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Health Policy in Brief

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Comments from Richard Besser on the Surgeon General’s Call to Action: “Community Health and Prosperity”

    • November 5, 2018

The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) President and CEO, in response to The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) invitation to submit comments in regard to the Surgeon General’s Call to Action: “Community Health and Prosperity.”

RWJF is the nation’s largest philanthropy dedicated to improving the health and well-being of all in America. Since 1972, we have worked with public and private-sector partners to advance the science of disease prevention and health promotion; train the next generation of health leaders; and support the development and implementation of policies and programs to foster better health. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being.

We know that health is inextricably tied to where we live, learn, work and play. But for too many of us, the prospects for good health are limited by things such as how much money we make, or discrimination we face.1 We recognize the Centers for Disease Control and Prevention’s definition of community health as “a multi-sector and multi-disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities, in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities."2 Our work and research continue to show improving community health has the potential to prevent disease and injury and improve individual and community prosperity. We also recognize that the pursuit of community health requires a range of strategies including efforts to change community conditions in order to ensure everyone has the opportunity for better health and well-being. This means access to good jobs with fair pay, high performing schools, affordable and stable housing, safe neighborhoods, and quality medical care. We all benefit when everyone has the opportunity to live in a place where the conditions promote health and well-being. This is health equity—when we all have the opportunity to be as healthy as possible.

That is why, now, more than ever, we are convinced that this vision must be championed not solely by those in the health sector, but also by sectors such as retail corporations, the criminal justice system, real estate development, financial institutions and the technology sector, as well as organizations focused on civic engagement, equity, and economic prosperity. Community efforts to improve resident and employee health needs to be coupled with strategies to change the community conditions and policies that contribute to better health and prosperity—and there are important roles for private and public sector actors in each approach.

Communities that provide the conditions for health and opportunity are associated with not only better physical and mental health for residents, but also lower rates of obesity and smoking and higher levels of education.3 All of these factors contribute to a healthier, more productive workforce that misses fewer days of work and drives lower health care expenditures.4

We applaud the Office of the Surgeon General, in collaboration with the Centers for Disease Control and Prevention, for exploring this issue of how to work together to build up the health of all our communities so that everyone thrives. We are pleased to provide the following information which demonstrates how investments in community health have the potential to improve the health and prosperity of communities.

Section 1: Evidence that suggests that healthier communities help private sector businesses to be more efficient, profitable, successful, or competitive:

Research points to a link between a lack of health-promoting policies in communities (one component of conditions for community health), and an unhealthy workforce.5 Improved community conditions for health, such as clean air laws, access to an abundance of healthy food options, clean and safe neighborhoods, and opportunities for exercise and physical activity, can help positively influence health behaviors and lead to a more productive workforce.

But what is the business case for improving policies and conditions in communities to better support health? To help answer this question, RWJF has supported eight research teams examining the dynamic relationship between the innovation and drive of American businesses and entrepreneurs and the needs and health of the residents in communities that support them.6 Topics range from how poor health outcomes negatively influence businesses to how labeling and incentives can be used to change consumers’ healthy food purchasing behavior. Other studies provide evidence on the value of employers’ investments in the health and well-being of workers and their communities and inform strategies and best practices for engaging businesses to contribute to building a Culture of Health. For example, one of these RWJF funded research teams7, found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). In one company, the annual value of lost wages due to ABT was more than $1.3 million per year. Employees reported that poor social and community health outcomes (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in “mental stress” leading to distraction, poor job performance, and more rarely, lapses in safety.4 As new evidence from these research studies emerge, we hope to share results with you and your team.

Section 2. Types of investments the private sector and local policy makers can consider to improve health and wellness of employees and families, and community well-being and prosperity.

While the unemployment rate is lower than it has been for many years, many families still struggle to earn steady and adequate income to meet their needs, achieve stable employment, and stable housing. Instability can also create a negative feedback loop, where stress and scarcity limit a person's executive functioning capabilities and affect their ability to achieve their goals.8

There is a need to develop strong public policies and programs to ensure stability and promote upward mobility and equity, using an approach that is driven and designed by the community. Policies that the private sector and local policymakers can work on together, and have a strong evidence base to improve the health and wellness of families and employees, include:

Paid Sick Leave: Employment that does not offer paid sick leave is plausibly linked to worse health outcomes including a higher risk of mortality through reducing one’s earnings and job productivity. If one continues to work while sick, a phenomenon known as “sickness presenteeism,"9 the duration and severity of illness may be lengthened, by not allowing for adequate medical attention and rest. In addition, paid sick leave may result in other positive effects, such as reducing the chances of spread of infectious diseases such as influenza to coworkers, and enabling care for sick children and elderly family members.10 Empirical studies have linked sickness presenteeism to a higher risk of serious coronary events.11 Furthermore, lack of paid sick leave has been shown to be a barrier to cancer screening and medical-care seeking in the United States.12

Paid Parental Leave: The beneficial effects of leave-taking for both parents and children are well-documented: paid parental leave policies have been associated with increased breastfeeding, decreased infant mortality, decreased postpartum depression, and increased immunizations.13 Researchers also found that providing family supportive programs like paid leave promotes the retention and recruitment of employees and increases worker productivity.14 Nearly 90 percent of businesses surveyed about the effects of California’s paid leave law said that the policy had either a positive effect on productivity or no noticeable effect.15 Despite these benefits, parents in the United States face incomplete job protection laws and a patchwork of state and local policies that provide partial pay for only some parents. As a result, only about 13 percent of private-sector workers in the United States have any paid leave through their jobs.16

Fair and Stable Scheduling: Employment instability is an increasingly important social problem in the United States that threatens the well-being of families and communities and poses considerable challenges to our safety net. Many workers experience unpredictable, variable, and nonstandard hours, temporary or contingent employment, and involuntary part-time positions. Precarious employment has also increased in the past 30 years, due to macroeconomic changes and the use of workplace policies that pass risk from the market onto workers. Research indicates that employment instability leads to economic insecurity for workers, their families, and their communities.17 Research has also shown that flexible scheduling improves employee health,18 work-life-balance19 and stress.20

 

Section 3: Types of partners or coalitions that have invested in community health and the scope of their collaborations contributions

Although there is growing evidence that links neighborhood conditions to health and well-being, and in turn, health care costs, there is still inadequate investment in changing neighborhood conditions to improve community health.21 As such, there is a growing movement to engage the private sector, beyond corporations, in investing in these community conditions. There is also an expanding array of data and tools to help guide this work, as follows:

The role of community development: The community development sector, including but not limited to banks and non-profit finance institutions, is a natural ally for community health, investing more than $200 billion annually in low-income neighborhoods, including housing, child care centers, and supermarkets. And we are seeing increasing alignment of the work of the community development and health sectors, as was envisioned by the nonpartisan RWJF Commission to Build a Healthier America in 2014.22 Together, the community development and health sectors “can bring health outcomes explicitly into focus for community investments, help optimize intervention strategies for health, and provide natural experiments to build the evidence base."23 By addressing both the built environment and the social and service environment, these partnerships have the potential to transform neighborhoods and build health equity.24 Here are a few examples:

  • The Healthy Neighborhood Equity Fund (HNEF) blends funding from banks, individual impact investors, foundations, and the Boston Medical Center through a private equity fund that finances transformative mixed-income, mixed-use, transit-oriented development projects in several Massachusetts cities. With a longer time horizon and lower target return than typical private equity funds, HNEF invests in projects and neighborhoods that would otherwise be unable to access this type of financing. Equally important, projects go through a rigorous review process using a scorecard with more than 50 measures that assess the project’s likely community, environmental, and health impacts. The current HNEF project pipeline is concentrated in Boston, where six projects have already leveraged an additional $121.5 million of private and public investment in low- and moderate-income neighborhoods, will build 528 new housing units, create over 106,000 square feet of commercial space, including neighborhood retail and office space, and generate nearly 1,100 new construction jobs and over 140 new permanent jobs.25
  • The Urban Land Institute’s Building Healthy Corridors project implements strategies for transforming commercial corridors into places that support the health of the people who live, work, and travel along them. In Cleveland, Ohio, a public-private partnership invested $200 million in significant transit-focused infrastructure improvements to connect the city’s two largest commercial districts. The result of the new transit line was $6.3 billion in new development, 13,000 new jobs, and more than 4,000 new residential units along the corridor.26

Two other initiatives that are showing promise in aligning the work of the private sector community development and health initiatives include:

  • Invest Health operates across 50 mid-size cities in 31 states and is transforming how city leaders work together to help low-income neighborhoods thrive by increasing and leveraging private and public investments. Early evaluation of this effort is demonstrating how new cross-sector efforts are helping cities cultivate a pipeline of health-promoting projects, like affordable housing development or childcare system improvements, along with new sources of capital. An evaluation of this initiative found progress in addressing equity, understanding social determinants of health, strengthening cross-sector teams, and implementing built environment projects.27
  • The Strong, Prosperous, And Resilient Communities Challenge (SPARCC) is helping six regions across the United States refine and integrate policies and practices that shape the built environment. They address the issues of racial equity, health, and climate resiliency by making sure that new infrastructure investments make their communities places where everyone thrives. SPARCC aims to influence community development and social impact investing far beyond the six regions.28

The role of anchor institutions: Community anchor institutions, such as hospitals, health systems, universities, and other private sector employers that have a long history in a place, can serve as a catalyst to attract and retain residents, create jobs, and support economic growth through local procurement and investments in health and economic development. Hospitals and health systems, for example, have an array of non-clinical assets—from their ability to make loans; to expertise in real estate, financial deals, and project management; to significant property holdings—that can be leveraged not only for the benefit of the community but for their own benefit as well.29 By thinking broadly and investing strategically, anchor institutions can be better partners in solving the most pressing issues in their community. Here are a few examples:

  • The Center for Community Investment (CCI) found that hospitals and health systems that engage in population health initiatives can make communities healthier places to live.30 These initiatives are geared to overcome the failure of the market to deliver the basic conditions that all communities need but that have been historically disinvested (such as low-income communities and communities of color), including stable, affordable housing, community centers, grocery stores, childcare facilities and other basic infrastructure improvements. CCI is now working directly with hospital systems such as Kaiser Permanente (Oakland, California) and Nationwide Children’s Hospital (Columbus, Ohio) to increase investments in the upstream social determinants of health, with an emphasis on affordable housing. Kaiser Permanente recently announced a $200 million investment to support lower- and middle-income households in rapidly changing communities, with the aim of reducing homelessness by focusing on supportive housing and “preventing displacement or homelessness of lower- and middle-income households in rapidly changing communities,” as well as making affordable homes healthier and more environmentally sound.31
  • The Democracy Collaborative has helped frame “the anchor mission,” or the understanding that a hospital or health system may not only provide charitable and philanthropic support for the community, but may also shift or re-orient basic institutional business practices to benefit the place in which it is based.32 The Democracy Collaborative has partnered with University Hospitals, a regional health system based in Cleveland, Ohio, to deploy targeted procurement strategies aimed at creating local jobs and community wealth. In one recent 5-year period, University Hospitals drove 92 percent of a $1.2 billion construction and expansion budget into the regional economy, including purchasing from more than 100 minority-owned local businesses based in the area.33 

Driving investments with evidence: Local health data can serve as a rallying point and common platform to help residents, community leaders, policymakers, and the private sector set common goals for community health improvement and drive change together. Through health impact assessments and data resources available at state, county, city, and census tract levels, public-private partnerships can design community plans and investments so that they target areas of greatest need. Here are a few examples:

  • Health impact assessments (HIA) can help evaluate the potential health effects of a plan, project, or policy before it is developed or implemented. For example, a HIA in Oakland, California reviewed a proposed housing development for low-income seniors and noted that the project’s location and design could expose residents to unhealthful levels of noise and to poor indoor air quality because the building’s intake vents were located near the freeways. To remediate this environmental harms, the assessment recommended including adding central air filtration and a courtyard and entryway designed to buffer noise, and these were incorporated into the developer’s final design.34
  • The United States Small-Area Life Expectancy Project (USALEEP), the City Health Dashboard, and the Opportunity Atlas provide health data at the Census tract level. USALEEP provides life expectancy data at birth for most census tracts in the United States. The City Health Dashboard provides metrics on health outcomes and factors that drive health. The Opportunity Atlas provides a powerful tool for looking at the factors that shape economic mobility, allowing businesses to see opportunities to improve health and well-being in the communities where their employees and customers live. The County Health Rankings and Roadmaps identify where a county is doing well and allow leaders to identify and prioritize their community’s health needs with support from the Take Action Center and What Works for Health resources.

Section 4. Descriptions of important barriers to and facilitators of success

A recent workshop summary34 from the Roundtable on Population Health Improvement, reported that the most commonly reported barriers for business to engage in community health included a lack of understanding (e.g., what “health” is, why it is important to care about health beyond the workplace, diverse agendas and potential misalignment of multiple stakeholders, who is responsible, and potential benefits and risk); the lack of a strategy, playbook, framework, or model to move forward; the overall complexity of the problem; issues of trust (especially in a competitive business environment); the lack of a common language; return on investment; the lack of metrics; and a lack of leadership buy-in.35

Some benefits that may drive intentional investment in population health, include an enhanced corporate image, increased visibility, stewardship and social responsibility, employer choice, enhanced employee morale, job satisfaction, job fulfillment, teamwork, engaged employees, increased productivity, increased creativity and innovation, the improved attraction and retention of top talent, reduced illness absences, reduced absenteeism in general, reduced workplace injury, reduced benefits cost (including health care cost as well as short-term and long-term disability and workers’ compensation), better management of an aging workforce, and an increasing awareness and knowledge of self-management and health.

Section 5.  Private sector and local policy maker rationales for making investments in community health

Locally, people living in America  want to see businesses maintain strong relationships with the communities where they operate, with 82 percent agreeing that companies should communicate effectively with and listen to input from local communities.36  Furthermore, numerous community health practitioners have also established clear linkages between lack of economic opportunities and poor health outcomes. Research has shown that for many people in the United States., their life chances are contingent on geographic and temporal factors.37, 38 A recent study found that county-level economic opportunity was positively associated with self-reported overall, physical, and mental health in adults aged 25–35 years in the United States.39

This is why place-based strategies are critical to improving health and opportunity. Private-sector businesses are key decision-makers in several place-based strategies to improve social and economic factors, health behaviors, and the physical environment. For example, local schools and postsecondary institutions can partner with businesses to provide internship and employment development opportunities, and similarly, business leaders can work with community-based organizations to provide mentoring, tutoring, counseling, or vocational training to reduce dropout or truancy rates. Here are a few communities that have successfully engaged in these partnerships:

  • To empower young people and expand educational opportunities to improve health, leaders in Spokane County, Washington—including school officials, local universities, the business community and other partners—responded with a series of innovative steps, including full-day kindergarten; skill-building training sessions for young students; a real-time early-warning system to monitor student attendance and grades; and targeted dropout prevention programs. Spokane County also works with businesses and employers to assess the skills needed for high-demand, high-paying jobs—and to provide the resources to educate and train community members with those very skills.40

In Algoma, Wisconsin, the school superintendent spearheaded the building of a community wellness center and a new addition for the high school’s technical training department named Wolf Tech. Private donors and local businesses paid more than half of the $3.5 million cost. Algoma businesses that once looked outside the community to recruit their workforce are now collaborating with local educators to cultivate it. To ramp up the school’s technology, Precision Machine Inc., a local manufacturer of precision parts for industries like aerospace and printing, donated two pieces of equipment. WS Packaging, a local label and packaging products company, installed a printing line just like the one at its neighboring plant. Wolf Tech fills orders for products from local customers, receiving donations in return that are invested in new machinery. Wolf Tech is a springboard for students and local companies to find homegrown talent, ready for local jobs that pay a living wage, high school graduates can plant local roots, build careers, and enjoy a healthy income and job security—all of which contributes to better health.41

Section 6. Successful efforts that promote and sustain private sector investments in community health.

Employee health also is influenced by the communities where employees work and live. Community resources, education, access to healthy foods, exercise options, and social capital are important determinants of health. A growing number of employers are investing in the health of communities by sponsoring community events, building walking paths, and donating goods to public schools to build a culture of health outside the four walls of the organization.42 Many recent reports have shown that communities are working with businesses to improve population health and equity. These reports and projects include:

  • Health Enhancement Research Organization (HERO): An Environmental Scan of Role of Corporate America in Community Health and Wellness:43 Sponsored by the National Academy of Medicine’s Roundtable on Population Health Improvement, this report provides a literature review of current knowledge of corporate involvement in population health.
  • The Vitality Institute: Beyond the Four Walls: Why Community is Critical to Workforce Health:44 This report features best-practice case studies of businesses and community groups.
  • John Quelch and Emily Boudreau:  Building a Culture of Health: A New Imperative for Business:45 This textbook sets out to understand how every company impacts public health and introduces a robust model, rooted in organizational and scientific knowledge, for companies committed to making positive contributions to health and wellness. Focusing on four interconnected areas of corporate impact, it not only discusses the business imperative of promoting a healthier society and improved living conditions worldwide, but also provides guidelines for measuring a company’s population health footprint. Examples, statistics and visuals showcase emerging corporate involvement in public health and underscore the business opportunities available to companies that invest in health.
  • BSR™ (Business for Social Responsibility™): A New CSR Frontier: Business and Population Health:46 This report highlights the role of Corporate Social Responsibility (CSR) teams in leading this work by helping their companies examine the positive and negative health and wellness impacts of business across the value chain, and by helping them identify ways to deliver better business results and health outcomes.
  • Health Workplaces, Health Communities:47 A national employer-community collaboration focused on better health. This initiative provides business and community leaders with practical tools and strategies for building support and investing in shared priorities. Because health and well-being is more than a nine-to-five proposition.

The business case for improving health can extend far beyond the workplace. It is increasingly accepted that our health is related to where we live, learn, play, and work—that is, in every corner of our communities. We are pleased to share this research that links improvements with community conditions and resident health with the economic prosperity of residents and businesses in communities. While the research is still emerging, RWJF remains committed to seeking and sharing solutions based on the best available evidence and look forward to working with the Administration and other partners to ensure that everyone in America has a fair and just opportunity to live the healthiest life possible.

References

1. Robert Wood Johnson Foundation. “Building a Culture of Health.” How We Work (2018), www.rwjf.org/en/how-we-work/building-a-culture-of-health.html (accessed October 2018).

2. Goodman, R.A., Bunnell, R. and Samuel F. Posner. “What is ‘community health’? Examining the meaning of an evolving field in public health. Preventive Medicine 67, Supplement 1 (2014): S58-S61.

3. Robert Wood Johnson Foundation. “Healthy Communities.” Our Focus Areas (2018), www.rwjf.org/en/our-focus-areas/focus-areas/healthy-communities.html (accessed October 2018).

4. Stewart WF, Ricci JA, Chee E, Morganstein D. Lost productive work time costs from health conditions in the United States: Results from the American Productivity Audit. J Occup Environ Med. 2003;45(12):1234-1246.)

5. Ziransky V, Yach D, Tsu-Yu T, Luterek A, and Stevens D. Beyond the Four Walls: Why Community is Critical to Workforce Health. Vitality Institute; 2015.

6. Engaging Businesses for Health. www.academyhealth.org/about/programs/engaging-businesses-health

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8. Mullainathan, S., and Shafir, E. (2013). Scarcity: Why having too little means so much. New York, NY, US: Times Books/Henry Holt and Co.

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11. Kivimäki M, Head J, Ferrie JE, et al. Working while ill as a risk factor for serious coronary events: the Whitehall II study. Am J Public Health. 2005;95(1):98-102. Markussen, S. J Popul Econ (2012) 25: 1287. doi.org/10.1007/s00148-011-0390-8

12. Peipins LA, Soman A, Berkowitz Z, and White MC. The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: results from the National Health Interview Survey. BMC Public Health. 2012;12:520. Published 2012 Jul 12. doi:10.1186/1471-2458-12-520

13. San Francisco's Paid Parental Leave Ordinance. Authors: William H. Dow, Julia M. Goodman, and Holly Stewart.  PPLO Issue Brief #1, University of California at Berkeley, November 2017

14. Matos, K. and Galinsky, E. (2014). 2014 National Study of Employers. Families and Work Institute Publication. Retrieved 26 September 2018, from http://familiesandwork.org/downloads/2014NationalStudyOfEmployers.pdf

15. Milkman, R. and Appelbaum, E. (2014). Low-Wage Workers and Paid Family Leave: The California Experience. What Works for Workers? Public Policies and Innovative Strategies for Low-Wage Workers (p. 305). New York: Russell Sage Foundation Publications.

16. Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Higher wage workers more likely than lower wage workers to have paid leave benefits in 2018 on the Internet at www.bls.gov/opub/ted/2018/higher-wage-workers-more-likely-than-lower-wage-workers-to-have-paid-leave-benefits-in-2018.htm (visited November 01, 2018).

17. Stable Schedules Study to Promote Low-Income Worker Health and Well-Being: worklifelaw.org/projects/stable-scheduling-study/report/

18. Joyce K, Pabayo R, Critchley JA and Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database of Systematic Reviews. 2010;(2):CD008009.

19. Schieman, Scott and Glavin, Paul. (2017). Ironic Flexibility: When Normative Role Blurring Undermines the Benefits of Schedule Control. Sociological Quarterly. 58. 51-71.

20. Grzywacz JG, Carlson DS, Shulkin S. Schedule flexibility and stress: Linking formal flexible arrangements and perceived flexibility to employee health. Community, Work and Family. 2008;11(2):199-214.

21. Super Church, Maggie. “Investing in Health from the Ground Up: Building a Market for Healthy Neighborhoods,” in What Matters: Investing in Results to Build Strong, Vibrant Communities (2017): 266-274.

22. RWJF Commission to Build a Healthier America. “Time to Act: Investing in the Health of our Children and Communities,” (2014) www.rwjf.org/content/dam/farm/reports/reports/2014 (accessed October 2018).

23. Jutte, D.P., Jennifer L. Miller, and David J. Erickson. “Neighborhood Adversity, Child Health, and the Role for Community Development.” Pediatrics 135 (Supp 2): S48-S57, March 2015.

24. Mattessich, P.W. and Ela J. Rausch. “Cross-Sector Collaboration To Improve Community Health: A View Of The Current Landscape.” Health Affairs 33, no. 11 (2014): 1968-1974.

25. Super Church, Maggie. “Investing in Health from the Ground Up: Building a Market for Healthy Neighborhoods,” in What Matters: Investing in Results to Build Strong, Vibrant Communities (2017): 266-274.

26. Urban Land Institute. “Building Healthy Corridors: Transforming Urban and Suburban Arterials into Thriving Places.” Urban Land Institute Building Healthy Places Initiative (October 2016). uli.org/wp-content/uploads/ULI-Documents/Building-Healthy-Corridors-ULI.pdf (accessed October 2018).

27. Invest Health. “Evaluation of Invest Health: Findings.” Invest Health. www.investhealth.org/news-archive/invest-health-evaluation-report/ (accessed October 2018).

28. Kabel, C., Amy Kenyon and Sharon Z. Roerty. “The SPARCC Initiative: Fostering Racial Equity, Health, and Climate Resilience in the Built Environment.” Community Development Investment Review, Federal Reserve Bank of San Francisco, issue 1 (2017): 043-051.

29. Hacke, Robin and Katie Grace Deane. “Improving Community Health by Strengthening Community Investment.” RWJF Issue Brief (March 2017). www.rwjf.org/content/dam/farm/reports/reports/2017/rwjf435716 (accessed October 2018).

30. Hacke, Robin and Katie Grace Deane. “Improving Community Health by Strengthening Community Investment.” RWJF Issue Brief (March 2017). www.rwjf.org/content/dam/farm/reports/reports/2017/rwjf435716 (accessed October 2018).

31. Kaiser Permanente. “Kaiser Permanente Announces $200 Million Impact Investment, Partners With U.S. Mayors and CEOs to Address Housing Stability.” Press Release (May 18, 2018), share.kaiserpermanente.org/article/kaiser-permanente-announces-200-million-impact-investment-partners-with-u-s-mayors-and-ceos-to-address-housing-stability/ (accessed October 2018).

32. Norris, Tyler and Ted Howard. “Can Hospitals Heal America's Communities?” The Democracy Collaborative (December 2015), democracycollaborative.org/content/can-hospitals-heal-americas-communities (accessed October 2018).

33. David Zuckerman. “Hospitals Building Healthier Communities: Embracing the anchor mission.” The Democracy Collaborative (March 2013), democracycollaborative.org/content/hospitals-building-healthier-communities-embracing-anchor-mission (accessed October 2018).

34. Aaron Wernham. “Health Impact Assessments Are Needed In Decision Making About Environmental And Land-Use Policy.” Health Affairs 30, no. 5 (2011): 947-956.

35. Roundtable on Population Health Improvement; Board on Population Health and Public Health Practice; Institute of Medicine. Business Engagement in Building Healthy Communities: Workshop Summary. Washington (DC): National Academies Press (US); 2015 May 8. 3, Why Should Businesses Engage in Population Health Improvement. Available from: https://www.ncbi.nlm.nih.gov/books/NBK298904/#

36. Just Capital. justcapital.com/issues/communities/maintains-strong-relationships-with-communities/

37. Chetty R, Hendren N, Kline P, and Saez E. Where is the land of opportunity? The geography of intergenerational mobility in the United States. Q J Econ. 2014;129:1553–1623.

38. Putnam R. Our Kids: The American Dream in Crisis. New York: Simon and Schuster; 2015.

39. Venkataramani AS, Brigell R, O'Brien R, Chatterjee P, Kawachi I, and Tsai AC. Economic opportunity, health behaviours, and health outcomes in the USA: a population-based cross-sectional study. Lancet Public Health. 2016;1(1):e18-e25.

40 Robert Wood Johnson Foundation. “Spokane County, WA: Education as a Catalyst for Better Health.’” RWJF Culture of Health Prize Winners Collection (2014), www.rwjf.org/en/library/articles-and-news/2014/07/coh-prize-spokane-wa.html (accessed October 2018).

41. Robert Wood Johnson Foundation. “Live Healthy, Live Well, ‘Live Algoma.’” RWJF Culture of Health Prize Winners Collection (2017), www.rwjf.org/en/library/features/culture-of-health-prize/2017-winner-algoma-wisconsin.html (accessed October 2018).

42. Giving in Numbers, 2017 edition. Committee Encouraging Corporate Philanthropy. 2017 [cited 2018 Oct 14]. Available from cecp.co/wp-content/uploads/2017/10/Giving-in- Numbers-2017.pdf?redirect=no.

43. Environmental Scan of Role of Corporate America in Community Health and Wellness: hero-health.org/wp-content/uploads/2014/12/HERO-EnvScanFinaltoIOM.pdf

44. Oziransky V, Yach D, Tsu-Yu T, Luterek A, and Stevens D., Beyond the Four Walls: Why Community is Critical to Workforce Health. Robert Wood Johnson Foundation/Vitality Institute. www.rwjf.org/en/library/research/2015/07/beyond-the-four-walls--why-community-is-critical-to-workforce-he.html. Additional case studies of effective partnerships is also featured on the Vitality Institute website: www.thevitalityinstitute.org/communityhealth

45. Culture of Health: A business imperative: www.springer.com/us/book/9783319437224

46. A New CSR Frontier: Business and Population Health: www.bsr.org/en/our-insights/report-view/a-new-csr-frontier-business-and-population-health

47. Healthy Workplaces Healthy Communities: get-hwhc.org/whats_working/case-studies/

 

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national culture of health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at twitter.com/rwjf or on Facebook at facebook.com/RobertWoodJohnsonFoundation.

Media Contacts

Melissa Blair

Robert Wood Johnson Foundation (609) 627-5937

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