Culture of Health Blog Our blog features perspectives from Robert Wood Johnson Foundation staff and guest authors about efforts to build a Culture of Health. Thu, 29 Sep 2022 10:00:00 -0400 en-us Copyright 2000- 2022 RWJF (RWJF) <![CDATA[Three Lessons on How Communities Can Support the Struggle for Water Justice]]>

Access to clean, safe water is a basic human right—a right we strive to protect in our Chicago neighborhood. These important lessons we've learned along the way may help other communities facing similar challenges.

Water Pipe and Scales

The Flint water crisis prompted anxious school districts nationwide, including ours in Chicago, to test water in our public schools. The results were alarming: Thirty-seven percent of schools had levels of lead in the water fountains that were far above the federal limit.

This was the beginning of our journey toward water justice in Little Village.

Little Village is a small, culturally and economically vibrant Chicago neighborhood that is home to many Latine families and children. But industrialization and climate change have posed stark threats to our well-being. To build a healthier community, through the years we have worked alongside courageous local leaders to wage tireless grassroots campaigns. For example, one community-led effort transformed contaminated land into open green space—the first public park to be built in Little Village in 75 years. Another effort succeeded in shutting down a coal plant that was polluting our air with toxic fumes.

Most recently, our organization, the Little Village Environmental Justice Organization (LVEJO) has turned its attention to ending the water crisis facing our community. By sharing our experience and key lessons that we have learned along the way, we hope other communities facing similar challenges can find a path forward for catalyzing change:

1.      Be guided by the community

We regularly hold community meetings that give Little Village’s residents space to voice concerns about whatever is preventing them from living their healthiest lives. When the disturbing results about lead water in schools emerged, upset parents started raising their concerns at these meetings. In listening to them, we realized that our residents had very little knowledge about lead and its devastating impact on children. Our organization stepped up.

We set out to share basic lead information and instruct residents on how to test for it in the water at their homes and workplaces. In addition, we distributed filters and portable bottles for immediate access to safe water.

We listened to the community and met their needs every step of the way. While responding to the lead water crisis in schools, we uncovered many more barriers to safe drinking water—including failing water infrastructure, rising water rates, and increased flooding.

To address these issues, in 2018 we launched a water justice program to ensure clean, safe, affordable drinking water and equitable water infrastructure improvements in our community.

This is a hallmark of our approach. Our work is guided by what we hear and learn from the community about the biggest challenges they face daily—whether that’s trouble paying bills, fearing unsafe water, or facing sewer backups. We view community members as the experts. Their involvement is paramount to informing our research and decisions on policies and programs to advocate for.

2.      Work together for greater impact

Survival without water is nearly impossible. Yet when COVID-19 hit, people throughout the nation, including those in our Chicago community, were disconnected from their water services if they couldn’t pay their bills.

LVEJO was among several advocates to respond by distributing water bottles to residents without water. On the policy side, we worked alongside others to continuously advocate for a moratorium on water shutoffs in Chicago, successfully protecting the right to water. In 2022 the city passed an ordinance that ended water shut-offs for non-payment permanently. This means no one will ever again lose access to water entirely simply because they can’t afford it.

We won these victories by working side by side with youth, residents and—importantly—other local organizations. Collaboration made our voices louder and made us stronger.

With some of the fastest rising water prices in the nation, affordability continues to be a major concern—in fact, a recent report found that Chicago’s lowest income households pay on average almost 10 percent of their income on their water bill, double the U.S. EPA threshold of 4.5 percent. Spikes in water prices often go unnoticed, so we’re continuing to advocate to get permanent financial assistance programs in place and establish long-term affordability solutions to ensure Chicagoans can turn on the tap.

To continue this momentum, we are working to establish and formalize the state’s first Water Justice Coalition, bringing local groups together to build a community-based movement to solve the water crisis across Illinois.

3.      Prioritize equity

Illinois has the most lead water pipes in the nation—confirmed to be at least 600,000 and more likely up to 1 million lines—with the majority being in Chicago. With 96 percent of residences in Little Village built before 1986, when lead pipes were finally banned, it’s likely that a high number of homes have lead in their drinking water.

We know there is no safe level of lead, and we should be replacing lead pipes with the urgency of the public health crisis it is. In 2021, Illinois passed the Lead Service Line Notification Act, which mandates the removal of all lead service lines in the state, joining Michigan and New Jersey as the third law of its kind. Despite enacting legislation, progress has been slow.

We joined a working group with the Chicago Department of Water Management to advise on the equitable implementation and outreach of their lead service line replacement program and continue to urge them in implementing innovative solutions to expedite the replacement of the lines.

The results: Low-income residents and homes with children now have the opportunity to apply to a program to get their lead service line pipes replaced for free. This is in stark contrast to the past, when the replacement cost fell on the homeowner. Over the past year, the city has also removed some barriers from the application requirements so more households can apply to the program.

The city has also launched a pilot program to replace all lead service lines in an entire block of a low-to moderate-income neighborhood, which it is piloting in Little Village. If this works, it could become a blueprint for a more efficient city-wide approach that accelerates water equity.

While we are far from the ideal pace of removing lead pipes from the ground, we are encouraged by this progress. With $15 billion in funding to replace lead pipes now available through the Infrastructure Investment and Jobs Act, we hope states and municipalities see that it is possible to place equity at the center of lead service line replacement and ensure no one is left behind.

Protecting the Right to Water

Clean water is a human right. Jackson, Mississippi has been in the headlines most recently, but in every state there are communities where residents struggle to access safe, affordable drinking water.

At LVEJO, we will continue to fight this injustice and protect the right to water. As we move forward, we will remain dedicated to cultivating a space that centers the voices and needs of communities suffering the greatest impact.

Learn more about how strengthening our water system and other public infrastructure can advance health equity.


About the Authors

Brenda Santoyo is Senior Policy Analyst at Little Village Environmental Justice Organization whose work is focused on water justice.

Jeremiah Muhammad is the Water Justice Program Manager at Little Village Environmental Justice Organization.

Thu, 29 Sep 2022 10:00:00 -0400 Brenda Santoyo Built Environment and Health Public and Community Health National Water & air quality <![CDATA[Four Reasons We Need School Nurses Now More Than Ever]]>

A relentless advocate for school nurses reflects on the central role they play in advancing health equity within schools and communities. 

A woman meets with a student during a sports physical.

The 2022-2023 school year will be the fourth marked by COVID. With schools facing unprecedented challenges, school nurses are preparing for a demanding year.

No one is more familiar with these challenges than Robin Cogan, MEd, RN, NCSN, FNASN, FAAN, who has spent more than two decades of her 35-year nursing career as a school nurse in Camden, New Jersey. She is New Jersey Director for the National Association of School Nurses and faculty at Rutgers University-Camden School of Nursing. Here, she discusses the essential role nurses play in advancing health equity in schools and communities as well as what they need in order to continue caring for children.

Students Have Urgent and Growing Needs

One of my most vivid memories is discovering that a 4-year-old pre-school student wasn’t eating her school lunch. Instead, we noticed her stuffing food into her pockets, day after day. Her family was new to our country and had endured a grueling journey on foot from El Salvador to get here. When we asked why she wouldn’t eat, the child shared that she felt responsible for feeding her family. Our school came together and provided a food pantry to support the family and other families in similar circumstances.

That is just one example of how school nurses advance health equity within schools and communities. We are the chief wellness officers, the care coordinators, the people who know what resources are available in our communities. We recognize emerging problems and mitigate the struggles children and families face. We eliminate barriers by connecting families to resources. We get eyeglasses for children who can’t see well, and do tube feedings for medically-fragile children, which allows them to be in school.

We also deal with life-and-death situations. Twenty-five percent of students with an undiagnosed food allergy have their first anaphylactic event at school. Students have asthma attacks at school that can be deadly. Some are medically fragile. Some are newly diagnosed with diabetes. Up to 30 percent have chronic health conditions. COVID remains with us, and now monkeypox.

Ultimately school nurses are an investment in student wellness and achievement because health happens in the community and at school. So having a school nurse democratizes healthcare. But just 40 percent of schools have a full-time student nurse and 25 percent have no school nurse at all.

Stressed Communities Create Stressed Children

A few years ago, I heard from a former student who I had known when he was 8 or 9 years old. Now a grown man, he reminded me that I had once invited him to sit with me in my office when I noticed that he wasn’t having a good day. He disclosed that he had been contemplating suicide that day, and my words and presence saved his life. He is now a thriving adult and father to three boys.

You never know the impact you have. One caring adult in a child’s life is a protective factor. Often that caring adult is a school nurse.

We know that no dysregulated child ever calms down because you tell them to, that a stomachache is often a sign of anxiety, depression, or a problem at home. We can encourage a child to identify emotions and connect her or him to a school counselor or psychologist. We can open communication with parents.

Prior to COVID, we were spending up to 34 percent of our time on mental health issues. These mental health needs escalated with COVID and the resulting isolation. We even faced a divisive election season and may be heading for another. All of this turmoil seeps into what happens at school. Children observe adults and absorb stress and conflict within communities which ultimately affects their ability to learn.

I sometimes say that school nurses are population health gold. We are the epicenter of every concern a child brings to school, be it racism, hunger, homelessness, threats to undocumented families, opioids, or something else.

COVID Exacerbated Challenges

For school nurses, COVID added a second full-time job on top of the full-time job we already had. Many of us became the de facto community health department, engaging in intense COVID-related duties. We conduct contact tracing and testing; we track students who are quarantining. We put mitigation strategies in place in schools. We monitor outbreaks, run school-based vaccine clinics, and are responsible for reporting new cases, which is complex and time-consuming when it involves a city, county, and state. We inform parents when their child is symptomatic or exposed to contagion.

Many school nurses have been so preoccupied with protecting children from COVID that we are terrified we’ll miss a more typical health problem.

As challenging as facing COVID has been, it’s also transformed public perceptions of school nursing. Suddenly, headlines acknowledged our role on the frontlines of the pandemic. That has been gratifying.

Diverse School Nurses Deliver Culturally Sensitive Care

I am inspired by the remarkable trailblazer, Charity Collins—the first Black school nurse. She served a segregated, underserved Black Atlanta school community in the early 1900s. Still, today, school nurses are currently 90 percent white and trend older. We need school nurses who reflect the communities they serve.

I work in a community that is largely Black and Brown, and I am White. My urban school district is 13 miles from my house, but there’s a 10-year life expectancy gap between where I live and where I work. That’s the difference between privilege and poverty. I don’t reflect the community I serve, so I walk in cultural humility.

We don’t just have a shortage of school nurses; we have a diversity problem among school nurses and a failure to pay a livable wage. Some school nurses are paid on a teacher scale, starting at an entry level that may ignore decades of nursing experience in another, non-school setting. It varies from locality to locality, but nearly all school nurses take a huge pay cut when they leave the acute care setting. One school nurse told me she donated plasma twice a week to make up for it.

And we don’t have an infrastructure for upward mobility for school nurses. I’ve been in the same job for 22 years. We need a place to grow.

We need more diversity, better pay, better mobility—and making that happen starts with doing a better job sharing the true story of who we are and what we do. School nurses care for other people’s children. It doesn’t get more consequential than that.

Explore stories about school nurses from across the nation on Robin Cogan’s blog, The Relentless School Nurse.


About the Author

Robin Cogan is a Nationally Certified School Nurse (NCSN) and has been a school nurse in New Jersey’s Camden School District for over two decades.

Thu, 15 Sep 2022 10:45:00 -0400 Robin Cogan Social Determinants of Health <![CDATA[Can Global Insights Help the U.S. Reframe Obesity?]]>

Diet and physical activity alone do not determine body size. Lessons from abroad reveal how the United States can improve policy around childhood obesity by taking culture into account.

Illustration for blog on weight.

The spread of body positivity is at an all-time high. Celebrities and influencers are celebrating larger bodies. Models of a variety of sizes are promoting beauty and consumer products. And a flood of social media posts and TV shows urge us to love our bodies as they are.

Despite this positive rhetoric, weight bias and fat shaming remain rampant. Thinness is a Western ideal that has had enormous influence around the world, spread first through colonization and echoed today through social media and pop culture. It's an ideal that has racist roots: during the slave trade, middle and upper class white women were told to eat “as little as was necessary in order to show their Christian nature and also their racial superiority” in the words of sociologist Sabrina Strings. Body size became associated with discipline and self-control and used to suggest who did and did not deserve freedom.

Childhood Obesity and Weight Discrimination

While unintentional, anti-fat attitudes have also made their way into public health policy. Take efforts to address childhood obesity: there is no shortage of interventions that concentrate on diet and exercise, based on conventional wisdom that weight gain results from more calories consumed than expended. But this focus on individual behavior feeds into biases that being overweight is the result of a lack of self-discipline or a moral failing. 

While improving nutrition and levels of physical activity is beneficial, such a singular approach fails to acknowledge that individual food and lifestyle choices are embedded in larger environmental, economic, and social contexts—including a global food system that supplies the market with cheap, convenient, and hyper-palatable, ultra-processed products.

Learning from the World

Diet and physical activity play a role in body size, but they are not the only factors, and often not the most important. Recognizing this, different interventions across the world are shifting their efforts toward promoting health for all body sizes and taking a holistic approach to improve childhood nutrition.

Looking for global insights into the cultural contexts of size and health, our report identified three key areas in which the United States can improve health policy around childhood obesity.

We must recognize that:

Food is More than Nutrition

Cultural values, historical legacies, personal tastes, and financial constraints frame our food choices. Brazil recognizes this insight with its innovative dietary guidelines. The guidelines are simple and culturally appropriate, depicting plates with natural, unprocessed foods regularly eaten by all social classes, including traditional Brazilian foods. The guidelines also provide advice on how to eat, for example avoid snacking, eat at the same time every day, and eat with others as a way of strengthening social bonds and reinforcing healthy eating habits. Imagine if the 2025 U.S. dietary guidelines focused more on cultural aspects of eating than on nutrient balance; what could that look like?

Health is More than Weight

Large-bodied patients overwhelmingly report that their caregivers focus on weight to the exclusion of other conditions. Yet, in recent years, the limitations of body mass index (BMI) as a diagnostic measure have become clear. Not all individuals—classified as obese by BMI are ill—a sizable percentage have healthy metabolic measures. In fact, a 2016 study found that half of those in the “overweight” and a quarter of those in the “obesity” categories had healthy metabolic measures, while over 30 percent of those in the “normal” weight category had unhealthy metabolic measures. This classification of fat as unhealthy has spurred decades of weight discrimination, feeding into shame and stigma that have resulted in lasting psychological trauma for large-bodied kids. In Japan, annual checkups include a battery of laboratory tests in addition to body size measures to assess risk of obesity. Japan recognizes that a high BMI is just one risk factor that, depending on the individual physiology, may or may not need to be treated. Imagine if the U.S. looked beyond BMI to classify how weight impacts health—how could that change our understanding of a patient’s actual needs?

Diet is More than Individual Choice

Low wages, long work hours, school food programs, restricted access to healthy food, and the built environment all interact in different ways to create diets that are more likely to be calorie dense and nutrient poor. We need to look at these underlying social, environmental, and economic systems that produce overweight and obesity together. In the Netherlands, the Amsterdam Healthy Weight Programme is working across government units, including housing and schools, with the business sector and local food entrepreneurs, and in partnership with local neighborhood and civic groups to advance an integrated approach to child weight. It’s a 20-year “marathon” that launched in 2013 and advocates for a reasonably paced run towards healthy living, rather than a sprint to lose weight. Imagine if the U.S. overcame policy silos and took a whole systems approach to addressing inequalities associated with poor nutrition—could we then ensure every kid grows up healthy and at a healthy weight?

What we label “obesity” is produced by interrelated systems in which human biology interacts with environments, social norms, economic structures, and historical legacies. To effectively improve child nutrition, we must de-center the role of the individual, look beyond weight, and have policies and interventions that take into account the cultural contexts and colonial legacies that produce community environments that can contribute to obesity.

As we do so, we must center the voices and lived experiences of those most directly affected by these policies and interventions. In reality, there is no universally ideal body nor a single size for good health. As we take steps to improve children’s diets and address the health risks associated with certain types of fat, it is crucial that we avoid shaming and blaming those with large bodies. All body types deserve the best possible health and healthcare.

Read the full report: Reframing Childhood Obesity: Cultural Insights on Nutrition, Weight, and Food Systems


About the Authors

Edward (Ted) Fischer is a Cornelius Vanderbilt Professor of Anthropology. He directs the University’s Cultural Contexts of Health and Wellbeing Initiative.

Tatiana Paz Lemus is an anthropologist and project manager at Vanderbilt University’s Cultural Contexts of Health and Wellbeing Initiative.


Wed, 7 Sep 2022 10:00:00 -0400 Tatiana Paz Lemus Childhood Obesity Disease Prevention and Health Promotion Built Environment and Health International <![CDATA[These Books on Health Equity Inform and Inspire]]>

The bold voices featured on this reading list offer empowering perspectives on advancing racial justice and health equity.

Books as Swings

During these tumultuous times, the sweltering heat need not slow our determination to achieve health equity. In fact, these remaining summer days give us all a chance to step back and consider the many intersecting influences on health in a larger context.

One way to do that is by delving into a good book! Reading can inform and deepen our commitment to shaping communities that give everyone in America a fair and just opportunity for health and wellbeing. Several of our colleagues have authored or contributed to books that mix personal stories, on-the-ground experiences, and insightful ideas to remind us of the opportunity to make a difference.

Find space during your next getaway or staycation to delve into this sampling of works!

Take Us to a Better Place

RWJF’s first-ever book of fiction helps us envision ways to build a healthier world. “Writers imagine how we might all thrive if we all had the inalienable right to participate in a culture of health that was actively supported economically, societally, politically,” writes Roxane Gay in the book’s introduction.

One story, The Plague Doctors, by award-winning author Karen Lord, visualizes life on a small island beset by a pandemic. The Plague Doctors was selected as one of 2021’s Best American Science Fiction and Fantasy stories.

Download the free e-book or audiobook.

The Beautiful Darkness: A Handbook for Orphans

Joshunda Sanders shares her mother's story and asks how we can create mentally healthy cities that foster care and healing for those who struggle with mental disorders.

RWJF Senior Communications Officer Joshunda Sanders describes her journey from a childhood caring for her mentally ill mother to the pursuit of an elite education and a professional career. This moving memoir of adversity, faith, and perseverance paints a personal portrait of how the social determinants of health shape our lives.

She writes, “My mother gave me the gift of faith, which has been essential to my life’s work as a writer and to my development as a human being, a woman, and a Black woman. From her, I also inherited a deep belief in the severe empathy that tragedy and heartbreak can bestow. I learned to laugh from my gut. I learned not to take anyone or anything for granted or to feel entitled to anything at all. Because of her, I am a fighter.”

You Are the Best Thing: Vulnerability, Shame Resilience, and the Black Experience

RWJF Award for Health Equity winner Yolo Akili Robinson is a mental health advocate who brings healing to Black communities by confronting intergenerational trauma and challenging rigid norms around masculinity. His essay “Unlearning Shame and Remembering Love,” appears in an anthology edited by activist and founder of the #MeToo movement Tarana Burke, and Brené Brown who is known for her research on shame, empathy, courage, and vulnerability.

Robinson shares, “I have patterns to unlearn, new behaviors to embody and wounds to heal...I am unlearning generations of harm and remembering love. It takes time.”

Black Boy Shining and Black Girl Shining

As a researcher, educator, and advocate, Rhonda Tsoi-A-Fatt Bryant has dedicated her career to improving the lives of marginalized youth. Her children—Andrew and Leigha—inspired two vividly-illustrated children’s books. Black Boy Shining and Black Girl Shining bring to life uplifting affirmations aimed at fostering positive self-image and bold ambition to help children thrive.

The Political Determinants of Health

While many of us are familiar with the social determinants of health­—structural conditions that we are born into, live and die in—Daniel E. Dawes introduces us to a new framework in The Political Determinants of Health. He explores how a systemic process of structuring relationships, distributing resources and administering power operate simultaneously to advance or hinder health equity.

This explainer video describes how the political determinants of health affect us at the individual level.

Internationally renowned scholar and Harvard professor David Williams who wrote the foreword notes "With leaders like Daniel Dawes and his innovative approach to addressing structural inequities, I believe that the mighty walls of oppression and resistance that we currently face can be overcome and that the fight for health equity can serve as a desperately needed critical inflection point to provide justice for all and elevate America to its rightful place among the world's leaders."

The Contagion Next Time

Sandro Galea, dean of the Boston University School of Public Health, underscores the foundational inequities and lack of preparedness that allowed COVID-19 to take its terrible toll—and then points to lessons that can help us do better. “The awakening to deep-seated racial economic injustice that really came to the fore in 2020 was extraordinary and should illuminate a path forward,” says Galea.

Recognizing and capitalizing on the power of compassionate love is the place to begin, he wrote in a post last year. “Choosing love to advance health and racial equity starts with acknowledging both the harms that have been inflicted upon some populations and a celebration of all that we have in common and how we are stronger together. Then we must move from acknowledgment to action.”

Necessary Conversations: Understanding Racism as a Barrier to Achieving Health Equity

RWJF's Alonzo Plough and Jackie Orr discuss stories, ideas and strategies for working together to advance health equity.

RWJF’s chief science officer Alonzo Plough urges us to reckon with racism, highlights the harms of racial injustice, and offers strategies to advance health equity.

“We have deepened our understanding of what it means to build partnerships and community power and the centrality of leadership by those who are most affected by the decisions that influence their lives,” writes Plough. Understanding why meaningful conversations about race are so critical encourages us to do the hard work of engaging in them.

Download the free e-book.

Rx for Racial Healing: A Guide to Embracing Our Humanity

Change agent Gail Christopher lays out a model for fostering human connection and eradicating the racial hierarchy that has been embedded in the United States since its inception. By illuminating the ways in which issues of racial equity thread through housing, education, health, and economic opportunity, Christopher seeks to heal injuries of the past and create a space that allows us to be comfortable striving together. “We can stand up as American people and learn to see ourselves in the face of each other,” she says. “We can learn to demonstrate empathy and compassion for one another.”

Reducing the Health Harms of Incarceration

Published by the Aspen Health Strategy Group (AHSG), which includes RWJF president and CEO Richard Besser as a member, this book offers five big ideas for confronting the damage wrought by incarceration. It includes background papers that examine mass incarceration as a manifestation of structural racism, grapple with its impact on community heath, and explore the challenges of treating mental health and addiction in carceral settings.

“More than 10 million people are incarcerated every year in the United States and an astonishing 45 percent of Americans have a family member who has been jailed or imprisoned,” write AHSG co-chairs Kathleen Sebelius and William Frist.

Sign up and explore content like this and learn about new grant opportunities in our weekly Advances newsletter!


About the Author

Najaf Ahmad

Najaf Ahmad is senior managing editor of the Culture of Health Blog where she highlights perspectives about how the Foundation is advancing health equity in communities across the nation.

Thu, 18 Aug 2022 13:00:00 -0400 Najaf Ahmad <![CDATA[Connecting Systems to Build Health Equity]]>

Working together, academic and community-based researchers can strengthen connections across medical, social service and public health systems to help diminish structural racism. Funding is available to support their innovative approaches.

Large group of people in the convergent arrows form.

My maternal grandfather had some good fortune in his life. As both a veteran and an employee of the Ford Motor Company in Detroit, he was eligible for health benefits from two sources. That meant that along with traditional medical services, he could readily access dental care, medical devices, and social services that included counseling and housing assistance, if he needed them. He could even ride his motorized scooter to the Veterans Administration hospital and meet up after clinic appointments with buddies who shared many of his life experiences, providing the social connections so essential to wellbeing.

As my career in health administration evolved, I began to realize that such a palette of services is rare. More typically, people feel as if they are living inside a pinball machine, batted incessantly from one corner to the next in their search for help. Because medical, social service, and public health systems have never been well threaded together, the fractured and inequitable distribution of services and support has become commonplace.

To live the healthiest life possible, people need access not only to appropriate providers and treatment but also, at times, help dealing with housing instability, food insecurity, social isolation, financial strain, interpersonal violence, and other social determinants of health. No single system can provide all of that; instead, systems need to work seamlessly together to provide it as best they can.

Consider the consequences when they do not. Traveling to the doctor to be monitored for diabetes becomes a low priority when it means taking time off from work or arranging childcare, or when the required co-payments or deductibles are unaffordable. Lacking a stable address or forced to navigate complicated transportation routes, someone can miss an appointment to determine their eligibility for financial assistance and be cut off from various supports. The health harms of segregated housing, food apartheid, and employment discrimination are intensified by systems that operate independently of one another.

Growing the Evidence for Coordinating Systems

Systems for Action (S4A) is an RWJF research program dedicated to addressing these challenges by aligning medical, social service, and public health systems. We support evidence-based studies that identify innovative ways to diminish fragmentation, rebalance power, and confront the structural racism that is so deeply embedded in many of these systems.

We already have a body of research that tells us how best to design multi-sector initiatives that will advance health equity. Clearly, we should expand the pool of available social services and support—it is not enough to rely on screening and referrals if there aren’t enough services to go around. We also need to reallocate resources so they are not overweighted towards medical care at the expense of social services and public health. Likewise, social service and public health stakeholders need more voice and authority on any team of collaborators.

RWJF’s National Commission to Transform Public Health Data Systems has identified other attributes of invigorated multisector initiatives. Importantly, these include enhancing communication across sectors, recognizing that we can only build bridges when we understand one another’s language. Better use of public health capacities, including the field’s expertise in surveillance, community outreach, and health education, is also key. And an equity-centered approach requires that we disaggregate data in order to understand how race, ethnicity, geography, socioeconomic status, and other demographic characteristics influence outcomes.

New Funding Opportunity

Despite all we have learned about cobbling together disconnected systems, significant knowledge gaps remain. Through a Systems for Action funding opportunity, we are soliciting innovative new ideas for alignment, emphasizing strategies to help dismantle the enduring structural racism within many of our systems.

S4A initiatives always emphasize rigorous methodology but we think we can create more interdisciplinary opportunities for those who are fully grounded in community experiences to connect with academic researchers. We know there is a lot of amazing work underway in local communities.  But on-the-ground experts are sometimes limited by resource shortfalls—or the many other demands that compete for their attention, which can limit their capacity to apply formal methodological or practice-based knowledge. This CFP gives priority to projects that are defined and initiated within communities for a simple reason: without that voice, we don’t know enough to drive effective change. Rather than make assumptions about what people within communities need, we want them empowered to identify their own concerns and define the outcome measures they care most about.

Toward that goal, we are offering two categories of research awards so that stakeholders within the domains of medicine, social services, and public health can engage with one another on equal footing. Recognizing that theory, rather than practice, sometimes dominates research, the CFP emphasizes the importance of an action plan—we want to know how you will put new scientific knowledge to work in service to health equity.

  • Developmental studies: Perhaps your organization is already thinking about strategies for aligning systems but has not yet begun to test them. A pilot study will help you assess the feasibility and potential value of your idea—including whether you can readily engage stakeholders across sectors, successfully recruit study participants, and collect and analyze data. This 12-month developmental grant will position you to respond to future S4A proposal solicitations or pursue other funding opportunities.
  • Impact studies: These three-year awards allow you to measure the impact of a novel strategy to align delivery and/or financing structures across medical, social service, and public health systems. Open only to participants who can document the results of a previous pilot study, your proposal should explain how you will measure health equity and create a model for addressing the structural racism that remains lodged within these three domains.

To live their healthiest lives, people need services similar to what my grandfather enjoyed. It’s why S4A looks forward to your proposal for linking systems to advance health equity.

People with lived experience of racial injustices are especially encouraged to apply. The final proposal is due October 5 at 3 p.m. EDT.


About the Author

Jacquelynn Y. Orr is a program officer in the Research, Evaluation, and Learning unit. As a strategic liaison to RWJF’s efforts to transform health and healthcare systems, she draws upon her extensive skills in physician practice management, medical education, healthcare delivery, public health, and health disparities research.

Thu, 4 Aug 2022 11:00:00 -0400 Jacquelynn Y. Orr <![CDATA[Help Us Learn How to Close the Racial Wealth Gap]]>

It’s past time to close the racial wealth gap, which undermines health in families and communities affected by structural racism.

Illustration of Wealth Gap

Editor’s note: This funding opportunity is now closed.

Can your family withstand a difficult diagnosis, a missed paycheck, or a significant rent increase? For many families and communities, those financial shocks are impossible to weather and gravely impact health and wellbeing. A survey conducted this year found that two-third of Americans have put off care they or a family member need because of cost.

This is the result of the racial wealth gap, which refers to how hundreds of years of structural racism have deprived Black and Indigenous families and other communities of color of assets and resources that accumulate and transfer from one generation to the next. Today, the racial wealth gap is a chasm; previous research shows that, for each dollar of wealth held by White families, Indigenous families have about 8 cents, Black families have about 13 cents, and Latino families about 19 cents.

Our nation’s policies have limited wealth and opportunity, especially for Black, Indigenous and other communities of color. From the appropriation of millions of acres of Native American land, to the Emancipation Proclamation which freed slaves but did not establish a federal policy that Black people could own land, to the internment camps that cost Japanese Americans their homes and businesses, home and land ownership have been afforded only to some. Housing discrimination in many forms, including redlining and predatory lending, continues today.

Those grave injustices have been compounded by discrimination of other kinds. Efforts to dismantle protections for racial minorities in higher education are ongoing. Tax-paying immigrants have long been denied social services that are available to others. We have an unrelenting gender- and race-based wage gap, which penalizes women of color most of all. And the COVID-19 pandemic exacerbated many inequities.

The Racial Wealth Gap Undermines Health

The racial wealth gap has a clear and direct impact on health and is a root cause of disparities in health, wellbeing and survival. The most obvious reason is that, in our country you have to pay for healthcare, from doctor’s visits to preventive services to medications that can prolong, improve, or even save your life. If you cannot pay, you may be burdened with a staggering amount of medical debt or you may not get the care you need.

Research shows that overall health is linked not only with a country’s overall level of wealth, but also with how that wealth is distributed—and in the United States, distribution of wealth is deeply, fundamentally, and increasingly unequal. Health equity is impossible unless we dismantle structural racism, overcome the racial wealth gap, and distribute wealth more equitably.

That’s why the Robert Wood Johnson Foundation’s (RWJF) work to advance health equity and a Culture of Health incorporates a focus on economic inclusion for all families, no matter their race or zip code. If you live in a community that has little or no capital coming in, your health and wellbeing is unlikely to be secure. Community and family wealth are essential to good health.

Funding Research into the Solutions We Need

Policies that build and sustain economic security and wealth for families of color are the focus of our funding opportunity. We are not looking for research that only documents the problem or examines the harm the racial wealth gap causes. Rather, we are looking for research that identifies community-oriented policies that can effectively dismantle the racial wealth gap.

Applicants must propose investigations into policy solutions that align with the work of racial justice organizations and community groups. Among the many potentially transformative policies being proposed and tested right now are:

●       Baby bonds,
●       Reparations,
●       Tax credits and exemptions,
●       Community land trusts,
●       Community asset ownership,
●       Universal basic income,
●       Confronting and closing the racial wealth gap for people with disabilities,
●       Support for Black, Indigenous, and People of Color (BIPOC)-owned businesses, and
●       Many others.

We aim to fund research into how effective those and other policy ideas are at creating environments that enable communities and families of color to dream, invest, and design inclusive economies that build and sustain generational wealth. We expect the evidence that emerges from this work to inform and incentivize policymakers to invest in solutions.

We welcome applications from people and groups that may not have applied for RWJF grants before and will look favorably on applicants that center community involvement in their research design. By doing so, we hope to help change the demographics of who does policy research and diversify those who are considered experts.

In all its grantmaking, RWJF centers health equity by looking for researchers who bring lived and professional experience to the table, produce nuanced, racially disaggregated data, make communities affected by the research a part of the research process, and utilize equitable evaluation principles.

Through this new program, we intend to advance anti-racist policies and make it possible for communities of color that have been denied opportunities throughout our history to finally build intergenerational wealth and reap the health and economic benefits it provides.

This funding opportunity is now closed. Learn more about our policy and law research through our Policies for Action program. 


About the Authors

Alexandra Zisser supports RWJF’s research efforts in health and health equity, including its Policies for Action initiative, which seeks to build the evidence base for policies that can improve racial equity in health and wellbeing in the United States. 

Mona Shah, a senior program officer in the Research-Evaluation-Learning unit, joined RWJF in 2014. Drawing on her deep commitment to research and its potential to impact health and healthcare, she praises the Foundation’s work in making its extensive research accessible to the public and policymakers alike.

Thu, 28 Jul 2022 11:00:00 -0400 Mona Shah Social Determinants of Health Public and Community Health <![CDATA[Three Local Policy Solutions That Can Advance Park Equity]]>

Urban parks are a smart investment for health, but not everyone has a park nearby. These local policy solutions can help bring parks to every neighborhood.

Park Equity Graphic

When I want to get some fresh air, exercise outdoors, or connect with the healing power of nature, I go to one of the many green spaces close to my home. These local parks contribute to my mental and physical health, and improve my quality of life considerably.

We all need parks, but not everyone has one nearby. Black, Latino, and other communities of color have fewer parks than white, wealthier neighborhoods. And the parks they do have are half the size and five times more crowded. It’s time to fix this inequity and create parks and green spaces that will serve generations to come.

The Power of Parks

The pandemic underscored just how important parks are to creating strong, healthy communities. Parks protect health and promote mental wellbeing by providing people of all ages and abilities opportunities for physical activity, time in nature, social connection, and respite. Research shows that time in parks can decrease levels of stress and anxiety by 50 percent.

Parks and green spaces also have environmental benefits that can help guard against the health harms of climate change: they cool temperatures, cleanse air, filter stormwater, and replenish groundwater. Research reveals that neighborhoods within half a mile of a large park are six degrees cooler than neighborhoods without nearby parks.

Simply put, urban parks are a smart investment for health and essential community infrastructure that should serve every neighborhood.

Advancing Park Equity

Far from being accidental or coincidental, persistent inequities in the quantity, quality, and distribution of parks are born from historical policies including redlining and racial covenants that resulted in parks being built in neighborhoods that are mostly white and well-off. These disparities are perpetuated by current policies, systems, and norms that underinvest in the communities that need parks the most.

Now, many cities want to address these long-standing inequities. And while the most obvious solution may be to acquire new parkland or upgrade existing parks, local policy and systems change can also increase park equity. This approach is particularly useful in older, built-out communities where undeveloped land is not readily available or where economic constraints may limit new park development, maintenance, and operations.

In a recent report, Prevention Institute identified a number of promising policy options to advance green space equity. Here are just three of those solutions that are gaining traction across the United States as cities pursue a park system that can be enjoyed by everyone:

●       Prioritize equity in city decisionmaking. By centering internal processes and practices around the goal of equity, city parks departments and green space agencies are taking steps to close gaps in parks access. For example, patterns and trends in development, community planning, and financing have influenced where parks were built in San Diego for decades, leading to stark differences in access to open space. Now, the city is prioritizing investments in park-deficient neighborhoods, ensuring long-ignored communities receive their fair share. What’s more, the city is putting all development impact fees—one-time payments made to the city by developers—into a citywide pot to be used primarily by neighborhoods where new parks are most needed and will be most used.

●       Change land use policies. Underutilized city lands and public right-of-ways have the potential to be turned into pocket parks, urban plazas, and community gardens. In fact, the greening of America’s unused spaces is taking place in cities of all sizes. In Chicago, alleys have been transformed into safe, green, community spaces with plants and public art. In Cleveland, residents and community groups have used grant funding to reimagine vacant lots as community gardens, orchards, and vineyards. Adopt-a-lot programs in places including Baltimore and Pittsburgh have empowered residents and neighborhood groups to steward and care for hundreds of city-owned vacant lots, turning them into green community assets.  About 15 percent of the land in U.S. cities—more than 9 million acres—is deemed vacant or abandoned, providing ample opportunities.

●       Establish joint use agreements. Green spaces and recreational facilities owned or operated by schools, other public agencies, and private entities, including non-profits such as YMCAs and Jewish Community Centers, can offer a simple solution. From Hernando, Mississippi to Tucson, Arizona, cities small and large have established joint use policies with local school districts, so that when school isn’t in session, the school yard is opened up to the neighborhood to enjoy. According to the Trust for Public Land, public school districts own two million acres in America. Transforming them all into shared spaces would create access to the outdoors for 20 million people.

People, Parks, Power

The People, Parks, and Power initiative, a joint effort of the Robert Wood Johnson Foundation and the Doris Duke Charitable Foundation, led and managed by Prevention Institute, is working with 14 community-based organizations in urban, low-income communities of color across the nation that are taking on these and other policy innovations to increase access to parks and green space.

In the past, imbalances in political and economic power and a legacy of racial discrimination in the conservation movement have excluded groups led by people of color from full participation in park and green space work or have tokenized their involvement. Over the next two years, these 14 groups—with influence from Black, Latino, Indigenous, youth, queer, and women leaders—will organize and build power among community residents and advocate for local policy and systems change to advance park equity. Together, the funded organizations will advance national momentum toward an equitable future, addressing community priorities central to the environment, health, and racial justice.

The Importance of Policy Change

To truly reap the health, social, and environmental benefits of these vital public spaces, we need to make sure everyone, everywhere, can visit a park nearby. While funding and building new parks is crucial, this approach on its own will not reverse park inequities. We have an opportunity now—by changing policies, institutional practices and power dynamics—to bring parks to all communities.

Learn more about how you can advance park equity and join a growing network of park equity advocates.


About the Author

Pamela Russo

Pamela Russo, senior program officer, joined the Foundation in 2000. The major area of her work is improving health at the community level, based on the understanding of health as the result of interactions between social, environmental, behavioral, healthcare, and genetic determinants.

Wed, 27 Jul 2022 13:00:00 -0400 Pamela Russo Built Environment and Health Public and Community Health National <![CDATA[Better Tobacco Control Policy Starts Locally]]>

To advance health equity, we must fight preemption and restore local control over tobacco regulation.

Tobacco and Housing Illustration.

This post is the third in a blog series (the first on preemption as a policy tool and the second on strengthening public health authority) that explores how preemption has served as a double-edged sword in either supporting or undermining efforts to advance health equity. We explore how some states have limited tobacco control at the local level and why local policies are critical to advancing health equity and protecting communities from commercial tobacco.

“By introducing pre-emptive statewide legislation we can shift the battle away from the community level back to the state legislatures where we are on stronger ground.” —Tina Walls, Philip Morris, July 8, 1994

The U.S. Food and Drug Administration is poised to ban menthol cigarettes and flavored cigars later this year. In 2019, the federal legal age to purchase tobacco products increased from 18 to 21.

These are significant public health victories that will save lives. The use of commercial tobacco products undermines health and continues to be a leading cause of preventable death in our nation. Decades of predatory marketing has targeted Black communities with menthol advertising, driving health disparities.

Local communities have long been engaged in the fight against tobacco. As early as 2005, 540 localities raised the age minimum to purchase commercial tobacco products to 21–well before the federal government did so for the entire country. It’s no surprise that these innovative tobacco control policies emerged at the city or county levels before being adopted by states or the nation. Laying the groundwork at the local level is often how policies are tested and the first step toward building broader support.

The tobacco industry has been keenly aware that local efforts to protect public health threaten its profits. Rather than challenging tobacco control policies city by city, the industry had more success persuading state legislators to pass policies that purported to address the problem but, in fact, had little—if any—health benefits. These state policies preempted stronger local tobacco control policies the industry especially disliked.

This is yet another example of preemption, which occurs when a higher level of government limits the authority of a lower level of government to act on a particular issue. When it is used in this way, preemption threatens not only public health but also health equity–and even democracy–by undercutting community and grassroots engagement and hindering local efforts to advance equity-driven policies.

Preventing Local Action on the Sale and Marketing of Tobacco Products

Last year, Florida Governor Ron DeSantis signed a bill raising the state’s tobacco purchasing age to 21, while stripping local governments of any power to regulate the sale and marketing of commercial tobacco. Since federal law already banned the sale of tobacco to youth under 21, the bill’s public health provisions were nearly meaningless–but its clause preempting local tobacco control was truly harmful.

The tobacco industry is adept at crafting deceptive legislation like this, which appears to advance public health but actually harms it by limiting or squashing local action. This strategy is designed to confuse legislators and the public alike and protect industry profits.

Florida’s law is one example of how states are misusing preemption. With this law in place, localities can’t go further to regulate tobacco, even when it is in the best interest of their community. Reversing the harm of decades of marketing of menthol cigarettes to Black people is a social justice as well as a health issue that many cities and counties across the country have sought to address. Smoking-related diseases are the number one cause of death among Black people in the United States, claiming 45,000 Black lives every year.

Local bans on menthol tobacco products would save lives, reduce health disparities, and decrease youth smoking rates. But Florida’s law preempted them.

Preventing Local Action on Smoke-Free Workplaces

Thirteen states have adopted laws that preempt local governments from putting smoke-free air policies in place, preventing cities from going further than the state does to regulate smoking in workplaces. Eight of these states have tobacco control laws that are particularly weak, providing no protection from secondhand smoke exposure in non-hospitality workplaces, restaurants, and bars.

One example is Tennessee’s workplace smoking ban, known as the Tennessee Non-Smoker Protection Act. It includes an exemption for any music venue, restaurant, or bar that prohibits entry for those under age 21—exposing workers to secondhand smoke and forcing them to choose between their health or their livelihood. This policy also has negative implications for health equity, as many of these jobs pay minimum wage and are disproportionately held by women and people of color.

States with policies preempting local public health laws often have the highest rates of disease. The adult smoking rate in Tennessee is 20 percent, the fifth highest in the nation. Rates of chronic disease in Tennessee are high, too. The state ranks third in prevalence of chronic disease including diabetes, cardiovascular disease, and asthma—conditions that have a direct link to tobacco use. High rates of smoking and related chronic disease costs all Tennesseans, with $2.67 billion in healthcare costs attributed to tobacco use each year.

In light of these dire circumstances, lawmakers in cities like Nashville and Memphis might like to pass a law that would protect musicians and bar workers, but their hands have been tied.

Public health advocates in Tennessee passed a bill to restore local power to take action on smoke-free air and effectively lift preemption for municipal ordinances to address smoking in age-restricted venues. Governor Bill Lee recently signed this legislation, which allows individual cities and counties to set policies for their communities, proving that advocates for local tobacco control can reverse harmful preemptive policies.

Why Local Tobacco Policy Matters

When misused, preemption undermines equity. Local tobacco control measures are a critical tool for communities seeking to improve health outcomes by addressing the disproportionate targeting of people of color by the tobacco industry. Restrictions on public health authority threaten local officials’ power to protect the communities they serve from commercial tobacco and the harmful effects of secondhand smoke.

Using tools like home rule reform, advocates can take a proactive approach to broadening the authority of localities to address public health challenges like commercial tobacco.

Tennessee isn’t the only state that is reversing preemption as cities, towns, and community members champion the local tobacco control policies that will protect kids and save lives. After decades of restrictions on city and county efforts to combat commercial tobacco use, in 2019 advocates successfully lobbied the Colorado legislature to repeal the tobacco preemption law, paving the way for localities to raise the tobacco purchasing age to 21 and to tax and regulate tobacco products. Since the law was repealed, at least nine local proposals to raise taxes on tobacco products have passed by ballot initiative in Colorado.

By enacting tobacco control at the local level, public health advocates can build a strong evidence base to advocate for these policies in other communities, at the state level, and even federally by:

Making local laws a blueprint. They demonstrate the possibilities and show that going further on tobacco regulation at the state level—whether by regulating the sale or marketing of commercial tobacco or by establishing more smoke-free public spaces—would be feasible and enforceable.

Gathering health data that shows impact. After a policy is implemented, public health advocates and community members can conduct research to determine the effect of policies on health outcomes, helping make the case for policies grounded in health equity.

Refuting false economic impact arguments. Implementing a local policy offers an opportunity to gather real economic impact data to refute the industry’s narrative that tobacco control policies would cause communities to lose business or decimate the tourism or hospitality sectors.

The tobacco industry will almost certainly continue to adapt, and preemption will remain one of its primary strategies to weaken tobacco control. Public health advocates must be strategic too, and work in coalitions to fight and reverse policies that would limit local governments’ authority to protect their residents from the dangers of commercial tobacco.

Explore which states preempt smoke-free air laws and learn why local control is critical to protect public health.

Thu, 14 Jul 2022 13:45:00 -0400 Delmonte Jefferson Public and Community Health National <![CDATA[A Generational Opportunity to Invest in Our Children]]>

We identified exemplary practices to help foster the nurturing, stable environments that children need from birth through adolescence to thrive.

2017 Culture of Health Prize Communities: Garrett County, MD

The United States has the most advanced medical care system in the world and spends the most per capita on healthcare. Yet we lag behind other developed nations on important health indicators, including infant mortality, child wellbeing, adult disability, and overall life expectancy. The status quo is failing our kids, denying them a healthier and brighter future. More kids than ever face the prospect of growing up less healthy and living shorter lives than their parents. Children are more likely than any other age group to be poor and live in medically underserved and socially vulnerable communities. Unless we collectively take significant steps to improve our children’s health and development, we will face adverse consequences for years to come.

There is growing evidence on how to improve children’s wellbeing. With support from the Robert Wood Johnson Foundation, the Integrated Care for Kids-InCK Marks Initiative spent the last six years bringing together pediatric practitioners, health administrators, policy experts, and advocates. InCK Marks’ advisors assessed pediatric healthcare practices and innovations, metrics, finances, and culture to identify tangible solutions that advance a culture of health for kids.

This work continually pointed us to—and eventually rooted us in—the value of early investments in preventive health and health promotion. While the return on investment may not be immediate, the dividends are lifelong, with ripple effects into all facets of life. The needed investments encompass more than just medical treatment; health systems must respond more proactively to the determinants that play a lasting role in children’s health, including economic (housing, food, and basic income) and social (relational supports and opportunities) factors.

InCK Marks’ research shows that what matters most for children is the context in which they are born and develop. To thrive, they need safe, stable, and nurturing environments from the start. While there remains much to learn, InCK Marks’ work identified exemplary programs and practices that are advancing a new standard of integrated, primary healthcare for children, with impressive results. We synthesized our findings into three overarching recommendations: (1) Prioritize children, (2) Build on what works, and (3) Invest in value.

Prioritize children. The U.S. health system can play a key role in advancing racial equity and improving population health. Yet too often, health transformation efforts do not adequately include children. While children represent one-quarter of the U.S. population and half of people on Medicaid, they account for less than one-tenth of overall medical expenditures and only one-fifth of Medicaid program costs. Policymakers and health systems have focused much of their attention on health transformations that aim to cut healthcare costs and improve outcomes.

Children are the country’s most diverse age group and their healthy development is most affected by their home and community environments. That alone is reason to prioritize them. But children also are developing personalities, habits, and behaviors that have lifelong implications for their health. Establishing positive health trajectories during childhood has, by far, the greatest overall returns on investment.

The Robert Wood Johnson Foundation’s focus on health transformation and building a Culture of Health recognizes that health is more than the absence of disease or infirmity and that responding to social determinants can improve well-being. While focusing on adults and those with disabilities is where immediate cost containment opportunities are greatest, we need to recognize that a focus on children is key to advancing population health and rectifying longstanding racial inequities.

Build on what works. A broad, compelling body of research shows the efficacy of primary healthcare transformation for children. InCK Marks identified and worked with champions and child health practitioners who are using innovative strategies to reach children and families to recognize research-based models to build upon (DULCE, Help Me Grow, HealthySteps, Medical Legal Partnerships, etc.) and systemic approaches to developing integrated, community-based responses. InCK Marks synthesized the research examining these programs and identified the practice elements and approaches they shared.

There is now knowledge and a leadership base to move to a much broader standard of child healthcare that supports families in providing safe, stable, and nurturing home environments for their children. This is consistent with the pediatric field’s own guidelines for well-child care and family-centered medical homes. It is particularly important for practices serving socially vulnerable and medically underserved communities, where relational and community health workers can provide key supports. For example, the Center for Health Care Strategies is working with pediatric practices that understand that comprehensive care involves screening for the needs of the whole family. This includes connecting families to supports in respectful and culturally relevant ways, including play groups, library time, fatherhood initiatives, economic stability efforts, and peer-to-peer parent support groups.  

Invest in value. Current financing for children’s healthcare is, at best, sufficient to provide basic medical care—immunizations, treating disease and illness, and identifying and responding to medical conditions affecting physical health. This addresses only a small share of factors affecting health.

Going beyond such medical care will require additional resources. While the research clearly illustrates the value of providing enriched primary healthcare for children and expanding the community health workforce, the U.S. model for pediatric care falls short. Given that it covers two in five children and a much greater proportion of those who are most vulnerable, Medicaid must be leveraged to develop a value-based financing system that reimburses at higher levels for enriched child healthcare. This will require an investment approach that does not demand immediate medical health offsets, and additional investments measured in long-term improvements in health and in social, educational, and economic well-being.

InCK Marks and a host of leaders in the field recognize the key to advancing the health transformations the country needs will require new public policies and investments, with much greater attention to child health and frontline primary care that truly engages families. The COVID-19 pandemic heightened awareness of the critical need for essential workers in the health and caregiving professions. The challenges and opportunities ahead are to prioritize children and ensure sufficient investments to meet this moment.

InCK Marks and the experts it gathered are committed to identifying and advocating for practical solutions that ensure the nation’s healthcare system prioritizes children’s health, wellbeing, and development.

Visit for more information and to learn about how practice, policy, and mindset shifts can advance child health care transformation.


About The Authors

Martha Davissenior program officer, seeks to address violence through her work in strengthening families to create nurturing, healthy environments that promote children’s positive development.

Charles Bruner is recognized for synthesizing research and using the best available information to develop policy aimed at improving child opportunity and health through collaborations with researchers, policymakers, advocates, and children and families.


Tue, 5 Jul 2022 14:00:00 -0400 Charles Bruner Early Childhood Child and Family Wellbeing National <![CDATA[Supportive Housing Can Help End the Homeless-to-Jail Cycle]]>

The best way to break the harmful homelessness-jail cycle? Keep people housed, first; then quickly provide the supportive services they need to thrive.

Hands holding a cardboard house.

Maria* is finally starting to feel at home. After living on the streets for eight years and a brief stint in a halfway house, she now has a permanent home in the Sanderson Apartments in south Denver. “I love my life, and I love myself, and I love my family,” she said, beaming. “And I found myself, found out who I am, where I belong.” The Denver Supportive Housing Social Impact Bond Initiative (Denver SIB) helped her find this stability.

There are many common myths about how to end homelessness. At RWJF’s Evidence for Action program, we wanted to test what truly works. We funded Sarah Gillespie and Dr. Devlin Hanson at the Urban Institute to conduct an evaluation of the Denver SIB program.

What we learned is that supportive housing has several benefits. It can help end the homelessness-to-jail cycle, free up public resources for other priorities, and ultimately, it creates stability for people experiencing homelessness.

Supportive housing seems to be especially beneficial for people with frequent interactions with the criminal justice system, and leads to better health outcomes for individuals and communities. In fact, the Robert Wood Johnson Foundation has included reducing incarceration among 35 illustrative measures to track progress toward building a Culture of Health in America

In this Q&A, I spoke with the evaluators of the Denver SIB program about how to break the devastating homeless-jail cycle. 

How do you explain Denver’s Social Impact Bond to address homelessness?

Denver—like many cities—recognized a broken system in which people experiencing homelessness were not getting the help they needed, while costing taxpayers considerably. In 2016, the city decided to implement a supportive housing program to end the harmful homelessness-jail cycle.

The Denver Supportive Housing Social Impact Bond Initiative used private investment, housing tax credits and vouchers, and Medicaid reimbursement to provide a supportive housing program that aimed to increase housing stability and decrease jail stays among people who were experiencing chronic homelessness and had frequent interactions with the criminal justice and emergency health systems.

Sarah Gillespie Sarah Gillespie is an associate vice president in the Metropolitan Housing and Communities Policy Center at the Urban Institute, where her research focuses on homelessness.

This evaluation busted many myths! Despite the common public narrative, the evaluation showed that with the right housing and services, communities can end homelessness and people with complex needs can succeed in long-term, stable housing. 

We found that when offered housing first with supportive services, people quickly enter housing and stay there. They also experience many longer-term benefits, including reduced jail time.

The initiative used a Housing First approach, which aims to quickly get people out of homelessness and into housing, without requiring that participants meet typical preconditions (such as employment, income, absence of a criminal record, or sobriety). 

Our research team designed an evaluation to see if supportive housing achieved the city’s goals. 

More than five years in, results from Denver’s five-year supportive housing program show a better way to invest in people and communities. What surprised you most about the findings?

Our evaluation further showed that program participants had fewer interactions with the criminal justice system compared to those who received usual care services (for example, emergency shelter) in the community, including:

  • Eight fewer police contacts (34% reduction)

  • Four fewer arrests (40% reduction)

  • Two fewer jail stays (30% reduction)

  • 38 fewer days in jail (27% reduction)

Devlin Hanson Devlin Hanson is a principal research associate in the Center on Labor, Human Services, and Population at the Urban Institute.

And people participating in the program stayed housed over the long term. Not only did they access more days of housing assistance, but 77 percent remained in stable housing after three years.

Ultimately, supportive housing is a better use of taxpayer dollars than the current business as usual: in addition to the benefits to those participating in the program, the costs of providing supportive housing are largely offset by savings in other services such as jail stays, court costs, police time, and local emergency services.

You also evaluated the program’s effects on people’s use of health care services. What did you find?

There were significant findings on the use of detoxification facilities, preventive healthcare, and emergency care that indicate that supportive housing increases access to and use of preventive healthcare while decreasing the use of costly emergency care. Compared to those who received usual care services in the community, people referred to the Denver supportive housing program had:

  • A 65 percent reduction in visits to short-term, city-funded detoxification facilities

  • A 40 percent decrease in emergency department visits

  • A 155 percent increase in office-based visits

  • A 29 percent increase in unique prescription medications to support their wellbeing

The findings of the Denver SIB evaluation weren’t unique. Los Angeles County’s Housing for Health initiative provides permanent supportive housing programming (housing placement, financial subsidies, and supportive services) to people experiencing homelessness who frequently use county-provided health services. Similar to the Denver SIB findings, research from RWJF’s Systems for Action program showed the Housing for Health initiative was effective in addressing long-term housing needs, reducing jail time, and lowering the use of emergency room and inpatient visits. 

What were the key components to Denver’s success with this SIB program?

Two qualities made Denver’s program stand out. 

First, this was a well-targeted intervention. Participants became eligible for the program after frequent arrests and documentation of homelessness. Without this laser focus on the most vulnerable residents, it would have been harder for the Denver SIB to find such big impacts across multiple systems.

Second, the program had a very high quality of implementation. The Colorado Coalition for the Homeless and Mental Health Center of Denver were excellent service providers; both hit high benchmarks for success including engagement rates, take-up rates, and housing stability rates. Along with these providers, the Denver SIB had a high level of collaboration across many other partners in local government and national technical assistance and evaluation organizations. This collaboration helped solve implementation challenges quickly and effectively—and ultimately improved outcomes for individuals and communities.

How can this evaluation be put to use?

As chronic homelessness surges and pandemic-related eviction moratoriums end, evidence from the Denver SIB and other similar initiatives disrupts the story that homelessness is an unsolvable problem. 

Housing First ends the homelessness-jail cycle. Cities need more development of and funding for subsidized housing along with services to help people access and stay in housing. We hope policymakers and practitioners use these data to advocate for supportive housing as a better solution.

Learn more about RWJF-supported initiatives and resources for communities working to ensure access to safe, stable, affordable housing for all.

* Program participants’ names have been changed to protect their anonymity.


About the Author

Erin Hagen

Erin Hagan is the deputy director of RWJF’s Evidence for Action program.

Thu, 23 Jun 2022 11:00:00 -0400 Erin Hagan Built Environment and Health <![CDATA[Three Policy Lessons to Advance Health Equity During an Ever-Evolving Pandemic]]>

Many COVID policies and practices exacerbated longstanding health disparities. Here’s how we can change that going forward.

Capital Building

Since Omicron first appeared here in December 2021, the United States has had a 63 percent higher COVID death rate than other high-income nations. We also continue to experience deep disparities by race and ethnicity for risk of infection, hospitalization, and death from COVID. Even though federal agencies issued guidelines on how to stay safe, it was our local and state responses that explain many of the differences in health outcomes.

We turned to researchers working with Systems for Action, Policies for Action, and Evidence for Action, all signature research programs of the Robert Wood Johnson Foundation, to find evidence-based answers within policies, practices, and data to help explain these disparities. The questions included: Which responses worked best during the pandemic for our population as a whole and for communities at greatest risk? And how can we respond to future large-scale national emergencies in ways that better protect the health of vulnerable people and communities?

Here are three important lessons that emerged:

1. Pandemic Response Policies Must Protect People at Greatest Risk

While rapid policy responses to COVID (from physical distancing to temporary paid leave) were meant to protect the general public, many of these policies left out groups most vulnerable to the health and economic consequences of COVID-19. For instance, the federal Families First Coronavirus Response Act excluded some 60 million workers, including health care providers and first responders who could not stay at home or practice measures such as physical distancing.

Safety net programs like paid leave weren't accessible to many gig workers and part-time employees—even after evidence showed that lower-income workers were more likely to get COVID. When vaccines became available, the government prioritized groups by age rather than by risk, bypassing many people in essential industries who continued going to work to keep the nation running while risking exposure to coronavirus.

Julia Raifman is a researcher at Boston University School of Public Health who helped develop a database to track state implementation of health and social policies in response to COVID. She notes: “It’s been really striking to track these policies because we see there are several that leave out the lowest income, informal sector workers again and again: minimum wage policies, unemployment insurance policies, paid leave policies, and health insurance. We need to ensure that social support policies reach people who have part-time jobs or work as independent contractors, who are most likely to need support to avoid food and housing insecurity. We also need policies like an OSHA (Occupational Safety and Health Administration) emergency temporary standard that reaches all workers.”

2. Policymakers Should Take Steps to Expand and Protect Insurance Coverage Through Medicaid Expansion and Other Measures

In what proved to be the most significant test of the U.S. health insurance system since the implementation of the Affordable Care Act, the pandemic and associated recession affected insurance coverage, making it harder for those with low incomes to access healthcare. Rapid-response research found that the presence of Medicaid expansion was associated with protective effects on coverage for Black and Latinx populations during the rise in the uninsured rate.

“Medicaid has tremendous potential to protect people from economic shocks,” said study author Aditi Bhanja who is a research advisor at the Women’s Refugee Commission. “While our study covered just four states, the data suggests that extending safety net benefits is beneficial to individuals and communities. As we are bound to encounter future emergencies, it is important that we rapidly assess how well our system can support the most vulnerable among us.”

3. Partnerships that Improve Care for People with Complex Needs Are Especially Important During a Pandemic

People living with complex medical, behavioral health, and social needs require an integrated approach to care. One study in progress is evaluating the effectiveness of California’s Whole Person Care (WPC) initiative that coordinates services for people receiving Medi-Cal. These pilots use diverse care coordination teams to help reduce silos, improve the value of care, and increase access to care—ultimately helping improve the health and well-being of people participating in the program.

During the COVID-19 pandemic, partnerships formed through WPC held strong. “Many of the staff in WPC programs were public health workers who were reassigned to deal with urgent COVID response activities,” said evaluator Nadereh Pourat of the UCLA Center for Health Policy Research. “Still, they were able to use their experience and connections to provide important benefits to people in the program, like helping people experiencing homelessness to be housed quickly because they were already enrolled in the program. Building partnerships between county health agencies, other agencies, and community providers and organizations [now] means that you don’t have to begin from scratch in public health emergencies.”

How Policy Can Support Healthy Equity In the Future

This evidence suggests better policies and policy implementation can improve health. The COVID-19 pandemic has demonstrated that this is an important moment to reset policies that scale up and support the tools that are most effective in controlling the spread of COVID and to prioritize protections for people who have been left behind by many pandemic-era policy decisions.

We know what works: more inclusive social policies that prioritize disproportionately impacted communities, including racial and ethnic groups as well as essential workers. We must extend benefits and expand safety net programs like Medicaid, especially for those facing health disparities. We must continue to build partnerships among sectors, agencies, programs, community groups, policymakers, and stakeholders, both to benefit public health efforts currently underway and to better prepare us for future public health emergencies.

A treasure trove of rapid-response COVID-era policy research exists—let's rely on this evidence to address health inequities during the pandemic and after it ends.

The COVID-19 pandemic revealed how racism has shaped the life course of Black and Brown communities.

LISTEN to my discussion with Dr. Alonzo Plough about his new book, Necessary Conversations, which examines racism as a barrier to health equity and offers strategies to build a healthier, more equitable future.



Jacquelynn Y. Orr, program officer for Research-Evaluation-and-Learning, is a strategic liaison to the Foundation’s efforts to transform health and healthcare systems.

Thu, 16 Jun 2022 11:00:00 -0400 Jacquelynn Y. Orr Health Disparities Healthcare Coverage and Access <![CDATA[Necessary Conversations: Talking Frankly About Race]]>

Engaging in honest dialogue about race sometimes means lowering our defenses and acknowledging our feelings so we can walk together toward racial equity. 

Illustration of a group talking. Illustration by Amir Khadar

The opening of the Tops Friendly Market in East Buffalo was a triumph of community activism, a victory for residents who struggled for years against food apartheid. In a neighborhood that had long lacked a full-service supermarket, the store became a symbol of local empowerment in one of the nation’s most segregated cities.

This segregation is a contributing factor in why White people in Buffalo have a longer life expectancy than their Black neighbors living on the East Side. To counter these conditions, residents persevered in efforts to shape a healthier, more equitable neighborhood—residents like 67-year-old Church Deacon Heyward Patterson. Deacon Patterson volunteered at a soup kitchen and even drove his neighbors to Tops Friendly Market to access nutritious food when they didn't have transportation of their own. He was murdered while helping load groceries into someone's car.

The murder of Deacon Patterson and others sparked outrage across the nation. But when the initial shock fades away, we need to look harder at the role of racist systems and structures that endure in the United States and how they contribute to unbridled violence and lives that are cut short.

It is long past time to reckon with this nation’s dark, shameful history of white supremacy. 

Until we recognize how present-day inequities—in all their forms—root back to a deeply flawed past, we will see more East Buffalos, more mainstreaming of “replacement theory,” and less willingness to do the hard work of advancing racial justice. 

This is the subject of my new book, Necessary Conversations published by Oxford University Press. I suggest that having meaningful conversations about race is a step towards that reckoning. Dozens of leading thinkers and doers—activists, policymakers, researchers, educators, and journalists—contributed their provocative ideasAs editor of these important chapters about understanding racism as a barrier to health and wellbeing, I am honored to highlight some of their thoughts here.

“There is a structure and an architecture that created inequality, and those exist whether individuals operate with racial animus or not.” —Nikole Hannah-Jones

The prevailing American narrative builds on the premise that, as the Declaration of Independence states, “all men are created equal” and that we have progressed steadily towards that ideal. In reality, believes Nikole Hannah-Jones, the racial hierarchy that spawned the inception of human bondage has defined this country ever since. Her 1619 Project challenges common assumptions about slavery and race and lifts up the pivotal contributions of enslaved people in building the American economy.

Necessary Conversations Over 50 leading researchers, policymakers, journalists and others shared wisdom on how to create a brighter, more equitable future together. Their insights and strategies offer direction and hope. DOWNLOAD this free book!

In reframing our history, Hannah-Jones opens the door to action. “What I find useful is a sense of rage over the choices we make every day that some people are valuable, and some people aren’t,” she says. “I don’t want us to feel hopeful that we will change it one day. I want us to do something about it right now.”

“Having a conversation about race is not about blaming all White people for slavery and its consequences, but rather about acknowledging the existence of slavery and its consequences.” —Beneta Burt

Sharing authentic stories about racism is vital to help White people recognize their own privilege and for people of color to feel they are being heard and respected. At the Mississippi Urban League, Beneta Burt facilitates dialogue in safe spaces “that allow people in the room to be uncomfortable,” and then to work through their discomfort together. And at the University of South Carolina, the Welcome Table uses storytelling to enable intimate conversations that build trust, uncover hidden biases, and encourage honest, personal exchanges about race.

“To move forward, this nation must heal the wounds of our past and learn to work together with civility, and indeed, with love... We must build the capacity to see ourselves in the face of the other.” —Gail Christopher

Gail Christopher believes that empathy and compassion are skills that can be taught—and that hearts and minds must be changed before it is possible to change institutions. Her Rx Racial Healing Circles™ bring together small groups to foster appreciation, belonging, and consciousness change, assets that she believes are necessary to move past “otherness” and enable people to recognize their shared humanity.

The health harms of racial injustice are reflected in maternal mortality, the incarceration experience, immigrant health, climate change, and so much else. 

Stories and data about specific populations reveal the harsh results of racial disparities. In her shocking New York Times cover story, “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis," Linda Villarosa tracks the tragedy of Black maternal and infant mortality across class lines. She lays much of the blame on the structural racism that is embedded “in the lived experience of being a Black woman in America,” coupled with the often-unconscious but pervasive racial bias of a medical system that is still dominated by White physicians.

Likewise, the impact of serving jail or prison time hits Blacks hardest. In Mississippi, 75 percent of those serving prison sentences of 20 years or more are Black men. Alesha Judkins describes barbaric conditions at Parchman, the notorious state penitentiary, including black mold, food infested with rat feces, and bed shortages that force imprisoned people to sleep on the floor. More hopefully, she also talks about the efforts of her advocacy organization,, to end cash bail, reduce extreme sentences, restore family connections, and redirect investments from criminal justice to community development. 

The power to retool societal structures so that they elevate equity, rather than undermine it, rests with all of us.

Informed by historical and contemporary realities, Necessary Conversations concludes hopefully, emphasizing the power to end structural racism through narrative change, innovative approaches to knowledge-building, inclusive decision-making, and coalition-building.

Our contributors remind us that centering actionable research on equity allows us to think more broadly about how we measure what works, gives pride of place to community engagement, and respects complexity in study designs. By acknowledging that our beliefs, assumptions, and values influence what data we collect, and how we use it, we can move beyond what Jara Dean-Coffey calls the traditional “Western-centric, White-dominant frame.” Dean-Coffey offers the Equitable Evaluation Framework as an alternative tool for reimagining the purpose and practice of evaluation.

“The stakes are too high for evaluation not to be an instrument of change and in service of equity and liberation.” —Jara Dean-Coffey

Read my book, Necessary Conversations and listen to my book discussion where I share ideas and strategies to make real change to create health equity. Together, we can dislodge structural racism at its roots and work toward equity. 


About the Author

Alonzo Plough

Alonzo Plough, chief science officer and vice president, Research-Evaluation-Learning, is responsible for aligning all of the Foundation’s work with the best evidence from research and practice and incorporating program evaluations into organizational learning.

Thu, 9 Jun 2022 11:00:00 -0400 Alonzo L. Plough Social Determinants of Health Health Disparities <![CDATA[What We Learn from Taking the Public’s Pulse]]>

Findings from a national survey underscore the need to continue educating people about the root causes of inequities and how racism affects health. 


We’ve come to expect a flood of polling around election time, conducted or commissioned by universities, media outlets, partisans, and others. So why would a foundation invest in putting a poll into the field? On what topic? And when? RWJF’s Research, Evaluation, and Learning (REL) team supports various surveys and polls to gain insight into the public’s opinion on a range of topics from health to systemic racism to the effects of COVID-19 on day-to-day life. Findings can help philanthropy, policymakers, and stakeholders better gauge public awareness of a problem and support for a particular policy intervention, reveal shifting attitudes and shed light on whether people think systems change can advance health and equity.

Carolyn Miller, REL Senior Program Officer talks with Anita Chandra, a Vice President at RAND, on what we can learn from one of the Foundation's numerous survey efforts—the months-long RWJF/RAND COVID-19 survey and how it can inform policy solutions designed to address structural racism and improve health and prosperity.

The COVID-19 and the Experiences of Populations at Greater Risk survey measured the views of more than 3,000 people on multiple issues over 15 months, shedding light on public experiences with the pandemic and views on its connection to structural racism in health. What’s the purpose behind multiple surveys of the same respondents over such a time span?

Necessary Conversations Survey results reveal the importance of dialogue about systemic inequities given how deeply ingrained attitudes about race are. Download a free new book that shares insights by leading researchers, policymakers, journalists and more on how to engage in honest conversations that spur action.

This survey makes it possible to track changes in public attitudes over a tumultuous period. Tracking the same people over time provides a window into how stable certain values and attitudes are and how perspectives can change over time. It also gave us the opportunity to make adjustments and additions to the survey to better understand public views throughout the pandemic on issues ranging from mask mandates to vaccines to personal freedom. Another benefit was that we oversampled those hit hardest by the pandemic, people of color and those with low incomes. We also wanted to understand the views and values of these groups, something that is understudied. That made this survey distinct.

As the pandemic took a greater toll on communities of color, and George Floyd’s murder brought calls for racial justice, public concern over systemic inequities increased but then seemed to fade from public discussion. What did the survey reveal about public views on the link between racial inequities and health?

It reflected exactly that. In July 2020, about two-thirds of survey respondents agreed that people of color faced greater harm from COVID-19 than White people and 57.5 percent agreed that they faced greater financial impact. That was significant. But more than a year later, those numbers dropped to 52.7 percent and 50.3 percent, respectively.

What that tells us, I think, is it’s important to continue the dialogue about systemic inequities and health because attitudes about race are deeply held and ingrained. We noted movement only for some, and not a lot of movement for most, on recognition of health inequities. So that tells us we need to recognize that people tend to settle back into their core values and beliefs once an issue has faded from the headlines. Even when there are flash points along the way, like those we saw during the most intense period of the pandemic, people’s views tend to change slowly. The findings underscore the value of tracking that over time, so we recognize and are reminded of the need to continue educating people about the root causes of inequities and how racism affects health.

Our survey showed that more people cite having a low income and/or living in a rural area as barriers to healthcare than being Black or Latino. What do you take from that?

Yes, that’s telling. People are more likely to recognize social and economic inequalities than racial inequities. They’re not wrong about economic and geographic disparities being serious issues, so it’s good that they understand that. What’s missing from that analysis is the overlay of race, and in particular the reality that a disproportionate share of those in low-income households are people of color. And of course, if people don’t recognize the racial aspect, they’re less likely to connect the problem to structural racism.

The survey findings also showed us what policy approaches the public supports now and where more public education might be needed. Can you tell us more about that?

One of the striking findings was that more than two-thirds of the public see the pandemic as a moment for positive change, with one in four people seeing improving access to healthcare as the change they would most like to see. That was by far the most common societal change respondents identified. Also, the survey showed that most of the public fully supports global vaccine equity and sees the importance of accelerating efforts to get the world vaccinated because it bears on Americans’ safety and security. While previous surveys of the public have highlighted a sense of health individualism in the U.S., it was encouraging that there appears to be recognition of the interconnectedness of our world.

This COVID survey showed us that many people don’t believe systemic racism affects health. Given where people are, how do we sustain awareness of the effects of racism on health and actually address the problem, without driving potential supporters away because of the language we use?

Respondents to our survey were evenly split on whether talking about race divides us, though Black respondents and those with highest incomes are much more likely to believe that it’s not the talk that divides us. Sometimes, words like “race” and “racism” can be polarizing for some audiences so we need to unpack what they actually mean and better articulate how structural racism is embedded in our systems to find opportunities for consensus and genuinely civil discourse on the topic. As researchers, we need to figure out through a variety of survey methods how to talk about some of these issues without using terms that put people in their separate corners. Despite polarization, our survey showed that people are eager for positive social change. As noted earlier, ensuring access to healthcare for all is a top priority and something that many respondents see as the duty of government. Addressing this, along with tackling income inequality—another top reported interest—is a start.

We’re often asked about the extent to which these types of surveys lead to action or inform specific policies or practices. How does this one contribute to better health and/or greater health equity?

Survey findings, of course, can contribute to our knowledge about health trends or phenomena. Findings like the ones from our survey are critical to a national push for health equity because they show whether people recognize health inequities and whether they support policies to address them. That kind of information helps community leaders, including public health departments, learn how to shift mindsets and rewrite narratives in order to build support to address structural barriers and improve health outcomes. Without this information and the guidance it provides, it would be hard to achieve durable improvements in health equity.

Learn more about the survey which explores deeply-rooted views on health, equity and race.


About the Author

Headshot of Carolyn Miller

Carolyn Miller, a senior program officer in the Research-Evaluation-Learning unit, brings to the Foundation a long and diverse career in private sector, government, and academic research. She views her work with RWJF as “an incredible opportunity to be part of guiding and supporting the research efforts of the Foundation as it helps to move our nation toward a Culture of Health.”

Tue, 7 Jun 2022 11:00:00 -0400 Carolyn Miller Health Disparities Social Determinants of Health <![CDATA[Strengthening Public Health Authority is Critical to a Healthy, Equitable Future]]>

What happens when elected officials use preemption to usurp public health authority, and what can be done about it?

Strengthening Public Health illustration.

This post is the second in a blog series that explores how preemption has served as a double-edged sword in either supporting or undermining efforts to advance health equity. We explore how some states have limited public health authority and what must be done to rebuild a public health infrastructure that centers equity.

Public health professionals are trained to protect people’s health—from controlling the spread of infectious disease to ensuring the water, air, and food are safe. When the pandemic hit in early 2020, state and local public health authorities acted swiftly to stop the spread of a novel, contagious virus. Within months, 39 states had issued explicit stay-at-home orders and 20 had travel restrictions in place. To ensure safe living conditions amid dangerous outbreaks and the economic downturn, some states and localities even suspended evictions and water and utility shut-offs.

Stripping authority from public health officials endangers lives

But more and more, policymakers are using preemption to strip public health officials of their powers, preventing them from protecting people and their communities. Preemption is when a higher level of government, such as a state legislature, restricts the authority of a lower level of government, such as a city council. Historically, the federal government has used preemption to enforce states’ compliance with federal civil rights laws.

But over the last decade, state governments have been preempting local governments on issues like minimum wage, paid sick and family leave. Unfortunately, the COVID-19 pandemic brought this to a head. As a result, many local governments lack the authority to enact laws and policies that can also reduce health inequities among those who are  disproportionately harmed by the impacts of COVID-19—women, people of color, and workers in low-wage jobs.

In many states—Arizona, Florida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and West Virginia, among others—statewide stay-at-home orders established a regulatory ceiling, preventing local governments from imposing stricter requirements. Take Arizona, where the governor issued an executive order prohibiting any county, city, or town from issuing any order or regulation “restricting persons from leaving their home due to the COVID-19 public health emergency.”

Some states didn’t have any statewide stay-at-home orders in effect but still preempted local governments from issuing their own orders, which created a regulatory vacuum. For example, although the Iowa Governor Kim Reynolds did not issue a statewide stay-at-home order, she and the state attorney general informed local officials that cities and counties lack the authority to close businesses or order people to stay at home.

And in places where local governments implemented measures to protect public health on the advice of infectious disease control experts, state officials responded in threatening and punitive ways. For example, Georgia Gov. Brian Kemp sued Atlanta’s then-mayor, Keisha Lance Bottoms, when she tried to protect city residents with a mask mandate.

The results? During the Delta surge, states that resisted public health protections had much higher numbers of preventable deaths. Between August and December 2021, Florida experienced 29,252 excess deaths, compared to New York’s 8,786 more than triple. And states such as Georgia and Florida experienced longer surges, greater economic disruption, and worse health outcomes than other states like New York and New Jersey, where stronger masking and vaccination policies existed.

What can be done to strengthen public health authority?

To counter the trend of preemption upending public health efforts, here are suggestions for health officials, schools of public health, and state and federal governments to help strengthen public health authority and advance health equity:

Make public health visible—to the public and policymakers

Local public health authorities play myriad roles in protecting and promoting community health—not just during emergencies, but all the time. They set up testing and vaccination clinics and fight infectious disease, but they also address water and air pollution, develop strategies to decrease tobacco use, reduce obesity and diabetes, and work with other social service agencies to keep communities healthy. But in many communities, people aren’t aware of everything their public health agencies do for them. By engaging community members in their work—through health fairs, working with the community to identify health issues of importance to them, and other forms of outreach—public health officials can build community support, which in turn will help them better meet their community’s needs.

Teach public health law to public health students

The COVID-19 pandemic has underscored the need for health officials to be conversant in public health law. Schools of public health should incorporate law into their curricula, so that graduates are better equipped to deal with issues like preemption and threats to public health authority. Furthermore, agencies should have funding for and access to law expertise.

Public health solutions must center equity

As the country recovers from the health and economic impacts of COVID-19, states can use preemption to advance health equity by setting floors for minimum health standards. For example, California and Oregon have preempted certain local laws to encourage more affordable housing. States should encourage local governments to build on these minimum standards in ways that serve the people’s needs.

Increase funding for public health

As public health officials work to combat preemption misuse and protect the health of their communities, they must have strong funding and infrastructure supporting them. For years, public health in the United States has been consistently and drastically underfunded. Even though the Administration’s proposed 2023 budget includes some targeted investments in public health, there needs to be an adequate and stable funding stream. This includes investments at the local level and beyond the immediate crisis of the COVID-19 pandemic.

Incentivize the workforce

Over the last decade, local public health departments have lost more than 56,360 employees. One report estimates that an additional 80,000 full-time workers are needed to adequately staff the public health workforce. Supports like loan repayments, continued learning, and a modernized public health curriculum would go a long way to recruiting and retaining the next generation of public health leaders.

COVID-19 has underscored the importance of having a strong, modern public health system. Now, more than ever, public health officials must be able to do their jobs. The misuse of preemption is preventing them from doing that. To advance health equity, preemption must bolster public health authority—not undermine it.

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About the Authors 

Fri, 3 Jun 2022 13:45:00 -0400 Monica Hobbs Vinluan Public and Community Health <![CDATA[A Community Vision of Mental Health]]>

Centering the community in making its own decisions, confronting a long legacy of trauma and violence, and honoring genuine emotion are among the pathways to mental health that many residents of Palm Beach County are embracing.

In Palm Beach County, Florida residents are tackling neighborhood challenges together. Teamwork and a commitment to inclusiveness and civic participation helped the county earn an RWJF Culture of Health prize.

Six communities that comprise the Healthier Together place-based initiative are asking local people what they care most about. Their questions sometimes surface surprising answers. Many residents say they want to focus on mental health and that “feeling whole in mind, body, and spirit” is what really matters to them. But the way they think about mental health often differs from the way a clinical provider considers it. “It’s not a traditional definition, it’s their definition,” said Jeanette Gordon, whose Healthier Neighbors Project in Riviera Beach and northern West Palm Beach is all about fostering engagement, empowerment, and balance.

Organizing a multi-generational street cleanup may not at first blush seem deeply connected to mental health, but the Healthier Lake Worth Beach community saw it as a natural fit. “They wanted to create the conditions where their kids could thrive,” explained Pat McNamara, CEO of Palm Health Foundation, which funds Healthier Together. And what could be better for emotional wellbeing than that? Under the umbrella of mental health, Palm Beach County communities are activating other priorities as well, each one identified by those who live there—including gaining access to healthy foods, confronting the root causes of trauma and violence, and creating opportunities for youth.

Increasingly, residents recognize themselves as part of a countywide movement to celebrate behavioral wellness. Whether they are participating in guided peer group conversations, expressing their emotions in murals, taking to heart the reassurance that “it is okay to shed tears,” or releasing pent-up anxiety through dance, they are responding to the message that their feelings are normal and deserve to be honored. “I see you,” belted out Angela Williams as she led an exercise class in a Healthier Delray Beach neighborhood park. It was a shoutout to an enthusiastic group moving vigorously to a beat, but it was also a broader statement about the importance of becoming visible.

In 2017, the BeWellPBC initiative was launched to amplify voices in Palm Beach County that have too often been left out of planning conversations about behavioral health services. The initiative brings together “lived experts” with “learned experts” to foster a community-driven dynamic that lifts up collaborative approaches to mental health. BeWellPBC’s philosophy is built on “be” statements: be hopeful, understood, supported, connected, informed, open, compassionate, and transformative—and be you. Within that authentic framework, mindsets can be changed and systems overhauled.

Pat McNamara articulated a theme that runs through all of this work—solutions to mental health challenges are best forged in a climate of cooperation by those who are most affected by them. “When we learn how to live better with each other and care for each other, we’re healthier,” he said.

Watch this video about Palm Beach County and learn more about this Culture of Health Prize winning community.

Thu, 19 May 2022 00:00:00 -0400 Culture of Health Blog Public and Community Health National <![CDATA[Nurses Can’t Care for Us if We Don’t Care for Them ]]>

After two years of a pandemic, nurses are more stressed and burned out than ever, and too many are leaving the profession. What are the systemic changes needed to truly support them? 


I confess I have felt ambivalent about Nurses Week since 2011, my first year as a second-career registered nurse. Back then, in addition to a full-time communications job, I was working weekends in a long-term care facility. Despite having no experience other than clinical rotations just nine months before, I had been given a short orientation that I essentially had to structure myself; I was then thrown onto a skilled nursing floor with 15 residents during the day and 32 residents at night—most of them unable to walk on their own, some with dementia, and all with at least one chronic condition. I was hanging tube feeds, flushing central lines, and dressing stage IV pressure ulcers, all while trying to keep everyone safe and happy.

My colleagues and I received many tributes during Nurses Week—a message from the administrator, posters and food in the break room, giveaways. Don’t get me wrong; the gestures and the sentiment were lovely. But what I wanted more than encouraging emails and pizza was help. What I wanted was permission to say “I’m scared and could use some more support,” but nursing culture there—and in many places, still—was “sink or swim.” Not long after, I decided to “swim” out of long-term care, rather than make an error that would cost me my license or, worse yet, a resident his or her life.

I’m not telling you this so you’ll feel sorry for me; I’m telling you this because I have come to realize that I wasn’t alone in feeling frightened and overwhelmed on the job. Almost anyone who takes their nursing responsibilities as seriously as they should has felt that way at one point or another. And now, this Nurses Week, with two years of this awful pandemic under our belts, nurses—particularly those on the front lines—are feeling more stressed and burned out than ever; many are leaving the profession.

Whitney Fear (Oglala Lakota), a psychiatric nurse practitioner, discusses the impact of nurse burnout.

New research supported in part by the Robert Wood Johnson Foundation (RWJF) shows that throughout the entirety of 2021, the total supply of RNs decreased by more than 100,000 in one year—a far greater drop than ever observed over the past four decades. Numerous studies conducted throughout the pandemic have revealed frighteningly high burnout rates among nurses. In a May American Journal of Nursing editorial, two nurses argue that it’s time to stop assessing the prevalence of nurse burnout and instead “focus on what we know might mitigate burnout.”

Aside from being the right thing to do, why is it so important to act now to address this crisis?

The profession is at a critical inflection point, and not just because we need nurses at the bedside and in the clinics. Numbering nearly 4 million, nurses have more contact with patients than any other healthcare providers. Nurses play an essential role in ensuring all patients get high-quality care. Fewer nurses, coupled with widespread burnout, will only exacerbate the inequities already rampant in our healthcare system. Writer Savala Nolan, in her essay, How I Survived a Racialized Pregnancy in the American Healthcare System, describes the numerous touchpoints along her journey where her care was negatively impacted by the implicit bias of healthcare providers—including her nurses—and systematized racism. While education is partly key to alleviating this centuries-old problem, we need broader systemic change that digs deep into the roots of structural racism and provides the kind of support that reduces stress and burnout in those who deliver care. In the documentary Who Cares: A Nurse’s Fight for Equity, mental health nurse practitioner Whitney Fear (Oglala Lakota) points out that patients who receive poor care are often getting that care from a burned-out provider.

In other words, it’s hard for exhausted and stressed nurses to provide the compassionate and patient-centered care that they were trained to provide, that they want to provide.

So what’s the solution? The National Academies of Medicine report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, funded by RWJF and released last year, lays out a number of key steps educational institutions, employers, policymakers, and others can take to drive the kind of systemic changes that will improve nurse health and well-being post-COVID. It’s no surprise that free donuts and coffee mugs aren’t on the list. The bottom line: Until we care for our nurses, they’re not going to be able to care for us.

There are two kinds of people in our country: Nurses, and those who love nurses. So during Nurses Week 2022, I hope that nurses and those of you who love them will come together to call and work for the changes that will give us the tools to do what we came into this profession to do. Nurses, let’s come together as never before to share our stories, raise our voices, and tell our employers, our communities, and this country’s leaders what we need. If you’re among those who love us, we hope you, too, will fight for change on our behalf.

As for me, I am now fortunate enough to work here at the Robert Wood Johnson Foundation, where I spend my days using both my communications and nursing knowledge. Off the clock, I volunteer for my county’s medical reserve corps and a nurse-run community clinic, where I have the systems and supports I need to provide the holistic, person-centered care I was trained to provide.

And it reminds me why I became a nurse in the first place.

Explore these resources for coping with burnout, and download this infographic on supporting nurse well-being.


About the Author

Beth Toner

Beth Tonersenior communications officer, has more than 25 years of experience in marketing and corporate communications. She is also a registered nurse with clinical experience in long-term care and community health settings.

Mon, 9 May 2022 10:00:00 -0400 Beth Toner Nurses and Nursing Nursing <![CDATA[What Nurses Can Teach Us About Health Equity]]>

I talked to a fellow nurse about inequities in healthcare settings, our own experiences with bias, and the importance of acknowledging and confronting the harms associated with structural racism.

Nurses wearing masks.

In Manhattan’s financial district, the average resident can expect to live until the age of 85. In East Harlem, life expectancy is only 76 years. Ten stops on the subway and a nine-year drop. That’s what Jasmine Travers, a nurse and New York University assistant professor, told me when we talked about the importance of digging out the root causes of health disparities.

As Black women in the nursing profession, both of us understand the need to “get real” about structural racism because we’ve seen how it plays out at the patient’s bedside and in our own professional lives. In fact, Jasmine left hands-on nursing to pursue research into the policies, practices, and structures that impede good outcomes. Talking about the realities of racism isn’t easy, but being uncomfortable isn’t an excuse to avoid tough conversations. The goal is not to accuse or shame anyone, but rather to shine light on enduring inequities, the forces that perpetuate them, and the ways we can heal the damage they do.

As an example, Jasmine described differences in how hospital staff sometimes approach pain control. The immediate response to a White patient’s complaint tends to be “let’s see how we can ease the pain.” But patients of color face more scrutiny. Too often, the first question a healthcare provider asks is, “what’s really going on here?”—the assumption being that pill-seeking behavior needs to be ruled out before considering the use of pain meds.

Talking about racism isn’t easy. But these nurses remind us: Being uncomfortable is no excuse to avoid tough conversations that shine light on health inequities and show how to heal the damage they cause.

Bias can also stall opportunities for career advancement. Medical/surgical hospital units may have a diverse staff, but Black nurses don’t seem to get the same offers of promotion as their White colleagues do. “There were just never people of color in leadership,” recalls Jasmine. “It just didn’t seem like those opportunities were achievable for specific racial and ethnic groups. It was kind of unspoken.”

As nurses, we pledge to respect our patients and provide them dignified care. We can’t do that if our leaders don’t reflect the people they serve. “It impedes the ability of nursing to achieve excellent care,” Jasmine says. “If we are all just one-minded, one background, all share the same thoughts, we’re not going to see the blind spots. We’re doing such harm.”

Here are some steps to change that:

Understand what perpetuates structural racism.

Too often, we don’t recognize our own advantages or the unconscious biases we hold. Jasmine has a personal take on this. As a Black nurse, she sometimes felt disadvantaged compared to her White peers. But she also realized she was benefiting from certain privileges that were denied nurse assistants and nursing home care workers, who are overwhelmingly people of color. Acknowledging that totality pushed her to say, “Hey, let me see how I may be part of the issues that we are seeing when it comes to structural inequities or structural racism.”

We all need that kind of awareness, even if takes an emotional toll. Let’s face it: Who wants to hear that their well-intentioned actions contributed to inequity? But it is only by listening respectfully, rather than turning away defensively, that hidden barriers reveal themselves and we gain the agency to break them down.

Serve as a mentor and encourage colleagues to pursue leadership roles.

Early in my nursing career, I started applying for positions as a charge nurse, even though my co-workers told me the job was out of reach. Management sent the same message—despite getting great reviews and salary raises, I kept hearing “that role doesn’t suit you” when I applied for supervisory positions. No one explained why I wasn’t a good fit, but it was easy to see that none of the leaders in my workplace looked like me.

The same not-so-subtle racism is reflected in the forces holding back highly-educated people of color, Jasmine told me. “Despite having these advanced degrees, we’re always needing to work 10 times, 15 times, a hundred times harder than the next person and we still struggle.”

We have to challenge the assumptions behind all that, raising our voices to say, as Jasmine does, “This is not how things should be.” Let’s find allies, become role models to peers who need our support, and make broad-based commitments to bring more people of color into leadership positions. That’s the only way we will transform culture.

Become an agent of change.

It didn’t surprise me that Jasmine wants us to walk the walk, not just talk the talk. “At some point, we need to move from discussion to actual institutional change,” she insists. It’s a matter of “being part of the table, being part of the decision-making.” Join the workplace committees and neighborhood community boards where choices are being made that affect the lives of people of color. Urge your institutions to offer in-service education about health disparities and inequities. Share knowledge about how long-standing systemic inequities can be unraveled. By acting on the belief that all of us can make a difference, we can confront structural racism together.

Listen to my entire discussion with Jasmine Travers about dismantling structural barriers on the SHIFT Talk podcast.



Nacole Riccaboni

Nacole Riccaboni is a board-certified RN and critical care nurse practitioner with a passion for professional advocacy and community building. She hosts SHIFT Talk, a podcast sponsored by the Robert Wood Johnson Foundation that brings together nurses to talk about the challenges they face both on and off the clock.

Thu, 5 May 2022 13:00:00 -0400 Nacole Riccaboni Nurses and Nursing Health Disparities National Nursing <![CDATA[Good Things Happen When Nurses Lead]]>

A retired nurse CEO says we need nurses in government, on the boards of for-profits, and mentoring the next generation given their powerful role in influencing people, policies, and systems.

Mentor the Next Generation of Nursing illustration.

Maria Gomez has had her finger on the pulse of our healthcare system and the people it serves throughout her storied, 30+ year career running a community health center that serves a low-income, immigrant community in greater Washington, D.C. Maria entered the United States at age 13, started Mary’s Center after becoming a nurse, and helped grow it into a powerhouse serving 60,000 people each year. Mary’s Center helped pioneer an integrated model of healthcare, education and social services to put people on a path to good health, stability and economic independence. In 2012, President Obama presented Maria with the Presidential Citizens Medal. She retired in late 2021. Here, in the second part of a two-part interview, she reflects on the challenges facing our healthcare system, how nurses can continue leading efforts to meet them, and what we can learn from the pandemic.

What are the greatest challenges facing our healthcare system?

Today, it’s all about the numbers—the number of patients you see and the number of minutes it takes. Because that’s how you get paid. To transform lives, we need to change how we address patient needs. Providers can’t do it all in 15 minutes. Some are so overwhelmed by the numerous demands on them that they’ve grown numb to what their patients are feeling. Too many smart, incredibly passionate people who devote themselves to healthcare have become disheartened, burned out, and are even leaving the workforce. This is the most discouraged I’ve seen providers in my career.

To improve things for both patients and providers, we must support interdisciplinary teams of doctors, nurses, social workers, care coordinators, etc. And we need to ensure they have sufficient time and space to discuss their patients’ needs and coordinate care. Changing incentives will transform care and help address the high costs of healthcare.

Nurses have always been on the frontlines of delivering healthcare. What is your advice and vision for the profession moving forward?

Maria Gomez portrait. Nurses have a powerful role to play in influencing people, polices and organizations. —Maria Gomez READ Part 1 of the Q&A

Nurses have a powerful role to play in influencing people, polices and organizations. They are leaders, and we need them to lead hospitals, health centers – even architecture firms. For example during a renovation project during my time at Mary’s Center, one of the project leads was a nurse who could see the big picture, identify safety issues and lead the project with a perspective that was empathetic to patient and providers needs.

In working closely with patients, nurses have a first-hand understanding of the need for affordable childcare and paid leave. We need nurses running for office, sitting in the House and Senate, and educating our leaders to ensure policies make sense and are relevant to our community.

We need nurses serving on the board of directors even on for-profit companies. They have an instrumental role in influencing decisions related to employee well-being, benefits, paid time off and even advocate for childcare so parents can get to work and their kids are in a safe and educational setting.

I’d also like to see more minority nurses mentor the next generation, and more nursing schools address social determinants of health so their students can continue their education without becoming hungry or homeless or leaving school to become family caregivers.

What have we learned from the pandemic?

The pandemic has shown us that our communities are very resilient, but also very vulnerable. We learned about how unevenly the wealth in our nation is distributed. Black and Hispanic individuals, children and families and those with low incomes suffered the most, both from illness and from the economic fallout. Even the middle class were just a few paychecks away from disaster. We need to reckon with the structural barriers that have created such tremendous disparities between those who have everything and those who have nothing.

A silver lining of the pandemic is how it has helped us realize that we’ve paid little attention to our families, and even to our own well-being. It’s why we need to adapt workplaces that facilitate a balance between being a productive worker, and having enough time for our own wellbeing and that of our families. Getting that balance right is very important and yes this rebalancing does take resources.

What advice do you have for those who will continue your legacy?

Never forget about the people you are serving. Systems are only as good as the people in front of them providing  the guidance and support and that requires careful listening. It takes smart, passionate teams to drive change. Be pragmatic but never stop envisioning what you can achieve alongside your team. And if we are genuinely committed to tackling the racism embedded within our healthcare system, we must actively recruit racially and ethnically diverse healthcare staff at all levels. Last, but not least, we must analyze our data to drive quality, this mean equally analyzing both qualitative and quantitative data.

I will continue advocating for investments in comprehensive programs and for organizations to get general support dollars, so providers are liberated to provide the care they were promised in school – the care their patients desperately need.

Read Part 1 of this Q&A with Maria Gomez, then learn more about all the remarkable RWJF Award for Health Equity honorees.


About the Author

Najaf Ahmad

Najaf Ahmad is senior managing editor of the Culture of Health Blog where she highlights perspectives about how the Foundation is advancing health equity in communities across the nation.

Mon, 2 May 2022 11:00:00 -0400 Najaf Ahmad Nurses and Nursing Public and Community Health National Nursing <![CDATA[Understanding the Link Between Affordable Housing and Structural Racism]]>

Creating inclusive communities requires more than fair housing laws. We need enforcement to end residential segregation and the disinvestment that shortchanges so many communities of color.

Understanding the Link Between Affordable Housing and Structural Racism

To this day, I still choke up when I remember the moment, two decades ago, that changed my life. As part of the Martin Luther King Day of Service, I had volunteered to help feed some folks who were homeless. At the end of the afternoon, I turned to one of the women who ran the sponsoring program, and said, “That was great, I look forward to doing this again next year.”

She paused, looked directly at me, and said quietly, “We do this every week.”

In those words, I suddenly heard a calling. My Dad was a church pastor and I had always expected to follow his path. But now I wondered, “Am I going to preach about this, or am I going to actually do it?” And so I signed up to work among people who were living mostly on the streets. Some struggled with mental illness or substance use, others had been forced from family homes because of their sexual identities. All were poor and most were Black or Brown. I learned to listen, not judge, and to think more broadly about how poverty and race intersect.

Black and Brown Skins Don’t Ruin a Neighborhood

At Fair Share Housing Center, my faith, my passion for people, and my commitment to social justice are intertwined. Our broadest goal is to break down the structural racism that has existed since this country was founded. Housing is our entry point because zoning, land use, and housing policy are tools that governments at the federal, state, and local levels have long used to create a white middle class and disinvest in neighborhoods occupied primarily by people of color. If we are to create opportunities for everyone to live where they choose, we have to confront the legal, policy, and practice structures that sustain patterns of residential segregation and its damaging health consequences.

New Jersey has a one-of-a-kind mechanism by which to do this. The Mount Laurel doctrine, a series of watershed rulings by the New Jersey Supreme Court beginning in 1975, requires every municipality in the state to take deliberate steps to provide affordable housing for low- and moderate-income people. The court said New Jersey’s constitution did not permit state or local land use policies that discriminate against individuals based on income. I can’t overstate the importance of this decision—the original plaintiff, Ethel Lawrence, has been called “the Rosa Parks of housing” and the case is often compared to the landmark Brown v. Board of Education decision that ended legal school segregation. No other state has such sweeping requirements.

And yet the struggle for affordable housing in New Jersey, ironically one of the most segregated states in the nation, continues. Fair Share was founded specifically to safeguard and advance the Mount Laurel doctrine because we know that fair housing laws alone are not enough; those laws also need to be enforced. That means we spend a lot of time litigating noncompliant municipalities. In 2015—forty years after the first Mount Laurel decision—we won a major court battle that required towns to redress long periods when they failed to meet their fair share obligations. As a result, approximately 50,000 more affordable housing units are currently being built.

Let’s be honest about the racist narratives that policymakers use to defy requirements to house people without deep pockets. When folks hear that affordable housing is coming, they immediately assume that low-income Black and Brown people without jobs will move into their neighborhoods and rising crime and falling property values will quickly follow. None of that is true, as a study of one of the first developments to follow the Mount Laurel ruling demonstrated. In thriving, racially integrated New Jersey communities like South Orange, Maplewood, and Pennsauken, health, well-being and economic opportunities improve for everyone, regardless of race or class.

But until we reframe prevailing narratives about what it means to have Black or Brown skin in this country, we will continue facing an uphill battle to create inclusive communities throughout New Jersey.

Housing by Choice

Fair Share champions housing as a human right. Erecting a framework that guarantees housing for all allows us to reimagine what is possible and pursue it vigorously.

We talk a lot about giving people options and opportunities. Yes, we believe that affordable housing should be available in high-opportunity communities, but we are pushing equally for investments in neighborhoods that have been historically starved of resources. Displacement, not gentrification, is our concern—we want more investments to cultivate assets in communities of color, but those investments must improve the lives of long-term residents, not drive them out.

A universe of strategies is needed to galvanize action on affordable housing. We put muscle into advocating for the Fair Chance in Housing Act, which limits the use of criminal background checks by landlords and was signed into state law on Juneteenth, 2021. No other state has a statute as strong ours, although we need vigilance to ensure it is fully enforced. We are also committed to preserving and maintaining existing affordable housing, supporting first-generation homeowners, advocating for stronger enforcement against housing discrimination, pushing for eviction protections, and ensuring that disaster relief funds are distributed equitably.

Becoming Part of the Solution

Our experiences offer many lessons. One is that every community is unique, which means we have to understand the distinctive assets, institutions, history, and priorities of any place we work. We have also learned to be persistent, recognizing that the pursuit of justice never ends; we can’t walk away after a win and say our work is done.

Collaborative action is the core ingredient of Fair Share’s power. We knit together coalitions because we know that a collective voice is much stronger than a lone one. Together, advocates and agitators, faith leaders and civil rights activists, and many other stakeholders become a force for legislative and policy prescriptions that cannot go unfilled.

To our allies wondering how to become part of changing the narrative, I say get involved in local issues that impact housing. What do you want in a neighborhood and what land use policies will allow its amenities to be more broadly shared? Is your community doing enough to attract housing that lower-income people can afford? Learn how Fair Share, our partners in the United Black Agenda, and the New Jersey Governor’s Wealth Disparity Task Force are building equity. Support our efforts and connect with stakeholders in your own regions who are trying to open doors.

Understand, too, the larger context in which we do our work. This country was built on the backs of enslaved labor, yet our founding documents declare that all men are created equal. A lot of us believe passionately in an even broader message of equity and we are fighting to realize it. Affordable housing is an engine to win that struggle.

Learn more about how where you live impacts your health. 


About the Author

Rev. Eric Dobson is Fair Share Housing Center’s Deputy Director. He joined Fair Share Housing Center as an ordained minister, a community organizer, outreach specialist, and social entrepreneur. He holds a BA from Temple University in Religion and has extensive experience working with diverse audiences and communities, specializing in interfaith outreach.

Thu, 21 Apr 2022 10:00:00 -0400 Rev. Eric Dobson Social Determinants of Health National <![CDATA[Four Reasons the Expanded Child Tax Credit Should Be Permanent]]>

The expanded Child Tax Credit was one of the best policies enacted in generations. As we look to the future, we should continue what works.

Mom with children in protective masks choose fruits to buy in the store.

For children and families, last year’s expansion of the Child Tax Credit provided crucial support, helping them afford basic needs like food, clothing, and housing. Yet this historic policy achievement that almost immediately reduced child poverty was fleeting. Just six months after the first payment went out, the opportunity to help children thrive abruptly ended. The expanded policy was never extended, and these families are now right back where they started.

Research shows that long term, sustained cash assistance has the greatest impact, confirming that this policy should be permanent. As we mark Tax Day here are four reasons why the expanded Child Tax Credit should be permanent:

1.  Reduces the number of children living in poverty. (That should be reason enough).

Even in a nation as wealthy as the United States, 10 million children experience poverty. The damaging effects of the conditions of poverty are relentless: hunger, homelessness, substandard schooling, and a lack of access to healthcare and child care. The populations hit hardest by the pandemic are the same ones experiencing the highest poverty rates: Black, Hispanic, and Indigenous children and their families.

Child Tax Credit Chart. Source: Center on Budget and Policy Priorities

As my colleagues noted in Academic Pediatrics, we know how to fight poverty, so let’s do it. Few policy initiatives in our nation’s history have sought to address poverty like the expanded Child Tax Credit. Advance payments of the expanded credit put more than $77 billion into the pockets of 61 million families. The typical Child Tax Credit lifts millions of children out of poverty every year. It is estimated that the expanded (and fully refundable) Child Tax Credit would reduce the number of children experiencing poverty by more than 40 percent in a typical year, with even bigger declines among children of color disproportionately affected by poverty. (See state-by-state declines.)

But we are already seeing what happens when this support disappears. Following the expiration of payments in December 2021, millions of children have fallen right back into poverty.

2.  It helps families afford basic needs.

There is no good time for the expanded Child Tax Credit to expire, but to let it happen amid a time of rising food and energy prices is particularly egregious. More than 90 percent of families with incomes below $35,000 spent the money on food, utilities, housing, clothes, and education, since families with no or low wages spend a greater share of their income on these staples. The real impact of this policy can be seen across the country. This is how families relied on this extra support:

●     Donna and her husband are raising their two grandkids. They used the Child Tax Credit “to keep on top of the bills, food, clothes for the kids and for ourselves, shoes for the kids and us, the furniture.”

●     Juliana and her husband have been hit hard financially throughout the pandemic, and her work as an ER nurse took an emotional toll on her and her family. She changed jobs as a result, but the subsequent decline in income has been a struggle in its own right. “[The monthly child tax credit] helps a lot. That little bump that it gives me every month [is how] I'm able to kind of keep afloat.”

●     Pristine is a single mother of two children and also has been struggling financially during the pandemic. She is adjusting and learning how to juggle work and find (and afford) child care. “ ... as far as with the child tax credit that I get each month ... currently, I'm using it towards rent.”

Only last month, 42 percent of families reported difficulty in affording basic household expenses. As the stories above illustrate, the expanded credit was a lifeline for millions of families. And that lifeline is now gone.

3.  It reduces food insecurity.

In 2020 (the most up-to-date data available), an estimated 38 million people in our country were food insecure. This is one in eight Americans, including almost 12 million children who do not have consistent access to enough food to live an active, healthy life. Black and Hispanic households experience food insecurity at almost triple the rate of White households.

Of all the essentials for which the expanded Child Tax Credit helped families pay, a state-by-state analysis reveals that food topped the list just about everywhere. In fact, advance Child Tax Credit payments were associated with a 26 percent reduction in household food insufficiency.

4. It produces an astounding return on investment.

Research shows that the $97 billion annual cost of a permanently expanded Child Tax Credit would be far outweighed by $982 billion in annual social benefits. This includes improved health and longer lifespans for kids, healthcare costs savings, and increases in future earnings, which drives a corresponding rise in tax revenue. In other words, an astounding 1,000 percent return on investment.

What Needs to Be Done

Our country should not stand for even one child living in poverty. Making the expanded Child Tax Credit permanent and ensuring that families with no or low wages remain eligible for the full amount should be an easy call. And we can do even more to maximize its potential by:

●     Making it easier for the people at the lowest income levels to verify their eligibility, file tax returns, and receive payments.

●     Repealing a provision of a 2017 law that makes children without Social Security numbers ineligible.

●     Rejecting proposals that impose work requirements on eligibility, which would disproportionately affect children of color and those further from economic opportunity.

The expanded Child Tax Credit is more than just tax or fiscal policy. It speaks to whose lives we value and whether we can ever truly become a nation where every person has the opportunity to live the healthiest life possible. This is about people like Donna, Juliana, and Pristine who work so hard to support their families and deserve support to make sure their children grow up healthy. The fate of the expanded credit remains undecided. But whatever happens, this is one fight worth having.

Read more from my colleagues Rich Besser and Dolores Acevedo-Garcia in their op-ed for The Hill, What the Child Tax Credit Fight Says About America.


About the author

Monica Hobbs Vinluan

Monica Hobbs Vinluan, who joined RWJF in 2015 as a senior program officer, has been a passionate professional advocate for health promotion and a distinguished government relations professional on a variety of health and well-being issues for two decades.

Mon, 18 Apr 2022 08:45:00 -0400 Monica Hobbs Vinluan Child and Family Wellbeing <![CDATA[This Policy Tool Can Advance–Or Impede–Racial and Health Equity]]>

There is great urgency to ensure local governments are able to enact policies that protect and enhance the health of their communities.

Illustration for Health Equity blog

This post is the first in a blog series that explores how preemption has served as a double-edged sword in either supporting or undermining efforts to advance health equity.

On a host of issues ranging from commercial tobacco regulation to public health authority, paid sick time to advancing the health of children and families, a policy tool known as preemption can impede local decision-making. Preemption is when a higher level of government, such as a state legislature, restricts the authority of a lower level of government, such as a city council. Depending on how it is used, preemption can either support or undermine efforts to advance health equity.

In one example of the latter, we know that health and economic well-being are intertwined, which is why raising the minimum wage has been used across the United States to advance health equity for workers in low-wage industries. In 2016, the majority-Black city council of Birmingham, Ala., passed an ordinance raising the minimum wage from $7.25 to $10.10 per hour. But the new minimum wage never took effect because the majority-White state legislature responded with a law preventing municipalities from setting their own minimum wages. It effectively nullified Birmingham’s ordinance.

Eight years later, Alabama still follows the federal minimum wage of $7.25 an hour. At that wage, someone working 40 hours a week, 52 weeks a year, earns about $15,080. Birmingham decision-makers recognized in 2016 that $7.25 an hour is not a living wage. Yet to this day the state still prevents the local government from acting.

Even with this example, preemption isn’t inherently bad. For example, federal civil rights laws passed during the 1960s preempted state or local laws that enforced discrimination. Statewide smoking bans in restaurants and public places advance health equity, while state inclusionary housing laws promote fair housing and zoning policies at the local level. Such policies set a minimum health or equity standard that local governments can choose to build on and strengthen.

Lately, however, many state legislatures have wielded their power to prevent communities from addressing their own needs, particularly as they relate to dismantling systems of oppression, improving public health, and advancing policies that improve equity and civic participation.

State Interference is on the Rise

Dozens of state legislatures have abused preemption to impede or undo progress for communities that historically have been disadvantaged. They have enacted laws to thwart local governments’ attempts to raise the minimum wage, mandate paid sick leave, tax sugar-sweetened beverages, protect residents from pollution, and regulate tobacco. Some legislatures are curtailing local authority over voting rights, education, criminal justice and police reform, and public health.

Over 400 preemption bills were filed in state legislatures during the 2021 session—and nearly 300 are already up for consideration this year. Oftentimes, special interests—corporations and lobbyists—lead preemption efforts when they believe their interests are threatened.

Some bills take a broader swipe at local governance rather than just focusing on one issue. For example, in Florida, HB1, an anti-protest bill framed as a backlash to racial justice demonstrations in 2020, doesn’t address just protests—it also limits local budget control, particularly around criminal justice and police reform.

The broader the preemption, the greater the risk that authority best managed by local governments will be shifted to the state without open and transparent debate. Florida’s HB1 was used to undermine the ability of residents and local officials to participate in their own democracy.

There are many ways in which state overreach can exert a chilling effect on local governments. A long-standing law in Colorado punished municipalities for even proposing to regulate tobacco products—meaning that the issue couldn’t even come up for a debate. Under the law, local governments that tried to regulate tobacco products forfeited their share of the state sales tax on cigarettes. After the law was repealed in 2019, dozens of local governments launched tobacco regulation campaigns.

Other states have enacted “vacuum preemption” to prohibit cities from making certain kinds of laws, even in the absence of any state standards—leaving a policy vacuum. After the city of Austin, Texas, sought to address housing discrimination by prohibiting landlords from rejecting otherwise qualified tenants based solely on their income source, the state legislature invalidated Austin’s ordinance. This prevented localities from adopting similar measures without establishing any statewide protections and despite clear evidence that housing discrimination disproportionately harms people of color. In doing so, the state legislature quashed debate on the issue.

How These Laws Affect Health

A growing body of research demonstrates the harm—including lower life expectancy, high infant mortality, and worse overall health—caused when preemption is used to subvert measures designed to advance racial and health equity. A report from the Partnership for Working Families examined preemption of minimum wage, sick leave, and affordable housing policies in four states and found that it is associated with poor outcomes for women of color. A study assessing the effects of preemption on birth outcomes found that infant mortality would have been more than 5 percent lower on average had minimum wage increases been enacted, preventing 400 infant deaths in 2018 alone.

The public health community and its partners must anticipate, assess, and provide evidence to help counter preemptive policy proposals that exacerbate health disparities and inequities.

Explore the Local Solutions Support Center to understand and track preemption across various issues. 


About the Authors

Katie Belanger is the Lead Consultant at Local Solutions Support Center. During her tenure at LSSC, Katie has focused on deepening cross-movement collaboration by building and supporting state campaigns and coalitions to defend against state interference in local policymaking and advance home rule reform. 

Matt Pierce is a senior program officer at the Robert Wood Johnson Foundation. He works in the areas of public health law and tobacco control. Matt is interested in finding more equitable ways to promote health and well-being. 

Thu, 14 Apr 2022 13:00:00 -0400 Matt Pierce Health Disparities National <![CDATA[Why We Need Healthy School Meals for All]]>

Healthy School Meals for All offers students and schools the stability and support they need as they continue adapting to pandemic-driven change amidst ongoing challenges. Now is not the time to let this policy expire.

Student being served lunch in cafeteria

Families around the country, mine included, are feeling fortunate to have our kids back in school after a turbulent, unpredictable couple of years. Students, teachers, and school officials were forced to navigate unexpected changes.  For most, the ongoing shifts from virtual to in-person learning were stressful and added to many other pandemic-induced hardships. Through it all, school districts quickly spearheaded innovative approaches to ensure they could continue to serve much-relied-upon school meals to students. They implemented “Grab and Go” models allowing parents to pick up meals in school parking lots or other community hubs; loading up school buses with meals and dropping them off at stops along neighborhood routes; and delivering meals directly to students’ homes.

Schools were able to offer this continuity and flexibility because when the Covid-19 pandemic forced nationwide school closures—and hunger and food insecurity spiked—Congress passed the Families First Coronavirus Response Act and CARES Act in 2020. 

Provisions in these laws provided the U.S. Department of Agriculture (USDA) with authority and funding to implement waivers that permit schools nationwide to serve meals to all students free of charge (also known as universal school meals). The measures also allowed schools flexibility to help ensure that meals are provided safely during a public health emergency. That includes distributing meals to families outside of the school setting and temporarily serving meals that meet the less stringent nutrition standards of the Summer Food Service Program, which require fewer fruits and vegetables than USDA’s current nutrition standards for school lunch.

This adaptability and universality of school meals for all has also been so important because for tens of millions of children in the United States, school isn’t just a place to learn, but a place where they depend on receiving healthy meals. The pandemic highlighted how critically important school meals are for preventing child hunger and ensuring millions of families have enough to eat, especially those furthest from economic opportunity. Unfortunately, the child nutrition waivers are scheduled to expire on June 30. We must find a way to do right by our children, families, and schools by extending these waivers through, at minimum, the 2022-23 school year.

New, Unexpected Challenges for School Nutrition Programs

Historically, school nutrition programs are often understaffed, underfunded, and overlooked. The pandemic led to additional financial losses. According to USDA data, school food service departments reported more than $2 billion in federal revenue losses from March to November 2020. Challenges continued to emerge throughout the pandemic and are still impacting school nutrition programs today.  

For example, the Roswell Independent School District in New Mexico saw a sharp drop in school meals participation due to forced school closures. Now, with students in school, its nutrition program, like many others, is facing supply chain issues. 

Kimberly Meeks, the district’s Student Nutrition Director, said she struggles to get the products she needs to feed her students. One week she ordered 100 cases of chicken nuggets but ended up receiving only 30. She has to tackle new challenges each week to ensure the meals have enough nutrients, including how to get her students protein without the planned food. 

“I put out a menu, but it gets changed almost daily. Because we never know what we're going to get in or how much of that product. I spend most of my day now trying to figure out what food we're going to serve,” said Meeks.

Across the country, school nutrition programs are scrambling to fill in gaps when they don’t receive the food they order. Many have been forced to find new vendors when orders are canceled or delayed, and even make trips to local stores to purchase necessary food and supplies. A national survey from December 2021 reveals 97 percent of school nutrition program directors are challenged by rising costs due to supply chain issues. 

On top of the insufficient quantities of menu items, school nutrition directors are dealing with higher food costs and staffing shortages making planning and serving meals that much harder.

And, while offering free school meals for all has meant students’ ability to pay for meals has not been a concern for school nutrition departments or students themselves, this would change if the program were allowed to expire. We would revert back to a time when students and families had to deal with the stress and stigma of not being able to afford a full-price meal and schools had to contend with debt accumulated from lack of payment.

As Meeks expressed. “We don’t turn kids away. We’ll feed them no matter what, but if free meals end, the debts will increase greatly.”

Benefits of Healthy School Meals For All

There is overwhelming evidence of the benefits universal school meals offer to children. In fact, an extensive review of 47 research studies conducted before the pandemic finds that offering healthy school meals to all students at no charge is a sound and vital investment that helps kids, families, and schools by:

  • Reducing levels of food insecurity among children from families with lower incomes.
  • Increasing the number of children participating in school meals programs in nearly all cases.
  • Improving kids’ diet quality in the majority of circumstances, especially when schools have strong nutrition standards in place for fruits, vegetables, or whole grains.
  • Improving children’s academic achievement, including test scores and readiness to learn.
  • Helping schools financially, especially schools with a high percentage of students from households with low incomes.

Offering meals to all students free of charge not only reduces financial and administrative burdens on school nutrition programs, it boosts participation in school meals programs. All of these are critical strategies for helping mitigate school districts’ financial losses during this economically precarious time.

For more than 70 years, our nation’s school meals programs have been a lifeline for millions of kids. And the emergency measures that have helped schools meet the needs of kids and families throughout the pandemic provide a roadmap for modernizing and improving the programs. The evidence is clear: offering nutritious meals to all students at no charge can help children grow up healthy, lift their families out of poverty, and alleviate significant financial, logistical, and administrative burdens faced by schools. This is not a stopgap measure; it must be continued with the goal of making it a permanent policy. 

Learn more about school meals, including the Foundation’s recommendations for modernizing and improving the programs to prioritize equity and support children’s health.


About the Author

Jamie Bussell

Jamie Bussel, a senior program officer, has extensive experience in developing programs and policies that promote the health of children and families.

Mon, 11 Apr 2022 12:45:00 -0400 Jamie Bussel Early Childhood National <![CDATA[How Can We Use Local Data to Address the Impacts of Structural Racism on Community Health?]]>

Thirty-five local non-profits will be awarded up to $40K to work with local data to dismantle structural racism via a new funding opportunity.

Editor's note: This funding opportunity is now closed. 

Columbus, Ohio redlining map. A redlining map from 1936. In communities throughout the nation, there is strong correlation between redlined places and worse health outcomes.

The COVID-19 pandemic reinforced how place matters for health. Some communities have the conditions needed to help their residents thrive—like safe streets and parks, safe and affordable housing, and access to healthy foods. But too many communities—particularly places where people of color and those with low incomes live—have lacked these resources. This lack of resources is a result of the legacies of structural racism, such as redlining that shaped the socio-economic trajectories of communities, and modern-day racist practices, like systemic disinvestment from communities of color.

To inform efforts to improve community conditions shaped by structural racism, the Robert Wood Johnson Foundation (RWJF) has released a call for proposals (CFP). In order to best represent the voices of those most impacted by societal injustices, we aim to meaningfully engage community organizations. Up to 35 local non-profit organizations will be awarded up to $40,000 over nine months.

Who Should Apply

We are searching for local non-profit organizations that meet the following criteria:

Local: Projects must focus on neighborhoods, cities, counties, or metropolitan areas within the United States.

Community-Driven: Projects should meaningfully engage with community members to address the issues that matter to them. This could include collaborating with community members to define questions of interest; determine what data and analysis are needed; collect, analyze, and interpret data; share data in accessible formats; and/or translate findings for local audiences.

Timely: Applicants must complete projects within a nine-month period, and data should be connected to near-term decision-making and action. We recognize that the changes needed to address community conditions shaped by structural racism are going to take time. This grant opportunity is intended to catalyze initiatives and collaborations working with community members to bring about these changes.

The Urban Institute is collaborating with us on program design and documenting lessons for the field. Technical assistance will be available to grantees, including reviewing data collection instruments and protocols, consultations with subject matter experts, and referrals to tools and examples that are relevant to grant projects. 

How Communities Have Used Data to Advance Health Equity

This CFP builds on RWJF's earlier effort to provide timely support for the use of data to inform local COVID-19 response and recovery. Examples of relevant projects include: 

Meeting Urgent Needs: Para Los Niños (PLN) in Los Angeles, worked to close gaps in pandemic response systems and met immediate community needs with resources such as food, diapers, educational materials, and cleaning supplies. And through surveys, interviews, and quantitative data, PLN partnered with residents and community organizations to learn more about challenges in the community—such as food and housing insecurity, transportation gaps, and mental health. Drawing on their deep partnership and trust with the community, PLN worked with residents to use what they learned to organize the community (virtually) and develop a Community Bill of Human Rights that sets a long-term advocacy and policy agenda. “We recognized that if basic needs were not being met, communities could not lead systems-change efforts,” said Brenda Aguilera, director of community transformation at Para Los Niños.

Tackling the Child-Care ConundrumStarting Point, partnering with Case Western Reserve University, analyzed survey and demographic data in Cuyahoga County, Ohio, at the neighborhood level to identify where large gaps exist between available child-care slots and the projected demand for care as parents tried to return to work following the pandemic shutdown. Resulting data, which were interpreted and presented in a Story Map in consultation with child-care providers and families, informed a successful advocacy effort to get child-care workers priority access to the COVID-19 vaccine, and continues to shape the local child-care industry’s response to the pandemic.

Making Free Mental Health Services Accessible: Cook County Family Connection (CCFC) used survey data to document the effects of the COVID-19 pandemic on residents and families across rural Cook County, Georgia. The resulting "Rural Voices" report reveals the challenges residents were facing in food security, physical health, mental health, employment, and child care and education. Analyses of the data revealed a three-fold increase in mental distress during the pandemic. In response, the local mental health agency assigned a full-time therapist to serve students in Cook County schools. CCFC also raised awareness about crisis counseling resources, and delivered a series of trauma-informed care workshops for their community partners.

Bringing Healthy Food to the Community: Urban Harvest, working with the Kinder Institute for Urban Research at Rice University, gathered quantitative data and qualitative community input on local residents’ food access, food choices, and shopping behaviors. They learned that many residents would prefer to purchase food grown locally by small farmers, but they were largely unaware of local food markets or didn’t know how to access resources to make it affordable. Through this initiative, they identified schools, churches, and community centers in areas with high food insecurity and deployed mobile food markets where they were needed most. They continue to use these data to raise awareness of food insecurity and encourage innovative solutions to providing healthy, affordable food.

The progress that these organizations have made demonstrates the power of pairing relevant data with community engagement.

Read more stories on the last round of data work in collaboration with Urban Institute.


About the Authors

George Hobor

George Hobor, is a senior program officer working to promote healthy, more equitable communities. George is committed to building the capacity of the nonprofit and public sectors to use data and research in their program and policy development, and to advancing a broader conception of health that extends beyond the healthcare system. 

Wojcik Staff Photo

Oktawia Wójcik, is senior program officer. A distinguished epidemiologist, Oktawia's work focuses on driving demand for healthy places and practices and building a Culture of Health through research that informs both grantmaking and broader health-related policy and practice.

Mon, 4 Apr 2022 10:45:00 -0400 Oktawia Wojcik Health Disparities Public and Community Health National <![CDATA[Relatives Raising Children: Why is it so Difficult?]]>

Child-welfare systems and policies shouldn't create so many unjust barriers for children growing up in nontraditional families.

Families face challenges illustration.

Life is harder than it has to be for families where grandparents or other relatives step up to care for children when their parents can't. Our family-supportive policies and systems were designed to serve “traditional families,” with services aimed at “parents” and foster families, not relatives who step up. These families face unnecessary barriers to getting the support children need to thrive. This is especially true among Black and American Indian families, who make up a disproportionate share of the 2.6 million families in the United States where children are growing up without parents in the home. The pandemic has made things worse. COVID-19 has robbed thousands of children of their parents and sent them into the care of relatives.

What happened to the Brown family of Baton Rouge, La., helps to tell the story of grandfamilies, also known as kinship families, which form when children are separated from parents through life events like death, illness, incarceration, or deportation. After a horrific onslaught of gun violence killed four members of their family, Robert and Claudia Brown took custody of three grandsons. They fought for 12 years to adopt the boys.

The Browns struggled through trauma, grief, and loss. They scrambled to pay lawyers while supporting three growing boys. They blew through retirement savings. They didn’t know about services or support that could have bolstered their mental health and financial security.

The Browns faced many obstacles simply because they were grandparents raising grandchildren. U.S. family-support systems, services, and policies were not designed for families like theirs.

The RWJF grantee Generations United included the Browns in its 2021 annual report on grandfamilies. While the deadly crimes that befell the Browns were unusual, the struggle they experienced afterward unfortunately was not—it is the story that millions of U.S. families endure. 

What U.S. Systems, Services, and Policies Look Like for Grandfamlies

Support for grandfamilies is woefully inconsistent, fragmented, siloed, underfunded, biased, and inadequate. Systems that are often aimed at “parents” differ within and across county and state lines, are strapped for money, and fail to consider diverse cultural norms that comprise the U.S. today.

Families face challenges illustration.

For example:

  • Without a legal relationship, caregivers are often unable to access key benefits for the child, enroll them in school, or consent to their health care.

  • Fathers, uncles, or other male family members are often overlooked by the child welfare system as potential caregivers for children.

  • A caregiver’s age or relationship to the child can be a barrier to support. In some states, great-grandparents can’t access the same services as grandparents. 

  • In some states, a caregiver who is not related by blood or marriage cannot apply on a child’s behalf for benefits such as Medicaid or Temporary Assistance for Needy Families (TANF).

Despite all this, children in grandfamilies thrive. Their lives tend to be safer and more stable than those of children in the care of foster parents they are not related to. They experience better behavioral and mental health outcomes. Their families are better at helping them preserve their cultural identity and maintain community connections.

Rosalie Tallbull, a member of the Northern Cheyenne tribe in Colorado, struggled through a confusing, sometimes baffling journey in the child-welfare and judicial systems to gain custody of her grandson Mauricio, whose mother struggled with alcoholism. Caseworkers treated Rosalie very poorly, leaving her in the dark about services and supports Mauricio should have received. A landmark law, the Indian Child Welfare Act, was designed to help families like Rosalie's, but lack of funding and limited resources made it difficult for tribal officials to help her.

With help from a grandparents' support group, Rosalie was able to get aid for her grandson through the Supplemental Nutrition Assistance Program (SNAP) and TANF. And after two years, she won full legal custody of Mauricio.

While the Browns and Tallbulls eventually secured some helpful support and services for their grandchildren, they were difficult to access and there were fewer resources than were available to unrelated foster families.

Monthly Financial Assistance for One Child chart.

The vast majority of grandfamily caregivers step up to keep families together, keeping children out of foster care. In fact, for every child being raised by a relative in foster care, 18 are being raised by relatives outside foster care. Many caregivers are never given the chance to become fully licensed foster parents, which would give access to more resources that their families need like access to monthly foster care payments.

Families like Rosalie's and the Browns’ shouldn't have to fight so hard. They go to great expense and effort to raise children—they deserve the same support for life's essentials that families with more traditional arrangements receive. 

Governments and child-welfare agencies need to do many things to ease the needlessly cruel burdens faced by nontraditional families. Our country understands inequities better than it did before. But it still has work to do. To start, Generations United recommends: 

  • Support quality kinship navigator programs, which link grandfamilies to the benefits and services they need.

  • Promote financial equity with a kinship caregiver tax credit, improving access to foster care maintenance payments and TANF.

  • Implement recommendations of this advisory report to Congress, including changing workplace policies to recognize grandfamilies' needs and improving their access to respite care, child care, and counseling.

  • Support grandfamilies as part of opioid settlement funds.

Learn more in Generations United’s 2021 State of Grandfamilies in America Annual Report, Reinforcing a Strong Foundation: Equitable Supports for Basic Needs of Grandfamilies.


About the Author

Jennie Day-Burget

Jennie Day-Burget, an award-winning public relations and communications professional, joined RWJF in 2015. She provides communications support to RWJF initiatives aimed at creating the conditions for communities across the nation to thrive, and to ensuring that our policies, systems and environments help children and their families access the resources needed to maintain a healthy weight.

Thu, 24 Mar 2022 11:00:00 -0400 Jennie Day-Burget Child and Family Wellbeing Social Determinants of Health National <![CDATA[How a Nurse Leader Took on the Social Determinants of Health]]>

Trailblazing nurse and recently retired CEO of a community health center reflects on her legacy of providing care that prioritizes the social determinants of health.

Doctor and patient illustration.

Maria Gomez was 13 years old when she immigrated to the United States with her widowed mother to escape violent political turmoil in Colombia. They landed in Virginia on a snowy day with no boots, no coat, and not speaking a word of English. Together, they faced many challenges while navigating their new life. In spite of them, Maria’s gratitude and drive to give back led her to a nursing career. She ultimately joined a group of advocates in launching Mary’s Center to address gaps in access to healthcare and structural barriers that many immigrants face.

Today, Mary’s Center uses an integrated model of healthcare, education, and social services to serve patients at five clinics and two senior wellness centers in Washington, D.C. and Maryland. In 2012, President Obama presented Maria with the Presidential Citizens Medal, the second highest civilian honor in the United States.

After an illustrious career, Maria retired in December of 2021. She shared reflections on how she has led efforts to serve a diverse population and insights into the challenges our healthcare system and nation face. In this interview, Maria discusses how she shaped a system of care that aims to build trust with patients and provide integrated care that addresses more than medical needs.

Mary’s Center started out as a community health center that primarily served pregnant women and infants. Can you describe what that work has entailed and how you’ve continued serving pregnant immigrant women?

Mary’s Center started out caring for pregnant women from Central America who were fleeing war and violence, and who struggled to find care for a variety of reasons, including insurance status and language barriers. These challenges put them and their babies at risk for poor maternal and infant outcomes.

Today, many of our patients grapple with conditions beyond the pregnancy itself. Their lives are shaped by social determinants of health—the social, economic, and environmental factors that influence health. For instance, they may live in an apartment with occupancy limits, so the addition of a baby brings fear of being evicted. They may fear the pregnancy will cost them their jobs. Potential job loss and the additional mouth to feed makes new mothers worry about their finances. And there are constant concerns about family members being deported. As if these stresses aren’t enough, the brutal toll of domestic violence often begins or escalates around pregnancy and can lead to homelessness.

Some women have all of those stressors in one family. It’s why we have focused on the full set of circumstances that ultimately affect maternal health. Our services have included home visits by culturally humble providers. This helps build trust with women who are hesitant to seek care because of past negative interactions with the healthcare system. We are also proponents of telemedicine which has been lifesaving for women on bedrest who can’t visit their providers in person.

You clearly found a way to address needs that are unmet in a traditional healthcare setting. Thanks to your leadership, Mary’s Center has grown from initially serving 200 patients in a basement, to now serving 60,000 patients per year at five clinics and two senior wellness centers. How did your guiding principles help Mary’s Center evolve and expand services?

The work I’ve led has been grounded in the perspective that treating physical health in isolation from individual, family, and community contexts falls short. We listen to the community. The healthcare, social services, and education we provide address the challenges our patients face.

Maria Gomez discusses Mary’s Center school-based mental health program which aims to support students, their families and educators.

For example, we recognize the importance of multi-generational education. My mother didn’t know how to get an ID, what to do if I missed the school bus, how to use a bank, or how to negotiate with the landlord when she fell behind on rent. She didn’t learn conversational English, which made it difficult to navigate these daily needs and move up the economic ladder.

We started a teen program because many young people have no idea how to enter careers that are different from their parents, who may be cleaners or construction workers. Those are good, honest jobs, but we also want teens to understand how they can apply for college and pursue careers that offer opportunities to advance and pay a liveable wage.

For our elderly population, we understood how damaging loneliness and isolation can be. So we aimed to keep them engaged and socializing through in-home social support by peer volunteers, as well as nutrition and health education through our senior wellness centers.

How have you developed trust and relationships with patients during your career? 

Building trust begins with hiring staff who resemble the community they serve. That trust is further strengthened by being open to humbly listening and learning about their cultures. We must understand who our patients are beyond their physical state and the burdens they carry that can affect overall well-being.

For instance, years ago, one of our patients disclosed that she appreciated her provider. But she wished the provider would have asked about her native Ethiopia, which she could not stop thinking about since her people there were suffering due to famine. Her words hit me hard. It drove home just how important it is for providers to be aware of how trauma and stress are affecting a patient’s mental health.

It’s also why we have trained our staff around trauma-informed care. We acknowledge that many people have faced trauma, even our providers. That trauma in turn influences how a provider responds to patients. Acknowledging past trauma and understanding related triggers ultimately influences how providers treat their patient’s trauma and brings compassion and sensitivity to care.  

To build trust, we also seek those who truly embrace our mission when hiring staff. We make sure they understand our model of integrated health, education, and social services and recognize that the more interaction patients have within our own system, the better their outcomes. We mentor and encourage our team to be mission-driven in their work. Unfortunately, this is not an activity reimbursed by payers. There’s still not an understanding of the direct correlation that employees who embrace the mission of their workplace deliver better and more empathetic care.

Maria Gomez is a recipient of the RWJF Award for Health Equity. Learn more about how winners like her are implementing systems-level solutions to advance health equity and transform lives within in their own communities.


About the Author

Najaf Ahmad

Najaf Ahmad is managing editor of the Culture of Health Blog where she highlights perspectives about how the Foundation is advancing health equity in communities across the nation.

Thu, 17 Mar 2022 11:45:00 -0400 Najaf Ahmad Social Determinants of Health International <![CDATA[How Can We Prioritize Equity in Public Health?]]>

RWJF leads the design and development of an independent public health institute in New Jersey.

Young woman takes blood pressure of a woman at a table.

Editor's Note: Acenda awarded grant to launch the New Jersey Public Health Institute.

We are proud to live in one of the most racially and ethnically diverse states in the nation. Our home state of New Jersey is also a national leader in areas such as expanding health care coverage, enacting paid family leave, and maintaining low smoking rates.                                                       

Unfortunately, however, these bright spots are offset by glaring disparities with roots in our nation's long history of racism that persists to this day. For example, a Black woman in New Jersey is seven times more likely to die from pregnancy-related causes than a White woman and Black babies are more than three times more likely than White babies to die before their first birthday.

The COVID-19 pandemic exposed and worsened these inequities, especially along racial/ethnic lines.  

In addition to the role played by social determinants of health, a major contributor to these disparities is a state public health system strained for decades by lack of funding and insufficient coordination across health and related sectors. Experts agree the system lacks the capacity to simultaneously achieve its core missions while equitably responding to and managing public health emergencies such as the COVID-19 pandemic.

New Jersey ranks 31st in the United States in state funding for public health, according to the Trust for America’s Health. And a report from Rutgers University found that New Jersey has the lowest median per capita state appropriation for public health among states the study examined. New Jersey’s public health workforce, on a per capita basis, is among the smallest  among states in the comparison—only half that of regional neighbors Connecticut, Maryland, and Massachusetts, the Rutgers report stated.

Another part of the problem is New Jersey’s unusual governance structure. The Garden State has a heavily fragmented system for delivering services, hampered by its “home rule” fondness for local control. The result is a state divided into 565 municipalities and over 600 school districts. “Seizing the Moment,” a report supported by the Robert Wood Johnson Foundation (RWJF), the Nicholson Foundation (Nicholson), and National Network of Public Health Institutes (NNPHI), notes that this arrangement impedes cross-sector, cross-regional collaboration that—in other states—helps attract funding, develop expertise, and build capacity to more effectively deal with public health problems. A public health institute in New Jersey could offer the health coordination our state sorely lacks and complement the work of the state, local, and regional public health departments.

Charting a Path Forward

Public health institutes are nonprofit organizations that support efforts toward a more stable, robust, public health infrastructure to address health and social needs in the context of community amid intolerable barriers to good health along racial, ethnic, and other divides. There are 45 public health institutes in more than 30 states.

In Virginia, the Institute for Public Health Innovation in 2020 assisted in rapidly building up human capacity to respond to COVID-19. In under a month, the Institute recruited, hired, and trained 80 new staff. By the end of January 2021, it had added over 640 people, including case interviewers, contact tracers, community health workers, epidemiologists, environmental health specialists, call center staff, wellness specialists, and response team managers. As the pandemic response shifted to vaccine access, some team members began assisting that effort. More than half of the Institute’s deployed staff are people of color, and staff report speaking over 60 different languages.

In 2017, the Public Health Institute of Metropolitan Chicago conducted a landscape analysis of home-visiting services in partnership with the city’s Department of Public Health to improve services for pregnant women and children and reduce system inefficiencies. This helped guide a strategy for developing a vision and strategy to coordinate maternal child health and early childhood home-visiting services in Chicago.

In these instances—and many more across the nation—public health institutes contributed to significant accomplishments well beyond the capacity of other health entities.

For many years, public health leaders have explored the possibility of establishing a public health institute in New Jersey. In 2013, and again in 2019, studies and convening processes were conducted that strongly supported the creation of a public health institute in the state. Key conclusions emerged that are still valid today:

  • A public health institute could help the state overcome longstanding challenges, such as health inequities and underfunding of public health infrastructure and initiatives.
  • An institute should have a close, clearly-defined relationship with the state Department of Health (NJDOH).
  • An institute should be established through an incubator organization that would facilitate it becoming an independent Section 501(c)(3) organization. The feeling was that a newly-created, independent entity stood a better chance of winning the trust of public health leaders throughout the state.

The joint RWJF, Nicholson, NNPHI report capped a 10-month planning effort that built consensus on mission and values. Establishing a public health institute would be a key part of a reimagined public health system for New Jersey. In the wake of a deadly pandemic for which the state was unprepared, and amid intolerable barriers to good health along racial, ethnic, and other lines, all who envision a state with better health and greater equity for all residents need to seize this moment.

Learn more about RWJF’s commitment to health and equity in our home state of New Jersey.



Sallie George

Sallie George is a program officer at the Robert Wood Johnson Foundation, working in several key areas to support the Foundation’s health and leadership efforts in communities nationwide.

Maisha Simmons

Maisha Simmonsdirector of New Jersey grantmaking at RWJF, is dedicated to helping New Jersey be a healthier place to live, work, and play.

Thu, 10 Mar 2022 00:01:00 -0500 Sallie George Public and Community Health National <![CDATA[Why Now is the Time to Pursue Bolder Gender Equity Policies]]>

It's time to reinvigorate our nation’s fight for gender equity. Other countries can offer inspiration and practical solutions to improve health and well-being for people of all genders within our lifetime.

Two young girls play outside.

As a mother of two girls, I often wonder what would it look like if women didn’t have to exit the workforce to cover childcare? If men taking paternity leave was the norm, rather than the exception? If our kids had more female and LGBTQ role models to look up to in elected office?

I became hopeful last year when the White House launched the United States’ first-ever National Strategy on Gender Equity and Equality—a concerted effort to make these “what ifs” a reality.

While we have seen important advances toward gender equity in the U.S, most improvements in employment, education, and income happened before the turn of the century. Progress has dwindled or stalled entirely in the past decade. The COVID-19 pandemic, which has forced women out of the workforce in record numbers, is a stark reminder of the gender inequities that still exist. It's time to reinvigorate our nation’s fight for gender equity.

Gender Equity is Good for Our Health

Today in the U.S., women experience barriers to education, income, employment, and healthcare that continue to limit our opportunities for good health and well-being. Women of color often face the greatest injustices. Take employment, for example. For every dollar White fathers were paid in 2018, White mothers made 69 cents; Black mothers made 50 cents; Native American mothers made 47 cents; and Latina mothers made just 45 cents. Addressing this pay gap can have significant health benefits, as higher incomes can lead to healthier living conditions, access to healthcare and protection from chronic stress.

Gender equity is not just a women’s issue. Transgender and nonbinary people, for instance, are too often denied the affirming and culturally competent care they need. In fact, in 2021 one in three transgender adults reported having to teach their doctor about transgender people in order to receive appropriate care. Men also experience gender discrimination. A survey revealed that men overwhelmingly value care work and want to share it equally with their partners. Yet, they often feel trapped by society’s gender norms that stigmatize taking paternity leave or carving out flexible hours for caregiving.

We cannot hope to improve health and health equity in the U.S. without ensuring that everyone, regardless of gender, has a fair and just opportunity to thrive–at work, at home, at school and in the doctor's office.

Lessons From Abroad

From Canada, to Mexico and all the way to Malawi, other nations have succeeded in transforming some of the systems that keep gender inequities in place. As the U.S. begins implementing its national gender strategy, these nations can offer insights that can help guide our approaches and strengthen our ability to close gender gaps.

The International Center for Research on Women searched the globe for policies and initiatives that have accelerated progress on gender equity and identified promising examples in four areas:

●       Political representation. In the U.S., women make up less than 30 percent of Congress despite accounting for over 50 percent of the population. Iceland and Rwanda, two countries with vastly different histories and political contexts, set out to increase women’s participation in government using the same strategy: establishing electoral gender quotas. With the help of quotas and strong grassroots organizing, including training for aspiring female leaders, these nations have rapidly achieved near-equal political participation of women. Women’s presence in office has led to a greater focus on health, education and wage parity. Vice President Kamala Harris’ arrival to the White House was a significant step toward gender equity, but how can we ensure this progress is sustained and achieved at all levels of government?

●       Economic participation. Annually, the U.S. government contributes $500 per child on early childhood care, compared with a $14,000 average in other developed nations. Without access to child care assistance, mothers are often forced to leave the workforce to provide care. Fathers spend more time at work and miss out on enriching caretaking roles. Spain has designed an early childhood education policy that has helped parents overcome both of these issues. In 1990, the country opened up public school enrollment to toddlers under the age of three. In just a few years, the number of three year olds in school skyrocketed and formal employment for their mothers increased by 8 percent. Could the same happen in the US?

●       Health. While maternal mortality rates were rising alarmingly in the U.S., they were plummeting in Estonia. The Baltic country’s vastly different approach to maternal care may explain this stark contrast in birth outcomes. All pregnant women in Estonia, regardless of residency status, receive free maternal healthcare throughout the full course of pregnancy, including prenatal care and up to three months after the delivery date. New moms in the U.S. still face the highest risk of death among high-income countries. How can we follow Estonia’s example and provide more comprehensive maternity care and postpartum support for all birthing people?

●       Education. Despite our best efforts, the U.S. is not closing the STEM gender gap at an acceptable rate. Tunisia, though traditionally considered less gender equal, had the world’s second highest share of female STEM graduates in the late 2010s. Here, teachers and parents are encouraged not to underestimate girls’ math abilities and instead affirm STEM as a field where women thrive. By systematically and steadily tracking women and girls into science and math throughout their early education, the country’s Ministry of Education is heightening their opportunity and preparation to go into these fields as adults. Could an approach like Tunisia’s help more women and girls love STEM in the U.S.?

Learning in Action at the City Level

Alongside national efforts, cities around the world are taking action to advance gender equity. Los Angeles is one such bright spot. In 2015, Mayor Garcetti signed Executive Directive No. 11, “Gender Equity in City Operations,” calling on every City department to achieve gender equity.  As the city began to transform government services and systems, from public transit and parks to its own hiring processes, it took inspiration from cities abroad including Bogota and Barcelona. Today, Los Angeles—alongside London, Barcelona, Freetown, Mexico City, and Tokyo—is a founding member of the City Hub and Network for Gender Equity (CHANGE), an effort that is helping other cities around the world apply a gender lens by sharing models for how local leaders and governments implement gender-focused and inclusive policies, and developing data and indicators to measure progress toward these goals.

It’s Time to Close the Gap

It is possible to close gender gaps—and cities and nations around the world are showing us that we can do it rapidly.  What’s more, research shows that people are healthier in countries with high gender equity. Communities, local leaders and policymakers across the U.S. should feel empowered to pursue bold strategies here at home, buoyed by the progress and lessons from abroad. We can–and must–make progress on gender equity within our lifetimes. Doing so will significantly improve health and well-being for all in the U.S.

We’re working together with global leaders and local communities to bring gender equity lessons to the U.S. from countries across the world. Join our Reimagined in America webinar on March 11 to learn more.


About the Author

Shuma Panse

Shuma Panse, senior program officer, joined the Robert Wood Johnson Foundation in February 2016, bringing extensive experience in business engagement on health, public-private partnerships, and global health.

Tue, 8 Mar 2022 10:45:00 -0500 Shuma Panse Health Disparities International <![CDATA[The Pandemic Underscored Why We Need Equitable Telemental Health Services]]>

Policies that increase access to telemental health services are key to ensuring mental healthcare is equitable and inclusive.

Online therapist talks with patient.

As a practicing social worker, I believe that mental healthcare is a right, not a privilege. LGBTQ+ and persons of color face numerous barriers to finding affirming mental healthcare and often experience racism and/or discrimination while accessing those services. Through support of the Robert Wood Johnson Foundation’s Health Policy Research program and in collaboration with my research partner Liana Petruzzi, I’m working to help shape a health and mental healthcare system where racism, homophobia, and transphobia are not tolerated or perpetuated.

The COVID-19 pandemic forced us to look at how trauma, stress, and a public health crisis combine to influence our mental health and wellness. This new reality drove the nation to significantly increase its investment in telehealth services. Now in our third year of the pandemic, we must reflect and ask ourselves if that investment is working, and more importantly, if it is equitable. We have a serious opportunity to better meet the needs of Black, Indigenous and People of Color (BIPOC) individuals and communities—needs that must not be ignored. 

Barriers in Delivering Mental Healthcare During COVID-19

In March 2020, the Centers for Medicare & Medicaid Services issued temporary waivers for telehealth services to expand access to healthcare during the pandemic. Telehealth services use remote communication technologies, such as FaceTime, Google Hangouts, or Zoom. This made it easier for people enrolled in Medicare, Medicaid, and the Children's Health Insurance Program to receive care through telehealth services while remaining safely at home.

Three weeks after the expansion, the demand was clear. Telehealth services increased by 154 percent, along with a 120 percent increase in tele-behavioral health claims in the spring. But with high demand comes the challenge of accessibility. Recent surveys suggest at least 36 percent of people in America have delayed medical or mental health treatment during the pandemic, and estimates are even higher for BIPOC individuals.

Prior to the pandemic, communities of color were already at increased risk for conditions like depression and anxiety due to structural and interpersonal racism. The pandemic, the police killings of George Floyd, Breonna Taylor, and others, as well as increased Anti-Asian and anti-immigrant hate, have all contributed to a spike in mental health conditions among Black, Asian, Latino and multi-racial adults; this spike continues to serve as reminders that structural racism persists.

We Can and Must Do Better

The mental health system was already stacked against LGBTQ+ and BIPOC communities, and those at the intersection. My clients have talked about the interpersonal racism they’ve experienced from their predominantly White therapists and how hard it was for them to find a Queer therapist of color. These stories are not unique, and for so many others seeking services, waiting months to find someone who is affirming of your identity is the final deterrent to seeking care.

While we should celebrate expanding access to telehealth services, we must be honest that simply expanding services does not address the root problem. In order to meet the need, we should reflect the current mental health infrastructure to find avenues of improvement.

One major improvement would be ensuring that future legislation intentionally ensures telehealth is equitable and accessible. Congress and the current administration should make a significant investment in technology in community health centers, training programs for BIPOC communities, and distribution of technology such as smartphones or tablets within these communities, to ensure that vulnerable communities can access telehealth services.

While some providers have returned to in-person care, the pandemic has created geographic barriers for those who seek telemental health services. COVID-19 forced people to relocate for a variety of reasons such as unemployment, gaps in childcare, or caretaking for elderly relatives, which may require moving across state lines. Mental health licensure reciprocity across state lines is needed to allow mental health providers to treat their patients even if they move. This is critical for BIPOC patients who already face challenges when finding a therapist of color; it will mean they do not have to wait even longer to find a new therapist in their new state and will be able to maintain continuity of care.

In August 2021, the Biden administration announced investments—totaling over $19 million—to be distributed to 36 award recipients through the Health Resources and Services Administration. While this is a significant investment, it will surely not meet the demand that continues as we navigate our third year in the pandemic. We need federal policies to standardize telehealth practices across insurance plans and federal funding to expand broadband internet to poor and rural areas across the country.

To further the reach, we should also look for examples at the local, state, and federal level to see where telemental health services and policies are working, and how they may be replicated. For example, New York announced a wide-ranging telehealth bill in January 2022 that would pave the way for multi-state telehealth programs, support specialist consults, and improve telehealth training. The bill included many components, including eliminating geographical restrictions in Medicaid coverage, creating an open-access continuing professional education telehealth training program, and expanding telehealth services for mental health and substance abuse treatment. New Jersey also signed legislation (S-2559) that extends the requirement that health benefits plans reimburse healthcare providers for telehealth and telemedicine services at the same rate as in-person services. Massachusetts passed legislation to permanently do the same.

Also needed is increased mental health services across healthcare and community settings, such as federally-qualified healthcare centers, schools, or community centers. This is particularly important for communities of color, non-English speaking individuals, low-income individuals and households, people with disabilities, and rural communities that may be more inclined to receive mental health services from a trusted clinic or community center. We must invest in more therapists who are from these communities, who may help patients of color to feel safer sharing mental health needs and racialized trauma experiences.

Expanding telemental health services made the impossible possible. But to truly build a Culture of Health that is equitable for all, we must fight for more equitable and culturally responsive mental health services.

Working Together to Advance Health Equity

As a current RWJF Health Policy Research Scholar, I am inspired and motivated by the work of my cohort members and other cohorts working to advance health equity. They give me hope by working together and remembering that a different reality is not only possible, but probable, if we work in an intentional community.

Meet other Health Policy Research Scholars across the nation and learn about their work.



Daniel Do.

Daniel Do is a current Health Policy Research Scholar. His hope is to be a part of the change that creates a health and mental health care system where racism, homophobia, and transphobia are not tolerated or perpetuated.

Thu, 3 Mar 2022 11:00:00 -0500 Daniel Do Healthcare Coverage and Access <![CDATA[Can We Redefine “Progress” to Center Well-Being?]]>

What can we learn from communities in the U.S. and around the world about changing the narrative on progress? What does it mean in practice to take a well-being approach?

A man rides his bike along a pedestrian only pathway.

For many months, our society has grappled with defining our “new normal.” The COVID-19 pandemic has exposed and deepened inequities that undermine well-being. Combined with a worldwide outcry for racial equity, we have been challenged to reconsider how the United States defines “progress.”

Our nation’s traditional story of progress has been limited to measures like economic growth and employment. When leaders tout our country’s successes, they cite GDP numbers, job growth, and unemployment rates.

On an individual level, a person’s bank account balance, the car they drive, and their generational wealth are heralded as markers of success. These benchmarks only tell a fraction of the human story. They also overlook how structural racism has undermined economic opportunity for communities of color among other outcomes.

What if we considered basic needs—like food, housing, education and employment—combined with needs like safety, dignity, and belonging? Together, they mean people are thriving and able to create meaningful futures. What if we made our collective well-being central to how we define and pursue progress? This means thinking of well-being holistically, encompassing everything people need to thrive and create meaningful futures, including physical and mental health, basic needs, social and emotional needs, and the well-being of our communities, our environment, and our planet.

At the Foundation, I’m part of a team that looks around the world for solutions to some of society’s biggest challenges. Last year, we partnered with RAND Corporation and Metropolitan Group to explore how communities are working to shift narratives around progress to center on a well-being approach. In this instance “narratives” refers to the collection of stories and experiences that shape our shared ideas about the world and why things are the way they are. (See the report for a full explanation.) Our hypothesis is that as long as the dominant narrative is “progress is economic growth,” it will be hard to take a different approach.

Through our work, we’ve learned how other countries are challenging the status quo by pursuing a well-being approach—that is, making decisions based on their impact on human and planetary well-being as well as economic growth, through policy, budget, and practice change, and by recalibrating narratives about what matters most. From New Zealand to the United Kingdom to Bhutan, countries are defining what well-being looks like, measuring how people are doing, and prioritizing well-being in budgets. They are demonstrating that it is possible to broaden narratives around progress to focus on well-being—which includes having a sustainable, just economy—along with a more robust and holistic set of other factors.

How are U.S. communities adopting lessons from abroad?

Last year, RAND Corporation and Metropolitan Group set out to understand how leaders across the United States could put some of these global lessons into practice. Here’s what they learned.

A food justice coalition is expanding the meaning of “economy”

HEAL Food Alliance, a national coalition of more than 2 million food justice practitioners, experts, and advocates, set out to reclaim the original meaning of the word “economy,” which stems from the Greek word meaning “management of home.”

They wanted to demonstrate that economic success should be measured by how resilient an economy is and how much it serves the well-being of its people. So, the team created a four-part video series that reimagined local economies as they relate to HEAL’s main work areas—health, environment, agriculture, and labor—lifting up their members’ voices, most of whom are excluded from mainstream narratives.

The City of Jackson, Mississippi, is framing broadband as a well-being issue

In 2017, Jackson’s city government developed a “dignity economy” model centered on well-being. The goal: to improve residents’ quality of life, ultimately laying the groundwork for new generations and businesses to thrive.

More recently, the city saw improving broadband access as a core strategy in its well-being approach. Using a well-being narrative, the team framed expanding broadband access as an investment with many economic and civic well-being benefits—from empowering residents to fully participate in democracy to offering better access to healthcare. Now, the challenge is to evaluate and discuss broadband outcomes across multiple dimensions of well-being (e.g., how it benefits social connection and mental health), not merely as an economic return on investment.

Cities across the country are applying data to bolster a well-being narrative

The National League of Cities convened leaders from across the country to help explore how the global research on well-being narratives resonates with efforts in the United States. Many cities are starting well-being work by creating an equity index to guide policy decisions. For example, the City of Charlotte’s Built City Equity Atlas helps the city set policies to prioritize investment in neighborhoods that have been under-resourced, and to identify policies that can mitigate unintended consequences such as gentrification and involuntary displacement.

For Charlotte and other cities, an equity index can be a precursor to establishing a well-being narrative because it defines and tracks all the elements of well-being, helping to make the case for a broader city goal. Municipal leaders in the United States also said they need evidence that a well-being approach will be effective and need help to counter current definitions of progress that are based on economic growth. “We have a bureau of labor,” said one participant, “but not a bureau of well-being,” pointing out current disconnects and the type of shifts needed to fully align with a well-being approach. In a separate but related project, National League of Cities also released a well-being message guide to support cities’ efforts.

Moving forward, we have the opportunity to establish a narrative about progress centered in well-being, in a way that is authentic, equity-based, and effective in shifting mindsets and actions. With this research and the work of our partners in mind, how can you advance well-being narratives in your work?

For more stories and insights, including the work of One Fair Wage and Peace First, read RAND Corporation and Metropolitan Group’s latest research, What if Progress Meant Well-Being for All? You can also explore the Foundation’s ongoing well-being learning journey.


About the Author

Karabi Achary

Karabi Acharya, who has drawn upon her expertise in anthropology, public health and systems thinking in working with the citizen sector in the United States, South Asia, and Africa, joined RWJF in 2015. She directs the Foundation's strategies for global learning as it identifies best practices in other countries and adapting them to improve the social determinants of health in communities in the U.S.

Wed, 23 Feb 2022 10:45:00 -0500 Karabi Acharya Child and Family Wellbeing International <![CDATA[What Research Tells Us About Effective Advocacy Might Surprise You]]>

Storytelling can be a powerful tool to increase support for policies; but, depending on the audience, it can also have the opposite effect.

Megaphone illustration.

As the pandemic continues, our early child care and education systems have become increasingly fragile. Decades of divestment in school buildings means that many schools are ill-equipped to confront an airborne virus. Educators and others in the workforce are calling in sick or quitting at such high numbers that some areas have called in the National Guard to help schools stay open. The strain when children are sick or when schools close is impossibly hard on working families foremost, but it also disrupts society writ large.

Parents and other advocates are speaking up to demand better solutions. They share personal stories to illustrate both where systems have failed them, and also what is desperately needed. But when is storytelling effective and when does it backfire?

We recently conducted two studies: the first looked at communication to the general public, and the second to state legislators, both designed to generate support for public investments in affordable, accessible, high-quality childcare for all. What we found might surprise you (it definitely surprised us!)

We found evidence that policy narratives (short stories that paint a mental picture of what a problem is, who is affected, and how it came to be) were particularly effective at increasing support among the general public—notably, those who were initially most opposed. However, with state legislators, we found the opposite was true: the same narratives were not effective at increasing support and, in fact, appeared to deepen existing political divides.

Why Focus on Early Childcare and Education and How We Came to These Conclusions

Narratives are a frequently used form of persuasion in policy making and are commonly recommended in advocacy strategy. However, previous research has not tested the effectiveness of narrative strategies in the context of recent debates about early childcare and education policies and programs.

To explore the effectiveness of storytelling among the general public and state legislators we crafted a narrative about the impact of accessible, affordable, and high-quality early childcare and education in the context of advancing equity. The story was highly contextual and explained the circumstances of families who didn’t have access to affordable, high-quality child care. Like many other issues, lack of access is often framed as a failing of the individual parents or caregivers rather than shortcomings in the systems and structures that benefit some communities and impede others. Informed by previous work we have done related to messaging on equity, we knew that we needed to share a story that illustrated equity by painting a picture of the inequitable experience and then what equity would look like in the solution: in this case, increased investments in high-quality and accessible early childcare and education. Our story was about society changing the odds, rather than the story we often hear about individuals beating the odds.

Increasing Policy Support Among the General Public

Our findings offer tips for engaging members of the general public, particularly those who are ambivalent or inclined to oppose childcare policies:

●      Tell stories that paint a picture about what the problem is, who is affected, and how the problem started; avoid jargon in favor of clear descriptive language.

●      Repeat simple advocacy messages that emphasize the need for affordable, accessible, high-quality childcare for all.

●      Describe structural barriers to childcare (like cost, availability, and access) and describe clear policy solutions.

●      To preserve favorable childcare policy attitudes in the face of opposition, alert audiences to the likelihood that they will hear opposition arguments and build their resistance to the opposition arguments.

●      Use highly descriptive messages structured around fundamental principles of equity (like investing more in communities that are starting with the least) and which create clear mental images about what is involved in equitable solutions to the problem, as opposed to merely naming "equity" and hoping the term will connect those dots in audience members’ minds.  These messages can resonate across the political spectrum.

Considerations for Communicating With State Legislators to Increase Policy Support

The same stories that moved public opinion undermined some state legislator support for early childhood investments. This may be a recipe for increased partisan entrenchment or skepticism about stories, since stories are commonly used by legislators themselves to persuade fellow lawmakers to support policy priorities.

So what should you do to move legislators?

●      Know your audience, their contexts and histories on the issue, and find your allies—reinforce preexisting support from those already inclined toward the policy

●      In very polarized issues, consider focusing on delivering effective messaging to the public, who can help to shape policies indirectly by influencing decision-makers.

●      Recognize that the communication and persuasive task differs for those in decision making roles as compared with those in the general public: what they need to consider differs. You will want to sculpt your overall strategy, and subsequent messages, to suit these differing needs, considerations, and contexts.

More Resources to Help Shape Communication

If you’re interested in learning more about how media and messaging help form narratives and shape mindsets in a complex, polarized and changing information environment, check out the Collaborative on Media & Messaging for Health and Social Policy. This site synthesizes research—including research that we have led—from a broad set of studies on how to shift opinions to advance health equity, while identifying potential obstacles and pitfalls to avoid along the way.

There are subtleties to advocacy messaging—there’s no one size fits all approach. But evidence demonstrates that what advocates say, and to whom, can help or hinder efforts to build a Culture of Health.

Use our Storytelling for Social Change Messaging Guide to help shape your strategy.


About the Authors

Jeff Niederdeppe is a Professor and Director of Graduate Studies in the Department of Communication at Cornell University. He is Director of Cornell's Health Communication Research Initiative (HCRI) and Co-Directs the Cornell Center for Health Equity (CCHEq).

Liana Winett is an Associate Professor and Associate Dean for Student Affairs & Community Engagement at the OHSU-PSU School of Public Health, where she teaches graduate level courses in media advocacy and mass communication for public health.


Thu, 17 Feb 2022 11:00:00 -0500 Jeff Niederdeppe