Health promotion programs have long focused on education about personal health behaviors like tobacco and alcohol use, diet, and physical activity. Health behaviors have an important role in health, but they are not the whole story. Social determinants of health, conditions encompassing social and environmental factors like access to quality health care, economic stability, relationships and interactions, the health and safety of neighborhoods and built environments, and access to quality education throughout the lifespan (Healthy People, 2020), account for about 70% of the influence on health and quality of life. Policies and practices influence social determinants of health in ways that lead to unfair or unjust differences in health among groups of people known as health inequities (Burton et al., 2021).

In national rankings, Kentucky is currently positioned near the bottom for health behaviors and outcomes and in the lower half for many social, economic, and clinical care factors that influence health (United Health Foundation, 2021).

Recognizing the growing need for holistic programming and resources that target policies and practices that affect community well-being (Kentucky Cooperative Extension, 2019) and motivated by the FCS mission to improve life quality through education, research and outreach, FCS Specialists (Luecking, Kostelic, Jury and McCulley) worked with Extension Agents (Workman, Baldauff, Congleton, and Giles) to develop Pathways to Wellness (P2W). 

Under the leadership of Dr. Courtney Luecking and FCS Agent (now Specialist) Leslie Workman and Senior Nutrition Education Program Assistant Angela Baldauff, the P2W Team supported existing programs that encouraged healthy behaviors (Koukel et al., 2018), but aimed to create a transition that strengthened the capacity of Extension to engage in policy, system, and environmental changes that address the root causes of health inequities (Burton et al., 2021).

The goal of Pathways to Wellness is to prompt action to promote a culture of health. Specifically, the program aims to increase knowledge about social determinants of health and increase beliefs in the ability of individuals and the community to take action to change factors in the environment that promote health for all people. The curriculum includes a series of four interactive lessons and a web-based platform to support continued learning, engagement, and action between lessons (4 peer-reviewed publications, facilitator guide, PowerPoint presentation, marketing materials, activities/discussion questions, evaluations, success story templates). The lessons focus on pathways to wellness where we live, work, and play (overview of social determinants of health); with family and friends (relationships); in the world around us (environment); through champions for community health (culture).

This program rolled out statewide to agents in Fall 2022. Three training opportunities were offered to FCS agents across the state, and 48 agents participated in the 6-hour training. Thirty-six agents completed a brief evaluation about the training experience and their initial reactions to the program. Using a 5-point Likert scale, with 5 representing strongly agree, agents reported that as a result of the training, they gained knowledge (4.5) and skills (4.3) about the topics presented (4.5), and plan to apply what they learned in county programming beyond efforts beyond implementing Pathways to Wellness (4.4). Agents reported looking forward to “seeing change in the way people in my community perceive health and wellness”, “Working on programming outside of the “traditional” box of FCS”, “community people seeing they have a voice in making changes”, and “teamwork opportunities to bring unity to the county”.

The training feedback indicated the content and approach of Pathways to Wellness was new to many agents. Many were unaware of statistics regarding social determinants in their county and the influence these factors have on health – “My aha moment was about slide 9. I never thought about how health behaviors impact our health so much less than all the other factors that are beyond our control.” This left some feeling unsure about the ‘right’ audience to start with and feeling somewhat neutral about readiness to implement the program (3.9) - “I love this topic and think it is important, but might be more effective if I build up regular programming first and can reach more people in the near future”.

Following training, a pilot evaluation of the program was conducted with eight agents who were committed to offering the program within 6 months of training. The pilot project examined FCS agents’ perceived acceptability, feasibility, and appropriateness of the program and the fidelity of implementing it. The pilot also examined the efficacy of the program to increase knowledge about the multiple levels of influence on health and increase self- and collective efficacy to take action to change factors in the community that promote health for all people. Preliminary analyses have identified opportunities to address concerns about audience and implementation as well as future programming to facilitate translating the “amazing conversations” into actions that promote health for all.

References:

Burton et al. (2021). Cooperative Extension’s National Framework for Health Equity and Well Being. [Report of Health Innovation Task Force]. Extension Committee on Organization and Policy. Washington D.C. https://www.aplu.org/members/commissions/foodenvironment-and-renewable-resources/board-on-agriculture-assembly/cooperative-extension-section/ecop-members/ecopdocuments/2021%20EquityHealth%20Full.pdf

Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [cited [August 11, 2022]. Available from: [https://health.gov/healthypeople/priority-areas/social-determinants-health].

Koukel, S., Newkirk, C., Bercaw, S., Letto, B., & Malekian, F. (2018). Cooperative Extension and health literacy: A national focus. Journal of Human Sciences and Extension, 6(2). Available at: https://www.jhseonline.com/article/view/721

Steinbrook, R. (2006). Imposing Personal Responsibility for Health.?The New England Journal of Medicine,?355(8), 753–756. https://doi.org/10.1056/NEJMp068141

United Health Foundation. (2021). America’s Health Rankings Annual Report. America’s Health Rankings. https://www.americashealthrankings.org/explore/annual/measure/Overall_a/state/KY

University of Kentucky Cooperative Extension Service. (2019). Kentucky Extension Community Assessment Statewide Report. https://extension.ca.uky.edu/files/kentucky_extension_community_assessment_2019.pdf

University of Wisconsin Population Health Institute. (2022). County Health Rankings Model. County Health Rankings. https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model