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commentary

(Health Affairs)

August 1, 2018

Local Development of a Culture of Health: Learning from Sentinel Communities

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by Anita Chandra, Todd Rogers, Margaret Tait

We are in the midst of polarizing discussions across the country about American health values and how much we are willing to invest to promote well-being for our neighbors and ourselves. Many people recognize that social, economic, and environmental factors drive health and want to understand how different communities are taking on the challenge to improve population health.

To advance this thinking, in 2014 the Robert Wood Johnson Foundation (RWJF) articulated an ambitious vision for building a Culture of Health. The RWJF recently released an updated report and set of national measures (PDF) detailing more of what has surfaced since 2014. The 35 national measures are distinct by design: They are intended to inspire actions that will improve health, well-being, and equity from sectors (such as businesses or community development organizations) that are not traditionally considered in the lead as health-promoting sectors.

The Culture of Health is focused on establishing health as a priority and affecting change in four Action Areas: making health a shared value, fostering cross-sector collaboration to promote health and well-being, building healthier and more-equitable communities, and strengthening health services and systems.

Community innovation is central to building a national Culture of Health. Across each of these Action Areas, communities are advancing population health and addressing issues of health equity, and many are doing so in unique ways.

But how do communities move toward prioritizing health, and how does social change happen across diverse American communities? Through an innovative sentinel community design, the RWJF and its partners, RTI International and the RAND Corporation, are approaching community learning a bit differently. Community health analyses often measure traditional outcomes associated with interventions or place-based investments, which offer important insights about how communities can improve a set of health outcomes.

In the Sentinel Communities study, however, our goal is to understand how health is discussed and acted upon and how those discussions and actions naturally emerge and evolve in a community. We build off of the sentinel surveillance model, often used in disease monitoring, to follow the development of a Culture of Health as it is happening organically over time.

In our sentinel community design, we aim to understand how each of thirty communities (cities, states, or regions) is working within its context and history to promote health and well-being. For that reason, we are not exclusively examining communities that are widely known for their health innovations. Instead, we selected a range of places that are different in a host of demographic, social, and political ways and differ as to their stage of evolution toward a Culture of Health. While we have an initial set of aims, informed by the Culture of Health Action Framework, we are not bound by a static set of structured questions. We are looking to understand how health has been embedded into community actions, policies, and programs, and how community systems actively promote health, well-being, and health equity.

Through a mix of key informant interviews, as well as document and policy review and other secondary data analysis, we seek to not just document health issues and note the coalitions that have been formed to address them. Rather, we seek a deeper understanding of how communities evolve in building a Culture of Health, including how they (1) message about health and well-being, (2) partner and align systems and investments, (3) use data, and (4) address health equity.

We are also interested in unpacking the historical traumas that communities have faced and how those stresses continue to affect community health and well-being. In short, we want to understand how the Culture of Health Action Framework resonates in communities not whether they use the framework, but, rather, if and how these Action Areas are part of health investments and decision-making. In the analysis that will be ongoing for at least five years, we are working to answer questions such as

  • What motivates communities to begin working on population health and well-being? What is contributing to or impeding development of shared values of health?
  • What are the different paths that communities take if and when they build local interest in, and commitment to, health? What obstacles do they face when trying to build an interest in health? What propels them forward?
  • Which nonhealth sectors are typically the “early adopters” of improvements in population health, well-being, or equity? Which nontraditional partnerships (such as a school district and health care system working together to provide comprehensive health care for families at locations within schools) emerge?

Emerging Themes

Although we are in the early stages of learning about each community (see the list of thirty communities and initial reports), there are already themes emerging that warrant deeper investigation within and across communities. These insights will continue to populate the Culture of Health website so that all communities can benefit from learning about how values come to be shared locally and how health progress is made. Here are just a few themes:

  • In some communities, anchor institutions play key roles in health and well-being. Traditionally, health-sector and academic institutions have been leaders in these efforts. We are examining a greater range of anchor organizations (including for-profit businesses) that may be instrumental in community health.
  • Health equity is more a part of the conversation now as gaps in income, access to care, and educational achievement are widening across America. But do communities explicitly take this on as a goal? What does that mean within communities that differ demographically and politically?
  • We are gathering more information about when and how nonhealth sectors take on health. For example, what motivates and sustains the interest of business in moving from inward-focused employee wellness programs to corporate social responsibility and a shared value in community health?
  • We are working toward a deeper understanding of the issues that may be more prevalent in rural communities. We're learning about the effects of industries moving out of small, rural communities where they may have long been the top employer. These shifts are profound in small communities where there may already be limited employment opportunities.

We will examine these and other issues closely over the next several years. As the United States grapples with health care spending and changing demographics on a national scale, the Sentinel Communities project will illuminate stories from local communities and paint a picture of the ways in which communities strive to build a Culture of Health. We hope that other communities will read these reports, identify areas that are similar to their experiences and challenges, and find important pathways and insights that can be applied to their local context.


Anita Chandra is director of RAND Justice, Infrastructure, and Environment. Todd Rogers is a senior scientist in the Center for Health Policy Science and Tobacco Research at RTI International. Margaret Tait is a doctoral student at the University of Minnesota in the Department of Health Services Research, Policy and Administration.

This commentary was first published on July 31, 2018 on Health Affairs Blog. Copyright ©2018 Health Affairs by Project HOPE — The People-to-People Health Foundation, Inc.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.