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Healthier Communities: Connecting measures of upstream factors to address structural equity

Written by Tamara Dubowitz, Laurie Martin and Anita Chandra on January 24, 2020

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There are three separate, but related challenges to our ability to translate measures portfolios like Culture of Health into sustainable action to advance health equity that must be addressed.

The Robert Wood Johnson Foundation recently released their updated Culture of Health measures, to track movement toward a nation where everyone, regardless of background or zip code, has a fair and just opportunity for health and well-being. Last year, we wrote about the measures on this blog, demonstrating alignment with Build Healthy Places Principles for Building Healthy and Prosperous Communities.


The principles, synthesized and collated by Build Health Places Network, advocate for community-led solutions that embed equity, collaborate across sectors, and embrace a holistic view of building health and prosperity which strongly aligns with RWJF’s commitment to building a culture of health and addressing health equity. We also note the benefits or ‘health return on investments’ of approaching community investment cross-sectorally. While the Culture of Health measures are illustrative and primarily focused on tracking national progress towards a greater value for health, these measures are meant to inspire discussion about the relationship of structural factors that influence health and well-being. In addition, by putting upstream influences together as bundled drivers of health outcomes, the Culture of Health measures portfolio motivates a new discussion of health equity. But there are three separate, but related challenges to our ability to translate measures portfolios like Culture of Health into sustainable action to advance health equity that must be addressed if we are to achieve its vision of healthy, equitable and more prosperous communities.


First, it is unclear if the development of health policies and other strategies are truly employing a complex, adaptive systems approach[*]. Ensuring every individual has an equitable opportunity to achieve their highest form of health and well-being requires us to view health systems as complex, because there are many connected parts of the system (e.g., human, physical, organizational). It also requires us to acknowledge that the health system is adaptive because its components (e.g., health care, policymakers, individuals) are frequently adjusting their behavior to try to achieve their own goals, which may or may not correspond to the ultimate goals we have for the system as a whole (e.g., improved health and well-being). Currently, it is challenging to develop solutions that take into account both the complexity and adaptability of the system. This means stakeholders revert to addressing issues in silos.  It is unclear if health researchers and policymakers have the tools to consistently employ a complex adaptive systems approach in their work. The Culture of Health measures set is one step to viewing the system components together because the measures capture different parts of the broader health system and can be used to reflect these connections.


Next, it is difficult to implement a historical, cumulative and lifecourse approach to both practice and policy. There are system-level inequities and historical factors that influence multiple drivers of health at the same time. Yet these are often addressed in ways that do not reflect the full implications of the factors and ways which may reinforce existing inequities. For example, federal housing policy (e.g., redlining) implemented over time created and reinforced multiple levels of inequity in the United States, including racial residential segregation. Such policies created outcomes including displacement, as well as disproportionate location of retail, economic and educational opportunity. Such conditions have multi-generational impacts, creating a cycle of poverty and poor health. Models like community allostatic load that begin to account for disparity and injustice over time, across the lifespan of individuals and a community, must be part of research and policy development. The Culture of Health measures set includes these types of upstream drivers of health, such as early educational opportunity and housing affordability, and encourages us to view these upstream influences together and over time. But it is important that the measures set is used for this purpose and combined with other information to unpack the effects of cumulative influences of these drivers of health.


Finally, sustainable action to advance health equity requires difficult discussions of tradeoffs and choices and an understanding that many drivers of health are linked. We often miss a real dialogue about the important links between drivers and how investments (or lack of investments) in one area may have cascading impacts on health and health equity. For example, when considering policies that encourage housing affordability, we should consider the implications of such policies on access to other health-promoting factors including walkability, air and water quality, early childhood education and economic opportunity. These are all measures in the Culture of Health measures set. Using another example, efforts to improve access to early childhood education may be shaped by transportation systems and the economic opportunity environment. Making early childhood education policy without regard to transportation systems or the economic and labor market may be limited in its impact. But, communities are not going to be able to invest in every promising solution. Tough decisions will need to be made about where investments are made and who may not receive the benefits. Examining measure impacts together can be one way to sort the tradeoffs of health investment choices.


The above challenges are tough, but not insurmountable. Connecting the Culture of Health measures with Build Healthy Places Principles for Building Health and Prosperous Communities can be an important part of this effort. Taken together, connecting principles with measures like these can monitor how potential strategies to improving health and well-being are informed by the many players within our complex health system, consider the cumulative and impacts of those strategies, and take into account the important trade-offs, particularly from the perspectives of those who stand to gain (or lose) the most.

[*]system in which the interactions and relationships among components are dynamic and at the same time affect and are shaped by the overall system.


Tamara Dubowitz is a senior policy researcher at the RAND Corporation and faculty at the Pardee RAND Graduate School.  Her work has utilized both quantitative and qualitative methods to examine individuals within their social and structural contexts.


Laurie Martin is a senior policy researcher at the RAND Corporation with over 20 years of experience in the field of epidemiology, public health andhealth policy. She is also a member of the Pardee RAND Graduate School faculty.


Anita Chandra is vice president and director of RAND Social and Economic Well-Being and a senior policy researcher at the RAND Corporation. Throughout her career, Chandra has engaged government and nongovernmental partners to consider cross-sector solutions for improving community well-being and to build more robust systems and evaluation capacity.