Regional cultures and health outcomes: Implications for performance measurement, public health and policy

Abstract

The U.S. Medicare program now ties payment to health care providers based on their patients’ outcomes. This change comes as compilations of data on geographic variations in health outcomes and quality of care indicate patterns that appear to be deeply ingrained. This study explores whether cultural characteristics correlate with health outcomes such that quality indicators may be measuring something other than quality of care, and whether regional subcultures have a significant impact on public health. It concludes that two cultural dimensions, social capital and traditional/rational-secularism, which explain a sufficient proportion of outcome variations to cast doubt as to whether outcome measures capture provider quality. Correlations are explored between American regional subcultures identified by Joel Lieske and the variation in health outcomes. In a multidimensional analysis of Lieske's typology, results indicate that certain U.S. subpopulations have cultural advantages or disadvantages relating to health.

Keywords:

• Culture
• Health outcomes
• Health policy
• Health seeking

Notes

2 This journal does not follow convention of using quotation marks to introduce invented or coined expressions per APA Publication Manual Section 4.07. The reader should not interpret these category names as being in use or understood outside of the studies for which they were coined.

3 Notably, Colin Woodard (2011) produced another similar typology: He refers to the Border subculture as “Greater Appalachia;” divides Anglo-French between “New France” and a “Yankeedom” that also includes the Germanic and Nordic regions; and designates the “Heartland” subculture as “Midland.” Although Woodard's names are different, the Woodard, Lieske, and Ezzati-Murray maps all overlay each other nearly identically. The primary exception is that Lieske's use of American (northern) Baptist as an indicator for assignment into the Heartland cluster, and leads to the anomaly of West Virginia not being classified as part of the Border region. Ezzati and Murray place West Virginia in America 4; Woodard places it in Greater Appalachia; and the Ezzati/Murray maps demonstrate life expectancy in West Virginia to be as poor as in other Border subculture areas. The US Census ethnicity map also provides an interesting overlay. In the counties/states in the Border subculture, census respondents were most likely to describe their ethnic origin as “American.” This phenomenon among Scots-Irish is well known and was the basis for Patrick Griffin dubbing the Scots-Irish “The People With No Name” in his book of that title.