Factors related to health civic engagement: results from the 2018 National Survey of Health Attitudes to understand progress towards a Culture of Health

Evidence on the role of socioeconomic and environmental determinants in shaping individual and community health has been building for many years [1‐3], and it is increasingly understood that addressing the structural drivers of health outcomes requires broad-based efforts that reach beyond the traditional health care and public health systems. This includes significant reallocations or realignment of resources [4], and changes in laws, policies, and regulations [5]. In democratic systems, civic engagement – through formal voting, advocacy, and involvement in civic organizations – is one way in which people ensure that governmental and nongovernmental actors work to change laws and policies or take other actions that promote healthy communities. In addition to providing a potential avenue for system change, civic engagement has been shown to be positively associated with physical health [6‐10], health behaviors [11, 12], mental health [8, 12, 13], and well-being [14, 15]. The specific impact may vary across specific health conditions [16, 17]. Nonetheless, these associations hold across various forms of civic engagement, including voting, membership in community organizations, and direct community service [18].

The role of civic engagement in both systems-level and individual health is reflected, among other places, in the Culture of Health action framework advanced by the Robert Wood Johnson Foundation [19, 20], which is founded on a vision in which “everyone in our diverse society leads healthier lives now and for generations to come” and is premised that accelerating health improvement requires broader collective action and cultural and social mobilization. The Culture of Health action framework [19] identifies civic engagement as a key driver needed to make a health a shared value, which is one of the framework’s four action areas. Civic engagement is viewed as a critical process through which “people develop and use knowledge, skills and voice to cultivate positive change,” and translate the value they place on community health into action. According to the framework, civic engagement is linked to two additional drivers that help support and conduct civic engagement [18].

One of those drivers is mindset and expectations, or the way in which individuals and communities frame the importance of health and well-being, the factors that influence it, and the shared role of individuals and organizations in actively promoting health and well-being [21]. Indeed, previous research in political science suggests that individuals are more willing to engage civically to promote public goods that they place a high value on [22, 23]. Moreover, other research suggests that how individuals understand and frame the causes of and degree of personal responsibility for health conditions such as diabetes (e.g., as the result of individual behavior vs. environmental conditions) is linked to their willingness to support investments in community health [16, 24, 25]. The importance of mindset and expectations in health is also supported by research and practice evidence from social network theory, community resilience, narrative theory, well-being science, and asset-based community development, each field articulating pathways by which individual and community sentiment about an issue is formed and addressed [21, 26, 27].

The other driver is sense of community. This driver captures an individual’s sense that he or she has a personal connection to the community (membership), that the community matters to him or her (belonging), and he/she has shared experiences with others (events, memories) in the community. Sense of community is positively associated with personal well-being and is framed as another key driver of making health a shared value [26]. Sense of community has been shown to be significantly and positively associated with community and civic participation in adults [28‐31].

To date, the literature linking civic engagement, mindset and expectations, and sense of community remains somewhat limited, and there has not been much examination of the link between these two drivers and civic engagement specifically related to health activities. There has also been limited work around the relationship of health civic engagement to other factors including perceived barriers to taking action to invest in community health, and perception of how external organizations and agencies may have an impact on community health. Given that the Culture of Health action framework also builds on the idea that both individual and community action is needed to improve health, well-being, and health equity, understanding the public’s perceptions about readiness to engage individually and collectively is key. To illuminate those relationships, our team used the 2018 National Survey of Health Attitudes fielded by Robert Wood Johnson Foundation (RWJF) and RAND to address two aims: first, to describe patterns in health civic engagement in the U.S. population and, second, to explore the relationship between health civic engagement, sense of community, valued investment in community health, perceived barriers to taking action to invest in community health, and the perception of the role of external organizations and agencies in community health, net of other social and demographic factors known to be related to civic engagement and potentially to health civic engagement.

We build upon a new and innovative data set on health attitudes in the U.S. to cross-sectionally analyze factors that account for variations in health civic engagement. As part of a larger effort to track progress in building a Culture of Health [18, 19], RAND worked with RWJF to design and field the National Survey of Health Attitudes, aimed to provide insight on how people in the U.S. think about, value, and prioritize health and consider issues of health and health equity. The survey was initially fielded in 2015, and an updated version was fielded in 2018. The later version serves as the focus of this study with more detail provided elsewhere [32, 33]. Both versions were administered online and survey data for 2018 was collected from 7187 respondents via the RAND American Life Panel (ALP) and the Ipsos KnowledgePanel. The sample is based on nationally representative internet panels whose members are recruited via probability-based sampling methods. A central goal of the survey was to measure making health a shared value, within the Culture of Health action framework. As such, the survey included questions about how the public views the value of investing in community health, the perceived sense of community, and health civic engagement. The survey also contained other items including measurement of barriers to taking action to invest in community health as well as perceptions of what has an impact on community health.

Health civic engagement was measured by a set of questions that asked about activities in which individuals are involved that might influence government and civil society actions about health, including two questions about voting for a candidate based on his/her position, and questions about contribution of time or money to organizations working to pass health laws or policies, lobbying for a health-related causes, and attending meetings or working with neighbors to fix community problems (Table 1). Sense of community, in turn, was measured via a set of 16 items (Full Sense of Community Scale) including those from the Sense of Community Index (SCI) [36], which consists of two subscales – membership (six items) and emotional connection (six items) and four additional items that were specifically designed for this survey to capture health-related sense of community and community capacity to improve health (Table 1).

Valued investment in community health was captured with five questions about how individuals prioritize the importance of health opportunity and access via greater investment in improving access to healthy and affordable food, safe spaces for outdoor activities, safe housing, and different modes of transportation (Table 1). Because individuals may be less likely to engage civically when they perceive significant barriers to doing so [23, 38, 39], we also examined barriers to taking action to invest in community health. This included items eliciting perceptions about whether individuals know how to get involved, whether that involvement will make a difference, and whether they think that meaningful influence over community health is only limited to certain community groups.

Other variables we considered included self-rated health [40], financial problems because of or experience with a chronic health condition, and burden of caring for others. Years living in the community provided a proxy for the rootedness in a community. Several decades of research suggest that willingness to vote or undertake other forms of civic engagement is associated with multiple socioeconomic factors [41, 42], thus we included measures of employment status, educational attainment, marital status, race/ethnicity and city size of residence as multiple socioeconomic and demographic variables that could be related to health civic engagement. Finally, age and gender were included as covariates given prior work showing the influence of both age and gender to civic engagement [43].. The main measures used in our analysis are listed in Table 1.

As expected, respondents reporting a strong sense of community and those who prioritize community investments in health more frequently reported engaging civically around health, controlling for variations in measures of socioeconomic status, perceived barriers, and a host of other variables. This is consistent with the view, embodied in the Culture of Health action framework and grounded in the literature, that individuals who view health as an issue requiring collective or community investment and who identify strongly with their communities are more likely to engage civically specifically to address health issues [21, 44, 45].

The findings also have potentially interesting implications for how we understand the barriers to health civic engagement. We did not find clear evidence that those perceiving barriers to act to improve community health (e.g., not knowing how to get involved, not believing that involvement makes a difference) were less likely to engage civically around health, suggesting that addressing these attitudinal barriers may not be enough to activate health civic engagement. The limited literature in this space to support or contradict our finding highlights the question of how to inspire and motivate health civic engagement.

We did find evidence that one’s own poor health, was associated with lower levels of civic engagement around health. This aligns with a number of earlier findings [18] from the U.S. and elsewhere suggesting that those in poor health or with disabilities are less likely to vote or engage civically in other ways. In one study, people with disabilities were 20 percentage points less likely to vote than people without disabilities of similar demographics [9]. In another longitudinal study in Ireland and Britain, individuals with poor self-rated health were significantly less likely to report voting in past general elections [46]. While the direction of the causality is not always clear, it might point to the need to broaden access to mail-in ballots and other measures to lower the burdens of political participation. It also suggests that activities to expand health civic engagement may need to address the unique challenges faced by those with chronic health conditions, including, for example, difficulty with mobility and regular participation in activities which require travel. Respondents who reported that poor health of a friend of family member impacts their life, those who reported financial problems due to health, and those who reported helping others who were ailing were all more likely to be civically engaged in health-related activity. This suggests that some degree of experiencing a health-related challenge or barrier may motivate individuals to take action. Without being able to assess the direction of causality, this does suggest the possibility that the burdens of caring for others may be a catalyst for health civic engagement, or perhaps that those who help others in need are also more inclined towards involvement in the community.

Finally, consistent with many other studies of civic engagement and political participation, we found that those with higher levels of education and higher income were more likely to engage civically around health. In light of previous research cited above linking civic engagement with individual health [16, 47, 48] benefits, such findings are an important reminder that the health and well-being benefits of civic engagement do not accrue equitably to all. First, as efforts are underway to advance health equity, these findings further underscore the challenges in engaging Americans in health civic engagement. Second, the health benefits of civic engagement are also not experienced equally. We did observe a notable finding worthy of further investigation: African American/black respondents were more likely to engage on health issues civically than white Americans, while Asian respondents were less likely than all other groups, adjusting for all other factors. There are many potential explanations for this disparity (data not shown), given that in the broader survey, we also observe the same racial/ethnic differences in willingness to invest in community health (only 17% of African Americans/blacks would not invest in any community health priorities vs. 33% of white Americans). It could be that African American/blacks believe there is a greater need to engage civically for health, or there may be a stronger view that this approach to health improvement will be more effective.

This study offers important new insights about health civic engagement and the role of community health attitudes and sense of community. Still, the findings are subject to a few limitations. First, the cross-sectional nature of the data used in this analysis means we cannot assume the observed relationships between civic engagement, sense of community and value placed in community health investments are causal. Perhaps more importantly, though, the study was unable to assess the extent to which individual civic engagement impacts the health of communities through fostering changes in socio-economic drivers of health, or the possibility that civic engagement may promote policies or other collective actions that compromise the health of some groups (e.g., lobby for weakening of environmental protections). This also reflects a broader tendency in the current research (e.g., 43, 44) to focus on health impacts on those who are engaging in civic activities [19].