Culture of Health Blog

Providers need to be equipped with the tools to help patients make healthy choices. That’s why the Alliance for Healthier Generation is recognizing innovative training programs providing nutrition, physical activity and obesity counseling education to their students.

Even at the young age of four, Luke was overweight. In fifth grade, he tried out for the baseball team, and although he made it, he struggled that season. He was slower than the other kids as he rounded the bases, and he started having knee pain from the extra weight on his joints. Luke and his family knew they had to do something. But they dreaded going to the doctor, knowing he’d get weighed and then have to confront the escalating numbers on the scale. Year after year, the same thing would happen, and they’d have the same discussion with his doctor when they finally worked up the nerve to go. But the weight never came off.

Apprehension about a visit to the doctor is something we all face, no matter our age or health. Who among us doesn’t get a little nervous before our annual visit, knowing we might face a difficult conversation about losing weight, or flossing more, or stopping smoking? These are things we all know, but have a hard time talking about.

And even worse, if we do have these important conversations, they can lead to feelings of shame and disappointment.

But the reality is that it’s not necessarily your doctor’s fault. Even with the hundreds of thousands of hours of education your doctor gets in classrooms and hospitals, most receive little to no training in how to talk to patients about making healthy choices. In fact, fewer than 30 percent of medical schools meet the minimum number of hours of education in nutrition and exercise recommended by the National Academy of Sciences, Engineering and Medicine.

We’re all well aware that education leads to better jobs and higher income. Just as important, research also links education to reduced risk of illness, increased vitality, longevity and academic success that extends to future generations.

That’s why the situation for schools in Lawrence, Mass., was particularly concerning back in 2010. At the time, more than one out of every four Lawrence kids dropped out of high school. This led the Massachusetts Department of Education to put Lawrence’s schools into receivership by 2012, placing them under new management to safeguard state assets. The state-appointed “receiver,” was granted authority to develop an intervention plan to overhaul the schools through steps you might expect such as expanding the school day and replacing half the districts’ principals.

But the district also took one critical step by acknowledging that a family’s financial stability strongly influences how well children do in school—and whether they drop out.

Between 2000 and 2011, almost 1 million service members or former service members were diagnosed with at least one psychological disorder either during or after deployment, according to recent research by the Institute of Medicine (IOM). As a follow up, the U.S. Department of Defense (DOD) asked the IOM to evaluate the department’s efforts to prevent psychological disorders among active-duty service members and their families. That report was recently released.

The report includes recommendations on how the DOD can improve care.

Finding 1: DOD has implemented numerous resilience and prevention programs for service members and their families, but it faces a number of challenges, including an insufficient evidence base to support its interventions and a lack of systematic evaluation and performance measures.

Recommendation 1: By targeting resources to develop the evidence base and disseminate that evidence, DOD’s prevention efforts can be both more effective and cost effective.

Finding 2: There is a need for DOD to improve approaches for identifying and intervening with service members and their members who may already have or may be at risk for developing a psychological disorder.

Recommendation 2: DOD should dedicate funding, staffing and logistical support for data analysis and evaluation to support performance monitoring of programs for accountability and continuous improvement.

Finding 3: Screening, assessment and treatment approaches for psychological health problems are not always implemented between and within the DOD and the U.S. Department of Veterans Affairs (VA) in a consistent manner or aligned with the evidence base, which threatens the delivery of high-quality care and hampers evaluation efforts.

Recommendation 3:

• There are opportunities to improve processes of training and evaluating clinicians, including the incorporation of continuing education and supervision; standardized periodic evaluation; and a greater emphasis on coordination and interdisciplinary.
• The DOD and VA should invest in research to determine the efficacy of treatments that do not have a strong evidence base.
• Both departments should conduct systematic assessments to determine whether screening and treatment interventions are being implemented according to clinical guidelines and departmental policy.
• Accessible inter-department data systems should be developed to assess treatment outcomes, variations among treatment facilities and barriers to the use of evidence-based treatment.

This commentary originally appeared on the RWJF New Public Health blog.

Each year hundreds of public health researchers and practitioners meet to share research and best practices on creating a stronger public health system at the annual Keeneland Conference in Lexington, Ky. The conference, which will be held this year April 8-11, is sponsored by the National Coordinating Center for Public Health Services and Systems Research, based at the University of Kentucky.

Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), will speak at the opening lunch about threats and opportunities for public health, and how we can re-shape the system to create a healthier future for all. We caught up with him to get his insights before the conference on the evolving role of public health. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Kuehnert is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois. 

NewPublicHealth: What are you going to talk about at Keeneland?

Paul Kuehnert: I think a lot of us are familiar with the data on our health care system, and the inter-twined issues of access, quality and cost. And the fact that younger Americans have a lower life expectancy than young people in other developed countries. We’re just not getting the health outcomes that one would expect from the amount we’re spending.

When you pit that against our legacy in public health, and what’s happening in the environment we operate in, I think there’s a real need to identify the threats and opportunities and re-imagine what we’re doing. We’re working from old models that need to be really questioned. What I’m hoping to do, and that others will do, is to provoke some creative thinking about where we need to go in public health to truly meet the challenges that face our communities and our nation.

NPH: What do you see as some of the major public health challenges today?

Kuehnert: For me, one of the first that comes to mind is that issue of life expectancy. With all the resources we have, we’re actually losing ground. It’s extremely concerning and has to do with a number of underlying dynamics—but particularly the epidemic of chronic disease, things such as obesity, heart disease, cancer, and all of those threats to our health. And there are also the incredible health disparities, the inequities that are reflected in our health across the country.

The National Prevention and Health Promotion Strategy offers a comprehensive plan to increase the number of Americans who are healthy at every stage of life. A cornerstone of the Strategy is that it recognizes that good health comes not just from quality medical care, but also from the conditions we face where we live, learn, work and play—such as healthy homes, clean water and air and safe worksites. The strategy was developed by the National Prevention Council, which is composed of 17 federal agencies including the Department of Education, the Department of Housing and Urban Development and others.

As the Strategy is rolled out, NewPublicHealth will be speaking with Cabinet Secretaries, Agency directors and their designees to the Prevention Council about their prevention initiatives. Follow the series here.

This week, NewPublicHealth spoke with Estelle Richman, Senior Advisor to the Secretary of the Department of Housing and Urban Development.

NewPublicHealth: Why was it important for the Department of Housing and Urban Development (HUD) to be involved in the development of National Prevention Strategy?

Estelle Richman: HUD’s mission is to create strong, sustainable, inclusive communities and affordable housing for everyone. HUD is more than bricks and mortar. We need to get away from thinking that housing is just about putting a roof over your head. It’s your home, and your family’s health and safety and your children’s education are all dependent on where that home is. HUD views housing as a platform for improving a wide range of outcomes.

That’s what makes HUD dovetail perfectly with the National Prevention Strategy; the whole concept of affordability of housing and the quality of neighborhoods and the understanding of that influence on health. HUD invests about $50 billion annually on affordable housing and community development and these investments impact health. We don’t do it alone and none of our partners can do it alone. But together we can bring significant experience and expertise to the table so that we can truly mitigate and help prevent health hazards.

NPH: What approach is HUD taking to address the challenges of health related to housing?

Estelle Richman: One of the most obvious places where we make a substantial difference is the physical environment of housing, including a focus on lead-based paint hazards, mold and pests and all the many things that contribute to respiratory disease, allergies and other illnesses.

Another factor not always immediately connected is housing affordability and health. Many households are now paying more than 60 percent of their income in order to remain in their homes. And if you’re paying a huge amount of your income just to pay your rent or your mortgage, then you’re cutting something else—such as food, health care, medicine and transportation. That puts people at risk for both physical and mental health problems. Children in families that have been behind on rent are more likely to be in poor health, have increased risk of developmental delays and suffer from food insecurity than children whose families are stably housed.

NPH: What are some of HUD’s key initiatives in helping to foster sustainable, healthy communities?

Estelle Richman: We know that physical and mental health depends on sustainable and economically vital neighborhoods where we have access to transportation, good schools, safe places for children to play and places to go shopping for healthy and wholesome foods.

HUD’s Moving to Opportunity for Fair Housing Demonstration Program has shown that moving to better neighborhood environments is associated with improved mental and physical health for adults, lower rates of extreme obesity, lower rates of diabetes, less psychological stress and less major depression for adult women. So being able to stabilize where you live and the quality of your housing can make a difference.

We’re trying to reach some of these same goals through our Choice Neighborhoods Program, which is part of a partnership between HUD, the Department of Education, the Department of Justice, the Department of Health and Human Services and the Department of the Treasury. Choice Neighborhoods actually builds on the success of Hope VI, which was begun in the 1990s and was set up to transform some of the worst public housing by developing mixed-income communities. In Philadelphia, for example, when they were able to switch to Hope VI, you saw a distinctive change in those neighborhoods. Schools got better, neighborhood stores moved in, transportation became more accessible. When we talk about Choice Neighborhoods now, we consider employment assets, quality education, and a wider range of stakeholders, including nonprofits, private firms, local government and public housing authorities.

NPH: What changes can be made to housing and home standards to help improve home and neighborhood safety?

Estelle Richman: We believe the home environment is a major influence on health and well-being and that threats to housing quality include everything from excess moisture, mold, allergens, and poor indoor air quality, to structural deficiencies and lead contamination.

NPH: And what is the approach to minimizing risks such as lead poising from lead-based paint?

Estelle Richman: Our Office of Healthy Homes and Lead Hazard Control is looking at this. We know that housing that was built before 1978 may have lead-based paint, with homes built before 1940 having the highest levels of lead in paint. So it really doesn’t matter if you make a million dollars—if you’re living in a house built before 1978, the odds that there’s lead somewhere in that house is high enough that everyone needs to be concerned about their children. So the standard has to be set high enough that we protect everyone.

NPH: What is HUD doing in the area of secondhand smoke in homes and who are your partners?

Estelle Richman: That is a big agenda items for many divisions of the Department.

Our partners in this are the Housing Authorities, some of the landlords, and just about anyone else who’ll talk to us. My best example of this is the Boston Housing Authority, which is on track to now to implement a total smoke-free policy this fall. They found that their asthma rates were twice as high as those for residents living in non-subsidized housing. They have done a lot of work over the last several years educating themselves, their clients, and offering folks as much support as possible to stop smoking, and now they’re ready to implement a smoke-free policy.

There are several other cities that have announced that they are looking at instituting smoke-free policies—San Antonio, Minneapolis, Portland, Oregon and all of the housing authorities in the State of Maine are among them. We’re offering whatever technical assistance we can to help them do it. We’re working in partnership with HHS, the American Academy of Pediatrics and the American Lung Association and trying to gather many other community supporters.

As we push, I think we will always find folks who believe that they want to continue to smoke, but we’re also finding that there are many people who are ready for smoke-free policies in their housing.

NPH: What are some current efforts of working across sectors to improve housing and better health in that housing?

Estelle Richman: Our Section 811 Project Rental Assistance Demonstration Program is a rental demonstration program to provide housing for people who have disabilities. It provides $85 million in funding to state housing agencies and other appropriate entities to provide long-term housing rental assistance for approximately 2,800 people. Many of these folks will have physical disabilities and will often need assistant care or assistive technology in order to live in the housing, which means that most of them will also be involved with the state Medicaid Agency, as well as their state Health and Human Services Agency.

To develop the program we worked hand in hand with the Centers for Medicare and Medicaid Services. I can’t tell you the number of positive emails I received. People were anxiously awaiting it. It is fully integrated with non-disabled populations, which was critical to the disabled community. To be a part of the program, a state housing agency must partner with the state Medicaid agency to submit a grant. So this is a true partnership. It’s integrated housing, it’s supportive housing and it helps get people out of institutions.

NPH: What are examples of partnerships you have within the Federal government?

Estelle Richman: We meet with our partners at HHS every week. We talk about our joint projects and about projects that we would like to work on together. We’re also a very strong partner with the Department of Veterans Affairs (VA). You may know that we’re working with the VA around eliminating veterans' homelessness by 2015. There is also an HHS part of it so that we can know that our veterans who are coming home not only have good health care, but they also have a place to live. As I’ve said, we all have to have partners and it is, in essence, the core of that partnership that helps us make progress. The National Prevention Council has actually brought these partners together and I credit them for being part of what keeps us working together. It’s very easy in some of these very large bureaucracies to drift off and do your own mission and I think one of the things the National Prevention Council does is help us all realize that we all share prevention, we all work on it together.

NPH: What are some of the other critical partners in communities?

Estelle Richman: In any level of government, the level you need to get to is the level of where the people are. So you need to get down to neighborhoods, you need to get to communities and when you go down in communities, you really need to talk to your hospital and health care systems, community neighborhood groups, schools and PTAs. Also what rises to the top of the page real quickly is transportation. If you have not figured out how to get transportation as a partner then you’re going to have a hard time getting prevention, promotion and health care to work outside the city center.

Each community is different. You need to talk to the folks and get a feel for what’s going to make a difference in that particular community.

NPH: Tell us about the Partnership for Sustainable Communities.

Estelle Richman: It is a multi-partner collaboration among HUD, the Department of Transportation and the Environmental Protection Agency. These two agencies have not always been traditional partners for HUD. Through the Partnership, we are coordinating federal housing, transportation, and environmental investments and looking at things like water infrastructure, roads, sidewalks, transit lines, and job creation opportunities as all of those things are necessary for a healthy and vibrant community life. Several of the Sustainable Communities grant recipients are partnering with the public health sector, including in conducting health impact assessments, increasing access to fresh foods, and encouraging active living that includes opportunities for exercise in one's daily commute and routine. They’re realizing that to improve public health, it’s critical to actually support and create the communities that are not only going to be economically sustainable, but that also maximize environmental, energy-efficient and socially sustainable design and development strategies.

NPH: What had the National Prevention Council brought to the table that was not there before?

Estelle Richman: When you have an initiative like the National Prevention Council, you set goals, you set measurable outcomes and you also have skin in the game of what the big group is doing. You’re held accountable, but you’re asking to be held accountable. And it’s not accountable to your silo, it’s accountable to the larger group.

And I think it’s that choice of accountability to the larger group for health care that affects all of us. The concern about health care is not an issue just for struggling families or folks in foreclosure or families that are in the lower incomes. Health care is something we are all concerned about. In the end, it holds us all accountable for better communities.

This commentary originally appeared on the RWJF New Public Health blog.

A group of professionally-attired policy-makers, influencers and public health professionals in Washington started their day this morning the way students at Namaste Charter School in Chicago do every day—doing upper and lower body exercises and stretches to make physical activity the first learning component of their school day. The Washingtonians—and some key education and health officials from around the country—were at the launch of “Health in Mind,” a project of the Healthy Schools Campaign and Trust for America’s Health (TFAH) that has released actionable recommendations focused on improving student learning and achievement through healthier schools. The recommendations were presented at today’s event to U.S. Department of Education Secretary Arne Duncan and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius.

“Unless we address health and wellness in schools, our nation’s efforts to close the achievement gap will be compromised,” said Rochelle Davis, president and CEO of the Healthy Schools Campaign, a national group that has focused on improving food and fitness in Chicago public schools.

Health in Mind aligns with the National Prevention Strategy introduced two years ago by the National Prevention and Health Promotion Council, which brings together 17 federal cabinet offices and agencies. The Strategy commits the entire federal government, not just the health agencies, to integrate health into their work and make a healthier nation a priority across sectors.

“The Strategy and these recommendations represent a major culture shift in how the nation views health—health will no longer be separated from education, transportation, housing and other clearly connected policies,” said Jeff Levi, executive director of TFAH and chair of the Advisory Group on Prevention, Health Promotion and Integrative and Public Health. “Health in Mind’s focus on students and schools promises to have a long-term payoff by improving education and quality of life for today’s kids as they grow up—they will do better in school and be healthier.”

The National Prevention and Health Promotion Strategy is about to celebrate its first anniversary. The Strategy offers a comprehensive plan aimed at increasing the number of Americans who are healthy at every stage of life. A cornerstone of the National Prevention Strategy is that it recognizes that good health comes not just from receiving quality medical care, but also from the conditions we face where we live, learn work and play such as clean water and air, safe worksites and healthy foods. The strategy was developed by the National Prevention Council, which is composed of 17 federal agencies including the Department of Agriculture, the Department of Education, the Department of Housing and Urban Development, the Office of National Drug Control Policy and others.

As the Strategy is rolled out, NewPublicHealth will be speaking with Cabinet Secretaries, Agency directors and their designees to the Prevention Council about the initiatives being introduced to help Americans work toward the goal of long and healthy lives.

This week, NewPublicHealth spoke with Mary Engle, Director of the Federal Trade Commission's (FTC) Division of Advertising Practices, and National Prevention Council designee.

NewPublicHealth: Why is health a priority for the FTC? Why was it important for FTC to be involved in the development of the National Prevention Strategy?

Mary Engle: When you think about our mission, which is to protect consumers and maintain competition in the marketplace, health is such an important part of that. We want to make sure consumers aren’t misled about health services and products marketed to them and that they don’t pay more than they need to.

Initiatives that are a priority for us include combating deceptive advertising of fraudulent cure-all claims for dietary supplements and weight loss products; monitoring and reporting on the marketing of food to children as well as alcohol and tobacco marketing practices; and developing consumer education materials designed to empower consumers to make informed health care decisions and to avoid fraud.

NPH: What FTC initiatives support the National Prevention Strategy?

The 2012 County Health Rankings, a joint project of the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute, were released this morning. For the third year in a row, the reports rank the health of nearly every county in the nation and show that much of what affects health occurs outside of the doctor’s office. The County Health Rankings confirm the critical role that factors such as education, jobs, income and environment play in how healthy people are and how long they live. NewPublicHealth spoke with Patrick Remington, MD, MPH, County Health Rankings Project Director and Associate Dean at the University of Wisconsin School of Medicine and Public Health, about this year’s release.

>>Join our Twitter Q&A TODAY, April 3, at 1 p.m. EST, and follow the rest of the NewPublicHealth coverage of the 2012 County Health Rankings launch.

NewPublicHealth: What’s new for the County Health Rankings this year?

Dr. Remington: The County Health Roadmaps are new. The County Health Roadmaps project includes several efforts to build connections with local communities and national partners and leaders, including grants to coalitions across the U.S. that are working to improve the health of people in their communities; grants to national organizations to activate local leaders and affiliates to improve health; a prize program to recognize communities taking action whose promising efforts will likely lead to better health; and tools and resources to help groups working to improve the health of people in their communities.

The County Health Roadmaps is our response to the demand that has arisen by communities to help them find solutions. We were pretty good in the first two years at pointing out problems. Over the last year, we heard loud and clear that’s not good enough to just point out problems. The Roadmap is just one tool. It’s certainly not the automobile; it’s not the vacation plan. It is just a tool that communities need to use to come together and decide where they want to go and the Roadmap can tell you how to get there.

But an even better question is what is the same. We want the County Health Rankings to be an annual check-up that can be counted on by communities to provide residents with a way to compare the health of where they live to other counties in their state. Although we might add a measure or two each year, I think the most important message is that we’ve continued to use the same approach to measure and rank the health of counties.

NPH: What is that approach?

In Detroit, Michigan, the Joy-Southfield Community Development Corporation has developed a targeted approach to promoting health equity, based on the four factors measured by the County Health Rankings: health behaviors, clinical care, social and economic factors and physical environment. Despite its location in one of the most racially segregated cities in the country, with poor public transportation, high poverty and unemployment, and vast food deserts, the Joy-Southfield neighborhood has become a hub of partnerships and activities aimed at long-term health improvement. Several community groups and funders have collaborated to empower youth through mentoring and community garden projects; renovate vacant properties to attract new businesses; improve community safety; provide job training and foreclosure prevention services and more.

NewPublicHealth spoke with David Law, PhD, Executive Director at Joy-Southfield, about the program.

NewPublicHealth: Tell us about the Joy-Southfield Community Development Corporation. How did your priorities evolve, and how did the County Health Rankings help shape them?

More and more businesses and employers are taking action to improve the health of their employees and communities at large. Recently, we spoke with Jeff Johnson, President of Johnson Machine Works, Inc., and Joy Schiller, Director of Wellness at Des Moines University, about why their organizations have made wellness a priority, from the perspective of two very different businesses—one big, one small; one academic, one industrial. Both are members of the Wellness Council of Iowa, a group of business leaders committed to creating healthier workplaces for employees.

NewPublicHealth: Why did your organization join the wellness movement?

Joy Schiller: There’s a real recognition that we as a health sciences university should be kind of a role model for the rest of the state and the nation. I tremendously appreciate as a wellness director that one of our goals is to provide education to our students and opportunities for wellness so our students on a personal level can see the benefits of maintaining a healthy lifestyle. When they go out as health care practitioners, they will be more apt to reinforce to their patients the importance of healthy lifestyle habits and how critical it is to quality of life and preventing chronic health problems.

Jeff Johnson: Our business is a steel fabrication business. We’ve got skilled welders, cutters and fitters, engineering types, detailers and project managers. It’s a real rough-and-tumble kind of a business.