ALIGN for Health and Well-Being Toolkit

actions

In the context of these workshops, the results of narrative change, such as cultural shifts, policy changes, and program changes

catalytic measures

Measures that do one or more of the following actions:

help set goals (near-term and adaptable versus long-term)
frame issues (e.g., health and well-being are about more than health care)
create common terms to help individuals and organizations see a commonality of interests
shift venues (e.g. change how and where an issue is framed and discussed)

These measures often can be used as sentinel indicators of community health and well-being to map to the community health narrative North Star.

culture

Sharing and alignment of beliefs, attitudes, values, and actions across a set of individuals, organizations, and decision environments (e.g., where policies or laws are made)

data

Any facts, statistics, or inputs used for analysis that come from multiple sources, including administrative files and records, encounters, interviews, focus groups, social interactions, or social media

experiences

Events or encounters related to lived or personal experiences and/or current events or experiences in a community

indicator

A specified percentage, number, or amount of something to be measured (e.g., number of people with cancer, percentage of a budget that goes to parks)

influencers

Individuals, organizations, or collective leadership that lead or provoke health conversations, shape stories about health, and/or set the priorities for health in a population or community

investments

The allocation of community resources, which include financial resources, community policies, and time dedicated by community leaders

equity

Includes

procedural equity: the perceived fairness of processes and procedures in decisionmaking
contextual equity: how preexisting social conditions influence equity
distributive equity: how social welfare and need is balanced

In some community contexts, the word equity might not be useful or desirable. Here are some options for terms that could help keep the conversation going:

health opportunities
social contexts around health
fairness in health
health for all
health choices

frames

Underlying values and beliefs about what influences outcomes (e.g., health outcomes)

health equity

The fair and just access to the opportunity to be healthy for all

measure

A way of categorizing something to assess, track, or understand it (e.g., positive mental health, health care investments)

messages

The articulation of the narrative frame that serves as the strategic foundation for storytelling

mindsets

Ways that individuals and groups think about a topic, such as health and well-being

narrative

The critical frames and resulting stories and messaging that influence and inform the way people and communities see and describe the world

A narrative helps to articulate a way of understanding the world and informs how people then act.

performance-based measures

Measures that are focused on accountability and linked to rewards and punishments

These measures tend to be most useful to track a department’s or organization’s effectiveness.

stories

Accounts of experiences via oral or written tradition

Narratives can represent the aggregation of stories that we see, hear, and experience.

values

Individual and community principles or standards of behavior

well-being

The full range of assets and capabilities that people need to thrive and create meaningful futures

Well-being is multifaceted and includes

individual well-being: the state in which people experience happiness and satisfaction and can realize their full potential
community well-being: the combination of social, economic, environmental, cultural, and political conditions identified by individuals, families, and their communities as essential for them to flourish and fulfill their potential
collective well-being: the expression of the connections between individual and community well-being. When communities (e.g., places or cultures) are characterized by a strong collective well-being, they have the collective will and connected experiences that allow community members to work together to address systemic harms and build a future together. For instance, collective well-being can refer to the strength and quality of connections among people, between people and institutions in the community, and between people and nature.

Module 1 Making the Case

Why Health Equity and Collective Well-Being Matters

If you have not reviewed the toolkit introduction, start there first.

Get Started

What Is in This Module?

This module includes elements of casemaking—explanations of why health, health equity, and well-being matter and why the focus areas of this toolkit are important for community health.

Use this module to invite the leaders in your community who represent different sectors into conversations about health and well-being. See the Introduction if you are unsure about which leaders to include in these conversations. This module includes information that can be used to explain core health and well-being concepts to others in your community and offer them motivation to work together through the rest of the toolkit. There are also discussion prompts to facilitate digging deeper into these concepts. These discussions can be directed by a group leader or done collaboratively.

A computer or mobile device (if using the digital toolkit)
A whiteboard or large easel pad in a central location for group exercises
Easel pads for each small group
Markers (enough for each small group)
Printouts of the resources provided at the end of the toolkit (e.g., Participant Workbook, glossary) to provide as handouts; printouts of module pages for those who do not have a computer or mobile device
Optional sticky notes or notepads for individual brainstorming
Pens, markers, and paper for notetaking, if preferred

Skills Acquired to Make the Case

By the end of this module, Making the Case, participants from your community will be able to

explain what drives health in the United States
describe why well-being is important for your community
identify sticking points that could be affecting efforts to improve the health and well-being of your community.

Organization of This Module

This module proceeds in four sections that build on each other:

Discussion

Introductory Discussion Prompt

Here are some ideas for icebreakers that you can use before starting this module with your community group. Ask each participant to share the following:

What is your name?
What organization do you represent?
How would you define health?

Section A What Drives Health?

Compared with peer countries, the United States spends a significantly larger portion of its gross domestic product (GDP) on health care. Yet Americans have shorter life expectancies and report lower levels of life satisfaction, and health inequities and social isolation contribute to substantial social and economic costs. The facts highlighted in this section offer a generalized picture of the state of health in the United States in 2025.

As of 2024, Americans spend more than 17 percent of the nation’s GDP on health care (U.S. Centers for Medicare & Medicaid Services, 2024).
- Since 2009, this number has either remained relatively stable or increased (U.S. Centers for Medicare & Medicaid Services, 2024).
- It is projected to hover close to one-fifth of GDP (U.S. Centers for Medicare & Medicaid Services, 2024).
- These numbers exceed comparable peer countries, such as the member countries of the Organisation for Economic Co-operation and Development (OECD) which include Australia, Norway, Germany, United Kingdom, and South Korea, among other nations.
Americans do not get the same returns in life expectancy as OECD countries.
- The average American’s life expectancy is fewer than 80 years, compared with OECD countries, whose citizens have life expectancies that are well over 80 years (OECD Better Life Index, undated-a).
- Reported life satisfaction follows similar patterns, and Americans report worse life satisfaction (OECD Better Life Index, undated-b).
The mortality gap between Americans with college degrees and Americans without college degrees is widening, and it serves as one example of health inequity.
- Some research estimates that there is a gap of more than ten years in life expectancy between Americans with a high school diploma and Americans without and an 11-year gap between Americans with a college degree and Americans with a high school diploma (Case and Deaton, 2021).
Health inequities make it difficult for all Americans to achieve good health, and such inequities impose significant costs on communities.
- These costs result in higher demands for health care and other services, poor health outcomes (such as increased mortality and morbidity), and negative impacts on social and economic well-being, including an individual’s ability to be productive and contribute to the economy (Anderson, 2023).
In recent years, there have been increasing concerns about American pessimism and its bearing on health.
- Related issues, such as disconnection and social isolation, also play a role in the state of health in the United States (Cahn and Hurst, 2023).

Visual

Visuals to Share

Figures 1.1. and 1.2 can be used in a presentation to or alongside a discussion with a community group.

Bar chart comparing US healthcare spending (% of GDP) to other countries. — Figure 1.1 U.S. Spending on Health Care, as a Percentage of Gross Domestic Product, Compared with Other Countries

Bar chart comparing US life expectancy to other countries — Figure 1.2 U.S. Life Expectancy, in Years, Compared with Other Countries

Consider these interesting facts about U.S. health expenditures.

It is often estimated that health expenditures are allocated this way:
- More than 85 percent is spent on access to health care.
- Far less is spent on other factors that contribute the most to health outcomes, such as influencing healthy behavior changes (Bipartisan Policy Center, 2012).
- Research shows that health care services matter, but they contribute only 10 to 20 percent to what makes people healthy.
- Behavioral factors and environmental factors contribute far more—as much as 70 percent.
  - These factors can include where people live, the supports or assets that are available in their communities (e.g., access to green space), and whether people can make healthy choices (e.g., because they have access to healthy foods) (Gnadinger, 2014).
Disproportionate spending on health care services over behavioral and environmental factors could be driven by immediate demands for medical interventions and the structure of the health care system, which prioritizes treatment of existing health conditions over preventive measures and holistic health determinants (Bradley and Taylor, 2013).

Visual

Visuals to Share

Figures 1.3 and 1.4 can be used in a presentation to or alongside a discussion with a community group.

Pie chart comparing US health care expenditure amounts — Figure 1.3 U.S. Health Expenditures

Pie Chart showing what factors are most important for making people healthy — Figure 1.4 What Makes People Healthy

Section B Why Is Well-Being Important?

The concept of well-being, or the ability to live a meaningful and productive life, speaks to a growing understanding that health (as it has been traditionally defined) is only one part of a broader pursuit to thrive and flourish. Refer to Table 1.1 or the glossary for definitions of individual, community, and collective well-being. Well-being is important for many reasons, including the following:

Well-being has become an important topic in conversations about health, likely because of
- the rise in diseases of despair (e.g., suicide, substance abuse),
- stagnation in life expectancy
- concerns about hopelessness and a lack of optimism among Americans (Gallup, 2021).
Instead of relying on only economic indicators, some U.S. communities also consider well-being as a benchmark of progress (e.g., a measure of how people are meeting their potential across many social dimensions) (Wellbeing Economy, undated; Chandra, Salazar Mejía, and Messenger, 2021).
Concerns about a lack of social connections have grown, whether between people or between people and the community institutions that serve them, suggesting that promoting community and collective well-being is an area of increasing opportunity (Office of the Surgeon General, 2023).

You can print the table and use it as a handout or share the table on a screen.

Table 1.1. Toolkit Key Terms

Health equity

The fair and just access to the opportunity to be healthy for all (refer to Section C in this module or the glossary for different ways to talk about health equity in your community, if needed)

Well-being

The full range of assets and capabilities that people need to thrive and create meaningful futures

Individual well-being

The state in which people experience happiness and satisfaction and can realize their full potential

Community well-being

The combination of social, economic, environmental, cultural, and political conditions identified by individuals, families, and their communities as essential for them to flourish and fulfill their potential

Collective well-being

The expression of the connections between individual and community well-being

When communities (e.g., places or cultures) are characterized by a strong collective well-being, they have the collective will and connected experiences that will allow community members to work together to address systemic harms and build a future together.

Discussion

Discussion Prompt 1B.1

As a group, take a moment to digest these facts so far about health and well-being, and then discuss the following questions:

Is anything surprising about this information?
How do these health facts show up in our community? Where are we allocating resources to help make people healthy?
What are we doing to address specific health issues, such as issues of morbidity and mortality?
Where are our health inequities? How are we addressing them, if at all?
What is our community doing to address a lack of social connection and/or other well-being outcomes?

Sometimes in community conversations about health, common themes will emerge. While testing the exercises in this toolkit, we noticed themes related to how participants discussed issues of funding and such concepts as well-being. If these themes emerge as your community proceeds through this module, we offer some potential responses:

“We should just put more money into health care or the health department. The problem is our lack of funding.”
- Although support for the health department or a hospital in the community is important, strengthening the health system is not only about investing in those two types of organizations.
- Given the extent to which health is produced or driven by behavioral and environmental factors, all parts of the community must be engaged in addressing health-related issues.
- That means making sure that community-wide policies, investment choices, and other decisions include all community sectors (e.g., health, education).
“We cannot focus on such lofty ideas as well-being when we have real and acute issues to address.”
- Well-being is not a nice-to-have feature of a community; it is a critical component that affects whether people can not only survive but also thrive.
- Well-being is a holistic concept that recognizes that people have many needs that must be addressed so they can meet their potential.
- Recent and troubling trends in the United States—such as increased reports of hopelessness, despair, and a lack of social connection—demonstrate that a consideration of all dimensions of well-being makes a difference in fostering healthy and productive communities.
Take, for example, the following health statistics from Washington state:
- In 2023, Washington ranked relatively high (seventh of the 50 states plus the District of Columbia) on its health system performance (Radley et al., 2023).
- However, the state ranked relatively low (49th) on the prevalence of mental illness (Reinert, Fritze, and Nguyen, 2024).
- These data demonstrate that communities have well-being needs that the traditional health system is currently unable to address.

The Sentinel Communities project (described in more detail in the annex), which followed communities all over the United States, determined several hallmarks of communities that are consistently working to improve health and well-being. These communities:

prioritize the value of health in all decisions that they make
recognize the challenge of health inequity and are actively working to address inequities across sectors
center the importance of advancing everyone’s well-being—their ability to thrive and flourish—as a primary objective to support all members of the community.

Discussion

Discussion Prompt 1B.2: Aligning with the Three Hallmarks

How well is your community aligned with the three hallmarks described in the previous section? Reflect on the answers to these questions and how they might indicate sticking points that could be affecting your ability to improve the health and well-being of your community:

What are examples of our community prioritizing health in all decisions?
What are examples of our community elevating the issues of health equity and well-being?
What could we be doing better?

Pose the following questions to the group. Explain that future modules will help your group dig into specific sticking points that have been identified in prior research (as discussed in the following section).

Section C Sticking Points That Affect Improvements to Health and Well-Being

Key Terms

The Sentinel Communities project identified three important objectives for communities to consistently work toward to improve their health and well-being. These objectives are as follows:

advance narratives that support health, health equity, and well-being
capture data that help a community better understand health equity and well-being
align investments that actively work to address health equity and well-being.

In studying a variety of communities across the United States, researchers at RAND and the Robert Wood Johnson Foundation found that communities were often getting stuck in one or more of these areas. Either a community was not successfully advancing health narratives that were widely embraced by community members, the data that a community collected did not give actionable information to address equity or promote well-being, or a community’s stated health equity and well-being priorities were not adequately resourced in the community, resulting in stalled efforts or rhetoric taking the place of action. These types of challenges are the sticking points that we focus on overcoming in the rest of the toolkit.

Different communities approach the issue of health equity in different ways. Sometimes the word equity might not be useful or desirable. Fortunately, there are other ways to approach this concept. What is important is not the specific term but finding ways to help different people, groups, and neighborhoods lead healthier lives so that everyone in the community can be healthier. Here are some options for terms that could help keep the conversation going. Think about which of the following term or terms might work best for your community:

health opportunities
social contexts around health
fairness in health
health for all
health choices.

Section D Ready to Move to the Next Module?

By the end of this first module, you should have discussed the following:

what drives health in your community (Section A)
why a focus on well-being is important for your community (Section B)
sticking points to achieving health equity and collective well-being in your community that you want to tackle as you complete the remaining modules (Section C).

If you have a good understanding of these issues in your community, you are ready to move to the next module—Module 2: Walking the Talk. If not, you can revisit the sections of this module and the corresponding exercises to deepen your insight.

After completing this module, document your key takeaways and action items. There is a place to do this in the Participant Workbook.

Pages

Downloads

Module 1 Making the Case

What Is in This Module?