In 2013, the Robert Wood Johnson Foundation (RWJF) established a new strategic framework, the Culture of Health (CoH). CoH is founded on a vision in which "all in our diverse society lead healthier lives now and for generations to come."
For the CoH vision to be realized, the framework requires a national paradigm shift from one that thinks of health in terms of disease, treatment, and health care toward one that prioritizes well-being broadly. Recognizing this, RWJF asked RAND Health to help design an actionable path to fulfill CoH goals. The results, a framework consisting of four action areas and measurement strategy, were published by RWJF (2015) and detailed in a RAND report, Building a National Culture of Health: Background, Action Framework, Measures, and Next Steps (Chandra et al., 2016). The framework is presented in Figure 1.
Figure 1. Culture of Health Framework
Briefly, the outcome that anchors the vision is presented in the bottom box: improved population health, well-being, and equity. This outcome is based on a new paradigm in which keeping everyone as healthy as possible is a fundamental and guiding value in the United States. The first action area in the supporting framework involves making health a shared value of society in order to forge a common cause around CoH. This first area is critical to the CoH vision, as all members of a community and indeed, the nation, must work together to become and stay healthy. The second action area, fostering cross-sector collaboration to improve well-being, recognizes that multiple aspects in people's lives affect overall health; this action area reminds us that traditional health care organizations and networks will need to work with nontraditional partners, such as education, labor, housing, and food outlets, to achieve CoH. The third action area, creating healthier, more equitable communities, is designed to enhance the ability of all members of a community, regardless of economic and health status, to access resources and opportunities needed to lead a healthier life. Finally, the fourth action area, strengthening integration of health services and systems, encompasses a commitment to equity that ensures individuals' access to high-quality, efficient, and integrated systems of public health, as well as health care and social services that are capable of meeting the health needs of the American population, across lifespans and "health spans" (i.e., from sick to well).
The research team sought stakeholder input in the course of developing the framework and measures for two purposes: (1) to support the conceptual development of the CoH action framework; and (2) to support the development and use of CoH measures by those doing CoH-related work on the ground. The information and insight gained over the course of stakeholder interviews and small focus group sessions helped inform the CoH framework. However, it should be noted that stakeholder input represents only one component that informed the CoH action framework and measurement strategy process. The process also involved extensive literature review, expert consultation, and iterative prioritization exercises among the CoH team at RAND and RWJF. As such, the findings from interviews and focus groups should be contextualized in broader CoH-related analysis.
Data Collection and Coding Methods
To gather stakeholder input, the team conducted 74 semistructured interviews and eight small focus group sessions within the United States and internationally. The team also attended two community events with CoH focus to gather information. The team sought to collect responses from stakeholders that would have a direct relationship to CoH or are active in bringing about similar changes in organizations. As CoH is a holistic approach to national and community health, stakeholders represented both traditional health providers and caregivers as well as community leaders, innovative organization leaders, and leaders in education, criminal justice, employment, housing and other fields outside of health that have an impact on people's overall well-being. Stakeholders were recruited from U.S. cities and internationally and included organizations engaged in multiple and diverse CoH initiatives, communities from a mix of health-related community rankings, and diverse geographic regions.
Once collected, insights and other stakeholder input were coded. Qualitative analysis was conducted to reveal themes that applied to the CoH framework, as well as each individual action area.
Findings
A summary of findings general to CoH and those specific to each of the action areas can be found in Tables 1 through 5. A short discussion of each group of findings follows the corresponding table. This section ends with a brief discussion of findings related to CoH measurement.
Table 1. CoH: Themes from Interviews and Focus Groups
Action Area
- Implementation of the culture of health across multiple action areas
Themes
- Consider an individual's larger social context or environment when determining factors that may be influencing his or her health
- Build knowledge of and connection with communities to foster a culture of health
- Work at multiple levels, from individual to organizational to system, to build a culture of health
- The phrase culture of health was intuitive and appealing to a large majority of stakeholders, but some stakeholders had concerns about the phrase's inclusivity
- Provide continued health education and communication to create a shared value of health among all stakeholders
- Political support for policies or interventions that may be costly or unpopular in the short term may be difficult to garner
- Evaluation and data are important to inform a culture of health, but stakeholders reported limited capacity and funding to collect them
- Consider ways to make building a culture of health "good for business" to incentivize strategies to build a culture of health
- Social media data could be useful to track development of a culture of health, but few stakeholders use these data
The findings in this group (Table 1) suggest that a large number of stakeholders felt that the phrase culture of health was intuitive, appealing, and helped move the conversation beyond health as the absence of disease and exercising or eating right. But some also expressed concerns that the phrase may not be seen as inclusive of all populations, may not translate well to other cultures, and may not be intuitively inclusive of traditionally marginalized populations. Stakeholders also emphasized that inclusion of the word "health" in the phrase might lead to it being seen as primarily health-sector work; however, the conceptualization of CoH intends to go beyond that to the whole community and it defines health in a broad way. There were also concerns that the term "culture" can be interpreted as very personal and ingrained and not something that is mutable in the way envisioned by the CoH action framework.
Table 2. CoH Action Area 1: Themes from Interviews and Focus Groups
Action Area
- Making health a shared value
Themes
- Culturally tailor processes to build a shared value of health; it is not "one size fits all"
- Engage community residents as key partners to promote shared values and social cohesion
- Collaborate with a wide range of organizations to promote shared values
- Train public health professionals on how to change social norms
- Integrate civic engagement activities into health promotion programs to create shared values
Making health a shared value elicited limited feedback among stakeholders when compared with the other areas in the CoH action framework (Table 2). There are a number of possible explanations for this. Many said they had never thought of tracking community activation around health and strategies for encouraging individuals to value and prioritize health. Since we spoke to many stakeholders within the health sector, the idea that health is valued and that health equity is important may have been taken for granted. Some stakeholders felt it was more important for the health sector to value the contributions of other sectors than for all to explicitly prioritize health. The interviews revealed that these themes may not be a part of the typical strategic thought process for the organizations stakeholders represented, or that they are concepts that lie within the foundation of the organizations' work but are not part of their activities.
Table 3. CoH Action Area 2: Themes from Interviews and Focus Groups
Action Area
- Fostering cross-sector collaboration to improve well-being
Themes
- Define prevention and health promotion broadly to help potential collaborators see where they have influence
- Engage a visionary leader, community leaders, and nontraditional partners to build a culture of health
- Clearly articulate economic benefits from cross-sector collaboration for organizations to sustain commitment over time
- Develop strategies to maintain consistent organizational participation in the collaboration, despite staff turnover
- Measuring the extent or quality of partnerships may be a challenge for culture of health initiatives
- Competing priorities and community size can challenge cross-sector collaborations
For the second action area (Table 3), nearly half of stakeholders (46 percent), both domestic and international, cited experience collaborating with partners in other sectors. More than a third (35 percent) underscored collaboration as an integral aspect of building CoH. Stakeholders shared insights on key partners for forming collaborations, how to build and sustain collaborations, and other key lessons learned. In multiple communities, local and state governments are leading efforts to build CoH. Also, stakeholders are collaborating with partners from diverse sectors, and partnerships among health care centers, local businesses and business organizations, academic institutions, nonprofits, and faith-based organizations are leading to creative approaches to dealing with health issues.
Table 4. CoH Action Area 3: Themes from Interviews and Focus Groups
Action Area
- Creating healthier, more equitable communities
Themes
- Develop innovative initiatives to promote equitable opportunities for healthy environments
- Utilize a variety of specific strategies or initiatives to create a social, physical, or economic environment with equitable opportunity for healthy choices
- Strategically used communication, media, and messaging can shape health environments and should be targeted as part of an environmental strategy
- Consider health in all policies or leverage a broad approach to create a healthy environment
Findings related to the third CoH framework action area suggest there is a shared understanding across both U.S. and international organizations of the importance of social, physical, and environmental factors in improving individual and community health (Table 4). Many stakeholders discussed the importance of geographic access to social and health services, as well as daily opportunities for individuals to engage in health-promoting behaviors. Overall, stakeholders felt that the public health sector has become more sophisticated in communicating and thinking about the social determinants of health, but more work should be done to train public health professionals to communicate persuasively about social determinants.
Table 5. CoH Action Area 4: Themes from Interviews and Focus Groups
Action Area
- Strengthening integration of health services and systems
Themes
- Develop relationships with integrated health initiatives in the community
- Promote proactive strategies, but be aware that shifting funds away from treatment to prevention will be a challenge
- Start by focusing on a specific health need to generate more integrated care collaboration models
- Shift the focus of health care to prioritize delivering quality care and providing an optimal consumer experience
- Coordinate health and other major systems in a community to fit within a broad frame of health promotion
For the final action area, there was a collective agreement about the need to integrate the community and patient care and to implement innovative approaches to connecting patients with their health care teams (Table 5). Some stakeholders discussed their use of data, measures, and information technology as a means to identify needs, assess goals, and to streamline patient-provider interactions. Yet, fragmented data and insufficient infrastructure still pose challenges for many stakeholders. Adequate workforce development, education, and human resources resonated as key elements to promote prevention and healthy lifestyles. Some organizations highlighted the importance of cost-effectiveness of interventions, but others noted that social investors are not just interested in the financial return but also in the value they bring to people's lives.
Findings Related to CoH Measures
Findings from the interviews and focus groups suggested a lack of available measures and existing capacity necessary to evaluate most community health initiatives rigorously and comprehensively. Stakeholders also expressed a need to develop measures specific to each aspect of CoH. Some stakeholders offered a number of recommendations of suggested measures for the CoH action areas.
Conclusion and Moving Forward
Together, the findings hold positive implications, as well as suggestions for RJWF to consider in moving forward with CoH and implementation of the CoH action framework. As already suggested, the findings suggest that the name of the strategic framework, Culture of Health, is both appropriate and intuitive. However, care must be taken when relaying the term "culture," as this can be interpreted in a variety of ways depending upon the audience.
Findings also suggest that evaluations and data are important to inform CoH but stakeholders have limited capacity and funding to collect appropriate data, and that measures of shared values and social cohesion were among the most difficult to conceptualize. Additional guidance and support may be needed to convince stakeholders of the value and utility of measures related to cross-sector collaboration. System-level measures of equitable opportunities are unavailable, but are critical to tracking progress and outcomes for this area. Stakeholders also stressed the importance of finding ways to describe both monetary and social values of CoH. Tools such as the Social Impact Calculator (Low Income Investment Fund, 2014) can provide the social value of participation. Monetizing the value is the first step; however, communicating about this value is critical to sustainability of the CoH action framework. Finally, because the CoH framework goes beyond traditional health and health care to include well-being and preventive efforts and all aspects of the environment that contribute to health, CoH leadership should be mindful of pitfalls pertaining to outreach and communication. Without a strong vision and clear-cut communication, strategic frameworks this broad in scope can be challenging. It can be difficult to help stakeholders see their role in the framework and understand "what is in it for them." Furthermore, it can be a challenge to identify a clear funder, since funders often fund in specific areas.
When analyzed together, the findings also offered a number of recommendations for RWJF to consider moving forward:
- Leverage existing community capacities to implement and communicate CoH and related efforts. The findings suggest that for the vision of CoH, community, and cross-sector approach to be achieved, leaders must find ways to integrate with grass-roots efforts led by community residents all the way up to policy-level interventions that affect governance structures and protocols. Expertise will be needed to engage whole communities, promote cross-sector collaboration, navigate political processes, and use an array of communication technologies and media to shift social norms. To fully engage the private sector, RWJF will need to communicate the economic incentives and cost benefits of building CoH clearly.
- Develop a strong and flexible set of leaders. Leaders that can help clearly articulate roles and benefits across sectors, navigate "siloed" funding streams, identify the ways that sector efforts can be better aligned, and find opportunities for nesting health into policies and initiatives will be needed to promote CoH across communities.
- Enhance CoH capacity to collect, analyze, interpret, and apply data. Findings suggest challenges in this area, but data, including "big data" that are collected from social media, will be needed. Measures of the benefits of cross-sector collaborations are also critical to the effort. Such data are important if CoH leaders wish to track progress and monitor community-level changes toward CoH adequately.
