In an earlier blog (May 28, 2010), we mentioned that we were looking for new ways to talk about social determinants of health in ways that made sense to general audiences. The Robert Wood Johnson Foundation recently released a report that addresses this issue. When they tested responses to the phrase “social determinants of health” it consistently tested poorly. They were hoping to indentify a proxy phrase for “social determinants” which was not successful, but they did uncover some of the important metaphors for Republicans and Democrats and tested several scripts for effectiveness in explaining the desired concept to general audiences. The complete report including a recording and slides from a recent webinar can be accessed at http://www.rwjf.org/pr/product.jsp?id=66428. Below are some of the key highlights from the webinar and report.
Democrats tend to talk about a “system” that has broken down leading to inequities in outcomes and poverty. And because it is a system, you can’t address just one part and hope for an adequate solution. They also talk about a “right” to equality and health and feel angry when this doesn’t exist (see slides 12-18 in the PowerPoint).
Republicans talked about life as a “journey” in which “choosing” bad paths leads to unhealthy outcomes. They talk about the ability to change this situation with a lot more optimism than Democrats do. In their view, access to resources makes a successful journey more likely, but resources are finite and can’t be guaranteed for everyone. This means that the word “balance” to them means bringing some down so that others can have more. Instead, establishing a suitable minimum is more acceptable (see slides 19-25).
These are deeply held views about the world and we, as public health practitioners, have to be careful to know who our audience is and what networks (mental images, frames) we are activating when we talk.
The RWJF researchers created and tested several messages based on these frames such as:
It's time we made it possible for all Americans to afford to see a doctor, but it's also time we made it less likely that they need to. Where people live, work, learn, and play has an enormous impact whether they stay well in the first place. Health starts in strong, loving families and in neighborhoods with sidewalks safe for walking and grocery stores with fresh vegetables. Health starts in jobs we can get to without hours of commuting and in work places free of unnecessary hazards. Health starts in schools that educate our children for the jobs of the 21st century so they can compete in the world economy, that feed them healthy meals rather than junk foods, and that send them home safe at the end of the day. And health starts in having the time and financial resources to play at the end of a hard day's work, because unrelieved stress takes its toll on our hearts and immune systems. As we work on fixing health care in America, we need to start where health starts, not just where it ends.
(See more on slides 41-44 in the PowerPoint)
Some of the keys to the success of these messages were to
- Prime the audience with things they already believe
- Use colloquial, emotional language
- Use one compelling fact (not a barrage)
- Offer solutions
- Incorporate personal behavior (this is an important frame that many people hold)
- Mix traditionally conservative and traditionally progressive values (it may help to start with ideas on the political right and move to the left so that audiences we’re trying to reach don’t tune out)
- Highlight how it affects all Americans
- Lead with something inspirational, then go to something specific, then back to something inspirational
In fact, these are good lessons for pretty much any health message. And just like other messages you might be writing, think about your audience, the message that you’re trying to get across, and TEST, refine, and TEST AGAIN.
Hopefully we can begin to use this research in how we talk about where health starts, not just where it ends.
04/27/2010
Health Equity and the Social Determinants of Health
Courtney Boen, Rebekah Gowler and Meghan Patterson
Center for Health Equity and Social Justice, Boston Public Health Commission.
1. Objectives:
· Define health disparities, health equities, and the social determinants of health.
· Understand a health equity framework
· Identify the social determinants of health
· Articulate the impact racism has on shaping the social determinants of health
· Identify how to use community assessments to shape practice.
2. What are health disparities? / What are health inequities?
· Health disparities: differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.
· Health inequities: differences in health status and mortality rates across population groups that are systemic, avoidable, unfair and unjust.
3. Disparities, Inequality and Inequity
DISPARITY= INEQUALITY and implies differences between individuals or population groups
INEQUITY refers to differences which are unnecessary and avoidable and, in addition, are also considered unfair and unjust.
4. Health Equity
The opportunity for everyone to attain their full health potential.
No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance
Distinct from health equality or health disparities
5. What explains these inequities in health? - A look at the social determinants of health
Segregation:
· Racial segregation concentrates poverty and excludes and isolates communities from mainstream resources.
· Segregation did not materialize naturally
· Today segregation is maintained by economic inequality.
Economic opportunity:
· ‘Poverty Tax”: residents in poor neighborhoods pay more for the exact same consumer products than those in higher income neighborhoods.
· Higher rates of asthma sleep disorders and lead toxicity are more likely in sub-standard housing.
· Food environment: Food desert are areas with no or distant grocery but with many choices of fast-food, convenience stores and liquor stores. Research show that residents in food desert suffer worse diet-related health outcomes, including diabetes, cancer, heart disease and premature health.
· Physical environment (fewer parks, recreational centers, swimming pools, and less walkable areas)
· Education: correlated with health outcomes and life expectancy.
· Social mobility, public safety,….
6. The stress of racism
· Creates structural barriers to health and well-being
· Stress associated with racism and discrimination takes a toll on the body: a study shows that Black women who reported they had been victims of racial discrimination were 31% more likely to develop breast cancer than those who did not. ( + reference to the movie “Unnatural causes: when the bough breaks”).
A health equity framework:
Social capital
Transportation
Education
Employment
Food access
RACISM <-------------- Socioeconomic Status --------------->HEALTH OUTCOMES -
Environmental exposure
Health behaviors
Access to health services
Housing
Public safety
Health and the built environment are inextricably linked: where you live impacts how you live.
- How do you work to eliminate health inequities?
We often say…. “I know my work is connected because….”
Degree of impact
Low High
We don’t We serve a We plan our work
Discriminate vulnerable in such a way to ensure it
Against anyone population addresses the factors
impacted by these leading to disparities
disparities
How can we all get here?
Low Degree of impact High
We don’t We serve a We plan our work
discriminate vulnerable in such way we ensure it
against anyone population addresses the factors
impacted by these leading to disparities
disparities
What can we do?
- Consider “upstream approaches”
- Aim for sustainable change in policy and practice: policy with long term consequences impacts the economic, social, physical and service environments.
- Engage staff and partners at all levels
- Ask questions differently:
Ex: How can we promote healthy behavior?
How can we target dangerous conditions and reorganize land use and transportation policies to ensure healthy spaces and places?
- Conduct a community assessment of the social determinants of health.
- Goal: Identify the key social determinants of health and racial disparities in the community, map assets and resources for addressing the identified needs, use results to shape and develop community-based strategies.
Proposed phases:
1. plan the assessment: review existing data, convene a team, develop tools, decide on methods.
2. conduct the assessment: utilize different methods as focus groups, listening sessions, interviews, paper survey, observations, windshield survey
3. document discussions and findings
4. develop an action plan,
5. organize the larger community
6. take action!
