Book Review  |   June 2009
To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, Volume XI
Author Affiliations
  • Susan M. Friedman
    Department of Government Relations, Chair, Health System Reform Task Force, American Osteopathic Association, Washington, DC
    Deputy Director
Article Information
Book Review   |   June 2009
To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, Volume XI
The Journal of the American Osteopathic Association, June 2009, Vol. 109, 294-330. doi:10.7556/jaoa.2009.109.6.294
The Journal of the American Osteopathic Association, June 2009, Vol. 109, 294-330. doi:10.7556/jaoa.2009.109.6.294
In 2008, John B. Crosby, JD, Executive Director of the American Osteopathic Association (AOA) recommended that the internal AOA Health System Reform Task Force review recently published books on healthcare reform and submit these reviews to JAOA—The Journal of the American Osteopathic Association for the benefit of osteopathic physicians. Following that recommendation, the current review covers To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology, Volume XI, a useful volume for osteopathic physicians and others who are interested in broadly defined healthcare reform plans. 
The Robert Wood Johnson Foundation (RWJF) is the largest philanthropic organization in the United States that is devoted exclusively to healthcare issues. The first volume of the RWJF anthology series was published in 1997. Succeeding volumes have brought much new and important information to policymakers and healthcare professionals and have provided critical analyses of the projects funded by the RWJF. The topics covered in these volumes offer a comprehensive understanding of the broad reach of the RWJF grants program. 
Volume XI of the series consists of 10 chapters on a variety of topics written by different evaluators and authors—some of whom offer outside, independent assessments of RWJF projects, others of whom provide inside stories of RWJF projects. The text is edited by Stephen L. Isaacs, JD, and David C. Colby, PhD. Isaacs is a partner in the consulting firm of Isaacs/Jellinek and president of Health Policy Associates, Inc, both in San Francisco, Calif, as well as a former professor of public health at Columbia University. Colby is the vice president of research and evaluation at the RWJF, and he previously served with the Medicare Payment Advisory Commission and the Physician Payment Review Commission. 
Chapter 1 of volume XI, “Improving Quality of Care,” chronicles the efforts of the RWJF to improve the quality of healthcare in the United States. Chapter 2, “Health Services Research,” examines the role of the foundation in establishing the academic field of health services research. In chapter 3, “Reducing Teenage Pregnancy,” the author traces the work of the RWJF over a 20-year period to address the controversial issue of adolescent pregnancy, including funding of school-based health centers and an abstinence-only program, as well as supporting the National Campaign to Prevent Teen Pregnancy. Chapter 4, “The Smoke-Free Families Program,” examines one of the foundation's longest running and most generously funded programs, designed to help pregnant women quit smoking. I discuss this chapter in detail after these brief chapter summaries. 
In chapter 5, “The Community Mental Health and Substance Abuse Partnership of Larimer County, Colorado,” the focus is on a Colorado program funded by the RWJF and local foundations that organize healthcare services for people who have both mental health and substance abuse or addiction problems. Chapter 6, “The Active Living Programs,” covers a series of foundation-developed programs designed to restructure urban environments in ways that encourage walking, bicycle riding, and other physical activities. Chapter 7, “The Urban Health Initiative,” describes an RWJF undertaking to improve the health and safety of children in five US cities. 
“Mentoring Young People,” the subject of chapter 8, examines research on mentoring of children and foundation-funded programs to encourage mentoring. In chapter 9, “The Robert Wood Johnson Foundation's Approach to Evaluation,” the authors describe the strengths and weaknesses of a four-tiered system of grant evaluation developed by the RWJF. The book concludes with chapter 10, “The Sports Philanthropy Project,” describing the work of the RWJF to assist foundations established by professional sports teams. 
Chapter 4, which focuses on the RWJF's Smoke-Free Families program, is quite informative and especially timely given the current national focus on the high cost of chronic disease. In the introduction to this chapter, the editors note that tobacco continues to be the leading cause of preventable death in the United States, and that, since 1991, the RWJF has expended millions of dollars on a range of tobacco-control activities. 
The author of chapter 4, freelance journalist and author Fen Montaigne, discusses how the RWJF funded the Smoke-Free Families program from 1994 to August 2008 with the goal of reducing smoking before, during, and after pregnancy. The program involved a three-step approach: fund research that identified effective smoking cessation treatments for pregnant women and their families; fund demonstration projects to find methods of incorporating effective programs into routine prenatal and postpartum care; and promote the acceptance of effective treatments by healthcare providers to help pregnant smokers and smoking parents quit the habit. 
As Mr Montaigne clearly describes, demonstration projects for the Smoke-Free Families program were established in Maine, Oklahoma, and Oregon using three different methods. In Maine, staff members from the demonstration project recruited physician practices to participate in a 9-month program in which obstetricians/gynecologists, family practitioners, and midwives attended three face-to-face learning sessions. The session participants learned to use the US Public Health Service's Clinical Practice Guideline, Treating Tobacco Use and Dependence—also known as the “5 As”: ask patients about their tobacco use at every visit and document findings; advise them to quit in a clear, strong, and personalized manner; assess their willingness to attempt to quit within the next 30 days; assist those individuals willing to attempt to quit using counseling and, unless contraindicated, pharmacotherapy; and arrange appropriate follow-up. 
In the Oklahoma initiative, project members worked with Oklahoma State University to encourage compliance with tobacco treatment guidelines among patients in 26 clinics and practices. The Oklahoma initiative also used practice enhancement assistants, who were nurses or social workers trained to coach physicians and other healthcare providers on how best to counsel pregnant smokers. 
In Oregon, the state Department of Human Services used trained health professionals to provide psychosocial support to women in their homes. Standardized documentation was used for tobacco screening and treatment, mandatory cessation counseling training for new maternity care managers, and new administrative rules that tied delivery of the 5 As to Medicaid reimbursement. 
The chapter author notes that participants in the Smoke-Free Families program met in 2006 to assess the program's accomplishments. They determined that significant progress had been made, with pregnant women having become much more likely to have heard about the perils of smoking. Michael C. Fiore, MD, director of the University of Wisconsin Center for Tobacco Research, is quoted as saying, “I think it's really good news that the rate of smoking among pregnant women is under 20 percent. That is certainly a success story from where we were in the 1950s, 60s, and 70s.” 
According to Mr Montaigne, another important conclusion of the research associated with the Smoke-Free Families program was that 5 to 15 minutes of counseling (ie, the “augmented 5 As”) during the first physician visit and each subsequent visit—supplemented by specific self-help materials—resulted in quit levels among pregnant smokers that were 2 to 3 times the rate of quit levels in control groups. After 5 years of intervention research, the Smoke-Free Families program opened a National Dissemination Office to promote the widespread implementation of prenatal tobacco intervention across the United States. 
The Smoke-Free Families program was the first coordinated effort to help pregnant women stop smoking. As noted in chapter 4, however, this program failed to find solutions to help the large numbers of heavily addicted pregnant smokers who cannot quit even after the 5 As—or the 60% to 70% of women who resume smoking within months of delivery. Nevertheless, C. Tracy Orleans, a senior scientist and distinguished fellow at the RWJF, is quoted as saying that the greatest success of the Smoke-Free Families program may have been the building of “critical evidence, and practitioner and policy support, for what is now regarded as the best practice standard for tobacco-cessation intervention in pregnancy—the augmented 5 As.” 
Healthcare reform is about expanding access to coverage and improving the healthcare delivery system. It is also about taking responsibility for one's own health and wellbeing. Several of the chapters in To Improve Health and Health Care touch on RWJF programs that have led to improved health. I would recommend this book to anyone who is interested in learning more about the kinds of programs that are funded by the RWJF and how these programs intersect with improved health and healthcare reform. 
 Edited by Stephen L. Isaacs, JD, and David C. Colby, PhD. 262 pp, $30.00. ISBN: 978-0-7879-8638-4. San Francisco, Calif: Jossey-Bass; 2008.
 American Osteopathic Association's Health System Reform Task Force
 The book reviews that follow are the first in a series written by members of the American Osteopathic Association's Health System Reform Task Force. The series aims to educate members of the osteopathic medical profession on current healthcare reform efforts as well as motivate them to learn more about the need for comprehensive healthcare reform and the role they can play in achieving it. Members of the AOA may learn more about health system reform by logging into the members-only section of DO-Online and selecting “Health System Reform” under the “Advocacy” tab. For more information on the AOA's Health System Reform Task Force, please contact Susan Friedman at or 1-800-621-1773, extension 8643.