3 TABLE OF CONTENTS FOREWORD to Talk About WHY WE NEED A BETTER WAY THE SOCIAL DETERMINANTS OF HEALTH by Jane Isaacs Lowe, Ph.D. page ii CHAPTER Peeling THE ONION How We Found a Better Way to Talk About the Social Determinants of Health page 1 1 CHAPTER WORDS Choosing Best Practices in the Language and Framing of Social Determinants of Health page 4 2 CHAPTER ONE FACT TO FIGHT FICTION Finding The Use of Data and Information to Support—Not Make—Your Case 3 page 9 IN PICTURES Thinking APPENDIX The Deep Metaphors That Drive How Politicians See Health Disparities by Elizabeth Carger A page 13 Changing OUR FRAME OF MIND APPENDIX The Role of the Mind, Brain and Emotion in Developing Messages by Drew Westen, Ph.D. B page 21 i VULNERABLE POPULATIONS PORTFOLIO

4 WHY WE NEED A BETTER WAY to Talk About FOREWORD THE SOCIAL DETERMINANTS OF HEALTH by Jane Isaacs Lowe, Ph.D. When the Robert Wood Johnson Foundation went through a restructuring in 2003, it organized all the programs that worked at the community level to advance health into a new programming group called the Vulnerable Populations Portfolio. The newly created portfolio included a vast array of programs focused on areas as disparate as long-term care, school-based health and chronic homelessness. The members of the team struggled to find a meaningful connection among the programs that could help them discern a strategy for managing the current groups of programs and making future funding decisions. ii ROBERT WOOD JOHNSON FOUNDATION

5 Health starts where we live, What emerged from that analysis was an understanding that the programs and projects learn, work and play. were united in that they each worked within the context of the social determinants of health. And while social determinants were well established in We tweaked it and refined it a little, and academic circles and have been the subject of what we ended up with was simple: Health starts considerable study, we quickly discovered that where we live, learn, work and play. We started the concept didn’t work on the ground. The to see the messages picked up everywhere, but grantees—most of whom were dealing with most importantly in media accounts of our real challenges at the community level, didn’t programs and in academic literature. necessarily resonate with this frame. For some While the new framework did well in its it was so patently obvious that it became a “road test,” we are an institution that prides itself truism. And as unsuccessful as the concept was on evaluation and measurement of the ideas we for existing grantees, it made even less sense put forward. So we decided to test the messages to organizations that approached the team for more rigorously—to make sure we were getting funding who hadn’t worked with us before. it right—but also that we hadn’t missed an As the team struggled to find a way to translate opportunity to make it better. So we engaged the topic so that it made sense to our colleagues Drew Westen, Ph.D., of Westen Strategies and and people in the field, the Foundation was author of The Political Brain to help us fine-tune developing a commission focused on the social the messages, and build on our earlier research. determinants of health— specifically focusing Dr. Westen worked closely with our own on why some Americans are so much healthier communications staff to conduct the research than others and why Americans overall aren’t as that’s reflected here. healthy as they could be. This work has helped us communicate more This work gave us an opportunity to find a new effectively, and there’s no reason to keep what frame for talking about the social determinants we’ve learned to ourselves. We hope that this of health. Not just for people working in the field, research and the way we’ve applied it is helpful but for policy-makers. We had to talk about the to you. Please use it freely, but let us know if topic in a way that people could understand, that you do. We’d love to continue to build on what was meaningful, and that didn’t align the topic follows here. with any existing political perspective or agenda. By working with a talented group of communicators, including Linda Loranger of Burness Communications, Allison Rosen of Chandler Chicco, Bob McKinnon of YELLOWBRICKROAD and Elizabeth Carger of Jane Isaacs Lowe, Ph.D. Olson Zaltman Associates, we were able to arrive Team Director Vulnerable Populations Portfolio at a frame that described the social determinants of health plainly, without political overtone. As we started using this new way of talking not only for the commission, but also for the work in the portfolio, we gained significant traction. III VULNERABLE POPULATIONS PORTFOLIO

6 CHAPTER THE ONION Peeling 1 How We Found a Better Way to Talk About the Social Determinants of Health It turns out that trying to figure out how to say something simply can be a complicated process. Each of us has developed our own set of beliefs and values. As we listen and learn new concepts, we try to fit what we hear into these existing frames. And because many of our beliefs are so deeply held, it means that even the most seemingly innocuous terms can be laden with meaning. ROBERT WOOD JOHNSON FOUNDATION 1

7 How we assign meaning to what we hear is largely dependent on the context in which we hear it. And this context is something that even the most self-aware person can have a difficult time expressing. So as we developed messages and tested their reception, we benefited from advanced market research techniques developed and used by Olson Zaltman Associates and Westen Strategies to get at these deeper-level insights. This guide is informed by an iterative research and message development process that includes three steps: Determine How Policy-Makers Develop Messages That We Strengthen the Messages 3 2 1 See the World of Health With Testing Can Road Test In late 2006, as the Robert Wood Johnson This research informed the commission’s To validate and strengthen the Vulnerable Foundation was establishing the Commission message strategy, and we also applied Populations messages, we engaged to Build a Healthier America, the Foundation their findings to how we framed the work in a partnership with Westen Strategies, commissioned Olson Zaltman Associates of the Foundation’s Vulnerable Populations a public opinion messaging research (OZA), a Boston-based market research Portfolio, which is deeply invested in finding firm. Together we developed a study built firm, to help us gain a “deep understanding solutions to address the impact of social on the messages we were already using of people’s thoughts and feelings about factors on those most vulnerable among to understand which language resonated health differences across populations in us. This messaging was successfully road with our priority audiences. We also wanted the United States.” The insights from this tested with media and policy-makers to know whether differences existed in research provided a framework for talking in 2008 and 2009. Our core message certain political segments’ receptivity to about the diverse issues addressed by emphasized “new pathways for improved our messages. Westen Strategies enlisted the Commission, with social determinants health that recognize the integral relationship Public Opinion Strategies to conduct of health chief among them. Specifically, between our health and where and how various stages of the research and ensure OZA’s work showed how people with we live, learn, work and play.” We looked that the end product would be informed different political perspectives see health to our grantees and the communications by a range of political perspectives. This differently. More importantly, the research experts who work with them to provide study went into the field in the summer identified ways to frame our messages valuable input that strengthened our of 2009. about health differences that would messages and ensured that we avoided resonate across the political spectrum. language that would fall flat on the front Working closely with OZA, we had the lines. Collaboration and a constant opportunity to dig deeper into how people feedback loop were a critical part of the see this issue, and then layer additional process at every stage. forms of research over their findings to get a more robust and precise understanding of how people see health. (Elizabeth Carger of OZA has written a highly detailed chapter on their work in this area, which is included as an appendix in this guide.) 2 VULNERABLE POPULATIONS PORTFOLIO

8 The first phase of this research was a series of In the final phase of the research, Westen Strategies focus groups held in multiple cities and grouped took that learning one step further by exposing by male and female swing voters in Ohio, Blacks these messages to more than 1,700 registered voters and Hispanics in Houston and opinion leaders in and capturing their conscious and unconscious Washington, D.C.. It was conducted by Public reactions. Dr. Westen details this research process Opinion Strategies (POS). With the feedback we and what we learned from it in an appendix at got from this process, we refined the messages. the end of this guide. POS tested the refined messages in a quantitative Internet survey of 1,000 registered voters. From start to finish, this research represents We’ve shared what we learned in settings small responses from more than 3,000 Americans and large—including conferences sponsored by across the country over four years—using the Centers for Disease Control and Prevention both traditional research methods and new, and Grantmakers in Health—and the response sophisticated market research techniques—to has been consistent: “This is great, but how can answer one primary question: I learn more?” This summary is our response to that question. How do we find a common language that will In the following pages, you will find both an expand Americans’ views about what it means overview of what we learned—which words, phrases to be healthy—to include not just where health and framing work and why—but also a detailed ends but also where it starts? description of the methodology and what we discovered in chapters graciously authored by If we can answer this question, we can pave Elizabeth Carger and Dr. Westen, whose work the way for more solutions that address this was critical to our understanding of how Americans critical link between our health and where we perceive this issue. live, learn, work and play. ROBERT WOOD JOHNSON FOUNDATION 3

9 CHAPTER Choosing WORDS 2 Best Practices in the Language and Framing of Social Determinants of Health There is no silver bullet, no single word or fact that will suddenly transform how people think about health. It is an intensely personal issue that carries with it complex beliefs, conflicted values and a deeply divided electorate about what leads to better health. Instead, in this research, we studied numerous long-form messages and shorter statements that could offer a proxy for the phrase “social determinants of health.” We uncovered a series of lessons, best practices, recommended language and watch-outs that can support better and more persuasive messages. 4 VULNERABLE POPULATIONS PORTFOLIO

10 SEVEN LESSONS: 3 6 1 Use one strong and compelling fact— Mix traditionally conservative Traditional phrasing of social a surprising point that arouses determinant language consistently values with traditionally progressive values. tested poorly in every phase of interest, attention and emotion—for Every phase of research showed that while research. maximum impact. Phrases like “social Loading messages some phrasing appealed to one down with more than one or two facts determinants of health” and political perspective over another, “social factors” failed to engage tends to depress responses to them. progressives had a tendency to the audience, even when we be more open to conservative added more context. However, the frames. Generally, however, we concept behind social determinants 4 need to be aware of these different of health does resonate with our worldviews and communicate audiences, as evidenced by our Identify the problem, but offer using language that puts us on pre- and post-testing of people’s potential solutions. Respondents, common ground. For example, attitudes after their exposure to particularly opinion leaders, prefer combining the notion of personal our messages. messages that include some kind responsibility, which is wholly of direction—either an example of embraced by conservatives with the kind of action that would address a message about opportunities, 2 the problem or a set of principles language that also appeals to that can guide us to where we need progressives, will appeal to a Priming audiences about the to be. broader audience. connection with messages they already believe makes the concept more credible. Messages that 5 7 incorporate the importance of available quality health care with Incorporate the role of personal Focus broadly on how social the need to address the social responsibility. The importance of all determinants affect all Americans factors that affect health were Americans having equal opportunity to (versus a specific ethnic group more convincing than those that make choices that lead to good health or socioeconomic class). This did not discuss medical care resonated with participants across the research showed that Americans When messages are at all. political spectrum. Incorporating this believe in equal opportunity to presented in colloquial, values- point made respondents more receptive health, but describing actual driven, emotionally compelling to the idea that society also has a role disparities consistently evokes language, they are more to play in ensuring that healthy choices negative reactions. Messages effective. Academic language, are universally available. that described disparities based including “social determinants,” on race or ethnicity fared poorly did not resonate with audiences with every audience except Black the way language like “health respondents. Furthermore, some starts in our homes, schools and focus group participants expressed communities” did. concern that focusing on one ethnic group reinforced negative racial stereotypes. ROBERT WOOD JOHNSON FOUNDATION 5

11 BREAKING IT DOWN: Below you’ll find one long-form message that was developed, revised, WHY THIS WORKED: tested and revised again based on what the research showed us. It was consistently the most persuasive message among all groups, Audiences flat out didn’t believe the • regardless of their political perspective. While we are not necessarily statement, “America is not among the top recommending that you use this in its entirety, it is helpful to understand 25 countries in life expectancy,” and they why the phrase worked. responded negatively to any message that led with that statement. However, when we start off with something most Americans already believe, “Americans lead the world in medical research and America leads the world in medical research and medical care,” they are more likely to medical care, and for all we spend on health believe everything that follows. care, we should be the healthiest people on Earth. • Words like “insured or “uninsured” are Yet on some of the most important indicators, politically loaded. But the phrase “ensure everyone can afford to see a doctor when like how long we live, we’re not even in the top 25, they are sick” doesn’t touch existing behind countries like Bosnia and Jordan. It’s time political hot buttons. for America to lead again on health, and that • Framing our message in the context of means taking three steps. The first is to ensure accepted beliefs like the importance that everyone can afford to see a doctor when of access to care or prevention helps our they’re sick. The second is to build preventive message fit into the broader thinking of what it takes to be healthy. care like screening for cancer and heart disease into every health care plan and make it available • The inclusion of specific solutions increased acceptance of the core message. to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy • Illustrating with examples like “playgrounds and parks” and “in the air we breathe and to stop for a test. The third is to stop thinking water we drink,” makes the concept of of health as something we get at the doctor’s social factors more tangible. office but instead as something that starts in our • In the statement, “Scientists have found,” families, in our schools and workplaces, in our other options were tested with more playgrounds and parks, and in the air we breathe specificity, such as “Scientists at the Centers for Disease Control and at and the water we drink. The more you see the universities around the country have problem of health this way, the more opportunities shown that the conditions in which you have to improve it. Scientists have found that people live and work have more than the conditions in which we live and work have an five times the effect on our health than all the errors doctors and hospitals enormous impact on our health, long before we make combined.” Presenting the fact ever see a doctor. It’s time we expand the way in a more colloquial, relatable way, we think about health to include how to keep it, stripped of the academic support, is not just how to get it back. more effective than a longer statement. 6 VULNERABLE POPULATIONS PORTFOLIO

12 SIX WAYS TO TALK ABOUT SOCIAL DETERMINANTS OF HEALTH: Our hope in this research was to find a tidy proxy that could replace “the social determinants of health” as the leading descriptor for this area of work. While our testing showed that this phrase doesn’t work for any of our audiences, we still don’t have that neat replacement. But what you’ll find here is a list of phrases that—in context—helped people understand the concept more clearly. These are the precise phrases that we tested and that scored well. 1 Health starts—long before illness—in our homes, WHY THESE WORK: schools and jobs. • The proxy statements use colloquial, values-driven language and relatable All Americans should have the opportunity to make 2 lifestyle references that engage the choices that allow them to live a long, healthy audiences. life, regardless of their income, education or ethnic • These statements all focus on the background. solution versus the problem. Your neighborhood or job shouldn’t be hazardous 3 Some of the statements implicitly • to your health. acknowledge the notion of personal responsibility. Your opportunity for health starts long before 4 you need medical care. Health begins where we live, learn, work and play. 5 The opportunity for health begins in our families, 6 neighborhoods, schools and jobs. A GLOSSARY OF “OTHER TERMS” The terms that people often use to describe health disparities People with a more liberal perspective on this issue often can get in the way of others accepting the idea of social describe health disparities as an injustice, whereas more determinants of health and who they are most likely to affect. conservative people never use this phrase. Though it was One of the things we learned from OZA’s research is that never commented on directly in the OZA health disparities people with more conservative views tend to have negative research, we suspect that the idea of health differences reactions to the goal of equal levels of health for everyone. being unjust would not resonate with conservative audiences As such, below are some phrases we suggest avoiding. because it may activate the same response as inequality. This would include the following type of language, which • Any variation of equal, • Leveling the playing field you should also avoid: equality or equalizing • Creating balance Unjust/injustice • Immoral • • Outrage • Unconscionable ROBERT WOOD JOHNSON FOUNDATION 7

13 A GLOSSARY OF “OTHER TERMS” (continued) Below is an evolving list of terms that describe the groups most profoundly affected by this issue. These descriptions are not only technically accurate but more representative of how we relate to each other as human beings and fellow Americans. These phrases have not been tested, but are reflective of the insights we gained from the research. The elderly population and Disappointing (as in Americans • Vulnerable Populations should be able to do better, not their families, nursing homes Too many Americans don’t have • let people fall through the cracks) and elder care the same opportunities to be as It’s time we made it possible for • healthy as others • Our aging parents and all Americans to afford to see a grandparents Americans who face significant • doctor, but it’s also time we made barriers to better health it less likely that they need to Our elders • People whose circumstances • • Elders have made them vulnerable to Poverty • Caring for people as they age poor health • Families who can’t afford the All Americans should have the • basics in life Refugees and immigrants opportunity to make the choices including children Americans who struggle financially • that allow them to live a long, healthy life, regardless of their Americans struggling to get by • • People seeking a new home income, education, or ethnic in America background Low-income workers Children caught between • • Our opportunities to better health and families two worlds begin where we live, learn, work From undocumented immigrants • People who work for a living and • and play to productive, tax-paying still can’t pay their rent People’s health is significantly • American citizens Hard-working Americans who • affected by their homes, jobs have gotten squeezed out of the and schools Youth and teens middle class in tough times Health Disparities • Families whose dreams are The years of opportunity • being foreclosed and danger Raising the bar for everyone • Teenagers: They aren’t just • Setting a fair and adequate • Violence in general, as well young adults baseline of care for all as gangs and intimate Lifting everyone up • partner violence Mental health or illness, including young people Giving everyone a chance to live • Unsafe streets • a healthy life It’s just as dangerous and • The epidemic of violence • Unfair • debilitating as any other • Street violence chronic disease Not right • • Intergenerational cycle of violence and abuse Teen dating violence and abuse • 8 VULNERABLE POPULATIONS PORTFOLIO

14 CHAPTER Finding ONE FACT TO FIGHT FICTION 3 The Use of Data and Information to Support—Not Make—Your Case As communicators, we can’t do our work without making use of the facts that are the foundation of our work. They establish the prevalence of an issue; communicate its effect in both economic and human terms; and communicate responsibly about the effectiveness of an approach or intervention. Funders and policy-makers place increasing value on sound evaluation and research to guide their investments and decision-making. RWJF relies exclusively on objective data sources, but over the course of this project, we were sometimes astonished by how people responded to specific data points that we used to support our messages. So much so that we thought it would be worthwhile to share some of those lessons here. ROBERT WOOD JOHNSON FOUNDATION 9

15 face value unless it is put in a more acceptable NINE FACTS ABOUT FACTS context. We shared an effective example of 1. Less Is Always More providing such context in the long-form message Regardless of how good or reliable the data is, example used earlier. this research showed us that less is more. America leads the world in medical research and If you can use two facts instead of three, use medical care, and for all we spend on health care, two. Or better yet, use just one great fact. we should be the healthiest people on Earth. When introducing information to people who Yet on some of the most important indicators, like may be skeptical about social determinants, how long we live, we’re not even in the top 25, we found that more facts made people feel like behind countries like Bosnia and Jordan. they were being sold or spun. 4. Specific Examples Matter 2. Use Complementary—Not Competing—Data In the previous example, POS tested several If you are using multiple pieces of information, versions where the only thing that changed they should be used to advance—not repeat— was which countries we used to illustrate the your narrative. If you are using multiple facts, point. We had 25 different countries to choose they should be complementary in advancing from. In earlier drafts, we used France, Spain or your message. For example, use one that Turkey as examples. The respondents rejected underscores the problem and another that them outright and refused to believe them. highlights the promise of an approach. One said, “Why are you picking on Spain? “In a Little Rock, Ark., middle school last month, Others said these countries were too “socialist” over 108 suspensions resulted from fights during or “backward” to have better health than the recess—a time when kids should be playing, U.S. does. However, when we switched the recharging their batteries and return to class ready countries to Bosnia and Jordan, the respondents to learn. After a new program called Playworks were more open to the information. was introduced into the school, suspensions dropped 5. Don’t Let Numbers Be Forgettable to zero. The program allows kids to spend more Specificity matters when it comes to examples, time playing instead of fighting, and teachers to but not so much when dealing with the actual spend more time teaching instead of dealing with number. Our level of precision doesn’t need to conflicts that carry over to the classroom. In fact, the approach the level of pi to prove that the research program has been shown to restore a whole week’s is valid. Why say 23.6 percent of those in poverty worth of class time that would have previously been didn’t graduate high school when you can say spent dealing with fights.” almost 25 percent? Complicated numbers are 3. Context Is King difficult to remember. Just think of the way you “Just the facts, ma’am” may help advance police remember or forget phone numbers. The larger work on Dragnet but it doesn’t help advance our the number the more important it is to round messaging. How and where a fact is presented in it into something memorable. We don’t suggest your message is critical, especially when that fact using this approach in a scientific journal. may challenge an existing belief. For example, if your fact could be perceived as a criticism, whether to a person’s race, country or cause, then he/she will most likely reject your fact at 10 VULNERABLE POPULATIONS PORTFOLIO

16 6. Break Down Big Numbers The numbers we work with can be both Speaking of big numbers, unless they are put mind-boggling and mind-numbing. It is into some kind of context, they can lose their meaning and intended impact. Recently, our job to break them down in a way that d Saul Wurman, TED, Richar the founder of illustrated this point when trying to put is both comprehensive and meaningful. “a trillion” into perspective. “Imagine a very wealthy couple who had a lot of a person who lives in a certain zip code in cash in reserve. I mean a lot. Well, one day 30 years Connecticut and someone who lives in North ago, they decided to start a small business. And it Dakota, respondents cried foul, thinking we was an awful business plan. So every day, for the cherry-picked the data and that this was an last 30 years, their business lost a million dollars extreme example. On the other hand, when every single day. To show you how much a trillion we told people that there was a life expectancy dollars is, they would have to lose a million difference of seven years between someone dollars a day for another 2,700 years to lose who graduated from college versus those who a trillion dollars.” didn’t graduate high school, people responded differently, and those differences were often The numbers we work with can be both associated with very different life circumstances. mind-boggling and mind-numbing. It is our So for those participants who had graduated job to break them down in a way that is both college and were more conservative, they actually comprehensible and meaningful. Reporting that believed the data but amazingly didn’t think that health insurance legislation costs a trillion dollars seven years of life was that much of a difference. (over 10 years) is an accurate estimate but creates Conversely, those who were not college graduates a completely different meaning than telling rejected the idea that education played any role someone that the cost of reform breaks down in how long someone might live. to $3 a day for every American. 9. Overall Messaging Rules Still Apply 7. The Value in a Number Is in Its Values Finally, we need to realize that facts aren’t a Numbers can represent both a value and our separate part of our message but an essential values. You can say that half of all parents in ingredient to telling our story. They benefit poor neighborhoods don’t feel safe letting their from the same lessons we’ve shared earlier in children play on the streets. Or you can try and this report. create a picture of what it must be like to feel There is no shortage of good data that trapped in your own home, unable to move supports the idea that our health starts long because of your job or income, not able to give before illness—in our homes, schools and jobs. your kids the most basic opportunities to play But there is still a long way to go to make sure outside or run free, but instead fear that they that we are using it to maximum effect. To could get caught up with the wrong crowd or this end, we have begun to aggregate these struck down by a stray bullet, like the neighbor’s sources and refine these messages online at kid next door. http// We invite you to visit this site, add your own 8. Imagine Why Someone Might Cry Foul? compelling data and comment on how you’ve Some of the most important lessons from the been able to successfully use great information research involved life expectancy data. For to make good things happen. example, when we stated that there was up to a 25-year difference in life expectancy between ROBERT WOOD JOHNSON FOUNDATION 11


18 APPENDIX IN PICTURES Thinking The Deep Metaphors That Drive How Politicians See Health Disparities A by Elizabeth Carger The following document is a summary of the report “Thoughts and Feelings About Health Differences Across Populations in the United States,” which was delivered to the Robert Wood Johnson Foundation in the summer of 2007. It reflects the findings from interviews conducted in Washington, D.C., with 31 congressional staffers and health experts who were affiliated in some way with either the Democratic or Republican Parties. This report will outline the Democratic view of social determinants of health, then the Republican view, and then summarize implications for communication strategies and common ground between the parties. Throughout the report we detail the deep metaphor frames that Democrats and Republicans hold. For those unfamiliar with the concept of a deep metaphor, they can be described as basic filters. These are frames that shape everything we hear, think, say and do. They operate largely below awareness and for this reason are especially powerful as they normally escape conscious attention. A given group of people or stakeholder community will typically share the same few deep metaphors on a topic. Knowing what their deep metaphors are has important implications for communications strategy. ROBERT WOOD JOHNSON FOUNDATION 13

19 privilege by virtue of birth,” and goes on affected by social determinants of The Democratic to discuss how unequal levels of health health. Broadly, containers keep Frames for Social based solely on the zip code in which things in and keep things out; they are Determinants of Health a person was born contradicts this physical, psychological, or social places. and Health Disparities foundational principle of American society. Containers can protect us or trap us; they can be open or closed, positive Across Populations The second level on which the deep or negative. metaphor system operates is that Democrats view poor levels of health For Democrats, low‐income communities SYSTEM as emerging from a complex and are isolated and self‐contained on all The deep metaphor of system forms interrelated system of social, cultural, three levels—physical, psychological, the fundamental underpinning for the economic, and biological factors. and social. They are physically isolated Democratic view of social determinants One Democrat states, “It’s all tied in locations that lack resources of health. Broadly, the system-deep together—housing, health care, energy, necessary to live a healthy life such metaphor refers to the unification and food.” Consequently, changing any one as easily accessible doctors’ offices, organization of separate entities into factor, such as access to insurance, is grocery stores with fresh foods, and a whole. The unity of a system means not going to fix the problem of health places to exercise safely. One Democrat that the parts are interdependent; these disparities. There are numerous social says “it’s like living within your own connected parts often operate in a determinants that we must address little world...the reality for poor predictable and recurrent pattern with simultaneously and comprehensively people is never leaving their culture certain results. in order to overcome the system of of poverty.” On a psychological level For Democrats in particular, the interrelated factors that results in poor this “culture of poverty” traps them system frame operates on two levels. levels of health, in certain communities. in a mentality that they can never First, American society as a whole Because this frame of a complex system get ahead, they are unable to take is a complex system that unifies all permeates the Democratic view of advantage of the opportunities in citizens. As such, all individuals, from health they often feel the need to discuss broader society. Democrats describe the poorest person in the Bronx to a multitude of issues and factors the poor as “a self‐contained group the wealthiest person in Manhattan, simultaneously, quickly moving from at the bottom of the pyramid with are interdependent, even if this is not one cause to another cause. This high unemployment, low job status.” readily apparent. When poor levels of Solving health-related problems seems makes their discussions seem complex health exist in some communities it particularly hopeless. The poor have and, at times, muddled. Even though eventually affects everyone and weakens watched grandparents and parents comprehensively addressing all social the entire system that is America. die of diabetes-related complications determinants of health makes perfect What holds this American system or heart disease and it has become sense to individuals operating in the together is a foundation of rights such almost an expected life outcome. There world of public health and policy who as freedom, opportunity, and equality. exists a psychological and cultural hold the same system frame, it may be For Democrats, health is itself a right; barrier to reaching out to the medical cumbersome and frustrating to those all Americans have the right to health community. A common Democratic who hold a different frame, as we will care and the right to lead a healthy life. manifestation of the container frame see with the Republican world-view. One Democrat states, “Health care is a involves barriers. They bring images CONTAINER right, it’s so fundamental to being able of blockades and “significant barriers Where the deep metaphor system to have a healthy lifestyle. [What makes related to health care [exist between the underpins the Democratic view of it a right are] the values of society, of Latino community/African-American American society and health-related federal government.” Another states community and White folks.”] issues, the deep metaphor container that “one of the real founding principles frames the way they view communities [of America] was the notion of absence of 14 VULNERABLE POPULATIONS PORTFOLIO

20 Finally, on a social level, the poor are that they are hard to separate at times) left out of the larger social system are a reflection of extreme imbalance in American society between the “haves” that Democrats see as underpinning America. This is particularly troubling and the “have nots.” For Democrats, a for Democrats as part of their situation where “it would take this chief fundamental view of society is that executive two hours to earn enough to fund a community kitchen for three everyone is interconnected, so having some groups left out of this system is years” is morally wrong —“S omething not only morally wrong, it weakens is wrong there, it’s out of balance.” the overall view of America as a well This is an important touch point functioning system of inclusion. One for Democrats. As we will see later, Democrat states, “Individuals at the Republicans have a more optimistic bottom of society’s rungs, economically, view of Americans’ health status, socially, etc., they’re the ones who whereas Democrats are angered by this get left out when it comes to access profound social imbalance, “It makes to affordable, quality health care. me very’s unjust and unfair ...we leave a sixth of Americans outside and profoundly disturbing.” “[I feel] the system...we as a society have a really angry, I mean really angry...I responsibility, an obligation, and it’s didn’t realize how angry I was about in our best interests to bring them in.” that until you asked me.” Or, in the Consider the digital collage that one collage below, “This woman who’s Democrat created, which exemplifies screaming [represents that] she’s angry the way low‐income communities trap that these problems existed for so long.” individuals in “containers” that separate Fig. 1 Collage cr eated by a Democrat to The second way that the balance-deep them from the larger social system, as show the separation of poor communities from metaphor frames how Democrats view wealthy White society. represented by the well‐dressed white issues related to health disparities is students at the bottom of the image eated by a Democrat Fig. 2 Collage cr in their discussion of remedies and highlighting anger over persistent social (see Figure 1). imbalance with regards to health levels. outcomes. Democrats seek equality— balanced distribution of resources, the BALANCE same health care treatment for everyone, The balance-deep metaphor encompasses and (ideally) equal outcomes in that all ideas of equilibrium, adjusting, communities would have roughly the maintaining or offsetting forces, and same levels of health. The language of things being as they should. Balance equality has been a cornerstone of themes can structure peoples’ thinking Democratic discussions of a multitude about social, moral, psychological of social issues, from health disparities and emotional domains. Democrats to employment to education. Statements predominantly express the negative side like, “Equality assumes that we are of balance. Having an interconnected all going to end up at the same level. social system while simultaneously Equity to me presumes a fair and tolerating pockets of isolated, self- even distribution of resources” pepper contained, impoverished citizens leaves the Democratic discussion of social Democrats with a profound sense determinants of health. Critically, this of imbalance. Health disparities and is not the language that is effective wealth disparities (issues that are so deeply interconnected for Democrats ROBERT WOOD JOHNSON FOUNDATION 15

21 “A long, windy road. There needs to be for Republicans, as we will see below. constant movement, a journey—it’s not However, it is important to understand where you’re going, it’s the fact that that this frame of equality—as expressed you’re moving...We’re a very different by the desire for balance in terms of population than we were a hundred access, treatment, and outcome—is years ago; the person laying out that a cornerstone of how Democrats road a hundred years ago—they had no construct solutions to health disparities idea what society was going to look across American populations. like.” This long‐term journey frame makes Republicans more hesitant to institutionalize programs to address The Republican social determinants of health, particularly Frames for Social in a federal government that is slow Determinants of Health to adapt to unforeseen, yet inevitable changes over time. and Health Disparities Across Populations Another important ramification of this much longer and linear journey frame as compared to the Democratic JOURNEY system frame is that Republicans are Where system forms the fundamental fundamentally more optimistic about lens through which Democrats view where we are today in terms of the society and health, the deep metaphor health of the American population. journey is the predominant frame Where the Democrats expressed through which Republicans view extreme anger over perceived social American society and health issues. imbalances, Republicans state, “Look Broadly, journey often frames our back to where the world was 80 years discussion of life itself. Journeys can be ago, 90 years ago. The average life fraught with challenge or can be smooth expectancy was middle age. ...I’m sailing; they can be direct or divergent. not going to die before I’m 55, where Some journeys are unpredictable, 100 years ago I couldn’t say that. It’s where others focus on a series of steps collective improvement that goes full that, if followed, will take you to a spectrum.” They also tend to compare predetermined place or goal. us to other countries to show how much farther along we are on our American The type of journey that a group journey overall, and our health journey describes can yield much insight into in particular. “The African lady with how they view a given topic. For the bundle on her head symbolizes that Republicans, American society as a ours is a society that has come so much whole is on a long, unpredictable farther than that. ...We have forgotten health journey through time. They use where our health system was 20 years metaphors of winding paths and stress ago. We don’t have the’s the importance of adaptability in the a little unrealistic to think that because face of an unknown future direction. we are short of perfection, that the One Republican states: system is somehow deeply flawed.” 16 VULNERABLE POPULATIONS PORTFOLIO

22 The difference in base level of optimism versus anger between the Republicans and Democrats could be a real source of tension between the two groups when it comes to discussing social determinants of health. Understanding these basic differences in emotional response to the issue could help anticipate touch points in a conversation where communication might break down. Much as they see America and health care as a whole on a journey through time, Republicans see individuals as on their own health journeys. Echoing the common theme of “individual Collage cr eated by a Republican to show different choices along the journey of health and how Fig. 3 responsibility,” Republicans view poor they lead to either positive or negative life outcomes. health as arising from bad choices along one’s path and the inability to overcome would lead him to a lower path, which The second Republican expression of obstacles to health that one encounters is disadvantage. Or the baby could take resource highlights an important aspect along the way. Rather than employing the upper path where they don’t have of this deep metaphor. Physical resources the Democratic frame of externally‐ a care about anything.” Thus, where are finite; we use up natural resources, imposed barriers that trap communities Democrats view American society and we spend money, we consume food. in poverty and low levels of health, the causes of low levels of health in Replenishing a resource takes time and Republicans frame poor levels of health certain populations as interconnected effort, and some resources can never be in terms of a failure to give individuals systems, Republicans view both as replaced. For Republicans, American in a community “a road map of how unpredictable journeys. society has a finite amount of resources, to achieve [health].” However, in the both monetary and service‐related. same line of thought they feel they RESOURCE We need to be realistic that every person must acknowledge that “...some of While Republicans focus on personal cannot have everything; we simply do these differences we create because... responsibility for choices made not have enough to go around equally. we lead ourselves to places.” In other along one’s health journey, they also One Republican states, “because of this words, Republicans feel it is important acknowledge that people living in world of scarce resources, there’s always to give individuals the opportunity and low‐income communities may lack rationing...balancing out how you’re the tools to make good choices in their the means and ability to choose the going to ration things with how much health journey, but at the same time right path toward health. This is redistribution you want.” Another says, we must acknowledge that they will an activation of the resource-deep “If we had unlimited resources, it’d be also make their own, sometimes bad, metaphor. Resources are essential to our great to say that everybody deserves and choices. The following collage portrays survival. They can be physical—such can have access to Cadillac health care, the common Republican theme of as a tool, person, or an organization, but we don’t.” a divergent path that individuals or intangible—such as a skill, a encounter in their health journey. This Because of American’s limited resources, body of knowledge, or a network of Republican states, “We start down the Republicans focus more intensely on relationships. Resources act as agents the baby progresses, there getting the most “bang for the buck,” enabling us to achieve important goals. are two paths that he could take. One ROBERT WOOD JOHNSON FOUNDATION 17

23 the government and what is expected “[Democrats] would be just as happy meaning that they want to be certain of the individual. Neither one of these bringing the high end down as you that they infuse resources into the most entities should bear the sole burden would bringing the low end up...I care critical programs and services that of raising levels of health in poor about bringing the low end up and demonstrate effectiveness in helping communities. “Government makes the fact that this reduces disparities individuals in low‐income communities decisions...and there has to be some is great, but it’s not the disparity that make better health choices. Where balancing of altruistic motivation to worries me, it’s the low end people not Democrats tend to see resources going redistribute and efficiency,” meaning doing well.” As illustrated very clearly into a system where they circulate that we should infuse resources by this participant, Republicans are through different communities and into the best places, but we should concerned about social determinants of programs without necessarily being expect individuals to take personal health and low levels of health in poor exhausted, Republicans see a zero‐sum responsibility in using them. communities, but they immediately game. If you pour all of your resources object to any plan that uses the into low‐income communities, there language of equality or creating equal is less for the rest of America, and you levels of health because it activates the simultaneously have not guaranteed deep metaphors of limited resources that you actually help that community and creating balance by taking things because you did not necessarily pinpoint away from the “haves” to give to the the most strategic uses of those funds “have nots.” and services. Another important expression of BALANCE balance for Republicans is their The final deep metaphor that frames conviction that it is unrealistic to expect the issue of social determinants of that everyone is going to have the same health for Republicans is balance, levels of health. In a free society where but it is expressed in a very different individuals make their own choices way than the Democratic framing of (again, relating back to the journey social imbalance. Where Democrats theme), it is natural that there will be see equality as both a solution (giving differences in individual’s health. We everyone equal services and access) and should, however, establish a minimum a desired outcome (equal levels of health acceptable level, providing enough across all communities), the language resources that people are able to achieve and ideas around equality are extremely health goals they set for themselves. A off‐putting to Republicans. They Republican states, “There [are] bound understand equality quite differently to be differences in health outcomes, than Democrats. While Democrats there are good reasons why some people see equality as raising the bottom so should be healthier than others. As long everyone is at the same level (lifting as we are willing to live in a society people out of the entrapping holes of where people are different and given poverty), Republicans view equality different levels of income, [we] will have as more of a scale where you have to to have different levels.” take things away from the people who are well‐off in order to give them to Finally, Republicans frame the best the poor. This frame directly relates to solution to health disparities as a the zero‐sum view of resources held by balance between what is provided by Republicans. One Republican states, 18 VULNERABLE POPULATIONS PORTFOLIO

24 This first meant scrapping all language as: choosing better paths, moving in the Implications and of equality since it was alienating to right direction, or enabling the pursuit Common Ground Republicans. This included moving of health goals all activate the frame of away from phrases like: journey and individual responsibility Considering the very different deep more effectively than words like: • Equality in health metaphors that frame Democratic lifting people out of poverty, breaking • Equal levels of health and Republican thinking about health boundaries, or providing access to Uniform health • disparities, it is not surprising that health, all of which evoke the Democratic Ending disparities • political gridlock prevents progress. frame of containers of poverty. • Closing the health divide Both groups use language and frames With the overall strategy of framing that are simultaneously foreign and For Republicans, the above language social determinants of health using frustrating to the other side. But areas activated the negative frame of taking more journey and resource-related of common ground do exist; there are away from the well-off and giving to the language, it is possible to use a map ways to discuss social determinants of poor. Better framing revolves around of the common ground between health that can improve the receptivity language of fairness and choice: Democrats and Republicans in terms to and impact of communications • Fair chance for good health of what creates poor health levels to among those who are initially less open Opportunities for better • identify specific topics to begin a more to the issue. health choices open discussion. • Giving a fair shot in all communities Before drafting specific language for One way to begin messaging to both Enabling people to choose the • a discussion of social determinants Democrats and Republicans is to select right path of health and public policy that constructs on this map as the starting • Giving tools to make better decisions would address them, the Robert point. This contrasts with choosing Wood Johnson Foundation had The last two phrases point toward the issues that only Democrats discuss (such to devise an overall strategy for deep metaphors of journey and resource, as dangers in homes like lead paint framing both the Commission and which were prominent frames for and mold or racism in the health care the larger conversation. Obviously, presenting data and information about system) or issues that only Republicans both Democratic and the Republican social determinants of health. Rather discuss (such as the role of genetics or views on health disparities could not than discussing factors that created the breakdown of families). This is not be simultaneously communicated, poor levels of health in low‐income to say that these issues cannot or should particularly as some issues, like equality, communities (a Democratic system not be brought into a discussion of the cause direct conflict between the frame), the Foundation talked about social determinants of health. Rather, groups. It was determined that there “resource‐poor neighborhoods” that it means progress will be smoother were more Republicans that needed do not offer “the same choices” for and faster by opening a dialogue and to be convinced of the importance individuals to pursue paths to better establishing a rapport using shared of social determinants of health than health. We can focus on language that ideas. This will also facilitate the later there were Democrats; most Democrats conveys the lack of options, choices, introduction of ideas where there is would readily accept the argument tools, resources, or opportunities in poor more disagreement. Conveying these that we needed to address this problem neighborhoods rather than inequality, social problems using individual stories regardless of the type of language that barriers to health, or systems of factors supported by only a few powerful was used. This is not to say that their working against the poor. This allows statistics or facts will also help to frames were ignored, but rather that the Foundation to discuss the social persuade skeptics more than many facts the communication strategy would determinants of health, but in a way and figures. This would be particularly employ language and images that were that also resonates at a deeper level with effective in trying to persuade a more in line with how Republicans Republicans. Likewise, language such Republican skeptic; telling the story frame the issue. ROBERT WOOD JOHNSON FOUNDATION 19

25 Fig. 4 Map of common ground between Democrats and Republicans regarding the causes of poor levels of health. Poverty/ Right to Socioeconomic Good Health Differences Not Upheld Lower Lack of Poor Health Productivity/ Exercise Damages Poor Diet Smoking, Low-Quality American Substance Medical Care Individualism Abuse Lack of Ineffective Bureaucratic Knowledge/ Health Care Education Cultural Differences to open discussion. The example of they already share. Consider a very of an individual who could not exercise the person needing a safe place to go hypothetical example—introducing the in a poor community due to the lack jogging would further illustrate the idea of individuals exerting more of a safe place to go jogging and a idea of government helping individuals control over their health status, perhaps community program that provided an exert control and what individuals can by government-sponsored programs, effective solution, which this individual accomplish when in a safe environment. might be a way of responding to what took advantage of and subsequently both parties see as ineffective health lost weight, for example, would activate Through the careful and deliberate use care bureaucracies and at the same the frame of an individual journey while of deep metaphor frames and consensus time building on the idea of American concentrating on one of the shared maps, the Robert Wood Johnson individualism. Thus, two existing ideas constructs on the map. Foundation and other agents wishing to in the shared map, one negative and address social determinants of health and Another way to use a map is to ask, the other positive, can be used to add differences in levels of health across missing “What ideas are from the map to the idea of sponsored programs that American communities can more that might appeal to both Democrats encourage individuals to exert more effectively communicate programs in a and Republicans and would help control over their health status. Cues way that resonates with both Republicans bring about actions to improve levels involving achieving greater balance (a and Democrats. Taken in conjunction of health?” The Foundation might shared frame) between government and with additional research and testing then introduce these ideas into the individuals might be used to introduce conducted by the Foundation, this discussion. However, the new ideas or discuss this idea. Each party will research can form the backbone of this that are potentially appealing to tend to interpret the idea in ways that communication strategy. both parties need to build upon or are consistent with their prior positions be complementary to those ideas but to do so in a way that is amenable 20 VULNERABLE POPULATIONS PORTFOLIO

26 APPENDIX Changing OUR FRAME OF MIND The Role of the Mind, Brain and Emotion in Developing Messages B by Drew Westen, Ph.D. Messages That Move Decision-Makers and Everyday Citizens The goal of this research was to develop messages and language designed to convey the idea of social determinants of health in a way that would be convincing to decision-makers and opinion leaders (often referred to in public opinion research as “decision elites” or “opinion elites”) as well as to the constituencies they represent. Thus, we wanted to identify language meaningful to both, the kinds of people who make or implement policy decisions related to health (across silos, whether in public health, transportation, environmental protection, or elsewhere) and to average American voters, whose attitudes they ultimately have to shape or reflect. What became clear over the course of this project was that the concept of social determinants of health includes two components—one more descriptive about the context for health or illness (the idea that where we live, learn, work and play influences our health) and one regarding disparities in health based on race, ethnicity, or class that raises questions about the fairness of those disparities. Translating these two components into effective messages requires different kinds of messages, with the first encountering less resistance when people are exposed to the ideas but still changing the way they naturally think about health (as something they get at the doctor’s office or hospital) and the second requiring efforts to activate people’s values. ROBERT WOOD JOHNSON FOUNDATION 21

27 neighborhood would today bring to matters and why both decision elites GOALS mind populist sentiments about the and ordinary citizens should care The goal of this multi-phase project recklessness of big business and the about it; was to translate the concept of social failure of government after Americans • determinants (and ultimately calls for To identify words and phrases have confronted two of the biggest action that stem from it) that might that resonate with both decision crises in generations, the financial otherwise sound bland or unintelligible elites and ordinary citizens and meltdown that has still left nearly to the lay ear—even the educated ear— to identify words, phrases, and 10 percent of Americans out of work into compelling, motivating messages concepts to avoid that render them and the BP offshore oil spill that is that not only create concern about the less likely to understand or care decimating the Gulf Coast in ways we way things are but create hope that about social determinants or health have not even begun to understand. problems related to social determinants disparities; and On the other hand, mentions of poverty are solvable (e.g., that something can • To develop a small number of proxy immediately evoke victim blaming and be done about disparities that lead to statements, “catch phrases,” or largely unconscious prejudices, as the shorter, less productive, less healthy “taglines” that capture the complex average American associates poverty lives for millions of people based on construct of social determinants with people of color. Finding ways to factors that are arbitrary or outside in a way that is understandable speak of the impact of poverty on health their control). and resonant to people other than without activating those networks—or experts in public health. The problem we faced was that the activating countervailing networks language of university researchers, THE APPROACH related to the middle class and middle think tanks, and nonprofits tends to The approach to messaging or class concerns—thus becomes essential be very different from the language of “marketing” social determinants in messaging on health disparities if decision-makers, let alone the language we took is rooted in contemporary the goal is to influence not only public of the kitchen table, where everyday neuroscience and in both a scientific opinion but public policy. people discuss ideas and values and pass and clinical understanding of the From this standpoint, effective efforts on attitudes to the next generation. To — networks of associations unconscious to get people to think more broadly accomplish goals influenced by data the interconnected sets of thoughts, about social determinants (and to from public health or other relevant feelings, images, metaphors, and feel something other than contempt, scientific research requires translation emotions—that are active in the anger, or unease toward people who of the language of science into the brains of persuadable audiences are rendered vulnerable by virtue language of policy-makers—and, as they read, watch, or listen to of the factors that produce health ultimately, the language of everyday information about social determinants disparities) requires an understanding people, whose support is essential to of health. Introducing the notion, of the multiple, often conflicting convince decision-makers that they can for example, that income level affects neural networks active when people and should act on the available science, health immediately activates a host process messages, which can generate particularly where it bears on what they of associations, positive and negative, ambivalence or indifference. Changing perceive as moral questions (e.g., health that affect the persuasiveness of the people’s attitudes requires activating disparities). message. On the one hand, Americans some networks, deactivating others, and value fairness, and the idea that wealth Thus, we undertook this research with linking networks that are not currently translates into health runs afoul of a three primary aims in mind: or adequately linked in their minds firmly entrenched value. Similarly, (e.g., that health is the flipside of disease • To develop a small set of values- messages that convey, in a visual and and hence deserves more significant based, emotionally compelling especially a visceral way, the idea of attention, or that health does not begin narratives about why the social toxic fumes or chemicals affecting at the doctor’s office or the hospital). context (and associated disparities) the health of kids in a particular 22 VULNERABLE POPULATIONS PORTFOLIO

28 health (to see its broader context) represents the assessment of what is ; the Although people are aware of some and health disparities but also to how latter represents the assessment of what of their attitudes in these regards, they responded unconsciously, using could be , or the art of the possible. many of these attitudes are not only cutting-edge technologies that allow conflicting but unconscious (e.g., both The approach we took to accomplish us to identify the activity of neural concern and contempt for people our goal reflects this basic distinction. networks and “gut-level” emotional who are vulnerable or less fortunate, In the first phase of the research, we responses in large samples without which may be triggered by different undertook qualitative (focus group) directly measuring brain activity. or sometimes precisely the same cues). and quantitative (survey) assessments This has multiple ramifications. It The project was led by Drew Westen, of public opinion (focus groups and a means that we have to attend closely Ph.D., of Westen Strategies, but telephone survey) when presented with to the connotations—and particularly represented a collaboration with the concept of social determinants, with emotional connotations—of the Ann Christiano at the Robert Wood an eye to learning how we might change language we use. It also means that Johnson Foundation, who took an it. Whereas the focus groups attempted optimal testing of messages cannot active role shaping the project at every first to understand the extent to which rely exclusively on conscious measures phase of the research; Public Opinion both everyday people and decision elites of people’s attitudes. We need to Strategies, which conducted the focus understand or spontaneously recognize complement traditional survey research groups and baseline survey in the first social determinants of health and then with technologies that measure the level phase of the project (assessing public tested messages designed to change their of activation of particular networks opinion); and Joel Weinberger, Ph.D. attitudes toward both social influences and associations to different phrases of Implicit Strategies, who worked with and disparities, the telephone survey designed to address the same concept us on the measurement of unconscious aimed at measuring baseline public (in this case, social determinants responses to the top proxy statements opinion on the causes of health, illness, of health). for social determinants (terms that can and disparities without trying to change be used to describe it with opinion elites them (understanding “what is”). Central to this approach is also the and the lay public) identified through view that changing public opinion In the second phase, we use quantitative multiple rounds of testing. requires not just presentation of facts methods (online surveys and but narratives that “tell the story” of experimental methods) to see how METHODOLOGY how someone or something got that much we could “move the needle” We conducted six focus groups way and what can be done about it. of both opinion elites and everyday (two with swing voters in Columbus, Effective communication uses language citizens, focusing on what might be Ohio; two with Latino and Black in the vernacular of target audiences called “swing voters” on issues related voters, in Houston, Texas; and two that is clear, evocative, and readily to social determinants—people without with “opinion elites” in Bethesda, remembered and retold, making use much knowledge of social determinants Md.) and a baseline survey in July and of the “story structure” to which our and without strong political leanings August of 2009. We defined swing brains evolved to respond. that would render them outside the voters in all phases of the research as persuadable . In likely realm of the Finally, central to the approach we took people who had voted for at least some this second phase, we used online was the distinction between public Democrats and Republicans over the technologies that allowed us to assess opinion research —the measurement last few years or considered themselves not only how representative samples of of where the public stands prior to political Independents (roughly a third registered voters consciously responded efforts to influence their attitudes— of the sample, and reflecting closely the to messages aimed at getting them designed to and messaging research population norms). We defined opinion to think and feel differently about change public opinion. The former elites in the focus groups as educated ROBERT WOOD JOHNSON FOUNDATION 23

29 direction or another to indicate their we compared the “gut reactions” or voters who worked in Washington, D.C., moment-to-moment responses to mostly in government, who held unconscious emotional responses messages presented in audio rather than management positions, and empirically generated by the top proxy statements text form). Respondents also rated for “social determinants” after a large for the remaining stages of the research multiple potential proxy statements for sample of respondents had heard the based on high levels of educational social determinants of health (phrases top narratives designed to “move the attainment, occupation (management, designed to capture the essence of small business owners, government, needle” on social determinants. the phenomenon they had just been etc.), sources from which they derived reading about) to identify those their news, and income level. The they found most compelling and Phase 1 baseline survey consisted of How Americans reflective of what they had just read. 1,000 registered voters, with an Spontaneously Think Messages were presented in random oversample of opinion elites, leading About Health and How order across respondents. to a sample comprising approximately one third decision elites (largely matching to Change Their Minds: The second study not only re-tested the sample in partisan affiliation), Qualitative Findings conscious responses to the top messages one third swing voters, and one third From Focus Groups revised based on the highlighter non-swing/non-decision elites (partisan results (indicating sections of each non-elite voters). message that respondents found We undertook the focus groups to get compelling or uncompelling) but also In Phase 2 (message testing and a sense of how Americans naturally used new market research methods refinement), we conducted two studies. think about social determinants and to assess unconscious responses Both collected data from samples of to test some initial messages aimed at messages and proxy statements. To voters online, obtained from panel changing their minds. The purpose of measure the potential effectiveness of companies that provide paid respondents the focus groups was not to produce different phrases designed to capture for market testing, weighted to match enduring knowledge, given the limited the concept of social determinants the demographics of a random national general data from six groups of 8–10 of health, conscious tests that ask sample of registered voters and not people each. Rather, the goal was to respondents what they think or feel only measured. inform the next stages of the research. about the phrases can only be part Thus, we will not emphasize the The first study assessed 1,000 registered of an integrated testing strategy. findings, although we will bullet some voters using online quantitative polling This is because people lack access of the most suggestive findings here: to compare the effectiveness of messages to their unconscious networks, and refined from the focus groups aimed at • When asked what influences people’s when asked how they think or feel, moving persuadable voters and decision health, only a small fraction of they make their best guesses. These elites to think and feel differently about respondents in the groups naturally responses which may or may not stem both social influences on health and thought of social determinants. from their unconscious associations, health disparities and a “highlighting However, when prompted with particularly emotional associations. This tool” to allow respondents to indicate, examples (e.g., social class, education, is particularly a problem on messages within messages, which parts of messages neighborhood), respondents readily in which race or ethnicity is an issue moved them positively (highlighted recognized them as causes of health (notably disparity messages), where in green) or negatively (highlighted and illness. two decades of psychological and in red). In this way, we could refine • Respondents across these groups neuroscientific research have shown the messages for the final stage of respond strongly to messages about that conscious and unconscious (often research (much like online dial-testing, social determinants of health when called explicit and implicit) attitudes where respondents move a dial one they were values-based and emotion- tend to diverge substantially. Thus, 24 VULNERABLE POPULATIONS PORTFOLIO

30 their own health as good or excellent laden but not when presented in urban children born into poverty) relative to fair or poor (42% to 21%). language perceived as more academic with “that’s not true.” Respondents Voters who reported fair or poor health (e.g., the language of public health preferred messages that focused more included, not surprisingly, Medicare experts). Failure to speak to core broadly on how a problem affects all recipients, those with incomes under American values uniformly depressed Americans rather than on one group $20,000, people with high school or another. people’s response to narratives educations or less, older voters, and designed to move them toward those without insurance. recognizing the importance of social These findings proved particularly context or the need to act on disparities. important in designing messages Perhaps the most instructive answer • As in every other domain we have in Phase 2 of the project. Next, that came from the baseline survey was studied, voters were more responsive however, we turn to the findings voters’ response to the following forced- to messages that included at least of the baseline survey. choice question: “Select which one one “killer fact”—a surprising fact comes closest to your own view, even that arouses interest, attention and if neither is exactly right: ‘being healthy emotion—than those that focused Attitudes Toward is something I have control over,’ only on abstractions. However, Health, its Context, and or ‘being healthy is something beyond loading messages down with more ” B y an 84 percent– my control.’ Disparities: Baseline than one or two facts tended to 16 percent margin, Americans tend to depress responses. Polling view their health as something largely • An important lesson of the focus under their control—and for which groups was that respondents, they have to take—and expect others The baseline survey explored voters’ particularly opinion elites, strongly to take—personal responsibility. This attitudes toward health and its social preferred messages that included is consistent with American culture and determinants. The demographics were some kind of action item or with previous research conducted for representative of the voting population prescription. In other words, they the Foundation over the last few years. (e.g., women constituted 52% of the wanted a description not only of It is also an important theme to address sample; people aged 35–43 constituted what the problem is but either in messages that appeal to Americans 44%; 39% had completed college; an example of the kind of action on social determinants, particularly 77% reported themselves having we could take to fix it or a set of messages about health disparities, health insurance; and a slightly higher principles for going from where we which Americans readily attribute to percentage considered themselves are now to where we need to be. a lack of responsible behavior, even Democrats rather than Republicans; Without a solution, they would when presented with data suggesting with 26% considering themselves frequently respond by saying that otherwise. This is also consistent with “Independents”). When asked to rate they saw the problem, but they what social psychologists have called their top concerns, 48 percent said couldn’t see the solution. the “just world hypothesis,” a tendency “the economy and jobs;” nothing • M essages that referred to disparities of people (at least in the West) to else came close, including health at based on race or ethnicity fared want to believe that people get what 14 percent. (The survey was completed poorly with all but Black respondents. they deserve (that the world is just just before the debates overheated White swing voters, like middle rather than morally capricious) and over health care reform, with talk class Latino voters, did not want hence, to blame people for their own of a “government takeover” and to hear about how people of a victimization or misfortunate, whether “death panels.”) particular color or ethnicity were or not they had any genuine role in suffering, and they roundly rejected Among all voters (the focus of the statistics contributing to it. even relatively obvious “facts” cited below, unless noted otherwise), (e.g., the high percentage of Black by a 2:1 margin, respondents described ROBERT WOOD JOHNSON FOUNDATION 25

31 expressing agreement with the following These numbers are in part dependent increase in respondents who believe the statement: “There is more to good health following five factors could influence upon how healthy people are or health: income level, education level, job than health care. A number of things consider themselves to be. Among those or work environment, neighborhood, affect people’s health that people do not with self-reported very good or excellent often think of as health care concerns, like and pollution. These data thus suggested health, 96 percent believed that people’s that Americans do not “naturally” where they live and work, the quality of health is under their control. For those contextualize health socially, but when their neighborhoods, how rich or poor they who report their health to be fair to are, their level of education, or their race presented with effective efforts to poor, the number drops to 62 percent— or ethnicity. These social factors have a influence them, they not only “move” in still a majority, even among those whose their beliefs but move substantially. greater impact and influence on a person’s health was often impacted by genetics health than the medical care they receive.” or adversity, but not as strong a majority. These numbers are graphically illustrated Even here, however, respondents were below. The left-hand column shows Messages That Move likely to emphasize factors over which those in self-reported good health, Voters people have control, with three of the whereas the right-hand column shows top five influences they saw on health those in worse health. We conducted two rounds of message testing online using large national Good Health vs. Poor Health Fig. 1 samples weighted by demographics to be representative of the population of registered voters. The first study 12% 2% 14% 4% Strongly Strongly Somewhat Strongly presented 1,000 respondents with Beyond Control Beyond Control Have Control Beyond Control seven messages and nine proxy statements to get at the concept of social determinants, with one message designed to describe social determinants in a more traditional way (relatively 39% 55% 48% dispassionate, factual, but written in Somewhat Strongly Somewhat lay language) and one proxy statement Have Control Have Control Have Control 26% using the term “social determinants” Somewhat Beyond Control itself. The other messages were designed to be more values-driven and evocative, building on both the theoretical approach underlying this research— attempting to “work with” rather than Despite the widely held belief in being diet, exercise, and smoking, against the way our brains naturally personal control over health, when and the others were factors that could work. This was accomplished by using a “primed” with the idea that social be attributed to external causes, poor strong narrative structure, attempting to factors can have a substantial personal decisions, or both (stress and be emotionally evocative and involving, impact on health, the majority of lack of access to health care). and focusing on the values that could voters—virtually identical across all bring voters on board. This approach After seeing messaging on social three groups (all voters, swing voters, was helpful particularly with disparities determinants, however, beliefs opinion elites)—recognized the messages, using what we had learned in substantially shifted, with a 31 percent importance of social determinants, the focus groups and baseline survey. 26 VULNERABLE POPULATIONS PORTFOLIO

32 The second study (which sampled 1,726 Messages that moved voters shared a particular structure: voters) measured conscious responses to the top four messages identified in THE STRUCTURE OF EFFECTIVE MESSAGES ON the first study, revised based on the SOCIAL DETERMINANTS data from the highlighter tool (largely altering or deleting material voters End with a principled solution STEP 3: Connect with voters STEP 1: indicating that they did not find or example that illustrates how the with an aspirational statement, compelling). This study measured both problem can be addressed in a a compelling metaphor, or an way that inspires hope, “bookends” otherwise emotionally compelling, conscious and unconscious responses the initial statement in a way that attention-grabbing statement. to the top six proxy statements after maximizes its memorability, or offers respondents had first heard all four STEP 2: Describe the problem a metaphor that “sticks.” narrative messages. in a way that is concrete, visual, and evocative. In both studies, voters rated narrative messages on a 0 –100 scale traditionally used by pollsters, in which a rating –100) (80 (mean score) CONVINCING MESSAGE INTENSITY –80 or abo ve suggests a “high of 70 emotional intensity” message (i.e., 42% Leads the world 68 one that moves people, and is likely to Starts where health starts 43% 66 move them to action), and a rating of 51–100 represents agreement with the Social by nature 66 42% message. In both studies, we used more 64 37% How we see a problem conservative thresholds of 80 –100 as indicative of high emotional intensity 62 Personal responsibility 35% –100 as indicating agr and 60 eement 33% 61 Same opportunity with the message. In the first study, we 29% Social disparities 57 asked respondents to indicate their first- and second-choice proxy statements 27% 56 Social determinants that captured for them the concepts they had read about in the messages. In the second study, after hearing and In the initial study, as seen in the table four focused on the social context and rating the top four messages revised above, six messages received scores one (labeled in shorthand as “Personal from the prior stage of online testing, in the 60s, of which three not only responsibility”) focused on disparities, respondents saw one of the six proxy received ratings in the mid to high 60s which was the harder “sell,” particularly statements (300 in each experimental but were also rated with high emotional to conservative voters, who were more condition) and rated it on the same likely to blame people for their position intensity (80 –100) b y over 40 percent 0 –100 scale as the messages and then on the totem pole. The traditional of voters, a metric frequently used as a completed two tasks aimed at assessing “social determinants” public health threshold for messages likely to move their unconscious responses to it, message fared relatively poorly. people to act. Of the top five messages, described below. ROBERT WOOD JOHNSON FOUNDATION 27

33 be able to see a doctor, and that health As can be seen from the highlighted Although various subgroups diverged should include prevention. The message words and concepts, voters strongly slightly in their evaluations of the also convinced respondents that health resonated with the notion of American different messages (e.g., not surprisingly, starts in our families, schools and workplaces Blacks were more convinced by messages leadership and the need to restore it. (a common-language translation of about social disparities), all groups Within that context, they resonated most “social determinants of health.” tended to rank-order the messages strongly to the idea that everyone should similarly, including swing voters and opinion elites. As in the focus groups, opinion elites tended to respond first as people and second as elites—that is, LEADS THE WORLD the same values-driven, emotionally compelling language that moved other America leads the world in medical research and medical care, and voters also moved them most. They for all we spend on health care, we should be the healthiest people did not need to see the “fine print” on on Earth. Yet on some of the most important indicators, like how long policies any more than other voters, but they did want the “gist” or examples we live, we’re not even in the top 25, behind countries like Bosnia and of solutions. Jordan. It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to The highlighter tool allowed us to see what resonated or turned off voters and see a doctor when they’re sick. The second is to build preventive care hence to revise the narratives between like screening for cancer and heart disease into every health care plan the initial online survey and the and make it available to people who otherwise won’t or can’t go in final one. Below is an example of the for it, in malls and other public places, where it’s easy to stop for a information provided by aggregating test. The third is to stop thinking of health as something we get in what respondents highlighted across hundreds of voters in the online survey, hospitals and doctors’ offices but instead as something that starts in showing the language that appealed to our families, in our schools and workplaces, in our playgrounds and them most. The darkest green indicates parks, and in the air we breathe and the water we drink. The more you language most frequently highlighted, see the problem of health this way, the more opportunities you have and lighter green shows language that to improve it. Scientists at the Centers for Disease Control and at still appealed to respondents but with lower frequency. (Red highlighting for universities around the country have shown that the conditions in which each message provided a similar window people live and work have more than five times the effect on our health into language that voters did not than all the errors doctors and hospitals make combined. It’s time we find compelling. For example, voters expand the way we think about health to include how to keep it, not tended not to resonate with references just how to get it back. to particular scientific organizations such as the CDC; they were content to know that “scientists” had uncovered a Key particular fact.) The darkest green indicates language most frequently highlighted, and lighter green shows language that still appealed to respondents but with lower frequency. 28 VULNERABLE POPULATIONS PORTFOLIO

34 As can be seen from the numbers below We report here the top three social 2. START WHERE the message, this narrative strongly determinants messages, revised based HEALTH STARTS resonated with all voters as well as with on the highlighter tool, as tested in the swings and opinion elites. A central final online survey. We also report the It’s time we made it possible for principle of messaging that applied top social disparities message. As can all Americans to afford to see a in this research as in other domains be seen from the ratings at the bottom doctor, but it’s also time we made it is that Americans have an aversion of each, the revisions were successful, less likely that they need to. Where people live, learn, work and play to messages that start negative. driving the ratings up roughly ten has an enormous impact whether Thus, in the focus groups, a version points per message, into the 70s, which they stay well in the first place. of this message that started with how indicates that respondents found them Health starts in strong, loving Americans have fallen behind proved extremely convincing. families and in neighborhoods much weaker than this version, which with sidewalks safe for walking reminded Americans that we have the and grocery stores with fresh 1. LEADS THE WORLD best medical research and health care vegetables. Health starts in jobs we can get to without hours of for those who can get it, and began America leads the world in medical commuting and in work places free the message on an aspirational note. research and medical care, and for all of unnecessary hazards. Health we spend on health care, we should It then spoke to the problem, with a starts in schools that educate our be the healthiest people on Earth. stark contrast with Bosnia and Jordan, children for the jobs of the 21st Yet on some of the most important two countries Americans would never century so they can compete in indicators, like how long we live, see as competitors. Given that these the world economy, that feed them we’re not even in the top 25, behind messages were tested in the midst of healthy meals rather than junk countries like Bosnia and Jordan. foods, and that send them home the debate over health care, and our It’s time for America to lead again on health, and that means taking safe at the end of the day. And goal was to focus people’s attention on three steps. The first is to ensure that health starts in having the time and factors that precede getting medical everyone can afford to see a doctor financial resources to play at the attention, we emphasized three steps when they’re sick. The second is to end of a hard day’s work, because to putting America back on top in build preventive care like screening unrelieved stress takes its toll on health. We began with health care and for cancer and heart disease into our hearts and immune systems. every health care plan and make it prevention but then moved quickly As we work on fixing health care in available to people who otherwise to social determinants. The language America, we need to start where won’t or can’t go in for it, in malls health starts, not just where it ends. throughout is the language of the and other public places, where it’s “kitchen table”—the kind of language easy to stop for a test. The third is to SWING: 75.5 ELITE: 72.7 TOTAL: 74.1 everyday people would use in talking stop thinking of health as something we get at the doctor’s office but about health and illness. instead as something that starts in our families, in our schools and What is notable about this message This second message also begins with an workplaces, in our playgrounds and is the combination of values that aspirational statement—about ensuring parks, and in the air we breathe and drives the positive response to it. that every American can see a doctor— the water we drink. The more you The primary one is American leadership but ends with a surprising twist that see the problem of health this way, and nationalism—values not typically the more opportunities you have to draws voters in, that we also make it less associated with health policy. The improve it. Scientists have found that likely that they need to. This message the conditions in which we live and message also emphasizes the values draws on language already used by the work have an enormous impact on of environmental protection, families, Robert Wood Johnson Foundation to our health, long before we ever see a and acting proactively to prevent describe social determinants—“where doctor. It’s time we expand the way a problem (problem-solving and we think about health to include how we live, learn, work and play,” and then pragmatism) before it starts. to keep it, not just how to get it back. uses a rhetorical device (repeating the 79.0 ELITE: TOTAL: 78.2 SWING: 77.4 ROBERT WOOD JOHNSON FOUNDATION 29

35 tends to drive down its ratings. People same structure in a series of statements, 3. SOCIAL BY NATURE can generally read, hear, and follow each beginning with “Health starts...”) three examples or themes in a message, to expand on the meaning of that We are social by nature, and when but beyond that, they find the message language. It closes with a memorable the ties that bind begin to unravel, incoherent or difficult to remember. phrase, namely that “we need to start so does our health. Health begins It begins to lose the narrative structure where health starts, not where it ends,” at home in our families, with a loving relationship between parents essential to an effective message. The that has the property marketers describe and their children, where kids can message then inoculates against a as “stickiness”—that is, characterized by expect to be safe, nurtured and concern we heard in focus groups— the tendency to “stick” in people’s minds. protected. Health begins with that it was too utopian, that no single healthy communities, with safe This message draws on a number of institution can solve the problem alone— streets, freedom from violence, and values as well, some of which are and and returns to its core theme with a parks where kids can play. Health others of which are not traditionally final, memorable statement that begins with a good education, associated with public health. These where children learn not only how “bookends” the opening statement with include the values of strong families, to read, write, and prepare for a touch of irony and humor that brings community, workplace safety, education, fulfilling, prosperous life, but how the message close to personal experience. to treat each other with dignity and competition in the global economy, respect. And health begins with Like the other messages, this one draws nutrition, security, and hard work. safe jobs and fair wage, where on a mix of values, some of which are people derive a sense personal The third top message takes a very familiar to public health and some of satisfaction from their work and different tack, emphasizing the which draw associative links to other connection to their co-workers. social nature of social determinants, domains and hence increase its power: No institution alone can restore juxtaposing the colloquial phrase, “ties families, communities, nurturance, a healthy America that nurtures that bind,” with a complex idea: that families and communities. That safety, prosperity, dignity, respect, safe we are biologically predisposed to will require leadership, and a work, fair wages, business, religion require certain social conditions to partnership of business, government, and leadership. One of the central and civic and religious institutions. optimize our health. Like the former characteristics of good messages is that We can’t eradicate illness, but message, this one makes use of the they activate multiple values, not simply we can foster health. And health rhetorical device of structural repetition one (good health). In so doing, they begins with healthy relationships, (“Health begins...”). Also like the activate the positive feelings associated healthy communities, and healthy former statement, and central to with each of those values unconsciously, jobs, which protect us from the a strong, memorable message, stress of everyday life. That’s one which has an impact that is sometimes it does not overuse the device. Any prescription that doesn’t require additive and sometimes multiplicative. message that includes more than a co-pay. three principles, three examples, or 74.2 ELITE: TOTAL: 73.9 SWING: 73.6 three structurally similar sentences 30 VULNERABLE POPULATIONS PORTFOLIO

36 Several points are noteworthy about Our top health disparities message tested an area 150 miles constitutes. The this message. Perhaps most importantly, nearly as well as these messages (and message then begins to break down like virtually all effective messages on better than some with swing voters) in-group/out-group barriers, by comparing issues related to race, ethnicity, and and hence deserves note, particularly the concerns of the middle class with social disparities, the narrative starts given the difficulty developing messages the concerns of people who are poor, right and moves left. It begins with on health disparities that do not “turn noting that both are disadvantaged in a value that all Americans share but off” voters right of center politically, health vis-à-vis the wealthy. Finally, the is central to conservative ideologies, who tend to believe that hierarchies are narrative offers its central take-home particularly when applied to people who natural and that people’s misfortunes message: that people ought to have are readily viewed as “them” rather than are largely of their own making: equal opportunity to make choices that “us,” namely personal responsibility. We lead to good health , and that fairness learned in the focus groups, however, requires that Americans, regardless of 4. PERSONAL RESPONSIBILITY the importance of returning to this who they are, have a chance to make theme later in the message to reassure good decisions that could translate into People have a personal responsibility respondents to the right of center that good health. to take care of themselves and the messenger “really means it.” The their health. But it isn’t right when Like the other messages, this one draws message then draws upon another things outside our control—like on a range of values, many of which we value, central to Americans across the where we’re born or how much have already described, such as personal political spectrum—fairness—and money we make—affect our health. responsibility and fairness. In addition, In the entire city of Detroit—an area defines its meaning as it applies to it speaks to values of healthy eating, of nearly 150 square miles—there health. This second statement would hard work, affordable day care, and are dozens of “convenience stores” have had an entirely different meaning but only five grocery stores. equal opportunity. if not contextualized by the first An apple a day may keep the statement, which establishes that the The four statements presented here could doctor away, but you have to be messenger views fairness and personal able to buy an apple. And it isn’t all be used effectively in communications responsibility as complementary values, easy to get exercise if you have about social determinants with average to work three jobs just to get by, not as alternatives. The narrative then voters, swing voters, and educated or if you can’t easily get affordable goes on to cite a single “killer fact”— opinion elites and decision-makers. day care for your kids. We’re not that is, a fact that has a strong emotional They all drew average ratings in the 70s, just talking about the rich versus impact—namely that within 150 square which is extremely high. In contrast, the poor. On Average, middle miles in the city of Detroit, it is virtually a message using traditional “social class Americans live shorter lives impossible to find a grocery store. than those who are wealthy, determinants” language, statistics, and This suggests that even parents who and that’s not right. Money can’t rhetorical devices often used to speak want to exercise personal responsibility buy happiness, and it shouldn’t about health with the general public buy health. We have to take and act responsibly cannot do so for drew ratings in the 50s: responsibility for our lives and structural reasons (although terms such decisions. But all Americans should A growing consensus among scientists as “structural” are toxic to effective have an equal opportunity to make suggests although medical care is essential communications with the general the decisions that allow them to for relieving suffering and curing illness, public). In general, messages that recite live a long, healthy life, regardless social determinants of health are as or numbers (e.g., the number of millions of their level of income, education, more important than virtually any factor of children born into poverty) tend to or ethnicity. that contributes to health or illness. fail, particularly when they are overly Only an estimated 10 to 15 percent of “fact-heavy.” In this case, however, 73.9 SWING: 71.4 TOTAL: 69.0 ELITE: preventable mortality has been attributed the number has an emotional impact to medical care. Social factors can affect because of its magnitude and because health directly and indirectly as their the reader can readily picture how large ROBERT WOOD JOHNSON FOUNDATION 31

37 effects accumulate across individuals’ Proxy Statements for lifetimes and across generations, leading Social Determinants: to vicious cycles between social factors and Conscious and health. A person’s health and likelihood Unconscious Responses of becoming sick and dying prematurely are greatly influenced by powerful social factors such as education and income and We were interested not only in the quality of neighborhood environments. effective narratives to describe social Fortunately, many social factors can be determinants but also in proxy influenced by policies and programs. statements for the concept—ways of Building a healthier America requires describing “social determinants of individuals to make healthy choices and health” that do not sound so distant, a societal commitment to remove the Fig. 2 Participants saw this image during the cold, and abstract. Thus, in the first final phase of message testing. obstacles preventing too many Americans online study we measured people’s from making those choices. This will conscious responses to nine potential take a commitment from every sector— we asked participants to fixate their eyes proxies (including the term “social government, business and foundations— on an X in the middle of their computer determinants” itself, as a baseline for to promote opportunities for Americans screen and told them immediately comparison), and we tested the top six to live healthy and productive lives. following it they would see an image in the second online study for both of a family, about whom they would their conscious and unconscious appeal. Note that this message is very similar answer some questions. Respondents rated the proxy statements in substance to the messages that were for the extent to which they captured more effective: It makes the same points We presented these stimuli three times. the “gist” of the messages they had been in its opening sentence that health However, each time, between the image hearing in a way that was compelling begins long before people seek health of the and the image of a family of X to them. care, that social factors are essential ambiguous social class, ethnicity, and influences on health, and that the race (below), we presented the proxy To assess their unconscious responses quality of neighborhoods and factors statement, but this time at 30–50 to the proxy statements, we used a such as income and ethnicity can have a milliseconds—slow enough for the procedure that is being increasingly substantial effect on health and illness. brain to process (particularly since they used in corporate marketing for However, it does so in a language that, had read it before) but too quickly testing ads and taglines, namely an while written for a lay audience, is for them to be aware that they had unconscious priming procedure. For not the language of the kitchen table. even seen anything. This is called an this procedure, all respondents first Further, the language of “policies and unconscious prime. They then rated heard the four narratives described programs” is far less effective than the family on 10 positive and negative above (our top three narratives and the language of values, from which statements (e.g., “This family looks our top disparities narrative), to those policies and programs are healthy,” “This looks like a family familiarize them with the concept of ultimately derived. This message, like that can look forward to long lives,” social determinants in language we the successful messages, also speaks to “I get the feeling this family lives in a knew was compelling. They then saw solutions, but it does so in a way that dangerous neighborhood”). Although one of the six top proxy statements sounds bureaucratic, even though it they believed they were rating the (or the traditional social determinants speaks directly to individuals making family, over five decades of research statement, once again as a baseline; healthy choices, and it uses words such have documented that unconscious the traditional statement had received as “sector” that are abstract and distant primes can have a substantial impact the lowest ratings in the first round to the average person. on ratings of consciously perceived of testing). Following a test of their stimuli, particularly when the stimuli associations to the proxy statements, are ambiguous. 32 VULNERABLE POPULATIONS PORTFOLIO

38 The conscious ratings in both rounds of CONSCIOUS RATINGS OF DESCRIPTIVE PHRASES research were highly similar, as shown in the accompanying table. Five messages TOTAL ELITE SWING PHRASE performed extremely well, with ratings 81.5 82.0 81.7 Your opportunity for health starts long in the mid to high 70s and 80s on a before you need medical care. 0–100 scale. Two messages performed comparatively poorly. One was somewhat 81.5 Health starts long before illness, in our 81.2 81.8 “clunky,” defining social determinants in homes, schools and jobs. terms of four components, although this All Americans should have the opportunity 80.9 81.5 81.2 statement still received an average rating to make choices that allow them to live of approximately 70. The only message a long, healthy life, regardless of their to receive a rating below 70 was the income, education or ethnic background. traditional social determinants statement. Your neighborhood or job shouldn’t be 76.0 76.7 76.3 The table on the left shows how the same hazardous to your health. proxy statements fared unconsciously, 75.1 Health begins where we live, learn, work 76.0 74.4 with the data transformed to a 0–5 and play. scale for ease of interpretation, with 70.0 The opportunity for health begins in our 70.5 69.5 0 representing relatively low positive families, neighborhoods, schools and jobs. emotional response and 5 representing strong positive response. 63.0 If we want to improve our health, we need 62.6 63.3 to address the social determinants of health. As can be seen, with the exception of the first statement, which received high conscious ratings but generated a mediocre response unconsciously (relative to the other top proxy statements), the statements performed similarly consciously and unconsciously, with the two statements that performed worst consciously also doing so unconsciously. ROBERT WOOD JOHNSON FOUNDATION 33

39 The three statements that performed the UNCONSCIOUS EMOTIONAL REACTIONS TO best both consciously and unconsciously (scale of 0 –5) DESCRIPTIVE PHRASES would thus be the strongest candidates for brief ways of capturing the construct PHRASE TOTAL SWING ELITE of social determinants for the general 2.1 1.6 Your opportunity for health starts long 1.8 public. This includes both decision elites before you need medical care. and swing voters, and could be readily use in public service announcements 4.7 Health starts long before illness, in our 4.2 4.4 as “taglines.” One message—“Health homes, schools and jobs. starts long before illness, in our homes, All Americans should have the opportunity 3.4 2.5 4.5 schools and jobs”—captures the general to make choices that allow them to live construct of social determinants in a a long, healthy life, regardless of their relatively comprehensive way for such a income, education or ethnic background. brief statement and is easy to remember. A second—“Your neighborhood or job Your neighborhood or job shouldn’t be 4.8 4.1 4.7 hazardous to your health. shouldn’t be hazardous to your health”— is a strong message with a negative tinge, Health begins where we live, learn, work 1.8 1.7 1.9 that provides a motivation for action. and play. The third—“All Americans should have 0.4 The opportunity for health begins in our 0.1 0.3 the opportunity to make choices that families, neighborhoods, schools and jobs. allow them to live a long, healthy life, regardless of their income, education or 0.9 1.5 0.4 If we want to improve our health, we need ethnic background”—did remarkably to address the social determinants of health. well both consciously and unconsciously. Although it is longer than optimal for a proxy statement, it is a strong health disparities statement that generated strong positive responses. 34 VULNERABLE POPULATIONS PORTFOLIO

40 Conclusions The data reported here are only a beginning, but they represent a comprehensive effort at identifying ways of talking with the general public, including swing voters and opinion elites, about social determinants of health. The main “take-home points” include the following: KEYS TO EFFECTIVE MESSAGING ON SOCIAL DETERMINANTS Messages that overly academic. Americans, including opinion • sway Americans describe both elites, do not spontaneously facts and policy prescriptions at consider social influences on a moderate level of specificity– They tend to think about health. that is, at the level of principles health and illness in medical or examples, not specific policy terms, as something that starts at prescriptions or 10-point plans. the doctor’s office, the hospital, or the pharmacy. They recognize the • Americans consciously believe impact of health care on health, in equal opportunity to health, and spontaneously recognize the but messages that describe importance of prevention, but disparities evoke negative they do not tend to think of social reactions unless written carefully factors that impact health. to avoid victim-blaming and • to emphasize the importance They do, however, recognize of people exercising personal social factors and see their Messages about responsibility. importance when primed. disparities trigger unconscious Raising awareness of social prejudice unless carefully factors is not difficult, although constructed to redefine “them” people more readily recognize as “us.” voluntary behaviors that cause illness (e.g., smoking, overeating) • Messages that mix traditionally than arbitrary or social factors conservative values (e.g., the (e.g., race, ethnicity, income). value of small business) with • traditional progressive values Americans, including elites, do (e.g., equal opportunity) tend not resonate with the language to fare better in speaking to of “social determinants of health disparities. Starting right health,” but they do resonate and moving left is important in with the core construct. When connecting with conservative presented with the compelling Americans, who tend to believe narratives, Americans recognize that hierarchies are natural the importance of both the social and reflect poor choices, bad context and health disparities. judgement or bad behavior. • Messages that sway Americans, including elites, are values- based and emotion-laden, not ROBERT WOOD JOHNSON FOUNDATION 35

41 VULNERABLE POPULATIONS PORTFOLIO Health begins where we live, learn, work and play. The Vulnerable Populations Portfolio looks at factors outside of the medical care system that impact how healthy—or unhealthy—we are. We create new opportunities for better health by investing in health where it starts—in our homes, schools and jobs. LEARN LIVE WORK PLAY For more information about the Robert Wood Johnson Foundation’s Vulnerable Populations Portfolio, please go to . © 2010 Robert Wood Johnson Foundation Content from this report may be reproduced without prior permission provided the following attribution is noted: “Copyright 2010 Robert Wood Johnson Foundation” Design: Ideas On Purpose, New York, NY / 36 VULNERABLE POPULATIONS PORTFOLIO


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