Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. In this Idea Gallery, Bryan Samuels, Commissioner of the Administration on Children, Youth and Families, provides his perspective on how communities and organizations and families can work together to keep children safe, in honor of Child Abuse Prevention Month.

Nancy Barrand, Senior Adviser for Program Development at the Robert Wood Johnson Foundation (RWJF), also weighed in to provide some context for Commissioner Samuels' post:

Few events are more traumatic for children than being removed from their families and entered into the foster care system. In 2010, the Robert Wood Johnson Foundation funded the Corporation for Supportive Housing to develop and implement a pilot program in New York City that uses supportive housing to offer stability to families with children who are at risk of recurring involvement in the child welfare system. The New York pilot initiative, called Keeping Families Together (KFT), showed positive results in keeping and reuniting children with their families in a safe, stable environment. A 2011 evaluation indicates that the KFT pilot generated a 91 percent housing retention rate among participating families. By the end of the evaluation, 61 percent of the child welfare cases open at the time of placement in supportive housing had been closed, and there were fewer repeat incidents of child maltreatment.

Now, RWJF has partnered with the U.S. Department of Health and Human Services, Administration on Children Youth and Families and three private foundations – the Annie E. Casey Foundation, Casey Family Programs, and the Edna McConnell Clark Foundation – to jointly fund a $35.5 million initiative to further test how supportive housing can help stabilize highly vulnerable families. The national replication effort will be evaluated and we’re anxious to see whether, again, secure and affordable housing, when paired with the right services for struggling families, can reduce instances of child abuse and neglect.  The long-term gains in health and well-being, and costs saved, could be tremendous.

Commissioner Bryan Samuels on Child Abuse Prevention

Throughout the month of April, we turn our attention to the prevention of child abuse and neglect, celebrating those efforts in neighborhoods, faith communities, and schools that keep children safe and help families thrive. Whether formal or informal, these efforts involve wrapping caregivers and children in supports that reduce risk factors for maltreatment and promote protective factors, by decreasing stress, boosting parenting skills, and helping parents manage substance abuse or mental health issues.

Last year, more than 675,000 U.S. children were victims of maltreatment. These children are more likely than their peers to have emotional and behavioral problems, struggles in school, and difficulty forming and maintaining relationships. The effects of abuse and neglect can be pernicious and lifelong.

In recent years, we’ve come a long way in learning what it takes to help children who have experienced abuse and neglect heal and recover. We have interventions that help put families back together after maltreatment has occurred. But preventing abuse and neglect in the first place by giving families the support they need, when they need it, yields the best outcomes.

A new article published by the Association of American Medical Colleges highlights the important work of medical-legal partnerships. These efforts improve the health and well-being of low-income and other vulnerable populations by addressing unmet legal needs that can impact health, such as substandard housing and difficulty accessing public assistance programs.

According to the article, the partnerships integrate law students and lawyers into the health care team to provide direct legal assistance to patients, develop and align legal strategies develop and help change policies so that underserved people can get and stay healthy.

There are now more than 100 medical-legal partnerships around the U.S. that serve more than 50,000 patients each year at 275-plus health institutions.

Anne Ryan, JD, founder and director of the Tucson Family Advocacy Program based at the University of Arizona Medical Center-Alvernon Family Medicine Clinic, says her cases have included helping patients who were denied disability benefits, food stamps and Medicaid assistance as well as denied coverage by their insurer.

>>Learn more about the partnerships from the National Center for Medical-Legal Partnership, which is based at the George Washington University School of Public Health and Health Policy and supported in part by the Robert Wood Johnson Foundation.

A host of sessions focused on health equity at this year’s American Public Health Association meeting. Panel topics varied greatly, from the effects of health inequity on education outcomes to creative marketing strategies for reaching vulnerable populations; but overall, a few key themes emerged:

• Health inequities must be addressed as locally as possible
• Prevention is crucial
• Organizations must strive for greater diversity, especially in leadership
• In fiscal crunches, health equity requires creativity and commitment

Read more about these themes below.

Inequities in health must be assessed and addressed on a local level, whether by region, city, neighborhood or even block-by-block.

The California Endowment started the conversation by covering the conference halls with images from their Health Happens Here campaign, which draws attention to the vast differences in life expectancy that can exist from one zip code to the next. [Read more in a Q&A with California Endowment president Robert Ross.]

Last week at the American Public Health Association (APHA) annual meeting, a number of presenters took on an important, but often overlooked topic in the public health world: violence. Violence is often primarily considered a criminal justice or public safety issue, but there is a growing movement of public health practitioners that recognize that the health of vulnerable communities cannot be improved without first stopping shootings and killings.

When violence is present in a community, it impacts the physical, mental and emotional health of all residents. Violence also often prevents other positive changes from taking place. According to Greta Massetti from the Centers for Disease Control and Prevention, the current economic impact of youth violence is an estimated $14.1 billion in combined costs from medical care and work loss.

During the APHA meeting, speakers from organizations such as Cure Violence, UNITY and the Centers for Disease Control and Prevention discussed the latest research and strategies to prevent disease.

Treating violence as a disease

For many vulnerable communities, violence is the most pressing health issue. For children growing up in violent communities, the health impact is more than just the physical threat. As Benita Tsao from Urban Networks to Increase Thriving Youth (UNITY) pointed out, growing up in a community plagued by violence can often feel like being in a war zone.  That constant fear results in real health consequences, as evidenced by the increasing number of children who have grown up surrounded by violence and are now showing signs of chronic traumatic stress disorder. Experiencing ongoing trauma impacts young people’s physical, mental and emotional development, and has the ripple effect of making it harder to focus and succeed in school. 

The use of school-based health services has gained momentum and recognition across the United States as a unique tool in the fight to prevent poor outcomes in both health and education, especially among vulnerable populations. When last surveyed in 2008, the number of school-based or school-linked health clinics in the U.S. had surpassed 1,900. Recently, the federal government has acknowledged their potential, too, creating a distinct grant program for school-based health centers as part of ACA and recognizing them as providers in the Children’s Health Insurance Program Reauthorization Act. [Read more on school-based health center policy developments.]

The typical school-based health center (SBHC) provides free or low-cost basic physical and mental health services, and sometimes oral and vision care. They’ve been shown to reduce asthma-related ER visits and hospitalization costs; reach greater numbers of racial minorities, especially young men; and increase the likelihood by 10 to 20 times that a student uses mental health services. But, the conversation at the American Public Health Association annual meetings was focused on the unique effects these centers are having on students and communities beyond the clinic walls.

Youth Successfully Influencing Their Peers

One session on youth as public health champions covered how receiving services directly on campus involves youth in their own health and the health of their peers in a powerful way. Kathleen Gutierrez from the California School Health Centers Association highlighted innovative ways in which California’s SBHCs are utilizing youth as messengers. 

>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.

Sheila Regan manages hospital partnerships for Cure Violence, formerly CeaseFire, an organization based in Chicago that has pioneered a public health approach to stopping shootings and killings. A grantee of the Robert Wood Johnson Foundation, Cure Violence has been successful at reducing violence in cities across America.

This week at APHA, Cure Violence shared how violence presents all the same characteristics of an infectious disease. Like tuberculosis or cholera, violence appears in clusters; it spreads and can be transmitted. By changing the frame on violence, Cure Violence is able to use proven public health strategies from other epidemics to stop shootings and killings. Hospital partnerships are a key part in stopping the spread and transmission of violence.

NewPublicHealth: Can you explain how Cure Violence’s hospital partnerships work?

Sheila Regan: We have a number of partnerships with level I trauma centers that are committed to the public health approach to violence prevention. We serve patients who are violently injured, typically shootings, stabbings or beatings and work to prevent further violence, retaliation or re-injury, which are seen as normal in our culture. There are the doctors, police, nurses, social workers, and everybody you’d expect to see in the hospital. What we’re trying to do is introduce a third party—our workers—who can impact behavior and mindset around violence at an opportune moment.

NPH: When someone has been injured, what is the goal of Cure Violence working with them in the hospital?

"Black men today are more likely to receive a GED in prison than graduate from college. One in three black men, and one in six Latino men, are projected to go to prison in their lifetimes.

There is new hope--Sacramento is now responding to this crisis. This time last year, California Assemblymember Sandré Swanson created a special committee of legislators whose sole charge is to improve the life chances of these young men. The Select Committee on Boys and Men of Color spent the past year traveling the state hearing from black and brown men--adolescents, men who have "made it" and others who've turned their lives around. The Committee is in the process of presenting their findings and practical solutions.

For me, this is personal. In the 1960s, as a young boy growing up in a South Bronx housing project, I saw graffiti, shattered glass, broken elevators, zip guns and welfare. I didn't need a medical degree then to know that the place was unhealthy. And I didn't need a doctorate to understand that black and brown people were at the short end of the fairness and opportunity stick. My family was living it.

I understand now that successful, thriving young people aren't born. They're nurtured. The checklist to grow up includes caring adults, safe places to play, good schools and real job opportunities." – Robert K. Ross, President and CEO of The California Endowment

Robert K. Ross, MD, President and CEO of The California Endowment, recently returned from a three-month study leave to better understand the challenges and opportunities facing boys and young men of color across California and the country.

Dr. Ross is at the American Public Health Association gathering this week to discuss The Endowment’s Building Healthy Communities initiative and the foundation’s work to advance the health and well being of our young people.

NewPublicHealth: What are the goals of The California Endowment’s work with boys and young men of color?

Dr. Robert Ross: Many young people in California live in communities with concentrated poverty, under-resourced schools and unsafe streets. They are more likely to experience poor health, suffer from unemployment and lead shorter lives. This is especially true of young men of color—African Americans, Latinos, Asians and Native Americans.

Debbie Lee, senior vice president at Futures Without Violence and deputy director of Start Strong: Building Healthy Teen Relationships’ national program office, will speak Tuesday, October 30 about lessons learned from the Start Strong initiative at an APHA session on preventing teen dating violence.

Start Strong is a national program of the Robert Wood Johnson Foundation in collaboration with Futures Without Violence. The Robert Wood Johnson Foundation and the Blue Shield of California Foundation have invested in 11 communities across the country to identify and evaluate the most promising pathways to stop dating violence and abuse before it starts. This initiative uses a comprehensive community health model to prevent teen dating violence and promote the development of healthy relationships among 11 to 14 year olds.

NewPublicHealth spoke with Debbie Lee before her APHA session to find out more about the unique approach Start Strong is taking to building healthy relationships skills in youth and tackling teen dating violence before it begins.

NewPublicHealth: First tell us a bit more about the comprehensive approach that Start Strong uses.

Debbie Lee: Start Strong uses a multifaceted approach to promote healthy relationship behaviors among young adolescents in order to stop relationship violence before it starts. Its four key components include: educating and engaging youth in and out of school; engaging the people that influence teens; addressing policy change in schools and environmental factors that affect adolescent development; and then implementing communications and social marketing strategies to create and reinforce positive social norms.

NPH: This year’s theme at APHA is “Prevention and Wellness Across the Lifespan.” How does Start Strong fit into this theme?

Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. In this Idea Gallery, Jane Isaacs Lowe, Team Director for the Vulnerable Populations Portfolio at the Robert Wood Johnson Foundation, provided her perspective on the critical impact of public policies on the mental health of urban populations.

Recently I attended and spoke at the Social Determinants of Urban Mental Health conference hosted by the Adler School of Professional Psychology. Lynn Todman, the Executive Director of Adler’s Institute on Social Exclusion and the conference’s organizer, has been doing groundbreaking work on the link between public policies and the mental health of urban communities, including the Institute’s Mental Health Impact Assessment, which was developed in part through support from the Robert Wood Johnson Foundation.

It’s been exciting to see the field of health impact assessments grow so rapidly. But, of course, physical health is not the only outcome that matters; equally important is our mental health and its integral connection to physical health, especially for the most vulnerable among us. This is reflected in many of the organizations and models in which we’ve invested and which we’re helping to scale for greater impact. You’ll see it, for instance, in a video we just released on Child First, a psychotherapeutic home-visiting program that works with families with very young children who are showing signs of severe developmental, emotional, and behavioral problems. Child First partners with providers all across the community who touch these families’ lives — including doctors, day care providers, teachers, and social workers. If a provider sees a problem, she makes a referral to Child First, which then arranges a comprehensive assessment and home visit with a team of trained specialists, including a masters-level mental health clinician. That team works on the relationship between the child and parent or caregiver and on environmental factors, such as depression, substance use, domestic violence, food insecurity or homelessness that are detrimental to the child and family.

Ultimately, the goal is to foster strong, stable, nurturing relationships between parents and children and also create a safer and healthier overall environment for the child. In so doing, Child First effectively helps to buffer the developing brains of these young children from the damage caused by repeated exposure to toxic stress, and sets the families on a course toward stability and better health.

As Lynn Todman explains it, effective interventions for addressing the social determinants’ impact on mental health exist along a continuum — from trying to “fix” the individual within the clinical setting to structural reforms that create a social environment that will lead to better mental health outcomes. This is demonstrated in the Child First model, which goes beyond the clinical setting to engage individuals and institutions from across the community united by a common goal. The Adler School wants their students to be able to operate along that continuum, and to understand that, to improve outcomes, change will need to happen outside of the clinical setting, in the context of people’s lives and where they live, learn, work and play. This also must include the realm of policy change. Being able to contribute to this goal was well worth my time.

The other speakers at the conference reflected this belief in the need for interventions along a continuum and which engage individuals and institutions from multiple sectors. Lynn Todman’s background is as an urban planner, which is inherently a multi-disciplinary role. As an urban planner, she needed to understand housing, transportation, social services delivery, fiscal policy, and more. And she needed to be able to apply a lens that allowed her to see the connections between all of these seemingly different issues. It’s worth noting that it’s a lens through which Risa Lavizzo-Mourey is also looking in her recent chapter, “Why Health, Poverty, and Community Development Are Inseparable,” in the book, Investing in What Works for America's Communities. She makes a forceful case that, “community development and health must be partners in planning and building communities.”

We’ve pulled together some of the highlights from the conference, including resources that were shared by speakers. I hope you’ll take a look and, more importantly, put them to use in your own work.

>>Catch up on highlights from the Social Determinants of Urban Mental Health conference.

Much attention has been paid on NewPublicHealth and elsewhere to the connection between education, health, economic opportunity, and even life expectancy. Sadly, when we consider the health and life trajectories for our young men of color in this country, it’s clear that we have a lot of work to do. Boys and young men of color are more likely to grow up in poverty, live in unsafe neighborhoods and attend schools that lack the basic resources and supports that kids need in order to thrive. In addition, actions that might be treated as youthful indiscretions by other young men often are judged more severely and result in harsher punishments that have lasting consequences. Only about half of African American, Hispanic and Native American boys graduate from high school on time with their cohort. Down the road, pathways to stable, productive employment can be limited – they commonly lack access to career and positive mentorship connections. And disparities in their access to and quality of health care services persist.

RWJF Program Officer Maisha Simmons attests that the options for our young men of color have been too limited for too long. That’s why today the Robert Wood Johnson Foundation (RWJF), through its Vulnerable Populations portfolio, launched the Forward Promise initiative to strengthen education opportunities, pathways to employment and health outcomes for boys and young men of color. A new Call for Proposals released by the initiative today will focus on the following areas:

• alternative approaches to harsh school discipline that do not push students out of school;
• solutions that focus on dropout prevention and increasing school graduation rates;
• mental health interventions that tailor approaches to boys and young men who have experienced and/or been exposed to violence and trauma; and
• career training programs that blend workforce and education emphases to ensure that students are college- and career-ready.

NewPublicHealth caught up with Maisha about the challenges facing young men of color and the quest for collaborative solutions.

NewPublicHealth: Paint us a picture of the health and quality of life of young men of color. What are some of the causes of the disparities that persist?

Maisha Simmons: If you look at the statistics around men of color, specifically African American men, they usually die sicker and younger than any other population in this country. There are a lot of variables, but what we’ve begun to focus on is, what are some of the non-traditional, non-medical factors that go into that?

So for us, we began to really focus on education, workforce and mental health issues and how they coincide with opportunities for health. When you look at young men and boys of color, their school outcomes are often worse. There are large number of young men not finishing school  and they often don’t finish high school with their cohorts. We know the linkages between school and employment often have a collective impact on health outcomes.

NPH:  What are some other experiences that influence the health and quality of life of young men of color?