Editor’s note: This is part of a periodic series of Health Affairs Blog posts discussing the Culture of Health. In 2014 the Robert Wood Johnson Foundation announced its Culture of Health initiative, which promotes health, well-being, and equity. The initiative identifies roles for individuals, communities, commercial entities, and public policy that extend beyond the reach of medical care into sectors not traditionally associated with health. Health Affairs is planning a theme issue in November 2016 that will explore various aspects of the Culture of Health.
The Robert Wood Johnson Foundation’s culture of health initiative aims to start a movement to improve the health and well-being of everyone in America. The US continues to lag its global peers in overall health and in health equity. A dynamic movement focused on a culture of health could help address the societal inertia that has for decades stymied efforts to close these gaps.
But the pivot to culture also introduces perils. Culture is a tricky concept that both reflects and emerges from social inequalities. Historically, even well-meaning cultural analyses of social problems have drifted into victim blaming. In policy debates, “culture” is too often careless shorthand for “minority group.” In medicine and public health, cultural analyses may struggle to distinguish the biological or behavioral bases of behavior from their social context or structural causes. In short, when used injudiciously, culture can become a simplistic code word for group pathology or a means to stigmatize the vulnerable.
We are concerned that the culture of health initiative has left itself unnecessarily vulnerable to some of these perils because of how it defines culture. The initiative boasts a groundbreaking action framework, but that framework is built upon an anachronistic definition of culture. A better definition that acknowledges recent advances in the social sciences can provide a firmer conceptual and scientific foundation for building a culture of health.
Since the Foundation undoubtedly wants the idea of a culture of health to guide productive research, advocacy, and action, it makes sense to put some work into defining what is cultural about the culture of health. Done right, this definitional work can be more than an academic exercise and actually help make the culture of health a more powerful lever for change.
What is the Culture of Health?
The culture of health initiative encompasses four action areas that together constitute a framework for health improvement.
- Make health a value
- Foster inter-sector collaboration
- Create equitable communities
- Improve health-system integration
This is a dynamic recipe for fostering culture-driven change. However, this thoughtful framework rests upon a classic and antiquated definition of culture: “sharing and alignment of beliefs, attitudes, values, and actions.”
Over the last four decades, this shared belief model of culture has been criticized and largely abandoned by researchers who study the science of culture. It proved too vague to guide scientific inquiry; it erroneously cast people as passive consumers of culture rather than culture-creators; and it stressed how culture is shared, coherent, and aligned when in reality culture is typically messy—contradictory, convoluted, and often inarticulable. Perhaps most crucially for the culture of health initiative, shared-belief models fail to tie culture to social inequality and remain mute about the link between culture and individual-level cognitive processes and behavior.
Contemporary, inter-disciplinary definitions of culture can correct these shortcomings. They do so through a three-part definition of culture.
- Culture includes the personal and group-historical experiences that shape how people experience the world and what they want from it.
- Over time, people assemble a “cultural toolkit” that includes practical strategies for how to get things done in the world.
- Culture’s shared symbols and understandings lubricate social interactions and allow for the creation of communities and social institutions.
These contemporary understandings—grounded in empirical research ranging from brain scans to urban ethnography—provide a solid foundation for research, training, and action to develop a culture of health. Examples from our own scholarship illustrate the utility of this three-part cultural model.
A Tripartite Culture Of Health
In The End Game: How Inequality Shapes Our Final Years (Harvard University Press 2015), Abramson uses thousands of hours of ethnographic field observations as well as in-depth interviews in four urban neighborhoods to show how both culture and structure profoundly shape the health behaviors of a diverse sample of older Americans in community and institutional settings. As a first step in careful cultural analysis, Abramson charts the structural differences, e.g. in wealth and health-related resources, that distinguish the neighborhoods he studied. This provides the necessary context for his analysis of the “puzzling” neighborhood patterns that require understanding culture.
The experiences of Ray and Bill illustrate the shared personal and group-historical dimensions of culture. Ray uses holistic practices to deal with aches and pains whereas Bill defers to his physician. Both have insurance and resources to pursue either treatment. Both value health and longevity. Bill, a Latino man, sees his doctor as facilitating this. In contrast, Ray, an African American man with negative experiences with hospitals (and historical memory of Tuskegee), sees medical institutions as little more than a “hustle” to make money at patients’ expense. He views himself as the sole warden and expert on his health.
The cultural toolkit provides a window for understanding the experiences of Jane, an educated white cancer patient with myriad resources. Jane regularly skipped chemotherapy, anomalous behavior for someone with her demographic profile. Moreover, Jane understood the consequences of skipping treatment, and she had access to quality care. However, her cultural toolkit, honed over the course of a lifetime, was designed around the importance of enjoying life.
Jane and her social circle had numerous rituals built upon a foundation of carefree enjoyment. Their kit included few tools to make longevity a meaningful experience or to collectively honor the suffering one endures during chemotherapy. Thus, Jane continued to come together with her social circle to enjoy life in each other’s company, but her cultural world did not include shared practices to endure the rigors of chemo simply to live longer.
The experiences of Stuart Carroll illustrate how culture lubricates social life inside social institutions, including our health care system. Stuart participated in our National Institutes of Health-funded Patient Deliberation study, which used ethnography to examine how patients with advanced cancer made treatment decisions. Well-educated and wealthy, Stuart felt strongly connected to his care team. In describing his approach to treatment decision making, he said, “If I find somebody that I have a lot of faith in, I just go with them.”
Stuart wanted to click with his oncologist “personality-wise” and preferred not to do a lot of research on his own. When Stuart and his wife came to see the oncologist, the personality “click” was apparent. The visit often started with conversation about recent travels or outdoor activities such as bicycling or skiing. These warm personal conversations affirmed that Stuart and the oncologist belonged to the same community, and they appeared to establish a foundation for a trusting and effective patient-provider partnership within the clinic. It was no surprise that Stuart followed his oncologist’s treatment recommendations and even participated in a clinical research study that she recommended he consider.
Fostering A Culture Of Health
These cases illustrate the dynamics of culture and its relationship to patterns of health and health care. The tripartite definition of culture helps us understand that culture shapes what is desirable, what seems reasonable and practical, and how people pursue that which seems possible. A shared-values model of culture is elegant and intuitively appealing, but it provides little leverage for understanding the complex cultural dynamics of contemporary society.