Governors’ priorities for public health and chronic disease prevention: a qualitative analysis of State of the State addresses

Abstract

Governors use State of the State speeches to publicly outline state status, progress, and policy priorities. The purpose of this study was to qualitatively analyze the public health content of State of the State addresses from 2009 to 2013. Speech transcripts were collected and uploaded into NVivo10. Speeches were coded using a priori, general thematic codes followed by detailed sub-coding of public health text. Data was organized by emergent thematic patterns. From 2009 to 2013, 48 governors presented 72 speeches with public health messages. Framing current public health problems and outlining strategies were two of the three main themes that emerged. Problems were often framed using data or emphasizing economic costs. Governors outlined prevention strategies on tobacco, nutrition, or physical activity through increased funding, policies, or partnerships. Speech content provides information on priorities and trends and can be used to inform advocacy efforts. Future research should link these priorities to outcomes of legislation.

INTRODUCTION

States play an important role in public health and disease prevention efforts. The core of public health policy lies within state laws, regulations, and constitutional delegation to local authorities [1]. Statewide policies have reduced smoking and increased seat belt use and required systems dedicated to disease surveillance [2]. Within states, governors are uniquely positioned to influence public health priorities and funding for the state [3–5]. Typically, governors appoint the director of the state department of health and together with state legislatures determine public health investments and projects [6].

Governors have a distinct venue for communicating legislative priorities and the overall status of the state in a “State of the State” address. The State of the State address is an annual speech given by governors of most states of the USA to a joint session of their legislatures [7]. These speeches provide governors with a bully pulpit from which they can outline their priorities and can use the visibility of their posts to draw attention to specific policy innovations [8]. Content of these publicized messages can provide insight into legislative support or political context for public policy issues. Analyzing the speeches over a period of time can point to trends or changes in support and inform advocacy efforts.

Previous studies have explored these speeches as indicators of governors’ policy agendas [5, 9], but no published study reviews the content of State of the State addresses in relation to public health and chronic disease prevention priorities. To enhance our understanding of state interest in public health policy innovations and to inform advocacy efforts, the purpose of this study was to qualitatively analyze the public health and chronic disease-related content of State of the State addresses from 2009 to 2013.

METHODS

Data collection

To identify speeches, researchers conducted an Internet search for publically available State of the State addresses delivered between 2009 and 2013. Official homepages of governors and state legislative website were reviewed to compile speech transcripts. In some states, such as Arkansas, Montana, North Carolina, North Dakota, and Texas, State of the State addresses were given every other year instead of annually. Although most states were represented for most years, no State of the State addresses were publically available on the official homepages of governors or state legislative websites for Louisiana and Nevada in 2012. Characteristics of current and former governors were also gathered, which included gender, party affiliation, and year the governor assumed office. The primary data source for this information was the National Governors Association [2].

Analysis

All speech transcripts were uploaded into NVivo10 (QSR International). Because of the large amount of data in this study, our analytical process involved a number of steps consistent with qualitative content analysis methodology [10]. A flowchart of our coding process is depicted in Fig. 1. The first step involved grouping the data according to a priori codes based on common public policy priorities. Two research team members used this preliminary coding tool to individually code speech transcripts using these broad categories. Results between the two coders were compared and consensus achieved for any discrepancies. All data coded under “public health” was then moved to the final analysis step. Text coded as Healthcare (e.g., Affordable Care Act) was only included in this analysis if it was mentioned in the context of preventing chronic disease or promoting health.

Fig 1.

Coding scheme flowchart

In the final step, all speech content coded as public health was aggregated. This public health speech content was read and reread independently by both team members to gain thorough familiarity with the content and to develop an initial list of codes represented in the data. The researchers then discussed and reached consensus on a set of codes. Using this list of codes, the public health data from speeches were coded. Discrepancies in coding were discussed, and consensus was reached. The coded text was further explored and organized by three thematic patterns that emerged [10]: current public health problems, chronic disease prevention, and proposed solutions to improve public health.

RESULTS

Characteristics of governors

Between 2009 and 2013, 90 unique governors delivered a total of 238 State of the State speeches. Of these, 48 unique governors presented 72 State of the State speeches with public health and chronic disease prevention content. As depicted in Table 1, the 48 governors used for this analysis were mostly male (85.4 %) and identified as Democrat (56.2 %). The region of the USA the 48 governors represented was varied: approximately 30 % of the governors were from the Midwest, 30 % from the South, 30 % from the West, and 12.5 % from the Northeast. A total of 39 states had governors that delivered speeches that contained public health themes (Table 2). Only Kentucky and Oklahoma had governors that gave State of the State speeches that incorporated public health content across all 5 years assessed for this study.

Table 1.

Characteristics of states and governors included in analysis of State of the State speeches containing public health themes between 2009 and 2013 (N = 48 unique governors that delivered speeches that contained public health themes)

Variable	n (%)
Gender of governor
Female	7 (14.6)
Male	41 (85.4)
Region of country
Midwest	14 (29.2)
Northeast	6 (12.5)
South	14 (29.2)
West	14 (29.2)
Political party of governor
Republican	21 (43.8)
Democrat	27 (56.2)
Independent	0 (0.0)

Table 2.

States with governors that delivered State of the State speeches containing public health themes, by year (N = 39 states that had governors that delivered speeches that contained public health themes)

State	Year
	2009	2010	2011	2012	2013
Alabama				✓
Alaska	✓
Arkansas	✓		✓
Colorado	✓		✓	✓	✓
Delaware				✓	✓
Georgia	✓
Hawaii	✓		✓	✓	✓
Idaho	✓				✓
Illinois					✓
Indiana				✓
Iowa					✓
Kansas	✓	✓
Kentucky	✓	✓	✓	✓	✓
Maine	✓	✓
Maryland		✓	✓	✓	✓
Michigan	✓			✓	✓
Minnesota					✓
Mississippi				✓
Missouri	✓
Montana					✓
Nebraska					✓
Nevada		✓
New Hampshire					✓
New Mexico	✓
New York	✓			✓
Ohio				✓	✓
Oklahoma	✓	✓	✓	✓	✓
Oregon		✓		✓
Rhode Island		✓
South Carolina		✓		✓	✓
South Dakota	✓	✓	✓
Tennessee			✓
Texas	✓
Utah		✓
Vermont				✓	✓
Washington					✓
West Virginia	✓	✓
Wisconsin	✓	✓
Wyoming		✓

Current public health problems

The most commonly reported cause of lack of “wellness” within states was the current health care system. When discussing the health care system, the phrase “sick care” was cited by many of the governors over the 5-year study period. As noted in Table 3, several mentioned the need for a shift to prevention and a systematic change from taking care of the sick to keeping people healthy. Governors also brought to light that many of the current health problems in their state were related to the rising cost of health care. They recognized that these sharply rising costs directly impacts state economy and that increased costs were often caused by lack of access and affordability of health care for both individuals and businesses. This results in people unable to access preventive care or early detection of diseases. Several of them reported that lack of access meant costly utilization of emergency room care instead of primary care services and straining family and state budgets. Long-term costs of preventable diseases were also mentioned frequently in the State of the State speeches. Growing costs of treating preventable chronic illnesses particularly related to tobacco or obesity were of concern.

Table 3.

Emergent themes, subthemes, and representative quotes

Themes	Subthemes	Representative quote
Current public health problems	Current sick care model	“We have a system that doesn’t encourage healthy behavior in patients and doesn’t discourage unhealthy behavior. In essence, we don’t have a health care system; we have a sick care system.” Delaware, 2012
	Growing health care costs	“I want to take a truly meaningful step toward insuring West Virginia’s working poor—those who are trying hard every day to make a better life for themselves but who just haven’t been able to make enough money to even think about paying for health care. They often wait until they’re critically ill before seeking medical treatment, so they end up in emergency rooms and hospitals. That adds to the unmanaged care bills that increase everyone’s healthcare expenses.” West Virginia, 2009
	Linking health indicators to economic costs	“Another long-standing, costly problem for Kentucky continues to be our smoking rate, among the highest in the nation and directly responsible for $1.5 billion in health-care costs. The negative impact of our smoking rates—among adults, teens and pregnant women—has been tremendous. Through various efforts, we’ve shown improvement—our smoking rate is now 25 % instead of 28 %. But we can do more. We must do more.” Kentucky, 2010
Chronic disease prevention	Connecting specific health behaviors to chronic diseases	“It has been said that the infant mortality rate is the gold standard for measuring the health of a population. I will make it a priority to face this problem, head-on. We already know many of the factors that contribute to infant deaths. Too many mothers in our state—almost 20 %—use tobacco products while they are pregnant.” South Dakota, 2010
	Personal responsibility	“Protecting good health is largely a matter of personal responsibility, but government policy can help.” Alaska, 2009
Chronic disease prevention strategies	Tobacco taxes	“Cigarette taxes nationwide have proven to be one of the most effective ways to prevent youth smoking, and my budget proposes reversing the cigarette tax cut and increasing the tax by an additional 20 cents, which will still keep our cigarette tax below those of our surrounding states.” New Hampshire, 2013
	Public smoking bans	“Let’s ramp up our fight against cancer by enacting a public smoking ban. It is time. Twenty-four states including North Carolina have done it. If North Carolina, the largest tobacco producing state in the country can enact a public smoking ban, surely Kansas can.” Kansas, 2010
	Increased accessibility and affordability of fresh fruits and vegetables	“We will promote food distribution by creating large-scale distribution hubs strategically located across the state. Expanding food access for underserved communities can improve nutrition and lower costs related to obesity and diet-related disease while fostering community and economic development. Tackling the food access problem with New York agricultural products is a ‘win-win,’ benefitting underserved communities and New York farmers alike.” New York, 2012
	Taxes to discourage consumption of unhealthy foods and beverages	“I am proposing what is an overdue increase in the alcohol tax and will also propose a fee on soda and similar drinks. We can no longer ignore the fact that consumption of these and other such products contribute to rising public health costs. Revenues from these fees will be used to repair the public health infrastructure and also to fund prevention and education programs.” Hawaii, 2011
	Promoting physical activity	“I’m asking the legislature to pass a bill reducing liability to schools, so that moms and dads and others from our local communities can join our children in accessing tracks, courts and exercise equipment.” Oklahoma, 2012 “The best way to improve our health is to get fit. A year ago today I announced plans to close the Capitol smoking room and create a Capitol Fitness Center. That center is now open for tours and I invite all of you to come see it. This is an opportunity for lawmakers and Capitol employees to lead by example.” Oklahoma, 2013

The majority of governors framed their state’s current public health issues by highlighting indicators in the form of statistics, rates, or rankings. Only three governors reported their states’ overall health rankings; two as a way to demonstrate the dire need for improvement (MS and OK) and one (VT) to showcase the “healthiest state in the nation.” The most frequently mentioned statistics were tobacco use or smoking related death rates, rates of adult or childhood obesity, and infant mortality rates. Other public health indicators mentioned by governors included drug addiction (methamphetamine, in particular), teen pregnancy, oral health, autism, violence, workplace safety, and trauma deaths. Many of the issues highlighted were coupled with statements on the importance of prevention for both individual health and state economic health.

Chronic disease prevention

The governors who spoke about public health issues often related chronic diseases to specific behaviors that could be targeted for prevention efforts. In a more general sense, health screenings and regular primary care were cited as secondary prevention strategies to facilitate early detection and timely treatment of chronic diseases and conditions. More specifically, tobacco use was a behavior mentioned in the context of infant mortality, asthma, cancer, and heart disease prevention. Physical activity and healthy eating were cited as behaviors important to obesity prevention.

Another theme that emerged about preventing chronic disease and health conditions was personal responsibility. Many times this theme emerged in the context of how individual choices can impact the whole health care system and drive up costs for everyone. Also, it was mentioned that government policies can be the facilitator for personal choices about health. For example, increasing access to health care should be coupled with encouragement for personal responsibility over health and that this combination is the key to improving the health of the population.

Chronic disease prevention strategies

Governors that communicated concerns with chronic diseases in their state and the associated health behaviors often spoke congruently about strategies that individuals, organizations, and the state could take to better promote health. Most of these recommendations were related to tobacco, nutrition, or physical activity. Proposals around tobacco included the implementation or increase of tobacco taxes to reduce smoking rates or to increase revenue for public health initiatives. Governors that suggested a tobacco tax referenced other and nearby states or cities that have supported similar policies.

Another approach to decrease tobacco use and reduce the exposure of secondhand smoke was to initiate smoking bans in public places, including restaurants, state government buildings, and higher education institutions. Similar to the support conveyed for tobacco taxes, governors that proposed public smoking bans often cited other states or cities that have enacted comparable policies.

Several governors described strategies to promote improved nutrition as a means to reduce obesity and other chronic diseases in their state. Most strategies were related to increasing access to fresh fruits and vegetables, restricting unhealthy food options (particularly in schools), and implementing taxes, bans, or policies to discourage the consumption of unhealthy foods or beverages. On the subject of improving accessibility and affordability of fresh fruits and vegetables, governors supported farmers’ market initiatives, incentives for supermarkets to locate into low-income areas, the expansion or improvement of school breakfast and lunch programs to incorporate fresh and local produce, and the inclusion of fruits and vegetables into the Women, Infants, and Children (WIC) program. One governor discussed a transdisciplinary approach to facilitate access to fresh fruits and vegetables through regional food hubs.

Related to limiting less nutritious foods in schools, a few governors called upon school officials to “ban junk foods” and to “provide healthier choices in their vending machines.” Some governors also conveyed support for taxes, bans, or policies to dissuade the consumption of foods and beverages with little or no nutritional value and to raise funds for public health efforts, with a few mentions of taxes on sugar-sweetened beverages. Additional nutrition policies that were proposed included banning trans-fats and implementing a requirement for chain restaurants to post caloric information.

Of the governors that discussed strategies to promote physical activity, many demonstrated support for increasing physical education programs in schools and one governor encouraged joint use agreements as a way to increase access to places and opportunities for physical activity. Several governors promoted state- or governor-sponsored physical activity and wellness programs or events, including a 5-K race; outdoors, parks, and recreation initiatives; websites to connect citizens to physical activity and health-related community resources; and certification programs for worksite, schools, and communities to become designated as “healthy.” One governor shared her commitment to convert a smoking room in a state government building to a fitness center for state employees: “The best way to improve our health is to get fit. A year ago today I announced plans to close the Capitol smoking room and create a Capitol Fitness Center. That center is now open for tours and I invite all of you to come see it. This is an opportunity for lawmakers and Capitol employees to lead by example.”

Many of the governors in this study mentioned the importance of partnerships and planning in chronic disease prevention and health promotion. Some highlighted existing and future partnerships with hospitals, research institutions, universities, and nonprofit organizations (e.g., American Heart Association), and a number of governors alluded to the importance of “public-private partnerships” to move chronic disease prevention efforts forward. Few mentioned the development of state government taskforces, panels, governor’s councils, and statewide plans to address rising rates of chronic diseases. Although most governors discussed the necessary budget reductions that would impact certain public health programs and services, several described various strategies to increase funding for chronic disease prevention and health promotion. Funding sources included revenues from proposed tobacco and sugar-sweetened beverage taxes, tobacco settlement funds, American Reinvestment and Recovery Act funds, and budget appropriations that prioritized public health.

DISCUSSION

This content analysis revealed several findings that can be used to enhance state public health advocacy efforts. By taking note of the stated public health priorities in the speeches, researchers and practitioners can continually adapt to political and socioeconomic changes and revise policy goals accordingly [11]. Thus, public health policy goals can be tailored in response to the priorities presented by the governors. Those in research and practice have a unique opportunity to provide advocacy information on these goals that uses easily interpretable data or health statistics to outline the proposed economic benefit of improving public health through chronic disease prevention [12–15]. For example, public health and chronic disease prevention were discussed by the governors in the context of economic issues. They highlighted the cost of poor health or unhealthy behaviors on individuals, organizations, and the state, often citing data or statistical indicators. Researchers and practitioners can enhance advocacy efforts on the stated priorities by providing relevant evidence to governors on the extent to which prevention policies can impact state budget.

Second, it was clear that many governors had special priority health topic agendas and these were highlighted in their speeches, at times year after year. Priorities that were commonly mentioned included tobacco use and obesity, but topics such as autism, oral health, and traffic safety were also highlighted. Consistent mention of these priorities throughout speeches and across years made them appear as priorities with strong personal support. Future research should investigate what determines these priorities and the purpose of their representation in the speeches. Also, learning how these priorities are linked to state legislative or budgetary action would benefit advocacy efforts [15].

The speeches also revealed varied and innovative solutions proposed to address public health issues. Increasing access to preventive health services was a common proposal mentioned, likely due to the timing of these speeches with health care reform. Only one governor mentioned increased access to healthy food through food hubs and only one governor mentioned joint use agreements to increase physical activity opportunities, but the fact that these topics were even mentioned might be the impetus needed for general awareness and action. Public health advocates should be poised to provide information and assistance for action when these policy and environmental strategies are proposed [12, 16, 17]. Additionally, researchers and practitioners should look to states where successful innovative strategies have been implemented and disseminate this information to their own state’s office.

Lastly, the topic of personal responsibility for health has often been associated with a more conservative, anti-big government way of thinking [18, 19] but all mentions of this topic within these speeches were focused on the complementary relationship of policy and taking personal responsibility for one’s health. The governors who mentioned personal responsibility in this way demonstrated a keen understanding that major public health problems often require population-wide policy changes that alter the environment in which individual choices are made [20]. Framing public health messages in a way that indicates how laws and regulations can facilitate individual behaviors and choices may resonate across political ideologies. Advocacy should focus on the importance of policies for creating conditions that foster and support personal responsibility [19].

In spite of key findings, this study has limitations that warrant mention. First, the analysis was narrowed to only those speeches that included public health content, thus reducing the sample size from 238 speeches from 50 states to 72 speeches from 39 states. However, the fact that states were not equally represented in this public health subset indicates the lack of universal priority of the topic. Second, this was a content analysis to identify themes and trends in public health and chronic disease prevention and these priorities were not connected to legislation or state-level implementation. Lastly, this analysis was dependent on the accuracy of the documents accessed online. In spite of these limitations, this study has noteworthy strengths. It is a unique contribution to the literature because it is the first of its kind to look at public health priorities as publicized by governors through their annual speeches. Also, it sets the stage for future studies that can go more in depth into linking these priorities to policy action and state legislation.