Project Aims

1. Reduce the associated costs and risk factors of asthma and other chronic disease in the community through a systems framework

2. Address the health and wellbeing issues identified by the community, through collaboration between local health and social organisations, and community members

3. Create a practical model for implementing a collaborative, social-determinants approach to chronic disease, that can be adapted for different communities

4. Advocate for the importance of systemic, community-centric approaches in public health.


Our Approach

There are three components to our approach:

  1. A focus on social determinants of health, not on disease treatment

— Research1 shows that healthcare contributes only 20% of our health outcomes. Lifestyle factors make up 30%, whilst socio-economic determinants of health create 40% of our health. The final 10% is made up of environmental and genetic factors

  1. Place-based thinking that ensures appropriate, tailored solutions

— Each solution to a local, complex problem is different, because each community is different. Place-based, community-led solutions are reliably

more innovative, practical, economically viable and culturally appropriate2,3than large-scale, external interventions

  1. A commitment to collaborative action embeds local ownership for sustainable change

— Investing in local leadership, capacity and ownership ensures that solutions and programs are sustainable and can provide long-term change beyond the project lifecycle. Integrating the activities of various local organisations is more cost-effective, as existing community skills and resources can be used and built on and service overlap can be identified and eliminated.

1D. R. Williams, M. V. Costa, A. O. Odunlami& S. A. Mohammed., ‘Moving Upstream:

How Interventions That Address the Social Determinants of Health Can Improve Health

and Reduce Disparities’, Journal of Public Health Management Practice, 14/6 (2008), 8.

2M. Rosato et al., ‘Community participation: lessons for maternal, newborn, and child

health’, The Lancet, 372 (2008), 969

3The Royal Children’s Hospital, Place-based Initiatives Transforming Communities (2012).


Our Process

1. Identify communities that are ready for intervention

2. Partner with key, local stakeholders to help connect with and understand local community factors

3. Hold focus groups and do systems mapping with community members to understand their definition of wellness, and the underlying complex social drivers in health and wellbeing in their community

4. Hold focus groups with the service provider community to explore and discuss mapping data, share insights into the underlying drivers of poor

health outcomes and seek their perspectives

5. Facilitate a collaborative co-design workshop with representatives from both the community and service providers to explore potential intervention points to address the identified drivers of poor health

6. Facilitate the development of a collective impact project and roll out with the community

7. Mentor the community for 6 -12 months to develop leadership and ownership of the program to implement the co-developed solutions

8. Repeat in the next community.