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, 13 Jun 2019 13:00:00 -0400 en-us Copyright 2000- 2019 RWJF (RWJF) <![CDATA[Helping Dads Support Their Kids’ Health and Development]]>

Research shows that children and moms benefit when dads are actively engaged in their kids’ health and development. A new study examines barriers that make it difficult for some fathers to be involved and how to overcome them.

Dad holding his smiling daughter.

This Sunday, families around the country will celebrate Father’s Day and pay tribute to the special caregivers in their lives. It’s a time when I find myself feeling especially grateful for all the positive ways my own father has influenced my life and the crucial role my husband plays in raising our daughters.

I also think about the many dads I have been lucky enough to meet throughout my life. These are the special dads who are determined to make sure that all kids--both their own and others--have every opportunity to grow up healthy and happy.

One such father who stands out for me is Steve Spencer. I learned of Steve a couple of years ago when he represented his home state of Oregon at Zero to Three’s Strolling Thunder event. The event brings together parents from across the country to meet their Members of Congress and share what babies and families need to thrive. As a single dad raising two boys, Steve is a knowledgeable and passionate advocate for the kind of supportive services parents rely on to give their kids the healthiest start.

Steve put it best when he outlined the day-to-day realities of parenting, "It's really hard to put focus in trying to figure out a way to keep the apartment and get food in these kids' bellies and so on and so forth on top of taking care of him [his four-month-old son] and not sleeping."

Despite the constant juggling that comes with parenting, Steve is just one of many fathers who takes an active role in in his children’s health and development. And, according to a recent study in the journal Obesity, if the barriers that make participation difficult were removed, more fathers (and likely more mothers and caregivers in general!) could attend the many appointments and meetings that are essential to raising healthy kids. These include prenatal and pediatric care appointments, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) visits, home visits for pregnant women and families with young children, and Early Head Start activities, all of which help form the “circle of care” of a young child’s first few years.

The study, Engaging Fathers in Early Obesity Prevention During the First 1,000 Days: Policy, Systems, and Environmental Change Strategies funded by RWJF’s national nutrition research program, Healthy Eating Research (HER), looked at ways to engage more fathers in programs and practices that could help prevent childhood obesity during a child’s earliest years. The study highlighted emerging evidence about the “unique role” fathers play in childhood obesity prevention.

One of the pieces of research it references to support this found that “increases in fathers’ participation in physical child care (e.g., giving the kids a bath and getting them dressed) and the frequency of taking children outside to walk/play (which dads tend to do more of than bathing/dressing activities) were associated with decreases in the odds of childhood obesity from age 2 to age 4.”

And, the benefits extend beyond physical health. According to a study highlighted by the National Institute for Children’s Health Quality, “when fathers are more engaged with their children, their children have better developmental outcomes ... including fewer behavioral problems and improved cognitive and mental health outcomes.”

Most families divvy up routine child-care tasks like bathing, dressing and playing, among multiple caregivers in the way that works best for them. But it’s harder to do this with the programs and appointments examined in the HER-funded study, all of which specifically integrate obesity prevention services. This is because providers manage factors such as patient access and scheduling, so parents have less control.

We know that the earlier dads are involved, the better it is for moms and babies. But we lack robust evidence and a good understanding of participation rates and levels of engagement in the programs that serve kids and families during those first few years of childhood. As the study outlines, we are more informed about barriers to involvement and potential ways to address them. Some of these barriers include:

  • Inability to schedule appointments outside of regular (9-5) working hours and long wait times in clinics. Evening and weekend availability would help all dads and moms accompany their babies to appointments whether they’re at the local WIC office or with their pediatrician.
  • Lack of materials and information with images and messages that resonate with dads. Health care provider offices, WIC clinics, and home visiting and early Head Start programs are great resources to gather information about how to care for babies. But, handouts and booklets are dominated by pictures of moms and portray mom-centric activities such as breastfeeding. This can inadvertently leave dads feeling that their participation is not important, which is clearly not the case. Developing materials that are better tailored to fathers by sharing guidance on their specific roles could help create more inclusive experiences.
  • Programs like home visiting and Early Head Start have few male providers on staff who might be more comfortable/effective working with and engaging dads. More broadly, many program and clinic staff do not have much experience or formal training on how to effectively engage fathers. Hiring more male staff and implementing a robust program-wide “father-engagement training curriculum” may improve interactions with dads during appointments.  

And, the most significant challenge, which creates and/or contributes to the smaller-scale barriers listed above is the “lack of long-term, stable funding specifically earmarked for father-engagement activities.” Funding specifically designated to engage fathers would certainly make “father-focused programming, hiring of male providers, and the ability to offer extended-hour appointments” more feasible.

In the spirit of the holiday, let’s acknowledge the many wonderful ways dads show up for their kids. Then, when Sunday comes to a close, let’s commit together to continue addressing the challenges that so many dads (and moms!) face when it comes to giving their kids the best start from their very first days.

What other steps can support fathers in playing a more active role in their children’s health? Share your ideas in the comments below!


About the author

Jamie Bussell

Jamie Bussel, MPH, a senior program officer who joined RWJF in 2002, is an inspiring, hands-on leader with extensive experience in developing programs and policies that promote the health of children and families. Read her bio.

Thu, 13 Jun 2019 13:00:00 -0400 Jamie Bussel Child and Family Well-Being National <![CDATA[Training Police to Handle Trauma]]>

This 2018 Culture of Health Prize winner helps officers and the people they serve deal with the ‘bad things’ they witness and experience every day.

A policeman meets with students.

A veteran police officer in Cicero, Illinois, is quick with an answer when the therapist asks him: “What’s the worst thing you’ve witnessed on the job?”

Instantly, it’s 2010, an icy Valentine’s Day, and Officer Joseph Melone is staring in horror as flames engulf a three-story house. Melone is an arson specialist, and when the fire subsides, it’s his job to pick through the rubble. Seven people are missing. The oldest is 20; the youngest is that man’s newborn.

Melone finds the remains of the three-day-old baby.

“The 911 call from inside that place will haunt me until the day I die,” the 47-year-old Melone, now a sergeant, recalls. “You can hear the fire crackling around the caller and nobody could get in there.”

The story spills out from Melone as part of a training to give officers with the Cicero Police Department better tools for dealing with trauma in the lives of crime victims, as well as their own. The 8-hour course was built from scratch and tailored to the needs of the Cicero Police Department by local nonprofit staff from Youth Crossroads and the domestic violence agency Sarah’s Inn, as well as a psychologist from the local school district.

The idea for the course arose from a conversation the two of us had in early 2017 about the high suicide rate for members of the Chicago Police Department, which was 60 percent more than the national average, according to the Chicago Sun-Times. While the police department in Cicero is a tiny fraction of neighboring Chicago’s—160 versus 12,000—the pressure bearing down on officers is the same.

We recognized that in a community like Cicero, which is recovering from a history of gang violence, police need the tools for dealing not only with their own exposure to trauma, but also for helping community members overcome the effects of adverse experiences. It’s a way of shifting how law enforcement approaches and interacts with the citizens they are sworn to protect.

From those conversations, we worked together to put in place a trauma training course for every officer. And officers appreciate what they have learned.

Police officers are exposed to bad things every single day. They get used to it and don’t realize it, but over time the effects accumulate.

Learn how Cicero, Illinois—a Latino-majority town—is empowering residents of all ages to improve community health.

“It’s very important for police to understand the community,” says Cicero Police Superintendent Jerry Chlada, Jr. “If we’re going to be a partner, we have to understand everything.”

In one-on-one sessions, police officers gave direct input on what the course should cover. They talked about the types of situations that had the deepest impact on them, the supports they had, and the people they felt they could talk to.

The course focuses on three areas: what is trauma; how can an understanding of it shape how police do their jobs; and how police can manage trauma in their own lives.

In the first part, the trainers give words to situations the officers have observed in the line of duty—like adverse childhood experiences (ACEs). They explain how repeated exposure to stressful or violent events can affect someone emotionally, developmentally, and physically. They walk through particular situations, like dealing with victims of domestic violence who may not want to cooperate. 

In the second part, officers are guided through how to better interact with crime victims, using a technique developed by the military known as the forensic experiential trauma interview (FETI), which aims to calm a victim or crime witness in order to draw better information about an experience.

The last part of the course turns the table and looks at how trauma affects police. When they witness violence, trauma, and death, they can develop PTSD of their own. They often think, “I shouldn’t feel like this” and brush their feelings off. To give officers somewhere to turn for help, the training ends with information on resources, including counseling services and a 24-hour crisis hotline (Serve and Protect, 615-373-8000).

The positive feedback we’ve gotten from officers after trainings is overwhelming. Now, we have a therapist on call to help officers after intense, stressful incidents, and the department has created a wellness committee and peer support program to address stress and ways to improve the health of its officers. The group would like to train officers to help each other after traumatic events, so they’ll always have someone to tell their stories to. Someone who’ll understand when they say, “I’m not feeling right.”  

Training police is just one way we’re dealing with community trauma and building resilence in Cicero. We’re also engaging parents and school personnel to help transform Cicero public schools into welcoming, safe environments for their children. In the years-long effort to build a healthier community, everyone—including police—has a role to play.

Learn more about Cicero’s efforts to build a Culture of Health.

County Health Rankings and Roadmaps, an RWJF project, is hosting a webinar on how Cicero is addressing community trauma on June 18 at 3:00 p.m. Eastern. Learn more and register.



Vincent Acevez is a 20-year veteran of Cicero, Illinois’ police department, where he is deputy superintendent of the Patrol Division. He is a member of the department’s wellness committee.

Jaclyn Wallen is a licensed clinical professional counselor at Youth Crossroads, a nonprofit that works with young people in Cicero, Illinois. She helped design Cicero Police Department’s trauma training for officers.


Thu, 6 Jun 2019 13:00:00 -0400 Jaclyn Wallen Public and Community Health <![CDATA[To Improve Health Equity, Rural America Must Be Part of the Frame]]>

What does it take to build fair opportunities for health in rural communities? A passionate advocate shares firsthand insights, as well as a new funding opportunity aimed to help build on existing lessons.

Fostering Health Equity in Rural Communities image.

My family lives in Athens, Tenn., population 13,000, and we are familiar with the truths of an economy that has changed. We shake our fists at spotty broadband and crumbling roads. And we know what it’s like to watch main street awnings turn yellow and old factory stacks rust and crack in the sun, to lose family farms to corporate agribusiness, and see health care specialists move to medical centers 70 miles up the road.

But these challenges obscure a much deeper truth about my hometown and other places in the countryside: we keep showing up in many ways and in many roles as public servants, entrepreneurs, social change agents, and keepers of community memory.

For us, the key is to acknowledge that change is inevitable, that growth is necessary, and that communities should be the drivers of their own destinies.

My hometown is a proving ground for leadership and imagination. We may not have a gig of broadband, but we know how to assemble a community potluck on the fly. We know the ins and outs of local systems and relationships, and we’re pretty good at negotiating them. We’re used to living, working, and worshipping alongside folks with whom we agree and disagree, and this gives us a head start when it comes to bridging divides and joining forces in ways that improve health, equity and opportunity.  

For example, recently our YMCA partnered with The Arts Center to provide programming to at-risk youth in after-school care. And our public library regularly links up with our local public schools to provide STEM programming and coding classes to elementary school kids.

Our extension office partners with local health care providers to offer workshops on healthy living and facilitates Tai-chi classes for all ages in public spaces across town.

And we’re seeing steady progress—through the combined efforts of small business owners, city officials, local industry, and nonprofits—to revitalize our downtown. We recently achieved accreditation as a Main Street community.

So while many rural places lack more recognizable financial and civic resources, those assets take alternative forms: personal and family relationships; cultural cohesion; connection to place; or civic and religious infrastructure. Our devotion to social and civic rituals affect our mental and physical well-being, and can even extend how long we live. And a growing body of research shows that social connection is at the heart of good health.

Make no mistake, these collaborations are driven by relationships. A wise Athenian once told me that “real change moves at the pace of relationships.”

Lessons Learned Along the Way

At a time when we are trying to understand how ZIP codes influence our health and quality of life, rural people have lessons to share about what it takes to build equity and opportunity in their communities.

Here are lessons I’ve learned in my work with the Robert Wood Johnson Foundation:

  • Work with and through local and regional intermediaries. When it comes to making change in rural communities, you have to start with the schools; community-based organizations; regional health centers; faith-based institutions; and small businesses. Small businesses, for example, play a vital role in rural America, creating roughly two-thirds of new jobs and supporting the economic and social well-being of their communities.
  • Grow and engage leaders of different kinds and at different levels to get the work done together. This isn’t about another leadership training, but about finding champions in each community and helping them develop the skills they need to facilitate change. In Well-Connected Communities, volunteer leaders are helping their neighbors be healthier at every stage of life by coming together. In Athens, we are learning how to engage new messengers in small and big ways. At our quarterly Civic Saturdays, readers and speakers are strategically selected to bring new voice and experience to our civic rituals.
  • Connect people within and across sectors and geographies for peer learning and collective action. When you bring a diversity of perspectives to the table, you are more likely to generate the right energy and strategy around the solutions rural communities need most. Within our own Rural Assembly, we represent a diversity of cultures, geographies, and ethnicities, as well as a diversity in interests and expertise for our hometowns and communities. These range from climate and energy solutions to creative placemaking initiatives, from economic transitions to restoring our democracy.
  • Develop and strengthen the infrastructure for local, state, regional and national resource and information-sharing. Urban and rural boundaries are porous and our residents are itinerant; the roads leading in and out carry people, goods, and ideas without regard to ZIP code, making the futures of rural and urban places intertwined.

How You Can Be a Part of This Journey

RWJF released a call for proposals (deadline: May 22, 2019) to identify a Rural Learning and Coordinating Center that will build on these lessons. The aim is to better connect the work happening to improve community conditions for better health in rural America; advance the research and evidence that can support this work; and identify policy and systems solutions that support change in rural places because—despite talk of divides, we belong to each other. And to advance equity where we all live, rural must be part of the frame.

Hear more from Whitney Kimball Coe at the May 2019 Life in Rural America Symposium:


Whitney Kimball Coe serves as coordinator of the National Rural Assembly, a rural movement made up of activities and partnerships geared toward building better policy and more opportunity across the country. Her focus on building civic courage in communities is directly tied to a practice of participation in her hometown of Athens, Tenn., where she lives with her husband Matt and daughters, Lucy and Susannah.

Thu, 2 May 2019 13:00:00 -0400 Whitney Kimball Coe National Rural <![CDATA[Power and Opportunity in the States]]>

State policymakers have more flexibility than ever to advance health-promoting policies and programs, and to showcase effective strategies from which other states—and the nation as a whole—might learn. RWJF helps inform their efforts through research and analysis, technical assistance and training, and advocacy.

Map of United States.

Why States Matter

States have long been laboratories for innovations that influence the health and well-being of their residents. This role has only expanded with the greater flexibility being given to the states, especially as gridlock in Washington, D.C. inspires more local action. The bevvy of new governors and state legislators who took office early this year also widens the door to creativity.

Medicaid is perhaps the most familiar example of state leadership on health. With costs and decisions shared by state and federal governments, the program allows state policymakers to tailor strategies that meet the unique needs of their residents. Among other examples, efforts are underway in California to expand Medicaid access to undocumented adults, and in Montana to connect unemployed Medicaid beneficiaries to employment training and supports.

In Washington state and elsewhere, Medicaid dollars can now cover supportive housing services, while Michigan is among the states requiring Medicaid managed care organizations to submit detailed plans explaining how they address social determinants of health for their enrollees. All of this experimentation is happening as states struggle to control the growth of their health care spending—a balancing act of immense proportions.

States are taking action on early childhood health as well. For example, while subsidized child care for low-income families is funded primarily by the federal government through the Child Care and Development Block Grant (which got a record-breaking $5.8 billion boost from Congress in 2018), states have a big say in who qualifies for subsidies and whether to offer additional supports. This can lead to substantial variation across the country. Wyoming and Minnesota, for example, maintain child care copayments of $100/month or less from a family of three earning $30,000/year,­ while 14 states offer no subsidy at all for families at that income level, meaning they must pay fully out of pocket for child care. One in four states provide additional assistance, supplementing childcare subsidies with refundable tax credits to help families cover the costs of child and dependent care.

Not all state policies have a positive influence on health. Decisions about who qualifies for public benefits, ways to generate new state revenue, and how to implement and enforce laws related to housing, education, and civil rights can put well-being at risk, particularly for marginalized populations, if they are not carefully considered. States must be vigilant about their choices and pay attention to intended and unintended consequences.

To meet that responsibility, policymakers need access to the best available evidence, lessons from other states, and data and stories that can make the case for new investments and health-promoting policies. When policymaking is fully informed, it can help close persistent gaps in well-being and lead to breakthroughs that spread to other states and even to the nation as a whole.

How RWJF Supports the States

At the Robert Wood Johnson Foundation (RWJF), we keep a close eye on what is happening in state capitols because of their crucial role in building a Culture of Health. Look no further than state budgets: health care and education typically account for the largest outlays and both, of course, are core building blocks of individual and community well-being.

To have a voice in all this, our state-level work falls into three categories:

Research and Analysis: We fund assessments of the potential impacts of policy proposals, offer guidance to help states monitor and evaluate new programs, and study the results of policies once adopted. Without such analysis, experimentation can’t lead to new knowledge.

An example is From Safety Net to Solid Ground, an Urban Institute initiative that looks at how states are responding to federal safety net reforms in the context of nutrition assistance, housing supports, and Medicaid. Part of that work tracks the effects of adding or tightening work requirements in public benefit programs. We are also exploring how state fiscal decisions affect the public’s health, essentially showing that A Good State Budget is the Best Medicine.

Technical Assistance and Training: We provide non-partisan technical support to policymakers facing tricky policy design and implementation challenges. These stages in the policy cycle are crucial but underappreciated opportunities for promoting health equity.

One of our longest running and most successful technical assistance programs is State Health & Value Strategies, which helps states transform their health and health care systems. We also support longitudinal training and peer learning opportunities for state leaders, including health agency heads, Medicaid directors, and officials involved with children’s issues.

Advocacy: We invest in coalition building, storytelling, and policymaker education (without supporting lobbying). These activities raise public and decision-maker awareness of pressing issues, explain the implications of various policy approaches, and mobilize state residents, researchers, and private sector groups to support appropriate solutions.

One of our largest state-focused advocacy efforts—Voices for Healthy Kids—has  worked to build the capacity of advocacy organizations addressing childhood obesity and has ultimately contributed to the adoption of more than 120 childhood obesity prevention policies in 46 states. We also work to advance health-promoting policies related to early education, family social and economic supports, and health care coverage.

The November 2018 elections brought 20 new governors and thousands of new and exceptionally diverse state legislators into office, making this a timely moment for outreach. While some officials have strong governing and legislative records, many are new to the policy arena. And most state legislatures operate part time, with little staff to do any legwork. All of that makes state policymakers hungry for evidence and practical lessons to inform their decisions.

At RWJF, we have just publicly released a series of information-packed issue briefs—seven on Medicaid and six on early childhood development, all written with a state policy and decision-maker audience in mind. They address the basics of program structure, financing, and operations; summarize the available research on health impacts; forecast the most pressing challenges state leaders will face; and point toward best practices from around the country. These briefs provide another set of tools to support states in implementing policies that will improve health and well-being within their own borders, and across the country, in the most equitable manner possible.  

Learn more about the role states can play in promoting health from RWJF’s new briefing series: Key Medicaid Issues for New State Policy Makers and Giving Kids a Healthy Start to Life.


About the Authors

Headshot of Giridhar Mallya

Giridhar Mallya, MD, MSHP, is a public health physician and health policy expert. Working to advance the role of policy in building a Culture of Health, particularly at the state and local level, he views the Foundation as “a national leader in marshaling the evidence used to shape policies that foster healthier people, communities, and institutions.” Read his full bio.

Tara Oakman

Tara Oakman, PhD, is a senior program officer working to improve the value of our investments in health and health care and also to help ensure that all young children—supported by their families and communities—have the building blocks for lifelong health and well-being. Read her full bio.

Thu, 18 Apr 2019 14:00:00 -0400 Giridhar Mallya Health Care Coverage and Access Health & Health Care Policy <![CDATA[Tool Informs Medicaid’s Business Case for Investing in Prevention]]>

State Medicaid agencies and managed care organizations will now be able to estimate the health impact and health care cost savings of investing in childhood obesity prevention initiatives.

Children play on a school playground.

Today, nearly 50 percent of children—over 35.5 million—are enrolled in Medicaid or the Children’s Health Insurance Program. These programs are essential to low-income children, and particularly children of color, who are more likely to lack access to other forms of health coverage. Both programs have been providing medical care to kids for about half a century.

However, the treatment of chronic illness, special needs, and adverse birth outcomes often receive higher priority attention than preventive interventions. This is because treatment for medically complex conditions drives costs in the health care system. So it is where state Medicaid agencies, and the managed care organizations (MCOs) that help them control cost, utilization and quality, invest their time and energy.

With most of the focus on treatment, it’s often difficult to make the case for community-based, family-centered prevention. But some states have started to implement prevention activities addressing childhood obesity and other areas of health promotion and disease prevention.

In Alabama, the Children’s Center for Weight Management started a program, for which it receives Medicaid reimbursement that sends nurses and social workers to assess home environments of children with obesity. Through the program, nurses provide education, counseling, and medication adherence assistance. Washington D.C. offers a program at a community center, funded in part by its local Medicaid agency that includes obesity awareness and prevention, weight management counseling, cooking demonstrations, food shopping field trips, and exercise and dance classes. These are examples of states thinking outside the box to offer health services in nontraditional ways. With some recent innovations, more states will hopefully be encouraged to follow suit.

Making the Business Case for Prevention

Both private insurance companies and public programs like Medicaid play a crucial role in the healthy development of children. It’s important they connect enrollees with services that will best help them live a healthy and happy life even when the solutions go beyond the clinical setting.

This is why Nemours Children’s Health System developed the Prevention Business Case Financial Simulation Tool and accompanying user guide. While exploring strategies for Medicaid investment in preventative health services, Nemours discovered that there was a lack of tools and resources available to state Medicaid agencies and MCOs to make a business case for investing in prevention. To help these organizations fill this need, Nemours developed the Financial Simulation tool using existing research literature and partnering with the Maryland Department of Health to test and validate the tool with Maryland Medicaid data. The Financial Simulation tool provides key “return on investment” (ROI) information to any state interested in exploring and implementing childhood obesity prevention interventions.

The tool allows states’ Medicaid agencies and MCOs to estimate the cost of investing in various childhood obesity treatment and prevention services; health care cost savings resulting from intervention; expected short and medium-term health benefits; and a timeline of savings in order to provide evidence of the business case for Medicaid obesity prevention interventions.

It will be especially useful to state Medicaid agencies and MCOs that can use this data to make the financial case for investing in childhood obesity prevention. A lack of evidence on the costs, savings, and expected health outcomes of child obesity prevention interventions inhibits investment by Medicaid and MCOs. Policymakers searching for reliable evidence to make the case for cost-effective prevention can also use the tool as a resource when deciding legislative and budget priorities. Additionally, local and state health officers can use it to build the urgent case for continued support of Medicaid and can offer solutions of how to best use limited dollars. 

Beyond the immediate benefits of the tool, it also underscores the value of prevention for Medicaid agencies and can help shift decision-making toward prevention and medium and long-term ROI for many chronic health issues. Childhood obesity is a good place to start because of its relevance to lifelong health.

In addition to considering childhood obesity prevention, one strategy many states are exploring is Medicaid financing for home visiting, which offers home/community-based prevention services for pregnant women and families with young children. A recent report titled Medicaid and Home Visiting explored different states’ approaches to financing home visiting services with Medicaid. It would be great to build the “business case model” for interventions like home visiting and others that promote children’s physical, mental and emotional development so states could learn more about the myriad benefits of investing in these approaches.  

Both patients and health systems fare better when prevention and early intervention are used to meet the triple aim: care, cost, and outcomes. And, childhood obesity is a challenge for which prevention is particularly relevant.

If you’re part of a Medicaid agency or MCO, or a policymaker or advocate working on Medicaid-related issues, we encourage you to check out the Financial Simulation tool to learn about the various cost-effective childhood obesity prevention strategies that can be implemented in your state’s Medicaid program.

Learn more about the tool to help states estimate the Medicaid and MCO costs of investing in childhood obesity prevention on Nemours’ Moving Health Care Upstream Website.


About the Author

Staff portrait of Martha Davis

Martha Davis, MSS, joined the Robert Wood Johnson Foundation in 2014 as a senior program officer. Her work focuses on the root causes of violence, including child abuse and intimate partner violence. Read her full bio.

Thu, 11 Apr 2019 13:00:00 -0400 Martha Davis Health Care Coverage and Access Child and Family Well-Being <![CDATA[A Blueprint to Help Communities Promote Equity]]>

For far too long laws and policies have been used to promote the health of some, but not all. A new guide from ChangeLab Solutions puts the blueprint for change in everyone’s hands.

A group meets in a community center.

Change is not easy and it takes time. It can be especially challenging when we’re working to change policies and systems that have been in place for decades. But we know change is necessary because many people in America still face discrimination, live in poverty, and do not have the basics they need to be healthy.

We also know that some places are making progress to replace policies that are driving inequities with new policies that can help close health gaps. Places like Newark, N.J., where a unique collaboration led by the state’s largest health care system is accelerating a movement to transform the community’s food system.

Case Study: Partnering to Tackle Food Insecurity in Newark

RWJBarnabas Health (no affiliation with the Robert Wood Johnson Foundation) is New Jersey’s largest health care system, providing treatment and services to more than 5 million residents each year. In 2017, RWJBarnabas launched a new effort to tackle underlying factors that can make it more difficult for some to be healthy. These include poor housing, unsafe streets and lack of affordable, nutritious foods.

The Social Impact and Community Investment (SICI) practice works closely with local organizations and residents to understand their needs and vision for a healthier future. Led by Michellene Davis, executive vice president and chief corporate affairs officer at RWJBarnabas, the SICI practice truly puts health equity at the forefront.

“Health equity ensures that everyone, no matter who they are, receives access to the services and supports they need,” says Davis. “It takes all of us to provide the services and sustainable system changes we need to move the needle and ensure improved outcomes.”

Watch A Blueprint for Changemakers video.

The SICI practice conducted a community needs assessment that identified food insecurity as a driver of health inequities in Newark. In the city’s South Ward alone, more than 5,000 residents receive benefits from the federal Supplemental Nutrition Assistance Program (SNAP), commonly known as food stamps.

Working with local partners, the SICI practice held convenings throughout the city’s five wards. Those events sparked discussions that informed strategies for changing the city’s policies and systems to help more low-income residents access affordable, healthy food.

Together with the Greater Newark Community Advisory Board, area nonprofits, hospitals and other local organizations, the SICI practice has helped to accelerate changes that are creating a thriving food system in Newark—including urban agriculture plots, farmers’ markets, and community gardens. The practice is also working to streamline access to SNAP, WIC and other important programs that support low-income residents.

Davis believes these accomplishments are just the beginning of their work to proactively make their community healthier. She adds, “We’re looking to serve as a model for other communities with similar issues.

Achieving a Healthier, More Equitable America Starts One Community at a Time

There are more examples like Newark—places where leaders, universities, hospitals, businesses, churches, and philanthropies are working together to create opportunities so all residents have healthier choices.

Newark is one of eight communities that partnered with ChangeLab Solutions to reshape the city’s laws and policies. ChangeLab Solutions provides technical assistance—funded by RWJF—to help state and local leaders use policy change to improve health for all residents.

Using Law and Policy to Reshape Our Communities—and Improve Health for All

For more than 20 years, the ChangeLab team has been working alongside communities to help them create lasting changes that will help all residents live a healthy life. We know many places are working to achieve equitable outcomes but are struggling with how to do it.

Changemakers graphic.

A new resource, A Blueprint for Changemakers (Blueprint), is the how-to guide that answers this question. It is grounded in our work to help residents and policymakers develop and advance home-grown solutions that reflect their lived experiences and is designed to create healthy, equitable communities.

It is a guide to educate decision-makers, practitioners, and communities about legal and policy strategies that benefit children, their families, and the communities where they live. It is a gamechanger for all of us who are working to advance health equity.

Four Guiding Principles for Health Equity

The Blueprint explains the fundamental drivers of inequity—structural racism; income inequality; poverty; disparities in opportunity and power; governance that limits meaningful participation—and provides strategies for addressing each of them. All of the strategies in the Blueprint are grounded in four guiding principles that can help inform new laws and policies intended to spur equitable outcomes.

1.    Engage Community Members

Actively involve those who will be most affected by the laws and policies you are working to change. This means ensuring that residents understand potential trade-offs and indirect consequences of policy decisions and have a say in what happens. Community convenings and other efforts that encourage regular dialogues and meaningful participation can help to build trust between policymakers and residents. This is a win-win that affords residents more control over their environment and allows decision-makers to gain support for policy changes.

2.    Build Capacity

Assess your community’s needs first. Do you need to build more awareness or do you already have the political will needed to take action? As you’re identifying partners and developing leaders, consider a broad range of stakeholders that represent the community. With more organizations and resources at the table, you’re more likely to reform policies and achieve your health equity goals.

3.    Understand the Roots of the Problem

In order to develop a shared vision and plan for a healthier, more equitable community, take steps to understand local problems and the systemic issues that are causing them. Ask questions about where and how health issues originated. Use data to describe inequities and map disparities. Work with partners to determine whether the disparities are based on race, socioeconomic status, or other factors.

4.    Align Action to Solve Core Community Problems

Work together with your partners to map out the systems and conditions that contribute to those disparities and prioritize targets for collective action. Strategically aligning your work across sectors helps prevent resources from spreading too thin; pools capital for priority actions; and ensures that the issues you’ve identified are addressed from as many directions as possible.

What Can You Do?

We believe law and policy can be one of the most effective paths forward to a healthier, more equitable America. And you don’t have to be a lawyer or an elected official to use law and policy as a tool.

A Blueprint for Changemakers is a guide for all of us. Use it to start conversations. Use it to build partnerships. Use it to transform your community into a place where everyone has the opportunity to make healthy choices.

Learn more about how you can start promoting health equity in your community with A Blueprint for Changemakers.


About the Authors

Monica Hobbs Vinluan joind RWJF in 2015 as a senior program officer, and 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.

Shauneequa Owusu is senior vice president of innovation and impact at ChangeLab Solutions, where she works at the intersection of community development and health.

Thu, 4 Apr 2019 14:00:00 -0400 Monica Hobbs Vinluan Public and Community Health <![CDATA[How Home Affects Health]]>

A safe, secure home is where health begins. To build more equitable, healthier communities, we need to boost people’s ability to afford a good place to live.

A father and daughter play on a  swingset.

A roof over our heads. Shelter from the storm. A beautiful day in the neighborhood. Home is where the heart is.

None of these phrases directly talks about health. But in our common language, we clearly recognize the centrality to our well-being and our happiness of the homes and neighborhoods in which we live.

In fact, there is a strong and growing evidence base linking our homes to our health. Where we can afford to live impacts where we live—and our neighborhood’s location can make it easier or harder to get a quality education and earn living wages, to afford to eat nutritious food, and to enjoy active lifestyles. And when we’re spending too much of our income on rent or a mortgage, that leaves little to pay for transportation to work or the doctor or to put healthy food on the table for our kids.

No one in America should have less of a chance to be healthy or to live in a safe, secure, affordable home because of how much money they make, where they live, or the color of their skin.

This year’s County Health Rankings show us we still have work to do to reach that goal. More than one in 10 U.S. households spends more than half of what they earn on rent or mortgage payments, according to the 2019 Rankings. And the Rankings show stark differences across and within counties in whether residents can live in affordable homes, especially for those with low incomes and people of color.

Housing Burden

As housing expenses have outpaced local incomes, many families experience the burden of severe housing cost—meaning they pay more than half their income on housing. The 2019 Rankings find:

  • Renters are more likely to be severely cost-burdened than homeowners.
  • For low-income renters, the burden is particularly harsh. With less income to draw on, at least 1 in 2 pays more than 50 percent of their paychecks on rent.
  • Severe housing cost burden also disproportionately impacts blacks, who are more likely to rent than own.

Severe housing costs are associated with deep health and social costs for communities, according to the 2019 Rankings. Across counties, as the share of households experiencing the burden of severe housing costs increases, there are more children in poverty, more people who don’t know where their next meal will come from, and more people in poor health.

Policy and Practice Solutions

Housing policy, including discriminatory practices such as redlining, has historically influenced place-based inequities. Today, equitable housing policy and practice can be powerful tools for giving everyone a fair shot at a safe, secure, affordable place to live that promotes their health and well-being. We must keep in mind, however, that there is no single solution to high housing costs. Every community must look at the challenges in their neighborhoods and address the most pressing needs. Some places to start include:

  • Building and preserving affordable homes and strengthening neighborhoods in ways that engage community members in local decision-making and avoid displacement of longtime residents.
  • Connecting families to resources for affordable housing, like vouchers for low-income households.
  • Increasing housing stability and reducing the risk of homelessness by ensuring basic needs are met and improving access to social services.
  • Enforcing fair housing laws.

We’ve seen such approaches work in places like the 24:1 Community in North St. Louis County, Missouri. The community came together across sectors to make affordable housing a priority. Chris Krehmeyer, president and CEO of the neighborhood development group Beyond Housing, estimated that the 24:1 Community lost six or seven percent of its 15,000 households during the 2008 foreclosure crisis and had not rebounded since then. In a place where more than nine in 10 of public-school students qualified for free or reduced-price lunch and the unemployment rate was three times the county norm, a lack of affordable housing was a major issue. The majority of residents were renters, subject to a lack of stability and risk of homelessness when faced with high rents and low incomes.

Owning a home is an important vehicle for families to build wealth for their children and grandchildren, but we know from the Rankings data that not everyone has had a fair chance to pursue this valued American dream. The nationwide rate of homeownership for white families is 20 to 30 percent higher than the rate for families of color.

So the 24:1 Community sought to make affordable home ownership possible, and build wealth to create stability and opportunity across generations. In their innovative, comprehensive approach, residents own their homes, but lease the land, which is owned by a nonprofit land trust. The houses stay affordable because the trust controls the price owners receive when they sell. Buyers receive financial and homeownership counseling before they buy and supportive services after they sign the contract. There are early signs of success with increased stability for 98 percent of Beyond Housing families with school-aged children. And since the initiative launched, youth obesity has declined in the community, and the child poverty rate has come down significantly.

The Rankings release provides a timely opportunity for every community to have its own conversations and come to the solutions that will work best there. If you’d like to learn more about policies your community could implement, resources abound, such as Local Housing Solutions from the NYU Furman Center and What Works for Health from County Health Rankings and Roadmaps.

Many sectors—private developers, health systems, philanthropy, advocacy and citizen organizations, and local governments—will need to work together on comprehensive approaches to make safe, secure and affordable housing available to all. Because we cannot thrive as a nation when the factors that contribute to good health are available to some, but denied to others.


About the Author

Amy Gillman

Amy Gillman, who joined the Robert Wood Johnson Foundation in 2017, is a senior program officer with the Foundation’s work to promote healthy, more equitable communities. She seeks to elevate community development as a key strategy to advance RWJF’s efforts to build a national Culture of Health. Read her full bio.

Thu, 28 Mar 2019 14:00:00 -0400 Amy Gillman Public and Community Health <![CDATA[Where Mental Health and Social Justice Meet]]>

A leader committed to the mental health and healing of black communities shares his insights.

Face graphic.

A few years ago, I read a painfully insightful account in the New York Times of what it means to be a black American struggling with mental health. The author vividly describes how socio-historical “trauma lives in our blood,” materializing in our daily lives, and ultimately affecting our mental health.

A groundbreaking 2017 poll that the Robert Wood Johnson Foundation (RWJF) supported offers more insight into how discrimination fuels persistent stress. This stress leads to physiological responses that raise the risk of heart disease, stroke, and diabetes. Trauma and violence are also more likely to affect the lives of boys and young men of color, often leaving them with unresolved psychological wounds.

Compounding these problems are the many barriers that prevent African-Americans from receiving adequate mental health services. These include stigma, and a lack of representation among and trust of providers.

An inspiring leader I recently met—Mr. Yolo Akili Robinson—is dedicated to addressing this very problem. Robinson received a 2018 RWJF Award for Health Equity, which honors leaders who are changing systems and showing how solutions at the community level can lead to health equity. He is the executive director of BEAM, which stands for Black Emotional and Mental Health Collective. BEAM trains health care providers and community activists to be sensitive to the issues that plague black communities. BEAM has many programs that focus on men, boys, and nongender-conforming people.

I was pleased to delve deeper into Robinson’s work in the following Q&A:

What led you to your work in mental health advocacy?

I’ve been working in public health for the past 15 years, focusing on wellness, mental health, violence prevention, and HIV/AIDS. I saw huge pieces that were missing almost everywhere. I saw people who were visiting community-based organizations and hearing stigmatizing messages. For example, when I was working at an institution in Atlanta, a young man confided in an HIV testing counselor, “Sometimes I hear voices.”

The counselor’s response was unsettling. “Oh, my God, that sounds really bad. That’s crazy. You need to talk to somebody,” he said.

As a result, the young man grew fearful, shut down, and altogether avoided discussing what troubled him. Clearly, these kinds of messages and negative terminology are re-traumatizing and made him afraid to move forward with talking to a mental health worker and getting care.

What are the top mistakes that people within organizations might make in serving black clients—from receptionists to doctors—even though they’re trying to help?

It’s important to think critically about how we subconsciously respond to black people. For example, research suggests that medical students and residents may hold and use false beliefs about biological differences between blacks and whites to inform medical judgement. This may contribute to disparities in how they assess and treat pain, leading them to make different decisions about treatment than they would for white patients.

We all grow up internalizing things we hear, whether we like them or not. BEAM's approach to unconscious bias is that all of us grow up learning racism, sexism and other “isms.” So for me as someone raised and perceived as male, it would be impossible to not, in my 37 years of life, have learned biases toward women or have been taught behaviors that encouraged me to dominate, silence, or diminish them. That's an unfortunate aspect of American culture. Instead of denying or pretending to be "color or gender blind," we need honest exploration about the toxic things we learned and this can help us unlearn them, along with ongoing assessment. For example, as a man, am I taking up too much space? How am I using my power to support women? How could I be engaging other men to stop a culture of violence against women? That work is ongoing—and that means I need to always be cognizant when I am engaging someone different that I may embody privilege in relation to them. 

Can you mention a few of the unique barriers African-Americans experiencing mental health problems encounter when seeking care?

The biggest systemic-level barriers that many black people face are access and community. When I say access, I mean having health insurance and money for a co-pay; having transportation to get to and from services (especially in rural communities); and finding culturally competent, sensitive enrollment processes that take into consideration the burden and fear that engaging therapy will bring up for many in our community.  

Another barrier is the community. When our churches teach us that we can pray it all away, or our families believe that a "whoopin" or discipline is the issue instead of legitimate psychological distress, they keep us from getting the care we need and the intergenerational trauma continues. These issues, compounded with the structural barriers of ableism, transphobia, racism, homophobia, and black mental health myths are considerable challenges.  

If I’m not paying attention to my own wellness and biases, that may become a barrier that shows up in interactions with those in my care.

BEAM responds to these barriers in many ways. Our Black Mental Health & Healing Justice Training trains educators, activists, religious leaders, and many more who work in black communities on accurate mental health information, peer support skills, and strategies to dismantle mental health myths. Our training also holds space for the unique way racism, transphobia, sexism, and homophobia impact mental health, something few other mental health literacy interventions in the country do. This intervention helps really address community-level barriers.  

For systemic-level barriers, we provide training and technical assistance to organizations to help them integrate healing justice/mental health into their direct service and operations. Our Transforming Our Systems, Transforming Ourselves initiative also specifically supports organizations with assessing the wellness of their staff, as well as how they are impacting communities. I also have to mention our Southern Healing Support Fund, which offers micro-grants to black therapists, yoga teachers, and herbalists doing care support work in the rural deep South. 

You also work with African-American college-age men, helping them address rigid masculine norms that may contribute to poor mental health. What are these issues?

The unique intersection of race and culture has led to what we now call black masculinity. This is, among other things, the idea that black men should embrace hardness, which is emotionally harmful and counterintuitive to our well-being. This notion of masculinity is perpetuated across racial and ethnic categories. However, because of the economic disadvantages for black men, there is pressure to perform in ways that are debatably more rigid than for white men.

Through our efforts around Masculinity & Mental Health Training, we work with people who identify as men, asking them, “How did you learn about masculinity, and how did that influence your relationship to your emotional or mental health? How are the women in your life impacted because of being in a relationship with a person who doesn’t want to commit to their well-being? How does that create loneliness, violence, isolation, misogyny, and transphobia?”

Our program also involves a community project, so people can bring lessons into churches, fraternities, and schools. It’s not just the 20 or 30 folks in the room [hearing these conversations]—that dialogue is going to your dad and your uncle. We’re hoping this leads to further learning and empowers young people who come to believe, “I can interrupt violence when I see my friend or my boy being disruptive, and that doesn’t make me less of a man.” We have a lot of unlearning to do, but we can be different kinds of men and people. We can create a world that centers on healing and doesn’t create harm.

You also focus on helping caretakers to look after themselves. Why?

Many of us—who are doing healing justice, mental health, or other support work in our communities—are drawn to it because of our own trauma. We may be survivors of the very issues we are trying to address, such as assault or chronic illness. We develop an altruism that leads us to become self-sacrificial in our approach toward how we nurture others. We push ourselves aside, minimizing our own needs. Healing others actually becomes an avoidance mechanism.

Also, people can say things that trigger and awaken our own anxiety, like when I talked to a man about how he beat his daughter. These aren’t always amicable clinical interactions either. When you’re facing and listening to so much distress, it lands in your heart.

If I’m not paying attention to my own wellness and biases, that may become a barrier that shows up in interactions with those in my care. I can be more aggressive or short with someone, or I can burn out and become indifferent, or so exhausted that I don’t come to work. We need to recognize this and attend to wellness and make space for it. Some of my own self-care involves getting the basic essentials like sleeping, eating healthy foods (with the occasional sweet treat), getting downtime and going to therapy, which is honestly amazing. Having an hour to focus on my feelings and processing has meant everything. This is not something extra that you do after work. This is the work.

Learn more about the RWJF Award for Health Equity.


About the Author

Headshot of Dwayne Proctor

Dwayne Proctor, senior adviser to the president, believes that the Foundation’s vision for building a Culture of Health presents a unique opportunity to achieve health equity by advancing and promoting innovative systems changes related to the social determinants of health. Read his full bio.

Mon, 11 Mar 2019 13:00:00 -0400 Dwayne Proctor Social Determinants of Health <![CDATA[How Congregations Are Getting to the Heart of Health]]>

The Southeastern San Diego Cardiac Disparities Project works with faith organizations to provide holistic heart health programs in African-American communities. Its first steps are confronting racism and building trust.

Heartbeat graphic

Editor’s Note: This post originally appeared on the National Civic League website. We are reposting it with permission this February which is Black History Month as well as American Heart Month.

The Southeastern San Diego Cardiac Disparities Project is improving the cardiovascular health of black residents in South San Diego by altering two fundamental systems that can influence their health: faith organizations and health care providers.

Elizabeth Bustos, director of community engagement for Be There San Diego, and Reverend Gerald Brown, executive director at United African American Ministerial Action Council are leading the effort. They are recipients of the 2017 Award for Health Equity, which was presented to them by the National Civic League and Robert Wood Johnson Foundation. The Award honors leaders who are changing systems and showing how solutions at the community level can lead to health equity.

The heart of this project is trust—as well as its power to heal and build. It focuses on Southeastern San Diego, the city’s African-American hub—the community experiencing the county’s highest rates of heart attack and stroke. Its goal is to improve cardiovascular health in the 6,400 black adults living there by transforming faith organizations and health care, two influencers of health.

Southeastern San Diego is comprised of a cluster of working-class neighborhoods where over fifty percent of families earn less than the self-sufficiency standard. It has barren parks, too many liquor stores and fast-food restaurants, yet just one supermarket.

Bustos and Brown were not the first people to approach black congregations in Southeastern San Diego in hopes of forming a partnership around health. But previous efforts that over-promised and under-delivered left many congregations mistrustful of such partnerships. Over the years, many pastors had opened their congregations to researchers who came then disappeared. As Senior Pastor William Benson explained, “We were concerned about people coming into the community with passion, but what they really wanted was our numbers, our data...they would put in for grants and get the money, and it never came back to the community. We were tired of being played.”

A New Approach

Where others might gloss over or ignore the legacy of race and racism in shaping health in African-American communities, Bustos and Brown recognize that these are truths that must be discussed, confronted, and considered.

Brown pledged to his fellow pastors that, “We’re going to do things differently.” And indeed, they have. Bustos and Brown took the time to listen to these concerns, to acknowledge the community’s history, and to build relationships. Work meetings became forums for candid dialogue about the roles that race, exploitation, and neglect had played—and continue to play—in the community.

The pastors demanded that the project be transparent for them to consider joining. They wanted to know what data was going to be collected, who was going to collect it, and how it was going to be used. The project director developed a data stewardship agreement that gave the pastors the transparency they wanted and ownership of their data. It took nearly a year of listening, learning, and conversations to build the trust necessary to act.

The project puts the community in the driver’s seat. It calls for each congregation to develop its own “heart-healthy plan” to reduce heart attacks and strokes, based on its unique demographics, resources and needs. The plan must have three components: nutrition education; exercise and health monitoring; and tracking participants’ blood pressure and weight. The pastors also agreed to come together once a month to learn from one another. And they agreed to meet with clinicians, particularly doctors, to share their experiences with them. To date, 20 churches and a mosque have full-fledged programs to combat heart disease and strokes, and these are as varied as the faith organizations themselves.

As Bustos and Brown explain, this approach is not simply about creating a heart-healthy intervention. Rather, “it builds a structure for African-Americans to improve their health on their terms, relying on their trusted leaders, and controlling the way they interact with other powerful entities.”

Creating a Culture of Health Within Congregations

At Immanuel Chapel Christian Church, Pastor Christian developed a plan that calls for monthly meetings on a Saturday morning with her congregants. In her opening prayer at the meetings, she tells them that scripture calls for taking care of one’s body to be able to serve God. Afterward, they take a brisk “gospel walk” around the neighborhood, singing an inspirational hymn. They pass businesses, dilapidated houses and empty lots. Each month, they add another block or two to their walk.

Next, as they settle into the pews, the congregants hear from a featured speaker, usually an African-American health professional. The speaker explains the scientific and medical causes of cardiovascular disease and offers practical, culturally appropriate recommendations.

Afterwards, the participants each have their blood pressure and weight registered by a member of the congregation who isa retired nurse. If she sees a problem, she recommends they see their doctor or may gingerly nudge them with suggestions on how to step up their efforts to lose weight. It’s low-key and nonjudgmental.

As morning gives way to noon, the participants enjoy a healthy lunch and fellowship. In a single morning, they’ve nourished their soul, fed their body, participated in group exercise, and received disease prevention information from a trusted source in a language they understand—all paving the way for them to take action in protecting their health.

This work is not only transforming mindsets about health, it connects pastors more closely to their congregations. The doctors, nurses, personal trainers, teachers, and healthy cooking aficionados that pastors find among their congregants are then invited to form health ministries. These lay leaders implement the church’s heart-healthy plan; engage congregants in self-care; and uncover health issues. To date, the congregations are tracking around 2,000 people.

In messages to their flock, the pastors regularly speak on ways to prevent heart attack and stroke with small lifestyle changes. They encourage the congregation to take steps to become healthier: “Don’t forget to stop by to get your blood pressure checked;” “I’m looking forward to next weekend’s health class;” “Remember, no fried food at our monthly reception.” Many congregants publicly announce that they are trying to eat healthier and to lose weight.

Many attendants in these congregations are in their 60s, 70s or older. It’s worth noting, however, that many are the main caretakers of their grandchildren. The project underscores that prevention begins at an early age, and that these project participants are in a position to influence a younger generation.

Trust and Transformation

The legacy of racism and neglect hangs heavily over health discussions in these congregations. Mistreatment breeds mistrust. The pastors tell stories about how some of their congregants do not trust doctors. “There is such a huge trust issue,” Christian told the health care providers at the project’s annual health summit. “People are fearful. They remember what happened to their grandmother, to their sister, their next door neighbor.”

At the same time, the clinicians expressed frustration at how some of their African-American patients do not adhere to their medication regimen, and often follow a relative’s lead, instead of taking what is prescribed.

The project has created safe spaces for clinicians, particularly doctors, to interact with faith leaders. These exchanges provide insights not easily gained elsewhere, raising awareness among clinicians of the history and culture of African-Americans—with the goal of informing all levels of health care—from the treatment of individual patients to how a health system treats a community.

At one event, the ACC/AHA Cardiovascular Risk Calculator was introduced to the health care providers, many of whom were unfamiliar with it. The online calculator estimates the risk of the patient having a heart attack or stroke depending on a variety of factors, including race. Black patients face a significantly higher risk. On the spot, many doctors expressed an interest in beginning to use it. Furthermore, these community-clinical linkages have resulted in doctors volunteering to help the health ministries.

The collective impact of this project contributes to a Culture of Health by fostering a healthy lifestyle from the ground up: Pastors raising awareness of cardiovascular disease from the pulpit; congregants taking steps to reduce their disease risk; doctors and other health practitioners becoming more aware of African-American history. As Bustos and Brown will tell you, “It all begins with a willingness to build trust in a community, and trusting its members to lead the way to lasting solutions.”

Learn more about the RWJF Award for Health Equity.


Tue, 19 Feb 2019 15:00:00 -0500 National Civic League Public and Community Health National <![CDATA[Supporting the Whole Learner in Every School]]>

Social emotional development is key to every child’s education and paves a path to life-long health. A new report shares specific recommendations for research, practice and policy to promote all students’ social, emotional and academic development.

Students in a classroom.

Dr. James Comer is a pioneer. Decades before the science of learning and development caught up to him, he understood that all children need well-rounded developmental experiences in order to seize opportunities in life. His parents hailed from the deeply segregated South, but they helped him thrive in the era of Jim Crow, investing in his social and emotional well-being and providing safe, supportive, nurturing and demanding educational experiences.

Through that lived experience and Dr. Comer’s work as a physician and child psychiatrist, he understood that one of the most important ways to support children was to focus on where they spend a substantial part of their day: schools. He also understood that many children did not have opportunities to benefit from an environment that supported their well-being and their ability to have a full learning experience. He set out to change this through a remarkable model that has earned him the moniker “the godfather of social and emotional learning.”

The fundamental basis for Dr. Comer’s work is that in order for children to realize their full potential, their diverse backgrounds and circumstances must be recognized. When schools meet children this way, students feel valued, challenged, and free to express their agency.

The research supporting Dr. Comer’s work has endured and is being amplified each year. Learning is social and emotional, and we must focus on supporting the whole learner. The positive impacts of investing in a child’s social and emotional well-being begin early in life. One major 20-year study found that kindergartners with stronger social and emotional skills—who were more likely to share, cooperate, and help peers—attained higher education and well-paying jobs as adults. These kids became healthier, successful adults.

Photo of Jennifer Ng'andu and James Comer. Jennifer Ng’andu and Dr. James Comer.
Dr. Comer describes the need to support young people’s comprehensive development based on his more than 50 years immersed in this work.

This evidence was once again brought to bear through the National Commission on Social Emotional and Academic Development (the "Commission"), for which Dr. Comer serves as honorary co-chair. The Commission released recommendations about how to ensure that children land in schools that foster their full development. 

Getting to Brass Tacks

The final report is based on what the Commission learned from school leaders, educators, parents, and young people from all over the country. It makes recommendations across research, policy, and practice and focuses on the conditions that are critical to ensure every school in the country supports the whole child.

The Robert Wood Johnson Foundation (RWJF) has been proud to support the work of the Commission since its earliest phases of planning. Its work embodies our belief that every child deserves the opportunity to thrive in safe, stable environments, starting from the earliest ages.

While the recommendations are primarily focused on schools, they also acknowledge the broader contexts in which children and youth develop. They include:

1.    Set a clear vision that broadens the definition of student success to prioritize the whole child. Success in life depends not just on traditional academics, but on social and emotional skills such as collaborating well with peers, setting and working toward goals, and being aware of how one’s emotions and actions impact others.

2.    Transform learning settings so they are safe and supportive for all young people. This is about BOTH physical and psychological safety. We need to acknowledge that students come from diverse backgrounds and experiences and be sure to create spaces and conditions in schools that are welcoming to all.

3.    Change instruction to teach social, emotional, and cognitive skills; embed these skills in academics and in schoolwide practices. School leadership can bring a strategic approach to teaching students social emotional skills at all levels. Like all skills, these take time to develop. To be effective, they must be integrated throughout the school day, and not set up as an isolated class or activity.

4.    Build adult expertise in child development. Supporting the whole learner means supporting the caregivers and educators around them as well. All school staff—teachers, administrators, counselors, paraprofessionals, and others—must have access to professional development that integrates components of social emotional learning for youth of all ages.

5.    Align resources and leverage partners in the community to address the whole child. While schools are often the focus, we know they are not the only place where this work happens. School districts and leaders need to work together to build partnerships among other groups youth interact with, whether afterschool programs, recreation centers, etc.

6.    Forge closer connections between research and practice. The practices schools and community partners use must be based on the best available evidence. In order to make that happen, we all must work to more closely connect the researchers in this field with those putting that evidence to work.

Moving Forward

The good news is that Dr. Comer is now a leader among many. In December, the Prevention Research Center at Penn State University published a research brief that nicely encapsulates what decades of research show us about the impact social emotional development can have on kids, and principles of how to do it well. Penn State has published a series of briefs over the last two years, examining social emotional learning in early childhood and at every school level. The briefs have also explored how factors like school climate impact social emotional learning, and how to approach these strategies equitably, so that all children benefit. The work Penn State is doing to synthesize research on social emotional learning will continue this year as well.

RWJF also is excited work with MDRC on further evidence related to how approaches grounded in equity and social emotional learning can support the whole learner. CASEL, the Collaborative for Academic, Social, and Emotional Learning, will continue to work with states and districts across the country, sharing practices for what works. Child Trends has just released an analysis that shows that most states have policies that support parts of social emotional learning, but that those policies can be limited. That assessment is also part of a broader, comprehensive analysis of state laws and policies that elevate how states are advancing well-being of children across the nation.  

A child’s well-being and their education are inextricably linked. Children who succeed in education have the promise of better health later in life. And children who are healthier are more likely to go to and do well in school.

Dr. Comer’s prescient vision for children was brought to bear in the Commission’s report, and hundreds of stakeholders are rallying around it. We’re one of them, because we believe that every child deserves an opportunity to be their healthiest and live the fullest life possible.   

Read the Commission’s recommendations and share your comments on how else schools can support the whole child.


ABout the Author

Headshot of Jennifer Ng' andu

Jennifer Ng’andu is the interim managing director–program at RWJF. She helps lead grantmaking activities to advance social and environmental changes that help ensure that all children and their families have the full range of opportunities to lead healthy lives, while providing a strong and stable start for every child in the nation. Read her full bio

Tue, 5 Feb 2019 14:00:00 -0500 Jennifer Ngandu Child and Family Well-Being National <![CDATA[Data Maps the Impact of Where a Child Grows Up]]>

The Opportunity Atlas allows users to interactively explore data on children’s outcomes into adulthood for every Census tract in the United States. This can inform local efforts to build equitable, prosperous, and healthier communities.

U.S. Map for Opportunity Atlas.

In the Boston Edison neighborhood of Detroit, black children raised in low-income households have grown up to have an average household income of $28,000/year as adults, and under 1 percent of that population has been incarcerated as adults. In contiguous Dexter-Linwood, just one census tract to the north, the average earnings for the same group is $17,000/year, with adult incarceration rates hovering close to 8 percent.

If some neighborhoods lift children out of poverty, and others trap them there, the obvious next step is to figure out how these communities differ. Travel to Charlotte, N.C., which has one of the highest job growth rates in America. But data reveals (surprisingly) that availability of jobs and a strong regional economy do not translate to upward mobility in this region. Children who grew up in low-income families in Charlotte have one of the lowest economic mobility rates in the nation. What does help, according to the The Opportunity Atlas (the Atlas), is growing up with less discrimination, around people who have jobs and higher incomes—but only when those factors are found in their immediate neighborhood. If they are present a mile away, it doesn’t seem to matter much according to the data.

Those findings offer a glimpse of the remarkably rich insights gleaned from the Atlas—a vast and granular body of data mapped across the United States—now available online and without charge. It builds on decades of research led by Harvard economist Raj Chetty, with support from the Robert Wood Johnson Foundation. It offers new ways to understand what drives social mobility; where significant gaps persist; and how more effective policies and practices can promote greater equity toward a Culture of Health. Most significantly, this data is openly available for use to inform localized approaches to bridge the opportunity gap.

Social Mobility Is Declining

Using data from the U.S. Census Bureau and the Internal Revenue Service (IRS), the Atlas tracks the outcomes of 20 million Americans from childhood to their mid-30s in all 70,000 census tracts with the ability to analyze findings by race, gender, and income. In the past, we could measure neighborhood wealth and poverty at a given moment, but never before could we see how early childhood experiences can influence income into adulthood.

Sadly, the new findings challenge the bedrock principle that America remains a land of opportunity for all. Two broad trends emerge. First, adjacent neighborhoods with similar household incomes and racial makeup can produce children whose adult lives veer off in very different directions. And second, in a single neighborhood, children growing up in almost identical households (in terms of income and family composition) can diverge dramatically as adults—with race being the only differing characteristic.

As we drill deeper into the Atlas data, another conclusion is inescapable: We can no longer assume that children will lead better lives than their parents, and black residents are particularly at risk for moving down the income ladder. In one Prattville, Ala., tract, for example, black children who grew up in high-income households average $19,000 in annual household earnings as adults, compared to $55,000 for white individuals from the same economic group.

Along with income, with its well-established link to health outcomes—the Atlas includes local data on educational level, housing costs, rates of employment, incarceration, and teenage births. At RWJF, we know there is a direct line from opportunity to equity to health—with access to good schools; affordable housing; safe neighborhoods; and quality health care as some of the key stepping stones. When those resources are unevenly distributed across neighborhoods—and sometimes within the same few blocks, as the Atlas illustrates—health outcomes are certain to be inequitable as well.

Data Is a Starting Point

There is much more to learn from The Opportunity Atlas, especially at the local level, where knowledge can often drive the most direct action. Chetty’s team negotiated at length with the Census Bureau and the IRS to offer open access to this vast storehouse of anonymized data. That was a highly unusual decision for scholars, because data is the coin for academic advancement, and researchers typically hold it close. Their recognition that cooperation, not competition, is the best way to mine information and improve opportunity for children across the United States is truly something to applaud.

This new tool raises as many questions as it answers. Why do low-income American Indian children in Oklahoma move into the middle class as adults in much greater numbers than the same population growing up in South Dakota? Why do children in rural Eastern Iowa have greater economic mobility than children from similar family backgrounds in urban areas—while in parts of North Carolina, the rural/urban divide is reversed? Why do Compton and Watts, both poor communities in central Los Angeles, offer such different opportunities to children who are raised there? The Atlas is only a starting point to dig deeper into these kinds of questions.

Solutions Are Local

Ultimately, every community will have to figure out how to make the best use of the available information in their own backyards. The right solution often depends on very specific local conditions, resources, and preferences.

What Chetty and his team of economists and data scientists have done is to develop an elegant methodology that maps the roots of childhood opportunity, and to provide a user-friendly design so that descriptive data from every Census tract can be accessed with just a few mouse clicks. A detailed user guide explains how to break out and compare outcomes across regions.

The platform also allows viewers to overlay their own data onto the map. Whether it is the location of liquor stores or parks, rates of asthma or pre-term births, proximity to transportation or hospitals—that feature reveals how any of those health-impacting factors, or a combination of them, correlate with upward mobility.

From there, it is up to policymakers, advocates, scholars, and other community leaders to diagnose the nature of their own challenges, and identify setting-specific solutions. For example, based on the finding that some Seattle neighborhoods offer affordable access to upward mobility, the city developed the Creating Moves to Opportunity initiative, helping low-income families use housing vouchers to relocate to these so-called “opportunity bargains.”

There are countless other ways to use the Atlas. Becky Hatter, the president and CEO of Big Brothers Big Sisters of Eastern Missouri, sees it as a tool to “truly understand the lived experiences” of families. While in Rhode Island, the data is helping a mayor make strategic decisions about where to invest in new initiatives. In Jackson, Miss., Bill Bynum, the Hope Credit Union CEO, uses the information to “more effectively target robust, affordable, and responsible financial services that strengthen communities.”

In each of these communities, very big data is being used to look at very small areas. We think that is the way forward in the drive to create healthier, more equitable, and more prosperous neighborhoods across America.

How might your community apply findings from The Opportunity Atlas? Share your ideas in the comments below.

about the author

Headshot of Kerry Anne McGeary

Kerry Anne McGeary is an award-winning professor and researcher, and is a nationally-recognized economist whose extensive research has focused on economic policy, health economics, and health services. Read her full bio.

Wed, 9 Jan 2019 14:00:00 -0500 Kerry Anne McGeary <![CDATA[Creative Communities Are Addressing Social Isolation]]>

Social connections are not just nice to have—they can significantly affect our health and well-being. Inspired by creative approaches abroad, communities across the United States are taking steps to reduce social isolation and increase residents’ sense of belonging.

A man walks over a snow covered lawn.

It’s only January and already, I’m counting down the days to spring when warm weather will arrive. The long, cold months of winter can be isolating—the snow and subzero temperatures make it difficult to get out and about. Winter is particularly tough for children who can’t go outside to play, and for newcomers from warmer climates who are not accustomed to the cold. For people who don’t have meaningful social connections, the cold weather season can exacerbate the isolation they face year-round.

Social isolation is a serious problem for many. It can lead to anxiety, depression, substance abuse, and even suicidal thoughts. Social isolation can impact our health in other ways too—by escalating unhealthy habits, stress, lack of sleep—and putting us at higher risk for coronary heart disease and stroke.

Fortunately, there are many creative ways in which communities across the United States are tackling social isolation and building a sense of community.

Who Experiences Social Isolation?

Those who don’t struggle with this challenge might be surprised at who experiences social isolation. But for others, it’s easy to be in a crowd and feel alone. Conversely, you can live on your own and be incredibly connected. While solitude is a matter of choice, social isolation happens when you feel disengaged from others; when you feel you have nobody to call on if you need help.

Social isolation can result from a major shift in one’s life course—such as moving to a new town, having a baby, or falling on hard times. Many people feel marginalized or like they don’t belong because of their gender identity, race, ethnicity, or sexual orientation. Even young people with lots of online friends and relationships can feel disconnected when the only people they feel they can talk to are miles away.

We need positive social connections and strong social support networks throughout our lives: research shows that people who have meaningful social connections are happier, have fewer health problems, less depression, and live longer.

How Communities Are Tackling Social Isolation

When we issued a call for proposals to tackle social isolation in 2017, we really captured people’s attention and imagination, received hundreds of applications, and countless inquiries. Clearly, social isolation is an issue that is keeping many of us awake at night.

Here are some examples from our grantees who have taken inspiration from overseas and are working to increase meaningful social connections and a sense of belonging in their communities:

  • Bringing public life to winter cities: The public realm offers a unique opportunity to create socially connected and physically active communities. But the lack of winter-friendly design and programming in our cities discourages residents from spending time in public spaces during the cold season. With support from 8 80 Cities, three American cities are devising creative solutions—such as heated bus stops and indoor snowball fights—to turn public spaces into places to gather, socialize, and exercise during the cold season. They will be drawing upon lessons from cities in Canada and Nordic countries, including Iceland and Norway.
  • Strengthening social networks for young people: Bullying, suicide, depression, and substance abuse rates are unconscionably high among our young people. Recognizing that social isolation is a significant risk factor, an Icelandic program has dramatically decreased smoking, drinking and drug use among teens by getting young people to spend more time with friends and family. By investing in organized sport, music, art, dance and other clubs, Iceland’s cities were able to help kids find ways to feel more socially connected and part of a group. They also educated parents about the importance of talking to their kids about their lives, knowing who their friends are, and keeping their children home in the evenings. The program transformed family life and changed the way children are raised in Iceland. Now, the United Way is bringing this program to young people in the Matanuska Susitna Borough of Alaska.
  • Connecting families living in poverty to the community: Families living in poverty often have limited social networks and are often cut off from the support and opportunities that could positively impact their health and well-being. Saúde Crianca (Child Health) helps families living in Brazil's working-class neighborhoods, known as favelas, break barriers to social inclusion—connecting them to resources such as food, job training, and housing assistance. The organization also holds monthly coaching sessions that offer psychological counseling, health education, and emotional support. The University of Maryland School of Nursing is adapting the Saúde Crianca program for poor families with children under age 3 that live in the Upton and Mondawmin neighborhoods of West Baltimore.
  • Creating a peer support network for Latino LGBTQ youth: Latino LGBTQ youth can experience rejection from family members, religious communities, and peers. This threatened sense of belonging can lead to depression, chronic stress, attempted suicide, sexual risk, substance use, and exposure to violence. Inspired by successful efforts in Brazil and Peru, 4-H at Oregon State University is training young leaders in its Outreach Leadership Institute to become allies of their LGBTQ peers. They will do this by hosting workshops where these leaders use telenovelas (soap operas) to role play scenarios in which they must address stigma and stereotyping.
  • Improving social connections for incarcerated and returning citizens: The U.S. prison system is grounded in the belief that to facilitate public safety, society must isolate people convicted of crimes from their communities, families, and social supports. But this can backfire when people return home after serving time—considering the data showing that adults in the United States are re-incarcerated at much higher rates compared to other countries. Corrections agencies and service providers are beginning to rethink the role they play in helping recently incarcerated people enhance their social connections, drawing upon successes in Europe. In New Jersey, the Jewish Family Service of Atlantic County is implementing a program that supports people who are incarcerated—or have been recently released—to form new relationships—and maintain existing relationships with friends, families, and local community members, as appropriate to their needs and wishes. Additionally, leaders from corrections agencies in Connecticut and Massachusetts are working to transform the prison system for young, incarcerated adults to help them stay or get connected to their family and community, and are better prepared to return home.

Weaving a Tighter Social Fabric

We all need meaningful social connections and to feel like we belong. This is especially true for those most susceptible to social isolation—individuals and groups that feel they don’t belong because of their gender identity, race, ethnicity or sexual orientation. Others are new mothers; immigrants; those living in rural areas; people with disabilities; and individuals and families struggling to make ends meet.

So what can each of us do to increase meaningful social connections for ourselves, family, and others in our community? How can we ensure that our families, friends, and neighbors have the connections and relationships they need to thrive?

We can start by gaining a better understanding of the importance of social connections to health and well-being. Health providers can collect information about patients' social connections during visits and then work with them to develop practical strategies. City planners can shape public spaces as places for social interaction. Schools and educators can teach students how to build and maintain friendships and relationships, and strengthen their social and emotional skills. Community-based organizations, religious congregations, and social service providers can devise programs that encourage socializing and provide the supports needed—from transportation to coaching—for people to participate.

As you make your new year’s resolutions, think about how meaningful social connections can affect well-being and health. Reach out to others who could use a helping hand or who might need someone by their side. And remember—feeling connected to family, friends, and community can help all of us to thrive.

What are you or your community doing to address chronic social isolation?


About the author

Maryjoan Ladden / RWJF

Maryjoan D. Ladden, PhD, RN, FAAN, is a nurse practitioner working on leadership for better health and global ideas for U.S. solutions. She focuses on building the capacity of leaders and the wider workforce to collaborate across sectors, organizations and communities to promote a Culture of Health. Read her full bio

Mon, 7 Jan 2019 15:00:00 -0500 Maryjoan Ladden Social Determinants of Health International <![CDATA[Healthier Communities Start With Kids]]>

Focusing on our community’s youngest residents can spark broad vision and change.

A boy works on an art project at a local community center.

The small city of Hudson is nestled in Upstate New York and home to fewer than 7,000 people. The city was hit hard by deindustrialization in the late 20th century, facing economic decline as factories closed and industry jobs left. In recent years development has surged, with the opening of antique stores, restaurants and art galleries. The city has become a popular destination for tourists and second-home owners.

While our town is often celebrated as a story of revival, development has not benefited all of our community’s residents. For example, despite the presence of several high-end restaurants, there is still no grocery store. Rising costs have increased inequity, causing displacement for many families. Public funding is often directed toward maintaining Hudson as an attractive tourist destination versus addressing the needs of local youth and families.

Our organizations here in Hudson, Greater Hudson Promise Neighborhood and Kite’s Nest, have been working in partnership with many community organizations and individuals to improve conditions for youth and families.

Last year we were one of six communities across the country that were selected to participate in Raising Places, an effort to explore and spark ideas on how to create healthier communities that are vibrant places for kids to grow up. Greater Good Studio, with support from the Robert Wood Johnson Foundation, designed and facilitated this work.

Supporting Families Where They Live

Where we live shapes how well and how long we live. To raise healthy kids, families need stability and support. Raising Places emphasized that what is good for kids is also good for communities as a whole—stable housing that is affordable and safe; robust public transportation that benefits residents of every age; public spaces that support play; and opportunities to participate in the local economy.

How communities are designed and built and the opportunities they offer, including the decisions their residents and leaders make, create paths toward or away from health and quality of life for families. Developing these opportunities by uniting community members and leaders is exactly what Raising Places was about. The project recognized that a collective effort was necessary for identifying barriers that prevent kids and families from thriving and for finding solutions tailored to each community.

Principles to Guide Community Transformation

Every community has its own challenges and assets. This was evident through the Raising Places communities, which ranged from a rural town of 450 people to an urban neighborhood of 60,000. Despite these differences, the principles we applied through Raising Places could be useful to any community:

  • Focus on children. Framing the conversation around the wellbeing of children helps bring different stakeholders together and makes it easier to address complex issues. When we approach challenges in housing and jobs from the perspective of young people, we can make more progress in ways that benefit everyone.
  • Collaborate across sectors and perspectives. An important aspect of Raising Places was encouraging collaboration among diverse groups ranging from those working in community development to public health to early care and education. Individuals from across these and other sectors worked together as part of each community’s design team and came together around prototyping initial ideas—balancing clear group structure and clear ways for individuals to contribute.
  • Engage kids and families. It was just as important to bring youth and families into the conversations around the issues that affect them. Young people are rarely engaged as experts in their own experiences, and they provide valuable ideas and energy. And it’s critical that parents, grandparents and caregivers have a voice, especially when their kids are young and unable to advocate for themselves.

How Hudson is Putting These Principles into Action

Designing communities with kids as the priority not only helps set the next generation up for success, but it creates places where we all want to live. Hudson is a great example of this.

As our community design team began work through Raising Places to address one of our biggest issue—creating employment pathways for young people—transportation kept emerging as a key challenge. For decades, transportation challenges in our community have seemed intractable.

In order to improve the transit system, our community’s youth advisory board—a group of eight teenagers—led a workshop with residents to get their input on possible bus stop locations, routes and times. With this data, a pilot program was launched over the summer that provided free bus transportation to allow kids and teen staff to get to and from various summer youth programs.

As a result, we now have a new year-round, federally-funded bus system for children and teens, launched in partnership with our county department of social services and local school district. Every day, more than 65 children and teens receive free transportation after school, allowing kids and families to take advantage of high-quality out-of-school time programs in the area.

But this is not only a story of an improved transportation system. It’s an example of what’s possible when we support youth and community to design their own solutions. It’s an example of what happens when we work in partnership across organizations and agencies, to help public systems actively listen and respond to the communities they serve.

We’re hoping this is just the beginning of continued improvement of the public transit system, which will also benefit the broader community. It all started by approaching a challenge from the perspective of young people.

As more and more residents become involved in creating solutions like these in Hudson, we hope to be able to tell a new story about Hudson: a story about how a different approach to development can benefit all residents.

Learn more about what goes into building communities that prioritize the needs of children and families, and check out other collaborative, place-based efforts that RWJF is supporting to foster safer, healthier communities for kids.

about the authors

Sara Kendall is a co-founder and the assistant director of Kite’s Nest, a center for liberatory education in Hudson, N.Y. She is also a professor at Dawson College.

Joan E. Hunt is the co-director of the Greater Hudson Promise Neighborhood, which works to support youth and families in the Hudson City School District from cradle to career.

Mon, 10 Dec 2018 11:30:00 -0500 Sara Kendall Child and Family Well-Being National <![CDATA[A Free Clinic Builds “Bridges to Health” by Treating the Whole Patient]]>

How one rural clinic addressed its patients’ complex health and social needs successfully—and cut emergency room use and costs drastically.

Dr. Steven Crane discusses a patient with a nurse.

There’s no bus service in his small town in rural North Carolina, so Dean* drives 10 miles to The Free Clinics ("Clinics") in Hendersonville every couple of weeks whenever he has money for gas.

Staff there helped him find affordable medications and treatments for cancer and for his shoulder, which he injured by falling 20 feet on a construction site. He’s unable to read due to learning disabilities, so they’ve also helped him find lawyers to file disability claims.

Dean is also one of the patients who attends the Clinics’ Bridges to Health ("Bridges") program, a drop-in group session where patients can discuss their social and emotional concerns as well as medical problems. He has battled depression since the age of five after enduring early childhood trauma. He credits the Bridges sessions, along with the Clinics’ holistic care, with easing his depression and improving his physical health, as well as “opening up avenues for me to get help.”

“They make you feel like you’re wanted. The Bridges program has saved quite a few lives. I know people who had a tough hard lick with things like substance abuse that can lead you down a path where you don’t know how to get out. The people at the clinic help you see the light. They provide that light,” he says.

Addressing Complex Needs

Nestled near the Blue Ridge Mountains, the Clinics serves Henderson and Polk counties, agricultural communities with many residents who live in rural areas or are migrants living in tent camps. Thirty-eight percent of the adult population live in families with incomes below 200% of the federal poverty line.

While volunteering with the Clinics, Steven Crane, M.D., discovered that about 255 low-income, uninsured patients in the prior year accounted for 90% of the emergency room billing at a county hospital with a population of 100,000 people.

“These were very complex patients. Almost all of them had severe mental health or behavioral problems, or both,” Crane says. Seventy percent of the patients had experienced adverse childhood experiences such as poverty or abuse that can affect mental health and learning for a lifetime. They were typically uninsured, and had difficulty making and keeping appointments and following medical advice, compounding severe medical issues and turning into “frequent flyers” to the ER, as Crane puts it.

To address these interrelated and complex needs, Crane developed Bridges. Through the program, staff remove barriers to accessing care and screen each patient to determine their health needs, willingness to engage with a group process, and openness to embracing growth and change. The staff then create an individualized care plan.

Patients work with an integrated care team, which erases specialty silos. Available staff include physicians, registered nurses, a family nurse practitioner, addiction specialist, behavioral health provider, pharmacist, occupational therapist, and patient-health advocate. Patients get free bus passes and a lunch voucher, and have immediate phone access to a case manager. Many walk two miles to the Clinics from a homeless shelter.

The Clinics are a literal haven, too, especially for those living in turbulent households or without a place to live. “For many of these folks, it was the only safe place they had. Some would come to sleep here during the day because they couldn’t at home,” Crane says.

The heart of the Bridges program is the drop-in group care visits. Participants begin with a meditative centering exercise, then talk with group leaders and each other about life problems as well as how to handle their obstinate medical issues.

Results were swift and significant. In its first nine months, the Bridges program reduced per-member ER use by 72%, and about 80% of the patients saw their underlying health conditions improve. They also made progress in social determinants of health like housing and employment. The National Association of Free & Charitable Clinics presented Crane with the RWJF Award for Health Equity in 2017 for his vision, drive, and impact

Bridges to Health Infographic

Tapping Cultural Strengths

Community support is vital to the Clinics, which has more than 1,960 patients and many other programs in addition to Bridges, including an urgent care clinic. Approximately one-third of its operating funds are raised from local donations, a third from state and local funds, and the other third from private foundations. People donate time as well as money; the program has some 250 volunteers, many licensed professionals who recruit their peers.

“Volunteers started realizing that a lot of people who get services here are the working poor. I don’t go into meetings anymore and hear them talk about ‘those people,’ they talk about ‘our people.’ That’s a groundbreaking cultural shift,” Crane says.

The patients themselves are a source of strength and support. “It’s amazing how resilient many are. When they get together they help each other with resources,” Crane says. That may include talking about how to get kids out of foster care, for example, or finding good local legal help.

Asking patients to make life goals like these helps them make holistic progress, the Clinics’ Executive Director Judith Long says, adding, “If patients merely set clinical goals for themselves, they don’t have much improvement, but if they add social, relational, or resource goals to the mix, not only do they improve on those measures, they also have health gains.”

Patients help their own communities, too. Three of the Clinics’ programs began by patient request and investment. A patient-staffed community garden on site provides hundreds of pounds of free, fresh produce to patients. Donated, repaired bicycles are available for free for patients, thanks to a Bridges participant who inspired the program and assists with some repairs.


One woman, Maria*, was devastated to receive a diagnosis of diabetes, as her native Mexican culture regards it as a death sentence. Clinics' staff responded with clinical, educational, and behavioral interventions, and also addressed social determinants with home visits from a diabetes case manager and a patient health advocate, what Long calls “whole patient engagement on multiple levels.” Maria’s health drastically improved and she no longer needs medication. She then wanted to share what she has learned with her own largely migrant community.

So in 2017, following a model developed by Microclinic International, the Clinics started a program called HealthWays that trains lay people, including patients, to deliver health education programs on chronic conditions like diabetes. In its first program year that ended in June, 77% of the 177 participants had an improvement on at least one clinical indicator such as body mass index, blood pressure, cholesterol, blood glucose, or waist circumference. Seventy-seven percent lost weight, 100% increased their activity, and 81% completed the program. Maria is now a community teacher.

“We’re looking at how we can reach our vulnerable neighbors to help them live more healthfully, so we can keep them from needing us,” Long says.

Completing the Circle

The Clinics give back. Half of its interventions are community-wide. For example, Long recently helped gather 30 local leaders to work on a community behavioral health plan. Clinics’ staff are partnering to bring in nationally recognized trainers to lead trauma-informed programming, and are supporting the Henderson County schools with their trauma-informed schools process, assisting teachers to help them access appropriate care when children need extra support.

In November, Long and Crane will open the Bridges program in the Henderson County detention center. “It will give folks a place to land. The biggest problem many [inmates] have is to transition out. Bridges will help them build relationships,” Crane says.

Rob* can vouch for that. After he got out of jail two years ago, the Clinics provided him with medicine for his emphysema and bi-polar disorder, and counselling to help with addiction and alcoholism, which “had me whupped,” he says. In the Bridges sessions, “If you’re having a problem with your meds or with somebody, you can share it and get it off your mind.”

Rob relapsed a couple of times, but says he has been clean and sober for a year now. He has a place to live and supports himself as a handyman.

“If I hadn’t gone to the Clinics I would be dead now. They rescued me,” he says.

*Names changed to protect privacy.

Learn more about the RWJF Award for Health Equity.


About the author

Headshot of Catherine Malone

Catherine Malone, DBA, MBA, is a program officer at the Robert Wood Johnson Foundation working on the Foundation’s strategy to advance health equity, and enhance diversity and inclusion. Read her full bio.

Wed, 5 Dec 2018 11:00:00 -0500 Catherine Malone Health Care Coverage and Access <![CDATA[Don’t Try to Fit Rural Health Into an Urban Box]]>

In rural areas, lack of access to adequate care can be a matter of life and death. Transforming rural health requires creative, place-based solutions and a commitment to fostering local leadership.

A corn production farm.

The amputation was scheduled for that day. John’s* uncontrolled diabetes had stopped blood flow to his lower leg. With the tissue starting to die, it seemed inevitable that his foot would have to be removed to save his life.

Thankfully, a team I work with had recently helped bring telehealth services to the rural Colorado hospital where John had been admitted. A cloud-based video system connected to electronic health records enabled his doctor to consult with an infectious disease specialist hundreds of miles away in Denver. The specialist suggested one last “cocktail” of antibiotics, to be administered by I.V. The protocol worked. John kept not only his foot, but also his livelihood as a rancher: his ability to graze cattle, grow wheat, and provide for his family.

I wasn’t always bringing life-saving services to rural hospitals. At the beginning of my career, I was using music therapy to help patients recover from traumatic brain injuries. But as I helped individuals, I became increasingly concerned by larger systemic problems, especially by how a lack of access to care affects residents of rural areas. I saw too many people die simply because they could not get adequate medical attention. Inspired by my love for the people and places of the rural West, where my family roots run deep, I refocused my career on transforming rural health and health care.


The problem of rural health care access is a very intricate web. It can’t be solved in hospitals alone.


Today I am executive director of the Eastern Plains Healthcare Consortium, a new five-hospital collaborative. In this role, I help institutions improve health care delivery through various approaches like workforce sharing, telehealth services, and expanded access to broadband internet. Through the consortium, hospitals also pool resources to buy all kinds of supplies in bulk—from surgical gloves to anti-venom for rattlesnake bites—and then share them, reducing costs for everyone. These are game-changing measures for rural health. So is increasing access to affordable, healthy food, designing flexible place-based policies, and reintegrating human services into health care delivery so that all disciplines nurture the whole person.

Melissa Bosworth What we need is broad, systematic change, and that’s going to take a long time and a lot of patience. I’m probably not going to see it all happen in my lifetime. It’s important to realize that we’re in this for the long haul. –Melissa Bosworth

Recommendations for Rural Health Equity

As vital as those interventions are, I devote much of my attention to the broader challenge of helping communities change the way they solve systemic problems. As a consultant, I work not only with hospitals but also with other nonprofits to help them shape solutions that fit the intricacies and individuality of diverse communities and circumstances.

My colleagues and I tackle a wide range of challenges, from helping resolve water-rights issues to working with clinics serving transgender people—many of whom are homeless—to assisting with the development of high-tech smart homes that help keep seniors safe by monitoring their vitals, medications, and more. The problem of rural health care access is a very intricate web. It can’t be solved in hospitals alone.

Having learned from failures and successes alike, I can offer these five recommendations for anyone interested in improving rural health access and equity:

  1. Support local leaders and customized solutions. Every rural community is unique, faces particular challenges, and must shape its own solutions. Don’t ask people to conform to a model developed for an urban area or even another rural community. The key is finding champions in each community and helping them develop the skills they need to facilitate change.
  2. Design for both community and individual. Every solution must be community-focused and must also help individual people. Legislation and tax credits, for example, can attract medical students to study in rural areas and provide incentives for health care professionals to stay. This builds community capacities while benefiting individual providers and patients.
  3. Celebrate older generations. Older community members must be honored and included as key players in crafting local solutions. In working to overcome a community’s challenges, we need older generations’ wisdom. We need to know what has worked for that community in the past and then leverage that for the future.
  4. Take the long view. As a society, we’re into quick solutions. That approach won’t work for most rural communities. What we need is broad, systematic change, and that’s going to take a long time and a lot of patience. I’m probably not going to see it all happen in my lifetime. It’s important to realize that we’re in this for the long haul. 
  5. Respect and build on rural strengths. Every day, I see the pioneering spirit that built everything west of the Mississippi. I see people rising to meet the extraordinary challenges that come with living long distances from public services. Rural communities are good at capitalizing on existing resources in creative ways.

For there to be a serious investment in rural health leadership, we need to challenge stereotypes about people in rural communities. The rural folk I know are some of the most brilliant people and some of the most open-minded. We need to recognize and celebrate them as teachers with wisdom—as champions for their own places and for our country—and see how we can assist them in transforming systems of care and improving community health. It’s a crucial shift in perspective and approach.

I feel a responsibility not only to rural communities in the West, but to the rest of the country and beyond. So I am constantly thinking about how to help other communities build their leaders and capacity. I encourage you to think about this as well.

*A pseudonym.

Wherever you work, how can you apply the ideas outlined above to help bridge gaps and overcome barriers to access?


About the author

Melissa Bosworth, an RWJF Culture of Health Leader, is Executive Director of the Eastern Plains Healthcare Consortium, Principal of Vertical Strategies, and Assistant Professor at Regis University where she aims to teach the next generation of health equity leaders.

Mon, 12 Nov 2018 14:00:00 -0500 Melissa Bosworth Health Care Coverage and Access National <![CDATA[How the Future of Work May Impact Our Well-Being]]>

The health of workers in a rapidly changing work environment is often overlooked. In a time when incomes, schedules, and health care are becoming less predictable, what are the ramifications for health?

A group of men participate in an exercise class during work hours.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as an Uber driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on TaskRabbit. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a new report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today has no paid sick leave. Two-thirds lack access to employer-based health care benefits.

And what is workplace safety when there is no workplace? In the gig economy, marketplace matching apps like TaskRabbit and others can create difficult trade-offs for workers who depend on the income. If a worker leaves a job undone because she feels unsafe in a male client’s presence, for example, or if she is asked to do a different job than she signed up for, the client can give her a one-star rating and the worker will have little recourse. When online platforms like these tie ratings to higher pay, the incentive for workers is to put the job before safety.

And more change is on the way. In the past 20 years, the growth of jobs in non-traditional firms—platform-based jobs like Uber or Task Rabbit, self-employed freelancers, and subcontractors—have far outpaced the growth of traditional firms. Some economists estimate this sector currently makes up roughly one-third of the U.S. workforce and may reach 43 percent of all U.S. jobs in the next two years.

Well-Being in the Future Workplace

All of this affects health and well-being. Our job at the Robert Wood Johnson Foundation (RWJF) is to look at emerging trends and their implications for health and health care. Through our efforts to elicit pioneering ideas around the future of work, we’ve been exploring interventions to improve well-being in the workplace.

We’ve been thinking about three areas in particular. First, we’ve been exploring how the nature and structure of work detract or contribute to our well-being. How, for example, do erratic schedules affect diet and sleep? The evidence is pretty clear that they both suffer. Long days, back-to-back shifts, and unpredictable work hours also make parenting harder and high-quality child care nearly impossible to secure. Financial instability creates chronic stress, which has a destabilizing effect on health. Not only do vacillating incomes make it difficult to afford a doctor, but the chronic financial worries have a cumulative effect on the body.

Second, our Future of Work grantees have identified numerous examples where discrimination and bias, both intentional and unintentional, go unchecked in the gig economy, and traditional worker protections are absent, deepening vulnerabilities.

Takarah, for example, cleans homes in New York City through an app called Handy. Handy’s policy protects their cleaners against “no-show” clients by paying them a kill fee so long as they remain within 500 feet of the no-show client’s home for at least 30 minutes after the scheduled start time. The app tracks their location. But for some women like Takarah, waiting can get uncomfortable, particularly when she is working in wealthy, predominantly white neighborhoods like the Upper East Side.

"It’s uncomfortable because I am black and ... I stand out” as she waits out her 30 minutes on the stoop or sidewalk near the home. “So I don’t like to be in that situation,” she told researchers of a study we funded called “Beyond Disruption.” She will sometimes opt to leave, and forfeit her kill fee for the client’s no-show. “Sometimes I don’t get paid for that and I don’t think that is fair.”

Handy’s wait policy does not take into account the way racism shapes the kinds of scrutiny and risks that people of color may face in public space.

Finally, and on a more basic level, health insurance is increasingly the responsibility of the employee to secure, particularly in low-wage work and the gig economy. Policies such as the Affordable Care Act have taken steps to address this by allowing individuals to buy affordable health care on their own. Other innovations such as portable benefits uncouple health care from an employer. The construction industry, for example, allows workers to take their health care with them when switching jobs within the industry. In other fields, customer surcharges help pay benefits. Alia, a mobile platform created by Fair Care Labs, the innovation arm of the National Domestic Workers Alliance, collects money from clients to fund benefits for house cleaners such as sick leave, disability, and life insurance.

In our work, we’ve found that employers want to do the right thing but need help finding a clear path. Therefore, we supported the development of the Good Work Code, eight simple values that begin to codify a set of rights and obligations for both workers and employers. If you’re hiring a home-care worker, what’s a fair wage and how should you treat someone? And the flip side, what is good quality work? The code is a first step in promoting good standards and being clear about what those are.

People in the United States spend half their waking hours at work. We need both vibrant economies and jobs that enable people to live the healthiest lives they can. As RWJF works to build a national Culture of Health, we will continue to study the effects of work on health and health equity and find ways to ensure the changing world of work supports good health.

For more on the gig economy read Beyond Disruption How Tech Shapes Labor Across Domestic Work & Ridehailing at Data & Society.

We’d love to hear from you. How does work shape your life and health? What kind of policies would you like to see in the workplaces of the future that promote well-being and a Culture of Health?


about the authors

David Adler

David Adler is a senior program officer working ensure that the nation’s health and health care systems meet the needs of the people they serve. In particular, Adler’s work focuses on ensuring consumers are represented in all levels of health system transformation and exploring ways to use Medicaid as a lever for building a Culture of Health. Read his full bio.

Headshot of Paul Tarini

Paul Tarini, senior program officer, focuses on exploration, discovery, learning, and emerging trends that are important to building a Culture of Health, as well as fostering connections between health and health care. Read his full bio.

Thu, 8 Nov 2018 13:00:00 -0500 Paul Tarini <![CDATA[How States Can Better Engage Medicaid Patients]]>

Experts weigh in on practical approaches for engaging Medicaid beneficiaries to ensure that services are designed to meet their needs.

People walking in a hallway of a government building.

Medicaid is the largest health care program in the United States and impacts the lives of more than 76 million Americans, nearly one-quarter of the nation’s population. The program can play a powerful role in influencing the health and well-being of individuals and families.

State Medicaid programs can only be truly successful, however, if they are responsive to the needs and priorities of the clients they serve—not providers, but patients and their families. Medicaid officials understand this. However, in the resource- and time-constrained environments in which Medicaid staff operate, finding the right avenues for gathering meaningful consumer input can be a challenge.

The Robert Wood Johnson Foundation has been trying to address these challenges through its work to transform health and health care systems. As part of these efforts, the Foundation along with the Center for Health Care Strategies recently engaged experts, including representatives from across the patient advocacy world, around this issue. These experts include leaders from Altarum, American Cancer Society Cancer Action Network, Community Catalyst, Georgetown Center for Children and Families, Nonprofit Finance Fund, and the Patient Advocate Foundation.

Here are some practical, insightful suggestions from these partners regarding how Medicaid can better engage patients in the policymaking and implementation process.

  1. Meet people where they are. Policymakers and their staff should get out of stale conference rooms and into the communities where low-income people live, work, and go to school. Visit a range of counties (those with good and poor health outcomes) to understand what is facilitating or getting in the way of helping patients achieve better health. States can prioritize program planning and budgeting for this kind of learning and outreach as part of how they do business.
  2. Go beyond traditional, formal public meetings. Think about non-traditional venues and approaches to hear from patients. Experts suggest open enrollment sessions, local radio call-in shows (e.g., the Mayor of New York City participates in an hour-long “Ask the Mayor” radio call with WNYC), events with local celebrities, and random-dial text messages to solicit feedback.
  3. Start early and “de-wonk” the conversation by using plain, clear language. Engage enrollees around their vision for Medicaid during the conceptual phase of policy development and “de-wonk” the conversation by using everyday terms. Make it a goal for average citizens to know what Medicaid can do for them.
  4. Don’t stop engagement efforts after the design stage. Yes, meet with beneficiaries and their families early during implementation to hear how changes feel on the ground, but don’t stop there. Follow up. And follow up often. Monthly implementation calls with a pre-identified set of impacted enrollees can help Medicaid troubleshoot in real time.
  5. Ensure that leadership is at the table. Leadership presence is essential. State Medicaid directors, health plan CEOs, and leaders from budget and finance must be part of these conversations and hear firsthand where policy intersects with and impacts patients’ lives. In other words, if your state Medicaid office sends staff to go out and learn in the community, make sure leaders attend too.
  6. Partner with key community stakeholders. Partner with umbrella associations of multi-sector agencies like Catholic Charities that can offer representation of different communities. These are important groups to leverage because they can reach populations that are going to be very hard for state Medicaid agencies to reach. Talk with them about engagement formats that are will work best for their constituencies.
  7. Let consumers know that their voices are heard through actions. Report back to people on the impact of their input. Share decisions that were made as a direct result of patient feedback and ideas. And do so in multiple formats. Nothing should “end” with a report on a state website.

Some states are already refreshing their approaches to engaging patients in designing system transformation efforts. For example, Massachusetts Medicaid (MassHealth) developed the One Care Implementation Council to give consumers an active role in implementing the Financial Alignment Initiative in ways that truly reflect patient preferences. The One Care Council enabled consumers to go beyond serving in traditional advisory roles and instead become deeply involved as partners to the state in program implementation.

The Council, which was comprised of a diverse group of patients, family caregivers, community organizations, and providers, helped the state work through a range of implementation issues including enrollment processes, the effective use of assessment tools and care plans, care coordination strategies, and the use of peer supports. State partners attended council meetings, ensuring that decision-makers were at the table to hear patient experience and input and could incorporate feedback into state actions.

What more can be done to engage Medicaid beneficiaries, and how can we make these ideas easier to implement? Share your ideas in the Comments section below!


About the authors

Tricia McGinnis, MPP, MPH, is senior vice president at the Center for Health Care Strategies. In this role, she oversees CHCS’ broad delivery system and payment reform portfolio, and directs the organization’s far-reaching communications efforts and unique Medicaid leadership and capacity-building programs.

Andrea Ducas, MPH, is a senior program officer with RWJF, working to help build a Culture of Health. Having joined the Foundation in 2012, she praises its “distinguished reputation in public health and health care, and its unique vantage point at the nexus of health policy development and program implementation.”

Mon, 29 Oct 2018 14:00:00 -0400 Andrea Ducas Health Care Coverage and Access <![CDATA[How Supportive Housing Uplifts Families in Crisis]]>

Irma’s troubled life culminated in being thrown down the stairs when she was six months pregnant. Thanks to a program that’s addressing system-wide change, Irma and her family are now safe and secure with a new home and a brighter future. 

Supportive Housing program case worker, Melissa Rowe (right) with her client Irma and three of Irma's four children. Supportive Housing program case worker, Melissa Rowe (in white shirt) with her client Irma and three of Irma's four children: Joel, age 5, Delicia, age 3 and Julio, age 18 months.

Editor’s Note: Although foster care placement is sometimes necessary to ensure the safety and well-being of children, research indicates that keeping families together is generally better for children, parents, and the community. Working with the Corporation for Supportive Housing (CSH), the Robert Wood Johnson Foundation (RWJF) launched the Keeping Families Together (KFT) pilot in 2007 to explore whether supportive housing can help vulnerable families grow stronger, safer and healthier so that children—and their parents—may thrive. With the release of new findings from a federal demonstration project inspired by KFT, we are resurfacing this post.  

From too early an age, Irma faced a seemingly endless series of traumatic events that life threw at her as best she could—on her own.

But after a domestic crisis left her hospitalized, homeless, jobless, and in danger of losing her infant son, Irma finally received help from a supportive housing program that changed her life.

Keeping Families Together—the RWJF-supported model for the program that helped Irma turn her life around—has become my own personal touchstone for what building a Culture of Health should look like in the real world.

Irma’s story illustrates both the power of this model and the inner resilience that so many struggling families possess.

Overcoming a Life of Pain: Irma’s Story

Irma was only 9 years old when she ran away to escape an abusive stepfather. Ultimately, she also fled a string of foster homes, and even lived on the streets of Hartford for a while when she was 12.

Eventually Irma became a single mother, sleeping in a car at night with her baby so she could drive to her job during the day and save enough money for an apartment.

Later, Irma became involved with a man who fathered three of her four children. Over time, he became physically and emotionally abusive toward her. But because she relied on him to watch her young children while she worked double shifts to support her family, Irma couldn’t afford to leave him.

She was six months pregnant with her fourth child when he pushed her down a flight of stairs. The violent act sent Irma into early labor, and her son Julio was born prematurely, with dire health problems, including a collapsed lung and an unusually dangerous form of sleep apnea. He spent the first six months of his life in the hospital; Irma was hospitalized for three months. During that time, she lost her job and her home.

A friend cared for Irma’s three older children while she recovered in the hospital, but child welfare services wanted to remove Julio because Irma no longer had the means to care for him.

And Irma admits: She had nothing.

Fortunately, while in the hospital, a case manager from Connecticut’s Intensive Supportive Housing for Families (ISHF) program visited Irma. The case manager, Melissa, invited Irma to apply for assistance. Although wary of the offer, Irma accepted.

That’s when things finally changed.

Through ISHF, Irma qualified for a permanent subsidized housing voucher. Melissa not only got Irma into a new home, but helped her furnish it and obtain the equipment and supplies she needed to care for Julio.

Today, Irma and her children are safe and strong, together. Irma’s mother helps care for her oldest son. Meanwhile, Irma has started a job as a certified nursing assistant and is taking classes for an associate’s degree. She wants to pay it forward: She hopes eventually to have a job helping troubled kids, and to one day give up her housing voucher so that another family may benefit.

Supportive Housing As a Platform for Serving Families

ISHF is part of a federal demonstration that grew out of KFT, a small but highly successful pilot program in New York. Over three years, with funding from RWJF, the KFT pilot explored whether permanent, subsidized housing with wrap-around case management services for families in crisis could stabilize those families so that they could stay together, safely, instead of losing their children to the child welfare system.

KFT is a radically different approach to families in crisis—one that both recognizes the complexity and multiplicity of challenges that so many families face and completely restructures the system for helping them, putting families at the center.

To me, it also embodies a Culture of Health in action: addressing system-wide change equitably to create opportunities for vulnerable families to live healthier lives, starting with a safe and secure home.

Although KFT recognizes the primacy of protecting children from harm, it seeks to preserve families and ensure they have access to the resources they need to remain stable and be successful. Few experiences are more traumatic for children then being removed from their families, and kids who grow up in the foster care system are at high risk for heartbreaking outcomes, including substance abuse, violence, mental illness, homelessness, teen pregnancy, suicide, and early death.

And for parents like Irma who grew up in foster care themselves, that’s the last thing they want for their children.

KFT also acknowledges each family’s unique situation and the need to customize services accordingly. Instead of focusing on what families lack and where they may fall short, the KFT model focuses on bolstering their strengths to create safe and stable environments for families and their children. It uses a team approach, bringing together resources and supports from child welfare, public housing, mental health, child development, vocational services, and other sectors to address not only the children in the family but the family as a whole.

Unfortunately, Irma’s story isn’t unique. Research shows that domestic violence is a major cause of homelessness among women and children. Up to 57 percent of homeless women report domestic violence as the immediate cause of their homelessness.

Irma’s case manager, Melissa, recognized that Irma was a good mother who loved her children, and a hard worker. She saw that Julio didn’t need to be taken from his mother to be safe and protected. But his mother needed support.

A New Start on Life

Due to her difficult path, Irma hadn’t ever envisioned a bright future for herself. “I never thought I would finish high school, or be in college,” she says. “I always thought I would be a regular mom, just struggling...I never had faith or hope.”

But supportive housing has helped her find her own strength. “Now I have faith and hope, because I’ve shown that I can do it.”

The federal demonstration found that supportive housing overwhelmingly improves housing outcomes for families while reducing the number of children removed from their families and increasing the number of family reunifications. It helps struggling families break the cycle of homelessness and achieve greater stability, but it does not solve all the challenges of being poor. Five sites—the state of Connecticut; Broward County, Fla.; Cedar Rapids, Iowa; Memphis, Tenn.; and San Francisco, participated in the demonstration.

The KFT approach is catching on, and the demonstration findings will likely help to advance it. In addition to the five demonstration sites, New Jersey and New Mexico have used the results of the pilot program to design similar programs. California has launched a $10 million KFT-inspired program and evaluation.

No child should have to grow up traumatized and abused, forced to fend for herself in a system that doesn’t recognize her strengths.

As we continue to build a Culture of Health, where everyone—no matter what their circumstances are—has a fair and just opportunity to live a healthy and productive life, let’s remember the power of system-transforming programs like KFT and how we can use that power to help families change their lives for the better.

Learn more about Keeping Families Together and how it’s bringing together housing providers and child welfare agencies to strengthen society’s most vulnerable families and protect our children.


About the author

Headshot of Kerry Anne McGeary

Kerry Anne McGeary, an award-winning professor and researcher, is a nationally-recognized economist whose extensive research has focused on economic policy, health economics, and health services. Read her full bio.

Mon, 15 Oct 2018 11:00:00 -0400 Kerry Anne McGeary Child and Family Well-Being <![CDATA[How Collaboration Fosters Safer Communities for Kids]]>

Collaborative approaches can help ensure kids grow up with a solid foundation of safety and with a support system for those who are affected by violence.

Graphic depicting child playing with blocks

As the executive director of Philadelphia Physicians for Social Responsibility in the late 1990s, I worked closely with the local police department, the Women’s Law Project, and the district attorney. At the time, these forward-thinking professionals were frustrated. They were arresting the second and third generation of families involved in the criminal justice system. I knew some of these same individuals, and their histories as survivors of childhood trauma.

We were witnessing the downstream effects of unaddressed trauma in early childhood. Children who grew up traumatized landed in the juvenile justice system first and eventually within the criminal justice system as adults.

As a result, we knew we needed to find ways of building communities that would better support young children. Could we invest more upstream, in early childhood education, for example, and in doing so help prevent violence in our communities in the long-term?

Thanks to innovators like these and reams of new research on how early trauma and later violence affect individuals over a life course, we now understand that community conditions that impede children’s healthy development can impact everyone’s safety down the line.

We’re working alongside others to continue building evidence for and examples of communities that support the well-being of children and families. There is growing momentum to implement what we know—that early adversity like extreme poverty, violence, or neglect has long-term ramifications and that early stable and nurturing relationships have lifelong benefits. One example of this effort: Cradle to Community: A Focus on Community Safety and Healthy Child Development.

A collaboration between the Prevention Institute and the Center for the Study of Social Policy (CSSP), the project connects two fields that rarely work together: community violence prevention and early childhood development.

Six Strategies for Working at the Intersection of Community Safety and Early Childhood

This work led to six recommendations for communities that are developing collaborative, place-based approaches to ensure that all of our children have a solid foundation of safety and to build a comprehensive support system for children affected by violence at any age. The Prevention Institute and CSSP developed these recommendations through the UNITY City Network and Early Childhood LINC.  

  1. Build the capacity of youth, parents, and other family members to advocate for healthy communities for their children. Healthy communities enable members to live their healthies lives possible through access to important factors such as healthy food, quality school, stable housing, jobs with fair pay and safe places to exercise and play. Community members and those directly affected by violence must be active participants in making change within their own communities to create these conditions.
  2. Educate the community on the impact of unsafe neighborhoods on children. A basic fact sheet on the brain science of child development was very helpful for local leaders, who used the information to make the case for combining work in community safety and child development.
  3. Provide training and technical assistance for providers in community safety and early childhood development to enhance their ability to work across sectors. Options include convenings, a learning lab, peer learning forums, and technical assistance to identify opportunities for change. Fact sheets, profiles, and briefs help to guide practice, policy, and innovation.
  4. Build partnerships and coalitions. Partners can include those in community development, criminal justice, education, employment, and the health care sector. Community safety and early childhood development practitioners often use different approaches in their work and sometimes literally speak different languages. Bringing these diverse groups together helps build important shared understanding of each sector’s role and opportunities to work together and builds comprehensive systems of support for all children.
  5. Change organizational practices to focus on health equity and racial justice. The Prevention Institute facilitated conversations between leaders from both sectors to help them better understand the community conditions that shape behavior and to identify areas for change. For example, community members identified changing norms about fathers and fatherhood as one area of focus. Practitioners discussed offering support to men in their roles as fathers by changing language to be more inclusive, embedding fatherhood supports into early childhood programs and violence-interruption programs, and supporting their role as fathers among men who are incarcerated.
  6. Change policy, especially state and local policy, to support safe and healthy families and communities—policies that reduce poverty, improve access to education and training for all ages, curtail the cradle-to-prison pipeline, and enhance the economic and educational environment in neighborhoods. Polices that make it possible to blend different sources of public funding are also key.

The best thing? Efforts are already underway in reform-minded locales around the country to create great places for kids. In Baltimore, for example, the city health department is building on the success of B’more for Healthy Babies, a maternal and child health strategy. They are expanding comprehensive youth safety, wellness, and health programs for children from birth to age 5.

Housing this work in the health department helped leadership see the connections between child development and outcomes for children in the public health system. In California, First 5 Alameda County is supporting a comprehensive, place-based approach to supporting children in East Oakland’s Castlemont neighborhood. The project is taking a trauma- and resilience-informed approach and is connecting violence prevention with early childhood programming, housing, career opportunities, and education.

RWJF is also supporting several other comprehensive, place-based approaches to building communities where children thrive. Raising Places, for example, is using human-centered design principles to build healthier, child-centered communities. And the Mobilizing Action for Resilient Communities program brings together locales working to translate the science of Adverse Childhood Experiences (ACEs) into policies that foster resilience. Because communities that are good for children are not just good for children, they are good for everyone.

Consider how lessons from the report can benefit your community, and share what you’re already doing to create conditions where children and families can thrive in the comments below.


about the author

Staff portrait of Martha Davis

Martha Davis joined RWJF in 2014 as a senior program officer. Her work focuses on the root causes of violence, including child abuse and intimate partner violence. She seeks to address violence through her work in strengthening families to create nurturing, healthy environments that promote children’s positive development. Read her full bio.

Wed, 3 Oct 2018 11:00:00 -0400 Martha Davis Child and Family Well-Being National <![CDATA[New Data Provides a Deeper Understanding of Life Expectancy Gaps]]>

The more local the data, the more useful it is for pinpointing disparities and driving action. The first universal measure of health at a neighborhood level reveals gaps that may previously have gone unnoticed.

A father rides with his young daughter on a pink scooter.

When Dr. Rex Archer returned to his hometown of Kansas City, Missouri, to lead its health department in 1998, he was shocked by the city’s inequities. Life expectancy for white residents was 6.5 years longer than that of black residents. Gathering more data, he estimated that about half of the city’s annual deaths could be attributed to conditions in neighborhoods like segregation, poverty, violence, and a lack of education.

I also confronted stark disparities by neighborhood in my years as Philadelphia’s health commissioner, as does most every health commissioner/director across the country. It is truly unsettling to see how small differences in geography yield vast differences in health and longevity. In some places, access to healthy food, stable jobs, housing that is safe and affordable, quality education, and smoke-free environments are plentiful. In others, they are severely limited. Data can help us better understand the health disparities across our communities and provide a clearer picture of the biggest health challenges and opportunities we experience.

Introducing New Census-Tract Level Data

The more local the data, the more useful it can be for pinpointing disparities and driving action. That is why today’s release of life expectancy estimates by census tract is so exciting. This first-of-its-kind data, compiled by the United States Small-Area Life Expectancy Estimate Project (USALEEP), is the first time life expectancy at birth estimates are available nationwide down to the neighborhood level for virtually every community in America.

Existing county- and city-level data have helped policymakers understand how people live and where they die too early. But people often tell me that these levels of data may not apply to them in more rural places with more spread-out populations—or in more metropolitan areas. Higher-level data, by averaging across neighborhoods or communities, can mask gaps in opportunities for health from block to block, neighborhood to neighborhood. Many have asked for comparisons at a more granular level to better identify and address disparities.

USALEEP, the first universal measure of health at the neighborhood level, clearly reveals gaps that may previously have gone unnoticed. In doing so, it promotes conversations at the hyper-local level about resource allocation and health equity. Community leaders can pair this data with existing county-level and city-level data to allocate resources where they may be most needed in order to support healthier, more equitable communities.

These new data are available to everyone via the easy-to-use interactive tool available above. Typing in your street address reveals the average life expectancy for a baby born in your census tract or area, if current death rates do not change. You can then compare your area to nearby neighborhoods or communities, to county- and state-level data, as well as the national average. If you have a neighbor down the street who happens to live in a different census tract, your results might even be different, which we hope will spark some conversation about the differences in conditions and opportunities for health where we live. Ultimately, we hope this will inspire residents and leaders to work together to close the gaps these data illuminate.

There is no one-size-fits-all path to health, opportunity and equity for every community. But measuring health is an important start. Back in Dr. Archer’s hometown of Kansas City, a metro area of half a million people, maps on life expectancy were created, and they were a galvanizing force for residents and city leaders to go all in to make health equity a priority. It’s even baked in to the city’s official five-year plan: longer lives for everyone in Kansas City, no matter where they live or how much money they make.

As a result, they are consistently renewing a tax to fund public health services and safety net health care; addressing school absenteeism and discipline practices; passing policies on tobacco access, healthy food procurement, and opioid abuse prevention; addressing gun violence; and elevating the importance of economic justice. From government to nonprofits, business leaders to citizen activists, health and equity are top priorities guiding their everyday decisions.

Their hope is that over time, these initiatives will improve health equity in the city. Life expectancy will not change overnight. But the data will help pinpoint where there are gaps in the opportunities to live long and live well—and serve as a catalyst for coming together for change.

Kansas City is not alone in their efforts. Life expectancy data are valuable for so many working to improve health in their communities:

  • Policymakers can use these data to prioritize funding and policy change.
  • Public health officials and non-profit hospitals can use these data to inform community health assessments and plans.
  • Community development officials and planners can use these data to identify which neighborhoods need more investment—whether it is in the form of a health clinic, a pre-school, a community center, or improved housing.

Our hope is these data will galvanize change at a more macro-level as well. For example, the primary data that determines where low-income housing is built right now is measures of poverty. Shouldn’t health and length of life help inform these decisions as well? After all, quality, affordable housing has been found to promote better health. Considering USALEEP data alongside poverty metrics could galvanize a conversation about why it is important for people to live in better quality and affordable housing and how that could help prevent poor health in the long run.

USALEEP is a powerful new tool to show how place makes a difference in our lives. Our challenge is to present it in ways that catalyze conversations about the gaps, and what to do to close them. Fire up your browsers, dig into the data, explore evidence-informed strategies that can improve life expectancy in your area, and let us hear from you.

USALEEP is a joint effort of the National Center for Health Statistics (NCHS) at the Centers for Disease Control (CDC), which prepared the data for release; the National Association for Public Health Information Systems (NAPHSIS), which gathered the vital statistics; and the Robert Wood Johnson Foundation, which funded the project.

Help us bring these data to life! Learn more about a two-million-dollar opportunity to visualize USALEEP data and provide cross-sector solutions to improve health equity.


Donald F. Schwarz, MD, MPH, MBA

Donald Schwarz, senior vice president, Program, is guiding the Foundation's strategies and working closely with colleagues, external partners and community leaders to build a Culture of Health in America, enabling everyone to live the healthiest life possible. Read his full bio.

Mon, 10 Sep 2018 15:00:00 -0400 Donald F. Schwarz Health Disparities National <![CDATA[How Will Technology Influence Community Health? Help Us Learn More]]>

A $2.4 million funding opportunity will examine how technology’s impact on infrastructure in the near future can improve health equity in the United States.

Street car stop in New Orleans.

Louisville, Ky., has one of the highest asthma rates in the United States. To better understand this problem, community leaders blanketed the city with air quality sensors and equipped more than 1,000 asthma sufferers with GPS-enabled inhalers. They also downloaded traffic data from Waze, pulled in local weather information, and used manually-collected data on city vegetation.

Together, this data revealed that people used their inhalers most on days with high temperatures and high air pollution, and in areas with heavy traffic and few trees. Using this information, local leaders are now taking steps to increase the tree canopy and reroute trucks in neighborhoods where asthma is most severe. They are also exploring changes to city-wide zoning policies to improve overall health.

What happened in Louisville isn’t just a story of effective community engagement or savvy data analysis. It is an example of how technology can be used to shape our communities for the good—and with major implications for health.

Technology is Transforming Our Communities

Digital technologies are transforming the infrastructure that underpins our communities, changing how we live, work and play. Smartphones, for example, have enabled the growth of bikeshare and rideshare services, extending mass transit systems and expanding our options for how to commute to work, visit church or attend doctors’ appointments; sometimes with the added benefit of exercise. Vast troves of data generated by sensors on our city streets, like those in Louisville, are helping reduce traffic congestion or improve air quality. And technology is informing how we allocate space for traditional community features like parks and libraries.

When we look to the future, technology’s impact on the health of our communities is even more palpable. Self-driving cars promise to radically change who has access to transportation, how we get from place to place, and may even improve safety and reduce traffic deaths. Intelligent infrastructure, the combination of data and physical infrastructure, will undoubtedly transform agriculture and can improve public health response in rural communities.

But technology’s influence on our infrastructure and health also raises some important questions:

  • How are our communities being impacted by digital technologies? Are certain innovations making it easier or tougher for some communities to access the food, transportation, housing, and economic opportunities they need to support good health? For example, as on-demand car services flourish, some cities have cut back or rerouted public transportation, making it more challenging for residents to get around.
  • Are the shifts and disruptions in infrastructure, spurred by technological innovation, helping some people more than others? While new innovations may promise largely positive effects for the privileged, they could have dramatically different implications for communities experiencing inequities. Take the explosion of monitoring devices in our public spaces: while the data they generate can guide community improvements, the notion of being constantly watched only heightens the experience of unequal surveillance for many communities, which undermines good health and well-being.
  • As we look to the future, how can we ensure new and emerging technologies create, rather than hinder, opportunities for everyone in America to live a healthier life? While autonomous vehicles may make our roads safer, they will likely mean a loss of jobs for taxi and other drivers, and new, unanticipanted dangers for pedestrians. How can we best enhance the good and mitigate the bad effects of these innovations?

We Want to Hear From You

We’re seeking proposals that explore how tech-driven changes to our infrastructure might impact health in the near future, and how emerging technologies can be harnessed to transform infrastructure in ways that could improve health in diverse communities across America. We’re interested in funding a variety of projects from a wide range of researchers, advocates, community groups and city leaders, among others—whether responding to a lack of research evidence or policy framework, or planning a new intervention.

I asked a few of my colleagues what questions related to technology, infrastructure, and health were top-of-mind:

  • Jamie Bussel: How can data-driven technologies transform our food supply chain to increase access to healthy, affordable food and reduce food waste?
  • David Adler: Will “smart” cities and homes allow older people to stay independent and in their homes longer? Can high-tech communities improve health and well-being for older people who may need help with some aspects of daily life?
  • Paul Tarini: Will big data marketing influence our perceptions of health and what we need to do to keep ourselves, our families, and our communities healthy?
  • Deborah Bae: As more consumers shop online, will local businesses—which are often the backbone of communities—fail to thrive? How will this impact lower-income communities who often rely on local businesses for economic opportunities or basic needs like groceries and sending mail?
  • Steve Downs: How might Internet of Things technologies, such as connected sensors, digitally-controlled environments and robotics, change the way our residential spaces are designed and function?

These are just a few examples of the types of questions we think you could help us answer—we know there are many more to tackle. We’re counting on you to tell us where we should explore and help us anticipate the future so we can build a Culture of Health together.

The next Call for Ideas application opens on January 2, 2019. Learn more on our Pioneering Ideas Brief Proposal page.


About the Author

Headshot of Trene Hawkins

Trené Hawkins works with visionaries from various disciplines to discover new thinking about how to transform health and health care. Read her full bio.

Wed, 5 Sep 2018 10:00:00 -0400 Trene Hawkins Public and Community Health <![CDATA[Can Capturing More Detailed Data Advance Health Equity?]]>

How we measure America’s rapidly expanding diversity has critical implications for the nation’s health. A new PolicyLink report offers recommendations for improving how we collect and report data about racial and ethnic subgroups.

Does the kind of data we collect and report ensure everyone has a fair and just opportunity to live their healthiest life possible?

As the country grows more ethnically and racially diverse, there is a growing debate among health researchers about the value of breaking down data in more refined ways. The argument is that simply looking at health outcomes through the lens of broad racial or ethnic categories (e.g., black people or Asian Americans) doesn’t paint an accurate enough picture of health and well-being. It masks what’s happening within subgroups and glosses over the nuanced experiences that greatly influence outcomes in these populations.

Recently, the Robert Wood Johnson Foundation (RWJF) partnered with PolicyLink to identify the needs and gaps in how ethnic and racial data are collected, analyzed, and reported for each of the major aggregated ethnic and racial groups.

Chinatown Y Community Meeting

The Need for More Culturally Sensitive Data

When data are broken down by detailed racial and ethnic subgroups, or disaggregated, a more representative picture of health emerges.

In fact, for decades, the research community has agreed that it would be better to disaggregate health data. The reality is, however, that there are challenges to doing this well. Disaggregating data in research studies can result in very small sample sizes, for instance, which makes it difficult to measure outcomes accurately. Consequently, study participants are often lumped together into one of five distinct groups: black, white, American Indian, Latinx, or Asian American/Pacific Islander.

But the U.S. population is much more diverse than that and each person’s history and experiences are more nuanced, all of which can influence risk factors and health outcomes.

Case in point: Asian Americans account for 17 million people and nearly half of all refugees who arrived in the United States between 2000 and 2010. The experiences of someone who is a refugee, for example, is very different than a fourth-generation American or someone who immigrated for graduate studies.

 A July 2018 analysis showed that Asian Americans are now the most economically divided racial or ethnic group in the United States. There are a disproportionate number of Asian Americans in the top 10 percent of the U.S. income spectrum. But there are disproportionately more Asian Americans in the bottom 10 percent as well.

Use of aggregated data points related to health, education, and economics perpetuate the model minority myth that all Asians are healthy, affluent, and well-educated. It obscures the very real challenges that many people within Asian American communities face. Consequently, fewer resources are devoted to subgroups who are faring poorly.

There are many other examples of how broad racial/ethnic designations mask the social, cultural, and economic complexity of a group:

  • There are 562 federally recognized Indian nations in the United States. In addition to members of these tribes differing ethnically, culturally, and linguistically, they can live on or off reservations, which influences their access to health services and other major resources.
  • Forty-two million people in the United States self-identify as black or African-American. While most of them have lived in the United States for generations, more than three million are immigrants, mostly from different parts of Africa or the Caribbean.
  • The Hispanic/Latino population makes up about 16 percent of the U.S. population, and about three-quarters self-identify as Mexican, Puerto Rican, or Cuban, which represent strikingly different cultures and histories.
  • Individuals self-identifying as white represent more than two-thirds of the U.S. population and the cultural diversity of three continents (North America, Europe, and Africa).

By producing disaggregated data for detailed groups, you can always combine the data to produce summarized data on the entire group. However, the reverse is not true. You can’t get detailed data from aggregated data.

And without accurate data by detailed racial/ethnic group, some of the most disadvantaged in our communities are rendered invisible to policy makers, leaving their critical needs unmet.

Improving the Data Collection Process

Can changing the kinds of data we collect data advance health equity? Certainly. By no means is that a simple task. The Counting the Nation report Counting A Diverse Nation: Disaggregating Data on Race and Ethnicity to Advance a Culture of Health recommends sensitivities to consider, methodologies for researchers, as well as policies for government agencies to adopt.

Everyone has a part to play. We started working with the Asian and Pacific Islander American Health Forum to look at disaggregated rates of Asian American children who are overweight and obese. While prior research has concluded that childhood overweight/obesity rates were low among Asian Americans as a whole, this project documented significant differences across Asian American subgroups.

We’re exploring options for the next phase of our work in this space. Possible activities would include supporting advocacy for policy change at the state level, as well as state- and local-level training for demographers to learn how to better collect, analyze, and report on health data across different ethnic and racial groups.

Data drives action. And the way we collect those data will determine who gets the resources to make change happen. Further, as a research community, we must look for opportunities to disaggregate data in ways that are sensitive to the cultural, political, and social issues in our environment. In doing so, we need to collect, analyze, and report data in ways that do not put respondents at risk or perpetuate existing stereotypes.

Listen to a recording of a September 2018 PolicyLink webinar of a discussion around the findings in the Counting the Nation report, the pros and cons of disaggregating data, and what researchers need to move the field forward.

about the author

Tina Kauh

Tina Kauh joined the Robert Wood Johnson Foundation in 2012. In her role as a Research-Evaluation-Learning senior program officer, she evaluates the work of grantees, develops new research and evaluation programs, helps to develop and monitor performance indicators, and disseminates lessons learned. Read her full bio.

Thu, 30 Aug 2018 13:00:00 -0400 Tina Kauh <![CDATA[Community Resilience in the Eye of a Storm]]>

When Hurricane Harvey hit Houston in 2017, officials from Harris County Public Health had to get creative. Here’s how they kept Houstonians healthy in the wake of the storm and what they learned in the process.

Graphic of boots.

One year ago, in August 2017, Hurricane Harvey made landfall and then refused to leave. Hovering over Harris County, Texas—home to Houston—it dumped 1 trillion gallons of water, the equivalent of 40 million swimming pools, on the county’s 1,778 square miles. One community saw 10 inches of rain in 90 minutes. Drainage systems—all systems for that matter—failed or were disrupted in unfathomable ways. Water was as high as streetlights in some places. Potentially poisonous chemicals and dangerous bacteria surged through residential areas. People were trapped by flooded roads. Homes and lives were destroyed.

Those 10 days—from August 25 when the storm made landfall until September 4 when the sun finally returned—were some of the most challenging of Umair A. Shah’s career. Umair A. Shah, MD, MPH, is a physician, an emergency responder, and most importantly the executive director of Harris County Public Health (HCPH). HCPH is the county health department for the 3rd largest county in the nation serving 4.7 million people. He and his staff were in rapid response mode leading up to the storm, during the storm itself, and for several weeks in the recovery phase of the storm, often operating 24/7.

During a visit to the Robert Wood Johnson Foundation (RWJF), I had the pleasure of discussing Harris County’s response with Dr. Shah. “My staff came every day to do their jobs,” he told me, “while they too wondered about their own homes or how their family members were faring. I am so amazed by their absolute dedication to the needs of our community despite it all.” Dr. Shah himself drove 2,200 miles in 10 days visiting neighborhoods that were heavily impacted from the storm.

While surveying the damage, Dr. Shah was also reminding Harris County residents of how to stay safe after the storm. He informed them of a newly formed fleet of HCPH mobile outreach “Health Villages” that his department set up where they could get vaccines, food, and cleaning supplies. Dr. Shah offered some pearls of wisdom he has taken from the experience that he hopes to share with others working in public health. Here are the four major lessons:

Lesson 1: Take Public Health to the Public

Hurricane Harvey ravaged many homes, neighborhoods, and stores, leaving families without basic supplies. To address their needs Dr. Shah and his team took services directly to them. “We knew our communities, especially the most vulnerable, were not mobile so we simply had to be mobile for them,” he said. “Our tagline was ‘taking public health to the public.’”

Teams went door-to-door and fast-tracked a fleet of recreational vehicles (RVs)—outfitted as “Health Villages"—that they had planned to unveil later in the year. One of the RVs functioned as a roving mosquito museum that had been created for Zika virus prevention. It offered insect repellant and educated people (especially children) on how to reduce mosquito breeding sites. Others handed out food donated by the food bank and cleaning supplies along with information on how to properly clean mold. There were also PlayStations®, which turned out to be a big draw for kids as well as a chance to discuss immunizations and health screenings with parents.

Dr. Shaw of the Texas Harris County Public Health Department.

Our mobile units will be out this weekend bringing wellness and health services to more communities in need! Follow us to see where we headed next! @hcphtx on all Social Media.

Our mobile units will be out this weekend bringing wellness and health services to more communities in need! Follow us to see where we headed next! @hcphtx on all Social Media.

Other “Health Villages” had pet microchipping stations and offered vaccinations for cats and dogs. “[N]ot everyone thinks of their own health,” Dr. Shah said, “but they do think of their pet’s health.” Once there, the public health team could talk about many other public health issues: proper clean-up, how to protect against E.coli, how to cope after a disaster and other health concerns that residents faced after the disaster. The team also produced short “one-minute” videos on a variety of topics and uploaded them to YouTube. Which led to lesson #2.

Lesson 2: Communicate and Engage

Dr. Shah believes social media is the “public health communication tool of tomorrow that is available to us today.” In addition to YouTube, Dr. Shah’s team used Twitter, Facebook, Instagram, and other platforms to get the word out about safety, updates and response activities. They also used social media to put out calls for assistance. When hand sanitizers were not available through the official response channels, Dr. Shah’s team tweeted directly at corporate Twitter handles. Wal-Mart, H-E-B, and Whole Foods stepped up as did others. Grocery stores, local restaurants and the faith community, they all came to the rescue after calls went out on social media, Dr. Shah said.

“We’d say on Twitter, we need X and then the private sector would show up. We also monitored social media to see what was going on with people, what their needs were,” Shah said. “We’d find there’s an issue in this part of town, let’s connect our services to the identified needs.” It was often bidirectional communication, he said, which is when he recognized that “if we’re thinking about building the public health of tomorrow, we have to engage. We have to use traditional and social media alike.”

Social media allowed Dr. Shah and his team to focus both on immediate needs and raise the visibility of public health. “It truly comes down to what I call the 3 V’s of public health. When you raise the visibility, you have a chance at demonstrating the value of our work. And once you show the value, the 3rd V kicks in: validation. Validation by folks wanting to invest in the work resource-wise or through pro-health policies. It has worked for our department and though we are talking about emergencies here, indeed we have learned the 3 V’s go well beyond emergency response,” said Dr. Shah. 

Traditional broadcast media and radio were also critical elements that HCPH used to share their community’s story. They kept communicating with local and national media about the needs of their community. And, in turn they communicated important health information to the community itself. They advised people to use appropriate personal protective equipment during their clean-up efforts, reminding them not to swim in stagnant water, and telling residents to take care of their mental health.

The news cycle happens 24/7 and it was important to remind the world continually that even though the rain had ceased, the recovery process was far from over. Sharing the stories of community is important because it gives visibility to the often-unnoticed work of public health.

Lesson 3: It Takes a Village; Call on Partners

We often say, public health can’t do it alone, yet we continually try. It’s critical to leverage relationships from across county government and within the community. HCPH has an excellent relationship with all Harris County departments including the Harris County Office of Homeland Security and Emergency Management (HCOHSEM) that led the overall county emergency response. These internal partnerships are critical before, during, and after disasters. Hurricane Harvey was truly an ‘all-governmental’ response to a singular disaster.

Dr. Shah and his team also drew on community groups, nonprofits, volunteers, philanthropy, and the private sector. “We put them all into the mix,” he said. Doing so, they were able to bring more resources together and serve community needs more effectively. “The health department served as a key convener of others who could also help in the complicated health puzzle that the disaster created,” he said. “We were able to draw on strengths of each organization, and where there were limitations, we could lean on each other and fill those limitations by working together.” Leaders should be creating and nurturing these relationships year around, because you never know when you may need their help or are called upon to help them instead.

Lesson 4: Be Resilient; Plan for the Unknown

“We talk about ‘vulnerable populations’ but the truth is we’re all vulnerable,” Dr. Shah said. We’d be smart to plan for that vulnerability, when the sun is shining, before the disaster. And we must remember just because you just had a big storm doesn’t mean you can’t have another. The reality is we just don’t know when or where the next disaster will hit.”

Harris County, he said, is rebuilding better and rebuilding smarter. Dr. Shah and his team are leveraging existing partnerships while working with new partners whom they intersected with in the midst of the emergency. Since Harvey’s waters have receded, they’ve all been asking: How do we rebuild better? How do we create a more resilient, thriving community?

“Harris County and Houston were previously thriving, but there were challenges,” Dr. Shah said. “Strangely enough, Hurricane Harvey gives us the opportunity to tackle these challenges head-on. But we have to go beyond the last disaster, the last emergency. How is our community set up for tomorrow? We as a health agency have to drive that in some places, and just be at the table in others. The 3 V’s of public health matter. That’s doing our part. And when we do it together, that’s how community—all of our community—thrives.”   

Every state has unique strengths and weaknesses when it comes to health security. Check out the National Health Security Preparedness Index to see how your state is doing and to learn more about what it can do to improve.


about the author

Paul Kuehnert

Paul Kuehnert is associate vice president–program for the Robert Wood Johnson Foundation where he provides leadership and management direction for the Foundation’s work related to leadership and transforming health and health care systems. Read his full bio

Mon, 20 Aug 2018 13:00:00 -0400 Paul Kuehnert Public and Community Health National <![CDATA[A Journey From Philanthropy to Public Health and Back Again]]>

Brian Castrucci traces his path to CEO of the de Beaumont Foundation back to a “life-changing” internship at the Robert Wood Johnson Foundation.

A sign in a community park.

Many of us have had those moments in life where the decisions we make alter the path our lives take. Brian Castrucci, the newly appointed CEO of the de Beaumont Foundation, had one of those pivotal moments back when he had completed his first year of graduate study in public health.

At 24 years of age, Brian had a decision to make: return to school to complete his master’s degree in public health or accept a one-year internship at the Robert Wood Johnson Foundation (RWJF). He chose RWJF, and, he says, “it’s made all the difference.”

“What would I have missed if I hadn’t done that internship?” Brian told me in a recent conversation. “Simple. How to think. How to dream. How to boldly take on a change that is needed even when you know it’s going to be really hard.”

He considers that year the base for much of his early career success. Not only did he learn to think strategically and tackle big problems, like youth tobacco and substance use, but he saw models of partnership, collaboration, and how people at the top of their game work together to advance the field and change lives. “I had a chance to interact with, and learn from, leaders who I had read about in class. It was like a public health fantasy camp.”

And then, just as he was considering a career in philanthropy, he was encouraged to walk through another door. As his internship was ending, Brian told RWJF Senior Scientist Tracy Orleans, one of his mentors, that he was interested in staying on at RWJF. She wisely noted that wasn’t the best idea for a young person with a spark of public health passion. If he was to be truly effective in philanthropy, she told him, he needed time in the trenches.

Brian Castrucci We’re not going to improve population health by pushing more pills and procedures. We need better policies and partnerships if everyone is going to have an opportunity to achieve their optimal health. –Brian Castrucci

“I was essentially thrown out of the Garden of Eden,” he said with a laugh.

Today, with more than a decade of government health agency service behind him, he understands the wisdom of that advice. “I learned so much working in governmental public health—how to interact with elected officials, the ins and outs of government service, all the various governmental public health programs. Anyone who wants to make real change in public health should spend at least a couple of years working in a state or local health department.”

After stops at the Philadelphia Department of Health, the Texas Department of State Health, and the Georgia Department of Public Health, Brian returned to philanthropy. In 2012, he became the third employee to join the de Beaumont Foundation. The de Beaumont Foundation, founded in 1998, believes that a healthy nation requires a strong public health system and creates practical tools to build healthier communities. “Joining the de Beaumont Foundation was one of my best moves,” Brian said. “To find a workplace that shares your core beliefs and to have an opportunity to shape its path is an incredible experience.”

Six years later, he now leads the foundation as its CEO. “My experiences in state and local government, both good and bad, have been critical,” he said. “They made me a better public health practitioner. That’s not a degree or a title or a position to which you are appointed. That’s something you earn doing the work.” With a strategic focus on policy, partnerships, and the public health system, the de Beaumont Foundation has established itself as a leader and key partner in the public health field among government agencies, academia, and funders including RWJF.

Another valuable lesson he learned during his time at RWJF was that for philanthropy to be effective it cannot simply be a funder; it must also be a partner. “Collaboration between funders, grantees, researchers, and experts with community experience creates a valuable feedback loop between what the research shows, what is happening on the ground, and the strategic planning underway to make real change.”

Partnerships between philanthropy, practitioners, policymakers, and others are needed today as public health enters a new era. Where infectious diseases once drove public health priorities, today it is community conditions like unsafe or affordable housing, lack of decent-paying jobs and quality education, and decades of residential segregation that contribute to health disparities.

“We’re not going to improve population health by pushing more pills and procedures,” Brian said. “We need better policies and partnerships if everyone is going to have an opportunity to achieve their optimal health.” Recognizing that the “means to improved health in our nation may come from a legislature rather than a laboratory,” the de Beaumont Foundation created CityHealth, an initiative that promotes a set of nine policies—such as paid sick leave, early pre-K, and complete streets—that are critical to healthy communities. “We knew the importance of policy and wanted to help promote effective, bipartisan laws that we thought every city should have,” said Brian, “but we were relatively unknown and didn’t know how the ratings would be received.”

It was the kind of daring, bold—and strategic—plan Brian had seen at RWJF 20 years earlier. “Just one year after the initial ratings were released, we can say that we’ve contributed to 15 policy changes in the cities we monitor.”

Building on the partnership theme, Kaiser Permanente recently joined with the de Beaumont Foundation as a national partner in CityHealth. “Kaiser Permanente covers more than 12 million lives,” Brian said, “and they’ve become a partner in CityHealth. That’s a drop-the-mic moment. It shows increasing recognition that healthcare alone can’t make us healthy. That other community-based strategies are needed.”

He looks forward to continuing to build healthier communities, and through them healthier people. And, he credits his time at RWJF for helping him set his sights on that goal: “I don’t think I’d be doing any of this without that year at RWJF. Watching and listening to experts make change with thoughtful and targeted strategy—that was invaluable. It’s been a great arc.”

Brian hopes others can have a similar experience that he had 20 years ago at RWJF. Inspired by his own experience, the de Beaumont Foundation partnered with the Association of Schools and Programs of Public Health (ASPPH) to create a one-year fellowship for graduating public health students who want to use philanthropy to make lasting change. He hopes that other health philanthropies will consider joining de Beaumont in this partnership to expand early career opportunities in philanthropy.  

I’m sure many of my foundation colleagues—past and present—share my pride in success stories like Brian’s. In one short but pivotal year, he gained the skills and inspiration he needed to help bring about real and lasting change in our nation’s communities. Who will be the next future public health leader whose skills and passion are nurtured here in Princeton? Stay tuned!

How do the 40 largest cities in the U.S. fare when it comes to policies that can make lasting impacts in people’s quality of life? Find out through CityHealth's assessment.

about the author

Joe Marx

Joe Marx, director, program communications, blends his leadership, experience and passion for positive social change to help advance the Foundation’s goal of building a Culture of Health so that everyone in our diverse society will have the opportunity to live healthier lives. Read his full bio

Wed, 15 Aug 2018 11:45:00 -0400 Joe Marx Health Leadership Development <![CDATA[To Improve Health Disparities, Focus on Oral Health]]>

A team from our Clinical Scholars program believes that addressing oral health disparities can improve overall health and well-being, and help end cycles of poverty. They are bringing oral health to the community through school clinics, an app and an oral health protocol development for nurses, physicians, dentists and dental hygienists.

HEALing Community Center Atlanta

In January 2018, the Hollis Innovation Academy, a K-8 school, opened a dental exam room. Though it may seem unusual to see a dentist’s chair in a school, its presence reflects years of learning within this Atlanta community. Hollis's students live in English Avenue/Vine City, an area with one of the highest poverty rates in Atlanta. They also reside in one of three zip codes with the highest oral cancer rates in the city.

Early in my career as an ear, nose and throat specialist, I witnessed a deeply troubling pattern: on my first visit with a patient, I would diagnose him or her with advanced head and neck cancers. There would have been good treatment options if these patients had been seen much earlier. But time and time again, all we could do was rush the patient into an operating room, put in a tracheotomy to control the airway, and set up end-of-life care. I kept thinking that someone needed to get to this issue much sooner so that people wouldn’t die from something that could be treated effectively if caught sooner.

Eventually, I decided that person was me.

I started by looking at the zip codes of the patients coming in with advanced stage cancer. When I drove to those areas, I saw pockets of concentrated poverty. I talked—and more importantly listened—to residents to learn about their lives. I would park under bridges and outside drug houses, offering screenings for head and neck cancer out of the back of my car. It turned out that people wanted to visit the dentist, but they faced many barriers. Often, it could be as much as a 10-mile trip to get there. Not only were there transportation issues, but there were also fears of ending up with costly bills. Combined with larger societal barriers like a shortage of dentists, low Medicaid reimbursement rates, and an unwillingness of dentists to participate in Medicaid, it became clear that we needed a larger solution than exams out of the back of my Subaru.

A young boy once told me that he snacked on Twinkies because the apple he knew was healthier for him hurt his teeth when he bit into it.

Seeking to take the work to a larger scale, I teamed up with colleagues David Reznik, a dentist, and Hope Bussenius, a nurse practitioner, in the Clinical Scholars program. Together, our aim is to address barriers to accessing quality oral health services so that communities throughout Georgia, regardless of income, can live and thrive.

In each of our roles, we see every day how poor oral health can devastate lives: unnecessary tooth decay, expensive trips to the emergency department, and deadly advancement of oral cancers.

As if that weren’t enough, these oral health issues can reinforce a cycle of poverty and declining health. Individuals with missing teeth lack confidence. They are often passed over for work. They also have significant bearings on healthy eating. The stories are very painful  to hear. A young boy once told me that he snacked on Twinkies because the apple he knew was healthier for him hurt his teeth when he bit into it. His mother told us that her son was missing a lot of school due to tooth pain. In fact, tooth pain is one of the primary reasons that children miss school, and that also usually means a parent is missing work to care for them.

Ultimately, addressing oral health has implications for individuals’ overall health and well-being. Our team has developed a unique model called OH-I-CAN (Oral Health in Communities and Neighborhoods) aimed at increasing access to oral health services for low-income students and their families.

Below are a few key strategies we are using to address disparities in oral health, and can be adapted in other communities around the country.

Start With a Community Needs Assessments

A community needs assessment is a snapshot of a community’s strengths and weaknesses. It highlights resources that already exist and identifies areas in need of improvement. Conducting a needs assessment as a first step has enabled our team to work with leaders and resources that were already thriving in Atlanta neighborhoods. This allows us to target resources to develop effective, long-term solutions. For example, our assessment showed us the pressing need in the community where Hollis is located, so we focused our efforts there.

Bring Oral Care Into Schools

Every community has a school and it makes logical sense to bring health care to where students go every day. OH-I-CAN has integrated dental and primary care services, as the health clinic at Hollis now does. Students can have their teeth cleaned and receive other preventive care, and those with cavities and other problems are referred to a dentist at the nearby Neighborhood Union Health Center. Eventually, the clinic will be able to see adults from the community as well.

Integrate Oral Health Into the Services That Primary Providers Provide

Regular dental care can prevent infection, tooth decay and loss, compromised nutrition, and unnecessary advancement of some cancers. By integrating oral health into primary care, clinicians can better address the total health of a patient. Such integration can also improve access to care in low income and rural communities, who suffer the most from an uneven distribution of dental professionals. One way to do this is to train primary care nurses and nurse practitioners. In the coming year, OH-I-CAN leaders will focus on updating protocols in oral health care for nurses, primary care physicians, dentists, and dental hygienists at the state level. New nursing protocols, for example, would enable APRNs to provide basic preventive care—including oral hygiene instructions, oral cancer screenings, fluoride treatments, and appropriate referrals—in primary care settings.

Tap Into Technology

Many people are uncomfortable talking about their oral health. They might be embarrassed by their teeth and that they have been unable to take care of them. We are working to remove that barrier through the OH-I-CAN app. To capture patients' dental histories in such settings, the OH-I-CAN app, with versions tailored for children and adults, patients can answer questions on a tablet to create an oral health profile that is then saved to a data registry.

The website includes medical and dental facts, research information, and oral health care training data aimed at advanced practice RNs (APRNs) and physicians. The more we can make patients feel comfortable accessing oral health, the better we can provide services and put an end to the disparities we see today.

This process has been supported by our work through RWJF and some additional funding from the Dobbs Foundation. Eventually, our hope is that this clinic will become self-sustaining and other similar models will take root.

Learn more about how our Clinical Scholars are redefining health within communities, and share your ideas for how to address barriers to good oral health in the comments below.


Thu, 9 Aug 2018 15:00:00 -0400 Charles Moore Health Care Coverage and Access National <![CDATA[Four Ways to Build Inclusive, Healthy Places for All]]>

Inclusive public spaces for all are a central part of healthy, resilient communities. A new framework can help ensure that processes for shaping these spaces lead to design decisions that promote equity.

Healthy Places Swing Set

It has been said that inspiration comes when you least expect it. My visit to Melbourne, Australia, inspired me to take an international look at place-making. I was standing in Federation Square, restlessly waiting for my daughter to finish her shift. I hadn’t seen her in nearly a year. I was wearing my mom hat, not my urban planner’s hat.

Nevertheless, as my eyes swept the Square, I had the sense of being in a very special place. And while I didn’t know it at the time, I was not surprised to later learn that Federation Square in the heart of Melbourne has been recognized as one of the best public squares in the world. Fed Square, built on top of a working railway, comprises sculpted and natural elements; it has small spaces like fire pits; and large and medium-size open spaces for planned and unplanned activity. There is a large TV screen that broadcasts international and national sporting events (it is not always on). The Square is open 24 hours a day; has free Wi-Fi for all; rest rooms; and no signs prohibiting activity or lingering. Restaurants open their doors to it; and transit lines and shops surround it.

I visited Fed Square daily for eight days, and what impressed me was how well it reflected Melbourne’s rich cultural diversity; how seamlessly it connected to the streets, buildings and facilities on its periphery; and how welcoming it always felt. It is a place for people—the well-heeled, the not-so lucky—and everyone in between. I should note, though, that Federation Square’s value as an open public space and cultural hub is currently being tested. Controversial changes to it are pushing forward sans public review and participation.

Public spaces like these—parks, playgrounds, town squares, transit stations, streets and more—offer respite, a place to gather, socialize, and be active. They reflect history, culture and potential; strengthen communities and build social capital. However, not all spaces are created equally or equitably. Thinking back to a workshop I facilitated years ago here in the United States, I asked participants to describe a public place where they enjoyed walking or biking. Two students—leaders in a campus sustainability group—shrank when it was their turn, embarrassed to confess that they never had access to such a place.

A New Framework for Healthy Public Spaces That Support Equity

Building public spaces that welcome and enhance quality of life for all requires getting proximate to and working with communities. That’s why in 2017, the Robert Wood Johnson Foundation (RWJF) partnered with the Gehl Institute. We wanted to better understand how planners design public spaces in an inclusive way that supports health for all.

We traveled to places within the United States and destinations ranging from Copenhagen, Denmark, to Coimbra, Portugal. We sought to understand how their institutions, practices and places reflect their values. We interviewed experts and observed successful public spaces in action, looking for ideas that can expand and reshape our thinking and practices in the United States. Each stop along our learning journey gave us additional context to think more deeply about inclusion, health and equity in real places where people live, work, socialize, and struggle.

Public spaces--our parks, playgrounds, town squares, streets--can bring people together and make communities healthier. From Sweden to Seattle, Gehl Institute is uncovering how communities abroad are shaping public spaces.

Public spaces--our parks, playgrounds, town squares, streets--can bring people together and make communities healthier. From Sweden to Seattle, Gehl Institute is uncovering how communities abroad are shaping public spaces.

These insights informed an evidence-based framework of four principles to guide decision-making—The Guiding Principles of Inclusive Healthy Places. These four principles can help bridge the fields of public health and community planning/design to build and sustain healthy public spaces:

1.  Know the Neighborhood

A first step for planners is to invite everyone within a community to help map conditions, strengths, and resources. Public data sets, resident surveys, and observation can help identify what to build on and what needs changing.

For a project in Toronto, for example, planners set up tents in local parks, recreation centers, and farmers’ markets to answer residents’ questions and help understand how the spaces were used over time. And in the South Bronx, community members brainstormed ideas for renovating Lyons Square Playground during a series of sessions held at a nearby community center. Participating in the urban planning process empowered Bronxites to share their own visions of how best to fix what they viewed as a historic site. During the session, community members discussed nuts and bolts of how to engineer a park so that dog walkers, aspiring basketball stars, senior citizens, and toddlers would want to spend time there.

Data collection doesn’t end with the planning process. Monitoring progress toward goals over time helps residents stay involved and identifies health and well-being goals for the neighborhood.

2.  Gauge Trust, Build Trust, Develop Social Networks

It’s crucial to understand how people’s trust in civic institutions and in one another affects their engagement in the planning and design processes—and in their own community. Planners must create opportunities to work with communities and build trust among its members.

For instance, the city of Copenhagen tapped artist Kenneth Balfelt in redesigning Folkets Park. As he came onto the project, Balfelt noticed a “great deal of mistrust” that stemmed from several factors, including a culture where local officials would initially visit and ask for advice. Then a year later cranes and builders would move in to begin digging without citizens getting what they expected.

Balfelt approached the project as a mediator, and aimed to have the community share control of the renovation. He notes “through community involvement we would get a deeper understanding of their context, create local ownership, and ultimately make a public space in a true sense.”

3.  Design Public Spaces for Equity and Dignity

Folkets Park, Copenhagen, illuminated at night. The redesign of Folkets Park in Copenhagen accounted for the needs of people without homes. Photo Credit: Steven Johnson, Boundless

Efforts to build trust in the Folkets Park renovation also helped foster an inclusive, equitable process that involved listening to diverse groups, ranging from homeless migrants to activists, to young parents, to the elderly. Accounting for diverse perspectives help inform design decisions that respect the dignity of all people. This process helped Balfelt and team understand and address concerns about how flooding the park with bright light at night left the homeless feeling exposed and vulnerable. As a result, he strategically planned softer lighting to illuminate pathways at night.

Design has the ability to reflect values of social dignity, respect, and empathy. Even small details can make a huge difference, like the positioning of a small shelf on municipal trash cans that allow people to deposit and collect bottles for refund without rummaging through the bin. Creating inclusive, healthy places demonstrates just how important compassion is as a community value. And this is standard practice in Copenhagen.

Trash Can in Copenhagen. Trash cans equipped with “deposit” shelves provide an easier, safer, and more sanitary way of collecting discarded cans. Photo Credit: KHBpant

Here in the United States, at the 9/11 Memorial Plaza in New York City, planners worked with the slope of the land and rolling terrain to ensure that people in a wheelchair could get around without the need for ramps. And in San Antonio, children with severe special needs play alongside other children in a water environment. The creator of the first fully-accessible water park was inspired to undertake the project when he couldn’t find an inclusive place where his autistic daughter felt welcomed and others felt comfortable interacting with her. He brought together parents, special-needs therapists, doctors, and both people with and without disabilities to advise and help plan facilities that accommodate a range of needs for all park goers. He views Morgan’s Wonderland and Inspiration Island as places of inclusion “where everyone can participate together. Visitors have come from 67 countries and every state.”

4.  Foster Social Resilience

Places constantly change. Sustained inclusiveness relies on the capacity of communities and stakeholders to adapt to and leverage social, economic or physical changes around them. Fostering stewards of a space through participatory decision-making and other engagement means that when change occurs, everyone will continue to benefit from it.

For instance, in Ciudad Juarez, Mexico, the government and university students held a national competition to redesign Gran Plaza Juan Gabriel—a large plaza that had been vacant for some time. Along the way, they gathered data from nearby residents about the best way to use the space. With participation and leadership from the community, the city hopes the redesign will better represent the needs and preferences of the neighborhood’s residents, who in turn will be more likely to use the plaza and benefit from it.

Whether a project involves a riverside promenade, a new transit station, a small park, a day worker meeting site, or an outdoor area where people come for free meals, there are many ways to foster health and equity in public places. This new framework is a starting point for pursuing an inclusive process that leads to accessible, welcoming public spaces for all in the truest sense.

Download the new framework and share how public spaces in your community reflect inclusion and dignity for all in the comments below.


About the author

Sharon Roerty

Sharon Roerty, a senior program officer who joined RWJF in 2011, is an urban alchemist who has spent a lot of time at the intersection of health and transportation. Read her full bio.

Wed, 25 Jul 2018 11:00:00 -0400 Sharon Roerty Built Environment and Health International <![CDATA[Why We Must Turn Up the Heat on Tobacco Products]]>

We’ve come a long way in reducing tobacco use, but we can save millions of lives and advance health equity by doing even more.

A discount tobacco and alcohol store in Nashville, TN.

Although smoking rates have dropped by more than half over the past 50-plus years, tobacco use remains the number one cause of preventable deaths in the United States.

And not everyone has benefited equally from reduced rates in smoking—there are deep disparities in tobacco use and quit rates, depending on where people live, how much money they make, and the color of their skin.

Tobacco products disproportionately harm people with lower incomes and less education; people with mental illness and substance use disorders; people who identify as lesbian, gay, bisexual, and/or transgender (LGBT); and racial and ethnic minorities.

What’s causing these inequities? Part of it is marketing. Tobacco control efforts have not focused on closing racial, ethnic and socio-economic gaps. In fact, we know that the tobacco industry targets certain populationswomen, people who are black or Latino, and members of the LGBT community—with higher levels of marketing, exposing them to more tobacco product ads.

In addition, people in many of these groups are less likely to have health insurance—and, as a result, less likely to have access to smoking cessation products and services.

CDC Tobacco Graphic

Tobacco use is a substantial barrier to our nation’s collective efforts to build a Culture of Health. Tobacco products addict their users—often during their formative teen years, with lifelong consequences for health. The U.S. Centers for Disease Control and Prevention reported that, in 2015, more than two-thirds of smokers wanted to quit and 55 percent had tried to quit within the past year—but only 7 percent had succeeded in the previous 6 to 12 months. And even more telling is the fact that 9 in 10 smokers regret having started in the first place.

Tobacco’s enormous toll on our society underscores why it’s so important to reduce its use in order to build a Culture of Health.

We have a unique opportunity now, as the federal Food and Drug Administration (FDA) considers making new rules on limiting nicotine in tobacco, further restricting flavored tobacco products, and exempting premium cigars from its authority to regulate tobacco. Here’s what RWJF recommends:

Reduce Nicotine to Non-Addictive Levels

Nicotine is what makes tobacco products addictive—and it’s a key factor in whether kids who try tobacco become regular smokers. Limiting nicotine to non-addictive levels in all combusted tobacco products can prevent kids from becoming addicted and help more smokers quit. This action might lower smoking rates across all groups and could be particularly beneficial for those with lower quit rates, including marginalized populations.

Further Restrict Flavored Tobacco Products

Although the Tobacco Control Act bans the sale of most flavored cigarettes, menthol cigarettes are still sold throughout most of the country and e-cigarettes and cigars are sold in flavors like cherry, vanilla, chocolate, and clove that appeal to young people. FDA has found that menthol cigarettes lead to increased smoking among young people, greater addiction, and reduced success in quitting smoking. They are also disproportionately used by and marketed to African-Americans, who are more likely than whites to die from a tobacco-related disease.

Continue FDA Oversight of Premium Cigars

There is no reason for FDA to loosen its regulation of cigars. They pose a significant public health risk since they are addictive, toxic, and both youth and adults smoke them. Tobacco is the only consumer product that leads to disease and death when used as intended.

For the past 27 years, RWJF has played an important role in strengthening tobacco control policies, improving access to cessation supports, and reducing the burden of tobacco. As a nation, we’ve made significant progress in reducing tobacco use. Despite this, we simply can’t let our guard down given persistent inequities in tobacco use and tobacco-related disease, disability, and death.

We have submitted statements on nicotine, flavored tobacco products, and premium cigars to FDA during its public comment period to urge strengthening tobacco control policies and encourage others to do the same.


About the Author

Headshot of Matt Pierce

Matthew Pierce joined the Robert Wood Johnson Foundation in 2015. He works in the areas of public health law and tobacco control. Pierce is interested in finding more equitable ways to promote health and well-being. Read his full bio.  

Thu, 12 Jul 2018 14:00:00 -0400 Matt Pierce Disease Prevention and Health Promotion National <![CDATA[Practicing Cultural Humility to Transform Health Care]]>

Moving beyond culture competency to cultural humility acknowledges patients’ authority over their own lived experience.

Jennifter McGee Avila, Yolanda Radovic Jennifer McGee-Avila (right) pictured with her mother, Yolanda Radovic.

Health care delivery often involves a one-size-fits-all approach. As clinicians, we treat a patient with a particular diagnosis similar to the last patient we saw with the same diagnosis because it’s efficient—we think. But shifting that mindset is one of the best opportunities we have to help people truly thrive. An individual’s lived experience is rich, diverse, and complicated. And what it takes for each individual to live his or her healthiest life possible is as unique as each person is. In other words, a patient’s full life experience should inform how we shape their treatment.

To achieve a deeper understanding of our patients, it is essential for providers to practice “cultural humility” and acknowledge the unique elements of every individual’s identity. Many of us may be familiar with cultural competency—being respectful and responsive to the health beliefs and practices—and cultural and linguistic needs—of diverse population groups.

But cultural humility goes even deeper. It requires you to step outside of yourself and be open to other people’s identities, in a way that acknowledges their authority over their own experiences.

My own life experience has influenced my perspective on this. An important part of my identity is rooted in the relationship with my mother, my family, my history, and my experience as a woman of color. I was raised by a single mother, in an area with limited resources. I observed how my mother was treated differently compared to others because of her lighter skin. I witnessed the injustices that many faced based on implicit biases and how that affected not only their health, but their ability and willingness to seek care from people who represented systems that oppressed them.

These early experiences have helped me understand just how important it is to look beyond my own frame of reference. When I bring that lens to patient interactions, the experience is better for us both. They feel listened to and understood, and I can shape treatment that fits with their lives.

An important part of my identity is rooted in the relationship with my mother, my family, my history, and my experience as a woman of color.

I work for the Northeast/Caribbean AIDS Education and Training Center at the François-Xavier Bagnoud Center in Newark, N.J. For the women I work with—largely women of color with HIV/AIDS—the disease is just one aspect of their lives. They do not view themselves as solely people living with HIV/AIDS. They are mothers, sisters, friends, employees, and neighbors. Some openly discuss their race and ethnicity, and others do not mention those aspects of their identities at all.

By seeking to see someone in the way in which they identify instead of the way we might automatically categorize them, we are able to offer them the care they want and the care they need.

These women have also faced barriers to accessing health care that are rooted not only in their disease, but in their lived experience. For example, an infectious disease doctor and nurse practitioner that I worked with shared the case of a patient at the clinic who diligently sought medical case management and care for her HIV. However the same patient refused care by a physician for her cervical cancer because of earlier traumatic experiences. Unfortunately, this story is not unique. So while clinicians could treat aspects of her HIV, deeper work has to be done to address other elements of her identity to encourage her to get treatment for cancer.

Best Practices for Providers

As a Health Policy Research Scholar, I have been studying how we can provide better care to patients based on their lived experience. Based on my research and experience in the field, I encourage providers in all health-related environments to incorporate some of the following best practices:

  • Ask About Identity First  

Your patients don’t identify as their disease. Who they are is complex, and how they define themselves will have a big impact on how they receive and respond to their care. If you understand their values, and the various aspects of who they are, you will be able to better understand their barriers and strengths. This includes understanding the people and places in their lives, their passions, their commitments, and their priorities. I start by simply asking them to tell me about themselves. I ask them to tell me about their friends and family, their daily lives. I remind myself that there is likely a piece of them that is key to their life, that I may not even have considered before, and that will be important to incorporate into their care.

  • Disease Is Not the Only Issue

In many cases, disease is not the first thing on a patient’s mind. They may be facing barriers to safe and affordable housing, sufficient food, or stable employment that turn into barriers to accessing health care. While you as a clinician may be concerned with how to get them to their appointment, they are preoccupied with how to get their child to school. By fully understanding the complexity of their daily lives, you can support them in other ways that can also positively influence their health. Ask them about their life and work to understand what motivates them to seek care and what barriers they might face. A referral to transportation options or social services might be the key to helping them focus on their health.

  • Listen More Than You Speak

While we often view our own roles as helping patients, practicing cultural humility entails working with patients—actually walking alongside them—to achieve their health goals. They will always know more than you do about their needs, and they should have the dominant voice in the conversation.

  • Reflect on Your Own Identity

Practicing self-reflection is an essential component of cultural humility. In order to be open to the identities of others, we need to be aware of the perspective that we are applying from our own histories. Be critical. Ask yourself why you make the assumptions you do, or what parts of your own life might inform your understanding of your patient’s. Your identity can also be a bridge to empathy. I use my own experience as a woman of color to better connect with patients, even if I may not share the same experience as a woman living with HIV. 

Cultural humility isn’t about studying someone to better figure them out. It’s about acknowledging power imbalances, developing partnerships, and practicing self-reflection. When we integrate these concepts in the delivery of care, we lift up the voices of our patients.

We need more practitioners who acknowledge and integrate cultural humility into their daily practice. It’s not an instantaneous process; it’s long and at times tough, acknowledging biases we have within ourselves. You will have good days and bad days. And cultural humility is essential to working with your patients as people, and to improving health and well-being in an equitable and meaningful way.

Share your experience below and learn more about how our leadership programs are influencing health and health care.


About the author

Jennifer McGee-Avila is currently a third-year doctoral student in an interdisciplinary program through Rutgers School of Nursing and the New Jersey Institute of Technology in Urban Systems, with an Urban Health concentration. Read her full profile.

Thu, 21 Jun 2018 12:00:00 -0400 Jennifer McGee-Avila Health Care Quality and Value <![CDATA[A Successful Model That Predicts and Prevents Violence]]>

A surgeon in Cardiff, Wales, who regularly treated victims of violence, discovered that many cases went unreported. He devised a model for collecting data and collaborating with both law enforcement and community to predict and prevent violence. This approach is now taking root here in the United States.

Cardiff image

Weekend after weekend, the wave of emergency department (ED) patients would arrive. Oral and maxillofacial surgeon Jonathan Shepard would treat shattered jaws, knife wounds and other facial injuries at the hospital in Cardiff, Wales. These injuries stemmed from brawls in bars and nightclubs where broken glasses and bottles were wielded as weapons. Strangely, Dr. Shepard found that only 23 percent of these assaults treated in the hospital were reported to law enforcement.

Harnessing the Power of Data for Violence Prevention

Determined to find a way to stem the violence, Dr. Shepard mobilized health care providers, law enforcement heads, city officials and other local leaders in working together to address what was happening within their community.

Local hospitals agreed to gather basic anonymized information from each assault victim admitted to the emergency department, including the specific location of the violent incident, time of day, and weapon involved. They removed patient identifiers and shared the anonymous data with local law enforcement officials, who combined those data with their own records.

With these data, police were able to map when and where violence might happen, and concentrate resources on hotspot locations such as specific streets, businesses, schools, or transit stations, and during particular times of the week, to help prevent incidents.

A Violence Prevention Board (Board) consisting of local stakeholders also used the data to develop a series of interventions. For example, patterns within the analyzed data revealed that many violent assaults occurred in the entertainment district. After investigating this area, the Board learned that fights erupted when alcohol-intoxicated people bumped into each other on sidewalks and grew frustrated as they waited for orders at fast food restaurants and for taxis. The Board worked with the city to create more pedestrian-friendly streets, move bus stops and taxi stands, and appoint marshals to help manage the taxi stands.

The Board also helped pass an ordinance that required pubs and clubs to use plastic or toughened glass barware so broken glass could no longer be used as a weapon. And these data are being used to ensure safety risks are taken into account when awarding alcohol licenses.

With this pioneering approach, called the Cardiff Model for Violence Prevention, the number of violent incidents in Cardiff dropped 42 percent, while they increased in similar cities in England and Wales. And they stayed down—hospital admissions due to violence in Cardiff halved between 2002–2013.

It also generated significant savings for the city: An analysis by the CDC found that, for every dollar spent, the Cardiff Model saved more than 19 dollars in criminal justice costs and nearly 15 dollars in health system costs for a total of $6.6 million annually.

How the Cardiff Model Is Taking Root in the United States

More than half of violent crimes in the United States go unreported according to the U.S. Department of Justice. The Atlanta metropolitan area is no exception.

In 2015, DeKalb County Police Department and Grady Memorial Hospital established the United States Injury Prevention Partnership (USIPP) to pilot the Cardiff Model in the Atlanta metropolitan area, through a CDC Foundation grant funded by the Robert Wood Johnson Foundation (RWJF).

ED nurses at Grady Memorial Hospital now routinely collect anonymous data from ED and trauma patients who have experienced violence in a public place. Nurses ask patients three questions during intake to understand how, when and where their injury occurred. It takes them approximately 20 seconds to screen each patient. The data are then mapped to help the partnership decide where to focus prevention strategies.

With more comprehensive information on when and where fights and assaults in public spaces occur—whether it’s a bus stop, a park, or a convenience store—the police and the community have been able to take steps to curtail violence.

For example, USIPP is partnering with local businesses in the targeted areas to identify ways to increase security, such as repairing property, improving lighting and securing vacant lots, to help reduce crime. In one case, a local hotel owner has started an after-school program for neighborhood youth to keep them off the streets and give them with a safe space to play and have fun.

The DeKalb County Police Department has utilized the pilot data and results in the effective deployment of personnel and resources in the area designated for interventions, to target hotspot activities. Research has shown that disrupting crime “hot spots” is an effective way to reduce crime—they do not get displaced to nearby neighborhoods. As more hospitals are recruited to the effort, USIPP expects to gather more data that will help further pinpoint these hotspots and develop more targeted, community-based interventions.

Joining Forces to Prevent Violence in Communities

It may seem like common sense for hospitals and police departments to work together.

DeKalb County and Grady’s experience shows how effective a partnership centered around using data can be to help communities better understand and take steps to stop the pervasive violence in our neighborhoods that threatens health, well-being and quality of life.

It’s time to expand community partnerships between hospitals, law enforcement agencies and others. By working together, there is great potential to develop strategies that keep people out of jail and out of harm’s way, creating safer, more productive communities for us all.

Use the Cardiff Model Toolkit to curb violence in your community.


about the authors

Laura Leviton

Laura Leviton, PhD, who joined RWJF in 1999, has overseen evaluations in most of RWJF’s areas of focus. Leviton describes her senior adviser role as “striving to represent the quality and consistency of the Foundation’s research and evaluation and its impact on health and health care nationwide.” Read her full bio.

George Hobor

George Hobor, who joined RWJF in 2017, is a program officer working to promote healthy, more equitable communities. He 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 health care system. Read his full bio.

Mon, 18 Jun 2018 11:00:00 -0400 Laura Leviton Public and Community Health International <![CDATA[How Can We Help Kids and Families Eat Healthier?]]>

A $2.6 million funding opportunity for researchers studying how to improve children’s development through healthy foods and beverages.

A mother and daughter sit together while enjoying watermelon.

When our kids were around 5 months old, we knew it was time to begin nourishing them with more than breastmilk or formula. But the thought of where or how to begin was overwhelming to us first-time moms. We also understand that establishing healthy eating patterns in early childhood sets a foundation for sound dietary habits later in life. This is why we are sharing a funding opportunity for researchers who can help us better understand what and how our kids should be eating.

We have firsthand knowledge of how crucial the right nutrition information is. Despite seeking tips from pediatricians, friends and countless books and websites, we had no idea what to feed our babies. In addition, while options at the supermarket were endless, there wasn’t enough clear, objective information to help us make an informed decision about what to choose and why. (Ironically, the dog food aisle offered a wealth of thorough guidance on how to keep a dog’s coat shiny and her bones strong.)

We even faced uncertainty with the very act of feeding our babies! So many concerns popped up, like “Was the rice cereal supposed to be this watery? How can I tell if she likes it or if she’s still hungry or if she even ate any of it at all? Is this food a choking hazard?”


Nutrition research funding is now available for researchers/research teams studying ways—either through current or new pilot policies/programs—to improve children’s nutrition habits and help them grow up at a healthy weight.


The answers we were seeking did exist. But, parents don’t have the time to sift through long research or health articles. They need succinct, simple information that is easy to access and understand. Something like the new research-based videos from 1,000 Days, an organization that works to promote good nutrition for moms and babies from pregnancy until a child’s second birthday.

These videos are made for parents: they focus on one aspect of feeding at a time; tell you what signals to look for from your baby before you try a new food or feeding approach; and share specific instructions on the types of food to feed your baby, how to prepare them and exactly when and how to introduce them. Plus, they’re well under two minutes and can be quickly viewed on YouTube.

We’ve been proud to support the development of the 1,000 Days videos to help other parents facing the same struggles we did.

Videos by 1,000 Days–an organization that promotes nutrition for moms and babies–is based on HER research.

The 1,000 Days videos originated with a group of researchers and policy experts who came together to create the first ever, comprehensive set of technical, evidence-based feeding guidelines for babies 0-2.

This group received funding for their work through Healthy Eating Research (HER), one of our national programs. For more than ten years, HER has been working with researchers from around the country who are studying nutrition issues. The work they do informs federal and local food/nutrition programs and policies to improve the health and well-being of children and families.

Not only does HER support researchers to conduct their analysis and publish findings, it also helps communicate these findings to specific audiences who need them most. These are typically advocates, policymakers and the larger public health field.

For instance, HER has worked with researchers to develop complementary products such as issue briefs and infographics that synthesize lengthy journal articles to better emphasize the topic being studied and the subsequent findings. HER has also equipped researchers with the resources necessary to garner press coverage for an issue that is in the headlines or submit testimony to offer evidence on a topic connected to a hotly debated bill.  

In addition to assisting with the dissemination of research, RWJF and HER have succeeded in creating relationships with the country’s leading nutrition and obesity prevention organizations in addition to national health institutions such as the Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services, and the National Institutes of Health. One benefit of working with us is that our network and resources become available to you. And now is a great time to join our community.  

Details of This Funding Opportunity

The next round of nutrition research funding is available (application deadline: July 18, 2018). HER is awarding $2.6 million to researchers/research teams studying ways—either through current or new pilot policies/programs—to improve children’s nutrition habits and dietary intake to help them grow up healthy.

We are most interested in research that can impact kids and families, particularly those who are disproportionately affected by high rates of obesity and poor health, in the places they spend time including child care centers, schools and the neighborhoods where they live.

Some topics that are of importance are included in the list below. But, proposals do not need to be limited to these areas.

  • Federal nutrition programs such as SNAP, WIC, and School Breakfast and Lunch programs;
  • Strategies to increase access to healthy food and/or decrease access to unhealthy food including pricing incentives, water access, nutrition labels and procurement practices; and
  • Industry and/or retail practices that influence purchasing and consumption habits.

We know that many of you are studying innovative ways to help our kids eat healthier. This next round of funding could help you continue your work. It could also introduce that work to new and larger audiences who will use it in myriad ways from informing federal nutrition policy that has the potential to benefit millions of kids to equipping stressed out parents with the guidance they need to feed their babies. This is why we ask you to submit a written report once your project concludes, that includes findings that can be widely disseminated to advocates, policymakers and the research community.

View the archived 2018 Call for Applications to learn more.



Jamie Bussell

Jamie Bussel, MPH, a senior program officer who joined RWJF in 2002, is an inspiring, hands-on leader with extensive experience in developing programs and policies that promote the health of children and families. Her work focuses on ensuring that all children have the building blocks for lifelong health. Read her full bio.

Tina Kauh

Tina Kauh joined RWJF in 2012. In her role as a Research-Evaluation-Learning senior program officer, she evaluates the work of grantees, develops new research and evaluation programs, helps to develop and monitor performance indicators, and disseminates lessons learned. With her focus on research and evaluation with ethnic and minority populations, she values the “opportunity to understand and address critical health issues, such as childhood obesity.” Read her full bio.

Wed, 6 Jun 2018 10:00:00 -0400 Jamie Bussel Child and Family Well-Being National