Building a National Culture of Health

Background, Action Framework, Measures, and Next Steps

by Anita Chandra, Joie D. Acosta, Katherine Grace Carman, Tamara Dubowitz, Laura Leviton, Laurie T. Martin, Carolyn Miller, Christopher Nelson, Tracy Orleans, Margaret Tait, Matthew Trujillo, Vivian L. Towe, Douglas Yeung, Alonzo L. Plough

This Article

RAND Health Quarterly, 2016; 6(2):3


Because health is a function of more than medical care, solutions to U.S. health problems must encompass more than reforms to health care systems. But those working to improve health, well-being, and equity still too often find themselves traveling on parallel paths that rarely intersect. In 2013, the Robert Wood Johnson Foundation (RWJF) embarked on a pioneering effort to advance a Culture of Health initiative. A Culture of Health places well-being at the center of every aspect of life, with the goal of enabling everyone in our diverse society to lead healthier lives, now and for generations to come. To put this vision into action, RWJF worked with RAND to develop an action framework that identifies how the nation will work toward achieving these outcomes. This article provides background on the development of this action framework. The Culture of Health action framework is designed around four action areas and one outcome area. Action areas are the core areas in which investment and activity are needed: (1) making health a shared value; (2) fostering cross-sector collaboration to improve well-being; (3) creating healthier, more equitable communities; and (4) strengthening integration of health services and systems. Each action area contains a set of drivers indicating where the United States needs to accelerate change and a set of measures illustrating places for progress. Within the primary Culture of Health outcome—improved population health, well-being, and equity—the authors identified three outcome areas: enhanced individual and community well-being, managed chronic disease and reduced toxic stress, and reduced health care costs.

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Full Text

Since 2013, the Robert Wood Johnson Foundation (RWJF) has embarked on a pioneering effort to advance a Culture of Health, framed by ten core principles. RWJF asked the RAND Corporation to support the Foundation's development of an action framework and measurement strategy for a Culture of Health, building on these ten core principles. This study provides background on the development of this action framework, particularly the drivers and illustrative measures. The study also documents the first phase in developing the Culture of Health measurement strategy and complements other reports, including the RWJF publication From Vision to Action: A Framework and Measures to Mobilize a Culture of Health (Plough et al., 2015) and the RAND report Stakeholder Perspectives on a Culture of Health: Key Findings (Acosta et al., 2015). It draws on an environmental scan, diverse stakeholder engagement, and a series of inputs from core RWJF partners (e.g., analyses on health equity by Prevention Institute, business roles in workplace health by Health Enhancement Research Organization [HERO]).

Initial Motivation for the Culture of Health

Health and health care are at a crossroads in the United States (Davis et al., 2014; OECD, 2013). The country spends more on health care than any other nation. But Americans are not getting their money's worth. For example, the United States ranks only 26th in life expectancy among 40 of the most developed countries (Bauer et al., 2014; Galea et al., 2011; Link and Phelan, 1995; Mokdad et al., 2004; OECD, 2013). It has become increasingly clear that solutions to U.S. health problems must encompass more than reforms to health care systems. Health is a function of more than medical care. Health behaviors and the social and physical environment in which individuals live and work have a stronger influence on well-being than clinical services alone (Braveman, 2014; Galea et al., 2011).

This emerging understanding and the changing landscape of our nation's health suggest a need to rethink the relationships among all sectors of activity and their roles in health. This includes reimagining the health sector as one that balances health, public health, and social service systems to yield the highest value to individuals and communities. Some of this change in orientation to a broader view of health has been required as demographics shift (e.g., population aging, increase in immigration) (Pol and Thomas, 2000; U.S. Census Bureau, 2010). Coordinated efforts to promote wellness and prevent diseases are proliferating among a diverse set of stakeholders, including organizations that have not traditionally focused on health (Galea et al., 2011; Link and Phelan, 1995; Mokdad et al., 2004; OECD, 2013; University of Wisconsin Population Health Institute, 2014). These shifts have helped catalyze a national movement that demands and supports a widely shared, multifaceted vision for a Culture of Health.

In this context, RWJF laid out the ten core principles for a Culture of Health, initially delineated in Building a Culture of Health (Lavizzo-Mourey, 2014):

  1. Optimal health and well-being flourish across geographic, demographic, and social sectors.
  2. Opportunities to be healthy and stay healthy are valued and accessible to everyone across the entire society.
  3. Individuals and families have the means and opportunities to make choices that lead to healthy lifestyles and optimal well-being and functioning.
  4. Business, government, individuals, and organizations work together to foster healthy communities and lifestyles.
  5. Everyone has access to affordable, high-quality health care—both preventive and remedial.
  6. No one is excluded.
  7. Health care is efficient and equitable.
  8. The economy is less burdened by excessive and unwarranted health care spending.
  9. The health of the population guides public and private decisionmaking.
  10. Americans understand that we are all in this together.

Development of the Action Framework

While the ten guiding RWJF principles provided the critical foundation for describing what constitutes the end state of a Culture of Health, RWJF did not yet provide the operational or action framework for how the nation could begin to work toward achieving these outcomes. Since late 2013, RWJF has worked collaboratively with RAND to develop an action framework for the Culture of Health. The ten principles underlying the Culture of Health vision created a starting point for this action framework.

The goal of the framework (Figure 1) is to convey a holistic, integrated perspective on what it takes to achieve population-level health and well-being. The Culture of Health action framework is designed around four action areas and one outcome area. The action areas include (1) making health a shared value; (2) fostering cross-sector collaboration to improve well-being; (3) creating healthier, more equitable communities; and (4) strengthening integration of health services and systems. The outcome area—improved population health, well-being, and equity—is intended to serve as the key result of activities in each action area. While not represented in the figure, each action area contains a set of drivers indicating where the United States needs to accelerate change. The drivers provide a set of investment priorities that are core to sustained improvement in health over time and maintained progress in the action area, and, thus, they do not change over time. Each action area is also accompanied by a set of measures to illustrate progress in an action area. These measures are meant to invite dialogue among stakeholders to discuss key areas for progress in the action area (e.g., a measure on library access not only engages this sector but starts conversations about well-being amenities in communities) but are not intended to holistically capture all of the aspects to measure in a given action area. In other words, the measures serve as a starting point, but we recognize that various stakeholder groups may identify other aspects that merit monitoring or tracking for a given action area.

Figure 1. Culture of Health Action Framework

Action Area 1
Making health a shared value
Action Area 2
Fostering cross-sector collaboration to improve well-being
Action Area 3
Creating healthier, more equitable communities
Action Area 4
Strengthening integration of health services and systems
Improved population health, well-being, and equity

Our process for developing the action framework and translating the conceptual frame of the Culture of Health into something operational leveraged a schema used by members of the study team in developing both community resilience and civic well-being operational frameworks (Chandra et al., 2011; City of Santa Monica, 2015). We used a combination of literature review, structured discussion with experts, and other stakeholder engagement to guide development of the operational action framework (Figure 2).

Figure 2. Process for Action Framework Development

Figure 2. Process for Action Framework Development

Three analytic steps were used to move from the ten Culture of Health principles to the action framework. First, we examined how principles may cluster together. Team members independently organized the principles into clusters, then iterated as a team to review and name these clusters or action areas. After the principles were grouped, the team created notional logic models to determine how action areas would link together to drive or influence a Culture of Health. The exercise ensured that our choice of groupings aligned with available evidence (e.g., outputs and outcomes related to the evidence of what success may look like in an action area) and were conceptually clear. Finally, as part of a concept mapping effort with stakeholders, we checked our assumptions about the action areas—specifically, to determine whether the conceptual groupings we had recommended were useful and understood by a diverse set of stakeholders.

Development of Drivers and Illustrative Measures

To develop drivers and measures for each area in the action framework, the team conducted an environmental scan (literature review), completed a stakeholder engagement process that included input from RWJF partners, developed logic models and other graphics (e.g., creation of figures that illustrated how drivers and measures may relate, narratives of how drivers may work together using community case study examples), and reviewed all progress via team analysis. These four inputs were conducted over a period of approximately one year and employed an intensive, iterative process whereby the RAND and RWJF collaborative team engaged at least once per week by phone and met in person every two or three months.

Environmental Scan/Literature Review

The team, primarily led by RAND, conducted an environmental scan, which included a review of websites, the peer-reviewed and gray literature (e.g., reports, proceedings), and other materials that summarize issues related to culture, health, and the action areas in the Culture of Health action framework. The scan primarily focused on these topic areas:

  1. What is culture?
  2. What is health?
  3. What are influences for shared values and health, cross-sectoral collaboration, health environment, and health care system effectiveness and efficiency?
  4. What are key factors related to complementary areas for a Culture of Health, such as well-being, resilience, etc.?

The scan included a bibliographic search of published and gray literature using such computerized databases as Web of Science, Google Scholar, PubMed, Scopus, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the New York Academy of Medicine's Gray Literature. The results of this environmental scan provided insight into the key drivers in the action framework by helping to consider what elements are most relevant to developing a Culture of Health within the action areas, which drivers were most critical for each action area, and what measures require the most progress to achieve the outcomes in RWJF's vision (in short, whether improvement in a measure would have significant impacts on the action area and/or outcome of improved population health and well-being). An initial set of drivers was identified based on the following criteria:

  • relevance and alignment with the action area definition
  • indication of an aspect of the action area that needs attention, investment, and/or improvement in order to cultivate or develop a Culture of Health
  • ability of the driver to be used by or to be relevant to diverse stakeholder groups that need to engage to activate or cultivate a Culture of Health
  • potential link between the action in a driver and available ways to measure change (the linkage could also provide an opportunity for dialogue among key sectors needed for health improvement)
  • consistency with relevant or aspirational models or frameworks from other countries conducting work in population health and well-being.

We used the linkages among drivers within and across action areas to further parse the outcome of improved population health and well-being into three outcome areas. In short, we examined what ways change in the driver would lead to change in the outcome (e.g., whether it would change cost or well-being).

While the environmental scan was important for informing the drivers and measures development process, it was not the only input that informed the selection of drivers and measures. We describe the other inputs in the following sections.

Stakeholder Engagement

The stakeholder engagement process was primarily used for review and vetting of the drivers for the action framework. Stakeholders also provided some input on the measures to consider, but the weight of stakeholder analysis was used more for action framework review. There were four primary steps of stakeholder engagement:

  1. review by the RWJF Board of Trustees subcommittee developed for this work
  2. consideration by the RWJF network, which includes a diverse leadership network and presentations with relevant professional associations
  3. discussion with national and global stakeholders
  4. additional expert review.

The RWJF board subcommittee included five board members who represented the health, business, government, and academic sectors—Julio Frenk, Patricia Gabow, Jeffrey Koplan, Robert Litterman, and Peter Orszag. These subcommittee members were engaged throughout the entire action framework, drivers, and measures development process. Every quarter, over more than a year, the team presented progress on the action framework and solicited input on the action areas, proposed drivers, and, ultimately, illustrative measures. The board members helped the team to review driver candidates (there were usually about six to eight options per action area) to facilitate selection of the final three for each action area (or outcome area for the outcomes).1 In addition to the RWJF board review, we shared the action framework and considerations about drivers with members of the RWJF professional leadership network, a diverse online community of RWJF key partners representing research, practice, and policy fields. The third set of inputs came from stakeholder input outside of RWJF, primarily through focus groups and key informant interviews. We used those stakeholder inputs at the start of the process to review the action framework and action areas, and then throughout the first six to eight months of the effort to ensure that our consideration of drivers was aligned with public priorities. While we also solicited ideas for measurement from them, the stakeholders were primarily used for action framework and driver input.

Finally, we used additional expert review in two ways. First, we had a team of five well-established peer reviewers for the work: Nancy Adler, Sandro Galea, David Kindig, Michael Rodriguez, and Stephen Shortell. These experts, who reviewed the initial action framework and provided extensive comment on drivers and measures, were selected because they represented public health and clinical fields, as well as academic and practice experience. Additionally, we engaged several of RWJF's partners to inform the development of the action framework and drivers.

In addition to the literature review and stakeholder engagement, the team utilized the inputs from other research summaries commissioned by RWJF for this effort. These inputs were used in driver and measures selection.

Logic Model Development

The action framework development process also was guided by understanding the ways in which the drivers and then the final set of Culture of Health measures would catalyze, guide, and assess progress toward achieving a national Culture of Health. Developing a logic model helped the team explore how the drivers and potential illustrative measures may relate to each other (i.e., inputs, outputs, outcomes).

Team Analysis

The RWJF and RAND team used all of the inputs from the literature review/environmental scan, stakeholder inputs, expert review, and logic model creation to develop and fully inform the action framework, action areas, selected outcome, and associated drivers. The team used collaborative tools (e.g., online sharing sites, web presentations that allow comments in real time) to discuss action areas and drivers, initially dividing RWJF-RAND teams by action areas, and then coming together every week (and in person every few months) to present to each other. These team analysis sessions were critical for ensuring that we had thoroughly discussed the literature and expert inputs and identified priority drivers. In some cases, structured listing and sorting activities and independent team member prioritization processes aided us. Because the team intentionally included diverse representation by expertise (e.g., health services, epidemiology, economics, clinical, public health, social sciences), we were vetting drivers and, ultimately, measures through purposeful, multidisciplinary lenses.

Measures Development

The action framework provided a launching point for framing and informing RWJF's Culture of Health measurement strategy and measures. The measures were intended to capture key aspects of the action areas and drivers identified in the prior phase. While the core momentum for building a Culture of Health is derived from the action framework, the measures illustrate progress and spark dialogue about the many factors that influence and improve health. The measures are not meant to delineate every indicator of population health but, rather, to represent key elements of possible change.

Before we approached specific measures selection, we defined a measurement strategy and the principles for deciding which measures to include. One of our overarching goals in articulating a measurement strategy was to ensure that the ultimate measurement set represented each of the five parts of the action framework and the specific complementary drivers of interest within each action area. Several goals guided the overarching measurement strategy:

  • Measures needed to represent constructs that possessed demonstrated (or highly plausible) links to important health and well-being outcomes and also had some evidence about the types of interventions and resources needed to drive change in these measures. For example, we considered both the evidence linking complete street policies (i.e., every transportation project should make the street network better and safer for drivers, transit users, pedestrians, and cyclists) to health and well-being outcomes and the evidence of feasible strategies/interventions for implementing complete street policies. These steps were critical to finding actionable measures with the potential to change health and well-being within the next five, ten, or 20 years.
  • Second, we set the goal of selecting six to ten measures for each action area, roughly distributed across each of the three drivers in each action area to generate a total of 30 to 40 specific measures. This number was selected based on other national measurement efforts suggesting that more than 40 measures would be prohibitive and difficult to track and remember, and six to ten measures would reflect balance among the action areas.
  • Third, each measure had to apply at a national level or reflect national-level norms, interventions, or results. For instance, county-level measures of walkability in all 50 states could be aggregated to achieve a nationally representative measure of walkability and could be applied at county or organizational levels as well.
  • Finally, the measurement strategy needed to address issues of equity, both in how the strategy would subsequently be implemented as well as in the selection of measures to represent progress to address long-standing disparities. In the context of this work, equity meant two things. First, measures needed to allow for examination by race/ethnicity, income, and so forth. Second, the team included some measures that addressed social policy issues that had historically impeded health progress (e.g., residential segregation).

Measure Characteristics

What measure characteristics best reflect this strategy? First, measures had to be appropriate for use in diverse geographies, cultures, and ages (context and populations). Second, taken together, the grouping of measures had to reflect a mix of drivers of change and the actual indicators of change (i.e., outcomes). Third, the grouping of measures had to represent outcomes that were immediately achievable and those that were more aspirational to be achieved over a generation. Finally, the measures had to be placed in data monitoring and use contexts so that measures could be convincingly linked to data sources now or in the future and could be monitored over time.

Selection and Development of Measures

Based on the measurement strategy, the team undertook a process to identify associated measures. Our criteria for evaluating individual measures (i.e., “individual-level criteria”) included such factors as action area relevance and validity, and criteria to evaluate the full set of measures (i.e., “portfolio-level criteria”) included factors such as balance across drivers and accessibility to diverse stakeholders and sectors.

The team created spreadsheets for each action area, sorting prospective measures by drivers and listing information on each measure's source and prior use. We moved through several steps of review, first within action area teams, then as a full project team. We also assigned action area team members to review the measures from action areas other than their own in order to assess the lists and potential selections. We convened as a full project team weekly to present measures and candidate selections. We also conducted a series of exercises to review the measures by action areas and then as a full portfolio. This included various scenario reviews of how measures connected together, narrative creation (i.e., identifying the story of the measures together and how it maps to the action framework), and whiteboarding activities (e.g., putting the measures on cards and then documenting logic flows of how measures in action areas would lead to change in outcome areas).

The remaining sections of this summary describe each action area or outcome area, with attention to definition of the action area, brief discussion of drivers, and a list of the ultimate measure areas.

Action Area: Making Health a Shared Value

This action area focuses on the degree to which health is a shared value among individuals and the extent to which individuals feel a sense of interdependence. In this context, shared values mean that individuals and whole communities prioritize health and that health informs and drives local decisionmaking; that communities have high expectations for their environment, health system, and supporting services; and that people understand that their health influences and affects others, and vice versa. Accordingly, people are called to action to make decisions that promote not only their own health but also the health of those in their communities. Shared values among individuals can influence shared values among organizations, so making health a shared value is a multilevel process. It includes relationships among neighbors and family members, among organizations, and between individuals and organizations. The research guiding this action area relies heavily upon concepts related to social networks, community resilience, well-being, behavioral economics, and asset-based community development.

Three drivers are critical for ensuring that health is a shared value: mindset and expectations, sense of community, and civic engagement. The sentiment that a shared value of health (i.e., prioritizing health, thinking that it is something to be valued) is a prerequisite for building a Culture of Health was a theme common across the environmental scan, stakeholder input, and RWJF partners. To create a shared value of health, stakeholders and RWJF partners described the need to be able to communicate clearly and improve general population understanding that health is a priority. Creating this awareness would then create the demand for healthy communities, leading to changes that begin to shift the momentum toward a Culture of Health. To fully capture the drivers in this area, we needed to ensure that we had drivers that targeted the understanding of the general population (i.e., mindset and expectations), as well as the ability of a community to mobilize or organize around a demand signal to create health communities (i.e., civic engagement) and/or be influenced by a demand signal (i.e., membership and shared emotion connection created by a sense of community).

The mindset and expectations driver covers the perspectives and views about health held by individuals, families, and organizations. Understanding where community members start in their mindset and expectations will inform where community engagement and information processes may need to start in order to catalyze community health action (Cornish et al., 2014). A strong sense of community is critical for advancing a Culture of Health for two reasons. First, communities that can organize and connect effectively are better able to identify needs and promote action (Morrow, 2001). Second, communities that are strongly connected and have trust in structures, people, and processes can create a foundation that supports a culture (or cultures) of health and recognizes cultural values, norms, and traditions (Kawachi, Subramanian, and Kim, 2008). Relatedly, civic engagement processes in which community members feel that they can influence change, and want to influence change, are important to creating shared values for health (Anheier, 2004; Oakley, 1999). Civic engagement is a critical driver toward creating health demand and cultivating complementary plans and incentives that lead to shared results.

Given these drivers, we identified the following measure areas, within which specific, illustrative measures were identified:

  • value on health interdependence
  • value on well-being
  • public discussion on health promotion and well-being
  • sense of community
  • social support
  • voter turnout
  • volunteer engagement.

Action Area: Fostering Cross-Sector Collaboration to Improve Well-Being

The purpose of cross-sector collaboration to improve health and well-being is to optimize the contributions of multiple sectors by linking more traditionally health-focused sectors (e.g., public health, health care, social services) with sectors whose contributions to health and well-being have come into focus more recently (e.g., business, education, faith, housing, law, transportation, zoning). The quality and extent of these partnerships, as well as the nature and extent of investments in these partnerships, should be considered. Cross-sector collaboration holds unmet potential as an engine for aligning the assets, policies, and practices of multiple sectors to (1) improve the health and well-being of organizations, communities, and the nation; (2) improve health equity across diverse racial/ethnic and socioeconomic groups and populations; (3) help entities across sectors achieve their individual goals more effectively; and (4) find novel (and possibly more effective) strategies for fostering population health and well-being.

The view that cross-sector collaboration must be augmented and strengthened was another critical theme common across the environmental scan, stakeholder input, and RWJF partners. Three drivers are critical for ensuring that cross-sector collaboration is achieved: number and quality of partnerships, resources investments across sectors, and policies that support collaboration. These were laid out in a three-part sequence, whereby sectors would know their roles and contributions, work effectively together, and have the resources and policies to support ongoing collaboration.

For number and quality of partnerships, we asserted that in order to strengthen cross-sector collaboration, we should focus on the number and extent of collaborative partnerships between health and non-health sectors (number and extent of collaborative partnerships) (Baezconde-Garbanati et al., 2006; Pant et al., 2008). In short, it is important both to enumerate specific partnerships between the health sector and other sectors and to document the quality of these partnerships. This driver would also focus on delineating what contributions each sector can bring to a Culture of Health. The second driver focuses on the resource investments across sectors. This includes resources committed to drive partnership activities that produce positive health and well-being outcomes (Wholey, Gregg, and Moscovice, 2009). The third driver examines policy supports for productive cross-sector collaborations, ensuring that there is a structure that will maintain and develop partnerships over time (Barrett et al., 2005).

Given these drivers, we identified the following measure areas, within which specific, illustrative measures were identified:

  • local health department collaboration
  • opportunities to improve health for youth in schools
  • business support for workplace health promotion and a Culture of Health
  • U.S. corporate giving
  • federal allocations for health investments related to nutrition and indoor and outdoor physical activity
  • community relations and policing
  • youth exposure to advertising for healthy and unhealthy food and beverage products
  • climate adaptation and mitigation
  • health in all policies (e.g., support for working families).

Action Area: Creating Healthier, More Equitable Communities

The vision for this action area is to ensure that the physical, social, and economic environments in which people live, work, and play support the healthy choice being the easy choice for all residents, including those in historically disadvantaged populations—particularly minority racial/ethnic populations and those in low-income areas, which generally provide limited resources and opportunities for healthy choices. Recent work has reinforced the importance of addressing structural drivers of risk for poor health outcomes (Braveman, 2014). Some work has identified racial residential segregation in the United States as perhaps the most fundamental determinant of differences in access to social and economic resources, from schools to economic retail to services and activities that promote health behaviors (Acevedo-Garcia and Lochner, 2003; Acevedo-Garcia et al., 2003; Williams and Collins, 1995).

Social and physical aspects of neighborhoods, including maintained sidewalks for walking, well-designed and well-run programs at parks, and quality after-school programs, can encourage residents to engage in everyday physical activity and “active transport,” such as walking or cycling to work. Research has found associations between greater distance to parks and less engagement in physical activity and sports activities (Boone-Heinonen et al., 2010), as well as mental health outcomes (Sturm and Cohen, 2014). Given the importance of such large-scale investments and resources, assuring the opportunity for healthy choices for all in our diverse nation requires efforts at the community and organizational levels that recognize how the health of individuals is influenced by “upstream” factors, which represent many non-health sectors, including (but not limited to) housing, transportation, employment, and education.

Based on the literature review and stakeholder analysis, we identified three primary drivers for creating healthier, more equitable communities: (1) the built environment and physical living conditions, (2) the social and economic environment, and (3) policy and governance. We finalized these three as primary drivers because the literature review and stakeholder input noted that more investment and progress needed to be made in the physical, social, and economic aspects of community and that decisionmaking structures to effectively catalyze and maintain progress of each aspect were often missing. The first two drivers focus on the extent to which health-promoting physical, social, and economic environments are in place and equitably distributed. The third driver spotlights policies aimed at creating healthy environments, with an emphasis on collaboration between residents and large government and corporate institutions.

Given these drivers, we identified the following measure areas, within which specific, illustrative measures were identified:

  • housing affordability
  • access to healthy foods
  • youth safety
  • residential segregation
  • early childhood education
  • public libraries
  • complete street policies
  • air quality.

Action Area: Strengthening Integration of Health Services and Systems

The vision for this action area is a coordinated, overall health system that would balance and integrate health care, public health, and social services and systems. This system would be patient- and family-centered, assessment-driven, evidence-based, and team-based to meet the needs of all ages to improve health and well-being while minimizing the caregiving burden and enhancing the caregiving capacity of families and other support persons. It would address interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes provided in the context of a health team (real or virtual) that has established working relationships with families, clinicians, community partners, and other professionals (Antonelli, McAllister, and Popp, 2009). The importance of social services (and the lack of integration with the health care system to date) may help to explain why the United States spends more on health care than other Organisation for Economic Co-operation and Development (OECD) countries, spends relatively less on social services, and has worse health outcomes (Bradley and Taylor, 2013).

We identified three drivers for this action area: access, consumer experience and quality, and balance and integration. We finalized these three as primary drivers because the literature review and stakeholder input noted that these three areas were key to improving early use of health care services that are preventive, driving more balance in health care costs (a key outcome area), and maintaining the country's focus on high-quality health care. Further, the balance and integration driver was specifically included to prioritize interest in balance between health care, public health, and social services, a feature also being examined vigorously worldwide. Access refers to the ease of engaging in health and related ancillary social services. It was selected as a driver because it has been consistently linked to decreased morbidity/chronic disease burden, mortality, and health inequities; better quality of life; and overall cost savings (Institute of Medicine, 2001, 2002). Consumer experience and quality relates to the ease with which consumers can move within and across systems; have clear communication about health, costs, processes, and procedures; and receive care that is high-quality, respectful, and responsive to individual preferences (American Hospital Association, 2013; Institute of Medicine Committee on the Future Health Care Workforce for Older Americans, 2008). Balance and integration refers to integration across public health, mental/behavioral health, social service, and health care systems (e.g., data and information sharing, cost/financing models, shared risk) (Martin and Luoto, 2015; Institute of Medicine, 2014). This driver highlights the extent to which the country values or prioritizes health, as opposed to an emphasis on recovering from illness, and the extent to which these traditionally separate health-related sectors are operating as a unified health system.

Given these drivers, we identified the following measure areas, within which specific, illustrative measures were identified:

  • access to public health
  • access to stable health insurance
  • access to mental health services
  • dental visit in past year
  • consumer experience
  • population covered by an accountable care organization
  • electronic medical record linkages
  • hospital partnerships
  • practice laws for nurse practitioners
  • social spending relative to health expenditure.

Outcome: Improved Population Health, Well-Being, and Equity

Based on the environmental scan of the nation's progress in terms of achieving RWJF's ten principles of a Culture of Health, we identified three outcome areas (enhanced individual and community well-being, managed chronic disease and reduced toxic stress, and reduced health care costs) within the Culture of Health outcome of improved population health, well-being, and equity. We used these outcome areas to track observed impact if progress is made in the four action areas and the related drivers. Given that the drivers are in the action areas, we use the term “outcome areas” to distinguish from “drivers.”

The action framework for establishing a Culture of Health emphasizes well-being; thus enhanced individual and community well-being is one of the three outcome areas. The establishment of a Culture of Health is, by definition, a transformation in the way society thinks about health, a result that can only happen when complex, system-level change occurs. Therefore, looking at only traditional health outcomes, particularly ones that track specific disease conditions, is not comprehensive enough in scope (Kahneman et al., 2004; Ward, Schiller, and Goodman, 2014). Second, well-being acknowledges imperfect health—that people with chronic conditions or other illnesses can thrive and be healthy. Managed chronic disease and reduced toxic stress (or traumas that affect brain architecture or chemistry) is the second outcome area. Chronic disease is the leading cause of mortality in the world, and as the population ages, the complexity of those chronic conditions only magnifies (Yach et al. 2004). The human and economic toll of chronic disease on society is significant, including lost productivity, quality of life, and health care costs (Centers for Disease Control and Prevention, 2010). The action framework focuses on reducing preventable disease but also on improving the care and management of existing disease, knowing that many are burdened. Reduced health care costs is the final outcome area. Rising U.S. health care costs affect nearly everyone because costs are borne by employers, governments, and individuals alike. As such, progress in this outcome area will require improving efficiency in care delivery, changing payment, and fostering an individual-level impetus to improve health behaviors (Mokdad et al., 2004; OECD, 2013).

Given these outcome areas, we identified the following measure areas, which contain specific, illustrative measures:

  • well-being rating
  • caregiver burden
  • adverse child experiences
  • disability associated with chronic conditions
  • family health care costs
  • potentially preventable hospitalization rates
  • annual end-of-life care expenditures.

Implementation and Next Steps

This study provides foundational content for a vision of a Culture of Health, as well as the four action areas of the Culture of Health action framework. The study offers background to outline the conceptual underpinnings of the four action areas, the outcome area, how each is defined, and the drivers in each action area. The initial efforts to define and frame each of the action areas to advance the ten principles of a Culture of Health illustrated opportunities and gaps in current measurement to achieve that end. Given the groundbreaking nature of RWJF's initiative, the team anticipated that there would be limitations in the availability of measures that track progress in such areas as health promotion, community capacity for health, cross-sectoral collaboration, shared values, and well-being development. The environmental scan and first phase of stakeholder engagement underscore this challenge.

Over the next phase of the project, surveillance of sentinel communities will complement national monitoring of the Culture of Health by offering insight into how development of a Culture of Health evolves locally. The sentinel community phase of this project started in late 2015, with data collection lead by RTI International. This phase will be critical to understanding how communities are developing (or not developing) a Culture of Health, what data they use to track that development, and how certain Culture of Health measure data could be collected and analyzed as the national effort moves forward. Sentinel communities allow the team to complement national Culture of Health measures with more granularity on cultural change processes (or barriers), cross-sectoral engagement, and individual and community efforts to change the context in which health policies are developed and healthier conditions are created. The hope is to surface drivers of change and likely signals that allow assessment of how communities move toward a Culture of Health. The sentinel communities are not demonstration or place-based communities, but rather sites for naturalistically testing local Culture of Health measurement and overall progress (see for site list).

The team also will work to evolve the measures and build out the larger measurement strategy for the action framework. The measurement strategy includes guidance on how measures are tested and validated (e.g., processes for measures prototyping), instructions on how measures may apply to national and/or local context (e.g., factors to consider in local use or consumption), and insights for how measures are framed and communicated for wider, national consumption (e.g., core audience, key messages). This measurement strategy will need to acknowledge structural variables that support measures implementation and long-term use. This includes factors related to sectoral roles and engagement, governance structure and alignment to local processes, and coordination and integration with shared accountability structures nationally and locally.


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1 We targeted three based on practical feasibility and RWJF communication expertise suggesting that people cannot remember too many items—specifically, no more than three.

This research was sponsored by the Robert Wood Johnson Foundation and conducted within RAND Health.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.