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 26th in life expectancy among 40 OECD countries. Thirty countries have lower infant mortality rates.

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. Health behaviors, genes and biology, and the social and physical environment in which individuals live and work have a stronger influence on well-being than clinical services do. Research in RAND's Population Health program includes these broader determinants of health, with a focus on enhancing the population's well-being.

What Determines Population Health?

The determinants of health can be viewed as a continuum.

SOURCE: Adapted from Stiefel M, Nolan KA. Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.

  1. Upstream factors include social determinants of health such as income, education, and employment. They also include aspects of the physical environment that affect health, including the built environment such as parks and street grids, the food environment, community safety, and environmental pollution. In the aggregate, these factors comprise the overall context in which individual members of the population live.
  2. Individual factors are those characteristics of our genetic make-up, our physiology, and our behavior that determine how we are affected by, or exert influence on, the upstream factors. For example, risky behavior such as smoking or substance abuse will make some individuals more vulnerable to certain aspects of the physical environment—e.g., pollution. Risky behavior can also affect the likelihood that individuals contract HIV or other contagious diseases. Mental health issues such as anxiety and depression could play a strong role as well.
  3. Disease and injury may be the immediate outcomes that result from the interaction of upstream factors and individual factors. For example, we know that about 40% of premature mortality results from smoking, poor diet, lack of exercise and excess alcohol consumption.
  4. States of health include not just mortality but also functioning and health status. Indeed, the development of health status measures is arguably one of the most important contributions of health services research over the last five decades.
  5. Quality of life is what defines the well-being of an individual or a community. Thanks to health status measures, we can measure quality of life—for example, we can compare quality of life for an individual with mild dementia who resides in a nursing home compared with quality of life for an individual with the same condition who lives in the community.

Traditional medical care focuses on treating disease and injury, as measured by survival or functioning. Ultimately, the goal of medical care is to improve quality of life. But prevention and health promotion efforts seek to influence upstream and individual factors as a way to prevent or mitigate disease and injury. It is these factors that are the focus of the Population Health program.

Upstream Determinants of Health

Socioeconomic Factors

Socioeconomic status has long been acknowledged as a powerful influence on health. Work conducted in RAND's Labor and Population program has demonstrated the impact of socioeconomic status on health over the course of a lifetime.

But the most important socioeconomic factor in terms of health effects appears to be education, not income. Health disparities related to schooling have increased over the last 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 males with 16 or more years of schooling could expect to live 14.2 years longer than their black counterparts, while white women are living a decade longer than black women.

Health is a function of more than medical care.

There is also compelling evidence that living in a lower socioeconomic status (SES) neighborhood in the United States is associated with significantly greater wear and tear on an individual’s biological (e.g., cardiovascular, metabolic) systems. These effects are independent of an individual's own socioeconomic status.

Similarly, we found that the effects of low socioeconomic status and physical abuse early in life could also have physiological outcomes in adulthood. While education helped mitigate the effects of a low-income start in life, it had little impact on the effects of physical abuse, which could be seen in stress symptoms such as inflammation, cardiovascular function, and lipid metabolism. Low socioeconomic status is also related to heavy episodic drinking.

Neighborhood SES varies substantially nationally, with sometimes stark differences between adjacent neighborhoods. The fact that where one lives is independently associated with biological wear and tear suggests, as have many other studies, that improving socioeconomic status may also yield health returns and help to reduce health disparities.

Influence of the Physical Environment

Analyses of socioeconomic effects on health show that the better educated make better health choices. But people’s ability to make choices is greatly influenced by their environment. More specifically, "people can make healthier choices if they live in neighborhoods that are safe, free from violence, and designed to promote health. Ensuring opportunities for residents to make healthy choices should be a key component of all community and neighborhood development initiatives." (Time to Act: Investing in the Health of Our Children and Communities)

Understanding how the environment can promote healthier choices requires looking at associations between the environment and health from multiple perspectives.

Can We Help Shape the "Choice Environment"?

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RAND has studied different approaches to the question of whether policy can shape the choice environment. One approach 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.

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. But the composition of food vendors has changed little in the neighborhood (only about 10 percent of restaurants are new), and the prevalence of overweight or obesity has increased significantly more in South Los Angeles from 2007 to 2011-2012 than in the county at large. Another study of adults in Los Angeles County found little association between residents' diet and obesity rates and the proximity of fast food outlets, small convenience stores, or supermarkets.

"People can make healthier choices if they live in neighborhoods that are safe, free from violence, and designed to promote health."

Time to Act: Investing in the Health of Our Children and Communities

Similarly, 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. In addition, 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: Fruits and vegetables were equally available in high- and low-end stores, but the pricier stores actively marketed healthy foods, while the cheaper ones promoted junk foods. These findings suggest that marketing affordable healthy foods might be more effective than just locating supermarkets in food deserts.

After the supermarket opened, the research team compared the residents of the two communities on several dimensions. Findings did not always confirm conventional wisdom about how food deserts might influence obesity. Residents near the new supermarket did eat a better diet — 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.

These assessments of attempts to influence the choice environment underscore that we do not yet understand the forces that influence neighborhood health and nutrition.

How Can Neighborhoods Promote Health?

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Neighborhoods have a powerful effect on residents' physical activity. As a result, neighborhood design, especially public parks, is an important public health issue.

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

Among the insights from these studies: Neighborhood parks promote exercise, especially among residents who live within a mile of a park; pocket parks are used as frequently or more often than neighborhood parks and may be a cost-effective way to promote physical activity among inner-city populations. Opening school playgrounds on weekends could provide another exercise venue for children, especially in older, non-white, poor neighborhoods.

Modest improvements in marketing and signage at parks can increase activity and exercise. Consistent with that finding, the most important determinant of park use is the number of areas in the park that have organized and supervised activities.

A study about how perceived threats affects park use reached a similar conclusion. RAND observed 48 parks in low-income areas and surveyed park users and neighborhood residents about park safety. A majority considered their parks to be safe, and the frequent presence of (generally well-behaved) homeless individuals didn't appear to be a deterrent to park use (though intoxicated people changed this dynamic). Again, focusing resources on programming and activities may have a bigger effect on increasing park use than targeting perceived threats.

Another study looked at how different racial-ethnic groups use neighborhood parks and determined that the groups studied generally use parks at similar rates but differed in how they used the park, 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. Mental health appears to be a desirable measure for evaluating neighborhood improvement programs.

Parks can also affect mental health. Indeed, having an urban park nearby is associated with the same mental health benefits as decreasing local unemployment rates by two percentage points. Mental health appears to be a desirable measure for evaluating neighborhood improvement programs.

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

How Might Neighborhoods Degrade Health?

Of course, the environment can also damage health, especially in areas hit by disaster. For example, Hurricane Sandy recovery crews may be at risk from "fugitive" chemicals—that is, toxins dislodged from industrial sites by floodwaters and carried to business districts and neighborhoods where cleanup occurs.

A study now under way will try to determine the exposure and health risks for the contractors, volunteers, workers, and community members who helped out after the hurricane in Sunset Park, an industrial waterfront in Brooklyn. The longer aim is to develop an implementation plan that could apply to other industrial waterfronts in a disaster.

The method for assessing workers' exposure and risk includes significant community involvement to ensure that the study is transparent, integrates local knowledge and data, and supports planning a process that can be replicated.

Neighborhoods degrade health in other ways, too. Urban sprawl has been shown to have an effect on physical activity and obesity—and now coronary heart disease. A recent RAND study found that post-menopausal women who lived in more compact communities had a lower probability of experiencing an event or death related to coronary heart disease or myocardial infarction. And, of course, air pollution also damages health; for example, dirty air in California caused nearly 30,000 emergency room visits and hospital admissions from 2005 to 2007.

Risk of coronary heart disease also increases based on neighborhood socioeconomic status. An individual living in a higher-income neighborhood has, on average, a 10-year chronic heart disease risk that is 0.16 percentage points lower than a similar person residing in a low-income neighborhood. The association is larger in men than women and in whites than minorities. Similar results were observed between neighborhood socioeconomic status and risk of cardiovascular disease events.

Bringing Wellness to the Workplace

Urban sprawl has been shown to have an effect on physical activity and obesity—and now coronary heart disease.

Businessman eating a healthy lunch at his desk

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Increasingly, employers are seeking to make the workplace environment one that promotes healthy choices. Workplace wellness is a $6 billion dollar 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 comprehensive and prevention-focused.

The media and trade publications strongly endorse the programs as a good investment for employers. But our work tells a different story. Typical programs have two components: lifestyle management, which focuses on changing the behavior of employees at risk of develop costly chronic conditions, and disease management, which focuses on helping employees who already have a chronic disease better manage it.

Workplace wellness is a $6 billion dollar 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. Lifestyle management programs can reduce health risks such as smoking, obesity, and lack of physical exercise. 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 (ROI) 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, we recently published 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.

Individual Factors that Influence Health

Socioeconomic factors and the physical environment, which define the context in which we work and live, have a large effect on population health. But individual factors such as health behaviors have a smaller effect but nonetheless important impact. Among the most powerful of these factors are smoking, diet, exercise, and alcohol consumption. In fact, these four account for 40 percent of premature mortality. On the other hand, spirituality and resilience can modify the influence of upstream factors. The behavior of individuals can make them more vulnerable to the health threats in their environments, and all of the individual factors can potentially be influenced—either to reduce or to promote them—by the efforts of communities and individuals.

Our work enhances understanding of the scope and magnitude of behavioral factors such as smoking and substance abuse and explores how they can be prevented or treated. We also explore mental health and sources of spiritualty and resilience, which are increasingly recognized as important determinants of health.

Smoking, diet, exercise, and alcohol consumption account for 40 percent of premature mortality.

Combating Invitations to Smoke and Drink

The environment can promote risky behavior simply by inviting it. Teens encounter many invitations, both subtle and explicit, to use tobacco. Understanding the circumstances and effects of these invitations is the first step in helping teens refuse them.

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. Moving the tobacco display to a side wall had no effect on adolescents' susceptibility to future smoking.

Adolescents who shop in convenience stores multiple times per week have ample opportunity to be exposed to diverse forms of tobacco advertising. Moderating the effects of exposure could generate important health payoffs.

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; a study in Los Angeles County revealed that up to 95% use tobacco on a daily basis at an average of 15 cigarettes a day. The health risks for young homeless smokers are significantly higher than the average user because they often share cigarettes or smoke discarded cigarettes (known as sniping). About two-thirds of homeless youths would like to quit, and many homeless programs in the county offer smoking cessation programs. RAND has studied several types of smoking cessation programs and promoted best practices.

Another study examined whether homeless youths were using alternative tobacco products such as e-cigarettes, cigarillos, hookah, chewing tobacco, and other smokeless options. About half reported using e-cigarettes, but fewer than 1 in 5 youths were using them to help quit tobacco altogether.

Measuring Effects of Smoking and Smoking Prevention

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

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Nation-wide efforts to reduce health risks from smoking stemmed from the Tobacco Master Settlement Agreement in 1998. But among the 46 states that signed the settlement, only Arkansas invested all of its funds in health-related programming. The investment is paying off. For example, smoking rates among key populations, including teens, young adults, and pregnant women, have declined beyond what would have been expected without the program. Hospitalizations rates are also lower for smoking-related health conditions, including strokes and heart attacks.

But 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. We recently developed the PROMIS® Smoking Initiative, a versatile toolkit that measures key concepts relevant to adult smokers, including nicotine dependence, emotional expectancies, and social motivations. The smoking measures are an important contribution to a 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.

Resisting invitations to Drink and Use Drugs

What cannot be measured cannot be improved.

Invitations to drink are also ubiquitous. Exposure to alcohol ads has a persistent effect on drinking in mid-adolescence. One study showed that adolescent viewers were exposed to more beer, spirits, and alcopop ads on cable television than would be expected through incidental exposure. Another study found that white students who were exposed to alcohol ads were more likely to view the typical peer who drinks more favorably and to perceive alcohol use as more the norm than students who did not view the ads.

Research has tied youth drinking (and other risky behaviors) to the availability of alcohol in their neighborhood, the performance of the schools they attend, depression, and after-school employment. Studies have also found a link between early alcohol and marijuana use and subsequent DUIs among adolescents.

Similar to our findings about alcohol and tobacco ads, we found that exposure to advertisements for medical marijuana was associated with a higher probability of marijuana use and stronger intentions to use. Other RAND research found that advanced puberty for a youth's grade level was linked to greater substance use, that youths tend to pick friends with similar histories of marijuana use, and that the middle school students who used prescription drugs recreationally had poorer social functioning and greater delinquency in high school.

In an attempt to understand the factors associated with decreasing marijuana use or quitting altogether, one study evaluated a range of factors as predictors of marijuana use, non-use after a year, and cessation after six years. Results found that non-use was more likely among adolescents who did not move, had fewer marijuana-using friends, and did not exclusively have outside-of-school friends. Cessation was more likely among adolescents in less disadvantaged and more cohesive neighborhoods, and for those with within-school friends.

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Many communities, aware of these threats to public health, support programs designed to prevent substance abuse of all kinds. But local prevention practitioners face several challenges in implementing high-quality programs, including the significant amount of knowledge and skills required, the large number of steps that need to be addressed, and the wide variety of contexts in which prevention programs need to be implemented. These challenges have resulted in a large gap between the positive outcomes often achieved by prevention science and the lack of these outcomes by prevention practice at the local level.

Getting To Outcomes® was specifically designed to bridge this gap and help any agency, school, or community coalition interested in improving the quality of their programs aimed at preventing or reducing a range of negative activities among youth. It is both a model ("a fabulous cookbook for someone who's never done outcomes evaluation before") for carrying out prevention programming with quality, and a support intervention aimed at enhancing practitioners' capacity. 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. By building community capacity, GTO directly supports communities in improving their own health.

More broadly, the RAND Drug Policy Research Center has conducted research since 1989 to help decisionmakers in the United States and throughout the world address issues involving alcohol and other drugs. The center conducts policy research on a wide range of drug topics, with recent studies examining the potential effects of legalizing recreational marijuana, estimates of illegal drug consumption and user expenditures, and helping opiate users get the help they need.

One recent effort examined the 24/7 Sobriety Program in South Dakota, which started as a pilot in 2005. Researchers 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 at the county level. The associations were most evident among causes of death associated with excessive alcohol use, such as circulatory conditions. Nearly 17,000 individuals — nearly 3 percent of the state's adult population — participated in the 24/7 program between January 2005 and June 2011. A previous RAND study found that the 24/7 program reduced county-level repeat DUI arrests by 12 percent and domestic violence arrests by 9 percent.

Sexual Behavior That Puts People at Risk

Sexual behaviors such as having unprotected sex 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 studies aim to understand how a person's social network correlates to risky sexual behavior. One report in Los Angeles County found that young homeless men who had sex with other men were more likely to have safe sex and fewer sex partners if their networks included platonic peers who regularly attended school. They also had fewer sex partners if most in their network were not heavy drinkers. Similarly, a study of sexually transmitted infections in Mississippi 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. For example, stigma appears to be related to less adherence to medication regimens among African Americans living with HIV. Another study found that internalized stigma may play a role in whether and to whom African Americans revealed their HIV serostatus, with trusted network members, friends who were also HIV-positive, and sex partners more likely to know the person's HIV status.

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. This suggests that programs encouraging general medical service access may be important for disseminating HIV testing services to this high-risk, vulnerable population.

Our research also aims to help people with HIV who want to have children to do so safely. Based on our research in both Uganda and Los Angeles County, HIV providers need training to better counsel patients, and patients need more educational tools informing them of the risks, challenges, and options available to safely conceive an HIV-negative child.

Other related research has focused on a pilot program to reduce the risk of HIV among homeless women in Los Angeles County, 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.

Combatting Obesity

Children eating large hamburgers

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We have been gaining weight at about the same rate for the past 25 years. The epidemic affects all groups, whatever their race, ethnicity, or level of education, suggesting that obesity is driven by environmental factors that affect everyone.

The epidemic is costly. Obese individuals, on average, incur health care costs one-third higher than persons of normal weight, but costs for severely obese individuals are twice as high. We have shown that cutting the current rate of obesity in the United States in half—to the level in 1978—would reduce the burden of costly health problems like diabetes, hypertension, and heart disease; increase longevity and years of disability-free life; and significantly decrease Medicare and Medicaid costs. Savings to Medicare alone could reach $1.2 trillion by 2030.

Our work focuses on two of the most powerful environmental factors driving obesity—the economics of food consumption and the way in which food is marketed.

Environmental Factors Driving Obesity

  1. Cheaper and Easier. As a share of disposable income, Americans have the cheapest food in history. It is also easier to buy. Healthy foods are becoming more available, and Americans are indeed eating more of them. However, we have just added the fruits and veggies to our diets, without substituting them for high-calorie foods; as a result, overall we are consuming more calories. Policies (e.g., taxes on high-calorie foods) could provide incentives for consumers to make the switch, but to date, feasible options remain illusive.
  2. High-Calorie Foods on Display. Just as display cases bring cigarettes to the attention of consumers of all ages, prominent displays of calorie-dense snacks present temptations that can be hard to resist. Arguably, these displays put consumers at risk for obesity and associated chronic disease because our impulsive choices from them are largely automatic. Navigating grocery aisles can be treacherous! We know that it helps to use a grocery list along with some other tips for safer shopping.

Navigating grocery aisles can be treacherous!

Unfortunately, consumers who are trying to eat smart aren't getting any support from the typical restaurant. Ninety-six percent of the entrees from more than 200 chain restaurants contain more calories, fat, and sodium than should be consumed in one sitting. And despite pressure to increase their healthier offerings, restaurants aren't making meaningful changes. Standardized portion sizes might help.

Young people are not immune from the obesity epidemic. Yet again, socioeconomic status may play a role. Youths from wealthier families are significantly less obese in fifth and seventh grades than low-income youths. Also, children who were obese in fifth grade generally remained so five years later, especially when they were from low-income, low-education households or had a negative body image.

Of course, marketing and environment also have some responsibility for childhood obesity. One study found that the higher the percentage of outdoor advertisements promoting food or non-alcoholic beverages within a census tract, the greater the odds of obesity among its residents—even when controlling for age, race and educational status. In addition, the environment outside our schools—convenience stores, restaurants, and liquor stores—may negate the healthy school food policies and health education happening on campus.

However, policymakers could use school environments to their advantage when it comes to fighting childhood obesity. There is evidence that school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education can get kids to eat more fruits and vegetables, buy fewer snacks, and drink more water.

Our work underscores what many public health experts believe—obesity is a population-level problem that demands population-focused policies. Regulation is one option that has worked for alcohol. The bottom line: Ultimately, defeating the obesity epidemic will require creating a more balanced food environment.

Increasing the Use of Vaccines

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Individuals put themselves—and their communities—at risk when they decide not to vaccinate themselves or their children. 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. For example, we have already mentioned that depression can affect the age at which youths begin drinking, that antidepressants can help those with HIV, and that having an urban park nearby has psychological benefits.

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 Cognitive-Behavioral Intervention for Trauma in Schools (CBITS), a project that aims to help children overcome trauma from witnessing or experiencing violence or abuse; the impact of paternal mental health and substance use on children's mental health; how suicide prevention programs can better engage with parents; and a wide range of research on autism spectrum disorders, dementia, and post-traumatic stress disorder.

Understanding the Role of Spirituality

Religious books on a bench with church facade in the background

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Religious congregations (including churches, synagogues, and mosques) reach many lives and play an important role in working for social change. National surveys have found that about half of all adults attend religious services at least monthly. Congregations represent complex social networks. They provide structured access to resources such as informal support, trust, food, educational and job opportunities, and a variety of other social benefits.

Working with religious congregations offers two special advantages in efforts to improve the health and well being of minority populations:

  1. Congregations represent a way to reach the community through a trusted source. Their leaders are change agents, and working with congregations provides an opportunity to collaborate with them for the community's benefit.
  2. Congregations are not just an access point. In our work, we are also building capacity so that congregations themselves can advocate for policies that are equitable.

In a series of studies stretching back to the late 1990s, we have been exploring the many ways in which religious congregations affect both individual and community wellbeing. For example: Congregations can partner with public health organizations in a community to promote health education and disease prevention activities such as mammography screening. In collaboration with religious congregations, we have gauged how various approaches to screening, such as peer counselors, telephone reminders, or church-based mobile mammography, affect the participation of different ethnic groups.

Partnerships between community health centers and faith-based organizations are promoted as a way to increase outreach to underserved populations and support health-promoting behaviors and effective disease management. Through focus groups, we explored how low-income residents (African American, Latino, and White) viewed their communities, the meaning of health, the role of spirituality, and their experiences with and preferences for congregation-based health programming. All racial-ethnic groups deem spirituality important for health, but attendance at religious services, religious affiliation, and preferences for congregation-based health programming varied across and within groups. This work suggests that partnerships between health centers and faith-based institutions can facilitate health care access in underserved communities but may have limited reach among certain subgroups and individuals.

As one example, the stigma associated with HIV may prevent HIV positive individuals from seeking care and counseling, and make religious congregations reluctant to support HIV activities, including preventative HIV testing at church. Clergy and lay leaders have a very influential role. In our work we found that their norms and attitudes were more important influences than theological orientation in determining whether congregations promoted HIV activities. Another study suggested that simply knowing someone with HIV was associated with less stigma surrounding the disease. Others revealed that the factors associated with whether a congregation has an HIV program are different from those associated with other types of programs. Larger congregations are more likely to have other type of health programs, but for HIV programs, what mattered was having an official statement welcoming gay persons.

Promoting 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.

Promoting Equity

Equity is an overarching issue, affecting both medical care and prevention and health promotion efforts. It is obviously key in understanding upstream factors such as the effects of socioeconomics or the physical environment on health. But it is also central to understanding how access to health care and the quality of care received are influenced by age, ethnicity, or health status, to name but a few of the key variables.

By its nature, equity is an interdisciplinary issue. In particular, a substantial body of work in RAND Labor and Population has demonstrated the impact of socioeconomic status on health over the course of a lifetime. That work has also highlighted education as the socioeconomic factor that has the most powerful influence over health. The less educated are more likely to develop a chronic disease in middle age; the more educated tend to have fewer risky heath behaviors.

Disparities in medical care for women—some of which are detailed in a series of reports by RAND’s Women's Health Initiative—provide a good example of how equity concerns can be linked to upstream factors such as the physical environment and manifest as differences in medical care and health functioning.

Coronary heart disease is the leading cause of death in women—1 in 3 will die from it. But recent work showed that cardiovascular care in California is better for men than for women in 7 of the 8 regions assessed. Using visual data displays, the study mapped the rate at which women and men with cardiovascular disease had an annual cholesterol screening, a measure of quality of care for this condition. The gender gaps were most apparent at the county level, but masked at the state level. Similar disparities in screening, though of a lesser magnitude, existed between men and women who had diabetes.

The gender gaps varied by insurance plan: there were no significant gaps between and women insured with a commercial health maintenance organization (HMO), but the gaps were apparent for those insured with a commercial preferred provider organization (PPO). Knowing there is a problem is the first step towards solving it. Health plans could take a major step by collecting and analyzing data to identify the size and location of gender gaps in care.

The Affordable Care Act (ACA) may help address some of these gaps simply by increasing people's access to care. Since the Medicaid expansion and the ACA mandate for Americans to carry health insurance, colorectal screenings and HIV testing have both increased.

The less educated are more likely to develop a chronic disease in middle age; the more educated tend to have fewer risky heath behaviors.

Our work on equity issues in population health ranges widely, highlighting how assessment of medical needs and delivery of medical care should consider racial, ethic, and cultural factors. For example, cardiovascular risk factors are linked to poorer cognitive functioning among minority older adults, but the relationships vary by gender and medication use, underscoring the need to understand how ethnic and cultural influences contribute to cognitive impairment among this population.

Both practitioners and decisionmakers aim to reduce disparities in health care, but without appropriate data, they don’t know if their efforts are achieving equity. In our assessment of quality of care among Medicaid beneficiaries with schizophrenia in four states, we documented both poor overall quality of care as well as racial/ethnic disparities, which varied across states. We also found no improvement in these disparities between 2002-2008, suggesting that policies aimed at addressing these gaps need to be reconsidered.

Variation in the quality or nature of health services is a major theme emerging from much of our work. A recent example is our finding that the type of therapy kids receive for ADHD depends on where they live. Only one quarter of commercially-insured children who are treated with medication for attention-deficit/hyperactivity disorder also receive psychotherapy, and the percentage is far lower in many parts of the country. The variation doesn’t always reflect the number of available psychologists in an area. This work suggests that many children with private insurance who could benefit from therapy are not receiving it.

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 second report summarizes what stakeholders had to say about the concept of a Culture of Health, the measurements, and other elements used to inform this work. Finally, a third report summarizes results from a unique national survey of American health attitudes, expectations, and priorities.

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.