Building on its ambitious goal to create a "culture of health" in America, the Robert Wood Johnson Foundation is adding coaches and competitions to help local communities take up the challenge.

The additional support reflects the size of the task: getting schools, businesses, transportation agencies, and other institutions to take responsibility for their communities' health. Princeton, N.J.-based RWJF may be the nation's largest health philanthropy, but its power to change the culture rests mainly on whether it can persuade local leaders to play along.

The effort also acknowledges mounting evidence that social issues such as poverty and education, as well as personal action such as wearing a seat belt and quitting smoking, can have a greater impact on the population's health than a particular treatment prescribed by a physician.

Multiple interventions are needed to change culture.

Jim Marks, executive vice president of the foundation, used a smoking ban as an example. "It is really important," Marks said in an interview, but "we know that it is going to take more than one action." A national "culture of health" covers where people "live, where they learn, where they work, where they play, where they worship," he said.

Five years ago, RWJF partnered with the University of Wisconsin's Population Health Institute to try to measure the health of every county in the nation in two ways: current and future.

Current was based on statistics such as percentages of low-birthweight babies and of residents reporting in surveys how often they felt in poor health. Future took into account data such as percentage of adults who smoke, high school graduation rates, air pollution, and even density of liquor stores. Counties were ranked within their state on both overall measures.

The idea was local leaders would compare their rankings with others' and be galvanized into action.

The sixth annual County Health Rankings are being released Wednesday (www.countyhealthrankings.org). As in the past, they are influenced largely by issues such as poverty and education.

Ranked by current health measures, Bucks, Chester, and Montgomery - among the wealthiest of Pennsylvania's 67 counties - all are in the top 12. Delaware County is roughly in the middle. Philadelphia, as always, is dead last.

Burlington, Camden, and Gloucester Counties are in the middle of New Jersey's 21 counties or below; most of the above-average counties are in the wealthier north.

Most counties are healthier than they were in 2010. Rates of premature death, for example, improved everywhere. Philadelphia's 16 percent decline trumped all others, although it remained high and among the worst in the state. Many predictors of future health improved as well.

Still, the Robert Wood Johnson Foundation decided that relying solely on community leaders to notice and act was not enough. It started adding other guidance, and then a few coaches, now totaling 11 nationwide. New Jersey, as the foundation's home state, is the only one to get its own coach. Communities there also are competing for grants of up to $200,000 to "build a culture of health" in the state.

Toni Lewis, the new community coach for New Jersey, said that her work may involve sharing best practices and helping municipalities figure out ways to join together on common goals. She will work with towns, hospitals, businesses, nonprofits - pretty much anyone who is serious about improving residents' health.

Can a giant foundation like RWJF really change the nation's approach to health?

"The answer is a guarded yes," said David B. Nash, dean of the Jefferson School of Population Health.

"But all change is sustained at the local level," Nash added, and there must be the political will to pursue it.

"Philadelphia is a perfect example. We have unbelievable black on black violence, [many people are] obese, one in four residents smoke - and we've got five medical schools," he said.

"Wouldn't it be great," Nash continued, if the academic medical centers were to partner with community groups and the public health community to improve the public's health? "That would create sustainable change."

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@DonSapatkin