Just How Do We Define a “Culture of Health”?
What determines the health of nations? The answer is not clear: individual behaviors may seem dominant but, on closer inspection, yield to a complex interplay of genetics; economic constraints; cultural norms; social interactions; one’s prenatal environment; and many other interrelated, sometimes time-delayed, physically distant factors. Given this conundrum, a useful approach is an ecological perspective. Consider individuals nested within many overlapping, sometimes competing, sometimes supporting systems. Taken together, these systems form a culture of health in which each of us is embedded. Our new research project at Altarum Institute on the culture of health will seek to understand this complex social and ecological context in which population health and health-related behaviors are created and altered.
The starting place for our research is the basic question, “What do we know about population health?” The first point is to distinguish individual health status from public health and population health. If individual health is about whether or not you are sick or at risk of becoming ill and public health is about how to prevent disease at the community level, then population health is about the larger questions of how to enable people to be healthy and productive in their whole lives. It encompasses areas traditionally far outside the sphere of public health and medicine, such as transportation and commuting patterns. Transportation and commuting patterns create safety risks and stress for pedestrians and drivers; create localized air pollution; discourage walking; and, more subtly, simultaneously reinforce and discourage aspects of informal and formal social interaction and engagement, all of which have a complex impact upon health.
In many ways, a population health perspective means a return to the roots of public health. One hundred years ago, U.S. public health officials dramatically altered physical infrastructure to improve sanitation and hygiene, drain swamps, and improve housing. As a result, diseases like cholera, diphtheria, typhus, and malaria were virtually eliminated. By altering the ecology, disease was prevented at the “primordial” level. Population health now is necessarily somewhat different, even as the concept of “primordial prevention” applies: The interventions are in how we interact with one another; what and how much we eat; and other unintended consequences of automobile culture, sedentary lifestyle, and other relatively new emerging threats.
Unhappily, we actually know very little about current levels and rates of change in population health and its determinants. We do have some measures of individual health, as well as a number of new national initiatives to report on health measures for states and other localities. But what about entire populations? A new initiative from the University of Wisconsin Department of Population Health Sciences and the Robert Wood Johnson Foundation has begun this kind of population health monitoring and feedback at the county level. The MATCH program grows out of earlier work on individual Wisconsin counties but will encompass the entire United States. Look for more discussion on the MATCH program and our own efforts to display and visualize population health on the Health Policy Forum in the coming months. There are a number of other efforts under way both within the U.S. and internationally to begin to measure the health of populations.
The second question, once we have some understanding of population health itself, is, “What do we know and understand about the determinants of population health?” The word “determinants” itself is problematic: Health is surely not “determined” or cast in stone but is the result of interacting risk factors, environment, genetics, chance, and individual choices. By “determinants,” then, we mean broad risk factors that affect populations. One such factor is education at both the individual and group levels. Individuals with higher educational attainment have better health status, and communities with higher average educational attainment have better average health.
The pathways from educational attainment to improved health status are not clear: Work by David Cutler and Adriana Lleras-Muney indicates that it could be, but probably is not, due to differences that education causes in people’s decision-making and time horizons. It definitely appears related to income and social status. It might be related to a sense of individual and collective efficacy or control. The reason that the pathway matters is that it means that education will have (1) a better effect when combined with culture or environmental contexts that reinforce that pathway and (2) a more limited impact where these supports are lacking. At Altarum, we are undertaking a large research and analysis effort to help further our understanding of these pathways and mechanisms using new methods to match geographic data and group-level data with individual behavioral data. Our research here is very preliminary.
That the health policy research community does not know much about such pathways, despite decades of work, says something about the data available, the methods used, and the very nature of the problem. Communities and their health are more than just complicated and full of surprises. Formally, they may be examples of “complex adaptive systems” – ecologies with a complex web of feedback loops over time and spatial dimensions. These loops mean that direct causation may be difficult or impossible to demonstrate, that history can be as important as current levels or capacities, and that what we normally think of as the background (context and details of implementation) may actually be the key success factor.
What we should do in the face of such complexity and the potential uniqueness of each case is not exactly clear. At Altarum, we are proposing a variety of methods for looking at communities and social interventions, including some unique approaches using tools like agent-based modeling. While we cannot say for sure what the end result of this research will be, it is clear from where we are starting that there will be much to discover and share.
All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Read more.
Zack Cooper
Serena Vinter
Joanne Kenen