Sdh 2010

A New Way
to Talk About
THE SOCIAL
DETERMINANTS
OF HEALTH

VU LN ER A B L E P O P U L AT IONS PORT FOLIO

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

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

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

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

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

How we assign meaning to what we hear is largely dependent on the context
in which we hear it. And this context is something that even the most self-aware
person can have a difficult time expressing. So as we developed messages and
tested their reception, we benefited from advanced market research techniques
developed and used by Olson Zaltman Associates and Westen Strategies to
get at these deeper-level insights. This guide is informed by an iterative research
and message development process that includes three steps:

Determine How Policy-Makers Develop Messages That We Strengthen the Messages
1 See the World of Health 2 Can Road Test 3 With Testing

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

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

The first phase of this research was a series of In the final phase of the research, Westen Strategies
focus groups held in multiple cities and grouped took that learning one step further by exposing
by male and female swing voters in Ohio, Blacks these messages to more than 1,700 registered voters
and Hispanics in Houston and opinion leaders in and capturing their conscious and unconscious
Washington, D.C.. It was conducted by Public reactions. Dr. Westen details this research process
Opinion Strategies (POS). With the feedback we and what we learned from it in an appendix at
got from this process, we refined the messages. the end of this guide.
POS tested the refined messages in a quantitative
Internet survey of 1,000 registered voters.

From start to finish, this research represents We’ve shared what we learned in settings small
responses from more than 3,000 Americans and large—including conferences sponsored by
across the country over four years—using the Centers for Disease Control and Prevention
both traditional research methods and new, and Grantmakers in Health—and the response
sophisticated market research techniques—to has been consistent: “This is great, but how can
answer one primary question: I learn more?”
This summary is our response to that question.
How do we find a common language that will In the following pages, you will find both an
expand Americans’ views about what it means overview of what we learned—which words, phrases
to be healthy—to include not just where health and framing work and why—but also a detailed
ends but also where it starts? description of the methodology and what we
discovered in chapters graciously authored by
If we can answer this question, we can pave
Elizabeth Carger and Dr. Westen, whose work
the way for more solutions that address this
was critical to our understanding of how Americans
critical link between our health and where we
perceive this issue.
live, learn, work and play.


Choosing WORDS
CHAPTER

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.


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.


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 the
regardless of their political perspective. While we are not necessarily statement, “America is not among the top
recommending that you use this in its entirety, it is helpful to understand 25 countries in life expectancy,” and they
why the phrase worked. responded negatively to any message
that led with that statement. However,
when we start off with something most
Americans already believe, “Americans
lead the world in medical research and
America leads the world in medical research and medical care,” they are more likely to
medical care, and for all we spend on health believe everything that follows.
care, we should be the healthiest people on Earth. • Words like “insured or “uninsured” are
Yet on some of the most important indicators, politically loaded. But the phrase “ensure
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.


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 • Unconscionable


A GLOSSARY OF “OTHER TERMS” (continued)

Below is an evolving list of terms that describe the groups most profoundly affected by this issue. These descriptions are not
only technically accurate but more representative of how we relate to each other as human beings and fellow Americans.
These phrases have not been tested, but are reflective of the insights we gained from the research.

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


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.


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


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


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.


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


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


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


The difference in base level of optimism
versus anger between the Republicans
and Democrats could be a real source of
tension between the two groups when it
comes to discussing social determinants
of health. Understanding these basic
differences in emotional response to the
issue could help anticipate touch points
in a conversation where communication
might break down.

Much as they see America and health
care as a whole on a journey through
time, Republicans see individuals as
on their own health journeys. Echoing
the common theme of “individual
Fig. 3 Collage created by a Republican to show different choices along the journey of health and how
responsibility,” Republicans view poor they lead to either positive or negative life outcomes.
health as arising from bad choices along
one’s path and the inability to overcome
obstacles to health that one encounters would lead him to a lower path, which The second Republican expression of
along the way. Rather than employing is disadvantage. Or the baby could take resource highlights an important aspect
the Democratic frame of externally‐ the upper path where they don’t have of this deep metaphor. Physical resources
imposed 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 and
in terms of a failure to give individuals certain populations as interconnected effort, and some resources can never be
in a community “a road map of how systems, Republicans view both as replaced. For Republicans, American
to 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 person
these differences we create because… While Republicans focus on personal cannot have everything; we simply do
we 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 this
to give individuals the opportunity and acknowledge that people living in world of scarce resources, there’s always
the tools to make good choices in their low‐income communities may lack rationing…balancing out how you’re
health journey, but at the same time the means and ability to choose the going to ration things with how much
we 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 be
choices. The following collage portrays metaphor. Resources are essential to our great to say that everybody deserves and
the 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, a
Republican 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 on
are two paths that he could take. One enabling us to achieve important goals. getting the most “bang for the buck,”


meaning that they want to be certain “[Democrats] would be just as happy the government and what is expected
that they infuse resources into the most bringing the high end down as you of the individual. Neither one of these
critical programs and services that would bringing the low end up…I care entities should bear the sole burden
demonstrate effectiveness in helping about bringing the low end up and of raising levels of health in poor
individuals in low‐income communities the fact that this reduces disparities communities. “Government makes
make better health choices. Where is great, but it’s not the disparity that decisions…and there has to be some
Democrats tend to see resources going worries me, it’s the low end people not balancing of altruistic motivation to
into a system where they circulate doing well.” As illustrated very clearly redistribute and efficiency,” meaning
through different communities and by this participant, Republicans are that we should infuse resources
programs without necessarily being concerned about social determinants of into the best places, but we should
exhausted, Republicans see a zero‐sum health and low levels of health in poor expect individuals to take personal
game. 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 the
is less for the rest of America, and you language of equality or creating equal
simultaneously have not guaranteed levels of health because it activates the
that you actually help that community deep metaphors of limited resources
because you did not necessarily pinpoint and creating balance by taking things
the most strategic uses of those funds away from the “haves” to give to the
and services. “have nots.”

BALANCE Another important expression of
The final deep metaphor that frames balance for Republicans is their
the issue of social determinants of conviction that it is unrealistic to expect
health for Republicans is balance, that everyone is going to have the same
but it is expressed in a very different levels of health. In a free society where
way than the Democratic framing of individuals make their own choices
social imbalance. Where Democrats (again, relating back to the journey
see equality as both a solution (giving theme), it is natural that there will be
everyone equal services and access) and differences in individual’s health. We
a desired outcome (equal levels of health should, however, establish a minimum
across all communities), the language acceptable level, providing enough
and ideas around equality are extremely resources that people are able to achieve
off‐putting to Republicans. They health goals they set for themselves. A
understand equality quite differently Republican states, “There [are] bound
than Democrats. While Democrats to be differences in health outcomes,
see equality as raising the bottom so there are good reasons why some people
everyone is at the same level (lifting should be healthier than others. As long
people out of the entrapping holes of as we are willing to live in a society
poverty), Republicans view equality where people are different and given
as more of a scale where you have to different levels of income, [we] will have
take things away from the people who to have different levels.”
are well‐off in order to give them to
Finally, Republicans frame the best
the poor. This frame directly relates to
solution to health disparities as a
the zero‐sum view of resources held by
balance between what is provided by
Republicans. One Republican states,


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


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
Differences

of an individual who could not exercise they already share. Consider a very to open discussion. The example of
in a poor community due to the lack hypothetical example—introducing the the person needing a safe place to go
of a safe place to go jogging and a idea of individuals exerting more jogging would further illustrate the
community program that provided an control over their health status, perhaps idea of government helping individuals
effective solution, which this individual by government-sponsored programs, exert control and what individuals can
took 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 health
the frame of an individual journey while care bureaucracies and at the same Through the careful and deliberate use
concentrating on one of the shared time building on the idea of American of deep metaphor frames and consensus
constructs 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 to
Another 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 across
that might appeal to both Democrats encourage individuals to exert more American communities can more
and Republicans and would help control over their health status. Cues effectively communicate programs in a
bring about actions to improve levels involving achieving greater balance (a way that resonates with both Republicans
of health?” The Foundation might shared frame) between government and and Democrats. Taken in conjunction
then introduce these ideas into the individuals might be used to introduce with additional research and testing
discussion. However, the new ideas or discuss this idea. Each party will conducted by the Foundation, this
that are potentially appealing to tend to interpret the idea in ways that research can form the backbone of this
both 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


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.


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


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 how
many of these attitudes are not only could be, or the art of the possible. they responded unconsciously, using
conflicting but unconscious (e.g., both cutting-edge technologies that allow
concern and contempt for people The approach we took to accomplish us to identify the activity of neural
who are vulnerable or less fortunate, our goal reflects this basic distinction. networks and “gut-level” emotional
which may be triggered by different In the first phase of the research, we responses in large samples without
or sometimes precisely the same cues). undertook qualitative (focus group) directly measuring brain activity.
This has multiple ramifications. It and quantitative (survey) assessments
means 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, but
emotional connotations—of the the concept of social determinants, with represented a collaboration with
language we use. It also means that an eye to learning how we might change Ann Christiano at the Robert Wood
optimal testing of messages cannot it. Whereas the focus groups attempted Johnson Foundation, who took an
rely exclusively on conscious measures first to understand the extent to which active role shaping the project at every
of people’s attitudes. We need to both everyday people and decision elites phase of the research; Public Opinion
complement traditional survey research understand or spontaneously recognize Strategies, which conducted the focus
with technologies that measure the level social determinants of health and then groups and baseline survey in the first
of activation of particular networks tested messages designed to change their phase of the project (assessing public
and 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 unconscious
of 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 can
Central to this approach is also the them (understanding “what is”). be used to describe it with opinion elites
view that changing public opinion and the lay public) identified through
requires 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 and
how someone or something got that experimental methods) to see how METHODOLOGY
way and what can be done about it. much we could “move the needle” We conducted six focus groups
Effective 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 Black
that is clear, evocative, and readily called “swing voters” on issues related voters, in Houston, Texas; and two
remembered 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 and
brains 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 as
Finally, central to the approach we took likely realm of the persuadable. In people who had voted for at least some
was the distinction between public this second phase, we used online Democrats and Republicans over the
opinion research—the measurement technologies that allowed us to assess last few years or considered themselves
of where the public stands prior to not only how representative samples of political Independents (roughly a third
efforts to influence their attitudes— registered voters consciously responded of the sample, and reflecting closely the
and messaging research designed to to messages aimed at getting them population norms). We defined opinion
change public opinion. The former to think and feel differently about elites in the focus groups as educated


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


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


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


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


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


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

TOTAL: 78.2 SWING: 77.4 ELITE: 79.0


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


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


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


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


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


Conclusions

The data reported here are only a beginning, but they represent a comprehensive
effort at identifying ways of talking with the general public, including swing voters
and opinion elites, about social determinants of health. The main “take-home points”
include the following:

KEYS TO EFFECTIVE MESSAGING ON SOCIAL DETERMINANTS

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


VULNERABLE POPULATIONS PORTFOLIO

Health begins where we live, learn, work and play. The Vulnerable Populations Portfolio looks
at factors outside of the medical care system that impact how healthy—or unhealthy—we are.
We create new opportunities for better health by investing in health where it starts—in our homes,
schools and jobs.

LI VE LEARN WOR K PLA Y

For more information about the Robert Wood Johnson Foundation’s Vulnerable Populations
Portfolio, please go to www.rwjf.org/vulnerablepopulations.

www.rwjf.org

© 2010 Robert Wood Johnson Foundation

Content from this report may be reproduced without prior permission provided the
following attribution is noted: “Copyright 2010 Robert Wood Johnson Foundation”

Design: Ideas On Purpose, New York, NY / ideasonpurpose.com


VU LN ER A B L E P O P U L AT IONS PORT FOLIO

Sdh 2010

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