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. Mon, 30 Sep 2019 13:00:00 -0400 en-us Copyright 2000- 2019 RWJF (RWJF) <![CDATA[How Communities are Promoting Health and Responding to Climate Change]]>

Across the United States, people are recognizing that climate change is a major threat to any vision of a healthy future. They are responding by developing solutions to not only avoid the health harms from climate change, but also actively improve health and limit climate change.

A city park offers a walking path for the community.

In Austin, Texas, city officials have grown increasingly concerned about their residents enduring more days with extreme heat. In particular, they worry that extreme heat events prevent young people from getting physical activity and harm people’s overall well-being.  

Austin leaders decided to respond by increasing green space and tree shade around some of the city’s public schools, especially those that largely serve students of color or those in lower-income neighborhoods. More trees create cooler spaces for physical activity. They also help address climate change by decreasing the need for air conditioning, which use about 6 percent of all electricity produced in the United States. Trees are effective because green space and shade reduce temperatures over heat-storing concrete.

At first glance, planting some trees may seem like a limited and short-term approach in the face of a changing global climate. Trees, however, are an important climate solution because they remove carbon from the atmosphere. Increasing levels of carbon in the atmosphere causes climate change. We need more trees—lots more.

The effort in Austin is just one of the countless creative solutions that communities across the United States are implementing—from Portland to rural Alaska to parts of the Navajo nation.  

How We’re Learning from Solutions for Health and Climate Change in Communities

Through its Health and Climate Solutions program, the Robert Wood Johnson Foundation (RWJF) has funded seven grantees, including the City of Austin, in an effort to assess and learn from programs developed by innovative communities to address the health impacts of climate change while building a better, more equitable future. Each grantee seeks to achieve three goals: create opportunities for better health, advance health equity, and focus on climate adaptation or mitigation. We have a lot to learn from these communities because we know our rapidly warming planet is changing our air, water, food and weather, which is harming human health. We know that climate change is a major threat to any vision of a healthy future. 

Fundamentally, human health and the health of our planet are intertwined.

While every part of the United States is experiencing the health harms from climate change—including extreme heat, wildfires, more frequent and intense hurricanes, insect-borne diseases like Lyme disease or West Nile spreading to new regions, and toxic algal blooms—some people and communities are affected sooner and more directly. Where you live or work, your age, your pre-existing health conditions or chronic illnesses, as well as your race or income all influence what health harms from climate change you experience—and how strongly you feel them.  

For example, low income and communities of color are more likely to live near pollution producing power plants. People with pre-existing health conditions like asthma or heart disease face greater threats from air pollution and reduced air quality from hotter days. Climate change magnifies the inequities that prevent all people from having a fair and just opportunity to live a healthier life.  

Climate change doesn’t just harm our health, it deepens inequities. 

That is why we are looking for community-driven solutions to understand how people on the frontlines of climate harms are creating solutions that improve health and support their communities.  

Drawing on Local and Indigenous Knowledge for Health and Climate Solutions

Many Indigenous people, for example, have knowledge and experience to shape some of the most effective solutions. This is critical because Indigenous communities are also at greater risk for the health harms of climate change.  

For example, leaders in the Swinomish Indian Tribal Community are blending the CDC’s public health approach—the Building Resilience Against Climate Effects (BRACE) Framework—with traditional Indigenous values, understanding and practices. In Finland, Minnesota, and Navajo communities in New Mexico, farmers are using regenerative farming practices—a number of farming practices like crop rotation and different grazing practices—to improve the quality of crops, foster soil health, reduce the climate footprint of agriculture, and improve the ability of crops to withstand flooding, drought and heat.

The work in Austin, the Swinomish Indian Tribal Community, Minnesota and New Mexico are four of seven new grants to learn what is working on the ground. The other three projects are:

  • Buffalo, New York: People United for Sustainable Housing, Inc., (PUSH) Buffalo is helping weatherproof houses in cities to improve energy efficiency, community development and resilience and improve health, while boosting the local economy. 

  • Portland, Oregon: Friends of Trees is planting trees in low-income, ethnically-diverse neighborhoods to improve the health and well-being of local communities. 

  • Anchorage, Alaska: the Alaska Native Tribal Health Consortium (ANTHC) has developed an innovative, portable water sanitation system for homes in rural, Native Alaskan communities where climate change impacts on infrastructure and the environment makes it nearly impossible to access safe, clean water.

We can’t build a Culture of Health if we aren’t responding to both known and emerging threats to health—and taking steps to prepare for those that we know are coming. 

Learn more about how health and climate change are related—and how we can create solutions for health and climate together—by visiting


about the authors

Michael Painter

Michael Painter, a senior program officer, is a physician, attorney and health policy advocate. His work includes identifying cutting edge ideas and investments that could help build a Culture of Health. Read his full bio.  

Priya Gandhi

Priya Gandhi, a research associate in the Research-Evaluation-Learning Unit, helps develop and manage research initiatives and evaluations that generate evidence around programs, policies, and practices that can lead to a Culture of Health. Read her full bio.

Mon, 30 Sep 2019 13:00:00 -0400 Michael Painter National Environment <![CDATA[Policy Should Never Put a Child’s Health at Risk]]>

Here's why the proposed cuts to SNAP really hit home for me.

Mother bottle feeding her young son.

When I was a full-time pediatrician, I worked at a practice in the City of Philadelphia whose primary patients were teenage mothers and their children. Most of their parents were low-income with little to no outside support. Their lives were hard. Very hard. Many of the parents (grandparents to the newborns) were forced to choose between paying rent some weeks and having enough food to feed their children and grandchildren.  

I remember in particular one mother and her infant son who came to see me after he was born. She was scared because the baby was having trouble gaining weight, due in large part to the family not being able to afford much food. His grandmother was worried; given all the research showing how critical nutrition is to developing brains, I was concerned as well. Fortunately, the practice I worked in was a collaborative one, meaning that not only did we doctors work side-by-side with nurse practitioners, but also closely with social workers. And one of our social workers immediately went to work to get this family, in which the grandmother—who was the head of the household—worked full-time, enrolled in the Supplemental Nutrition Assistance Program (SNAP).

These are the types of situations and circumstances where SNAP is an absolutely essential lifeline. SNAP is the largest nutrition assistance program in the United States, helping to feed some 36 million people each month. SNAP provides temporary but critical support to help people who are struggling to gain access to nutritious, affordable food; nearly two-thirds of SNAP participants are children, older adults, and people with disabilities. It has a proven track record of helping families avoid poverty and hunger during difficult times, such as after losing a job or suffering a major injury or illness, while helping families achieve self-sufficiency and reducing health disparities.

Unfortunately, our social worker faced one bureaucratic challenge after another to get this family the food assistance it so desperately needed. The administrative burdens were significant—even for someone who had helped enroll multiple families previously—and as a result, the family’s eligibility was delayed by several months. While our practice worked hard to connect the family to food resources in the community to fill the gap, the little boy continued to have an extremely difficult time. The situation became so dire that we were on the verge of having to bring in the child welfare authorities to have the child removed from the home.

Child Food Insecurity Rate

Then, finally, a breakthrough. A new policy in Pennsylvania, known as broad-based categorical eligibility (BBCE), allowed people, particularly working families, enrolled in the Temporary Assistance for Needy Families (TANF) program to automatically qualify for SNAP. As it turned out, the baby’s grandmother was enrolled in TANF, meaning that when she automatically qualified for SNAP as a result, the baby and his mother were immediately enrolled as well. As the family started receiving that crucial extra support to buy the food it needed, the baby’s weight and well-being improved markedly. And just as importantly, the family was able to stay together. 

There are millions of families just like this one who depend every day on the support SNAP provides. Yet, inexplicably, a proposed new rule could take that support away. 

Earlier this summer, the U.S. Department of Agriculture proposed a rule change to SNAP that would eliminate states’ ability to adopt or maintain BBCE policies. The effects of this rule would be completely devastating to families across the country. An RWJF-funded analysis from our partners at Mathematica found that the rule would cause approximately 1.9 million SNAP households—coming out to nearly 3.6 million people—to lose program eligibility.  

The Urban Institute followed with a closer look at who would be impacted, including:

In fact, some of the most significant anticipated consequences of this rule come straight  from USDA’s own regulatory impact analysis, which predicts potential increases in poverty and food insecurity; billions of dollars in increased administrative costs for both the federal and state governments to administer the program; and millions of dollars in increased administrative costs for current and new SNAP applicants. USDA also estimates that approximately 500,000 children will also lose automatic access to free school meals if this rule takes effect, further exacerbating food insecurity for vulnerable children and making it harder for them to succeed in school. 

Data released this month from the U.S. Census Bureau confirms just how effective SNAP is at turning participants’ lives around. SNAP cut the U.S. poverty rate from 14.3 percent to 13.2 percent between 2016 and 2018, lifting 3.1 million people out of poverty in 2018 alone.  

Yet the department’s own conclusions show that this rule is fundamentally at odds with the mission and purpose of SNAP. Rather than providing people with access to nutritious food, this rule would take it away. Rather than making it easier for people to sign up and enroll, this rule would make it far more complicated. Rather than making it simpler for federal and state agencies to administer the program, this rule would make it more difficult.  

I remember vividly the faces and stories of my patients. And since the day this rule was introduced, I have often thought of that young mother and her baby son, struggling mightily to get enough food to eat and make ends meet, until they were finally saved by a social worker with compassion and a state policy with heart.   

The first rule of being a doctor is to do no harm. The same principle should apply to public policy, yet this proposal clearly fails that test.

Learn how many people would be impacted by this rule in your state.


about the author

Headshot of Don Schwarz

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

Thu, 26 Sep 2019 09:30:00 -0400 Donald F. Schwarz Child and Family Well-Being National <![CDATA[Expert Guidance on What Young Kids Should Drink and Avoid]]>

The nation’s leading health and nutrition organizations have issued evidence-based recommendations for parents, caregivers, health professionals and policymakers.

Young girl drinking from a cup.

“Should I be giving my toddler milk?”

“What’s the difference between fruit juice and a fruit-flavored drink?”

“I thought fat was good for my kids. Why should I switch my 2-year-old to low-fat milk?”

Every day, parents, caregivers, child-care providers and others struggle with questions like these about what kids should drink—and what they shouldn’t. They’re trying to do their best for kids’ health, but it’s not as easy as it may sound.

Ensuring that kids grow up healthy includes paying attention not only to what they eat, but also what they drink, especially during the early years when they are establishing their eating patterns. To do that, parents and caregivers need clear, consistent advice from health professionals about what drinks are healthiest for their kids. And policymakers need guidance so that they can create the strongest policies possible to help all children grow up healthy.

But, faced with an array of product choices and inconsistent messages about what’s healthy and what’s not, it can be challenging to know which beverages kids should drink, especially since recommendations seem to change every few months as kids get older.

Not only that, but until now there have been no healthy beverage guidelines for kids under age 2. The U.S. government’s Dietary Guidelines for Americans include recommendations for children ages 2 and older.

Coming Together for Kids’ Health

That’s why the Robert Wood Johnson Foundation funded Healthy Eating Research, a leading nutrition research organization, to bring together experts from four prominent health organizations—the American Academy of Pediatrics, the Academy of Nutrition and Dietetics, the American Heart Association, and the American Academy of Pediatric Dentistry—in an unprecedented collaboration to develop recommendations to help parents and caregivers choose what drinks are best for young kids.

It’s hard to imagine a group with better credibility on this subject—providing parents and caregivers with nutritional guidance they can trust. Just as important, we expect that this collaboration will improve the consistency of healthy beverage advice they receive from health professionals, like pediatricians and dentists, as well.

Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations is designed for children from birth through age 5 and should help inform:

  • Health professionals who help shape children’s diets, including pediatricians, family doctors, dietitians and nutritionists, nurses, dentists, and child-care providers
  • Food and nutrition programs that serve children, such as the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as the upcoming revision of the Dietary Guidelines for Americans
  • Parents and caregivers who make choices for children every day
  • Child-care centers and homes, schools, and afterschool programs that provide meals and snacks to children
  • Food banks that assist families with children
  • Restaurants and food companies, which can adjust their labeling, marketing, and serving sizes so that the beverages they offer children are healthier

The goal is to ensure that kids are served healthy beverages, whether at home, child care, school, or at a restaurant, and that parents and caregivers feel confident that they’re making the healthiest choices for their young kids.

The recommendations grew out of a 2017 workshop convened by the National Academy of Sciences to identify policy strategies for reducing consumption of sugar-sweetened beverages among young children.

During the workshop, we heard evidence that patterns of sugary drink consumption begin early in life—and disproportionately among black, Latinx, and American Indian children and those from families who have lower incomes. These families often have less access to consistent nutrition guidance as well as to affordable healthy food choices in the places where they live. Not coincidentally, children from these families are also at higher risk for developing obesity and tooth decay and, later in life, diabetes, than white children and those from families with higher incomes.

But the problem is across the board: Too many kids consume too many sugary drinks like fruit-flavored drinks, sodas, and other beverages with added sugars. The Feeding Infant and Toddler study found that, on any given day, nearly one in three (29 percent) children ages 12 to 23 months and nearly half (46 percent) of children 36 to 47 months have a sugary drink. Further, sugary drinks are the number one source of added sugar from all foods and beverages for children 12 to 47.9 months of age.

What the Recommendations Say

For most kids, the following guidelines can help set children on the path for healthy growth and development:

  • 0-6 months: Babies need only breast milk or infant formula.
  • 6-12 months: In addition to breast milk or infant formula, offer a small amount of drinking water once solid foods are introduced to help babies get familiar with the taste—just a few sips at meal times is all it takes.
  • 12-24 months: It’s time to add whole milk, which has many essential nutrients, along with some plain drinking water for better hydration. A small amount of juice is ok now, but make sure it’s 100% fruit juice to avoid added sugar. Better yet, serve small pieces of real fruit, which is even healthier.
  • 2-5 years: Milk and water are the go-to beverages. Look for milk with less fat than whole milk, like “skim” or “low-fat.” If you choose to serve 100% juice, stick to a small amount, and remember adding water can make a little go a long way!

We need to put our children on a path to drinking healthier beverages early, and these evidence-based recommendations are a perfect place to start. We are confident that these guidelines will supply parents, health care providers, child-care providers, and other caregivers with consistent information, messages, and tools for providing the right beverages for children at the right age and setting them up for optimal health. And they provide policymakers and industry leaders with the information they need to set policies and make products that better support children’s health.

Learn more about the recommendations and share with your networks.


about the authors

Mary Story, PhD, RD, is professor of Global Health and Community and Family Medicine, and associate director of Education and Training, Duke Global Health Institute at Duke University. She started this position in January 2014. Read her bio.

Tina Kauh, PhD, senior program officer, RWJF, develops new research and evaluation programs, supports the development of team strategy, evaluates the work of grantees, and disseminates key learnings. Read her bio.

Thu, 19 Sep 2019 10:00:00 -0400 Tina Kauh Childhood Obesity Early Childhood National <![CDATA[New Data on How We’re Measuring a Culture of Health]]>

Four years ago, we introduced a Culture of Health Action Framework and measures to help us track the nation’s progress toward becoming a country that values health everywhere, for everyone. Today we share progress to date.

RWJF - Allen County Kansas

It’s been four years since the Robert Wood Johnson Foundation (RWJF), along with the RAND Corporation, began using a set of national measures to help track our journey toward a culture where every person has a fair and just opportunity to live the healthiest life possible—regardless of where they live, how much they earn, or the color of their skin.

Our goals were to offer some catalytic signals of change with a focus on broader social and economic drivers of health, well-being, and equity. The initial set of measures were used to track how diverse stakeholders, including those outside the traditional health sector, were advancing health and well-being—and if and how health equity was improving.

Developing a clearer picture of what is changing via the Culture of Health measures can guide those who are working collaboratively to accelerate improvements. We offer a few highlights from recent updates to the measures (see also and share some data on our progress to date.

What Has Changed?

Since 2015, what do the data tell us about our progress in creating a Culture of Health in America?

We are seeing small but positive changes in the appreciation of the social determinants of health and the need for broader community health investments. However, there has been less movement in many of the structural and systems-level factors that critically influence health, well-being and equity.  

Here are just a few examples:

  • There is greater understanding that diverse factors influence health. A critical component of a Culture of Health is the shared understanding that we’re all in this together—that we recognize our health is interdependent with others around us. We measured these values and beliefs about health as part of National Survey of Health Attitudes. In 2018, 37 percent of surveyed adults (vs. 34% in 2015) believed that one’s surroundings (both other people’s behaviors—and factors like physical environment, social support, and community safety) strongly influence health and well-being.
  •  Consumer experience with health care is improving. According to the most recent Consumer Assessment of Healthcare Providers and Systems Survey, 18 states earned the highest consumer experience rating (five stars) in 2017. This reflects improved subjective consumer experience in care, including ease of navigation, transparency, and communication within and across health systems.
  •  Access to care is still a struggle for too many. On the other hand, we have seen little change with respect to access to care and services. There have been no improvements in access to dental care (about 39% continue to report receiving dental care in the past year). Treatment rates for mental illness and substance dependence or abuse also show no improvement, having held steady for the last four years with only 40 percent of those needing treatment having received it.
  •  Progress is stalled on key conditions that create healthier, more equitable communities. These conditions that represent some of the most entrenched, systemic issues are usually not tracked with other health measures even though they are key influences on health. There has been no change, for example, in the number of states with cross-sector climate action plans. At a local level, there has been little change in racial residential segregation in neighborhoods, which is linked to poorer health and economic outcomes. This degree of racial segregation is largely unchanged from 2015, with white residents in America still living in the least diverse neighborhoods.

What Do These Changes Mean?

To summarize, people are expanding their views of what influences health and there have been some targeted improvements in health care and public health access. A key objective of the newly updated Culture of Health measures is to catalyze more discussion and action across sectors. We welcome growing interest in areas that these measures represent—from a focus on community health amenities like public libraries—to the importance of managing the effects of toxic stress in childhood reflected in the appointment of the California surgeon general.

Yet, the critical systemic changes needed for more transformative health improvements have been slower to follow.

Looking Ahead

RWJF will continue to monitor changes in structural determinants of health because doing so is essential to truly understanding progress in health equity. We also will support further work to spur progress in health care and social, economic, and environmental drivers of health. A fuller description of these measures and the data underlying them can be found at Exploring them can illuminate trends and help to pinpoint areas where targeted efforts may pay dividends. For instance, our failure to make significant—or any—progress in addressing decreased life expectancy; continued challenges associated with high rates of chronic disease; and increasing rates of maternal mortality are gravely concerning and demand investigation.

RWJF and its partners are committed to building public will to change our culture into one that values health everywhere, for everyone. With so much at stake, this imperative should be widely recognized as a national priority.

Success is within reach, but it will take a real commitment to turning research into action, and vision into a reality where we can all live the healthiest lives possible.

Learn how to take action and be part of the solution at



Alonzo L. Plough, PhD, MPH, is chief science officer and vice president, Research-Evaluation-Learning at the Robert Wood Johnson Foundation. Read his full bio.

Anita Chandra is vice president and director of RAND Social and Economic Well-Being and a senior policy researcher at the RAND Corporation. Read her full bio.


Thu, 12 Sep 2019 10:00:00 -0400 Alonzo L. Plough National <![CDATA[Using GIS Mapping for Better Health]]>

This 2018 Culture of Health Prize winner uses geography-based technology to quantify, and solve, a range of challenges.

A woman wears a helmet while riding a bike.

Since at least the 1600s, people have used maps to track and manage diseases and other health effects, and to pinpoint their causes. From plague and cholera to cancer and heart disease, this approach has been a vital tool in the public health toolbox. Maps, combined with data, are powerful because they help people visualize where disease clusters and how it interacts with the physical places in which we live. 

In the digital age, technology can be tapped to promote healthy communities in ways that have would have been impossible a decade ago. Geographic information system, or GIS, mapping is lighting new paths forward. In my rural community of Klamath County, Ore., we’ve used GIS mapping to better understand our community’s challenges and the possible solutions. Here are two case studies that illustrate how Klamath County has used GIS mapping in the past, and a third that shows how we’d like to use it in the future:

Making the Case for a Protected Bike Lane

About six years ago, the leaders of Sky Lakes Medical Center’s wellness center in Klamath Falls, which helps people manage their chronic illnesses, wanted to identify parts of town where people struggled with health. Professor John Ritter, of nearby Oregon Institute of Technology, used anonymized data for 60,000 Sky Lakes patients to create maps that revealed something surprising: Adult residents living along a corridor on the west side of town had a high incidence of obesity, a low incidence of diabetes, and tended to be on the younger side. 

We saw the opportunity to help prevent residents from developing diabetes by creating a protected bike lane to give people a healthy and safe way to get around. The maps helped us persuade city and county officials, who approved the plans, and helped us raise money for construction from private foundations and individual donors who funded the project.

The two-mile-long bike lane opened last June. We won’t know its impact on people’s health for several years, but we plan to study it.

Keeping Cigarettes Out of Young People’s Hands

In Klamath County, nearly one in four adults smokes. Almost a quarter of 11th graders have ever smoked a cigarette and about 40% have tried other tobacco products or vaping. Because tobacco addiction commonly starts in adolescence, we were concerned by the fact that in 2015, inspections by Klamath County Public Health found 35% of tobacco retailers illegally sold products to minors. 

Using public addresses of schools and retailer addresses provided by the public health department, Professor Ritter created a map that showed many of the county’s 80 or so tobacco retailers were within steps of schools. 

Klamath County Public Health was able to use that information to support our argument for tobacco sales licenses that retailers must apply for annually. That policy went into effect in January 2018, the same month Oregon officially raised the age of purchase for tobacco and vaping products from 18 to 21. The licenses make it easier for us to enforce tobacco sales laws and educate tobacco retailers if they struggle to comply. This year, the percentage of inspected tobacco retailers who illegally sold products to minors has gone down to 17%. That means we’re keeping tobacco products out of teens’ hands. 

Creating Safer Routes to Schools

A new project Professor Ritter is working on is putting data about the safety of the routes students take to school into an online map the public could access. That involves converting paper maps that show where sidewalks need to be repaired or installed into a digital format, then using a computer to predict the best, shortest path to school for every student.

To make those maps, he’ll need to figure out how to work with schools get student addresses in a way that protects privacy. If he succeeds, his maps will help the city prioritize work on sidewalks and roads along routes to school so students can more easily walk to school, working physical activity into their daily routines.

We’re fortunate that Klamath County is home to the Oregon Institute of Technology, where Professor Ritter teaches. But any community can find the resources to use GIS mapping. Many cities and counties have a GIS office. Your state health department may have GIS capabilities, too. And many private GIS contractors are ready to assist. However you go about it, GIS mapping can be an enormous boon if your community wants to study, understand and begin to solve its unique health challenges.

Read more about Klamath County and apply by November 4 to be a 2020 RWJF Culture of Health Prize-winning community.


About the Author

Jennifer Little directs Klamath County, Oregon’s public health department.


Thu, 5 Sep 2019 12:00:00 -0400 Jennifer Little <![CDATA[How Can We Advance Equity, Diversity, and Inclusion in Policies and Laws?]]>

Post-doctoral researchers: We need your life experiences and academic background to inform inclusive and equitable policies. We’ll provide funding and support.

Law and policies should address, not compound, inequities. This is personal and something I carry with me.

I was 10 years old when a man in my northern New Jersey community was beaten to death outside a neighborhood cafe. Soon after, another community member was beaten and sustained brain damage. The number of victims—all of whom were of South Asian descent—grew over the years. The violence ranged from verbal abuse to brutal assaults and murder. It wasn’t uncommon for my home and other South Asian homes to be vandalized while having to hear racial slurs.

Officials denied that these attacks were hate crimes and ethnically motivated. Research and data on discrimination and hate crimes against South Asians simply did not exist, and there wasn’t much diversity among local officials. It was therefore difficult for community members to get the protection we needed. It wasn’t surprising that there were subsequent and repeated acquittals of people who perpetrated the violence. Even living in the shadow of the Statue of Liberty, we didn’t feel a sense of freedom to live our healthiest lives because our laws didn’t do enough to stop racially motivated violence. It was years later when hate crime laws took effect.

The chronic stress stemming from discrimination and unsafe communities has an undeniable impact on health. At the Robert Wood Johnson Foundation (RWJF), we are working to broaden the discussion about what shapes health. We believe that includes deepening our understanding of how policies and laws can be more inclusive. We need more representation among lawmakers and researchers, as well as more diverse and disaggregated data to improve policies that support health equity. By building and sharing evidence, people from all walks of life will have a fairer chance at living safe, healthy, productive lives.

It’s in this spirit that we announce a new funding opportunity: Advancing Equity, Diversity, and Inclusion in Policy and Law Research.

Funding Opportunity

Policies for Action, an RWJF research program, has issued a call for proposals to study an existing policy or policy change from a new lens. We seek to elevate diverse perspectives in policy and law research.

The policy or policy change that you examine should have long-term impacts on health and well-being for a population of people. For example, policies increasing Medicaid access may affect children’s life trajectories for years to come. Workplace family leave policies may also have an indelible effect on lives. We welcome all research ideas but will prioritize studies that align with RWJF’s focus areas.

In addition to research funding, this opportunity includes working with mentors of your choosing as well as receiving professional development support from Policies for Action.

An important part of this grant is to usher the research findings into real change. By publishing, speaking about, or otherwise sharing your research, you will help to spread what works so many others can benefit.

Two-year grants of up to $250,000 each will be awarded to six researchers (two of whom will be New Jersey residents).

What Do We Mean by Laws and Policies?

We are interested in any type of law, legislation, policy, or governing rule that impacts a significant population. This could be a local, state, or federal law. It could also be a corporate workplace policy. It has to be an existing policy or a policy that is being revised. It can address a troubling inequity, but it doesn’t have to; the policy can be studied from an equity lens. I invite you to review our previously funded projects to understand the scope of what we study.

Who Should Apply?

The ideal candidate will bring personal experience that sheds light on the health implications of a policy or law, coupled with an academic background to inform the research.

Eligible candidates include, but are not limited to, individuals from underrepresented ethnic and racial groups in research disciplines, first-generation college graduates, people from low-income communities, and individuals with a disability. Make a case for how you bring a diverse perspective; we will consider all proposals.

We seek junior faculty members (with fewer than 10 years’ experience) on a tenure-track at an accredited college, university, or independent research institution.

You should name two mentors on your application. The first is a senior researcher at your institution who can guide you in your career, and the second is a senior academic in your field who can guide you in your research.

It’s our intention that by working with early-career researchers with diverse backgrounds, we can help inform what makes laws—and the research field at large—more inclusive.

Learn more about this funding opportunity by reading the call for proposals and watching our informational webinar.


About the author

Headshot of Mona Shah

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

Tue, 3 Sep 2019 14:00:00 -0400 Mona Shah Health Disparities Diversity <![CDATA[The Power of Local Data in Action]]>

With the City Health Dashboard, communities across the United States are using data presented on a feature-rich website to create healthier and more equitable communities. Lessons learned will help more community leaders pinpoint local health challenges and close gaps in U.S. cities and neighborhoods.

A meeting facilitator refers to a bar chart.

If you knew children born and raised in one neighborhood of your city tend to live 10, 20 or even 30 years longer than those raised in another, what kinds of questions would you ask?

Local data on social, economic, and health factors can help city planners, policymakers, and community advocates illuminate approaches to such challenges and drive change.

We heard from city leaders that there was a lack of data at the city and neighborhood level clearly showing which factors have the greatest influence on their community’s health and well-being. So we got to work and created the City Health Dashboard. Launched in 2018, the Dashboard integrates city- and neighborhood-level data from multiple national sources, providing 37 measures that address health, such as obesity rates and life expectancy, and conditions that shape health, such as child poverty, unemployment, and residential segregation. The country’s 500 largest cities—those with populations of approximately 66,000 or more—are all represented in the Dashboard, which also includes a rich set of resources to help cities take action to improve health.

For the City Health Dashboard team, our first year exploring the power of local data to understand and improve health was an exciting one, with many lessons learned. We delved into data on the availability of parks and affordable housing, rates of children in poverty and obesity, and other factors that affect health in the nation’s largest cities and towns. Out of this data exploration, we continued to address gaps in data needs, adding new features that make the Dashboard an even more powerful tool for cities and communities working to build a Culture of Health. We are excited to share three things we’ve learned from our first year, and we invite you to explore the Dashboard for yourself.

First, local data is so powerful because it allows cities to dig deeper into the factors that drive health. It’s hard to be healthy when you live in places where you can’t buy healthy food, find housing that is safe and affordable, or secure good-paying jobs. Local data illuminate these gaps, pointing to opportunities to take action and improve health. Neighborhood data is particularly helpful for small and mid-size cities that may lack the resources and capacity to conduct more comprehensive data collection and analysis.

With the Dashboard’s data and easy-to-use visualizations, community leaders in cities like Grand Rapids, Mich., population 195,355, can see how opportunities for health and well-being in neighborhoods right next to each other may differ drastically.

To ensure economic growth is equally distributed across communities in Grand Rapids, local officials used the Dashboard’s data on unemployment, income inequality, child poverty, and life expectancy to identify what they call “Neighborhoods of Focus” where residents are struggling the most. With partners like Invest Health, the city decided to focus on these 17 identified neighborhoods to make improvements and close opportunity gaps. For example, when the city received over $50 million in Low-Income Housing Tax Credits to provide more affordable housing, it targeted these resources to these Neighborhoods of Focus, ensuring the funds reached those who needed them most. Dashboard data provides the level of granularity city leaders need to identify patterns, connect the dots, and convene diverse community members to address issues for improving health.

Second, the Dashboard has revealed remarkable patterns regarding residential segregation and life expectancy. The Dashboard shows large gaps in life expectancy, some as large as 20 to 30 years, between neighborhoods within many cities. While the average gap across the Dashboard’s 500 cities between the neighborhoods with the shortest and longest life expectancies is 12.4 years, cities that have higher rates of neighborhood racial/ethnic segregation also tend to have greater life expectancy gaps between neighborhoods. Chicago has the largest gap in life expectancy at 30.1 years. Washington, D.C., has a life expectancy gap of 27.5 years, followed by New York City (27.4 years).

Dashboard data show that residential segregation is associated with shorter lives. This can be caused by a number of factors. Children who grow up in segregated neighborhoods tend to have less access to good schools and green spaces in which to play and exercise, as well as higher exposure to crime and environmental toxins. When these factors are combined, their influence on health can be especially damaging.

The good news is that we have tools and policies to help cities and communities improve their residents’ health. Research shows that universal pre-K programs, safe and affordable housing, higher minimum wage, and increased access to primary care all work to improve health. The challenges and the solutions will be different for every community. The Dashboard data equips cities to dig deeper and start conversations about how to build thriving and more equitable communities by improving education, housing, economic opportunity, and other factors.

Lastly, we’ve identified Dashboard features that are particularly valuable and strengthened them. We updated our Take Action section, offering city and community leaders additional strategies to drive change. For example, in addition to identifying resources for designing a “complete streets” policy to make roads safe and accessible to pedestrians and vehicles, you can now explore funding opportunities and partnership strategies that can help make these initiatives a reality in your community.

New interactive maps let you see where and how measures overlap, neighborhood by neighborhood. For example, in Buffalo, N.Y., neighborhoods with higher rates of children in poverty also tend to have higher rates of mental health issues. While this might seem intuitive, backing up intuition with data is how resources get allocated, programs enacted, and change initiated at the local level.


With 37 measures of health and well-being for 500 cities, you can use the Dashboard to compare across and within cities. With the addition of multi-year data for 29 metrics, you can now also track changes in your community year by year. These new Dashboard features help communities better understand their greatest challenges and, more importantly, to take action where it matters most.

Visit to explore the data, subscribe to our email list, and follow us on Twitter @cityhealthdata for the latest updates.

About the author

Marc N. Gourevitch, MD, MPH, is the Muriel and George Singer Professor and founding Chair of the Department of Population Health at NYU Langone Health. The focus of Dr. Gourevitch's work is on developing approaches that leverage both healthcare delivery and policy- and community-level interventions to advance the health of populations. Dr. Gourevitch leads the City Health Dashboard. Read his full bio.


About City Health Dashboard

City Health Dashboard was created by NYU Langone Health, Department of Population Health, in partnership with NYU Wagner Graduate School of Public Service, the National Resource Network, the International City/County Management Association, and the National League of Cities, with support from the Robert Wood Johnson Foundation.


Thu, 22 Aug 2019 12:00:00 -0400 Marc N. Gourevitch National <![CDATA[Walk With Us: Building Community Power and Connection for Health Equity]]>

What does it take to build community power? A community organizer-turned-funder shares first-hand insights, as well as a new RWJF funding opportunity to advance this learning journey.

A truck driver at a recycling facility.

While many think of the Bay Area of California as the center of big tech and wealth, my memories of Oakland take me back to its Port truck drivers. Working an average of 11 hours a day, waiting in long lines at the Port of Oakland to pick up their loads, truck drivers in the Bay Area were isolated—living in the rigs they decorated with photos of their children and families. You can guess all of the reasons this is unhealthy—stale air, diesel fumes, no bathrooms or opportunities for physical activity, just to name a few. Their days consisted of sitting...alone. And then driving cargo to a destination...alone.  

Like poor air quality, poor ergonomics and lack of physical activity, social isolation is also linked to poor health. Alternatively, people with more social connections live longer and are more likely to say they are in good health.

Back then, I was a campaign director advocating for environmental and occupational health protections for communities and workers. Part of my job included “walking the line” with faith leaders, visiting these truck drivers as they sat in their cabs and waited in long lines outside the Port to pick up a load. Some of them were recent immigrants working to support families back home. Most of them made low incomes, barely living paycheck to paycheck after paying for the cost of their $250,000 (or more) rigs. All of them worked grueling hours. We asked about their families, brought them food and water, faith leaders provided blessings, and we all encouraged them to get out of their cabs to socialize with each other. We also helped them advocate for access to bathrooms, cleaner air, and the power to improve working conditions.


Although I’m no longer out “walking the line,” I’m still helping to support communities to build social connection and power, particularly for low income residents and residents of color who are especially affected by poverty, systemic racism, and other challenges.


Here’s what this looks like at the Robert Wood Johnson Foundation (RWJF). RWJF’s “north star” is building a Culture of Health so that everyone, no matter who they are, where they live, or how much money they make, has a fair and just opportunity to live the healthiest life possible. We aim to build capacity in communities to enable them to remove social and economic obstacles to health, including powerlessness.

Investing in Power

We have a long history of support for “community power building” in tobacco cessation, access to health care, childhood obesity, and, more recently, school discipline and worker rights. Just a few examples include:

  • In 2004, we funded Tobacco Policy Change, which worked intensively with low-income and Native American communities and with communities of color to build coalition campaigns for tobacco control policies. We sought out agencies that had credibility within their communities even if they lacked expertise in health, including groups that had worked on safety, Main Street redevelopment, and housing.

  • In 2011, we worked with the Funders' Collaborative on Youth Organizing to increase resources to the field of youth organizing and promote the leadership of low-income young people and young people of color in social justice organizing.

  • More recently, we’ve continued our focus on capacity building with national civic and faith organizations with chapters, members and volunteers around the country, including NAACP, UnidosUS (formerly National Council of La Raza), Faith in Action (formerly PICO National Network), and the YMCA

  • Our Voices for Healthy Kids initiative is making it easier for all children to eat healthy foods and be active and Forward Promise is strengthening communities that raise and empower boys and young men of color.

  • Last year, we completed a philanthropy scan to learn how funders view and apply community power to their work.

Support for community power building has always been a part of our work to improve health. That said, our more explicit focus on health equity is necessitating a new and more explicit focus on community power building.  

Walk With Us

A call for proposals (CFP) was released, deadline: September 24, 2019, to build an understanding of the range of methods applied in innovative and effective community base-building that result in changes to community-level social, economic, and physical conditions that we know influence health and equity. 

Base-building is a set of strategies and activities used by residents, workers, consumers, and other constituencies to build collective strength and power to address a variety of inequitable conditions in communities. Base-building has been utilized for generations by grassroots-led organizations and institutions to build power specifically in historically excluded or underrepresented populations. 

We are seeking research proposals whose project teams will participate alongside other field and research experts in RWJF’s Lead Local program, which is exploring the question: how does community power catalyze, create, and sustain conditions for healthy communities?

Lead Local: Exploring Community-Driven Change and the Power of Collective Action is seeking to: 

  • Deepen understanding of how power and power building operates in place;

  • Build greater understanding of how to measure and track the impacts of base building, as a core aspect of community power building;

  • Create shared understanding amongst collaborative members of how community power informs the conditions for health equity.

This CFP will support research projects led by a collaboration between a grassroots-led organization(s) and a researcher(s), with the anticipated grant recipient to be a grassroots-led organization(s).  

While it’s a far cry from my days of “walking the line” alongside neighbors and faith leaders, this opportunity to learn more about the strategies used by residents, workers, consumers, and other constituencies to build collective power and address inequitable conditions in communities serves as a reminder that we don’t have to walk alone.  



About the author

Aditi Vaidya

Aditi Vaidya joined RWJF in 2017 as a senior program officer working toward the goal of building community power to support a Culture of Health. With her far-reaching expertise in organizing, environmental health, economic justice, corporate accountability, and worker rights issues, she seeks to employ these skills to help communities promote health equity. Read her full bio.

Tue, 20 Aug 2019 12:00:00 -0400 Aditi Vaidya National <![CDATA[Lessons on Nurturing Homegrown Leaders]]>

This community development advocate has learned that great things happen when residents are invested in, and empowered to, change their world.

My hometown of Eatonville, Florida, is known as “the town that Freedom built,” and for good reason: It was founded in 1887 by black freedmen on land they bought from a rare white landowner willing to sell large tracts to black people. Today, it’s the oldest historically black incorporated town in America. 

This place exists and has survived because of citizen leadership, vision, and persistence. Many people here, like me, have multigenerational ties to the town, and all of us take deep pride in Eatonville’s role in history. Many people who live or work here, or attend one of our many churches, have contributed to building a Culture of Health in town and winning recognition for our efforts from the state of Florida and the Robert Wood Johnson Foundation. But the spirit of collaboration that made that possible didn’t happen by accident. Eatonville has proactively empowered citizens to become leaders. We value the voices and contributions of all of our citizens.

This is how real systemic change happens.

In recent years, the town has promoted leadership in a number of ways. These have included Healthy Eatonville Team, which I chair, a group of citizens working to improve health in the town; Leadership Eatonville, a 12-month training program; and efforts to launch neighborhood associations in the town’s four quadrants, starting with the neighborhood of Catalina. Before I took the helm, Healthy Eatonville Team already had a track record of success, helping to refurbish the gym of a former high school, install bike racks around town and add a free bike share at our library in the heart of our historic downtown. The group also was behind making sure the town included healthy community design in its community redevelopment master plan, which was updated in 2016 and governs the work we do at Eatonville’s Community Redevelopment Agency, where I am neighborhood coordinator.  

We’re working on building on that list of accomplishments. It’s not always easy, but every step we take is worthwhile because of our commitment to the people of this town. Here are three things I’ve learned about nurturing homegrown leaders during my year of leading Healthy Eatonville Team.


We have a long and ambitious list of things we’d like to do to promote health and well-being in Eatonville. We can do them all—just not at the same time. And it’s important to remember that sometimes doing “small” things—like fixing sidewalks—can have a big impact in a town our size. I learned that people see sidewalks as a path to better health. So, Healthy Eatonville Team has gotten serious about sidewalks, and at the moment, we’re focusing most of our efforts there. 

Better sidewalks that connect throughout the town will improve residents’ ability to get around by foot and stay active. This is intuitive, but not the kind of thing that planners would necessarily focus on first if not for hearing the voices of the people who walk those paths. Though sidewalk improvements and repairs are already included in Eatonville’s comprehensive plan, taking the project on requires money and proper planning. So members of Healthy Eatonville Team have taken the initiative to look for state and federal grants to help fund the effort.

But even as we prioritize those sidewalks, Eatonville’s other ambitions on that list to improve health and well-being will get some love. This is where leadership across the work in our community is integral to our success. Communication and connection on the issues that unite us is essential. And it’s because of our approach that our town’s economic development projects, diabetes management and prevention efforts at the health and wellness center Healthy Eatonville Place, and our work to empower young people continue. Healthy Eatonville Team doesn’t have to focus on everything, but the group is an important mechanism for reaching consensus on issues that are important to people in town. To that end, we’re also getting more organized in how we educate other residents and communicate with town government about the changes citizens would like to see so we can coordinate our work and priorities.  

Eatonville, Florida

Lead, But Listen

Healthy Eatonville Team has been fortunate to have many “stakeholders”—like the principal of our elementary school, members of local health systems and foundations, business owners or representatives from nonprofit service providers—coming to meetings and joining the work of our group. These leaders’ involvement is important and aids coordination across sectors. But to truly represent citizen concerns, I want to ensure people who live in town—or work or go to church here—and aren’t normally viewed as leaders make up the bulk of our group’s participants. These often-undervalued members of our community must understand that the town needs them and their energy and activity. I want them to see, through their participation in our planning and activities, that their contributions are valuable to our collective progress. Once they recognize how important they are, they’ll be encouraged to do more and invite more people to do what they can. That’s how a movement toward better health grows.

Find Champions for Citizens’ Work

In Eatonville’s efforts to launch a neighborhood association in Catalina, one of Eatonville’s four quadrants, we’ve identified two residents as leaders. And to encourage and motivate them and get others in the neighborhood involved, we’re coordinating with Tarus Mack, one of our city council members who lives there. He sees the value of deep citizen involvement and plans to be a champion for the neighborhood association. Mack is going to speak with residents and actively participate in the group, modeling the type of engagement that will help Eatonville thrive and continue to feed our Culture of Health. Such on-the-ground engagement is also how today’s leaders inspire tomorrow’s.

People are often so busy with the many commitments in our lives, but seeing a member of our city government prioritize and engage at the neighborhood level will, we hope, inspire others to make a difference right where they live. Leadership comes in all shapes and sizes—something our small town knows about given our oversized historical footprint.

I’m excited about getting more people involved in improving health and well-being in Eatonville, and I’m confident we can keep building momentum. We cultivate the type of leadership that can spring forth from unexpected places. And once you get citizens engaged and invested in change, nothing will stand in their way. 

Read more about Eatonville, a 2018 RWJF Culture of Health Prize winner, and apply by November 4 to be a 2020 Prize-winning community.


About the Author

Jasmyne Reese is neighborhood coordinator for Eatonville, Florida’s Community Redevelopment Agency and a public policy intern at IMPACT Strategies, a political advocacy firm. She spent part of her childhood in Eatonville and now lives five miles away, in Altamonte Springs, Florida.

Thu, 15 Aug 2019 10:15:00 -0400 Jasmyne Reese Public and Community Health National <![CDATA[Global Approaches to Well-Being: What We Are Learning]]>

What can we learn from other countries about advancing well-being—a notion of health that extends beyond the absence of disease?

A father and mother hold their baby.

Three years ago, it dawned on me that the concept of “well-being” might lead to a world of learning opportunities that could deepen and broaden the Robert Wood Johnson Foundation's (RWJF) work to build a Culture of Health. I was in Copenhagen, at the World Health Organization Regional Office for Europe, for a meeting about the United Nations Sustainable Development Goals and developing measures for well-being. As I listened, I realized that many of us in the United States who were working toward improved well-being were not considering what others around the globe were learning as they incorporated well-being into policy and practice.

We were missing out on insights, for example, from years of research and community engagement underpinning New Zealand’s well-being indicators and recently announced national well-being budget. Officially introduced in 2018, the country’s Living Standards Framework redefines the national government’s priorities and measures of progress. It expands beyond economics to also consider policy impacts on human and environmental well-being.

And just a week after the New Zealand budget made international news, the United Arab Emirates was in the headlines with its National Strategy for Wellbeing 2031, which aims to promote social cohesion and prosperity by improving quality of life.

The idea of well-being has been integral to RWJF’s vision for a Culture of Health from the outset. In the spirit of the World Health Organization’s 1948 definition of health as a “state of complete physical, mental and social well-being, not merely the absence of illness or infirmity,” we have used concepts of well-being to broaden mindsets and strategies to improve health.

For RWJF, well-being includes people’s physical, mental, and social health, and the opportunities they have to create meaningful futures. It considers basic needs, like food, housing, education, employment, and income. It includes social and emotional needs, like sense of purpose, safety, belonging and social connection, and life satisfaction. And it is tightly linked with the well-being of our communities, our environment, and our planet.

But my Copenhagen trip prompted my colleagues and me to dive even deeper into what well-being means around the globe. Knowing that good ideas have no borders, we sought to identify promising practices that could help advance well-being in our own country. We were especially interested in building equity, as well-being approaches require inclusive processes and corresponding shifts in power. Well-being is also an important framework for equity because it is not a finite resource. While economic prosperity for some is often related to growing poverty for others, higher levels of individual well-being tend to increase group well-being.

As we continue our learning journey, we are seeking to understand the impact of these approaches. What do they add to efforts focused on social determinants of health, like income and education levels?

Here are some early considerations to share.

A Holistic Vision

By laying out a wide range of indicators that cross disciplines, a well-being driven approach demands collaboration and yields more holistic, integrated strategies. Rather than focusing narrowly on economic and health outcomes, well-being helps us see a more comprehensive picture, including early warning signs of crises to come.

Think of the isolation, disconnection, and deep worry that preceded the opioid crisis here in the United States. While we focused on job losses and economic declines and time-lagged vital statistics, we overlooked early signs of despair. Had we been measuring indicators of well-being, we might have focused on mental health support and community connection in addition to job creation, which may have led to dramatically different outcomes.

Tailored Approaches

Though every well-being effort is multidisciplinary, formulas for success vary and are customized to account for geographic, cultural, and political context. In Singapore, for example, decades of economic growth resulted in a strictly financial definition of personal success. As people focused solely on building wealth, their health declined. Even the Ministry of Health couldn’t capture attention when it declared a “War on Diabetes.” Eventually, the Ministry of Health and two universities recognized that reversing health crises required a shift in mindsets. Their new “health and wealth” narrative initiative aims to cultivate a cohort of university graduates who embrace this value system, leading to different personal, organizational, and societal decisions.

In the radically different context of Occupied Palestine, most people have spent their entire lives in warlike conditions. There, Birzeit University and its cross-sector partners are using community-based pilot programs to address the trauma of war and its impact on collective well-being. By addressing trauma as a holistic, socio-political issue, rather than an individual “problem to be treated,” advocates are alleviating social isolation and stigma and developing new indicators related to suffering, such as humiliation, insecurity, and deprivation.

Subjective Experience

To truly promote thriving individuals and communities, well-being approaches incorporate insights from psychology, sociology, economics, public health, and other disciplines. Metrics used to assess well-being encompass not only objective factors like income, but also people’s self-reported life satisfaction. Looking beyond objective data is vital, because simply checking off data boxes does not mean that an individual will experience well-being.

For example, according to one recent study, what people most want from the U.S. Medicaid system is not different interventions or coverage; rather, they want to be treated with respect and dignity regardless of their income, ethnicity, or insurance status. Unfortunately, these lived experiences, which have an undeniable impact on well-being, are not always measured or prioritized.

To ensure that subjective experience is taken into account, an NGO in the United Kingdom—Happy City—combines an objective Thriving Places Index with a simple, five-minute online survey. The Happiness Pulse employs user-friendly technology to measure the emotional, behavioral, and social well-being of individuals, groups, organizations, and communities. This tool is used to map strengths and needs and to evaluate impacts across projects and places.


The idea of well-being draws our attention to the fact that that we are essentially all in this together, even when we do not recognize it. Well-being approaches—including their sensitivity to the profound impacts of issues such as social isolation and injustice—shift our attention and action toward our interconnectedness.

Policies grounded in well-being also draw our attention to interconnection between people and the larger natural world. In Bhutan, for example, since the 1970s, Gross National Happiness (GNH) has provided a more holistic definition of progress than Gross Domestic Product (GDP) can alone. A key component of GNH is the recognition that all beings in the natural world are interdependent, and that the well-being of non-human life on Earth has intrinsic value. Using well-being assessments to guide decision-making, Bhutan has developed innovative natural resource and tourism policies and become the world’s first carbon-negative country.

What RWJF is Doing

In 2018, one of RWJF’s first steps on our learning journey was to convene thought leaders from five continents and 19 countries at the Rockefeller Foundation’s Bellagio Conference Center. The examples I cited above are all based on the work of people we met there. Since then, the participants—many of whom hadn’t met each other or RWJF before—have continued to collaborate, including on a recent Academy Health webinar on leveraging well-being measurement to shift narratives about what matters. We recently published a report based on those global insights and, as part of our Culture of Health series with Oxford University Press, will release a related book in 2020.

We are continuing to observe, test ideas, and explore how to integrate these insights from around the world into how we build and measure a Culture of Health across the United States, from our most rural communities to our largest cities.

Questions to Expand Well-Being Thinking

We encourage you to consider how these insights apply to your work and place. How are you, your organization, your city, or your country defining and pursuing progress? Does that encompass well-being? Who is missing from decision-making about what we value as a society? How does what we measure and report shape our narrative about what matters?

Learn more and sign up to be alerted when free copies of our Oxford University Press volume on well-being become available next year.


About the Author

Headshot of Alonzo Plough

Alonzo L. Plough, PhD, MPH, chief science officer and vice president, Research-Evaluation-Learning at the Robert Wood Johnson Foundation. Read his full bio.

Mon, 29 Jul 2019 11:45:00 -0400 Alonzo L. Plough International <![CDATA[Home Is Where Our Health Is]]>

Where we live affects how long and how well we live. Yet, affordable housing is out of reach for too many. RWJF is addressing housing stability, equity, and health through data and research. Read on to see best practices you can use in your community.

Everyone should have the opportunity to live in a safe community.

There is growing evidence that safe and secure housing is a critical factor in achieving good health. Where we live can determine whether we’re connected to: safe places to play and be active; quality jobs and schools; and transportation to get us where we need to go. Yet millions of people in America live in substandard or overcrowded housing, temporary shelters, in cars, and on streets. Disadvantages also exist for the many living in residentially segregated neighborhoods isolated from opportunity. For them and others, the inability to access quality housing and neighborhoods deepens challenges and makes it much more difficult to be healthy and break out of poverty. 

Housing’s profound effect on health is often overlooked and misunderstood. This year, the Robert Wood Johnson Foundation (RWJF), led by President and CEO Richard Besser, MD, is shining a light on the link between housing and health. In his Annual Message, Besser discusses how safe and affordable housing supports positive outcomes across the lifespan—and how unsafe and insecure housing can deepen inequity and undermine a Culture of Health. 

He shares stories from housing initiatives across the country—from Boligee, Ala., to Chelsea, Mass., to San Antonio. These examples show that when we improve the quality and affordability of housing—health and lives also improve. Creating safe and affordable housing—as an essential part of comprehensive efforts to transform impoverished neighborhoods into places of opportunity—becomes a pathway to helping communities thrive.

In this post, we share illustrations that reflect lessons learned from this important work. We also revisit past Culture of Health Blog posts in which experts have explored the role of housing as a determinant of health. With a focus on housing as a key to health, we hope to unlock better health for all.


Safe, Affordable Housing

The quality and stability of our homes shape our health.

Home is where the heart is, but it’s also where our health is. The quality and stability of our homes shape our health, our communities, and our society. When we live in safe, quality homes that are: free of physical, chemical, and environmental hazards; are near decent jobs, good schools, reliable transportation, and safe play spaces, we can flourish. When we don’t have these opportunities, we can suffer—and so do our communities. 

As Amy Gillman, a senior program officer at RWJF writes, “There is a strong and growing evidence base linking our homes to our health.”

But safe, stable, and quality housing is out of reach for millions of people in America—and that has profound implications for health. “Where we can afford to live impacts where we live,” Gillman writes, “and our neighborhood’s location can make it easier or harder: to get a quality education; to earn living wages; to afford and have access to nutritious food; and to enjoy active lifestyles.”


Housing Costs Can Undermine Health

High rent forces some to live in unsafe places.

The cost of housing in America is high—and getting higher in many places. Over the last two decades, rents have increased, while incomes have stayed flat. This takes an especially heavy toll on the 38 million “cost-burdened” families in America—more than half of whom spend over 50 percent of their incomes for the roofs over their heads.

To make ends meet, many families must live in unsafe or overcrowded housing. And many others—especially low-income families—after paying for housing, don’t have enough left over to cover necessities like nutritious food, health care, and transportation. As Gillman writes, “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.”


Housing Discrimination

Poor health is more common in places that are segregated.

In America, not everyone has the opportunity to live in an affordable, stable, safe home in a neighborhood that fosters well-being.

Unequal access to affordable housing contributes to other inequities, according to Kerry Anne McGeary, a senior program officer 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,” she writes. “When those resources are unevenly distributed across neighborhoods—and sometimes within the same few outcomes are certain to be inequitable as well.”




End Discriminatory Housing Policies

Housing and health inequities stem largely from decade-old discriminatory practices.

Not all discrimination is conscious,” writes David R. Williams, a professor of public health at Harvard University. It’s often built into policies and practices that affect where we live, learn, work, and play—all of which shape our health. 

Over the last four centuries, the “land of the free” institutionalized slavery, forcibly removed Native Americans from their lands, implemented a system of legalized racial segregation, denied housing loans, and more. 

The country has made progress, but racism and discrimination persist. Nearly half of black people, for example, say they have experienced discrimination when trying to rent or buy a house, limiting access to one of the most foundational needs for good health.

The result, says Sheri Johnson, director of the University of Wisconsin Population Health Institute, “has been an accumulation of disadvantage through decades and generations.”


Working Toward Solutions

The Robert Wood Johnson Foundation is working to build a national Culture of Health where everyone has the opportunity to live a healthier life. The evidence is clear that “where we live affects how long and how well we live”—including our home and all the essential resources to which our home connects us.

Read Rich Besser’s Annual Message to learn more about how our homes are key to our health.


About the Authors

Najaf Ahmad

Najaf Ahmad spreads vibrant stories about the Foundation’s work as content management editor of the Culture of Health Blog. Read her full bio.

Headshot of Jessica Mark

Jessica Mark brings extensive experience to her work as a communications officer for RWJF’s Healthy Communities theme.

Mon, 22 Jul 2019 12:00:00 -0400 Najaf Ahmad National <![CDATA[How San Antonio, Texas, Fixed Its Broken Truancy System]]>

Bexar County once handled 36,000 truancy cases a year. Now students get one-on-one help to boost their attendance, and truancy cases have dwindled.

Texas was the last of two states—Wyoming being the other—that treated truancy as a crime. Students and their parents faced court fines, and if penalties went unpaid, teen truants could be cuffed by constables and sent to jail.

None of this made any sense to me when 10 years ago, as San Antonio’s presiding municipal judge, I inadvertently began the process of changing the system across the state.

I had heard from a friend who handled attendance in one of the largest of San Antonio’s 16 school districts. This assistant principal was concerned because truancy cases filed in January could not be heard by justices of the peace until October. At the time, Bexar County, which includes the city of San Antonio, handled about 36,000 truancy cases a year.

I wondered why we weren’t figuring out why students were not going to school—as opposed to just jamming them into the school-to-prison pipeline. Troubled by that question and knowing there was nothing to preclude a municipal judge from hearing truancy cases, I stepped in to work through the backlog with another judge. We processed 1,200 cases over three weeks.

I could immediately tell the system was definitely broken.

Some students had special needs that weren’t being addressed. Others may have missed school because their families were homeless, or they had to work to support siblings and parents. 

In San Antonio and Bexar County, the municipal court took over the handling of all truancy cases, and immediately the number of criminal actions halved to about 16,000. We also established a system to use juvenile case managers to intervene with students and prevent truancy cases from escalating into criminal action.

Certainly, you had some kids who were just hard to reach. But a lot of the time we were able to identify clear issues that we could at least try to help them get addressed.

Meanwhile, a panel of lawmakers, judges, prosecutors, and educators was convened in 2013 to create a uniform approach to truancy prevention for the city and county that persists to this day. Juvenile case managers get involved as soon as a problem becomes apparent and work one-on-one with students and parents to come up with a “contract” for improving attendance. This could involve counseling, tutoring, mentoring, community service, or other types of services for the student or parent.

I went to Austin next and testified before state legislators for the need to remove truancy as a criminal offense. Some justices of the peace argued that without fines, the court had no teeth. They kept talking about teeth, and we were talking about heart. The measure to remove the criminal treatment of truancy became Texas law in 2015.

Today, San Antonio has more than 30 case managers at schools around the city and county who deal with truancy issues. The only way a formal case can be brought is through a civil process. Only about 16 truancy cases are filed a year. We were the first large court in Texas to receive a grant from the governor’s office to fund additional juvenile case managers with the express intent of intervening early on, preventing truancy and reducing the number of juvenile court referrals.

One of the early observations that we made, which kind of became the mantra of our court, is, “Kids don’t have truancy problems. They have problems that are causing them to be truant.” It’s one of the greatest achievements of my career that the entire state took up my mantra. Now, in San Antonio, we can really help students overcome their problems, instead of compounding them.

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



A judge sitting at the bench of a courtroom.

John W. Bull began his legal career as a small-town lawyer. He was elected to the municipal court in San Antonio in 1999 and became the presiding judge in 2004.

Wed, 17 Jul 2019 11:45:00 -0400 John W. Bull Child and Family Well-Being <![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 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, hosted a webinar on June 18 about how Cicero is addressing community trauma. Learn more.



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:

Where you live matters to your health. RWJF President and CEO Rich Besser discusses how housing is linked to health and equity in America. Read the 2019 Annual Message
  • 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.

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 and former RWJF staff member who worked on leadership for better health and global ideas for U.S. solutions. During her time at the Foundation she focused on building the capacity of leaders and the wider workforce to collaborate across sectors, organizations and communities to promote a Culture of Health.

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 inRaising 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 Health Care Quality and Value <![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.

Where you live matters to your health. RWJF President and CEO Rich Besser discusses how housing is linked to health and equity in America. Read the 2019 Annual Message

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