Another town copies it exactly and nothing happens.
Write down four reasons that could have occurred. Then rank them by how likely you think each is.
- Describe how the goals have been applied in other communities, with Healthy Cities Illawarra as the worked Australian example.
- Identify the features common to community approaches that work.
- Explain what lessons can be drawn from another community, and the difference between a lesson and a program.
- Apply the transfer test — mechanism first — to decide what carries across to a different context.
- Explain why community-led approaches outperform delivered-to approaches, in mechanism rather than in sentiment.
- Healthy Cities — an approach in which a whole local area, rather than a health service, takes responsibility for the conditions that produce health, working across sectors.
- Intersectoral action — health, education, housing, transport, planning and community organisations acting together on a shared aim.
- Community development — building a community's own capacity to identify and act on its priorities, rather than delivering a service to it.
- Community-led — priorities and design set by the community affected; distinct from consultation, in which they are asked to comment on someone else's plan.
- Settings approach — working through the places people already are — schools, workplaces, sporting clubs — rather than expecting them to come to a health service.
- Capacity building — leaving skills, relationships and structures behind, so the work continues after the funding ends.
- Sustainability of a program — whether it continues once the initial funding, champion or grant ends. Most do not.
- Transferability — whether what worked in one place will work in another, which depends on the mechanism rather than on the activity.
The syllabus names Healthy Cities Illawarra as an example of the goals applied in a community, and it is worth understanding as a model rather than as a list of projects.
What kind of thing it is. A long-running, independent, community-based organisation in the Illawarra region of New South Wales, working on the conditions that produce health rather than on treating illness. It is not a health service. It works by convening — bringing councils, health services, schools, businesses and community groups together on shared local priorities — and it has done so for decades, which is itself the most important fact about it.
The kinds of work such an organisation does. Food security and access to affordable fresh food; active transport, walking and cycling infrastructure and safe routes to school; community gardens and shared food growing; programs in schools and workplaces; social connection and reducing isolation; supporting participation by groups often left out of planning; and advocating in local planning decisions so that health is considered in decisions made for other reasons.
How it maps onto the four goals. Food security, activity and social connection are SDG 3. Programs in schools and support for participation are SDG 4. Focusing on groups usually left out is SDG 10. Walking and cycling infrastructure, community gardens, safe routes and planning advocacy are SDG 11. One organisation, working on all four, because the community's problems do not arrive sorted by goal.
The transferable feature is not any single project. It is that an independent, local, long-lived body existed whose job was to hold the connections between sectors that the health system's own structure keeps separate.
Quick check: What is the most transferable feature of a Healthy Cities approach?
Across settings — Australian and international, urban and remote — the successful examples share seven features. This list is what “lessons that can be drawn” actually means, and it is far more useful than a list of programs.
- The community sets the priority. Not consultation on a plan already written. The strongest single predictor of whether a program is used is whether the people using it had a say in what it would be. This is the self-determination mechanism from Lesson 2, in a general form.
- It works across sectors. Health alone cannot change housing, transport, food supply or schooling, and those are where the determinants sit.
- It works in settings people are already in. Schools, workplaces, clubs, community centres. Requiring people to come to a health service filters out exactly the people with the least time and access.
- It changes conditions, not only behaviour. A footpath, a bus route, a price, a policy. Conditions keep working when the campaign stops.
- It builds local capacity. Local people trained, employed and connected, so skills and relationships remain when funding ends.
- It lasts long enough. Determinants move slowly. A two-year funded project cannot change what a decade of conditions produced, and short funding cycles are the single most common cause of failure.
- It measures, and measures by group. Baseline, indicators agreed in advance, and disaggregation so that an improving average does not conceal a group left behind.
Two structural notes worth adding to any answer. First, the barrier to lasting community work is usually funding structure, not community willingness: short, competitive, project-based grants push organisations toward small, visible, time-limited activities and away from the slow conditions work that changes outcomes. Second, the presence of a person or body whose job is the connections — a coordinator, an alliance, an organisation like the worked example — is what distinguishes a partnership that functions from one that exists on paper.
True or false: Short, competitive, project-based grant funding pushes community organisations toward small visible activities and away from the slow conditions work that changes health outcomes.
Four further patterns. For each, the point is the mechanism, because that is what transfers.
- Community-controlled health services. Governance by the community served. Mechanism: services designed by the people who use them are experienced as culturally safe and are therefore used, so chronic conditions are managed rather than presenting acutely. Transfers to any community where trust in mainstream services is low — which is a question about the community, not about the service.
- School-based settings programs. Health work delivered where children already are: food, activity, vision and hearing, dental, mental health. Mechanism: universal reach without requiring a family to seek anything out, which removes the access gates from Lesson 8, and a health gain and an education gain from one action.
- Whole-of-town food and activity initiatives. Councils, schools, shops and clubs changing what is available rather than what is advertised. Mechanism: changing the default. People do not have to decide to be healthier; the easy option becomes the better one.
- Local advocacy in planning decisions. A community body appearing when transport routes, shop locations, housing density or open space are decided. Mechanism: health considered in decisions being made for other reasons, at the moment they are made, when changing them is nearly free — and prohibitively expensive afterwards.
Across all four, the same three-part shape: reach people where they are; change conditions rather than urging behaviour; and put the affected community inside the decision. That is the answer to “how have these goals been applied in other communities” at a level of generality that is actually usable.
Fill the gaps. Working through the places people already are, such as schools and workplaces, is called a approach. Health, education, housing and transport acting together on a shared aim is called action.
This is the second half of the sub-point, and it is the harder half. It is the same transfer test as Lesson 4, applied to communities rather than to countries.
- 1. Name the mechanism, not the activity. A community garden is an activity. The mechanism might be food access, or social connection, or a reason for people from different groups to meet, or visible community ownership of a public space. Those are four different mechanisms, and which one was operating decides what to build somewhere else.
- 2. Ask whether the mechanism can operate here. Is there an equivalent gap to fill, a body that could hold it, and a setting people already use? A settings approach through sporting clubs works where clubs are strong and fails where they are not.
- 3. Identify what was local. One committed council, a long-standing organisation, a particular funding source, a specific individual. If success depended on something not present in the new place, an equivalent must be built or the transfer fails.
- 4. Check the population. A program designed for one community's language, culture, age structure and work patterns may need substantial adaptation, and adaptation must be done with the receiving community rather than for it — otherwise the first principle has been broken in the act of transferring.
- 5. Decide what will be measured, before starting. Baseline, indicators, disaggregation, and a stated period. Without this you cannot tell a program that failed from one that has not finished.
Copy the mechanism, adapt the activity, rebuild what was local, and measure from the start. A program copied without its mechanism is a set of activities with nothing underneath them, which is the most common way a good idea fails in a second town.
Odd one out. Three of these are features shared by community approaches that succeed. Which one is not?
“Involve the community” is the most repeated and least explained sentence in health promotion. It works, and here is why — five mechanisms, none of them sentimental.
- Better problem identification. Communities know what is actually wrong. An outside body reads data and sees a rate; the community knows the bus stops running at six, that the shop closed, and that people will not go to a particular building.
- Acceptability. A program designed with the people who will use it is used. That is the acceptability gate from Lesson 8, and it is the gate that outside-designed programs fail most often.
- Reach into the networks that matter. Local people can reach the households an advertisement cannot.
- Durability. A program the community owns continues after the funding; a program delivered to a community stops when the provider leaves.
- Control is itself a determinant. Participation and control over decisions affecting your life are associated with better health independently of what the program does. So the process is part of the intervention, not the packaging around it.
And the honest caveat, because an evaluation needs one: community-led is slower, needs skills and time that a community may not have available unpaid, and can be captured by whoever is loudest. Being community-led is not sufficient. It has to be community-led and resourced and deliberate about including the people usually left out — which is where SDG 10's “leave no one behind” applies inside a community rather than between them.
Activities · find the mechanism
For each, name the likely mechanism and say what would have to be true in another community for it to transfer.
A community garden run on council land beside a housing estate.
A walking school bus, where children walk to school in a supervised group.
A sporting club that becomes a site for health checks and mental health conversations.
A local alliance that appears at council meetings whenever transport or open space is decided.
Match each approach to the mechanism that makes it work.
- Community-controlled service
- School-based program
- Whole-of-town food initiative
- Planning advocacy
- Care designed by the people who use it is experienced as safe, so it is used
- Universal reach without a family having to seek anything out
- Changing the default, so the easy option becomes the better one
- Health considered at the moment a decision is made, when changing it is nearly free
Choose one approach from this lesson. Run the five transfer steps for the community you know best.
Name the mechanism; say whether it can operate there and why; identify what was local in the original and what you would have to build; say how you would adapt it with the receiving community rather than for it; and state the measures you would set before starting, including how you would disaggregate them.
Lock it in. In one sentence, explain why a program copied exactly from a successful community can fail completely in another.
Evaluate the application of the Sustainable Development Goals to inform strategies for improving the health status of an Australian community.
Evaluate demands a judgement against criteria. Note carefully what is being judged: not the goals themselves, but their application as a tool for informing strategy.
Plan: criteria, the case for, the case against, a verdict that commits, then a qualification.
The application of the SDGs will be judged against three criteria: whether they identify the right determinants to act on, whether their targets and indicators make progress measurable, and whether they can be operationalised at the scale of a single community.
Against the first two criteria the framework performs well. Because SDGs 3, 4, 10 and 11 span health, education, inequality and environment, they direct planners to the determinants rather than to services alone, which counteracts the tendency to treat poor community health as a health-service problem. Their defined targets and indicators make progress measurable and comparable over time, and their international standing gives local advocacy a recognised language for arguing that housing or transport decisions are health decisions.
Against operability at community scale the framework is weaker. The goals were written for nation-states, so their indicators are often too coarse to detect change in a single community and may not be collected at that level at all. They identify what should improve without specifying how, so they inform priorities rather than strategies. And because they are non-binding, application depends entirely on local commitment and resourcing, which means the framework has no mechanism to compel the cross-portfolio action it implies.
On balance the SDGs are highly effective as a diagnostic and advocacy framework and only partially effective as a strategic one. Their strength is that they force attention onto the determinants and make the case for cross-sector action; their limitation is that they specify ends without means, so a community can apply them accurately and still require separate local evidence to decide what to actually do.
Their application is therefore most effective when paired with local data identifying which determinant is currently binding, since the framework establishes that education, equality and environment matter without establishing which of them matters most here.
The application of the SDGs will be judged against whether they identify the right determinants to act on, whether their targets and indicators make progress measurable, and whether they can be operationalised at the scale of a single community. Against the first two the framework performs well: because SDGs 3, 4, 10 and 11 span health, education, inequality and environment, they direct planners to the determinants rather than to services alone, counteracting the tendency to treat poor community health as a health-service problem; their defined targets and indicators make progress measurable and comparable over time; and their international standing gives local advocacy a recognised language for arguing that housing and transport decisions are health decisions. Against operability at community scale the framework is weaker. The goals were written for nation-states, so their indicators are often too coarse to detect change in one community and may not be collected at that level at all. They identify what should improve without specifying how, so they inform priorities rather than strategies. And because they are non-binding, application depends on local commitment and resourcing, leaving no mechanism to compel the cross-portfolio action they imply. On balance the SDGs are highly effective as a diagnostic and advocacy framework and only partially effective as a strategic one: they force attention onto the determinants and make the case for cross-sector action, but specify ends without means, so a community can apply them accurately and still need separate local evidence to decide what to do. Their application is therefore most effective when paired with local data identifying which determinant is currently binding, since the framework establishes that education, equality and environment matter without establishing which matters most here.
Propose strategies informed by the Sustainable Development Goals to address a major health issue in an Australian community.
Propose asks you to put forward a course of action for consideration, justified. Each strategy must be tied to a goal, a determinant, and a reason for expecting it to work.
Plan: identify the issue and the community, then give each strategy with the goal it draws on and the mechanism it relies on.
The issue selected is high rates of type 2 diabetes and cardiovascular disease in a regional community with above-average socioeconomic disadvantage, limited public transport and a single general practice serving a wide catchment.
First, extend primary care capacity through a nurse-led chronic disease clinic with outreach to outlying towns, drawing on SDG 3's universal health coverage target. This works because the binding problem is not the absence of effective treatment but the frequency of contact, and continuity of monitoring is what prevents progression to complications.
Second, deliver health literacy and cooking programs through schools and adult education, drawing on SDG 4, and target subsidised access at the households with least capacity to participate, drawing on SDG 10. This works because knowledge alone does not change behaviour where cost is binding, so pairing education with affordability addresses both halves of the constraint rather than one.
Third, invest in the built environment under SDG 11 — safe walking and cycling routes connecting housing to the town centre, lit and maintained public recreation space, and a community transport service to the clinic. This works because it raises incidental physical activity and clinic attendance without requiring individuals to acquire new resources or motivation, so its effect does not depend on who chooses to participate.
Effectiveness would be assessed against local indicators rather than national ones: clinic attendance and continuity rates, the proportion of diagnosed patients meeting management targets, and preventable hospital admissions from the catchment — because the SDG indicators themselves are too coarse to detect change at this scale.
The issue selected is high rates of type 2 diabetes and cardiovascular disease in a regional community with above-average socioeconomic disadvantage, limited public transport and a single general practice serving a wide catchment. First, extend primary care capacity through a nurse-led chronic disease clinic with outreach to outlying towns, drawing on SDG 3's universal health coverage target; this works because the binding problem is not the absence of effective treatment but the frequency of contact, and continuity of monitoring is what prevents progression to complications. Second, deliver health literacy and cooking programs through schools and adult education under SDG 4, and target subsidised access at households with least capacity to participate under SDG 10, because knowledge alone does not change behaviour where cost is binding, so pairing education with affordability addresses both halves of the constraint. Third, invest in the built environment under SDG 11 — safe walking and cycling routes connecting housing to the town centre, lit and maintained recreation space, and community transport to the clinic — because this raises incidental activity and attendance without requiring individuals to acquire new resources or motivation, so its effect does not depend on who chooses to participate. Effectiveness would be assessed against local indicators rather than national ones: clinic attendance and continuity, the proportion of diagnosed patients meeting management targets, and preventable hospital admissions from the catchment, since the SDG indicators themselves are too coarse to detect change at this scale.
Return to card 01. You gave four reasons the copied program might have failed. Check them against the five transfer steps: did you name the mechanism problem, or did your reasons stay at the level of funding and effort? The mechanism problem is the one most people do not see, and it is usually the actual answer.
Multiple choice · 5 questions
MC 1. A settings approach to health promotion means:
- A. setting targets before a program begins
- B. working through places people already are, such as schools, workplaces and clubs
- C. establishing a new health service in a community
- D. adjusting a program's settings for each participant
MC 2. The strongest single predictor of whether a community program is used is:
- A. the total amount of funding it receives
- B. whether the people who will use it had a say in what it would be
- C. how widely it is advertised
- D. the qualifications of the staff delivering it
MC 3. Short, competitive, project-based grant funding tends to undermine community health work because it:
- A. requires organisations to employ too many staff
- B. pushes organisations toward small, visible, time-limited activities and away from slow conditions work
- C. prevents organisations from measuring outcomes
- D. is only available to government agencies
MC 4. A successful transfer of a community approach to a new place is best described as:
- A. the same activity delivered identically
- B. a possibly different activity carrying the same mechanism, adapted with the receiving community
- C. the same activity with more funding
- D. a new activity chosen by the funding body
MC 5. Participation and control over decisions affecting one's own life are associated with better health independently of what a program delivers. The consequence for community health work is that:
- A. the process of involving the community is part of the intervention, not packaging around it
- B. programs should be designed entirely by experts to be effective
- C. participation should be measured instead of health outcomes
- D. community involvement adds no measurable benefit
Short answer · exam style
SA 1. Understand Band 4 Describe how the Sustainable Development Goals have been applied in a community, referring to work across more than one goal. (4 marks)
SA 2. Analyse Band 5 Explain why community-led approaches tend to be more effective than programs delivered to a community. Refer to at least three mechanisms. (5 marks)
SA 3. Evaluate Band 6 Evaluate what lessons can be drawn from how the goals have been applied in other communities, and applied to a different community's context. (6 marks)
📖 Comprehensive answers (click to reveal)
Multiple choice: 1 → B. 2 → B. 3 → B. 4 → B. 5 → A.
Activity 1 model answers: 1 → Mechanism could be food access, social connection, a reason for different groups to meet, or visible community ownership of public space — identify which, because they transfer differently. For it to transfer: an equivalent gap must exist, land and water must be available, and someone must be resourced to sustain it beyond the first season. 2 → Mechanism: activity built into the day rather than requiring a decision, plus safe routes and adult presence. For it to transfer: children must live within walking distance, the route must be safe enough, and adults must be available at that hour — which fails in dispersed or car-dependent areas. 3 → Mechanism: a settings approach reaching people, often men, who do not attend health services, in a place where they already trust the people around them. For it to transfer: the club must be genuinely central to the community, and the conversation must be led by people already part of it. 4 → Mechanism: health considered at the moment other decisions are made, when changing them is nearly free. For it to transfer: a standing body must exist with the knowledge and continuity to appear reliably — this is the least glamorous and most transferable of the four.
SA 1 (4 marks): A community approach described accurately, working across sectors rather than as a single health service [1]. Work identified against at least two goals, with the connection explained — for example food security and active transport under SDG 3 and SDG 11, school programs under SDG 4, and deliberate inclusion of groups usually left out under SDG 10 [2]. How it operates described: convening councils, health services, schools and community groups on shared local priorities, over a long period [1].
SA 2 (5 marks): Three mechanisms explained [3] from: better problem identification, because the community knows what is actually wrong rather than only what the data shows; acceptability, so the program is used; reach into networks an advertisement cannot enter; durability, because an owned program continues after funding ends; and control itself being a determinant, so the process is part of the intervention. A fourth mark for connecting one of these to earlier content, such as the acceptability gate or self-determination [1]. A fifth mark for the caveat [1]: community-led is slower, requires resources and skills, can be captured by the loudest voices, and must be deliberate about including those usually left out.
SA 3 (6 marks): What other communities did, described with at least two distinct approaches and their mechanisms [2]. The features they share identified as the lessons: community sets the priority; intersectoral; settings-based; changes conditions rather than urging behaviour; builds local capacity; lasts long enough; and measures by group [2]. Transferability analysed properly: name the mechanism rather than the activity, ask whether it can operate in the new context, identify what was local and must be rebuilt, adapt with the receiving community, and set measures before starting [1]. Judgement [1]: what transfers is the mechanism and the set of features, not the program — a different activity carrying the same mechanism is a successful transfer, and an identical activity without it is not; and the most transferable single lesson is the existence of a resourced local body whose job is to hold the connections between sectors, because that is what the health system's own structure will not supply.
Two things to carry into the last lesson. The seven features are what “lessons that can be drawn” means, and the five transfer steps are how a lesson becomes a plan rather than an imitation.
The final lesson closes the module: you will identify the major health issues for a community, build a strategy using the four goals, and — the part that earns the highest marks — say how you would know whether it worked.
Mark lesson as complete
Tick when you've finished the practice and review.