Healthy Populations and Communities: In Depth

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Healthy Populations and Communities: In Depth

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Why focus on population health? The United States spends more on health care than any other nation. But the country doesn't get its money's worth. The U.S. ranks only 27th in life expectancy among 34 OECD countries, and 26th in infant mortality.

When confronting these facts, policymakers and practitioners tend to focus on traditional medical care as both potential causes of the shortfalls and potential solutions. However, health is a function of more than medical care. Many other factors have a stronger influence on well-being than clinical services do, including education, income, and employment; behaviors like smoking, diet, and exercise; and access to healthy food and parks. Research in RAND's Population Health program includes these broader determinants of health, with a focus on enhancing the population's well-being.

Socioeconomics Affect Long-Term Health

Work conducted in RAND's Labor and Population program has demonstrated the impact of socioeconomic status on health both in the short term and over a lifetime. The most important socioeconomic factor in terms of health effects appears to be education, not income.

The quality of schools that a person attended seems to significantly affect all health outcomes in adulthood, and these disparities have increased over the past three decades. The likelihood of having one of five chronic diseases—arthritis, heart disease, diseases of the lungs, hypertension, or diabetes—in middle age has increased for the less educated, and the effects are more severe. The more educated also have better health behaviors, including less smoking and more exercise.

It is no surprise, then, that education also affects life expectancy. When education and race are combined, the disparity is even more striking. In 2008, white American men with 16 or more years of schooling could expect to live 14.2 years longer and women a decade longer than their black counterparts.

Similarly, combining socioeconomic status and race reveals gaps in hospital readmission rates, their diagnosis and the quality of care coordination that they receive.

There is also compelling evidence that living in a lower-income neighborhood—whether you are low-income or not—is associated with significantly greater wear and tear on a person's cardiovascular, metabolic, and other biological systems. Neighborhood socioeconomic status is associated with more susceptibility to coronary heart disease and cardiovascular disease related to air pollution.

The fact that where one lives is associated with biological wear and tear and long-term outcomes suggests that improving socioeconomic status may also yield health returns and help to reduce health disparities.

Health is a function of more than medical care.

Does the 'Choice Environment' Influence Obesity?

While it's clear that the better educated make better health choices, does their environment help them do so? Much of our obesity work involves understanding whether policy can shape the so-called "choice environment."

RAND has studied different approaches to this question. One was making unhealthful foods harder to get (by banning new fast-food restaurants); another was making healthy foods easier to get (by bringing supermarkets to "food deserts"—areas without full-service grocery stores). In the end, RAND found that people's proximity to stores or fast-food outlets had little effect on obesity rates, but price and junk food marketing did.

Las Vegas, Nevada, United States - June 3, 2011: At the south end of the Las Vegas Strip you can see the Food court with signs (Starbucks, Del Taco, DQ Orange Julius, Panda express, Noble Roman's Pizza, Sbarro, Subway and Wendy's).

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Specifically, our study of a ban on new fast-food restaurants in one low-income Los Angeles neighborhood found that the ban failed to have its intended consequences. This zoning regulation, implemented in 2008, restricted the opening or remodeling of standalone fast-food restaurants in South Los Angeles. A few years later, the restaurants were mostly the same (only about 10 percent were new), and the prevalence of overweight or obesity had increased significantly more in South Los Angeles than in the county at large.

Our PHRESH study (PHRESH stands for Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health) of a Pittsburgh neighborhood's first supermarket in more than 30 years also yielded some unexpected results. The study compared the neighborhood to a similar area without a supermarket to determine how food choices changed.

An initial assessment of shopping habits in both food deserts revealed that 75% of residents were already shopping at full-service grocery stores in other neighborhoods rather than their small neighborhood shops. The price of food had more influence than proximity on where people shopped, and residents who shopped mostly at a low-priced store were at higher risk of obesity. Marketing also seemed to matter: Pricier stores actively marketed healthy foods, while the cheaper ones promoted junk foods.

Once the new supermarket opened, residents did consume less sugar and fewer calories, and shoppers felt that they had better access to healthy, affordable foods. But improved diet wasn't associated with how often residents used the supermarket.

Backing up these results, other studies have found that the proximity of neighborhood grocery stores, convenience stores, and restaurants had little association with residents' obesity. For children, what did seem to matter was the healthfulness of the food at home and parental supervision over what kids ate. In contrast, one study did find some relationship between obesity and a lack of sit-down restaurants in a neighborhood.

RAND researchers have also examined the marketing of impulse purchases, the oversized portions on restaurant kids' menus, the inconsistency of menu calorie counts, the potential impact of new nutrition labels, and the long-lasting effects of holiday binge eating, which accounts for 60 to 70 percent of annual weight gain.

Holiday binge eating accounts for 60 to 70 percent of annual weight gain.

Promoting Exercise Through Public Parks

Children playing in a park fountain

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Conventional wisdom is that Americans are exercising less, in part because they are working longer hours and have less free time. But the truth is that leisure time has increased over the past few decades, paid work hours have gone down, and self-reported exercise has increased (even though a majority of Americans fall short of physical activity recommendations).

In a series of studies, we have been exploring the role that public parks play in encouraging people to exercise more. Many studies used RAND's System for Observing Play and Recreation in Communities (SOPARC) tool, designed by RAND investigators to obtain direct information on community park use, including characteristics of parks and their users. SOPARC provides an assessment of park users' physical activity levels, gender, activity modes/types, and estimated age and race/ethnicity groupings. It also provides information on individual park activity areas, such as their levels of accessibility, usability, supervision, and organization. An online app and users guide make SOPARC available for general use, providing a valuable tool for communities to use in making decisions about park resources.

RAND is finding that the nation's parks have much unmet potential. In the first national study of neighborhood parks, we found that park use by adults and seniors is limited and is particularly low among girls, women, and those in high-poverty areas. But a few simple enhancements such as walking loops, fitness zones, and supervised classes geared toward older people could significantly boost their use. Even cities like Los Angeles, where parks are popular with adults, could use these methods to draw more people to its parks, according to more than a decade's worth of research on LA's facilities.

Insights from RAND's many park studies:

Public parks aren't the only option. Opening school playgrounds on weekends, closing streets for CicLAvias, and making neighborhoods themselves more walkable could also provide opportunities to get people's hearts pumping.

Modest improvements in marketing and signage at parks can increase activity and exercise, as do supervised activities. In fact, the presence of organized and supervised park activities was the strongest predictor of increased park use in one study of low-income neighborhoods. Another study looked at how different racial-ethnic groups use neighborhood parks and determined that people generally used parks at similar rates but in different ways, whether for exercise, socializing, or a combination of the two. Parks can also affect mental health. Having an urban park nearby is associated with the same mental health benefits as decreasing local unemployment rates by two percentage points.

Detailed evidence about park use and its health effects is essential if communities are to make smart choices about allocating scarce but valuable resources.

Are Wellness Programs a Good Investment?

Businessman eating a healthy lunch at his desk

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As the saying goes, an ounce of prevention is worth a pound of cure. Smoking, diet, exercise, and alcohol consumption account for 40 percent of premature mortality, so helping people to lose weight, stop smoking, and manage their weight goes a long way toward a healthier population. Wellness programs aimed at doing just that are popular with both health insurers and employers.

Workplace wellness is a $6 billion industry in the United States. Employers offer the programs to improve the health and well-being of their employees, increase their productivity, reduce their risk of costly chronic diseases, and improve control of chronic conditions.

Wellness programs are becoming a standard component of benefit packages, and how they are designed has a significant effect on employee participation. Employers who offer incentives and provide a comprehensive set of program offerings have higher participation rates—particularly when programs are prevention-focused.

Are these programs good financial investments? The media and trade publications strongly endorse this view, but our work tells a different story.

Typical workplace wellness programs have two components:

  1. Lifestyle Management, focused on changing employees' behavior (smoking, diet, exercise) to prevent costly chronic conditions
  2. Disease Management, focused on helping employees who already have a chronic disease better manage it

The benefits (or costs) of each differ significantly.

Workplace wellness is a $6 billion industry in the United States.

The overall return on an employer's workplace wellness program is about $1.50—that is, a return of $1.50 for every dollar the employer invested in the program. But the returns for the individual components differ dramatically: $3.80 for disease management but only $0.50 for lifestyle management for every dollar invested. So if an employer wants to improve employee health or productivity, an evidence-based lifestyle management program can achieve this goal. But employers who are seeking a healthy return on investment on their programs should target employees who already have chronic diseases. How programs are executed also really matters.

In a classic example of designing practical applications of its research, RAND developed a toolkit to help small and midsize employers build an effective workplace wellness program. The toolkit synthesizes lessons learned and best practices from multiple projects and many years of research into a five-step guide for planning, implementing, and evaluating a successful workplace wellness program.

Tobacco: Out of Sight, Out of Mind?

The best way to prevent a lifelong smoking habit is not to start in the first place. RAND studies how to prevent young people from picking up the habit, and how to help long-term smokers quit.

One way to make cigarettes less of an attractive nuisance is to move cigarette display cases—the so-called tobacco power wall—from behind the cash register. Using RAND's StoreLab—which replicates a typical mid-size convenience store in a Pittsburgh office building—researchers found that adolescents who shopped in the store with the power wall hidden were about half as likely to report that they would smoke in the future as teens who shopped in the store with the power wall behind the cash register.

A separate study found a similar elevated future smoking risk after participants were exposed to pro-smoking advertising in stores, but exposure to smoking in movies had no effect. Another study found that friends may influence a person's reaction to pro-smoking media.

Smoking is particularly rampant among homeless youths, with minorities especially at risk. In Los Angeles County, up to 95% of homeless youths use tobacco on a daily basis at an average of 15 cigarettes a day. The health risks for these youths are significantly higher than for the average user because they often share cigarettes or smoke discarded cigarettes (known as sniping).

Newport and Camel cigarettes are stacked on a shelf inside a tobacco store in New York

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About two-thirds of homeless youths would like to quit, and many homeless programs in the county offer smoking cessation programs. Alternative tobacco products are often promoted as a way to quit smoking, and about half of homeless youths reported using e-cigarettes, cigarillos, hookah, chewing tobacco, and other smokeless options. However, fewer than 1 in 5 were using them to quit tobacco altogether. RAND also found that the use of alternative tobacco products by non-daily smokers correlated to higher nicotine dependence—but not with less frequent cigarette smoking.

The nicotine patch is another method for quitting. Our study of a small group of smokers found that a short counseling session helped increase their adherence to using the patch and their abstinence from tobacco.

Despite sustained interest in smoking cessation programs, the field has lacked comprehensive measures of smoking behavior and outcomes. And what cannot be measured cannot be improved. RAND recently developed the PROMIS® Smoking Initiative, a versatile toolkit that measures a person's nicotine dependence, emotional expectancies, and social motivations. The smoking measures are an important contribution to broader effort funded by the National Institutes of Health to develop a system of highly reliable, precise measures of patient–reported health status for physical, mental, and social well–being.

Taking the Lead on Marijuana and Opioids

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What cannot be measured cannot be improved.

On one hand, an increasing number of states are legalizing marijuana, while on the other, they are battling an epidemic of opioid abuse that killed roughly 35,000 people in 2015. With drugs in the national spotlight, RAND's Drug Policy Research Center is more crucial than ever.

The Drug Policy Research Center examines a wide range of drug topics and drug policy, with recent studies exploring the potential effects of marijuana legalization on consumption, "middle ground" models for legalization, options for the federal government, the financial effects on tax revenue and enforcement, the use of edibles or vaporizers, and how parents can talk to their kids in this new environment.

RAND is also working to help opiate users get the help they need. A large part of RAND's research involves increasing the use of buprenorphine, an alternative to methadone. While a patient on methadone receives their treatment at a clinic, buprenorphine can be taken at home, which could be a boon for patients in areas where clinics are scarce. However, only doctors with certain certifications can prescribe the drug, and there is a limit on the number of patients they can treat. RAND research suggests strategies to help prescribers treat more patients safely and effectively and informs policy initiatives designed to increase access to treatment.

Given that many people become addicted to opioids after taking prescription painkillers, alternative treatments for chronic pain may be one way to battle the opioid epidemic. RAND examines not only the efficacy of complementary and alternative treatments such as acupuncture, chiropractic, and mindfulness meditation but also policies to better integrate them into the health care system.

Researchers are also engaged in treatment and prevention measures, including SUMMIT, a brief treatment for substance use disorders, and motivational interviewing, which uses social networks to combat substance use. RAND also developed Getting To Outcomes®, a tool to help communities improve the quality of their local programs aimed at drug prevention and other negative activities among youth. Initially focused on drug prevention, GTO has been used extensively to address a wide range of issues, ranging from teen pregnancy prevention to mental illness prevention and early intervention.

For treating alcohol abuse, RAND has done numerous studies of the 24/7 Sobriety Program in South Dakota. Researchers have found that the program requiring alcohol-involved offenders to abstain from alcohol and submit to frequent alcohol tests was associated with a 4 percent drop in deaths (most obviously for diseases associated with excessive alcohol use, such as circulatory conditions), and a 12 percent decrease in repeat DUI arrests. The 24/7 program has already been adopted in Montana, and California is considering it.

Helping the Homeless Avoid HIV

Sexual behaviors can put individuals at risk of contracting sexually transmitted diseases and HIV. A large body of RAND's work has focused on the serious epidemic of HIV among homeless people, where rates of infection are estimated to be three times higher than in the general population.

Many RAND studies aim to understand how a person's social network correlates to risky sexual behavior. For example, homeless youths with friends who regularly attend school are more likely to practice safe sex. A study of sexually transmitted infections found that people whose partners are incarcerated or substance users are more at risk of disease.

How a person's social networks view HIV also matters. Stigma appears to be related to less adherence to medication regimens among African Americans living with HIV, and internalized stigma may play a role in whether and to whom African Americans reveal their HIV serostatus.

Medical mistrust among African-American males with HIV also predicts lower medication adherence and may help to explain disparities in adherence rates (as well as related HIV health outcomes) between African-Americans and other racial/ethnic groups. Conversely, a study of homeless men in Los Angeles found that just having access to medical services largely predicts whether a person gets tested for HIV.

Other related research has focused on a pilot program to reduce the risk of HIV among homeless women in Los Angeles County, helping HIV-positive people have children safely, promoting condom use to prevent HIV in Brazil, HIV-related risk and resilience among trans women in Lebanon, the factors influencing sexual risk behaviors and HIV testing among male sex workers in Lebanon, and the positive impact of antidepressants on HIV patients in Uganda.

Preventing and Preparing for Outbreaks

Boy receiving a vaccination

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Vaccines play an outsized role in population health, but the public's suspicions abound. Childhood vaccines are one target of suspicion—despite being proven to be safe and effective.

RAND has researched what influences parents to avoid or delay vaccinations, studied whether parents would be willing to pay more for pricier new combination vaccines that reduce the number of injections needed, and written about policies that might persuade hesitant parents to vaccinate their children on the recommended schedule.

A majority of Americans also avoid the annual flu vaccine. RAND has studied how many people are immunized against influenza, why they avoid the vaccines, and how to increase vaccination rates and address public skepticism. One place to start is by increasing vaccination rates among health care professionals themselves.

RAND researchers frequently offer their expertise when outbreaks occur or threaten to emerge. After the 2009 H1N1 threat, RAND recommended ways to strengthen preparedness in the event of a future pandemic and briefed Congress on lessons learned. After a measles outbreak at Disneyland caused California to mandate that all schoolchildren be vaccinated regardless of religious or personal beliefs, RAND provided its expert analysis of the outbreak and the new policy.

Individuals put themselves—and their communities—at risk when they decide not to vaccinate themselves or their children.

Improving Mental Health

"There can be no physical health without mental health," the World Health Organization says. People with poor mental health are more likely to have chronic physical conditions—and people with chronic physical conditions risk developing poor mental health.

While mental health issues can strike at any age, assisting young people with their psychological problems can help them avoid many behaviors with potentially long-lasting consequences like dropping out of school, abusing drugs, and earning less money over a lifetime. Helping youths avoid these pitfalls is a key part of RAND's work with the California Mental Health Services Authority (CalMHSA). This coalition of California county governments is investing in prevention and early intervention programs specifically targeting the mental health and wellbeing of students in the state's public colleges and community colleges as part of a larger project with RAND.

When work began in 2011, RAND found that about 20 percent of these California college students reported current mental health issues, and 11 percent said their academic work had suffered significantly as a result—yet only 1 in 5 sought treatment.

Instead of advocating for more clinicians on campus or more mental health screenings, CalMHSA took a different approach. It designed trainings, social marketing campaigns, and online resources to help people on campus recognize and support students in need of mental health care, combat the stigma of mental illness, and give students tools for dealing with stress and personal and emotional problems.

The result? In the 2013–2014 school year, the researchers found an increase of 13.2 percent in the number of college students receiving mental health services and a 15 percent spike among community college students accessing care. Based on research linking improved mental health to higher graduation rates, the researchers estimate that an additional 329 students will graduate each year. The return on investment is also encouraging; the net societal benefit for California is estimated to be more than $6 for each dollar invested in prevention and early intervention programs.

Other recent work on this topic includes:

Building Community Resilience

Residents in some communities appear to suffer less trauma from disasters such as floods and earthquakes, and community resilience has become a catch phrase in public health. But what exactly does it mean? A resilient community is one that can withstand and recover from disasters and learn from past disasters to improve its future responses.

Because the process of building resilience involves the whole community—individuals, community organizations, the private sector—a resilient community is also innovative when times are tough. RAND research in multiple sectors—including infrastructure, security, and economic development—contributes to the community's efforts.

A resilient community is one that can withstand and recover from disasters and learn from past disasters to improve its future responses.

Our work identified 8 levers that can help move a community systematically towards resilience. They include partnership to unite government and nongovernmental partners; engagement to ensure that at-risk populations participate in planning; education so that residents and organizations have the information they need; and self-sufficiency to build residents' self-reliance.

These levers are being tested in a community resilience toolkit so that community coalitions can see what works best for their residents. An easy to use, self-guided online training shows organizations and communities how to develop an action plan for disaster response and recovery. A hallmark of community resilience is the ability to learn from the past. The painful process of rebuilding in the aftermath of Hurricanes Sandy and Katrina underscores the need for comprehensive recovery plans that meet the community's needs and involve everyone.

But resilience is not just about disasters. Communities are using the toolkits to respond to daily stress such as community violence and climate change, promoting community health in a more comprehensive way.

Re-Envisioning Population Health

A new vision of population health is emerging. This vision sees the concept broadly as the total well-being of communities and their residents. Accordingly, promoting population health will depend on a shared understanding of all the factors that drive health and well-being and investing across sectors (not only health care) based on that understanding. Informing this investment will require robust frameworks for measuring drivers of well-being and assessing the impact of initiatives to improve well-being. RAND is taking a step forward in this reconceptualization of population health through two efforts. Each effort is rooted in social change theory, the history of cultural movements, and an understanding that a more holistic definition of health is required in order to motivate progress on aspects of population health, well-being, and equity.

First, RAND is working with the Robert Wood Johnson Foundation to advance its strategy to build a national culture of health (www.cultureofhealth.org). RAND's role has been to partner with the Foundation to develop the action framework that guides the strategy, to inform new dialogue among nontraditional stakeholders and sectors that influence and invest in health, and to create conditions for tracking and monitoring this national movement.

Building a National Culture of Health: Background, Action Framework, Measures and Next Steps sets the foundation and conceptual underpinning for the action framework. A series of follow-up reports summarize the perspective of stakeholders; the results of a unique national survey of American health attitudes, expectations, and priorities; and how incentives and cultural alignment can advance a culture of health.

In addition to Culture of Health, RAND is on the leading edge in developing strategy and measurement for community well-being. This work also rests in the principles of creating shared values and a cultural movement to propel action in population health. Working collaboratively with the City of Santa Monica, and funded by Bloomberg Philanthropies' Mayors Challenge, RAND has created a new model of how cities can embed wellbeing principles and measurement in the core actions of city planning. This work is developing new insights into how a population health and wellbeing orientation can change the role of cities, informing local policies, programs, as well as data systems and culture.