May 30 2014
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A Table for Change at the Center of a 'Culture of Health'

Justin List, MD, MAR, is a Robert Wood Johnson Foundation/VA Clinical Scholar and primary care general internist at the University of Michigan. His research interests include community health worker evaluation, social determinants of health, and improving how health systems address the prevention and management of non-communicable diseases.

Justin List

Recently, the Robert Wood Johnson Foundation announced a shift from its focus on health care toward building a “culture of health.” As a buzz phrase, “culture of health” carries promise to transform how Americans think about health, but it carries a risk to mean so many things as to dilute its meaning. For example, I saw a recent picture on Twitter where two people anonymously answered “what does the culture of health mean to you?” with “feeling guilty for not taking a sick day.” If we think of the culture of health as a web of health experiences, that answer might be best placed somewhere along an outer ring of the web. But what would be at the center of the phrase’s web of meaning?

To start, a culture of health goes beyond the health care system and incorporates every day experiences and choices people make that affect their health. Building a culture of health means not only looking at clinics and hospitals under the microscope but also looking more closely at how our communities impact health. The culture of health concept offers every person in America a larger vision and momentum for changing how Americans experience health, and it requires everyone’s participation to make change happen.

As a physician, I struggle with what role my colleagues and I play in building a true culture of health. Recent obesity statistics may suggest we’re not so effective. Obesity rates fell for children ages 2 to 5 years old since 2003-2004, according to researchers from the Centers for Disease Control and Prevention. Meanwhile, obesity rates remained essentially unchanged for most other age groups and even higher in women in over 60. From the health system side of the equation, why might that be?

Health care professionals work within a fragmented health care system with too little time available to comprehensively address how patients think about and experience health outside the clinic door. We’re up against city and town layouts that don’t promote physical activity and a food environment that often makes healthy eating a more difficult option. But I’m not just a doctor. I struggle with the same choices. Will I pass up the convenient cookie or brownie at a meeting where I’ll be sitting for two hours? Will I exercise after a long day where I’m sitting much of the time? Simply put, we live in a “built environment” that needs radical change to promote healthy choices in the most mundane moments of the day.

A baby-boomer patient of mine stated it best about the culture of health: “Doc, it’s just so hard to make healthy choices in our society.” He wants to try out a vegetarian diet, but he lives in a food desert, which is a low-income area far from supermarkets. He wants to exercise more, but coupled with a brutal winter, bad roads, and no nearby gym, he has limited options. His observation that “we really have to drive everywhere in our country” is something I hear across the spectrum of income levels and backgrounds. He told me that he wasn’t trying to make excuses but that the easier choices before him were the unhealthy ones. These two factors alone—access to food, exercise environment—are just a few of his hurdles for improving his health.

More people need to engage with one another to make choosing health the easier choice.

He also doesn’t have a social network around him that would motivate change. I can recommend dietary changes and exercise to my patients for addressing obesity, but how useful is that recommendation when the current landscape of food and environment complicates their efforts? Who is responsible for creating a culture of health?

It’s true; health professionals have their hands full in the clinic managing disease. Tackling what we call “social determinants of health,” such as food insecurity, poverty, environment, and housing, requires even more work. When we improve these determinants, we build a stronger culture of health.

But many must do this work if we are to create a robust pro-health culture. Imagine a team of health professionals, social workers, urban planners, advertisers, community organizers, city and state policy-makers, business leaders, and everyday citizens assembling together to change our environment—indeed, to change the physical structure of our communities in some cases. It’s happening in pockets around the country. Public school menus are becoming healthier in parts of Chicago and greenways are developing in Detroit to promote ease of individual and group exercise. Programs like Cooking Matters help teach families healthy cooking on budgets. These collaborative efforts encourage healthier choices, but as our obesity statistics show, we have more to do.

Building a culture of health requires getting everyone at the table for change. Some strategies to improve health will work better than others. We’ve seen heated controversy and mixed research results around a soda tax in New York City, for example. But public health officials, big business, and concerned citizens need to be at that table. Let’s couple smaller changes like building parks and urging healthier snacks at meetings with bigger changes in what foods are mass produced and sold and how we upgrade our communities to encourage more activity. Our greatest chance for success at building a rich and meaningful culture of health, of truly creating a pro-health environment, means more people need to engage with one another to make choosing health the easier choice across the country.

Tags: Clinical Scholars, Social Determinants of Health, Voices from the Field