Join the Conversation: #healthcomm Communicating Public Health: Message Design Strategies to Promote Awareness and Action to Address Social Determinants.

Join the Conversation: #healthcomm

Communicating Public Health:Message Design Strategies to Promote

Awareness and Action to Address Social Determinants of Health

Jeff Niederdeppe, Ph.D.Associate Professor

Department of CommunicationCornell University

[email protected]

Collaborators• Sarah E. Gollust – University of Minnesota SPH• Colleen L. Barry – Johns Hopkins SPH• Michael A. Shapiro, Hye Kyung (Kay) Kim, Helen Lundell,

Sungjong Roh – Cornell University

Funding Support• RWJF Healthy Eating Research Program (69173, 68051)• RWJF Health and Society Scholars Program• RWJF Grant to University of Wisconsin Population Health

Institute – Mobilizing Action Toward Community Health

• What are we trying to communicate, to whom?

• What are we trying to change?• What are we up against?

• Three lessons learned

1. Education and awareness may not be enough2. Connect messages to broader values3. Opposing messengers are a challenge

• Some concluding thoughts

Presentation Outline

Traditional Health Communication

• Focus has largely been on changing individual behavior,

BUT…

• Behaviors and health outcomes are largely shaped by larger social, political, economic environments

• Need different message strategies, may be at odds with a focus on individual behavior

Features of Many Health Issues• Strong sense of personal responsibility for health in

public opinion and discourse

Public Opinion about Factors that Very Strongly Influence Health

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PersonalHealth

practices

AffordableHealth Care

Has HealthInsurance

Income Education Where aPerson Lives

Race/ethnicity

Source: Robert, S. A., & Booske, B. C. (2011). U.S. opinions on health determinants and social policy as health policy. American Journal of Public Health, 101, 1655-1663.

• Strong sense of personal responsibility for health in public opinion and discourse

• Powerful industries promoting health-harming products, incredible $ resources to fight regulation

Features of Many Health Issues

For Example…

• Strong sense of personal responsibility for health in public opinion and discourse

• Powerful industries promoting health-harming products, incredible $ resources to fight regulation

• Wide body of evidence on the influence of the larger social, economic, physical, and built environment

Features of Many Health Issues

Ecological Model of Healthy Eating

• Strong sense of personal responsibility for health in public opinion and discourse

• Powerful industries promoting health-harming products, incredible $ resources to fight regulation

• Wide body of evidence on the influence of the larger social, economic, physical, and built environment

• Complex mechanisms linking these factors to health outcomes and behaviors

Features of Many Health Issues

Factors that Cause Obesity: A Systems View

(105 variables)

Who is the Target of the Message / Campaign?

Healthier Environments to Improve Health

and Reduce Health Disparities

Policies To Create Healthy Environments

PolicymakerAction

Public Opinion (persuade the opposition)

Public Opinion(mobilize

issue publics)

What are the Targeted Outcomes for Effective Communication about Population Health?

What are the Targeted Outcomes for Effective Communication about Population Health?

1. Increase awareness of health disparities

2. Increase belief that disparities are worth addressing

3. Heighten belief that societal forces and actors cause, and are responsible for, poor health and disparities

4. Promote support for policies with potential to improve social determinants and reduce disparities

5. Mobilize action to advocate for social change

Lesson 1: Raising Awareness is Not Sufficient

Lesson 1: Raising Awareness is Not Sufficient

• Priming group differences

Priming Group Differences

• Public support for government intervention depends on type of group difference– Economic disparities: greatest support– Racial disparities: least support

• Perceptions of the causes of group differences matter– Relates to underlying attitudes about causality,

responsibility, and fairness– Behaviors vs. social structure vs. genetics

Sources: Rigby et al. (2009); Lynch & Gollust (2010)

Lesson 1: Raising Awareness is Not Sufficient

• Priming group differences

• Pre-existing awareness and values lead to “biased processing”

Control Social Determinants0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Proportion Agreeing "Dia-betes Caused by Social and

Economic Factors"

Experimental Causal Frame Viewed

Control Social Determinants2

2.2

2.4

2.6

2.8

3

3.2

3.4

3.6

Level of Support for Non-Medi-cal Diabetes Prevention Policies (higher values, more support)

Experimental Causal Frame Viewed

Democrats

Independents

Republicans

Source: Gollust, Lantz, Ubel; AJPH (2009)

Biased Processing of SDH Messages

Biased Processing of SDH Messages

• Focus group insight

• Without concrete mechanisms for how SDH produce disparities, people fill in the blanks with preconceptions

• In response to a chart showing the bivariate association between education and life expectancy:

“Maybe somebody didn’t go on to school or even didn’t finish high school but they might have gotten a good education at home in terms of how to be a healthy person.”

Source: Lundell, Niederdeppe, & Clarke, 2013

Lesson 2: Connect Messages to Larger Values

Lesson 2: Connect Messages to Broader Values

• Acknowledge personal responsibility

– BUT…

• Proceed with caution

Insights from Mall Experiment

• Methods• 500 participants, 4 conditions, summer 2010• Michele’s story – environmental and economic

causes of obesity, neighborhood development as an effective solution

Niederdeppe, J., Shapiro, M., Kim, H. K., Bartolo, D., & Porticella, N. (2013). Narrative persuasion, causality, complex integration and support for social policy. Health Communication, doi:10.1080/10410236.2012.761805.

MALL EXPERIMENT

Three groups were exposed to

Michele’s story about

(1) the causes of obesity and

(2) neighborhood development as

one solution

MALL EXPERIMENT

Insights from Mall Experiment

• Methods• 500 participants, 4 conditions, summer 2010

• Research Question:• How strongly should a story emphasizing SDH as

causes and solutions for obesity • Acknowledge personal responsibility• To increase complexity of thinking about obesity’s

causes, and • Maximize support for obesity policies?

MALL EXPERIMENT

Example of Condition Differences

• High Responsibility• Here, she feels comfortable getting out of the house and exercising

outside – activities Michele sees as tremendously important for improving her health. This has helped Michele to develop healthier lifestyle habits.

• Moderate Responsibility• Here, she feels more comfortable getting out of the house and getting

outside. This has helped Michele to have more options for improving her health – even though following through on them is a challenge.

• Low Responsibility• Here, she feels more comfortable getting out of the house, even if she’s

not intending to exercise.

MALL EXPERIMENT

Condition Effects on Support for Obesity-Reducing Public Policies

Liberals Moderates Conservatives2.22.42.62.83.03.23.43.63.84.04.2

High Mid Low Control

MALL EXPERIMENT

Niederdeppe, J., Shapiro, M., Kim, H. K., Bartolo, D., & Porticella, N. (2013). Narrative persuasion, causality, complex integration and support for social policy. Health Communication, doi:10.1080/10410236.2012.761805.

Condition Effects on Intentions to Engage in Diet and Exercise

Normal Weight Overweight or Obese2.22.42.62.83.03.23.43.63.84.04.2

High Mid Low Control

MALL EXPERIMENT

Niederdeppe, J. et al. (2013). Effects of emphasizing environmental determinants of obesity on intentions to engage in diet and exercise behaviors. Preventing Chronic Disease, http://dx.doi.org/10.5888/pcd10.130163.

… BUT Proceed with Caution

• Personal narratives can shift emphasis to individual responsibility

• Stories about individual children can increase blame to children for obesity

• Policymakers counterargue individual narratives unless combined with broader statistics or a story told about the community

Sources: Barry, Brescoll, Gollust (2013); Niederdeppe et al. (2014b)

Lesson 2: Connect Messages to Broader Values

• Acknowledge personal responsibility

– BUT…

• Proceed with caution

• Identify novel values related to population health improvement to reach broader coalitions

Identify novel values (1)

Source: Gollust, Niederdeppe, Barry, 2013

Source: Lynch and Gollust (2010)

• Fairness and equal opportunity, not equal outcomes

Identify novel values (2)

Lesson 3: Opposing Messages(-ers) are a Challenge

Lesson 3: Opposing Messages(-ers) are a Challenge

• It can be useful to anticipate and try to offset counter-arguments from opponents of social change

• Content analysis of arguments used to support and oppose the tax in public discourse• Niederdeppe et al., AJPH, 2013

• Public opinion poll gauging response to discrete pro- and anti-tax arguments• Barry et al., AJPM, 2013

• In-depth interviews with SSB tax proponents and advocates in jurisdictions where taxes proposed• Jou et al., AJPH, 2014

How tackling opposing arguments can be useful

NATIONAL EXPERIMENT

Surveys to Identify Resonant Frames – Pro-Tax

NATIONAL EXPERIMENT

Surveys to Identify Resonant Frames – Anti-Tax

NATIONAL EXPERIMENT

• Strongest pro-tax arguments focus on:• Largest driver of obesity (“softening the ground”)• Provides funds for childhood obesity prevention

• Beverage industry outspends pro-tax advocates by a large margin; anti-tax arguments resonate strongly

• Inoculation Theory• Protect from subsequent (persuasive) attack by

highlighting source motives and countering weak arguments (“industry demonization”)

Theoretical Rationale

NATIONAL EXPERIMENT

• Randomized experiment conducted from October-December, 2012 using the survey research firm GfK Group (Knowledge Networks)

• 3,118 completed baseline survey and follow-up (sent 1-week later and completed within 2 weeks)

National Randomized Experiment

NATIONAL EXPERIMENT

Overview of Experimental Conditions

Arm Approach Time Period 1 Time Period 2

Arm 1 Control condition No exposure No exposure

Arm 2 Control condition No exposure Strong con-message 1

Arm 3 Single message(not countered) Strong pro-message 1 No exposure

Arm 4 Single message(countered at time 2) Strong pro-message 1 Strong con-message 1

Arm 5 Multi-message Strong pro-message 1, strong con-message 1 Strong con-message 2

Arm 6 Multi-message (w/repeat pro-message)

Strong pro-message 1, strong con-message 1

Strong con-message 2, strong pro-message 2

Arm 7 Inoculation frame Inoculation (weak con-message with refutation) Strong con-message 1

Arm 8 Inoculation frame (w/repeat pro-message)

Inoculation (weak con-message with refutation)

Strong con-message 1, strong pro-message 1

NATIONAL EXPERIMENT

A Strong Pro-Tax Argument

Supporters of a tax say that sugary drinks may be the single largest driver of obesity in the United States. More children are obese today than in previous generations. Rates of obesity have tripled among children and teens over the past 30 years. Children and teens drink twice as much soda and other sugary drinks as they did 30 years ago. Supporters of a tax say drinking a 20-oz soda is equivalent to eating 16 packets of sugar. That’s 240 empty calories in a single bottle. When people consume sugary drinks, they do not feel full, so they tend to eat more food. Children who drink sugary beverages also prefer foods with higher calories, leading to worse overall nutrition.

NATIONAL EXPERIMENT

A Strong Anti-Tax Argument

Opponents of a tax say obesity is a matter of how many calories people consume, not where those calories come from. A tax on sugary drinks is arbitrary because it does not affect other unhealthy foods like donuts, cookies, and candy bars. Obesity is a complex problem that cannot be solved by focusing on just one small part of a person’s diet. Sugary drinks account for only 7 percent of calories in the average American's diet. Science shows that obesity is caused by an imbalance between the calories we consume through food and drinks and those we burn through daily activities and exercise.

NATIONAL EXPERIMENT

Inoculation Treatment

Soda companies will try to convince you that a tax on sugary drinks is arbitrary because it does not affect foods like donuts, cookies, and candy bars. They will say that they are an unacceptable intrusion of government into people’s personal choices. They will call them “food taxes” to try to confuse people.

But sugary drinks are not food – they have no nutritional value. In fact, research suggests that sugary drinks are the single largest driver of obesity in the United States. Nobody is telling anyone what to drink. But, by adding a few pennies to the price of a soda, many people will choose differently.

NATIONAL EXPERIMENT

Tackling opposing arguments can be useful…

Support for SSB Tax Policy SSB Companies Try to Get Kids to Drink SSBs2.00

2.25

2.50

2.75

3.00

3.25

3.50

3.75

4.00

4.25

4.50

4.75

5.00

5.25

5.50 No exposure Strong pro-, No anti- Strong pro-, Strong anti- Inoculation (Strong pro-)

Scale Midpoint

***

*

* Denotes p<.05; **p<.01 vs. no exposure control

NATIONAL EXPERIMENT

… At Least in the Short-Term.

No exp. t1, No exp. t2

Strong pro t1, No exp. t2

No exp. t1, Strong con t2

Strong pro t1, Strong con t2

Both t1, Strong con t2

Both t1, Both t2

Inoculation t1, Strong con t2

Inoculation t1, Both t2

2.00

2.25

2.50

2.75

3.00

3.25

3.50

3.75

4.00

4.25

4.50

4.75

5.00Baseline Follow-Up

Scale Midpoint

NATIONAL EXPERIMENT

No exp. t1, No exp. t2

Strong pro t1, No exp. t2

No exp. t1, Strong con t2

Strong pro t1, Strong con t2

Both t1, Strong con t2

Both t1, Both t2

Inoculation t1, Strong con t2

Inoculation t1, Both t2

2.00

2.25

2.50

2.75

3.00

3.25

3.50

3.75

4.00

4.25

4.50

4.75

5.00Baseline Follow-Up

Scale Midpoint

NATIONAL EXPERIMENT

… At Least in the Short-Term.

Lesson 3: Opposing messages(-ers) are a challenge

• It can be useful to anticipate and try to offset counter-arguments from opponents of social change

• BUT…

• Strategies to neutralize the opposition may not work across all social groups

Politically Polarizing Message Effects

Strong pro only Two-sided Inoculation-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

-5.3% -4.5%

-12.3%

14.0%†

-8.0%

15.1%*

2.9%

-7.6%

12.3%†

RepublicansDemocratsIndependents

Significant interaction term (β=-0.83, p=0.02) for Republican x inoculation

% difference from the no-exposure control group; †p<0.10; *p<0.05 from OLS regression

Lesson 3: Opposing messages(-ers) are a challenge

• It can be useful to anticipate and try to offset counter-arguments from opponents of social change

• BUT…

• Strategies to neutralize the opposition may not work across all social groups

• AND…

• It’s not always good to wake a sleeping giant

AND… It’s not always good to wake a sleeping giant (industry)

Source: Harwood et al., 2005

Some Concluding Thoughts

Also Need to Consider: Who Delivers the Message?

• Traditional news

Traditional news

• Growing capacity to cover disparities, but

• Covering them is still relatively uncommon

Also Need to Consider: Who Delivers the Message?

• Traditional news

• Novel messengers

Novel Messengers

• Violating expectations of a source can be powerful

• Partisan labels increase policy support when they take an unexpected position on a partisan issue

• E.g., Republican endorsing same-sex marriage• E.g., Democrat opposing abortion rights

Source: Bergan (2012)

Military leaders speaking to policymakers and the public

“When it comes to children’s health and our national security, retreat is not an option.”

“Retreat is Not an Option: Healthier School Meals Protect Our Children and Country”

Novel Messengers

What We Need to Know

• Need more work on the messenger

• Need more work on actions vs. opinions/perceptions

– What are the actions that individuals can take to influence policy?

Direct Democracy in CA and Other Places… But Limited Results

The Policy Process is Complex…

Source: Bulletin of the WHO (2006)

BUT Changes in Public Sentiment can Set the Stage for Changes in Policy

Source: Gallup (2012)

Questions? Comments?Thank you!

Contact me at [email protected]