Place-Based Public Health—Good for Business
Health care constitutes a significant portion of the expenditures for most employers in the United States.1 Acute or chronic health problems can result in employee absenteeism or reduced employee productivity.2 A study of more than 1 million Health Reimbursement Account participants examining the link between medical costs and productivity found that, for an average-size employer, for every $1 spent on medical costs, 40 cents are expended because of lost productivity.2 The impact of health status is also significant for mental health. Estimates show that US workers with depression cost employers approximately 44 to 51 billion dollars a year in lost productivity.3,4
Business leaders have taken notice of the importance of employee health and are now investing in programs to promote the health of their staff and control health care costs. These workplace programs are more prevalent in large organizations and often involve health behavior–based strategies to achieve goals such as weight loss and smoking cessation.5,6 Workplace wellness programs have been successful in getting employees to exercise more and engage in weight management. The Community Preventative Service Task Force of the Centers for Disease Control and Prevention recommends worksite programs to improve diet and physical activity and reduce weight.7 However, there are key outcomes, including clinical markers such as blood pressure and body mass index, and overall medical spending, which do not yet show clear improvements due to worksite wellness programs.8,9
Given what we know about what truly affects health, it makes sense that we need to combine this important work of workplace programs with population-based public health approaches that are geographically targeted to improve outcomes. Place-based factors outside of the health care setting such as community safety, social supports, employment and economic opportunities, and education drive the majority of health outcomes.10 Simply encouraging people to walk or run more is not as effective as also considering the walkability and safety of their neighborhoods. Similarly, workplace programs encouraging consumption of fruits and vegetables will be unlikely to enact change in participants without paying attention to whether employees can access affordable produce in their communities. We propose buttressing the engagement of business leaders in the health of their employees with opportunities to address socioeconomic and environmental determinants of health and community well-being. Place-based public health initiatives serve as ready-made avenues for employers to invest in improving these community-level factors that best determine health outcomes.
Public health agencies can work more closely with the business community to engage it in community or place-based approaches that support the health of its communities. Private investment of financial or in-kind resources into the community leads to shared value creation.11 Shared-value business models generate economic value while simultaneously producing societal value by addressing community needs. Private business can reduce internal costs by addressing barriers to health and well-being in surrounding communities. For example, poor transportation routes can drive up the cost of distribution; neighborhood safety issues also affect local businesses. Addressing these challenges by investing in targeted initiatives can help improve community health and the business bottom line.
Place-Based Public Health
Place-based public health refers to community-led activities to promote health that are based on community needs and priorities. Place-based public health initiatives ideally include a focus on upstream drivers of health outcomes such as poverty, discrimination, food access, affordable housing, and safe and multiuse streets. These initiatives can also encompass midstream targets. For example, increasing access to community health workers who can link community members to services can also have an impact on health.12 Rhode Island's Health Equity Zone (HEZ) initiative serves as an example of a place-based public health model. Through this initiative, the Rhode Island Department of Health creates and funds opportunities for all community members—residents, neighborhood organizations, policy makers, local businesses, and others—to collaborate to build healthier, more resilient communities. The Rhode Island Department of Health currently supports HEZs throughout the state that range in size from a neighborhood to a county. Using the public health structure of a local data–driven needs assessment to build an action plan with measurable outcomes, each HEZ works on different, community-determined projects, including food access, the built environment, youth support, affordable housing, transportation, and more, with the ultimate focus on moving in one direction with shared goals to improve the health and well-being of community members.13
Local Initiatives Support Cooperation (LISC) is a national organization with a place-based mission to connect public and private resources to communities in need. Local Initiatives Support Cooperation operates in 44 states and has 33 local offices. The organization uses funding from corporations, banks, foundations, and government agencies to provide loans, grants, and equity to community-based partners who work on issues of housing, education, jobs, and community safety.14 For example, LISC has invested more than $180 million in food access projects such as farmer's markets, community gardens, and food cooperatives nationwide.15 This model provides another example of how for-profit business can partner with nonprofits such as LISC to invest in the foundational drivers of health for their employees and surrounding communities.
Building vibrant and healthy communities requires involvement by all sectors of society. Place-based, community-centered, private investments are crucial to achieving and sustaining improvements in health outcomes over the long term. Place-based public health investments, in turn, can offer value to business entities. The conditions in which employees live, learn, work, and play cannot be ignored.16 By investing in the health of communities, businesses can also invest in the health and productivity of their employees.
Case Examples of Engagement Strategies
The Healthy Futures Fund—big investments for bold change
The Healthy Futures Fund is an initiative funded by LISC, Morgan Stanley, and The Kresge Foundation to improve health access and social determinants of health. This $200 million fund focuses on increasing access to federally qualified health centers and affordable housing.17 Funding is deployed to communities in the form of low-income housing tax credit equity, loans, new market tax credit, predevelopment financing, and grants. A $34 million contribution from the Healthy Futures Fund helped support the development of the $90 million Conway Center in the Benning Heights Neighborhood of Washington, District of Columbia. This development project, led by a trusted community-based organization called So Others Might Eat, will result in 202 affordable housing units, a job training center, and a health center that will care for up to 15 000 patients a year. The project is also designed to include green space, offices, and shops.18 In addition to the Washington, District of Columbia–based project, the fund has supported the development of federally qualified health centers in Illinois, Texas, New Mexico, and Rhode Island.19 The Healthy Futures Fund illustrates the power of private business to partner with the nonprofit sector to achieve ambitious goals with high health impact. In general, business investments in place-based public health initiatives are most powerful when done in collaboration with trusted community partners and alongside other funders.
Chicanos Por La Causa and UnitedHealthcare—partnering for success
Chicanos Por La Causa is a community development organization that describes itself as “an all-encompassing organization for the underserved.” Its mission is to help individuals become economically and politically empowered.20 Chicanos Por La Causa performs charitable work and manages for-profit businesses whose revenues are partly used to fund its community-based work in housing, education, and economic development. Chicanos Por La Causa has operated since 1969. Initially serving the Phoenix, Arizona, area, the organization now serves more than 300 000 individuals each year in Arizona, Nevada, and New Mexico. Although Chicanos Por La Causa has a wide reach, the organization has maintained its position as a trusted community resource by prioritizing strong, local ties to the communities it serves.
In 2016, Chicanos Por La Causa partnered with UnitedHealthcare to provide affordable housing for low- to moderate-income Phoenix residents. Through this partnership, UnitedHealthcare pledged access to approximately $20 million in capital. This commitment from UnitedHealthcare is part of the UnitedHealthcare My Connections program, an initiative to improve health and lower health care costs by improving access to essential social needs such as housing, as well medical and behavioral health services.21
The Newport Health Equity Zone—working with local businesses to improve health
Businesses can contribute to place-based public health efforts via in-kind contributions such as time and space and by changing business practices to support local public health initiatives. Newport, Rhode Island, is home to multi-million-dollar historic mansions and seaside tourist attractions and also has a significant low-income and mixed-income population. The Newport Health Equity Zone (HEZ) Collaborative focuses on the North End and Off-Broadway neighborhoods of Newport. The Women's Resource Center, a domestic violence prevention and intervention nonprofit, serves as the backbone organization for the Collaborative, which comprises numerous other local nonprofits, including The Boys and Girls Club, the Arts & Culture Alliance of Newport County, and The Martin Luther King Community Center. The initial community needs assessment conducted by the Newport Health Equity Zone revealed access to nutritious, affordable food as an important need. Only 19% of North End residents surveyed ate 1 serving of fruits and vegetables a day.
The needs assessment also identified transportation as an issue that needed more attention. The HEZ worked with local businesses to increase access to healthy food options, following the model of Shop Healthy NYC.22 The Collaborative worked with small corner stores and used marketing strategies, including product placement, to increase healthy food sales. The HEZ also worked with vendors at local farmers' markets to increase redemptions of SNAP and WIC benefits. To address transportation concerns, the HEZ engaged local businesses in efforts to make Newport more cyclist friendly. For example, the HEZ worked with local businesses to increase the number of bicycle stands located at store fronts.23 These relationships with local business resulted in a meaningful change toward better health outcomes for Newport residents.
Engaging business in building healthy and resilient communities
In September 2018, the Association of State and Territorial Health Officials (ASTHO) launched the 2019 ASTHO President's Challenge: “Building Healthy and Resilient Communities.” This Challenge, aligned with the National Association of County & City Health Officials (NACCHO) and the US Surgeon General's focus on community health and economic prosperity, calls on state, territorial, local, and tribal health officials to build healthier, more resilient communities by supporting investments in community-led, place-based approaches.24 One of the primary goals of the Challenge is to connect public health officials to business leaders and policy makers who want to invest in these community-led, place-based approaches and advance economic development by reaching across sectors.
The ASTHO President's Challenge goals are closely aligned with the US Surgeon General's Community Health and Economic Prosperity (CHEP) Initiative. The CHEP initiative advocates for a multipronged approach to creating community health and economic prosperity, including engaging businesses to be changemakers for health in their communities, implementing solutions to build the health of communities, and strengthening communities to be places of health and opportunity for all.24 Similarly, through this President's Challenge, ASTHO encourages public health leaders to seek out and cultivate new partnerships with business. When done right, these collaborations have the potential to greatly benefit communities and business partners.
2. Mitchell RJ, Bates P. Measuring health-related productivity loss. Popul Health Manag. 2011;14(2):93–98. doi:10.1089/pop.2010.0014.
3. Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression. J Am Med Assoc. 2003;289(23):3135–3144.
4. Greenberg PE, Kessler RC, Birnbaum HG, et al The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64(12):1465–1475.
5. Mattke S, Kapinos K, Caloyeras JP, et al Workplace wellness programs: services offered, participation, and incentives. Rand Heal Q. 2015;5(2):7.
8. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes: a randomized clinical trial. JAMA. 2019;321(15):1491–1501.
9. Jones D, Molitor D, Reif J. What Do Workplace Wellness Programs Do? Evidence From the Illinois Workplace Wellness Study. Cambridge, MA: The National Bureau of Economic Research, Inc; 2018.
10. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129–135.
11. Porter ME, Kramer MR. Creating shared value. Harv Bus Rev. 2011;89(1-2):62–77.
13. Alexander-Scott N Novais, Hall-Walker C, Ankoma A, Fulton J. Rhode Island's Health Equity Zones: addressing local problems with local solutions. J Health Dispar Res Pract. 2017;9:54–68.
14. Local Initiatives Support Corporation. Connecting communities with resources. http://www.lisc.org/about-us/
. Published 2016. Accessed May 24, 2019.
16. Robert Wood Johnson Foundation. A New Way to Talk About the Social Determinants of Health. Princeton, NJ: Robert Wood Johnson Foundation; 2010.