San Francisco Framework for Assessing Population Health and Equity

​Recognizing the essential role social determinants of health play in the health of San Franciscans, the Community Health Status Assessment examines population level health determinant and outcome variables.To guide Breadth of variable selection, we use the San Francisco Framework for Assessing Population Health and Equity, which is a modified version of the Public Health Framework for Reducing Health Inequities published by the Bay Area Regional Health Inequities Initiative.


Terms and Definition

Upstream health factors are the root causes of health inequities. Public health interventions targeting upstream factors are important in eliminating inequitable social structure, providing access to resources, and removing impediments in and adding support for conditions that support health.

Downstream factors are the consequences of health inequity. Public health interventions targeting downstream health factors are important to relieve the effects of health inequities.

Factors Affecting Health

Belief Systems
A set of mutually supportive beliefs (around ideology, religion, philosophy, or a combination) that shapes an individual’s or society’s knowledge, point of view, and interactions with the world.

Cultural and Societal Values
Commonly held standards of what is acceptable or unacceptable, important or unimportant, right or wrong, and so on, in a community or society. These values may not be static.

Discrimination and Stigma
The increase in support, from 1992 to 2007, for smoking bans in restaurants (from 45 percent to 64 percent), bars (24 percent to 44 percent), and sports arenas (67 percent to 79 percent) from 1992 to 2007 is an example of changing cultural values.

Unjust or prejudicial attitudes toward or treatment of an individual or group of individuals based on their actual or perceived membership in a certain group or category.

Institutional Policies and Practices
Institutional policies are written guidelines or rules about howhow to reach a particular goal. A person or body invested with authority develops policies. A number of factors may affect policy development, including underlying values or assumptions, wider concerns, research, consultation processes, and current events.

​Institutional practice is the organized way in which associated individuals or groups carry out a particular activity. Guidelines or laws may frame practice, but ultimately it is the result of individual actions.

Organizational Practices and Policies
​An organization’s routine use of knowledge for conducting a particular function that has evolved over time under the influence of the organization’s history, people, interests, and actions. Organizational practices and policies define the day-to-day experiences of community members, and shape the cultures in which they work and learn.

The Ontario Association of Food Banks developed a program to salvage potentially wasted food. The food is made into soup by “chefs in training”—19 former street youth interested in developing cooking and job skills — make the food into soup. The organization freezes the soups and trucks them to food banks across Ontario. This is an example of organizational practices and policies in action.

Public Policy
An intentional course of action that a government institution or officials follow to resolve for resolving an issue of public concern. The institution must manifest such a course of action in laws, public statements, official regulations, or widely accepted and publicly visible patterns of behavior. Public policy is rooted in law and in the authority associated with law. Intentional courses of action include decisions made not to take a certain action.

The Healthy Food Retailer Ordinance is an example of a public policy adopted in San Francisco. This 2013 ordinance established the Healthy Food Retailer Incentives Program to increase access to healthy food; reduce the availability of unhealthy options such as such as tobacco, alcohol, and processed foods high in salt, fat, and sugar in underserved parts of the city; and stimulate economic development and job creation by creating incentives for Healthy Food Retailers to open or expand in those underserved areas.

Living Conditions
​The circumstances in which someone lives.

​Economic Environment
Opportunities available to an individual to prepare for and obtain work, safe work environments, and income.

​Educational Attainment
The highest degree of education an adult 25 years of age or over has completed.

The condition of having paid work.

Money that a person earns from work, investments, business, and other sources.

Occupational Safety
Workplace conditions that affect the safety, health, and well-being of people engaged in work.

Physical Environment
The natural or artificial physical features of the world with which humans interact, with such as parks, housing, streets, buildings, air, products, art, and so forth.

Housing Human shelter related issues include volume, quality, safety, and affordability of spaces for human shelter.

Land Use
The human use of land. Land use involves the management and modification of natural environment or wilderness into built environment.

Natural Environment
Environmental features such as natural land, water, air, and the atmosphere. Related issues include access to and preservation of the environment.

The movement of people and goods. Related issues include accessibility, safety, and sustainability of systems that enable movement of people and goods.

​Service Environment
The availability of and access to essential services such as medical care and education in a community.

Health Care
Access to high-quality health care.

Access to high-quality educational opportunities.

Social Services
Government services provided for the benefit of the community such as subsidized food and housing.

​​Social Environment
The community in which one lives and/or identifies or interacts with.

The condition or perception of being safe from experiencing or causing physical or emotional violence.

The ability to walk in one’s neighborhood without the threat of violence is a characteristic of a safe environment.

Social Cohesion
A cohesive society works towards the well-being of all its members, fights exclusion and marginalization, creates a sense of belonging, promotes trust, and offers its members the opportunity of upward mobility. The components of social cohesion include, social capital, social isolation and social support.

Health Behaviors
Individual behaviors that affect health and well-being or help him or her prevent or detect disease.

Use of Alcohol and Other Drugs ​
Any chemical substance (legal or illegal), that changes a person’s mental state when consumed, and that may have potentially harmful effects, such as poisoning, organ damage, dependence, or even death, in the event of improper short- or long-term use.

Ethanol is an example of alcohol. Amphetamines, cocaine, heroin, and prescription drugs such as Vicodin are examples of drugs.

​The intake of food and drink, considered in relation to the body’s dietary needs. Good nutrition—an adequate, well-balanced diet—is a cornerstone of good health, along with regular physical activity.—World Health Organization (WHO)

​Oral Health
A state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity.—WHO

​Physical Activity
Any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity has been identified as the fourth leading risk factor for global mortality, causing an estimated 3.2 million deaths globally.—WHO

​Preventive Care
A variety of health care services that prevent sickness and detect health problems before they become more serious.

​Sexual Health
A state of physical, emotional, mental, and social well-being in relation to sexuality, not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. Attaining and maintaining sexual health requires respect, protection, and fulfillment of the sexual rights of all persons.—WHO

Sleep is as important to our health as eating, drinking, and breathing. It allows our bodies to repair themselves and our brains to consolidate our memories and process information. Poor sleep is linked to physical problems, such as a weakened immune system, and mental health problems, such as anxiety and depression. While adults need 7–9 hours of sleep per night, one-year-olds need roughly 13 hours, school age children around 11, and teenagers a little over 9 hours.

​Tobacco Use
Consumption of products made entirely or partly of leaf tobacco as raw material and intended to be smoked, sucked, chewed, or snuffed. All contain a highly addictive psychoactive ingredient, nicotine. Tobacco use is one of the main risk factors for a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases.—WHO

Electronic cigarette (e-cig or e-cigarette), personal vaporizer, or electronic nicotine delivery system devices that simulate tobacco smoking by producing an aerosol, usually contain a mixture of chemicals that may include nicotine. There is growing concern that these devices may cause addiction among non-smokers and reverse decades of work to de-normalize smoking.

Gene Expression (not shown)
Gene expression is the process by which genetic information gives rise to proteins that play a role in the functioning of our bodies. Gene expression is a result of both one’s genetic makeup (genotype) and the mechanisms that are used to increase or decrease the gene products (proteins). Environmentally induced changes in the expression of one’s genes can be both transient (for example, a response to an infectious disease), or permanent and heritable (epigenetics) such as a woman who is a BRCA1 gene carrier but does not develop breast cancer.

Psycho-social Factors
Pertaining to the influence of social factors on an individual’s mind or behavior, and to the interrelation of behavioral and social factors.

Lack of Control or Perceived Control ​
A lack of power or authority to affect the circumstances under which one lives and works.

A simple example of lack of control is when an employee is called in to work on her or his day off but cannot deny the request as he or he fears doing so will lead to dismissal.

Reactive Responding ​
Reactive responding is a type of response that occurs as a result of stress or emotional upset.

The capacity to adapt successfully in the presence of risk and adversity, and to recover from or adjust to misfortune or change.

Stress ​
A process in which environmental demands strain a person’s adaptive capacity, resulting in both psychological and biological changes that could place a person at risk of illness.

The term stress describes the ways in which the body copes with or adapts to psychological, environmental, and physical challenges. Chronic or repeated stress may contribute to poor health. The coping or biologic mechanisms through which stress manifest is also referred to as allostasis and allostatic load.—The MacArthur Foundation, Research Network on Socioeconomic Status and & Health.

Stress may result from major life events such as the death of a loved one, the loss of a job, getting a divorce, moving, or going to court, or environmental stressors such as exposure to violence or trauma, noise pollution, and so on.

Health And Well-Being
​Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.—WHO

​Well-being can be described as judging life positively and feeling good, as well as feeling healthy and full of energy. —Center for Disease Control and Prevention

Clinical Health
Clinical Health Health conditions that can be classified under the ICD-10 medical classification list.

Chronic Disease
A non-communicable diseases of long duration and generally slow progression. The four main types of non-communicable diseases are cardiovascular diseases (such as heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes.—WH

Chronic diseases are the nation’s leading causes of death and disability, and result in compromised quality of life and increased health care costs.

Communicable Disease
Disease that can be caught from another person or animal through direct or indirect contact.

West Nile virus is an example of a communicable disease that can be caught indirectly through a mosquito vector. Tuberculosis is an example of a disease that can spread from person to person through the air.

Injury ​
Damage to a person’s body.

Injuries resulting from accidents, such as traffic collisions, drowning, poisoning, falls, or burns, together with injuries resulting from violence, such as assault, self-inflicted violence, or acts of war, kill more than 5 million people worldwide annually and cause harm to millions more.—WHO

Mental Health ​
Not just the absence of mental disorder but a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to her or his community.—WHO

Functioning ​
An individual’s ability to perform activities required in her or his daily life. Deficiencies in physical, cognitive, or emotional functioning can have interdependent negative consequences on health and well-being.
Walking or mobility as well as activities of daily living, such as running errands or opening containers, are examples of physical functioning.

Quality of Life
An individual’s perception of her or his position in life in the context of the culture and value systems in which she or he lives and in relation to her or his goals, expectations, standards, and concerns. It is a broad-ranging concept that interacts in a complex way with the person’s physical health, psychological state, personal beliefs, social relationships, and relationship to her or his environment.—WHO

Premature deaths are deaths that occur before a person reaches an expected age: for instance, age 75. Many of these deaths are considered to be preventable.

Intervention Strategies

The act or a method of interfering with the outcome or course, especially of a condition or process.

An example of an intervention is directly observed therapy (DOT) for tuberculosis. DOT assures that patients take medications correctly, therefore enhancing treatment for the patient and preventing spread to others.

Advocacy ​
A political process by which an individual or group aims to influence public policy and resource allocations decisions within political, economic, and social systems and institutions.

Case Management
A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human service needs.

Civic Engagement ​​
Individual and collective actions designed to identify and address issues of public concern. Civic engagement can take many forms, from individual voluntarism to organizational involvement to electoral participation. It can include efforts to directly address an issue, work with others in a community to solve a problem, or interact with the institutions of representative democracy. Civic engagement encompasses a range of specific activities, such as working in a soup kitchen, serving on a neighborhood association, writing a letter to an elected official, or voting. An underlying principal of our approach is that an engaged citizen should have the ability, agency, and opportunity to move comfortably among these various types of civic acts.—American Psychological Association

A resident practicing civic engagement is one who is working to make a difference in the civic life of her or his community while developing a combination of knowledge, skills, values, and motivation to make that difference.
An individual can affect the quality of life in a community, through both political and nonpolitical processes.

Neighborhood groups who petition to add crosswalks or stop signs or take other measures to make walking safe in their neighborhood are civically engaged.

Community Capacity Building
Activities, resources, and support that strengthen the skills and abilities of people and community groups to take effective action and leading roles in the development of their communities.

Community Organizing
A process by which people come together, engage with other community members in identifying shared problems and desired solutions, and form organizations that act in the shared self-interest of the group.
Coordinating Services and Resources The alignment and promotion of social services and resources in order to better serve the population.

​Health Promotion and Prevention
Activities intended to promote the adoption of healthy habits in order to prevent rather than treat illness.

Medical Care
Treatment and prevention of disease by trained and licensed professionals.

Strategic Partnerships
An arrangement between two companies or organizations to help each other or work together so that each can achieve the things they want to achieve.