Improving Population Health

“Do the Math” for Population Health?

By David A. Kindig, MD, PhD

In recent weeks, I have been paying close attention to policy dialogues sparked by Hurricane Sandy. So when I heard Bill McKibben was bringing his Do The Math tour to Madison, I had to be there. The event made quite an impression on me, both in terms of packaging the argument for divestment in fossil fuel stocks, but even more particularly how McKibben has moved dramatically out of his academic comfort zone – understandably driven by his palpable fear that without action our planet will become uninhabitable within a few generations if not sooner.

McKibben is an environmental activist, who at age 27 wrote the The End of Nature. During his presentation he reflected that at the time, he thought a book was all that was needed to spark change. He now recognizes that while academic contributions are important, they’re not necessarily sufficient for social change.

McKibben has devoted himself to this work. He’s not a rock star type (even though the tour has all the elements, including a huge bus, high quality graphics, music, and videos from famous people like Desmond Tutu); this does not seem to be his comfort zone. He seems a bit uncomfortable in the limelight, and dresses very casually. He says he would rather be typing than touring the country.

The morning after attending the presentation, I awoke at 4 AM thinking about key elements of McKibben’s work and contemplating their relevance to broad population health challenges. Here’s what he’s done:

Taxes for Early Childhood Health in Palm Beach County, Florida

By Erik Bakken, BA

Progress in population health requires dedicated funding streams to guarantee the long-term viability of programs. However, in these cash-strapped times, securing grants can be like walking up a flight stairs doing a headstand. Seven counties in Florida are using an ingenious and unique method of continued funding through special districts to promote childhood and related family health programs. Known as children’s services councils (CSCs), these organizations gain the majority of their budget from levying small, additional property taxes. As health trajectories begin at day one, these councils work to ensure that all children meet key health indicators, such as prenatal care, parenting techniques, and school preparation. One such county is Palm Beach County, Florida; I spoke with members of the Palm Beach County Children’s Services Council (www.cscpbc.org) to better understand their mission and this exceptionally creative funding method for promoting childhood health.

Master Planning for Youth Comes of Age

By Kirstin Q. Siemering, DrPH, RD

This week, we’re building on a recent post, continuing the theme of master planning – but with a more targeted approach.

The National League of Cities (NLC) has catalogued more than 30 comprehensive youth master plans throughout the U.S. These plans (sometimes referred to as youth agendas, city blueprints, or children’s bills of rights) are typically developed through approaches similar to those used to guide land use and infrastructure decisions, but with a focus on young people. According to the NLC, these plans allow “city officials, school leaders, community partners and youth to take stock of local programs and services for young people, identify cost savings, reduce duplication of services, and strategically address pressing needs.”

A "Master Plan" for Population Health Improvement

By Kirstin Q. Siemering, DrPH, RD

Wikipedia defines "comprehensive planning" as:

 A term used in the United States by land use planners to describe a process that determines community goals and aspirations in terms of community development. The outcome of comprehensive planning is the Comprehensive Plan which dictates public policy in terms of transportation, utilities, land use, recreation, and housing. Comprehensive plans typically encompass large geographical areas, a broad range of topics, and cover a long-term time horizon.

Communities have been developing "Master Plans" to guide their long-range decision-making since the late 19^th century (notably, concern about sanitation and the spread of disease in urban areas was the major early impetus). Amherst, Massachusetts calls its new Master Plan -- its first in 40 years -- a "statement of community intent."

Make Way for Starbucks' Community Stores

By Kirstin Q. Siemering, DrPH, RD

Population health can be a hard sell for the business sector, where the nature of the work has historically meant a focus on profits to the exclusion of most if not all other priorities. Although we applaud the current expansion of worksite wellness programs, we recognize that these efforts represent only a fraction what is needed for broad and lasting change. For broad population health improvement, we need to get beyond individual knowledge and behavior to effect policy and environmental changes that make the healthy choice the easy choice.

As we consider tangible roles for businesses to play in population health improvement, it might be helpful to think of a continuum, with worksite wellness as a starting point. Many potential roles remain unexplored, but we should all take a vested interest in shaping how work on the other end of the spectrum might look.

Population Health Eye on Pre-Kindergarten

By Kirstin Q. Siemering, DrPH, RD

Here on the Improving Population Health blog, we recognize the important role that education plays in health outcomes. Earlier this year, David Kindig encouraged business sector investments in early childhood education as a means for improving the health of tomorrow’s workforce. And back in September, our “Eye On Pop Health” series focused on higher education, paying special attention to the need for community college reform.

This month, we’re celebrating the end of one impressive early learning initiative and the start of another. The Pew Center on the States’ ambitious, 10-year Pre-K Now campaign will end on December 31, 2011. The campaign’s goal, which was to advance high quality, voluntary pre-kindergarten for all three- and four-year old, hit many milestones as it worked toward transforming U.S. education from a K-12 system to a Pre-K-12 system. And last Friday, Domestic Policy Council Director Melody Barnes joined Education Secretary Arne Duncan and Health and Human Services Secretary Kathleen Sebelius to announce $500 million in grants to nine state winners of the Race to the Top Early Learning Challenge to spur improvement in early childhood education programs.

Population Health Eye on Affordable and Healthy Housing for All

By Kirstin Q. Siemering, DrPH

This past summer, several news articles called attention to the County Health Rankings’ finding that people who live in urban and suburban environments tend to be healthier than those living in rural areas. The Wall Street Journal and the CBS Early Show should be applauded for calling attention to the fact that of the more than 3,000 counties assessed in the 2011 Rankings, 84% of the unhealthiest were rural while 48% of the healthiest were either urban or suburban. But we need to keep in mind that cities are also home to populations facing enormous health challenges.

HIA: A Practical Tool for Factoring Health into Decision Making Across Sectors

By Pamela Russo, MD, MPH

Staying healthy, whether we’re talking about individuals or populations, is influenced by people’s access to high quality health care and clinical prevention - but there is powerful evidence that staying healthy is more strongly influenced by people’s education, job opportunities, economic status, and the social and physical environmental conditions where they are born, grow, live work, and age. This understanding needs to be conveyed in a useful way to those making decisions on policies, programs and projects in non-health sectors such as transportation, energy production, labor, or education, who rarely consider the consequences of their decisions on factors that influence health. Absent the consideration of effects on human health, we have often unintentionally created conditions that are either hazardous to human health or create barriers for people to adopt and maintain healthy behaviors. How can we convert the evidence on the multiple factors that drive population health into something decision-makers can use to build health into their equations?

Population Health Eye on Community Colleges

By Kirstin Q. Siemering, DrPH

We’ve often discussed the importance of education for population health. An individual’s level of educational attainment is important for ensuring both income and health. The level of education of the workforce in a community is also important for economic growth. In a 2010 Chronicle of Higher Education article, Chairman of the Salt Lake City Chamber of Commerce Mark Bouchard did a “then and now” comparison of how companies approach location decisions. Ten years ago, Bouchard said, the norm was for such efforts to be led by a firm’s real estate committee. These days, leadership is more often than not provided by human resource officials wanting to “know about the quality of the work force.” Since the article was published, this message has only become more relevant – and given the current 9% national unemployment rate, will likely remain so for some time.

While it may seem as if policymakers and advocates focus more on the importance of early childhood education and high school completion than on higher education, a recent and growing spotlight on community colleges has begun to draw attention to the challenges and opportunities of this piece of the puzzle. This past spring, the Brookings-Rockefeller Project on State and Metropolitan Innovation released Community Colleges and Regional Recovery: Strategies for State Action to promote the idea that the time is ripe for states “to maximize their return on every public investment dollar for long-term, sustainable economic growth.” While the report is not framed in population health terms, its message clearly aligns with a population health framework that recognizes social and economic factors as key drivers of health.

Locally Customized Population Health Policy Packages?

By David A. Kindig, MD, PhD

In my last post I suggested that those who allocate resources must provide ample guidance to ensure that local level health improvement strategies actually align with the best available evidence. I mentioned the University of Wisconsin What Works data base as well as the approach that the previous administration allocated its State Health Improvement Plan (SHIP) resources in the state of Minnesota. But I indicated that What Works is not tailored to individual communities and that the Minnesota example is limited to health behavior interventions, not all population health determinants.

We know from the County Health Rankings and our own experiences that communities vary widely in both their health outcomes and the factors or determinants of those outcomes. There are many examples of both high and low ranking counties which vary on their determinant profile…some have high health care quality and access but poor behaviors, others have high social factors like education and income but poor air and water quality. Given limited resources, it is critical that investments be made carefully to have the most impact.

Would it be helpful to identify a set of Population Health Policy Packages that suggest the best options for local communities to make, given their outcomes and health determinants profile? 

Population Health Eye on "Total Worker Health" in Lincoln, Nebraska

By Kirstin Q. Siemering, DrPH, RD

Lincoln Industries in Lincoln, Nebraska is the nation’s leading supplier of products requiring high performance metal finishing. The company was established in 1955 and employs over 400 people in an operation that runs 24 hours per day, seven days per week.

The company’s commitment to worker well-being has earned it widespread recognition. Lincoln Industries has been honored by the U.S. Dept. of Health and Human Services, the American Heart Association, Partners for Prevention, and others. The company has also been named one of the “25 Best Medium Companies to Work for in America” by the Great Place to Work Institute.

Population Health Eye on Food Deserts in Small Town America

By Kirstin Q. Siemering, DrPH, RD

People have been researching food access for at least 50 years, but it has only been since the mid-1990s that this has been framed primarily as a health issue. The term “food desert,” which has gained recognition in recent years, was coined by University of London researcher Steven Cummins to describe places without adequate access to healthy, reasonably priced food.

The United States Department of Agriculture (USDA) was directed by the 2008 Farm Bill to study food deserts throughout the nation. This effort culminated in the 2009 National Academies report, The Public Health Effects of Food Deserts, which concludes with research and policy recommendations. The USDA recently unveiled its food desert locator, which is part of Michelle Obama’s Let’s Move campaign (and a complement to its Food Environment Atlas). Urban areas are taking up the charge to increase residents’ access to healthy foods. Baltimore’s Department of Planning has a Food Policy Director and Food Policy Councils are cropping up across the country (The New York Times’ Mark Bittman recently wrote about food policy organizing in Detroit).

Population Health Eye on Utah's Wasatch Front

By Kirstin Q. Siemering, DrPH, RD 

When it comes to transportation policy, Utah’s Wasatch Front region is a frontrunner. The Wasatch Front is an urban area in north-central Utah that consists of a chain of cities and towns stretched along the Wasatch Range. Roughly 80% of Utah's population resides in this narrow region, which contains Salt Lake City, Provo and Ogden. With strong leadership, collaboration, and advocacy, the area has become a model for transportation policy to address rapid population growth and development occurring over the last half century.

So what does this have to do with population health?

Introducing New Series with an "Eye on Population Health"

This week, we are launching a new blog series with a Population Health Eye on Oklahoma. Our goal with this new “Eye on Population Health” series will be to highlight population health improvement efforts with a real-world perspective on people, places, policies, and programs at both local and state levels. My Associate Editor, Kirstin Siemering, DrPH, will be taking the lead with the new series as we broaden our lens to highlight  a variety of practical applications of population health principles.

Population Health Eye on Oklahoma

By Kirstin Q. Siemering, DrPH, RD

Oklahoma is one of the least healthy states in the country. In 2010, it ranked 46 in America’s Health Rankings (AHR), beating out only Nevada (47), Arkansas (48), Louisiana (49), and last place Mississippi (50). Oklahoma has struggled for some time: the state’s age-adjusted mortality rates have been consistently higher than the national average since 1981. Among Oklahoma’s health challenges, tobacco is arguably one of its most serious. In the 2010 AHR, Oklahoma ranked 49 for smoking prevalence, with only 0.2% separating it from lowest ranked Kentucky.

Nationally, smoking prevalence has declined dramatically over the past two decades, from about 30% in 1990 to about 18% in 2010. While many states’ statistics echo this trend, smoking rates in Oklahoma have held relatively steady since the mid 1990s, at about 25%. While these numbers paint a rather grim picture relative to the nation as a whole, Oklahoma’s prevention investments offer hope for a brighter future.

Building Healthy Communities: What We are Doing and Why We are Doing It

By Robert K. Ross, MD

We were fortunate to have First Lady Michelle Obama join The California Endowment in the recent kick-off our 10-Year Building Healthy Communities plan for the state of California. This $1 billion plan is likely our nation’s most robust strategic effort at confronting the thorniest of public health challenges: the social determinants of health.

For definitional purposes, we understand a “healthy community” as a place where children and youth are healthy, safe, and ready to learn. Since our foundation’s mission focuses on the health needs of underserved communities, we now find ourselves in the business of community change and transformation, from a disinvested, unhealthy place to one that is healthy and where young people can thrive.

The public health data and literature tells us that on the matter of health disparities, “place” matters. Access to healthy foods, fitness opportunities, public safety, quality housing, good jobs, and quality schools are as critical to attaining good health as is affordable health insurance and community health clinics. Hence, comprehensiveness is critical. This is why we have selected 14 low-income, underserved communities to focus a decade of support in by working with community leaders and residents. We invite their ideas, creativity, energy, voice, and passion in the transformation of their neighborhoods.

But while “place” and grassroots involvement are important, linking grassroots and local action to advocacy for broader policy and systems change is vital. Policy and environmental changes constitute the most sustainable path towards establishing a real “culture of prevention” in underserved communities and beyond. So, place and policy are the twin pillars of our Building Healthy Community plan. We are planning to invest roughly 60% of our grantmaking in grassroots-level activities and 40% of our resources in broader regional and statewide policy advocacy, organizing, and communications work. The “true north” of all of this: the results. We are looking at ten-year improvements in children’s health coverage, childhood obesity reduction, youth violence prevention, and school attendance.

The combination of the passage of national health reform legislation, unacceptable spiraling health costs, and a stubborn and pervasive epidemic of child and adult obesity demands that public health leaders (and other advocates for prevention) stand up and stand tall with community and civic leaders around our nation. Americans at the short end of the health equity stick need us to be bolder and more powerful on their behalf. At the California Endowment, we join public health--and community health--minded colleagues in the battle.

Robert K. Ross, MD, is president and chief executive officer for The California Endowment.

Collaboration Breeds Success in Memphis

By Joan Fischer, MA

Memphis resident Clintonia Simmons and her teenage daughter had already resolved to lose weight and exercise more when Simmons saw a newspaper ad for a town hall meeting about childhood obesity. The description spoke to the challenges Simmons and her daughter were facing, and she felt drawn to go.Simmons was expecting a small gathering, but it turned out that some 1,000 people were in attendance, including Gov. Phil Bredesen. As part of a national initiative called Shaping America’s Youth, the meeting was convened by Healthy Memphis CommonTable, a regional health and health care improvement collaborative that brings together a wide range of stakeholder groups—from government, business, health care, faith-based groups, NGOs, schools, neighborhoods, and the news media—and serves nearly one million people.

The gathering, held in 2006, changed Simmons’s life. “At the time, no one was helping children with obesity,” Simmons recalls. “There wasn’t much out there. Learning about it made me feel more committed.”

In fact, her idea for a business was born there. Healthy Memphis Common Table called for proposals, and Simmons had the idea of creating a series of “Get Fit” exercise and nutrition DVDs for young people. The Common Table helped her find resources—mostly, a network of professionals who would help her pro bono—to get the job done.

Simmons is now president of Healthy Kids & Teens, Inc., which provides exercise and nutrition classes to after school programs. She is a certified trainer and nutritionist and is working on her MBA in health management. To offer services to schools that cannot afford it, she holds an annual 5K walk/run benefit that has become one of the city’s most popular.

And, between them, Simmons and her daughter have lost more than 80 pounds.

That’s the kind of success story that makes the Common Table proud—and it, along with some 30 other projects targeting obesity, has dramatically improved health lifestyle awareness and behavior in greater Memphis, according to Common Table executive director Renee Frazier.

“The Memphis attitude about what we can do as a community to impact health has just totally changed,” says Frazier. “Down at the waterfront, people are jogging and running. Community gardens have sprung up. People understand that we can’t have as much fried food as we’ve always had, that we have to try to walk 30 minutes a day. And that’s because of the Common Table’s ability to motivate and engage the community so that people see the value of improving their health overall.”

Frazier acknowledges that moving an entire community’s health profile upward is a long-haul endeavor. But increased community awareness and healthy behavior changes, documented in a 2007 progress report, signify a trend in the right direction, she says.

The success of Healthy Memphis Common Table has drawn national attention. Suzanne Mercure, a consultant to the National Business Coalition on Health, calls the Common Table “a great example of broad collaboration” and cites their major accomplishments as including:

• Broad-based participation that takes projects to the local neighborhood
• Common education and messaging for wellness and healthy lifestyle
• Approaches directed for physicians and health care professionals, business/employers, and consumers
• Access to information on quality including profiles at the physician practice level
• Common evidence-based guidelines for such conditions as obesity
• Expanded options for those with diabetes for access to health care educators and support
• Grant support for quality improvement initiatives

Both Mercure and Frazier say that support from the business community, led by the Memphis Business Group on Health (MBGH), has been key to the Common Table’s success. MBGH worked especially closely with the Common Table on “Aligning Forces for Quality,” an initiative funded by the Robert Wood Johnson Foundation to engage consumers, providers, and payers to improve quality through public reporting of performance on key measures of quality of care.

On the Common Table website, consumers can also find quality ratings for patient experience, hospitals, and medical offices.

“We now have more transparency of information around quality of health care than we have ever had in this community, and that’s thanks to the Memphis Business Group on Health,” says Frazier.

Their partnership will continue to break ground with plans to create best practice guides for physicians whose ratings could stand improvement. Health plans in greater Memphis have agreed to collaborate on producing those guides, Frazier says.“This is important because typically the health plans would never do this type of work together,” she says. “Never in a million years.”

That unlikely collaboration bears further testimony to the vision and success of the Common Table—and the potential the Common Table approach could hold for other communities around the nation.

Joan Fischer, MA is a writer and editor with the University of Wisconsin-Madison.

Dynamic Duo: Healthy Food and Jobs

By Kirstin Q. Siemering, DrPH, RD

According to PolicyLink, 23 million Americans living in low-income communities don’t have access to a supermarket. In round figures, this translates to the combined populations of New York, Los Angeles, Chicago, Houston, Philadelphia, Phoenix, San Antonio, and San Diego.

Without supermarkets, people tend to have limited options when it comes to feeding themselves and their families. The corner stores and fast food outlets that often predominate in low-income areas offer an abundance of relatively inexpensive foods that are high in calories and low in nutrients—but little if any fresh fruit, vegetables, and other nutritious staples. Not surprisingly, people living in these communities suffer disproportionately high rates of diet-related chronic—and preventable—diseases such as obesity and diabetes.

But this hasn’t always been the case. These “food deserts” have developed in response to various economic and social forces affecting demographic shifts over the past 30-40 years.

This transformation dates back to the 1970s and ’80s, when the landscape of food availability in densely populated, largely poor city centers began to shift. Grocery stores expanded their square footage, consolidated into chains, and many closed their urban doors, taking jobs with them as they headed to the suburbs to build bigger stores more cheaply and expand their profits by serving more affluent clients. Food deserts also have sprung up in rural areas over the last decades. Hanna, Wyoming (population 800) lost its only grocery store just months ago; the nearest grocery store is now 80 miles away.

So what to do?

There’s a movement afoot to turn things around, store by store, community by community. One example is the effort is being led by Pennsylvania’s Fresh Food Financing Initiative (FFFI). In only four years—and with just $30 million in state seed funding—this innovative program has brought 83 supermarkets to underserved areas throughout the state and created 5,000 local jobs for local residents.

The program works by providing gap financing to prospective grocers who would like to open or renovate stores in underserved areas but have special needs that can’t be met through conventional financing. For example, for his downtown Philadelphia Shop-Rite store, grocer Jeff Brown needed additional funds for training and security. Funding from the FFFI helped him put what was needed into place while keeping his prices reasonable. Brown’s now profitable store caters to the ethnic and cultural food preferences of his clientele, including a pork-free meat room for Muslim customers. 

The project brings together The Food Trust, The Reinvestment Fund, and the Greater Philadelphia Urban Affairs Coalition in a public-private partnership that has won national acclaim, including a Smart Growth Award from the Environmental Protection Agency and recognition from the Harvard Kennedy School of Government. Most recently, in his 2011 budget, President Obama has requested $400 million to create a national Food Financing Initiative.

With luck and favorable fiscal and political winds the national FFFI will become an important driving force to enhance the food and employment landscape in underserved communities across the country.

Kirstin Siemering DrPH, RD is a researcher with the University of Wisconsin Population Health Institute.