Lesson 22 · Actions to promote and improve health
Applying the SDGs II: building and judging a strategy for your own community
The last three sub-points of this focus area are a single task: work out what is actually wrong in a community, decide what to do about it, and say how you would know whether it worked. The third is the one that separates a plan from a wish, and it is the one most answers leave out.
Name the biggest health issue for the community you know best. Then answer three questions about it.
How do you know it is the biggest — from data, or from what people say? Who in that community is most affected by it? And what would you need to see in three years to say it had improved?
- Identify the major health issues for a community, using both data and the community's own account.
- Build strategies to advocate and improve a community's health status, across all four goals.
- Answer “how do you know these strategies may be effective?” — the sub-point that carries the highest marks.
- Explain what advocacy is and why it is named separately from improvement.
- Evaluate a strategy before it is implemented, rather than only after.
- Needs assessment — systematically working out what a community's health issues are, using data and the community's own account together.
- Advocacy — acting to change the decisions, policies or conditions set by others, on behalf of or alongside a community.
- Strategy — a plan connecting an identified problem to an action through a stated mechanism, with a way of telling whether it worked.
- Process measure — whether the thing was done: sessions run, footpaths built, people reached.
- Outcome measure — whether health changed. Slower, and the one that matters.
- Baseline — the measurement taken before the strategy begins, without which no change can be demonstrated.
- Lag time — the delay between an action and the health outcome it produces; long for determinants, short for services.
- Evidence base — whether this kind of strategy has worked elsewhere, and by what mechanism.
- Unintended consequence — an effect not aimed at, including a widened gap.
Use two sources, because each one is blind to something the other sees.
What the data shows
- Local health statistics compared with state and national figures, and disaggregated by group within the community.
- Which conditions are more common here than elsewhere, and which are changing fastest.
- Service use patterns: avoidable admissions, emergency presentations, screening participation, immunisation coverage.
- The determinants: income, employment, education completion, housing, transport, food availability.
Blind to: anything not collected, anything about small groups that gets suppressed or averaged away, and everything about why.
What the community says
- What people themselves identify as the problem, which is frequently not what the data highlights.
- Barriers invisible in statistics: the bus that stops at six, the building people will not enter, the clinic with no evening appointments.
- What has been tried before and why it failed — the single most valuable and most often skipped input.
- What the community's strengths are, which determines what is possible.
Blind to: conditions people do not know they have, slow trends, and issues carrying stigma that no one raises.
Use both. Data without the community's account produces a technically correct plan that nobody uses; the community's account without data misses what is invisible from inside. Where the two disagree, that disagreement is itself a finding worth investigating.
Then apply three tests to shortlist: how much harm does the issue cause, how unequally is it distributed within the community, and is anything about it changeable at the level you can act? The second test is the one that follows from “leave no one behind”, and it frequently changes the priority.
Quick check: Local data and the community's own account disagree about the main health issue. The best response is to:
Take the issue and ask what could be done under each goal. Working through all four is what stops the plan being a list of health services.
Worked example: a regional town where type 2 diabetes is more common than the state average, onset is earlier, and the difference is concentrated in the lowest-income parts of town.
- Under SDG 3. Earlier detection through routine testing in general practice; a coordinated chronic care plan so the condition is managed continuously rather than in episodes; removing cost barriers to medicines and to podiatry and eye checks that prevent complications; and outreach to people not currently attending any service.
- Under SDG 4. Health literacy and food skills through schools rather than only through clinics, reaching families through children; support for school completion, which acts on income and control over the next twenty years.
- Under SDG 10. Target the strategy at where the burden actually sits rather than at the town average; involve residents of those areas in designing it; address cost as a barrier explicitly; and check that the plan does not simply reach the people already best served.
- Under SDG 11. Food availability and affordability — what the local shops actually stock; walkable routes, lighting and safe places to be active; transport to services; and considering health in planning decisions about where shops and facilities go.
Then advocacy, which the syllabus names separately for a reason: some of what needs to change is not within the community's own power. Advocacy is acting on decisions made by others — putting the case to a council on transport or planning, to a state government on service funding or bulk-billing access, and to local business on what is stocked and priced. A community can improve a great deal by itself and cannot decide where a bus route goes.
Improvement is what a community can do; advocacy is how it acts on what it cannot do alone. A strategy with no advocacy component has quietly accepted every constraint set from outside as fixed.
True or false: Advocacy is named separately from improvement because some of what determines a community's health is decided by others, and a strategy without advocacy accepts those constraints as fixed.
Note the wording: may be effective. The question is asked before the strategy runs, so it is about the reasoning that justifies trying it. Six tests, and they are the highest-value content in this lesson.
- 1. Is there a stated mechanism? Can you say how the action produces the health change, step by step? A strategy with no mechanism is a hope. This is the test that most proposals fail.
- 2. Has this mechanism worked elsewhere? Evidence from other communities, adjusted for what was local — the transfer test from the previous lesson.
- 3. Does it act where the problem actually is? If the issue is cost and the strategy is education, the mechanism does not touch the problem no matter how well delivered.
- 4. Will it reach the people who carry the burden? Ask specifically: who will take this up first, and is that the group with the greatest need? If not, the strategy may improve the average and widen the gap — which is the distribution rule from Lesson 15 applied to a program rather than a technology.
- 5. Is it feasible and sustainable? Funding beyond the first cycle, workforce, and a body to hold it. An excellent unfunded strategy is not a strategy.
- 6. Have you set the measures in advance? A baseline, process measures for the short term, outcome measures for the long term, disaggregation by group, and a stated period reflecting the lag time.
The lag time point deserves its own sentence, because it is where most evaluations go wrong. Removing a cost barrier can show a change in service use within months. A school completion program will not show in adult chronic disease for twenty years. Judging a determinants strategy on a two-year health outcome guarantees a false verdict of failure — so the right measure early is a process measure with a plausible link, not a health outcome that could not possibly have moved yet.
Fill the gaps. A measurement taken before a strategy begins, without which no change can be demonstrated, is the . The delay between an action and the health outcome it produces is the time. Whether the thing was actually done, as distinct from whether health changed, is a measure.
Naming these in an evaluation is what an examiner means by critical judgement.
- It addresses a symptom rather than a cause. Nutrition education where the problem is that fresh food is unaffordable and forty minutes away.
- It reaches the wrong people. Voluntary uptake follows existing advantage, so the program improves the average and widens the gap it was meant to close.
- It ends before the effect could appear. Two-year funding for a determinants problem, followed by a report finding no change.
- It was designed without the community. Technically sound, unused, and the reason is discovered afterwards.
- It has no measurement, or the wrong measurement. Either nothing was recorded, or a health outcome was demanded on a timescale where only process could have moved.
- It depends on one person. Held together by a single committed individual, and it stops when they leave. This is why capacity building is a design feature rather than a nicety.
The single most useful question to ask of any strategy before it starts: “what would have to be true for this to fail?” Answer it honestly, and the answer tells you what to design against. A strategy whose author cannot name a way it might fail has not been thought through.
Two truths and a lie. One of these statements is false. Find it.
Everything in this focus area, assembled. This structure answers any extended-response question on applying the goals to a community.
- 1. The issue. Named, evidenced from data and from the community, with who is most affected stated explicitly.
- 2. The determinants. Why this issue exists here — the mechanism, sorted by which goal each determinant sits under.
- 3. The strategies. One or two under each of the four goals, each with a stated mechanism, plus an advocacy component for what the community cannot decide alone.
- 4. Reaching the right people. Who will take it up first, whether that is the group carrying the burden, and what is designed in to make sure it is.
- 5. How you would know. Baseline, process measures for the short term, outcome measures for the long term, disaggregated by group, over a period matched to the lag time.
- 6. What could go wrong. The most likely failure mode, and what is designed in against it.
Steps 4, 5 and 6 are what most answers omit, and they are where the top band lives. Anyone can propose actions. Saying who they will reach, how you would know, and how they might fail is what turns a list into an evaluation.
And the idea this module has returned to at every stage: most of what determines a community's health is not decided by its health services. That is why the goals are in this syllabus, why advocacy is named beside improvement, and why the best answer to “how do we improve this community's health?” usually includes something that does not look like health at all.
Activities · build and judge a strategy
For each, apply the six tests from card 06. Say which test it fails most clearly and how you would redesign it.
A healthy eating information campaign in a town where the only supermarket closed and fresh food is now forty minutes away.
A voluntary six-week exercise program advertised online, in a community with a large low-income population.
A two-year funded program to raise school completion, to be evaluated on adult chronic disease rates.
A community health initiative run entirely by one enthusiastic local nurse in her own time.
Match each element of a strategy to what it establishes.
- Stated mechanism
- Baseline
- Disaggregation
- Advocacy component
- That there is a reason to expect the action to produce the health change
- That any later change can actually be demonstrated
- That an improving average is not concealing a group left behind
- That constraints set by others are not being accepted as fixed
This is the culminating task for the focus area. Using the community you know best and the issue you named in card 01, work through all six steps from card 08.
Keep it to trends and mechanisms rather than statistics, include an advocacy component, and do not skip steps 4, 5 and 6 — they are the ones that make the difference.
Lock it in. In one sentence, explain why “how do you know these strategies may be effective?” must be answered before a strategy begins, not after.
Evaluate the effectiveness of a community-level health initiative you have studied.
Evaluate demands a judgement against criteria. With a named initiative the temptation is to narrate what it did; the marks are for judging how well it did it.
Plan: name the initiative and the criteria, the case for, the case against, a verdict that commits, then a qualification.
Healthy Cities Illawarra will be judged against three criteria: whether it acted on the determinants of health rather than on services alone, whether it engaged the community as participants rather than recipients, and whether its effects were sustained beyond its initial funding.
Against the first two criteria the initiative performs strongly. It applied the Healthy Cities model of intersectoral action, so local government, health services, schools and community organisations addressed transport, recreation space, food access and social connection together rather than as separate portfolios. Community members participated in identifying priorities, which produced initiatives matched to local need and generated the local ownership on which participation depends.
Against measurable and sustained effect the evidence is weaker. Population health indicators move slowly and are influenced by far more than one local program, so attributing a change in chronic disease rates to the initiative is not possible with the data available. Funding has been intermittent, which interrupts the continuity that community trust and program delivery both require, and the model's reliance on local partnership makes it vulnerable to the loss of a few key individuals or a change in council priorities.
On balance the initiative has been effective as a model of how to act on the determinants and only partially effective as a demonstrated improver of measured health status. The mechanism — intersectoral action with genuine community participation — is sound and reproducible; what has not been established is an effect large and well-attributed enough to prove it at population scale.
This is a limitation of the evaluation rather than necessarily of the initiative: community-level programs act on determinants whose health effects appear over decades, so short funding cycles and short evaluation windows will systematically understate them.
Healthy Cities Illawarra will be judged against whether it acted on the determinants of health rather than services alone, whether it engaged the community as participants rather than recipients, and whether its effects were sustained beyond initial funding. Against the first two it performs strongly: it applied the Healthy Cities model of intersectoral action, so local government, health services, schools and community organisations addressed transport, recreation space, food access and social connection together rather than as separate portfolios, and community members participated in identifying priorities, producing initiatives matched to local need and generating the local ownership on which participation depends. Against measurable and sustained effect the evidence is weaker: population health indicators move slowly and are influenced by far more than one local program, so a change in chronic disease rates cannot be attributed to the initiative with the data available; funding has been intermittent, interrupting the continuity that trust and delivery both require; and reliance on local partnership makes the model vulnerable to the loss of key individuals or a change in council priorities. On balance the initiative has been effective as a model of how to act on the determinants and only partially effective as a demonstrated improver of measured health status — the mechanism of intersectoral action with genuine community participation is sound and reproducible, but no effect large and well-attributed enough to prove it at population scale has been established. That is a limitation of the evaluation as much as of the initiative, since community programs act on determinants whose health effects appear over decades, so short funding and evaluation windows will systematically understate them.
Justify the use of community consultation in designing strategies to improve a community's health status.
Justify asks you to argue for a position with supporting evidence — and, at this level, to show you have considered the alternative and still hold your position.
Plan: state the position, give the strongest reasons in order, deal with the objection, then restate the position as established.
Community consultation is not a courtesy but a design requirement, because a strategy's effect depends on participation, and participation depends on the strategy addressing what the community actually experiences as its problem.
Consultation identifies which determinant is actually limiting. Data can show that a community has poor diabetes control; only the community can explain that the clinic's hours conflict with shift work, or that the nearest fresh food retailer closed. A strategy designed without that information can be well evidenced in general and wrong in this place.
It also generates the ownership on which uptake depends. Programs imposed on communities — particularly where past interventions have been experienced as harmful, as for many Aboriginal and Torres Strait Islander communities — attract low participation regardless of design quality, and an intervention nobody attends has no effect however sound its evidence base.
The obvious objection is that consultation is slow, costly, and may produce priorities that diverge from the epidemiological evidence. That is real, but it argues for consultation that is properly structured and evidence-informed rather than for its absence — because the alternative is not a faster strategy but a strategy that is not used.
Community consultation is not a courtesy but a design requirement, because a strategy's effect depends on participation and participation depends on the strategy addressing what the community actually experiences as its problem. Consultation identifies which determinant is genuinely limiting: data can show that a community has poor diabetes control, but only the community can explain that the clinic's hours conflict with shift work or that the nearest fresh food retailer has closed, so a strategy designed without that information may be well evidenced in general and wrong in this place. It also generates the ownership on which uptake depends, since programs imposed on communities — particularly where past interventions have been experienced as harmful, as for many Aboriginal and Torres Strait Islander communities — attract low participation regardless of design quality, and an intervention nobody attends has no effect however sound its evidence base. The obvious objection is that consultation is slow, costly and may surface priorities diverging from the epidemiological evidence; that is real, but it argues for consultation that is properly structured and evidence-informed rather than for its absence, because the alternative is not a faster strategy but one that is not used. Consultation is therefore justified on effectiveness grounds alone, before any argument from rights or respect is made.
Return to card 01, and to the answer you gave at the very start of this module in Lesson 1, where you were asked how “Australians are among the healthiest people in the world” and “Australia has a chronic disease crisis” could both be true.
Write the answer you would give now, in three sentences. If it mentions distribution, determinants and something outside the health system, this focus area has done its job.
Multiple choice · 5 questions
MC 1. A needs assessment should use both local data and the community's own account because:
- A. the community's account is more accurate than data
- B. each is blind to something the other sees
- C. data is unavailable for most communities
- D. funding bodies require both
MC 2. Advocacy is named separately from improving a community's health status because it:
- A. is only required in remote communities
- B. acts on decisions and conditions set by others, which the community cannot change alone
- C. replaces the need for local action
- D. is a form of health education
MC 3. A strategy addressing determinants is evaluated after two years using a health outcome measure, and no change is found. The most likely explanation is that:
- A. the strategy was poorly delivered
- B. the evaluation period is shorter than the lag time, so only a process measure could have moved
- C. determinants do not affect health outcomes
- D. the baseline was measured incorrectly
MC 4. Which question most reliably identifies whether a strategy will widen rather than narrow a gap?
- A. How much will it cost?
- B. Who will take it up first, and is that the group carrying the burden?
- C. How many people will it reach in total?
- D. Which level of government will fund it?
MC 5. The most useful question to ask of a proposed strategy before it begins is:
- A. How much will it improve health?
- B. What would have to be true for this to fail?
- C. Has it been tried in Australia before?
- D. Who suggested it?
Short answer · exam style
SA 1. Understand Band 4 Explain how you would identify the major health issues for a community, and describe one strategy that could improve its health status. (4 marks)
SA 2. Analyse Band 5 Explain how you would know whether a strategy to improve a community's health may be effective. (5 marks)
SA 3. Evaluate Band 6 Evaluate the application of SDGs 3, 4, 10 and 11 to inform strategies to improve the health status of a community. (6 marks)
📖 Comprehensive answers (click to reveal)
Multiple choice: 1 → B. 2 → B. 3 → B. 4 → B. 5 → B.
Activity 1 model answers: 1 → Fails test 3, acting where the problem is: the barrier is availability and cost, not knowledge, so information cannot touch it. Redesign: act on food supply — a food co-operative, transport to a supermarket, working with the remaining shops on what they stock and price, and advocating in planning for a retail site. 2 → Fails test 4, reaching the people who carry the burden: voluntary, advertised online and six weeks long, it will recruit the already engaged and connected, improving the average while widening the gap. Redesign: deliver it through settings people already use, remove cost and transport barriers, recruit through local networks rather than advertising, and set a target for participation from the group carrying the burden. 3 → Fails test 6, measurement matched to lag time: adult chronic disease cannot move in two years from a school completion program. Redesign: process and intermediate measures — attendance, retention, completion — over the funded period, with the outcome measure specified for the long term and funding committed accordingly. 4 → Fails test 5, feasibility and sustainability: it depends on one person and stops when she leaves or burns out. Redesign: fund the role, build a small group around it, and design capacity building in so relationships and skills remain.
SA 1 (4 marks): Identification described using both sources — local data compared with wider figures and disaggregated by group, and the community's own account of barriers and of what has failed before [2]. One strategy described [1] with its mechanism stated, that is, how the action produces the health change [1].
SA 2 (5 marks): At least three of the six tests explained [3]: a stated mechanism; evidence that the mechanism has worked elsewhere, adjusted for what was local; acting where the problem actually is; reaching the people who carry the burden; feasibility and sustainability beyond the first funding cycle; and measures set in advance. The measurement plan specified [1]: a baseline, process measures short term, outcome measures long term, disaggregated by group. The lag-time point for the fifth mark [1]: judging a determinants strategy on a short-term health outcome guarantees a false verdict of failure, so the appropriate early measure is a process measure with a plausible link.
SA 3 (6 marks): A community and a specific health issue identified, with who is most affected [1]. Determinants explained and sorted by goal, so the strategies follow from the analysis rather than being asserted [1]. Strategies under all four goals, each with a mechanism, plus an advocacy component directed at decisions the community cannot make alone [2]. Reach addressed: who takes it up first, whether that is the group carrying the burden, and what is designed in to make it so [1]. Evaluation and judgement [1]: measures set in advance with a baseline, disaggregation and a period matched to the lag time; the most likely failure mode named; and a judgement on the framework itself — that the goals are most useful as a check against a plan that is only a list of health services, since most of what determines a community's health is not decided by its health services, while noting that the goals supply no funding, no workforce and no enforcement.
That is the module. Across twenty-two lessons the same argument has recurred in different forms: health is unevenly distributed, the distribution is produced by determinants mostly outside the health system, national averages conceal the groups that matter, and any action must be judged by whom it reaches as well as by whether it works.
For revision, three things carry most of the marks in this focus area: the six-step structure in card 08, the “how do you know” tests in card 06, and the discipline established in Lesson 1 of writing about trends, distribution and cause rather than about numbers.
Mark lesson as complete
Tick when you've finished the practice and review.