FOREWORD                 WHY WE NEED A BETTER WAY to Talk About                              THE SOCIAL DETERMINANTS OF HE...
What emerged from that analysis was an             Health starts where we live,                                           ...
Peeling THE ONION    CHAPTER     1                      How We Found a Better Way to Talk About the Social Determinants of...
How we assign meaning to what we hear is largely dependent on the contextin which we hear it. And this context is somethin...
The first phase of this research was a series of   In the final phase of the research, Westen Strategiesfocus groups held ...
Choosing WORDSCHAPTER 2        Best Practices in the Language and Framing of Social Determinants of Health          There ...
SEVEN LESSONS:      1                                       3                                          6     Traditional p...
BREAKING IT DOWN:Below you’ll find one long-form message that was developed, revised,tested and revised again based on wha...
SIX WAYS TO TALK ABOUT SOCIAL DETERMINANTS OF HEALTH:    Our hope in this research was to find a tidy proxy that could rep...
A GLOSSARY OF “OTHER TERMS” (continued)Below is an evolving list of terms that describe the groups most profoundly affecte...
Finding ONE FACT TO FIGHT FICTION    CHAPTER     3                      The Use of Data and Information to Support—Not Mak...
NINE FACTS ABOUT FACTS                                     face value unless it is put in a more acceptable               ...
6. Break Down Big Numbers                               The numbers we work with can be both Speaking of big numbers, unle...
Thinking          IN PICTURES     APPENDIX      A                       The Deep Metaphors That Drive How Politicians See ...
The Democratic                               privilege by virtue of birth,” and goes on     affected by social determinant...
Finally, on a social level, the poor are        that they are hard to separate at times)left out of the larger social syst...
for Republicans, as we will see below.       “A long, windy road. There needs to beHowever, it is important to understand ...
The difference in base level of optimismversus anger between the Republicansand Democrats could be a real source oftension...
meaning that they want to be certain        “[Democrats] would be just as happy            the government and what is expe...
Implications and                                This first meant scrapping all language      as: choosing better paths, mo...
Fig. 4   Map of common ground between Democrats and Republicans regarding the causes of poor levels of health.            ...
Changing           OUR FRAME OF MIND     APPENDIX      B                       The Role of the Mind, Brain and Emotion in ...
GOALS                                          matters and why both decision elites     neighborhood would today bring toT...
Although people are aware of some               represents the assessment of what is; the   health (to see its broader con...
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  2. 2. TABLE OF CONTENTS FOREWORD WHY WE NEED A BETTER WAY to Talk About THE SOCIAL DETERMINANTS OF HEALTH by Jane Isaacs Lowe, Ph.D. page ii CHAPTER Peeling THE ONION 1 How We Found a Better Way to Talk About the Social Determinants of Health page 1 CHAPTER Choosing WORDS 2 Best Practices in the Language and Framing of Social Determinants of Health page 4 Finding ONE FACT TO FIGHT FICTION CHAPTER 3 The Use of Data and Information to Support—Not Make—Your Case page 9 APPENDIX Thinking IN PICTURES A The Deep Metaphors That Drive How Politicians See Health Disparities by Elizabeth Carger page 13 APPENDIX Changing OUR FRAME OF MIND B The Role of the Mind, Brain and Emotion in Developing Messages by Drew Westen, Ph.D. page 21 V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O i
  3. 3. FOREWORD WHY WE NEED A BETTER WAY to Talk About 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 R OB ER T WOOD J OH NSON F OUN DAT ION
  4. 4. What emerged from that analysis was an Health starts where we live, learn, work and play.understanding that the programs and projectswere united in that they each worked within thecontext of the social determinants of health. Andwhile social determinants were well established in We tweaked it and refined it a little, andacademic circles and have been the subject of what we ended up with was simple: Health startsconsiderable study, we quickly discovered that where we live, learn, work and play. We startedthe concept didn’t work on the ground. The to see the messages picked up everywhere, butgrantees—most of whom were dealing with most importantly in media accounts of ourreal 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 itsit was so patently obvious that it became a “road test,” we are an institution that prides itselftruism. And as unsuccessful as the concept was on evaluation and measurement of the ideas wefor existing grantees, it made even less sense put forward. So we decided to test the messagesto organizations that approached the team for more rigorously—to make sure we were gettingfunding 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 engagedthe topic so that it made sense to our colleagues Drew Westen, Ph.D., of Westen Strategies andand people in the field, the Foundation was author of The Political Brain to help us fine-tunedeveloping 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 ownon why some Americans are so much healthier communications staff to conduct the researchthan 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 whatframe for talking about the social determinants we’ve learned to ourselves. We hope that thisof health. Not just for people working in the field, research and the way we’ve applied it is helpfulbut for policy-makers. We had to talk about the to you. Please use it freely, but let us know iftopic in a way that people could understand, that you do. We’d love to continue to build on whatwas meaningful, and that didn’t align the topic follows here.with any existing political perspective or agenda. By working with a talented group ofcommunicators, including Linda Loranger ofBurness Communications, Allison Rosen ofChandler Chicco, Bob McKinnon ofYELLOWBRICKROAD and Elizabeth Carger of Jane Isaacs Lowe, Ph.D.Olson Zaltman Associates, we were able to arrive Team Directorat a frame that described the social determinants Vulnerable Populations Portfolioof health plainly, without political overtone. Aswe started using this new way of talking not onlyfor the commission, but also for the work in theportfolio, we gained significant traction. V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O III
  5. 5. Peeling THE ONION CHAPTER 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.1 R OB ER T WOOD J OH NSON F OUN DAT ION
  6. 6. How we assign meaning to what we hear is largely dependent on the contextin which we hear it. And this context is something that even the most self-awareperson can have a difficult time expressing. So as we developed messages andtested their reception, we benefited from advanced market research techniquesdeveloped and used by Olson Zaltman Associates and Westen Strategies toget at these deeper-level insights. This guide is informed by an iterative researchand message development process that includes three steps: Determine How Policy-Makers Develop Messages That We Strengthen the Messages 1 See the World of Health 2 Can Road Test 3 With TestingIn late 2006, as the Robert Wood Johnson This research informed the commission’s To validate and strengthen the VulnerableFoundation was establishing the Commission message strategy, and we also applied Populations messages, we engagedto 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 builtfirm, to help us gain a “deep understanding solutions to address the impact of social on the messages we were already usingof people’s thoughts and feelings about factors on those most vulnerable among to understand which language resonatedhealth differences across populations in us. This messaging was successfully road with our priority audiences. We also wantedthe United States.” The insights from this tested with media and policy-makers to know whether differences existed inresearch provided a framework for talking in 2008 and 2009. Our core message certain political segments’ receptivity toabout the diverse issues addressed by emphasized “new pathways for improved our messages. Westen Strategies enlistedthe Commission, with social determinants health that recognize the integral relationship Public Opinion Strategies to conductof health chief among them. Specifically, between our health and where and how various stages of the research and ensureOZA’s work showed how people with we live, learn, work and play.” We looked that the end product would be informeddifferent political perspectives see health to our grantees and the communications by a range of political perspectives. Thisdifferently. More importantly, the research experts who work with them to provide study went into the field in the summeridentified ways to frame our messages valuable input that strengthened our of 2009.about health differences that would messages and ensured that we avoidedresonate across the political spectrum. language that would fall flat on the frontWorking closely with OZA, we had the lines. Collaboration and a constantopportunity to dig deeper into how people feedback loop were a critical part of thesee this issue, and then layer additional process at every stage.forms of research over their findings to geta more robust and precise understandingof how people see health. (Elizabeth Cargerof OZA has written a highly detailedchapter on their work in this area, whichis included as an appendix in this guide.) V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 2
  7. 7. The first phase of this research was a series of In the final phase of the research, Westen Strategiesfocus groups held in multiple cities and grouped took that learning one step further by exposingby male and female swing voters in Ohio, Blacks these messages to more than 1,700 registered votersand Hispanics in Houston and opinion leaders in and capturing their conscious and unconsciousWashington, D.C.. It was conducted by Public reactions. Dr. Westen details this research processOpinion Strategies (POS). With the feedback we and what we learned from it in an appendix atgot from this process, we refined the messages. the end of this guide.POS tested the refined messages in a quantitativeInternet survey of 1,000 registered voters. From start to finish, this research represents We’ve shared what we learned in settings smallresponses from more than 3,000 Americans and large—including conferences sponsored byacross the country over four years—using the Centers for Disease Control and Preventionboth traditional research methods and new, and Grantmakers in Health—and the responsesophisticated market research techniques—to has been consistent: “This is great, but how cananswer 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 anexpand Americans’ views about what it means overview of what we learned—which words, phrasesto be healthy—to include not just where health and framing work and why—but also a detailedends 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 workthe way for more solutions that address this was critical to our understanding of how Americanscritical link between our health and where we perceive this issue.live, learn, work and play.3 R OB ER T WOOD J OH NSON F OUN DAT ION
  8. 8. Choosing WORDSCHAPTER 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. V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 4
  9. 9. SEVEN LESSONS: 1 3 6 Traditional phrasing of social Use one strong and compelling fact— Mix traditionally conservative determinant language consistently a surprising point that arouses values with traditionally tested poorly in every phase of interest, attention and emotion—for progressive values. Every phase research. Phrases like “social maximum impact. Loading messages of research showed that while determinants of health” and down with more than one or two facts some phrasing appealed to one “social factors” failed to engage tends to depress responses to them. political perspective over another, the audience, even when we progressives had a tendency to added more context. However, the be more open to conservative concept behind social determinants of health does resonate with our 4 frames. Generally, however, we need to be aware of these different audiences, as evidenced by our worldviews and communicate Identify the problem, but offer pre- and post-testing of people’s using language that puts us on potential solutions. Respondents, attitudes after their exposure to common ground. For example, particularly opinion leaders, prefer our messages. combining the notion of personal 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 2 the problem or a set of principles a message about opportunities, 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 more convincing than those that (versus a specific ethnic group make choices that lead to good health did not discuss medical care resonated with participants across the or socioeconomic class). This at all. When messages are political spectrum. Incorporating this research showed that Americans presented in colloquial, values- point made respondents more receptive believe in equal opportunity to driven, emotionally compelling to the idea that society also has a role health, but describing actual language, they are more to play in ensuring that healthy choices disparities consistently evokes effective. Academic language, are universally available. negative reactions. Messages including “social determinants,” that described disparities based did not resonate with audiences on race or ethnicity fared poorly the way language like “health with every audience except Black starts in our homes, schools and respondents. Furthermore, some communities” did. focus group participants expressed concern that focusing on one ethnic group reinforced negative racial stereotypes.5 R OB ER T WOOD J OH NSON F OUN DAT ION
  10. 10. BREAKING IT DOWN:Below you’ll find one long-form message that was developed, revised,tested and revised again based on what the research showed us. WHY THIS WORKED:It was consistently the most persuasive message among all groups, • Audiences flat out didn’t believe theregardless of their political perspective. While we are not necessarily statement, “America is not among the toprecommending that you use this in its entirety, it is helpful to understand 25 countries in life expectancy,” and theywhy 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 like how long we live, we’re not even in the top 25, everyone can afford to see a doctor when behind countries like Bosnia and Jordan. It’s time they are sick” doesn’t touch existing political hot buttons. for America to lead again on health, and that means taking three steps. The first is to ensure • Framing our message in the context of 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 care like screening for cancer and heart disease what it takes to be healthy. into every health care plan and make it available • The inclusion of specific solutions increased to people who otherwise won’t or can’t go in for acceptance of the core message. it, in malls and other public places, where it’s easy • Illustrating with examples like “playgrounds to stop for a test. The third is to stop thinking and parks” and “in the air we breathe and 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 and the water we drink. The more you see the Centers for Disease Control and at problem of health this way, the more opportunities universities around the country have 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 enormous impact on our health, long before we than all the errors doctors and hospitals ever see a doctor. It’s time we expand the way make combined.” Presenting the fact 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. V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 6
  11. 11. 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, 2 All Americans should have the opportunity to make values-driven language and relatable the choices that allow them to live a long, healthy lifestyle references that engage audiences. life, regardless of their income, education or ethnic background. • These statements all focus on the solution versus the problem. 3 Your neighborhood or job shouldn’t be hazardous • Some of the statements implicitly to your health. acknowledge the notion of personal responsibility. 4 Your opportunity for health starts long before you need medical care. 5 Health begins where we live, learn, work and play. 6 The opportunity for health begins in our families, 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 • Unconscionable7 R OB ER T WOOD J OH NSON F OUN DAT ION
  12. 12. 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 notonly 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. Vulnerable Populations • Disappointing (as in Americans The elderly population and should be able to do better, not their families, nursing homes • Too many Americans don’t have let people fall through the cracks) the same opportunities to be as and elder care healthy as others • It’s time we made it possible for all Americans to afford to see a • Our aging parents and • Americans who face significant doctor, but it’s also time we made grandparents barriers to better health it less likely that they need to • Our elders • People whose circumstances • Elders have made them vulnerable to Poverty poor health • Caring for people as they age • Families who can’t afford the • All Americans should have the basics in life Refugees and immigrants opportunity to make the choices that allow them to live a long, • Americans who struggle financially including children 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 and play • People who work for a living and • From undocumented immigrants still can’t pay their rent to productive, tax-paying • People’s health is significantly American citizens affected by their homes, jobs • Hard-working Americans who and schools have gotten squeezed out of the middle class in tough times Youth and teens 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, • Giving everyone a chance to live including young people • Unsafe streets a healthy life • The epidemic of violence • It’s just as dangerous and • Unfair debilitating as any other • Street violence • Not right chronic disease • Intergenerational cycle of violence and abuse • Teen dating violence and abuse V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 8
  13. 13. Finding ONE FACT TO FIGHT FICTION CHAPTER 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.9 R OB ER T WOOD J OH NSON F OUN DAT ION
  14. 14. NINE FACTS ABOUT FACTS face value unless it is put in a more acceptable 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 to zero. The program allows kids to spend more 5. Don’t Let Numbers Be Forgettable time playing instead of fighting, and teachers to Specificity matters when it comes to examples, spend more time teaching instead of dealing with but not so much when dealing with the actual conflicts that carry over to the classroom. In fact, the number. Our level of precision doesn’t need to program has been shown to restore a whole week’s approach the level of pi to prove that the research worth of class time that would have previously been is valid. Why say 23.6 percent of those in poverty spent dealing with fights.” didn’t graduate high school when you can say 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 V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 10
  15. 15. 6. Break Down Big Numbers The numbers we work with can be both Speaking of big numbers, unless they are put into some kind of context, they can lose their mind-boggling and mind-numbing. It is meaning and intended impact. Recently, the founder of TED, Richard Saul Wurman, our job to break them down in a way that 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 The numbers we work with can be both differently, and those differences were often mind-boggling and mind-numbing. It is our associated with very different life circumstances. job to break them down in a way that is both So for those participants who had graduated comprehensible and meaningful. Reporting that college and were more conservative, they actually health insurance legislation costs a trillion dollars believed the data but amazingly didn’t think that (over 10 years) is an accurate estimate but creates seven years of life was that much of a difference. a completely different meaning than telling Conversely, those who were not college graduates someone that the cost of reform breaks down rejected the idea that education played any role to $3 a day for every American. in how long someone might live. 7. The Value in a Number Is in Its Values 9. Overall Messaging Rules Still Apply Numbers can represent both a value and our Finally, we need to realize that facts aren’t a values. You can say that half of all parents in separate part of our message but an essential poor neighborhoods don’t feel safe letting their ingredient to telling our story. They benefit children play on the streets. Or you can try and from the same lessons we’ve shared earlier in create a picture of what it must be like to feel this report. trapped in your own home, unable to move There is no shortage of good data that because of your job or income, not able to give supports the idea that our health starts long your kids the most basic opportunities to play before illness—in our homes, schools and jobs. outside or run free, but instead fear that they But there is still a long way to go to make sure could get caught up with the wrong crowd or that we are using it to maximum effect. To struck down by a stray bullet, like the neighbor’s this end, we have begun to aggregate these kid next door. sources and refine these messages online at http//sites.google.com/factsthatfightfiction. 8. Imagine Why Someone Might Cry Foul? We invite you to visit this site, add your own Some of the most important lessons from the compelling data and comment on how you’ve research involved life expectancy data. For been able to successfully use great information example, when we stated that there was up to to make good things happen. a 25-year difference in life expectancy between 11 R OB ER T WOOD J OH NSON F OUN DAT ION
  16. 16. APPENDICES
  17. 17. Thinking IN PICTURES APPENDIX A The Deep Metaphors That Drive How Politicians See Health Disparities 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.13 R OB ER T WOOD J OH NSON F OUN DAT ION
  18. 18. The Democratic privilege by virtue of birth,” and goes on affected by social determinants ofFrames for Social to discuss how unequal levels of health health. Broadly, containers keep based solely on the zip code in which things in and keep things out; they areDeterminants 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;Across Populations The second level on which the deep they can be open or closed, positive or negative. metaphor system operates is thatSYSTEM Democrats view poor levels of health For Democrats, low‐income communitiesThe deep metaphor of system forms as emerging from a complex and are isolated and self‐contained on allthe fundamental underpinning for the interrelated system of social, cultural, three levels—physical, psychological,Democratic view of social determinants economic, and biological factors. and social. They are physically isolatedof health. Broadly, the system-deep One Democrat states, “It’s all tied in locations that lack resourcesmetaphor refers to the unification and together—housing, health care, energy, necessary to live a healthy life suchorganization of separate entities into food.” Consequently, changing any one as easily accessible doctors’ offices,a whole. The unity of a system means factor, such as access to insurance, is grocery stores with fresh foods, andthat the parts are interdependent; these not going to fix the problem of health places to exercise safely. One Democratconnected parts often operate in a disparities. There are numerous social says “it’s like living within your ownpredictable and recurrent pattern with determinants that we must address little world…the reality for poorcertain results. simultaneously and comprehensively people is never leaving their culture in order to overcome the system of of poverty.” On a psychological levelFor Democrats in particular, the interrelated factors that results in poor this “culture of poverty” traps themsystem frame operates on two levels. levels of health, in certain communities. in a mentality that they can neverFirst, American society as a whole Because this frame of a complex system get ahead, they are unable to takeis a complex system that unifies all permeates the Democratic view of advantage of the opportunities incitizens. As such, all individuals, from health they often feel the need to discuss broader society. Democrats describethe poorest person in the Bronx to a multitude of issues and factors the poor as “a self‐contained groupthe wealthiest person in Manhattan, simultaneously, quickly moving from at the bottom of the pyramid withare interdependent, even if this is not one cause to another cause. This high unemployment, low job status.”readily apparent. When poor levels of makes their discussions seem complex Solving health-related problems seemshealth exist in some communities it and, at times, muddled. Even though particularly hopeless. The poor haveeventually affects everyone and weakens comprehensively addressing all social watched grandparents and parentsthe entire system that is America. determinants of health makes perfect die of diabetes-related complicationsWhat holds this American system sense to individuals operating in the or heart disease and it has becometogether is a foundation of rights such world of public health and policy who almost an expected life outcome. Thereas freedom, opportunity, and equality. hold the same system frame, it may be exists a psychological and culturalFor Democrats, health is itself a right; cumbersome and frustrating to those barrier to reaching out to the medicalall Americans have the right to health who hold a different frame, as we will community. A common Democraticcare and the right to lead a healthy life. see with the Republican world-view. manifestation of the container frameOne Democrat states, “Health care is a involves barriers. They bring imagesright, it’s so fundamental to being able CONTAINER of blockades and “significant barriersto have a healthy lifestyle. [What makes Where the deep metaphor system related to health care [exist between theit a right are] the values of society, of underpins the Democratic view of Latino community/African-Americanfederal government.” Another states American society and health-related community and White folks.”]that “one of the real founding principles issues, the deep metaphor container[of America] was the notion of absence of frames the way they view communities V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 14
  19. 19. 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 inthat Democrats see as underpinning American society between the “haves”America. This is particularly troubling and the “have nots.” For Democrats, afor Democrats as part of their situation where “it would take this chieffundamental view of society is that executive two hours to earn enough toeveryone is interconnected, so having fund a community kitchen for threesome groups left out of this system is years” is morally wrong —“Somethingnot 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 pointfunctioning system of inclusion. One for Democrats. As we will see later,Democrat states, “Individuals at the Republicans have a more optimisticbottom of society’s rungs, economically, view of Americans’ health status,socially, etc., they’re the ones who whereas Democrats are angered by thisget left out when it comes to access profound social imbalance, “It makesto affordable, quality health care. me very angry…it’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…Iresponsibility, an obligation, and it’s didn’t realize how angry I was aboutin our best interests to bring them in.” that until you asked me.” Or, in theConsider the digital collage that one collage below, “This woman who’sDemocrat created, which exemplifies screaming [represents that] she’s angrythe way low‐income communities trap that these problems existed for so long.”individuals in “containers” that separate Fig. 1 Collage created by a Democrat tothem from the larger social system, as The second way that the balance-deep show the separation of poor communities fromrepresented by the well‐dressed white metaphor frames how Democrats view wealthy White society.students at the bottom of the image issues related to health disparities is Fig. 2 Collage created by a Democrat(see Figure 1). in their discussion of remedies and highlighting anger over persistent social outcomes. Democrats seek equality— imbalance with regards to health levels.BALANCE balanced distribution of resources, theThe balance-deep metaphor encompasses same health care treatment for everyone,ideas of equilibrium, adjusting, and (ideally) equal outcomes in that allmaintaining or offsetting forces, and communities would have roughly thethings being as they should. Balance same levels of health. The language ofthemes can structure peoples’ thinking equality has been a cornerstone ofabout social, moral, psychological Democratic discussions of a multitudeand emotional domains. Democrats of social issues, from health disparitiespredominantly express the negative side to employment to education. Statementsof balance. Having an interconnected like, “Equality assumes that we aresocial system while simultaneously all going to end up at the same level.tolerating pockets of isolated, self- Equity to me presumes a fair andcontained, impoverished citizens leaves even distribution of resources” pepperDemocrats with a profound sense the Democratic discussion of socialof imbalance. Health disparities and determinants of health. Critically, thiswealth disparities (issues that are so is not the language that is effectivedeeply interconnected for Democrats15 R OB ER T WOOD J OH NSON F OUN DAT ION
  20. 20. for Republicans, as we will see below. “A long, windy road. There needs to beHowever, it is important to understand constant movement, a journey—it’s notthat this frame of equality—as expressed where you’re going, it’s the fact thatby the desire for balance in terms of you’re moving…We’re a very differentaccess, treatment, and outcome—is population than we were a hundreda cornerstone of how Democrats years ago; the person laying out thatconstruct solutions to health disparities road a hundred years ago—they had noacross American populations. idea what society was going to look like.” This long‐term journey frame makes Republicans more hesitant toThe Republican institutionalize programs to address social determinants of health, particularlyFrames for Social in a federal government that is slowDeterminants of Health to adapt to unforeseen, yet inevitableand Health Disparities changes over time.Across Populations Another important ramification of this much longer and linear journey frame as compared to the DemocraticJOURNEY system frame is that Republicans areWhere system forms the fundamental fundamentally more optimistic aboutlens through which Democrats view where we are today in terms of thesociety and health, the deep metaphor health of the American population.journey is the predominant frame Where the Democrats expressedthrough which Republicans view extreme anger over perceived socialAmerican society and health issues. imbalances, Republicans state, “LookBroadly, journey often frames our back to where the world was 80 yearsdiscussion of life itself. Journeys can be ago, 90 years ago. The average lifefraught with challenge or can be smooth expectancy was middle age. …I’msailing; they can be direct or divergent. not going to die before I’m 55, whereSome journeys are unpredictable, 100 years ago I couldn’t say that. It’swhere others focus on a series of steps collective improvement that goes fullthat, if followed, will take you to a spectrum.” They also tend to comparepredetermined place or goal. us to other countries to show how muchThe type of journey that a group farther along we are on our Americandescribes can yield much insight into journey overall, and our health journeyhow they view a given topic. For in particular. “The African lady withRepublicans, American society as a the bundle on her head symbolizes thatwhole is on a long, unpredictable ours is a society that has come so muchhealth journey through time. They use farther than that. …We have forgottenmetaphors of winding paths and stress where our health system was 20 yearsthe importance of adaptability in the ago. We don’t have the perspective…it’sface of an unknown future direction. a little unrealistic to think that becauseOne Republican states: we are short of perfection, that the system is somehow deeply flawed.” V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 16
  21. 21. The difference in base level of optimismversus anger between the Republicansand Democrats could be a real source oftension between the two groups when itcomes to discussing social determinantsof health. Understanding these basicdifferences in emotional response to theissue could help anticipate touch pointsin a conversation where communicationmight break down.Much as they see America and healthcare as a whole on a journey throughtime, Republicans see individuals ason their own health journeys. Echoingthe common theme of “individual Fig. 3 Collage created by a Republican to show different choices along the journey of health and howresponsibility,” Republicans view poor they lead to either positive or negative life outcomes.health as arising from bad choices alongone’s path and the inability to overcomeobstacles to health that one encounters would lead him to a lower path, which The second Republican expression ofalong the way. Rather than employing is disadvantage. Or the baby could take resource highlights an important aspectthe Democratic frame of externally‐ the upper path where they don’t have of this deep metaphor. Physical resourcesimposed barriers that trap communities a care about anything.” Thus, where are finite; we use up natural resources,in poverty and low levels of health, Democrats view American society and we spend money, we consume food.Republicans frame poor levels of health the causes of low levels of health in Replenishing a resource takes time andin terms of a failure to give individuals certain populations as interconnected effort, and some resources can never bein a community “a road map of how systems, Republicans view both as replaced. For Republicans, Americanto achieve [health].” However, in the unpredictable journeys. society has a finite amount of resources,same line of thought they feel they both monetary and service‐related.must acknowledge that “…some of RESOURCE We need to be realistic that every personthese differences we create because… While Republicans focus on personal cannot have everything; we simply dowe lead ourselves to places.” In other responsibility for choices made not have enough to go around equally.words, Republicans feel it is important along one’s health journey, they also One Republican states, “because of thisto give individuals the opportunity and acknowledge that people living in world of scarce resources, there’s alwaysthe tools to make good choices in their low‐income communities may lack rationing…balancing out how you’rehealth journey, but at the same time the means and ability to choose the going to ration things with how muchwe must acknowledge that they will right path toward health. This is redistribution you want.” Another says,also make their own, sometimes bad, an activation of the resource-deep “If we had unlimited resources, it’d bechoices. The following collage portrays metaphor. Resources are essential to our great to say that everybody deserves andthe common Republican theme of survival. They can be physical—such can have access to Cadillac health care,a divergent path that individuals as a tool, person, or an organization, but we don’t.”encounter in their health journey. This or intangible—such as a skill, aRepublican states, “We start down the body of knowledge, or a network of Because of American’s limited resources,road…as the baby progresses, there relationships. Resources act as agents Republicans focus more intensely onare two paths that he could take. One enabling us to achieve important goals. getting the most “bang for the buck,”17 R OB ER T WOOD J OH NSON F OUN DAT ION
  22. 22. meaning that they want to be certain “[Democrats] would be just as happy the government and what is expectedthat they infuse resources into the most bringing the high end down as you of the individual. Neither one of thesecritical programs and services that would bringing the low end up…I care entities should bear the sole burdendemonstrate effectiveness in helping about bringing the low end up and of raising levels of health in poorindividuals in low‐income communities the fact that this reduces disparities communities. “Government makesmake better health choices. Where is great, but it’s not the disparity that decisions…and there has to be someDemocrats tend to see resources going worries me, it’s the low end people not balancing of altruistic motivation tointo a system where they circulate doing well.” As illustrated very clearly redistribute and efficiency,” meaningthrough different communities and by this participant, Republicans are that we should infuse resourcesprograms without necessarily being concerned about social determinants of into the best places, but we shouldexhausted, Republicans see a zero‐sum health and low levels of health in poor expect individuals to take personalgame. If you pour all of your resources communities, but they immediately responsibility in using them.into low‐income communities, there object to any plan that uses theis less for the rest of America, and you language of equality or creating equalsimultaneously have not guaranteed levels of health because it activates thethat you actually help that community deep metaphors of limited resourcesbecause you did not necessarily pinpoint and creating balance by taking thingsthe most strategic uses of those funds away from the “haves” to give to theand services. “have nots.”BALANCE Another important expression ofThe final deep metaphor that frames balance for Republicans is theirthe issue of social determinants of conviction that it is unrealistic to expecthealth for Republicans is balance, that everyone is going to have the samebut it is expressed in a very different levels of health. In a free society whereway than the Democratic framing of individuals make their own choicessocial imbalance. Where Democrats (again, relating back to the journeysee equality as both a solution (giving theme), it is natural that there will beeveryone equal services and access) and differences in individual’s health. Wea desired outcome (equal levels of health should, however, establish a minimumacross all communities), the language acceptable level, providing enoughand ideas around equality are extremely resources that people are able to achieveoff‐putting to Republicans. They health goals they set for themselves. Aunderstand equality quite differently Republican states, “There [are] boundthan Democrats. While Democrats to be differences in health outcomes,see equality as raising the bottom so there are good reasons why some peopleeveryone is at the same level (lifting should be healthier than others. As longpeople out of the entrapping holes of as we are willing to live in a societypoverty), Republicans view equality where people are different and givenas more of a scale where you have to different levels of income, [we] will havetake things away from the people who to have different levels.”are well‐off in order to give them to Finally, Republicans frame the bestthe poor. This frame directly relates to solution to health disparities as athe zero‐sum view of resources held by balance between what is provided byRepublicans. One Republican states, V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 18
  23. 23. Implications and This first meant scrapping all language as: choosing better paths, moving in theCommon Ground of equality since it was alienating to right direction, or enabling the pursuit Republicans. This included moving of health goals all activate the frame of away from phrases like: journey and individual responsibilityConsidering the very different deep more effectively than words like: • Equality in healthmetaphors that frame Democratic lifting people out of poverty, breaking • Equal levels of healthand Republican thinking about health boundaries, or providing access to • Uniform healthdisparities, it is not surprising that health, all of which evoke the Democratic • Ending disparitiespolitical gridlock prevents progress. frame of containers of poverty. • Closing the health divideBoth groups use language and framesthat are simultaneously foreign and With the overall strategy of framing For Republicans, the above languagefrustrating to the other side. But areas social determinants of health using activated the negative frame of takingof common ground do exist; there are more journey and resource-related away from the well-off and giving to theways to discuss social determinants of language, it is possible to use a map poor. Better framing revolves aroundhealth that can improve the receptivity of the common ground between language of fairness and choice:to and impact of communications Democrats and Republicans in terms • Fair chance for good health of what creates poor health levels toamong those who are initially less open • Opportunities for better identify specific topics to begin a moreto the issue. health choices open discussion.Before drafting specific language for • Giving a fair shot in all communitiesa discussion of social determinants • Enabling people to choose the One way to begin messaging to bothof health and public policy that right path Democrats and Republicans is to selectwould address them, the Robert • Giving tools to make better decisions constructs on this map as the startingWood Johnson Foundation had point. This contrasts with choosing The last two phrases point toward the issues that only Democrats discuss (suchto devise an overall strategy for deep metaphors of journey and resource, as dangers in homes like lead paintframing both the Commission and which were prominent frames for and mold or racism in the health carethe larger conversation. Obviously, presenting data and information about system) or issues that only Republicansboth Democratic and the Republican social determinants of health. Rather discuss (such as the role of genetics orviews on health disparities could not than discussing factors that created the breakdown of families). This is notbe simultaneously communicated, poor levels of health in low‐income to say that these issues cannot or shouldparticularly as some issues, like equality, communities (a Democratic system not be brought into a discussion of thecause 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 smootherwere more Republicans that needed do not offer “the same choices” for and faster by opening a dialogue andto be convinced of the importance individuals to pursue paths to better establishing a rapport using sharedof social determinants of health than health. We can focus on language that ideas. This will also facilitate the laterthere were Democrats; most Democrats conveys the lack of options, choices, introduction of ideas where there iswould readily accept the argument tools, resources, or opportunities in poor more disagreement. Conveying thesethat we needed to address this problem neighborhoods rather than inequality, social problems using individual storiesregardless of the type of language that barriers to health, or systems of factors supported by only a few powerfulwas used. This is not to say that their working against the poor. This allows statistics or facts will also help toframes were ignored, but rather that the Foundation to discuss the social persuade skeptics more than many factsthe communication strategy would determinants of health, but in a way and figures. This would be particularlyemploy language and images that were that also resonates at a deeper level with effective in trying to persuade amore in line with how Republicans Republicans. Likewise, language such Republican skeptic; telling the storyframe the issue.19 R OB ER T WOOD J OH NSON F OUN DAT ION
  24. 24. 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 Knowledge/ Bureaucratic Education Health Care Cultural Differencesof an individual who could not exercise they already share. Consider a very to open discussion. The example ofin a poor community due to the lack hypothetical example—introducing the the person needing a safe place to goof a safe place to go jogging and a idea of individuals exerting more jogging would further illustrate thecommunity program that provided an control over their health status, perhaps idea of government helping individualseffective solution, which this individual by government-sponsored programs, exert control and what individuals cantook advantage of and subsequently might be a way of responding to what accomplish when in a safe environment.lost weight, for example, would activate both parties see as ineffective healththe frame of an individual journey while care bureaucracies and at the same Through the careful and deliberate useconcentrating on one of the shared time building on the idea of American of deep metaphor frames and consensusconstructs on the map. individualism. Thus, two existing ideas maps, the Robert Wood Johnson in the shared map, one negative and Foundation and other agents wishing toAnother way to use a map is to ask, the other positive, can be used to add address social determinants of health and“What ideas are missing from the map to the idea of sponsored programs that differences in levels of health acrossthat might appeal to both Democrats encourage individuals to exert more American communities can moreand Republicans and would help control over their health status. Cues effectively communicate programs in abring about actions to improve levels involving achieving greater balance (a way that resonates with both Republicansof health?” The Foundation might shared frame) between government and and Democrats. Taken in conjunctionthen introduce these ideas into the individuals might be used to introduce with additional research and testingdiscussion. However, the new ideas or discuss this idea. Each party will conducted by the Foundation, thisthat are potentially appealing to tend to interpret the idea in ways that research can form the backbone of thisboth parties need to build upon or are consistent with their prior positions communication strategy.be complementary to those ideas but to do so in a way that is amenable V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 20
  25. 25. Changing OUR FRAME OF MIND APPENDIX B The Role of the Mind, Brain and Emotion in Developing Messages 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.21 R OB ER T WOOD J OH NSON F OUN DAT ION
  26. 26. GOALS matters and why both decision elites neighborhood would today bring toThe goal of this multi-phase project and ordinary citizens should care mind populist sentiments about thewas to translate the concept of social about it; recklessness of big business and thedeterminants (and ultimately calls for • To identify words and phrases failure of government after Americansaction that stem from it) that might that resonate with both decision have confronted two of the biggestotherwise sound bland or unintelligible elites and ordinary citizens and crises in generations, the financialto the lay ear—even the educated ear— to identify words, phrases, and meltdown that has still left nearlyinto compelling, motivating messages concepts to avoid that render them 10 percent of Americans out of workthat not only create concern about the less likely to understand or care and the BP offshore oil spill that isway things are but create hope that about social determinants or health decimating the Gulf Coast in ways weproblems related to social determinants disparities; and have not even begun to understand.are solvable (e.g., that something can • To develop a small number of proxy On the other hand, mentions of povertybe done about disparities that lead to statements, “catch phrases,” or immediately evoke victim blaming andshorter, less productive, less healthy “taglines” that capture the complex largely unconscious prejudices, as thelives for millions of people based on construct of social determinants average American associates povertyfactors that are arbitrary or outside in a way that is understandable with people of color. Finding ways totheir control). and resonant to people other than speak of the impact of poverty on health experts in public health. without activating those networks—orThe problem we faced was that the activating countervailing networkslanguage of university researchers, THE APPROACH related to the middle class and middlethink tanks, and nonprofits tends to The approach to messaging or class concerns—thus becomes essentialbe very different from the language of “marketing” social determinants in messaging on health disparities ifdecision-makers, let alone the language we took is rooted in contemporary the goal is to influence not only publicof 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 theon attitudes to the next generation. To unconscious networks of associations— From this standpoint, effective effortsaccomplish goals influenced by data the interconnected sets of thoughts, to get people to think more broadlyfrom public health or other relevant feelings, images, metaphors, and about social determinants (and toscientific research requires translation emotions—that are active in the feel something other than contempt,of the language of science into the brains of persuadable audiences anger, or unease toward people wholanguage of policy-makers—and, as they read, watch, or listen to are rendered vulnerable by virtueultimately, the language of everyday information about social determinants of the factors that produce healthpeople, whose support is essential to of health. Introducing the notion, disparities) requires an understandingconvince decision-makers that they can for example, that income level affects of the multiple, often conflictingand should act on the available science, health immediately activates a host neural networks active when peopleparticularly where it bears on what they of associations, positive and negative, process messages, which can generateperceive as moral questions (e.g., health that affect the persuasiveness of the ambivalence or indifference. Changingdisparities). message. On the one hand, Americans people’s attitudes requires activating value fairness, and the idea that wealth some networks, deactivating others, andThus, we undertook this research with linking networks that are not currently translates into health runs afoul of athree primary aims in mind: or adequately linked in their minds firmly entrenched value. Similarly,• To develop a small set of values- messages that convey, in a visual and (e.g., that health is the flipside of disease based, emotionally compelling especially a visceral way, the idea of and hence deserves more significant narratives about why the social toxic fumes or chemicals affecting attention, or that health does not begin context (and associated disparities) the health of kids in a particular at the doctor’s office or the hospital). V U L N ER A B L E P O P U L AT I O N S P O RT F OL I O 22
  27. 27. Although people are aware of some represents the assessment of what is; the health (to see its broader context)of their attitudes in these regards, latter represents the assessment of what and health disparities but also to howmany of these attitudes are not only could be, or the art of the possible. they responded unconsciously, usingconflicting but unconscious (e.g., both cutting-edge technologies that allowconcern and contempt for people The approach we took to accomplish us to identify the activity of neuralwho are vulnerable or less fortunate, our goal reflects this basic distinction. networks and “gut-level” emotionalwhich may be triggered by different In the first phase of the research, we responses in large samples withoutor sometimes precisely the same cues). undertook qualitative (focus group) directly measuring brain activity.This has multiple ramifications. It and quantitative (survey) assessmentsmeans that we have to attend closely of public opinion (focus groups and a The project was led by Drew Westen,to the connotations—and particularly telephone survey) when presented with Ph.D., of Westen Strategies, butemotional connotations—of the the concept of social determinants, with represented a collaboration withlanguage we use. It also means that an eye to learning how we might change Ann Christiano at the Robert Woodoptimal testing of messages cannot it. Whereas the focus groups attempted Johnson Foundation, who took anrely exclusively on conscious measures first to understand the extent to which active role shaping the project at everyof people’s attitudes. We need to both everyday people and decision elites phase of the research; Public Opinioncomplement traditional survey research understand or spontaneously recognize Strategies, which conducted the focuswith technologies that measure the level social determinants of health and then groups and baseline survey in the firstof activation of particular networks tested messages designed to change their phase of the project (assessing publicand associations to different phrases attitudes toward both social influences opinion); and Joel Weinberger, Ph.D.designed to address the same concept and disparities, the telephone survey of Implicit Strategies, who worked with(in this case, social determinants aimed at measuring baseline public us on the measurement of unconsciousof health). opinion on the causes of health, illness, responses to the top proxy statements and disparities without trying to change for social determinants (terms that canCentral to this approach is also the them (understanding “what is”). be used to describe it with opinion elitesview that changing public opinion and the lay public) identified throughrequires not just presentation of facts In the second phase, we use quantitative multiple rounds of testing.but narratives that “tell the story” of methods (online surveys andhow someone or something got that experimental methods) to see how METHODOLOGYway and what can be done about it. much we could “move the needle” We conducted six focus groupsEffective communication uses language of both opinion elites and everyday (two with swing voters in Columbus,in the vernacular of target audiences citizens, focusing on what might be Ohio; two with Latino and Blackthat is clear, evocative, and readily called “swing voters” on issues related voters, in Houston, Texas; and tworemembered and retold, making use to social determinants—people without with “opinion elites” in Bethesda,of the “story structure” to which our much knowledge of social determinants Md.) and a baseline survey in July andbrains evolved to respond. and without strong political leanings August of 2009. We defined swing that would render them outside the voters in all phases of the research asFinally, central to the approach we took likely realm of the persuadable. In people who had voted for at least somewas the distinction between public this second phase, we used online Democrats and Republicans over theopinion research—the measurement technologies that allowed us to assess last few years or considered themselvesof where the public stands prior to not only how representative samples of political Independents (roughly a thirdefforts to influence their attitudes— registered voters consciously responded of the sample, and reflecting closely theand messaging research designed to to messages aimed at getting them population norms). We defined opinionchange public opinion. The former to think and feel differently about elites in the focus groups as educated23 R OB ER T WOOD J OH NSON F OUN DAT ION