Healthy starts for all: policy prescriptions.

CONTEXT: The Robert Wood Johnson Foundation Commission to Build a Healthier America recommended that substantial resources be committed to ensure all children have high-quality developmental experiences through family support, child care, and early education. This article reviews and updates the evidence base informing that recommendation and explores federal and state policy challenges involved in implementing it. EVIDENCE ACQUISITION: Reviews of published research, analyses of federal child health data sets, consultation with early development and state and local program experts, and site visits were conducted between 2006 and 2009, with statistics and literature reviews updated through mid-2010. EVIDENCE SYNTHESIS: The economic and social conditions of children's lives, especially in the early years, affect their health and development in childhood and across the life course. Forty percent of children in the U.S. live in families with incomes <200% of the federal poverty level and consequently are at higher risk of poor health and development. Recent advances in neuroscience and life course epidemiology reveal that these children are more likely to experience chronic or "toxic" stress resulting from frequent or sustained adverse experiences, increasing their lifetime risk of chronic disease. Intervening early in childhood by providing a safe, stable, nurturing, and stimulating environment can improve cognitive, emotional, and behavioral development and health outcomes in children--particularly socially and economically disadvantaged children--and both their health and social and economic well-being as adults. CONCLUSIONS: Coordination of multiple programs and funding sources, along with higher standards of accountability for services, outcomes, and ongoing evaluation of effectiveness, are needed to ensure more effective state and local programs providing early developmental support. Federal leadership and funding are needed to ensure that children at high risk for multiple adverse exposures and their families receive attention and services as early as possible.

Citizen-centered health promotion: building collaborations to facilitate healthy living.

Unhealthy behaviors, notably tobacco use; unhealthy diets; and inadequate physical activity are major contributors to chronic disease in the U.S. and are more prevalent among socioeconomically disadvantaged groups. Differences in the prevalence of unhealthy behaviors among communities with different physical, social, and economic resources suggest that contextual environmental factors play an important causal role. Yet health promotion interventions often are undertaken in isolation and with inadequate attention to these holistic social and economic influences on lifestyle. For example, clinicians' advice to patients to stop smoking or lose weight can help motivate people to change behaviors, but their ability to take subsequent action can benefit from coordination with community-based and public health programs that offer intensive counseling services, and from modified environmental conditions to facilitate behavior change where people live, work, learn, and play. Reshaping these environmental conditions to support healthier living is the subject of six recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America. Changing the conditions of daily life to make them conducive to healthy behaviors--what is here called citizen-centered health promotion--requires a concerted effort by clinical, educational, business, civic and governmental partners within communities. Linkages among clinical practices and community-based programs have been demonstrated to be effective, but moving from demonstration projects to sustainable community collaborations nationwide will require a proactive effort to establish the necessary infrastructure and financing.

Healthy homes and communities: putting the pieces together.

CONTEXT: This article reviews and updates the evidence base informing four recommendations of the Robert Wood Johnson Foundation Commission to Build a Healthier America (the commission) that address the creation of healthy, vital neighborhood and community environments. EVIDENCE ACQUISITION: Reviews of published research, consultation with experts in housing, community development policy, and site visits by the commission were conducted between 2006 and 2009. The literature reviews and national statistics were updated with publications appearing through the first half of 2010. EVIDENCE SYNTHESIS: The physical, social, and economic environments of local communities affect residents' health and exacerbate health disparities. Public and private decision makers are increasingly recognizing the importance of investing in cross-cutting strategies to reduce exposures harmful to health and to establish conditions that support healthful daily practices. Pilot and demonstration projects that engage community members in identifying priorities and implementing interventions that improve health and quality of life show promise in terms of their overall impact and effect on health disparities. CONCLUSIONS: Consistent with the broad policy directions outlined in the commission's recommendations, an effective population health improvement strategy requires enlisting new partners among public agencies including housing, transportation, recreation, community development, and planning, and joint efforts between private sector business and voluntary organizations. Evaluation research of community-based interventions is needed to generate strong evidence of impact in order to guide policy and secure future investments in such measures.

The economic value of improving the health of disadvantaged Americans.

BACKGROUND: Higher educational attainment is associated with better health status and longer life. PURPOSE: This analysis estimates the annual dollar value of the benefits that would accrue to less-educated American adults if they experienced the lower mortality rates and better health of those with a college education. METHODS: Using estimates of differences in mortality among adults aged ≥ 25 years by educational attainment from the National Longitudinal Mortality Survey and of education-based differentials in health status from published studies based on the Medical Expenditure Panel Survey, combined with existing estimates of the economic value of a healthy life year, the economic value of raising the health of individuals with less than a college education to the health of the college educated is estimated. RESULTS: The annual economic value that would accrue to disadvantaged (less-educated) Americans if their health and longevity improved to that of college-educated Americans is $1.02 trillion. CONCLUSIONS: This modeling exercise does not fully account for the social costs and benefits of particular policies and programs to reduce health disparities; rather, it provides a sense of the magnitude of the economic value lost in health disparities to compare with other social issues vying for attention. The aggregate economic gains from interventions that improve the health of disadvantaged Americans are potentially large.