Regional cultures, voter participation, and health

Health is foundational to building a strong nation. Voting is a means by which people can influence policies that affect their own health and the well-being of their communities. To reach people with messages that promote voter participation, communications should recognize the importance of regional cultures, i.e., regional norms, values, and belief systems. For elections to effectively engage voters in the importance of health as a policy issue, regional cultures should be identified and leveraged.

Voting and health

Higher levels of voting access correlates directly with an index of 12 public health measures across all US states.¹ Voter participation is associated with health and linked to health disparities.2, 3, 4 Voting allows citizens to actively influence laws, policies, regulations, and governmental practices that, in turn, may affect their health and well-being. US public health recognizes the importance of voting participation for health as Healthy People 2030 added this as a core objective with the 2030 target being 58.3%.^1,5

Does health and well-being increase voter participation or does voter participation improve health and well-being? Longitudinal studies point to a bi-directional relationship.³ Essentially, voting participation builds social capital, reflecting a degree of community collaboration to achieve mutual benefits, including population health.⁵ The preponderance of studies is cross-sectional in design and therefore limit causal inference, but there is general agreement that illness burdens of chronic diseases dampen voting participation. Cultural differences are recognized as a central element in the outcomes of elections that are, in turn, related to voter turnout.⁴

Regional cultures

How may regional cultures be defined so they can be identified and linked to tailored messaging that connects health interests to civic participation (e.g., voting)? When humans colonized or extirpated places once held by others, the first group of settlers that successfully created a self-perpetuating society powerfully influenced the dominant cultural characteristics of that society.⁶ Woodard discerned and mapped 13 unique regional cultures of the US using this method, showing US regional differences are linked to 17th, 18th, and 19th century settler-colonizer geography.⁷ The 13 “American Nations” each have their own unique cultural norms, values, and beliefs systems. For example, Yankeedom, in the North, was founded by Puritans who believed themselves to be a covenanted people tasked with creating a more Godly society in the New World and that they would be collectively rewarded or punished based on their performance; the culture they created prioritizes the common good over individual liberty and the pursuit of societal improvement through shared governing institutions. By contrast, Scots-Irish-founded Greater Appalachia is highly individualistic. This region's settlers came from war-ravaged Northern Ireland, Northern England, and Scottish Lowlands, where government institutions were weak and exploitative and one had to protect kith, kin, and herd oneself, creating a culture prioritizing personal sovereignty and individual autonomy and hostile to external authority, including governing institutions. The Left Coast on the Pacific side of the mountains in California, Oregon, and Washington, was settled by New Englanders and fur traders, prospectors, and farmers from the lower Midwest, producing an economically fecund hybrid of Yankee utopianism and Appalachian self-expression. It is no wonder that such profound differences in cultural roots are reflected in the current-day variation in civic engagement that ultimately drives population health and well-being outcomes. The 13 American Nations display a significant degree of variation in economic development, gender wage gaps, personality characteristics, voting behavior, social vulnerability, physical inactivity, obesity, life expectancy, chronic conditions, sleep insufficiency, and firearm violence.^4,8, 9, 10

At the intersection of regional cultures, voting, and health sits communications

In recent presidential elections, health behaviors, chronic conditions, and self-perceived health status varied significantly according to voting access, voter participation, and political disposition.^1,2,4,8 Along with differences in health outcomes, voter participation shows significant variability across these 13 geographic regions and like voting access, where voter participation lags, health status is lower.^4,8 Hence, regional cultures may be leveraged through communications to increase voter participation based on how they view the importance of the health agenda. To do so, we present three recommendations for public health to consider:

• 1.Focus the message on health through policy.
• 2.Connect voting to health through communications that respect local values, norms, beliefs, and traditions to resonate within a regional culture.
• 3.Remember that cultural change is constant. Social media, for example, may blunt regional differences while impacting ideological or political positions.

Good health is necessary for building a strong society. Connecting the desire for good health with voting participation will be more effective when culturally tailored messages are used instead of one-size-fits-all language.

Contributors

All authors were involved in the conceptualization of the study. NPP wrote the first draft. RA and CW edited and provided revisions on draft versions. All authors had access to any and all data related to this study.

Declaration of interests

The authors have nothing to disclose.