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Achieving a Culture of Health: Steps for Engaging State Government
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Achieving a Culture of Health: Steps for Engaging State Government

Dennis P. Scanlon, PhD; Jocelyn M. Vanderbrink, MHA; Mark Sciegaj, PhD; and Brigitt Leitzell, MS
Based on findings from a 2-state exploratory study, the authors articulate research-informed action steps for promoting state government roles in the pursuit of a culture of health.
ABSTRACT

Objectives: Based on findings from a 2-state study, the authors articulate research-informed action steps for promoting state government roles in the pursuit of a culture of health (COH). The action steps are meant to generate dialogue about what can reasonably be expected from state governments when thinking about health more broadly.

Study Design: A 2-state study based on secondary document review and semistructured key informant interviews.

Methods: Archival data were collected and synthesized to create in-depth policy summaries that provided background information and guided the development of semistructured interview protocols. Interviews with state-level stakeholders were recorded and transcribed. Research team members reviewed the transcribed data for major thematic categories and then drafted thematic memos that identified categories that facilitated (or hindered) the state’s movement toward a COH, the findings from which were discussed among all authors. Based on the exploratory findings, the authors then articulated a set of research-informed action steps for engaging state governments in pursuing a COH.

Results: The state governments of Oregon and Pennsylvania differ in their approaches to and success in ensuring the health of their citizens, and both face similar challenges in their efforts.

Conclusions: A COH may be easy to conceptualize, but it is by no means easy to accomplish. States face many barriers in pursuing a COH. By understanding both barriers and facilitators of developing a COH and arming themselves with research-informed action steps, those both inside and outside of state government will be better prepared to pursue a COH through state engagement.

The American Journal of Accountable Care. 2019;7(3):4-11
Five years ago, the Robert Wood Johnson Foundation (RWJF) challenged the nation to build a culture of health (COH) to improve health, well-being, and equity.1 To guide this shift from a medical care focus to a broader conceptualization of health improvement and reform, RWJF identified 4 interdependent action areas: (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 COH model is not intended to dictate a specific pathway for action but instead to identify the necessary components of effective action.2

Moving toward RWJF’s vision requires engagement, commitment, and a clear fiscal imperative from multiple sectors of society, including multiple levels of government (eg, federal, state, county, municipal, tribal). Although conversations about building a COH are gaining momentum nationally,3 limited studies have been published to date that specifically address the roles or motivations (or lack thereof) of state governments in pursuing a COH.4 More frequently, the challenge of state-level political gridlock has been noted as a barrier to the innovation and change needed to support a COH.5

In this paper we summarize findings from a 2-state study (Oregon and Pennsylvania) in which we assessed state government action in the pursuit of a COH. Although they differ in population size and geographic location in the country, Oregon and Pennsylvania have a similar mixture of rural and urban populations, with the US Census Bureau classifying 19% of Oregon’s 3.8 million residents and 21% of Pennsylvania’s 12.7 million residents as rural.6 We combined extant knowledge of these 2 states from the evaluation of RWJF’s recently concluded Aligning Forces for Quality (AF4Q) initiative with new documentation, interview data, and author insights in order to arrive at our conclusions, which we present here as research-informed action steps for promoting state government roles in the pursuit of a COH.

METHODS

Archival data were collected and synthesized to create in-depth policy summaries that provided background information and guided the development of semistructured key informant interview protocols. Archival data included materials collected and produced as part of the evaluation of the AF4Q initiative7-9; websites; state health assessments; state health improvement plans; State Innovation Models (SIM) grant materials; state government and departmental organizational structures, budgets, and strategic plans; and materials on nongovernmental state-level organizations working in social determinants of health (SDOH).

The summaries provided a general overview of (1) the political climate of each state government, including its recent political history; (2) state-level priorities, including each governor’s priorities and priorities related to health, healthcare, and SDOH; and (3) where evidence existed of multiple state agencies working together to address COH-related issues. Additionally, the summaries raised issues to explore during key informant interviews.

Semistructured interviews, which were tailored to each respondent, probed if and how major state-level agencies address COH-related issues, the extent of interagency governmental collaboration, and state collaborations with nonstate actors (eg, regional and state-level nonprofit organizations, local governments). Potential respondents were selected based on their roles or were suggested by government employees. Respondents served as deputy secretaries, advisors, directors, coordinators, or policy analysts in state government or held senior leadership positions in nongovernmental organizations. In total, 17 interviews were conducted (8 in Pennsylvania, 9 in Oregon). All interviews were recorded and transcribed.

Several members of the research team reviewed the transcribed data for major thematic categories. Memos were written for each transcript that grouped data by the identified themes. All memos were reviewed by a second analyst and thematic categories were refined based on new insights. Once the interview memos were completed and reviewed, preliminary insights and findings were written and disseminated to the research team for deliberation, which resulted in a high-level evaluation of each state’s undertaking in the 4 COH action areas, from which the authors developed research-informed action steps for promoting state government roles in the pursuit of a COH.


 
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