framing a public discussion on the social determinants of health lauri andress, ph.d. june 24, 2009

Framing a Public Discussion on the Social Determinants of Health

Framing a Public Discussion on the Social Determinants of Health

Lauri Andress, Ph.D. • June 24, 2009

Which message explains health disparities the best?Which message explains health disparities the best?

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1. The Health Environments we live in have important effects on health outcomes, and are defined by everything from the availability of decent paying jobs to decent housing to a good education and high-quality preschool.

2. African-Americans tend to be less healthy than Whites, due to how the body is affected by the day-to-day experience of having lower status. As they are treated slightly differently from other people, the brain and body automatically respond as they would to a threat, in

ways that can cause serious health damage.

1. The Health Environments we live in have important effects on health outcomes, and are defined by everything from the availability of decent paying jobs to decent housing to a good education and high-quality preschool.

2. African-Americans tend to be less healthy than Whites, due to how the body is affected by the day-to-day experience of having lower status. As they are treated slightly differently from other people, the brain and body automatically respond as they would to a threat, in

ways that can cause serious health damage.

Do we need a public discussion on the SDOH?Do we need a public discussion on the SDOH?

Depends … Depends …

Assumptions & AssertionsAssumptions & Assertions

• Social determinants of health [SDOH] are related to public policy.

• Making public policy in democracies involves politics and competing values.

• Advancing the SDOH takes political will and skills.

• Requires agreement on ideas and policy initiatives

• Social determinants of health [SDOH] are related to public policy.

• Making public policy in democracies involves politics and competing values.

• Advancing the SDOH takes political will and skills.

• Requires agreement on ideas and policy initiatives

Framing the DiscussionCultural learningFraming the DiscussionCultural learning

The group that defines the issue wins the day……………

Public PolicyPublic Policy

Values

Fundamental human needs of autonomy, empowerment, and human freedom…… The opportunities for full social engagement. Opportunities for people to craft a life they value.

Without relief from social inequality and poverty plus empowerment, improvements in health inequalities will not be achieved.

It is about keeping healthcare costs down…….

Social Justice

Healthcare Access and Quality

Racial and Ethnic differences in health

The conscious, strategic efforts by groups of people to fashion shared understandings of the world and of themselves that legitimate and motivate collective action." (1)

We want a public discussion that does the following …We want a public discussion that does the following …

• Demonstrates significant gaps between the health of wealthy and poor people• Explains the gradient of health along all socioeconomic levels• Shows the significant race-based gaps in health outcomes• Presents the science deemed important by experts

– The meaning of the gap between U.S. healthcare spending and outcomes when it comes to health

– The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.)

– The role of social exclusion [social inequality] in determining health outcomes– The role of circumstances-induced stress as a mechanism leading to health

disparities between different populations– The importance of both psycho-social and material causalities in creating

disparities• Offer a believable causal story that is different from the

– Right choices model– Health care access model– Individual behavior model

• Offers solutions that imply policy venues that improve health and reduce disparities• Emphasizes intersectoral policies that fight the deepest roots of the social

determinants of health

• Demonstrates significant gaps between the health of wealthy and poor people• Explains the gradient of health along all socioeconomic levels• Shows the significant race-based gaps in health outcomes• Presents the science deemed important by experts

– The meaning of the gap between U.S. healthcare spending and outcomes when it comes to health

– The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.)

– The role of social exclusion [social inequality] in determining health outcomes– The role of circumstances-induced stress as a mechanism leading to health

disparities between different populations– The importance of both psycho-social and material causalities in creating

disparities• Offer a believable causal story that is different from the

– Right choices model– Health care access model– Individual behavior model

• Offers solutions that imply policy venues that improve health and reduce disparities• Emphasizes intersectoral policies that fight the deepest roots of the social

determinants of health

• Demonstrates significant gaps between the health of wealthy and poor people

When you think about this statement, does it have meaning for you?

• Demonstrates significant gaps between the health of wealthy and poor people


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1. Yes

2. No

3. Not sure I understand the statement

1. Yes

2. No


• Explains the gradient of health along all socioeconomic levels

When you think about this statement, Does it have meaning for you?

• Explains the gradient of health along all socioeconomic levels


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1. Yes

2. No


1. Yes

2. No


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• Shows the significant race-based gaps in health outcomes


• Shows the significant race-based gaps in health outcomes


1. Yes

2. No


1. Yes

2. No


• The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.)

When you think about this statement, does it have meaning to you?

• The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.)

When you think about this statement, does it have meaning to you?

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1. Yes2. No3. Not sure I understand the statement


• The role of social exclusion [social inequality] in determining health outcomes


• The role of social exclusion [social inequality] in determining health outcomes


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• The role of circumstances-induced stress as a mechanism leading to health disparities between different populations


• The role of circumstances-induced stress as a mechanism leading to health disparities between different populations


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• The importance of both psycho-social and material causalities in creating disparities

When you think about this statement does it have meaning for you?

• The importance of both psycho-social and material causalities in creating disparities

When you think about this statement does it have meaning for you?

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1. Yes2. No


1. Yes2. No


A Public discussion looks like this…Possible messages that we need to transmit…

A Public discussion looks like this…Possible messages that we need to transmit…

• Certain groups of people are less healthy because they are socially or economically deprived.

• One of the best investments we can make is to improve living conditions of people at the lower end of the economic scale. Investments in everything from better housing, to good daycare to job training and school loans result in better health in a given community and fewer health disparities among groups of people.

• The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because– you are different or– because you don’t have the material goods that have been deemed

important in a society.

• We need to consider more carefully public spending oriented to closing the gaps in terms of rights and opportunities.



• The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because– you are different or– because you don’t have the material goods that have been deemed

important in a society.



In general, when you think about this statement do you:



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1. Agree

2. Disagree


1. Agree

2. Disagree






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1. Agree2. Disagree3. Not sure I understand the statement


• The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because you are different or because you don’t have the material goods that have been deemed important in a society.


• The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because you are different or because you don’t have the material goods that have been deemed important in a society.


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A Quick ReviewA Quick Review

Our In-House PollOur In-House Poll

Social MovementsSocial Movements

Agenda SettingAgenda Setting

Generating the public discussion…Features of Social Movements


Method of issue generation 1. Outside initiative- nongovernmental sources2. Mobilization- government source3. Inside access- bypass public use legislative process

Political opportunities• Openness of political system• Presence of elite alignments• Presence of state repression

Mobilizing structures• The type of structure• The impact of external opportunities• Other resourcesIndividuals MoneyKnowledgeFramesTechnical tools

Process informationDistribute information

Framing processes• The cultural toolkit of a society• Framing strategies• Frame packages• The structure and role of the media



Opportunity Organization

Social Change

FramesShared Cultural Understandings

Mediate Mobilizing structures

Agenda Setting


IssueIssue Public Problem

Legislative Agenda

Media

Public

SPIGS


Issue advocatesPolicy elites

Public4 levels

Media

GovernmentRegulatoryLegislative

Policy monopolyPolicy MadeRecognitionResources

Courts

ClaimsCognitive ModelsImageToneValues

Venues

Victory

FramesNarratives

Stories

Next StepsNext Steps

• Using Social movement elements as framework and the agenda setting model– The U.K.– Canada– United States

• Generally• Kentucky

• The Future

• Using Social movement elements as framework and the agenda setting model– The U.K.– Canada– United States

• Generally• Kentucky

• The Future

A Case StudyA Case Study

The emergence of the social determinants of health on the policy agenda in Britain: 1980--2003

The emergence of the social determinants of health on the policy agenda in Britain: 1980--2003

Results: Political ContextResults: Political Context• Conservative Government

– 1980 to 1996• Before the 80s

– Great discontent– Declining economy– Inflation out- of-control– Weak economy

• The 80s- Thatcherism– Smaller government– Privatization– Weakened unions – MUD

• Early 90s– Economic recession– High unemployment

• Conservative Government– 1980 to 1996

• Before the 80s– Great discontent– Declining economy– Inflation out- of-control– Weak economy

• The 80s- Thatcherism– Smaller government– Privatization– Weakened unions – MUD

• Early 90s– Economic recession– High unemployment

• New Labour – 1997 to 2003

• Shift to the “right”• Rhetoric

– Fiscally prudent– Stakeholder Society

• Responsibility• Equality of

opportunity• Inequalities

– Pledge to address– SID– RED -discreetly

• Poverty for children• Education• Minimum wage

• New Labour – 1997 to 2003

• Shift to the “right”• Rhetoric

– Fiscally prudent– Stakeholder Society

• Responsibility• Equality of

opportunity• Inequalities

– Pledge to address– SID– RED -discreetly

• Poverty for children• Education• Minimum wage

Political opportunities open the way for political action….

Results: Political OpportunitiesResults: Political Opportunities

• 1980: Publication of the Black Report

• 1985: Abolition of the Health Education Council

• 1996: SDOH policies, government publications,

and programs after

• 1980: Publication of the Black Report

• 1985: Abolition of the Health Education Council

• 1996: SDOH policies, government publications,

and programs after

• Temporal Element– Longitudinal Study– Issue generation & expansion – Long-run societal changes affect policies across the

entire political spectrum

• Changing institutional features help make sense of the issue generation tactics– Period One-1980 to 1996

• Issue Generation Method -- Outside Initiative• News articles = 63%

– Period 2-1997 to 2003• Issue Generation Method -- Mobilization Effort• News articles = 57%

• Temporal Element– Longitudinal Study– Issue generation & expansion – Long-run societal changes affect policies across the

entire political spectrum

• Changing institutional features help make sense of the issue generation tactics– Period One-1980 to 1996

• Issue Generation Method -- Outside Initiative• News articles = 63%

– Period 2-1997 to 2003• Issue Generation Method -- Mobilization Effort• News articles = 57%

Results: Issue generation & expansion Results: Issue generation & expansion

Results: Issue generation & expansionResults: Issue generation & expansion

Political Opportunities

Period 11980- 1996Issue Generation Method

Outside InitiativeNews articles =63%

Period 21997-2003Issue Generation Method

Mobilization EffortNews articles =57%

Results: Framing Results: Framing

• Grand debate and discussion on social class & inequalities– Poverty vs. The gradient

• Distinctive cultural toolkit– Inequalities frame package

• Media corresponds to official concerns– A linking mechanism– SPIGS & policymakers – Did not alter lay perceptions– Elite–level debates

• Grand debate and discussion on social class & inequalities– Poverty vs. The gradient

• Distinctive cultural toolkit– Inequalities frame package

• Media corresponds to official concerns– A linking mechanism– SPIGS & policymakers – Did not alter lay perceptions– Elite–level debates

The Media and FramingThe Media and Framing

By excluding or marginalizing other perspectives-notably a more political analysis of the origins of illness-as opposed to just the biomedical perspective- the media play a significant part in narrowing the public debate about health, illness, and society.

Results: Framing Results: Framing • Inequality, Health & Government

– British Social Attitudes Survey since 1983

– 40% of coded solutions call on Govt.

– 48 frames identified- 20 on inequality

• Most frequently identified inequality frame: – Government allocation of

resources to address poverty and social inequality.

• Inequality, Health & Government– British Social Attitudes Survey

since 1983– 40% of coded solutions call on

Govt. – 48 frames identified- 20 on

inequality

• Most frequently identified inequality frame: – Government allocation of

resources to address poverty and social inequality.

– Most frequently used catch phrases related to inequality were:

• “Division between rich and poor”;

• “gap between the rich and poor and/or

• reduce the income gap between the rich and poor;

• “health inequalities and/or health and inequalities”.

– Most frequently evoked image associated with inequality was:

• “Rich and poor divide”.

– Most frequently used catch phrases related to inequality were:

• “Division between rich and poor”;

• “gap between the rich and poor and/or

• reduce the income gap between the rich and poor;

• “health inequalities and/or health and inequalities”.

– Most frequently evoked image associated with inequality was:

• “Rich and poor divide”.

• National Familiarity with Poverty & Inequality

– Extensive lay and scientific publications• 95% of the news articles in the sample discussed,

analyzed the results of, or invoked popular writings or scholarly reports to support a discussion on the SDOH.

– History of advocacy for health linked to inequality in Britain

• National Familiarity with Poverty & Inequality

– Extensive lay and scientific publications• 95% of the news articles in the sample discussed,

analyzed the results of, or invoked popular writings or scholarly reports to support a discussion on the SDOH.

– History of advocacy for health linked to inequality in Britain

Results: Framing Results: Framing

Results: Mobilization StructuresResults: Mobilization Structures

Group Frequency

Political Parties 11%

Academic Institutions 9%

GovernmentParliament, Downing Street

28%

Advocacy Groups, Think Tanks, Not-for-Profits

9%

Summary: Results & ObservationsSummary: Results & Observations

• Positive political opportunity

• Distinctive cultural toolkit– Inequalities framing package

• Historical discussion on social class and inequality– At the public level– Among expert society

• Mobilization Structures

• Positive political opportunity

• Distinctive cultural toolkit– Inequalities framing package

• Historical discussion on social class and inequality– At the public level– Among expert society

• Mobilization Structures

Telling Stories: News media in CanadaTelling Stories: News media in Canada

• “Health” News stories = 4732• 13 daily Canadian newspapers• Healthcare = 65%• Physical environment= 13%• Socio-economic environment = 6%• Personal health practices = 5%• Scientific advances = 4%

• “Health” News stories = 4732• 13 daily Canadian newspapers• Healthcare = 65%• Physical environment= 13%• Socio-economic environment = 6%• Personal health practices = 5%• Scientific advances = 4%

To what extent do Canadian newspapers cover issues embedded in health policy documents?

They rarely report on the socio-economic influences that are frequently cited in the research literature as being most influential in shaping population health outcomes.

Telling stories: News media, health literacy and public policy in Canada Social Science & Medicine, Volume 64, Issue 9, May 2007, Pages 1842-1852 Hayes, et al.

Social Determinants & the United StatesSocial Determinants & the United States

• Achieving broad public acceptance of the social determinants issue will depend upon:– Political opportunities

– U.S. ideals, and values regarding: • Poverty • Inequality • Health • Health care

– Mobilization systems• A constituency

– Where the issue is lodged

Framing: How the issue is lodgedThe images and symbols used to communicate the issue

• Achieving broad public acceptance of the social determinants issue will depend upon:– Political opportunities

– U.S. ideals, and values regarding: • Poverty • Inequality • Health • Health care

– Mobilization systems• A constituency

– Where the issue is lodged

Framing: How the issue is lodgedThe images and symbols used to communicate the issue

Political Opportunities: United StatesPolitical Opportunities: United States• Government intervention• Government intervention

Ronald Reagan (1981) “Government is not the solution to our problem; government is the problem.”

George Bush The terrorist attacks in 2001 led to the creation of the Department of Homeland Security, the Patriot Act, the federalization of airport security, an expansion of money-laundering rules and federally subsidised terrorism insurance. Stock market collapse led to the Sarbanes-Oxley: act oversees corporate governance and accounting standards.

Government v market in America: The visible handMay 28th 2009 | INDIANAPOLIS AND WASHINGTON, DCFrom The Economist print edition

2007 International survey by Pew: American support for free markets had edged down from five years earlier. Americans, traditionally fonder of the free market than the rest of the world, became less so with arrival of the financial crisis –

Americans souring on unconstrained capitalism.

• Issue Generation o Outside initiative- nongovernmental sourceso Mobilization- government sourceo Inside access- bypass public go to legislative process

• Where issue is lodged • State• Local• Regulatory bodies• Academic –research institutions • NGOs• Community organizations• Courts or Policymakers

• How the issue is framed for e.g., • As racial and ethnic problem• As health care access & quality• As social injustice

•

United States ConsiderationsUnited States Considerations

United States: Cultural BarriersUnited States: Cultural Barriers

Values, Beliefs, and FramesPoverty

Land of Opportunity

Inequality

Health and Health Care

Values, Beliefs, and FramesPoverty

Land of Opportunity

Inequality

Health and Health Care

Values, Ideals, Frames, & FramingValues, Ideals, Frames, & Framing

• The Welfare State = Poverty • Who should we help?• How does it impact personality, families, labor

market?• What are the limits of social obligation?• Who provides in time of need?

• Market principles vs. social justice

• Bootstrap• Land of opportunity• Irresponsible vs. responsible

[Katz, 2001]

Values, Ideals, etc. … don’t assume we are all agreedValues, Ideals, etc. … don’t assume we are all agreed

… on Hurricane Katrina“Shame on anyone that makes this tragedy political, socio-economic or racial. … in the land of opportunity and personal responsibility the individual is ultimately accountable.”

Robert Buckley, Decatur, USABBC web site

… on Hurricane Katrina“Shame on anyone that makes this tragedy political, socio-economic or racial. … in the land of opportunity and personal responsibility the individual is ultimately accountable.”

Robert Buckley, Decatur, USABBC web site

•Inequality- Equality- Class•Natural and endemic to our society

• Life is unfair..• Potential for upward mobility

Isaacs & Schroeder, 2004]; [Kawachi, Daniels, & Robinson, 2005

Values, Ideals, Frames, & FramingValues, Ideals, Frames, & Framing

• Health: How do we think about it in the U.S.?• Healthcare access problem• Healthcare cost problem• Behavioral explanations• Genetic• Cultural problem: racial and ethnic groups• Socio-structural

Health: How we think about it in the U.S.?Health: How we think about it in the U.S.?

Public assumes a different causal story: RIGHT CHOICES

CHOICES

Character, Knowledge, Culture, Priorities, Values

Healthier

Less Healthy

GROUP A

GROUP B

GROUP C

CHOICES

Health: How we think about it in the U.S.?Health: How we think about it in the U.S.?

A “User-friendly” Conceptual Model: simple, easy to understand – seems like the whole story

A Moral Model: Not just how things do work, but how they should work – outcomes seem fair

HEALTH OUTCOMES

Health In the U.S. -- A Moral LensHealth In the U.S. -- A Moral Lens

Q: Do you think we as a society owe every person some kind of help for being healthy? Is something like that a right to have?

A: No. Not as a society, because see a lot of times people cause their health problems by the way they live.

Conservative African-American man, age 60

Q: Do you think we as a society owe every person some kind of help for being healthy? Is something like that a right to have?

A: No. Not as a society, because see a lot of times people cause their health problems by the way they live.

Conservative African-American man, age 60

It’s your own personal responsibility to do what you can to improve your health and keep yourself healthy ... If I’m going out, [if] I smoke a lot, if I’m carrying on excess weight or if I have four or five alcoholic drinks every day – I’m making that decision. That’s my choice, so I’m hurting myself. I think there’s too much of people not taking responsibility for their actions and just letting it go and thinking, well, you know, let somebody else take care of me.

Moderate White woman, age 75

Values, Views, Frames, & FramingValues, Views, Frames, & Framing

• Health care• If we spend enough we can get it right!• Consumer Logic

• Healthcare is a commodity• Preempts moral perspective• Not everyone has a right to a given consumer good• If you want it you work hard to get it or ---• It was a luxury you couldn't afford.

• Government intervention will not fix problem• But the government must do something…

• Scared for small businesses…• Want poor to help pay for costs but not be too

burdensome…

FrameWorks InstituteFrameWorks Institute

Values, Views, etc.Values, Views, etc.

• Where issue is lodged – State Health Departments– Local Health Departments– NIH– CDC– Policymakers

• How the issue is framed– Disparities as racial and ethnic– Disparities as access

– Disparities vs. inequalities

• Where issue is lodged – State Health Departments– Local Health Departments– NIH– CDC– Policymakers

• How the issue is framed– Disparities as racial and ethnic– Disparities as access

– Disparities vs. inequalities

Low Hanging FruitLow Hanging Fruit

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1. Early childhood education2. Place-based policies that improve communities 3. Racial and ethnic group differences in health4. Economic policies like the earned income tax5. Healthcare access and quality

1. Early childhood education2. Place-based policies that improve communities 3. Racial and ethnic group differences in health4. Economic policies like the earned income tax5. Healthcare access and quality

In an effort to form a healthy equity policy strategy which has been found to be the most responsive to the US cultural toolkit based on framing research?

In an effort to form a healthy equity policy strategy which has been found to be the most responsive to the US cultural toolkit based on framing research?

The FutureWhere do we go from here?

The FutureWhere do we go from here?

• Change the conversation– Framing research– New narratives

• refined and tested a set of messages• group of 300 subjects, including including113 individuals living in

Louisville and Jefferson County• Subjects were diverse in terms of age, gender, education and ethnicity.

They had no special expertise in areas related to health. Subjects • “pre-tested” with a group of 187 Americans from around the country,

before being edited and refined to the list tested in Louisville.

• The film --- Unnatural Causes

• Low hanging fruit

• Change the conversation– Framing research– New narratives

• refined and tested a set of messages• group of 300 subjects, including including113 individuals living in

Louisville and Jefferson County• Subjects were diverse in terms of age, gender, education and ethnicity.

They had no special expertise in areas related to health. Subjects • “pre-tested” with a group of 187 Americans from around the country,

before being edited and refined to the list tested in Louisville.

• The film --- Unnatural Causes

• Low hanging fruit

The EndThe End

Lauri Andress, Ph.D.www.bridgingthehealthgap.com

framing a public discussion on the social determinants of health lauri andress, ph.d. june 24, 2009

Documents

health environments

health outcomes

public policy

health disparities

serious health damage

public discussion

decent housing

good education