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Building a culture of health

Researchers analyze Healthy Hawai'i Initiative to gain insight on developing future health initiatives

Reducing rates of chronic disease through health promotion strategies can help build healthy communities and keep rising health care costs in check. Public health researchers and practitioners have long sought to build healthy communities by making healthy food more accessible, improving opportunities for people to be active and leading efforts to reduce tobacco use. Such public health initiatives often involve many different parties ranging from health care practitioners and public health researchers to community leaders. However, research on the complexity and scale of efforts to build a culture of health in multicultural communities is still somewhat limited.

To address this gap, Jay Maddock, PhD, professor at the Texas A&M School of Public Health and chief wellness officer at Texas A&M University, worked with a team of researchers from the University of Hawai’i to analyze the Healthy Hawai’i Initiative (HHI), a 20-year-old health promotion and disease prevention program based on the social ecological model in the highly multicultural state of Hawai’i. Their research, published in the journal BMC Public Health, relied on interviews with key participants in the design and implementation of the program, and analyzed the HHI’s successes and challenges to gain insight into how to develop future initiatives.

At the core of their research was a model known as the Culture of Health Action Framework (CHAF) that the Robert Woods Johnson Foundation developed in 2016 to guide the creation of health initiatives. The CHAF focuses on four key areas: making health a shared value for social cohesion, collaboration between different groups and sectors, creating healthier and more equitable communities and strengthening the integration of health services and systems. By working within the context of the CHAF, the research team can gain an understanding of how the HHI brought about policy and environment changes and develop insights into how the CHAF’s four focus areas interact.

Through their interviews and analyses of supporting documents, the researchers shed light on how the HHI’s goals were achieved and how the program contributes to a culture of health. The first common theme found in the research was the importance of making health a shared value. Creating a set of shared goals and values helped guide the development of policies and environmental changes. However, the interviewees noted that these shared goals had to include more than just the initial stakeholders, with the HHI relying on coalitions built around different health topics like childhood obesity and smoking. In addition to collaboration between researchers, practitioners and community leaders, the interviews highlighted the importance of working with legislators to bring about changes to policy or the built environment. Another theme that arose in the interviews was how changes in cultural norms are a crucial part of making health a shared value. For example, peer influences can play a crucial role in changing dietary habits.

“This effort shows the impact of working together over the long term to create sustainable impact,” said Maddock, who led the evaluation of the HHI from 2000 to 2015. “Creating a culture of health is not something that happens overnight but takes a dedicated group of people years to achieve.”

The study’s findings point to how important it is to develop health as a shared value and highlight the need for cultural shifts to bring about change. The need for collaboration between many different actors is another key observation from the study. The findings add to the body of knowledge in health policy and are in line with previous research. This study also highlights the complexity of changing health outcomes and how approaches aimed at the whole population can improve health overall while making inequities even more apparent. This shows the need to balance public health approaches to address health disparities while attempting to improve population health outcomes.

By analyzing the 20-year history of the HHI, the researchers have identified key points for other communities to consider when developing similar health initiatives. The study also showed that the CHAF, which is meant to be used when developing programs, can be useful for analyzing existing health initiatives. Their findings also provide clues on how the HHI can continue to build a culture of health in Hawai’i. These include the use of culturally based approaches and the importance of targeting health disparities. With a better understanding of the successes and challenges the HHI has faced over its 20-year history, this study provides insights into the best ways to improve public health.

Media contact: Dee Dee Grays,, 979.436.0611

Rae Lynn Mitchell

SPH - Director of Communications and Alumni Affairs

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