The prevalence of most behavioral risk factors varies substantially among states. The prevalence of current cigarette smoking ranges from 22 percent to 38 percent. Estimates of alcohol use show geographic clustering, with lower rates in the southeastern states. The prevalence of sedentary lifestyle, uncontrolled hypertension, overweight, and seatbelt use differs markedly among states. These findings represent an initial step toward the analysis of state-specific baseline risk-factor data for use in developing state programs aimed at reducing the leading causes of death in the United States.

Mason Haire, as quoted in In Search of Excellence 1982The indicators a society chooses to report to itself about itself are surprisingly powerful. They reflect collective values and inform collective decisions. A nation that keeps a watchful eye on its salmon runs or the safety of its streets makes different choices than does a nation that is only paying attention to its GNP. The idea of citizens choosing their own indicators is something new under the sun—something intensely democratic.

The US health care system has recently begun to account for patients' unmet social needs in care delivery and payment reform. This article presents a twenty-year qualitative case study of five stages of diffusion-testing and learning, standardization, replication, shifting from doing to enabling, and catalyzing broad adoption-of a practical approach for integrating social needs into clinical care. This case study of Health Leads and its funders confirms the importance of focusing on a clear aim, investing in model testing and standardization to enable subsequent responsiveness to the market, and the willingness of innovators and their investors to cede control of a model to allow local adaption and accelerate broad adoption.

Our title is with apologies to the memory of Edward Bellamy, whose book, Looking Backward, looked back from a Utopian future to describe the changes that had occurred in society to get to that Utopia.1Bellamy E. Looking Backward: From 2000 to 1887. Ticknor & Co, Boston, MA1888Google Scholar It was considered one of the most influential books of the early 20th century. We do not want to overstate what Prevention Research Centers (PRCs) have accomplished, but rather frame what they could become. Thus, this article is titled as if PRCs were in existence for 50 years to enable comment on what they have accomplished so far and to highlight a path that, over the next decade or two, might make them even more influential and stronger. One of the exciting things about looking back at PRCs is both being able to celebrate and honor the successes and yet also see the challenges that had to be overcome at various times during the years. This commentary details how the original kernel of an idea blossomed, spread, and yet also changed—especially how the original vision grew broader and more encompassing during the years from 1985 to 2035. Begun as little more than an idea with three centers, PRCs struggled to gain traction initially. PRCs were envisioned as a bridge between academic public health and public health practice—a way that better science could be made practical and where the practitioners could influence the questions that researchers addressed. Under the PRC model, Centers for Disease Control and Prevention (CDC), as an agency that dealt with both research and practical application, could be a source of ideas, methods, and innovation in the engagement with the schools of public health. In its role of supporting public health agencies, CDC could also promote real-world issues to academia. But after nearly a decade of slow growth, in the early 1990s and for the next decade or so thereafter, PRCs grew rapidly to a peak of 37 centers. In doing so, they represented the largest sustained funding source for community-based participatory research—a term coined around that time to signify engaging community members in discussions about what issues were important to them that might be solvable by research that they were part of. The requirement that each center develop a long-term relationship with a community that had great health challenges turned out to become one of the defining characteristics of PRCs. There had been examples in the past, like between Johns Hopkins School of Public Health and Washington County. But, these had become the exception rather than routine, and even where they existed had become less central to academic life. Community engagement also had its own set of challenges. Community-based research can be slow with regard to academic productivity. Communities themselves are often impatient to move quickly from study to solution. And finally, projects that are successful in a single community do not move seamlessly to many communities: Unique characteristics of individual communities often make adaptability to another site difficult. Further, there was little impetus from state or CDC/federal funding sources to expect their public health agency grantees to use scientifically proven models. Early evaluations of the PRCs essentially described glasses as half full at best, although gradually the scientific productivity of the centers became quite substantial.2Linking Research and Public Health PracticeA Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention. National Academy Press, Washington, DC1997Google Scholar, 3Franks A.L. Simoes E.J. Singh R. Gray B.S. Assessing prevention research impact: a bibliometric analysis.Am J Prev Med. 2006; 30: 211-216https://doi.org/10.1016/j.amepre.2005.10.025Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Yet influence of the research was less clear—being anecdotal rather than systemic, much like the first few decades of clinical quality of care health services research. One change during the 1990s that helped the centers become more influential was the development of the special interest projects as a funding source from CDC. Through this mechanism, CDC could ask the centers to address a specific issue of interest. This had the great value of connecting PRCs to colleagues in different parts of CDC who were interested in the results, plus it led to small groups of PRCs developing common interests or themes. This latter would become very important because it began the process of the centers becoming more than the sum of their individual parts. A body of work emerged from these themes, sometimes directly collaborative, sometimes merely related. However, the centers as a group, a force representing communities in need and issues of priority, were not seen as a voice for those themes or communities. The leadership was a strong voice for the need for a greater emphasis on prevention research efforts but seemed to struggle to speak to summative effects of their research, even when they had a body of work. Nevertheless, these thematic connections would serve to become the basis for the growth in size and influence that we see today. To try to sum up the first 30 years of the half century of PRCs, one would have to say they were too few, too weak, too isolated from each other, and probably most importantly, too quiet about how their science and communities could help the nation. The seeds for the eventual success of the PRCs came, as they do for most transformative ideas, during the time of crisis. The Great Recession of 2008–2012 led to deep cuts in the budget of CDC that required a large reduction in the number of centers, just as they had been gaining prominence in their schools. The cuts also seemed to suggest a lack of CDC support for the concept. At about the same time, the Affordable Care Act, largely about increasing health insurance coverage and access to care, had several large sections about prevention and community programs. This was the first health insurance legislation to emphasize the value of preventive interventions and community-based programs, like PRCs. Also during this time, the pressure of relentlessly rising healthcare costs as a proportion of gross domestic product was causing the Medicare and Medicaid programs to shift their funding from classic fee for service, volume-driven reimbursement toward alternative forms of reimbursement that emphasize preserving health and decreasing need for hospitalization, along with successful outcomes rather than diagnostic and therapeutic procedures regardless of result. It was this confluence of large societal forces, coupled with the emerging understanding of the importance of social factors as crucial in the distribution of illness in our society, that enabled the revitalization of the PRC idea. New champions arose, principally health systems, medical schools, and academic health centers, in the late 2010s and early 2020s, adding prevention and a strong community focus as an integral part of their mission. They became strong advocates of the PRCs, with some hospital systems even putting their community benefit dollars into local PRCs. Schools of public health and departments of preventive and community medicine incorporated elements of PRCs' engagement with underserved communities into the criteria for accreditation and for elevation of the public health programs to full school status. PRCs made strategic alliances with related models like the public health practice-based research networks, and brought other PRC-like structures into public health and medical schools. PRC leaders built on their thematic interests to become a national voice on research and policy regarding these areas of expertise and accomplishment. Another opportunity, which was not visible at the time, was that the contentiousness of the Affordable Care Act debate meant there was little energy for another major reform battle in health care. But prevention-oriented efforts at the level of individual communities, where local choices were central to which problems were chosen and what strategies were employed, were not contentious. In short, it was the crisis of the first decade of the 21st century that galvanized PRCs and their academic leaders to step up as the bridge between academic science and application on the ground in our most challenged communities that we see now. After 50 years, the original goal of PRCs, namely, practical research in challenged communities as a core part of the academic enterprise of scholarship, service, and training, has been accomplished. The bridge they have helped to build between public health academia and practice is broad, heavily traveled, and has brought longer, healthier, more-fulfilling lives to all. This publication is a product of the Prevention Research Centers Program at the Centers for Disease Control and Prevention. The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. No financial disclosures were reported by the authors of this paper.

This far-reaching set of articles brings together much of what we know about the measurement, trends, circumstances, and effects of childhood poverty. They compellingly show that the costs of childhood poverty are manifest in reduced education accomplishments and poorer health. The effect of poverty on children is large, persistent, and serious, with negative effects on almost every important contributor to a fulfilling life. Poverty is also depressingly common for our nation's children—almost half are affected—so the urgency to address this crisis cannot be greater. What we have learned about the ways toxic stress during the first few years of life permanently affects brain development means that we must reverse our underinvestment in our families and their children. Our future as a nation is tied to the success of these children. Taken as a whole, the reports of various interventions—from direct transfers of cash to parental employment to primary care to noncash assistance—all show promising reductions in poverty and/or related consequences, especially in the short- to intermediate-term. Many interventions, including medical coverage, Supplemental Nutrition Assistance Program benefits, and subsidized housing, can directly mitigate and reduce poverty. But most of these benefits are regularly at risk for families who need it most. If they earn a little more, for example, they risk losing their support. And often the employment they do find does not provide a sense of pride or progress. This cycle leads to emotional and financial stress that repeats during a young child's life. And that stress is felt by the child as well as the parents, with long-lasting effects on health and well-being. Good health does not just happen. It begins, is nurtured, protected, and preserved in families, neighborhoods, and schools—all the places where our children live, learn, and play. In any discussion of poverty and income-related interventions, the success of home visiting can seem surprising, so it is valuable to have an article that makes the case for it. It is worth reflecting on the idea that coaching and counseling (ie, emotional support, encouragement, and advice) can successfully contribute to reducing the effects of food insecurity, and inadequate housing and money, and how and why it succeeds. Perhaps home visiting operates through moderating stress, providing an increased sense of doing well as a parent, and building hope for a better life. Let us be clear we are not saying that a poor family only needs intermittent coaching and not actual direct financial support. Rather, this emotional support helps a young mother feel more confident of her abilities and hopeful about her child's future. The articles on home visiting, preschool, child care providers, and primary care highlight that specific interventions can be valuable, but no single intervention will be sufficient by itself. We have to promote a comprehensive vision and set of actions that address children's needs as a whole: a stable home life; a nurturing environment with engagement by parents, siblings, and other adults; the availability of good health care, healthful food, and physical and emotional warmth. All these are needed—money alone is not enough. However, the lack of financial resources make all those other needs much more insecure. It is important to frame, if briefly, these broad aspirations during this time when so many of our children's possibilities to have a long, healthy, fulfilling life in an increasingly diverse society are being eroded. Poverty and the concomitant family stresses are at the core of that loss. That brings us to why this supplement is in the journal Academic Pediatrics. Pediatricians, along with others in the child-caring professions, have long accepted the responsibility and the honor of being the voice and advocate for children. Science lends credence to our support for parents and our advocacy for policy that supports families' and children's needs. Our commitment to children other than our own gives our voice a moral standing. We have always known that what we can do within clinical care (or in schools) is helpful but not sufficient, and that no program or service can take the place of caring parents nurturing their children. However, our statistics and our children's outcomes are making it increasingly clear that millions of parents do not have the support, resources, and time to nurture their children enough. We also know that our science and our skills will improve, but never enough, unless our nation recognizes that they are all 'our children.' It is not something the medical profession can solve on its own, but it can shine a light on the consequences, and be clear that we cannot succeed as a profession unless our communities and our nation embrace that we are all in this together. That we all, regardless of what we work on, have an important responsibility to the future. We need to make sure that all children have the opportunity to succeed, and children whose family circumstances are more challenging need more help. This supplement on poverty aimed at pediatric leaders makes this statement.

The National, Heart, Lung, and Blood Institute convened a Think Tank meeting to obtain insight and recommendations regarding the objectives and design of the next generation of research aimed at reducing health inequities in the United States. The panel recommended several specific actions, including: 1) embrace broad and inclusive research themes; 2) develop research platforms that optimize the ability to conduct informative and innovative research, and promote systems science approaches; 3) develop networks of collaborators and stakeholders, and launch transformative studies that can serve as benchmarks; 4) optimize the use of new data sources, platforms, and natural experiments; and 5) develop unique transdisciplinary training programs to build research capacity. Confronting health inequities will require engaging multiple disciplines and sectors (including communities), using systems science, and intervening through combinations of individual, family, provider, health system, and community-targeted approaches. Details of the panel's remarks and recommendations are provided in this report.

As a group, jail-involved individuals, which we define here as people with a history of arrest and jail admission in the recent past, carry a heavy illness burden, with high rates of infectious and chronic disease as well as mental illness and substance use. Because these people have tended to also be uninsured, jail frequently has been their only regular source of health care. Three thousand three hundred local and county jails processed 11.6 million admissions during the twelve-month period ending midyear 2012. The Urban Institute estimated as much as 30 percent of some local corrections budgets is allocated to inmate health care services. This investment is largely lost when people are released back into the community, where they typically do not get treatment. For people with untreated substance use or mental illness, this issue reaches beyond public health, because without treatment, these people are at heightened risk of cycling into and out of jail for low-level, nonviolent offenses. This article offers eight policy recommendations to build a continuum of care that will ensure that jail-involved people get the care they need, regardless of where they reside. With the expansion of Medicaid eligibility under the Affordable Care Act, there is now a critical opportunity to bring the jail-involved population into the mainstream health care system, which benefits the health care and criminal justice systems and society at large.

In this issue of the American Journal of Preventive Medicine, Ng, Popkin, and Slining 1 Ng S.W. Slining M.M. Popkin B.M. The Healthy Weight Commitment Foundation pledge: calories sold from U.S. consumer packaged goods, 2007–2012. Am J Prev Med. 2014; 47: 508-519 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar , 2 Ng S.W. Popkin B.M. The Healthy Weight Commitment Foundation pledge: calories purchased by U.S. households with children, 2000–2012. Am J Prev Med. 2014; 47: 520-530 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar present findings from their independent evaluation of the Healthy Weight Commitment Foundation’s (HWCF’s) pledge to reduce calories sold in the U.S. marketplace by 1.5 trillion. The HWCF is a coalition of leading food and beverage manufacturers and other organizations, including many of the world’s largest corporations. Together, the 16 companies participating in the HWCF pledge account for approximately one third of all calories in the domestic food supply. 1 Ng S.W. Slining M.M. Popkin B.M. The Healthy Weight Commitment Foundation pledge: calories sold from U.S. consumer packaged goods, 2007–2012. Am J Prev Med. 2014; 47: 508-519 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The Healthy Weight Commitment Foundation Pledge: Calories Sold from U.S. Consumer Packaged Goods, 2007–2012American Journal of Preventive MedicineVol. 47Issue 4PreviewCorporate voluntary pledges to improve the health of Americans have not been held to either explicit measurable outcomes or a framework for independent evaluation. The Healthy Weight Commitment Foundation (HWCF), whose members include 16 of the nation’s leading consumer packaged goods (CPG) food and beverage manufacturers, voluntarily pledged to collectively sell 1 trillion fewer calories in the U.S. marketplace by 2012 (against a 2007 baseline), and sell 1.5 trillion fewer calories by 2015. This paper presents the findings of an independent evaluation of the 2012 HWCF marketplace pledge, conducted in 2013. Full-Text PDF Open AccessThe Healthy Weight Commitment Foundation Pledge: Calories Purchased by U.S. Households with Children, 2000–2012American Journal of Preventive MedicineVol. 47Issue 4PreviewAn independent evaluation of the Healthy Weight Commitment Foundation (HWCF) marketplace pledge found that the participating companies met and exceeded their interim 2012 sales reduction pledge. Full-Text PDF Open Access

The song 'Philadelphia Freedom' became popular in 1976, the bicentennial of our nation’s birth. That was also about the time that the obesity rate in our young people began to rise. And it has done so inexorably since then — until now.

The Robert Wood Johnson Foundation Commission to Build a Healthier America was charged to identify strategies beyond medical care to address health disparities in the U.S. related to social and economic disadvantage. Based on insights gained while providing scientific support for the commission's efforts, this paper presents an overview of major issues that arise when assessing evidence to inform policies and programs to address the social determinants of health. While many of the insights are not new, they have not been widely assimilated within medicine and public health. They have particular relevance now, given growing awareness of the important health influences of social factors. The discussion presented here is intended to highlight key considerations for researchers who study social determinants of health and policymakers whose decisions are shaped by research findings. Policies should be based on the best available knowledge, derived from diverse sources and methods. An array of tools and guidelines is now available to guide the assessment of evidence on the social determinants of health, building on--and going beyond--principles first articulated in the "Evidence-Based Medicine" movement. The central thesis of the current paper is that the standards for evidence to guide social policies must be equally rigorous but also more comprehensive than those traditionally used to inform clinical interventions, because social policies must deal with upstream factors that affect health through complex causal pathways over potentially long time periods.

On behalf of the Robert Wood Johnson Foundation (RWJF), I want to thank the Public Health Law Association and the American Society of Law, Medicine & Ethics for your leadership and the work that both you and the Centers for Disease Control and Prevention (CDC) have done to grow this field. RWJF is pleased to co-sponsor this conference.The music that opened this talk is a clip from Warren Zevon, who encouraged us musically to “send lawyers, guns and money.” Zevon was a singer/songwriter and social critic whose songs often took a jaundiced, somewhat cynical point of view. Even so, I know that I am probably stretching his meaning when I think of this song. I see “lawyers, guns and money” as his take on the major drivers of how change happens in a society.

Large differences in the opportunities and resources that Americans have to be healthy have led to sizable variations in health by geography, race and ethnicity, income level, and education. By enhancing the opportunities for good health in the places where we live, learn, work, play, and worship, community development initiatives can be important drivers of improved health. As articles in this month’s issue of Health Affairs attest, community development and public health are two forces that often have the same goals. Because there has been little research to date documenting which aspects of community development could have the greatest impact on health, it will be increasingly necessary to rigorously evaluate the impact of various interventions to guide policy makers in identifying the most important measures to take in an environment of constrained financial resources.

BACKGROUND:Few reports have addressed associations between family strengths during childhood and adolescent pregnancy and its consequences. We examined relationships among a number of childhood family strengths and adolescent pregnancy, risk behavior, and psychosocial consequences after adolescent pregnancy.METHODS:Our retrospective cohort of 4648 women older than 18 years (mean age, 56 years) received primary care in San Diego, CA. Outcomes included adolescent pregnancy and psychosocial consequences compared with number of the following childhood family strengths: family closeness, support, loyalty, protection, love, importance, and responsiveness to health needs.RESULTS:Of the cohort, 3082 participants (66%) reported 6 or 7 categories of childhood family strengths. Teen pregnancy occurred in 39%, 33%, 30%, 25%, 24%, 21%, and 19% of those with 0 or 1, 2, 3, 4, 5, 6, and 7 childhood family strengths, respectively (p for trend < 0.00001). When childhood abuse and household dysfunction were present, adjusted odds ratios (ORs) for adolescent pregnancy demonstrated an increasingly protective effect as numbers of childhood family strengths increased from 0 or 1 to 2 or 3, 4 or 5, and 6 or 7 (1.0 to 0.80), (1.0 to 0.80, 0.60, and 0.54, respectively). These findings were partly explained by progressive delays in initiation of sexual activity as the number of childhood family strengths increased. Adjusted ORs for psychosocial problem occurring decades later decreased as the number of childhood family strengths increased from 0 or 1 to 2 or 3, 4 or 5, and 6 or 7 (job problems, 1.0, 0.8, 0.6, 0.4; family problems, 1.0, 1.1, 0.7, 0.6; financial problems, 1.0, 0.9, 0.9, 0.6; high stress, 1.0, 1.1, 0.9, 0.8; uncontrollable anger, 1.0, 0.7, 0.7, 0.4).CONCLUSIONS:Childhood family strengths are strongly protective against adolescent pregnancy, early initiation of sexual activity, and long-term psychosocial consequences.

The Centers for Disease Control and Prevention's (CDC's) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has entered its 20th year — at the crossroads between adolescence and adulthood. As the 3 directors of the center to date, we offer our perspective on its developmental path and on the opportunities and challenges that lie ahead.

I left the Centers for Disease Control and Prevention (CDC) more than 4 years ago to go to the Robert Wood Johnson Foundation (RWJF). RWJF had gone through a time of substantial rethinking about its role in society and come to the conclusion that the focus should not be grantmaking; it should be creating social change for health. This could just as easily be said about public health — creating societal change to improve the health of the public. At its core, public policy the way a society frames what it wishes to become. Does it want all children immunized? Does it want to limit the use of tobacco? Policy doesn't have to be federal legislation or regulation; it can be corporate or local or state. But an organization, a field, or groups that are about social change will find they are often about influencing public policy. How does this fit with epidemiology and its history, and the history of CDC? It unlikely that John Snow would be revered in public health if he had merely studied cholera. His defining moment was when he removed the pump handle from the contaminated well that was the source of the epidemic. That intervention honored with an award called the Pump Handle Award that given by the Council of State and Territorial Epidemiologists. Our heroes have been tied to action. In 1983, giving the Wade Hampton Frost Lecture at the American Public Health Association meeting, Bill Foege, former CDC director, coined the term consequential epidemiology. Foege was taking sides in an active debate of the time by saying that epidemiology is a tool to change the world, not merely to study the world (unpublished material, 1983). The debate that Foege was speaking to was whether epidemiologists should engage in the political process. Should they advocate solutions about what should happen based on the science or merely do the science and let the advocates and policy makers use the science? Some people said that scientists would lose their objectivity if they took on this more activist role. This discussion has come back, quite strongly, in recent times in the context of the politicization of science. Politics and public policy can be tough business, especially recently. Bill Foege was of a very different opinion. It was his conviction that public health was inherently political, inescapably political. Foege argued that public health work occurs in a political context and that, divorced from that context, our science stillborn, a missed opportunity. To pretend otherwise self-delusion and a failure of vision and responsibility. The purpose of this essay to reaffirm that connection to activism. I state this not despite recent concerns about politicization of science but because of them. We must embrace both 1) activism and commitment to social change as central to public health, and 2) the central purpose of epidemiologic science, which to find, assess, and confirm truth, regardless of past findings or beliefs. These are different roles, and the space between them where the real excitement is. Actions are being taken based on the science as it known today, but the actions will change as the science advances. We are entering a period of economic pressure that likely to change the nature of America's medical care, the largest industry in our nation. We now spend about twice as much as other developed countries per capita per year. Despite the importance of biological science as the basis for improvements in diagnosis and therapy, it impossible to think of major changes in the medical care system that will not play out in public policy changes. The public's health and the societal factors that affect health span a much greater proportion of our economy and our society than even medical care does. This means that public health will have to address issues that have political implications. Yet the science behind what can be done does not mean it will be done. Our policy makers and the public have not been nearly as committed to the understanding that how our society organized, what our policies foster or inhibit, what our communities encourage and our institutions support are fundamental causes of good or ill health, just like biological causes, and they warrant study and action. If societal forces are not in alignment, scientific advances stall, and the value realized a meager fraction of its potential. Scientific understanding about any disease that not widely applied to people in need ultimately wasted. Similarly, widespread application of practices and policies that have no scientific evidence of effectiveness are just as futile. Scientific discovery and widespread application must never be separated. This a defining tension for all of public health. Scientists never feel they know enough to act. Practitioners and activists say the health problems are so significant we must act now; we can't wait for the science to be finalized. Both are right. Organizations only responsible for research will worry less about whether the findings are widely applied or are feasible and practical. Organizations only responsible for programs will likely hold to outmoded ways that are ineffective if their staff and clients like the program. Managed well, the combined responsibilities make both science and program better.