In 2014 the Robert Wood Johnson Foundation (RWJF) announced a bold new vision of building a national Culture of Health, where everyone—regardless of their ethnic, racial, geographic, or socioeconomic circumstances—has the means and opportunity to live the healthiest life possible.
To help achieve this vision, the RWJF is supporting research that goes beyond a traditional understanding of health as just the absence of disease, so as to achieve a broader understanding of the determinants of health and well-being and inequitable health outcomes. The foundation encourages creative collaboration across sectors and disciplines to help identify the best solutions to the nation’s most complex health issues.
The RWJF has committed roughly $25 million for three new national programs (Evidence for Action, Policies for Action, and Systems for Action) over the next three years to fund research that will help develop the evidence base needed to support this new vision.
Based at the University of California, San Francisco (UCSF), Evidence for Action is the first National Program Office established to award grants under the foundation’s new effort. Guided by the foundation’s Culture of Health Action Framework, the program funds innovative, rigorous, investigator-initiated research on the impact of programs, policies, and partnerships on health and well-being, with a particular focus on research that will inform the best approaches to advance population health and health equity.
Evidence for Action will award $6.6 million in research grants during its initial three years. Officially launched on June 1, the program is unique in that it accepts rolling submissions (no deadlines) and allows for investigator-initiated research topics and budget requests. We are seeking innovative ideas for advancing population health and health equity to be tested using rigorous research methods. We expect research funded through the program to provide knowledge about what actually works to improve health and reduce inequities. We are also interested in the development of new metrics or measures that can be used to assess health outcomes.
Evaluating Health Outcomes of Innovative Policies and Programs
This research program requires that we take a critical stance in relation to common, but untested, assumptions and closely held beliefs. Communities across the country are launching innovations, many of which may be based on intuitive beliefs or anecdotal experiences that suggest that these actions will lead to improved health outcomes. Unfortunately, we don’t always have strong evidence to back up these assumptions.
As important as it is to try creative new approaches, their value is diminished if they are not adequately evaluated along the way. Absent strong evidence that a given strategy works, and an understanding of the conditions or populations in which it is most effective, we risk inefficient allocation of resources, difficulty with replication and scaling, and (in the worst case scenario) perpetuation of poor or inequitable health outcomes. By funding research to evaluate the health outcomes associated with policies or programs—including “spillover” effects and unintended consequences, we can identify the most promising practices for improving population health and health equity and improve the case for targeting resources to scale implementation of those strategies.
We are especially interested in better understanding how health-relevant programs and policies outside of the traditional health sector (such as in housing, financial security, community development, labor, education, criminal justice, and so forth) affect health outcomes.
Creating New Measures of Health
Evidence linking programs or policies to improved health is often difficult to obtain, given the challenge of accounting for exposure to other determinants of health not directly targeted by the designated intervention, as well as the time lag between policy enactment, implementation, and measurable changes in health outcomes. In the interim, however, policy makers in the public and private sectors, practitioners and providers, and communities need to make decisions about where and how to invest time, effort, financial resources, and political capital to obtain valued outcomes. To help inform these decisions, we need newer and better measures of health and well-being: measures sensitive enough to detect progress in shorter timeframes and having strong associations with subsequent states of health.
One approach is to use well-established risk factors that contribute to multiple health problems and diseases and thus have a substantial impact on population health. For example, the substantive evidence necessary to definitively link tobacco consumption with health outcomes took decades to amass, but today we know that tobacco consumption is linked to a range of specific diseases and has a major effect on morbidity and mortality. We can confidently infer that a successful smoking cessation program will result in improved consequent health outcomes. Short- and intermediate-term outcomes—such as changes in beliefs or behaviors—are likely to be easier to assess than are later health outcomes—such as changes in disease rates—and can serve as interim progress measures of success.
We hope that researchers will propose new techniques and measures to capture overall health status, including new methods for characterizing health trajectories across the lifecourse. Currently, there is little incentive for health systems or even governments to invest in interventions or services that have long-term payoffs. Rewarding systems for keeping their patients on positive health trajectories, or shifting them from a more adverse trajectory to a more favorable one, should motivate greater interest in addressing determinants of long-term health.
Understanding the Action Framework
Research is needed both within each of the areas (making health a shared value; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; strengthening integration of health services and systems) of the Culture of Health Action Framework as well as around area intersections to understand how these domains influence one another.
Integrating consideration of the major determinants of health into decision making across all areas of society—from how we construct our housing and transportation systems to how we deliver care—and incentivizing systems and services to better align health, wellness, and equity goals should result in a healthier nation.
Systems and culture changes are never easy. We need evidence on the effectiveness of new approaches to make a compelling case for changing the current modus operandi. Evidence for Action will fund research that builds the case for change.