How Cultural Alignment and the Use of Incentives Can Promote a Culture of Health

Stakeholder Perspectives

by Laurie T. Martin, Linnea Warren May, Sarah Weilant, Joie D. Acosta, Anita Chandra

This Article

RAND Health Quarterly, 2018; 7(2):5

Abstract

In 2013, the Robert Wood Johnson Foundation embarked on a pioneering effort to advance a Culture of Health. This study focuses on two questions that are central to understanding how individuals and sectors think about health and are motivated to promote it: How can the commonly understood concepts of cultural identity (e.g., ethnic or religious; lesbian, gay, bisexual, transgender plus; military) and organizational culture be harnessed to develop a Culture of Health? How can incentives be used to promote individual health and engage investors and leaders within organizations or governments to promote health and well-being broadly? This study draws on 43 one-hour semistructured interviews that RAND researchers conducted with stakeholders whose work focused on cultural alignment, incentives, or both to learn how organizations are addressing and leveraging culture and incentives to promote health and well-being, as well as to identify facilitators, barriers, potential best practices, and lessons learned. Key findings include the following: Equity is often addressed in silos, which impedes progress toward a unified goal of health equity for all; members of specific cultural groups need to be given a voice in health-related activities; systems are built around prevailing cultural norms, making it challenging for those working with specific cultures to make cultural adaptations; and not all incentives are monetary. Recommendations include institutionalizing practices that ensure ongoing input from marginalized populations, identifying ways to help smaller organizations overcome structural inequalities, and institutionalizing health promotion efforts in sectors other than public health or health care to sustain collaborative efforts.

For more information, see RAND RR-1889-RWJ at https://www.rand.org/pubs/research_reports/RR1889.html

Full Text

Since 2013, the Robert Wood Johnson Foundation (RWJF) has led efforts to build a “Culture of Health that enables all members of our diverse society to lead healthy lives, now and for generations to come” (Plough, 2014). The Culture of Health Action Framework, published by RWJF in 2015, consists of four action areas and a fifth area focused on outcomes. Additionally, equity is an overarching theme of the Culture of Health Action Framework (Plough and Chandra, 2015). Health equity broadly refers to the opportunity of all to reach their full health potential, considering just and fair inclusion as a fundamental aspect of that opportunity (Braveman, 2014; National Academies of Sciences, Engineering, and Medicine, 2016; PolicyLink, 2014). Health equity, along with population health and well-being, is an intended outcome of a Culture of Health, and all three outcomes are embedded in the action areas, drivers, and measures that compose the Culture of Health Action Framework (Chandra, Acosta, et al., 2016).

This framework is intended to catalyze national dialogue about action and investments to improve population health and well-being. Building a Culture of Health is a bold vision that relies on traditional health promotion actors (e.g., public health and health care systems) and new and innovative partners (e.g., economic development investors, city planning commissioners) to make the changes to systems and communities that are required to sustain it. To understand how this framework is being used to advance action at the local, state, and national levels, RWJF has commissioned ongoing stakeholder engagement and other tracking and monitoring efforts from RAND and other organizations. Two questions emerged from an earlier literature review (Chandra, Acosta, et al., 2016) and stakeholder analysis (Acosta et al., 2016) as central to understanding how individuals and sectors think about health and well-being and how they are motivated to promote it:

  • How can the commonly understood concepts of cultural identity (e.g., ethnic or religious; lesbian, gay, bisexual, transgender plus [LGBT+]; military) and organizational culture be harnessed to develop a Culture of Health?
  • How can incentives be used to promote individual health and engage investors and leaders within organizations or governments to promote health and well-being broadly?

These two questions were identified as central to the Culture of Health effort because recognizing and addressing unique identities and experiences of people bound together by culture (at organizational or community levels) is often viewed as the first step in social movement and cultural change (Chandra, Miller, et al., 2016). Incentives are critical first steps in catalyzing interest and action to change, long before that change is sustained or institutionalized as part of daily practice and policy. Taken together, culture and incentives are necessary first elements in embedding a Culture of Health within and across sectors (Towe et al., 2016).

RWJF asked RAND to examine these two topics to gain insights into how organizations are addressing and leveraging culture and incentives to promote health and well-being, as well as to identify facilitators, barriers, potential best practices, and lessons learned that may inform future work in these areas. This report draws on the findings of interviews that RAND researchers conducted with stakeholders whose work focused on culture, incentives, or both and follows from an initial report on stakeholder perspectives, Stakeholder Perspectives on a Culture of Health: Key Findings (Acosta et al., 2016).

Data Collection and Analysis

We conducted 43 one-hour semistructured interviews with representatives of organizations doing work related to culture and/or incentives. Potential respondents were identified via existing RAND and RWJF contact lists and related conference proceedings, literature reviews, targeted Internet searches, and snowball sampling. They were invited to participate in the study via email, and interviews were conducted by phone.

We developed a semistructured interview protocol (see Appendix B) for these interviews. The general structure of the protocol was based on the objectives of the research as described previously: (1) to understand how the commonly understood concept of culture relates to attaining a Culture of Health and (2) to understand how incentives are being used to engage individuals, employers, and organizations in health promotion activities. We were interested in hearing about efforts in these two areas that align with the Culture of Health Action Framework, as well as barriers, facilitators, and lessons learned coming out of that work. Specific interview questions were developed based on topics for future research identified by an initial stakeholder report (Acosta et al., 2016) and literature related to how culture and incentives are being used to promote health and well-being.

With regard to culture, the protocol included questions about how health and well-being differ across cultures and whether there are any specific cultural barriers or facilitators to building a Culture of Health within communities in the United States or to using the Culture of Health Action Framework to inform the promotion of health and well-being. With regard to incentives, questions explored barriers, facilitators, and lessons learned about incentivizing organizations, employers, and individuals to promote health and well-being. Though interviews generally followed the established protocol, the goal of this effort was to obtain a diverse array of perspectives on factors related to culture and incentives. As such, questions were not consistently asked across interviews, and interviewers often tailored questions to interviewees' areas of expertise. Interviews were not recorded, but interviewers took detailed notes.

Three staff who conducted the interviews used notes to identify emergent themes across respondents, following a general inductive approach to analyzing qualitative data. We summarized emergent themes in three categories: (1) themes relevant for understanding how culture and addressing cultural differences in programs and policies promote health and well-being, (2) themes relevant for understanding how incentives are being used to promote a Culture of Health, and (3) cross-cutting or foundational themes raised by both sets of stakeholders as particularly relevant for their work promoting a Culture of Health. After themes were coded, the same staff responsible for interviewing and coding consulted the literature and previous stakeholder engagement work to determine the extent to which emergent themes added to what was already known about health promotion in a cultural context and using incentives for health.

This report was ultimately constructed around emerging themes within and across the culture and incentives domains and within RWJF's priorities of applying the Culture of Health principles to achieving health equity.

Findings

Cross-Cutting Themes

Although this project set out to capture perspectives from two sets of stakeholders (those working on issues of culture and those using incentives to motivate health and well-being), several themes emerged as cross-cutting and foundational to promoting health and well-being at multiple levels, including a number related to health equity:

  • Establishing health as a shared value is an important but challenging step in promoting health and well-being. Stakeholders described an array of opportunities for creating a shared value of health that is rooted in traditional cultural beliefs, including leveraging deeply held beliefs about family, religion or spirituality, and holistic well-being of one's self and one's community. Stakeholders noted that it is often challenging, however, to establish shared values or shared definitions of health when cultural beliefs do not align with Western beliefs (e.g., fatalistic views of disease), when working with multiple cultural groups, or when there are varied levels of acculturation within a single group. The concept of shared values was also cited as very important for incentivizing health, and stakeholders shared strategies for motivating diverse partners to view a desired health outcome as relevant to them. This is particularly true for large-scale models, such as Pay for Success, which requires a very clear and agreed-upon shared health outcome and objective that all parties are working toward.
  • There is a need to acknowledge the importance of both individual and community health and well-being. Related to the notion of shared values, stakeholders reported a need for better acknowledgment of and balance between individual and community health and well-being. While community health can be challenging to define, broadly speaking, it refers to the “health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health” (McKenzie, Pinger, and Kotecki, 2011). Participants noted that in the United States, there is more emphasis placed on individual health and far less attention given to public health. One participant described this phenomenon as the “culture of me,” noting that this focus on the individual is perhaps a bigger impediment to achieving a Culture of Health than any multicultural issue. Stakeholders felt that this was a particularly important issue for organizational and government leaders, who control how funds and resources are spent.
  • Data can support the development of shared values. Data, and in particular the sharing of data, were cited as an important facilitator for building a Culture of Health in the community. Stakeholders noted, for example, that data on health and well-being, population characteristics, the utilization of health and social services, and the financial impact or burden of that utilization can help align diverse stakeholders around a priority concern and a shared definition of health. Additionally, data, along with storytelling to contextualize the data, were described as particularly influential tools for stakeholders to raise awareness of issues in their communities and make the case for funding.
  • Stakeholders spoke of equity as requiring integration, collaboration, and thinking about health equity from a broader perspective than just health or resolving health disparities. Stakeholders noted that addressing health inequities will not be fully solved by one organization, or even by one sector alone, and requires more than targeting or adapting interventions to disadvantaged groups or cultural contexts. Participants pointed to the importance of having policymakers as a partner in efforts to address health equity. Stakeholders also felt that addressing equity requires keen attention to the historical causes of health inequities and cited the importance of taking a social activism and community resilience approach when addressing root causes of health inequity, including variable access to important social services and such basic needs as affordable food, stable housing, and safe neighborhoods.
  • Equity is often addressed in silos, which impedes progress toward a unified goal of health equity for all. One challenge noted by stakeholders is that equity is often addressed, and funding is often distributed, in silos by racial, ethnic, or gender divisions, which impedes progress toward a unified goal of health equity for all. Stakeholders noted, for example, that collaboration between organizations serving different racial or ethnic groups is often hindered by funding mechanisms that divide or place limitations on how funds can be spent by racial or ethnic groups.
  • Structural inequity among organizations serving different communities can pose a barrier to progress. One challenge raised by stakeholders is that smaller organizations working to support disadvantaged and marginalized populations are often at a significant disadvantage relative to larger organizations or systems with respect to access, data, and resources. They noted that such structural inequities, in turn, can pose a barrier to addressing issues of health equity because the organizations that need to be at the table and be part of the solution have a relatively smaller voice.
  • Addressing equity takes time and effort. Beyond the time and effort required to ensure equitable access to programs and services, stakeholders shared that they and their colleagues are often involved in significant work outside of their day-to-day service provision to educate those in other systems (e.g., universities, health care systems, governments) on issues related to equity and approaches to addressing health inequity.

Themes Related to Addressing Culture and Cultural Differences to Promote Health and Well-Being

Building a Culture of Health necessitates recognizing and addressing the diversity of cultures in the United States. For the purposes of this work, we defined culture broadly to include groups based on ethnicity, tribal affiliation, or religion and groups of people with unique experiences, perspectives, and beliefs, including military-connected individuals, LGBT+ populations, and economically or geographically defined groups (e.g., residents in government-subsidized housing). Several themes emerged as particularly important for addressing culture and cultural differences in efforts to promote health and well-being:

  • Addressing culture presents opportunities and challenges. Stakeholders noted that they adapted programs and messaging to fit the language and cultural context of the populations they serve. Stakeholders also emphasized the importance of having a strong connection to the cultures within their communities of interest, through either staff representation or connections with trusted leaders in the community. Stakeholders noted, however, that having the time and financial capacity to properly engage the community and accommodate multiple cultures can pose a challenge. Another challenge is that “diversity initiatives” are often targeted to a particular racial or ethnic group and do not account for all of the cultural groups served by the organization. Stakeholders also pointed to possible unintended consequences of health campaigns tailored to specific cultural groups that inadvertently portray the groups in a negative light.
  • Members of specific cultural groups need to be given a voice in health-related activities to reach the outcomes they desire. Stakeholders we interviewed pointed out that community engagement is very important, and discussions with communities should include a diverse mix of people, particularly representatives of marginalized populations for whom the effort is being developed. Stakeholders highlighted the importance of regular engagement with the community, rather than one-time engagement. Stakeholders cautioned, however, that while advocacy organizations can provide a powerful voice to traditionally marginalized populations, these organizations can supplement but should not replace the voices of the populations of interest. Stakeholders also noted that it is important to consider steps to ensure sustainable inclusion in ongoing discussions about health.
  • Meaningful community engagement takes time and money. Although this theme was raised with stakeholders in the context of equity, it was also discussed at length in the context of community engagement. Trust-building was highlighted as a particularly important but very time-consuming process. This trust-building step, while critically important, is often not adequately funded for the amount of time and resources needed to do this well, and essential costs, such as the purchase of food and beverages, are often nonreimbursable expenses. Another challenge is that current grants or awards are often looking for results within a relatively short time frame (e.g., six to 12 months) and do not allow adequate time for trust-building to take place.
  • Systems are built around prevailing cultural norms, making it challenging for those working with specific cultures to make cultural adaptations. Stakeholders reported that many systems suffer from a strong degree of inertia, operating via “business as usual” unless powerful catalysts force a change. Consequently, when constituents or clients require culturally informed adaptations to be made to policies or ways of working, they often confront challenges. However, stakeholders shared ways in which some health systems are adapting through the availability of translation services and the relaxation of policies, particularly around birth and the end of life. Stakeholders noted that such adaptations take ongoing communication and personal connections with system leaders, which enable them to advocate for the needs of their clients, without undermining health system policies. Respondents who advocated for systems change often did so on their own time, working outside of their organizational missions to provide direct health services or programming to educate others in their communities about the customs and needs of the cultures they represent.
  • Organizational culture plays an important role in how well organizations address cultural differences. Stakeholders spoke to the importance of organizational culture for appropriately addressing cultural differences in health and well-being efforts. In this report, organizational culture is broadly defined and extends beyond wellness programs to include organizational commitments to diversity and inclusion among employees; efforts to improve job satisfaction; managerial processes; approaches to mentorship and performance reviews; and leadership and decisionmaking processes around mission, vision, and ways of working toward them. Several aspects of organizational culture were noted as important facilitators, including modeling health to the community (e.g., through food choices at meetings or policies that promote work-life balance) and ensuring that program staff at all levels reflect the diversity of the individuals they are working to serve. Stakeholders noted that it is even better when members of the community or clients are brought on as staff or advisors. Stakeholders described ways in which these points apply equally well to local-, state-, and national-level leadership, in addition to local organizations.

Themes Related to the Use of Incentives to Promote Health and Well-Being

Stakeholders described ways that incentives are being used to motivate health and well-being at an individual level (e.g., to get individuals to adopt healthier behaviors, such as exercise) and ways that incentives are being used to motivate organizations or other investors to promote health and well-being. Several themes emerged as particularly important for how incentives may be used to promote health and well-being.

  • Incentivizing individuals requires a mix of short-term and long-term incentives that align with individual preferences. Stakeholders who use incentives to promote health and well-being noted that there is not a one-size-fits-all approach to motivating individuals to take action. Those interviewed also noted the importance of time preference in structuring an effective incentive program, as people and businesses tend to act in their short-term interests, even though they may reap more benefit from a longer-term investment in health.
  • Closed-loop systems promote investment in individual-level incentives and facilitate sustainability. While discussing issues of investment in and sustainability of incentives, stakeholders referred to closed-loop systems or settings, in which those paying for the incentives up front are the same organizations or entities that see the cost savings or, in some cases, increased revenue resulting from the incentivized behavior change. Stakeholders pointed out, however, that there are opportunities to close the loop within organizations that may help to advance workplace wellness. In many cases, the part of the company responsible for health insurance coverage (viewed as a corporate expense) is not aligned with health benefits and wellness programs (viewed as a benefit).
  • Not all incentives are monetary. Stakeholders acknowledged that while monetary incentives play a role, personal goals may be an even stronger driving force for many individuals. Stakeholders noted that the key is to find the underlying motivation or reason why people are interested in making a change. Incentives can then be aligned to match each motivation. Identifying this underlying motivation is also critical for long-term sustainability of the activities because even if the incentive goes away, the underlying motivation remains. With respect to organizational or systems change, stakeholders noted that most impact investors (e.g., philanthropic individuals, banks) are also driven by health as a shared value and the opportunity to positively contribute to the development of community well-being.
  • Some incentive models, like Pay for Success (PFS), have the potential to act as a catalyst for systems change, but they require government buy-in. Stakeholders commented that while the incentives structure embedded in PFS is a catalyst for change, the incentives themselves do not ensure that the change will be sustainable. In fact, the incentives currently in play in PFS models, usually private investment, are not seen as scalable without a broader belief on the part of the government that it can and should pay for successful outcomes resulting from services, as opposed to the amount of services provided regardless of their impact. Other stakeholders described the ways in which PFS models have encouraged public-private-philanthropic partnerships where they did not exist before.

Implications and Next Steps

Collectively, these findings point to a number of implications and potential next steps for thinking about fostering a Culture of Health in the United States. These implications are relevant not only for RWJF but also for others interested in supporting movement toward greater, equitable health for all.

  • Identify best practices for developing a shared definition of health within communities. Health as a shared value was seen as critical to promoting a Culture of Health. Yet stakeholders reported that there is a need to balance a very broad definition of health that may be understood better by a more diverse set of stakeholders with a definition that is more narrow and thus more actionable. In the context of PFS, establishing shared definitions of target issues and outcomes across partners is a critical first step in the process. This suggests a need for best practices in developing a shared value of health at a local level that resonates across key stakeholders and community members but remains actionable. Literature related to stakeholder engagement and consensus-building identifies best practices for creating structures that allow for co-development of definitions and goals related to health and well-being. These include assembling diverse workshops with attendees from sectors including public health, city government, education, community-based organizations, and residents. Such best practices should be compiled into a toolkit for communities looking to build consensus around a definition of health.
  • Remove restrictions around diversity and equity efforts. Diversity-related initiatives often have a narrow lens (e.g., they are targeted to a particular racial or ethnic group). While this is often by design and reinforced by funding that is earmarked for vulnerable populations, stakeholders noted that this can inadvertently cause inequities if such efforts and funds cannot be more broadly applied. Such findings point to the need to design funding opportunities that have diversity and equity as a focus but are not overly prescriptive regarding how funds can be used. Initiatives focused on addressing disparities or health equity should be crafted in a way that enables prioritization of priority populations but does not prohibit the opportunity for other community members to utilize or leverage the programs or resources that have been developed.
  • Institutionalize practices that ensure ongoing input from marginalized populations. Community engagement, and particularly engagement of marginalized populations, is important to the success of any effort to promote health and well-being, as it helps to ensure that the programs, supports, and efforts developed align with the priorities and needs of that population. Stakeholders or other program staff should look to institutionalize best practices that ensure ongoing input from diverse and marginalized populations so that they have a continued voice at the table. Empirically based practices for empowerment, such as storytelling, and other identity narratives should also be spread and more widely adopted. Funders can encourage sustained community engagement by building it in as a requirement for funding or a marker of program success.
  • Create flexibility in funding structures for well-justified efforts to build trust among disadvantaged populations. Funding is often tied to a budget cycle or specific short-term grant period, even though laying the groundwork to build trust often takes months or years. Flexibility should be built into funding structures for well-justified efforts to engage communities in dialogue, trust-building, and health promotion efforts. For stakeholders, this may mean adjusting expectations related to when the program may see a return on this investment. Funders may want to consider grants in smaller dollar amounts with minimal restrictions and longer time frames to support this very important but time-consuming effort. Such support can encourage thoughtful and, as a result, sustainable engagement that can be leveraged to build a Culture of Health in the community.
  • Strengthen research around the role of organizational culture in promoting population health and well-being. Building a Culture of Health requires a better understanding of how organizational culture directly and indirectly affects population health and well-being. While there is ample research on organizational commitments to employees' health and wellness through mainstream workplace wellness programs, examples of promising organizational practices related to building and maintaining a functional multicultural workforce and mechanisms by which employers are able to promote a holistic sense of well-being among their employees outside of workplace wellness programs are not well-studied. Moreover, more work is needed to understand the influence of the organizational culture of health-related organizations on the impact of their efforts to improve community health. Understanding these factors can point to potential organizational policies or practices that may improve the health and well-being not only of employees but also of their families and the broader community.
  • Identify ways to help smaller organizations overcome structural inequalities. Local organizations committed to addressing health inequity or promoting the health and well-being of vulnerable populations often have fewer resources, reduced capacity to take on such efforts as data collection and sharing, and a smaller and already overstretched staff. These limitations create an often-insurmountable barrier to meaningful engagement in efforts to promote health and well-being in the community. These barriers also preclude such organizations from participating in some of the new PFS incentive models that require substantial up-front resources. Communities looking to address issues of equity should ensure that these smaller organizations are included in the dialogue. Funders and other stakeholders in a position to drive change should identify ways to help smaller organizations overcome structural and resource inequalities so that they can work as equal partners to address issues of health equity and promote the health and well-being of the populations they serve.
  • Institutionalize health promotion efforts in sectors other than public health or health care to sustain collaborative efforts. Incentives, either monetary or nonmonetary, may attract initial collaborators or investors but are fundamentally only catalysts of collaboration. Research supports the idea that cross-sector collaborators should be engaged to take a sustained lead on efforts for health and well-being to create the system changes necessary to build a Culture of Health. Successful examples of these efforts have engaged the school system and other non-health sectors to implement health programming and collect health data.
  • Develop strategic approaches and tools for use by those who are interested in pursuing work in the Culture of Health framework. The diversity of interests and needs across communities will mean equal diversity in readiness to pick up the Culture of Health framework and do something with it. Stakeholders may benefit from a set of strategic approaches and tools developed by RWJF to help them apply the Culture of Health framework in their own work to promote health and well-being in their communities. Such approaches and tools should reflect the key needs identified in this report—in particular, best practices for the development of shared values and long-term community engagement.

References

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

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