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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
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)