Framing a Public Discussion on the Social Determinants of Health

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Framing a Public Discussion on the Social
Determinants of Health
Lauri Andress, Ph.D. June 24, 2009
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Which message explains health disparities the
best?

• The Health Environments we live in have important
  effects on health outcomes, and are defined by
  everything from the availability of decent paying
  jobs to decent housing to a good education and
  high-quality preschool.
• African-Americans tend to be less healthy than
  Whites, due to how the body is affected by the
  day-to-day experience of having lower status. As
  they are treated slightly differently from other
  people, the brain and body automatically respond
  as they would to a threat, in ways that can cause
  serious health damage.

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Do we need a public discussion on the SDOH?

• Depends
  

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Assumptions Assertions

• Social determinants of health SDOH are related
  to public policy.
• Making public policy in democracies involves
  politics and competing values.
• Advancing the SDOH takes political will and
  skills.
• Requires agreement on ideas and policy
  initiatives

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Framing the DiscussionCultural learning
Public Policy
Values
Healthcare Access and Quality
The group that defines the issue wins the day
Racial and Ethnic differences in health
It is about keeping healthcare costs down.
Social Justice
Fundamental human needs of autonomy,
empowerment, and human freedom The
opportunities for full social engagement.
Opportunities for people to craft a life they
value. Without relief from social inequality and
poverty plus empowerment, improvements in health
inequalities will not be achieved.
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We want a public discussion that does the
following

• Demonstrates significant gaps between the health
  of wealthy and poor people
• Explains the gradient of health along all
  socioeconomic levels
• Shows the significant race-based gaps in health
  outcomes
• Presents the science deemed important by experts
• The meaning of the gap between U.S. healthcare
  spending and outcomes when it comes to health
• The unexpected factors that have important
  effects on health (economics, neighborhoods,
  housing, education, racism, etc.)
• The role of social exclusion social inequality
  in determining health outcomes
• The role of circumstances-induced stress as a
  mechanism leading to health disparities between
  different populations
• The importance of both psycho-social and material
  causalities in creating disparities
• Offer a believable causal story that is different
  from the
• Right choices model
• Health care access model
• Individual behavior model
• Offers solutions that imply policy venues that
  improve health and reduce disparities
• Emphasizes intersectoral policies that fight the
  deepest roots of the social determinants of
  health

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Demonstrates significant gaps between the
health of wealthy and poor peopleWhen you think
about this statement, does it have meaning for
you?

• Yes
• No
• Not sure I understand the statement

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Explains the gradient of health along all
socioeconomic levelsWhen you think about this
statement, Does it have meaning for you?

• Yes
• No
• Not sure I understand the statement

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• Shows the significant race-based gaps in health
  outcomes When you think about this statement,
  Does it have meaning for you?

• Yes
• No
• Not sure I understand the statement

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The unexpected factors that have important
effects on health (economics, neighborhoods,
housing, education, racism, etc.)When you think
about this statement, does it have meaning to
you?

• Yes
• No
• Not sure I understand the statement

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The role of social exclusion social inequality
in determining health outcomesWhen you think
about this statement, does it have meaning for
you?

• Yes
• No
• Not sure I understand the statement

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The role of circumstances-induced stress as a
mechanism leading to health disparities between
different populationsWhen you think about this
statement, does it have meaning for you?

• Yes
• No
• Not sure I understand the statement

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The importance of both psycho-social and material
causalities in creating disparitiesWhen you
think about this statement does it have meaning
for you?

• Yes
• No
• Not sure I understand the statement

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A Public discussion looks like thisPossible
messages that we need to transmit

• Certain groups of people are less healthy because
  they are socially or economically deprived.
• One of the best investments we can make is to
  improve living conditions of people at the lower
  end of the economic scale. Investments in
  everything from better housing, to good daycare
  to job training and school loans result in better
  health in a given community and fewer health
  disparities among groups of people.
• The chronic anxiety felt from living daily with
  the sense of social inequality that you cannot
  participate in normal life leads to significant
  health consequences and group differences in
  health either because
• you are different or
• because you dont have the material goods that
  have been deemed important in a society.
• We need to consider more carefully public
  spending oriented to closing the gaps in terms of
  rights and opportunities.

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Certain groups of people are less healthy
because they are socially or economically
deprived.In general, when you think about this
statement do you

• Agree
• Disagree
• Not sure I understand the statement

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

• Agree
• Disagree
• Not sure I understand the statement

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The chronic anxiety felt from living daily with
the sense of social inequality that you cannot
participate in normal life leads to significant
health consequences and group differences in
health either because you are different or
because you dont have the material goods that
have been deemed important in a society. In
general, when you think about this statement do
you

• Agree
• Disagree
• Not sure I understand the statement

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We need to consider more carefully public
spending oriented to closing the gaps in terms of
rights and opportunities. In general, when you
think about this statement do you

• Agree
• Disagree
• Not sure I understand the statement

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A Quick Review

• Our In-House Poll

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Social Movements

• Agenda Setting

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Generating the public discussionFeatures of
Social Movements

• Method of issue generation
• Outside initiative- nongovernmental sources
• Mobilization- government source
• Inside access- bypass public use legislative
  process

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

• Mobilizing structures
• The type of structure
• The impact of external opportunities
• Other resources
• Individuals
• Money
• Knowledge
• Frames
• Technical tools
• Process information
• Distribute information

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

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Generating the public discussionFeatures of
Social Movements
Opportunity
Organization
Mobilizing structures
Mediate
Frames Shared Cultural Understandings
Social Change
Agenda Setting
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Agenda Setting
Legislative Agenda
Public Problem

• Issue

SPIGS
Public
Media
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Agenda Setting
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Next Steps

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

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A Case Study

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

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Results Political Context

• Conservative Government
• 1980 to 1996
• Before the 80s
• Great discontent
• Declining economy
• Inflation out- of-control
• Weak economy
• The 80s- Thatcherism
• Smaller government
• Privatization
• Weakened unions
• MUD
• Early 90s
• Economic recession
• High unemployment

• New Labour
• 1997 to 2003
• Shift to the right
• Rhetoric
• Fiscally prudent
• Stakeholder Society
• Responsibility
• Equality of opportunity
• Inequalities
• Pledge to address
• SID
• RED -discreetly
• Poverty for children
• Education
• Minimum wage

Political opportunities open the way for
political action.
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Results Political Opportunities

• 1980 Publication of the Black Report
• 1985 Abolition of the Health Education Council
• 1996 SDOH policies, government publications,
  and programs after

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Results Issue generation expansion

• Temporal Element
• Longitudinal Study
• Issue generation expansion
• Long-run societal changes affect policies across
  the entire political spectrum
• Changing institutional features help make sense
  of the issue generation tactics
• Period One-1980 to 1996
• Issue Generation Method -- Outside Initiative
• News articles 63
• Period 2-1997 to 2003
• Issue Generation Method -- Mobilization Effort
• News articles 57

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Results Issue generation expansion
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Results Framing

• Grand debate and discussion on social class
  inequalities
• Poverty vs. The gradient
• Distinctive cultural toolkit
• Inequalities frame package
• Media corresponds to official concerns
• A linking mechanism
• SPIGS policymakers
• Did not alter lay perceptions
• Elitelevel debates

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

• Most frequently used catch phrases related to
  inequality were
• Division between rich and poor
• gap between the rich and poor and/or
• reduce the income gap between the rich and poor
• health inequalities and/or health and
  inequalities.
• Most frequently evoked image associated with
  inequality was
• Rich and poor divide.

• Inequality, Health Government
• British Social Attitudes Survey since 1983
• 40 of coded solutions call on Govt.
• 48 frames identified- 20 on inequality
• Most frequently identified inequality frame
• Government allocation of resources to address
  poverty and social inequality.

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Results Framing

• National Familiarity with Poverty Inequality
• Extensive lay and scientific publications
• 95 of the news articles in the sample discussed,
  analyzed the results of, or invoked popular
  writings or scholarly reports to support a
  discussion on the SDOH.
• History of advocacy for health linked to
  inequality in Britain

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Results Mobilization Structures
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Summary Results Observations

• Positive political opportunity
• Distinctive cultural toolkit
• Inequalities framing package
• Historical discussion on social class and
  inequality
• At the public level
• Among expert society
• Mobilization Structures

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Telling Stories News media in Canada
To what extent do Canadian newspapers cover
issues embedded in health policy documents?
They rarely report on the socio-economic
influences that are frequently cited in the
research literature as being most influential in
shaping population health outcomes.

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

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

• Achieving broad public acceptance of the social
  determinants issue will depend upon
• Political opportunities
• U.S. ideals, and values regarding
• Poverty
• Inequality
• Health
• Health care
• Mobilization systems
• A constituency
• Where the issue is lodged
• Framing How the issue is lodged
• The images and symbols used to communicate the
  issue

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Political Opportunities United States

• Government intervention

George Bush The terrorist attacks in 2001 led to
the creation of the Department of Homeland
Security, the Patriot Act, the federalization of
airport security, an expansion of
money-laundering rules and federally subsidised
terrorism insurance. Stock market collapse led
to the Sarbanes-Oxley act oversees corporate
governance and accounting standards.
Ronald Reagan (1981) Government is not the
solution to our problem government is the
problem.
2007 International survey by Pew American
support for free markets had edged down from
five years earlier. Americans, traditionally
fonder of the free market than the rest of the
world, became less so with arrival of the
financial crisis Americans souring on
unconstrained capitalism.
Government v market in America The visible
hand May 28th 2009 INDIANAPOLIS AND WASHINGTON,
DC From The Economist print edition
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United States Considerations

• Issue Generation
• Outside initiative- nongovernmental sources
• Mobilization- government source
• Inside access- bypass public go to legislative
  process
• Where issue is lodged
• State
• Local
• Regulatory bodies
• Academic research institutions
• NGOs
• Community organizations
• Courts or Policymakers
• How the issue is framed for e.g.,
• As racial and ethnic problem
• As health care access quality
• As social injustice

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United States Cultural Barriers

• Values, Beliefs, and Frames
• Poverty
• Land of Opportunity
• Inequality
• Health and Health Care

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Values, Ideals, Frames, Framing

• The Welfare State Poverty
• Who should we help?
• How does it impact personality, families, labor
  market?
• What are the limits of social obligation?
• Who provides in time of need?
• Market principles vs. social justice
• Bootstrap
• Land of opportunity
• Irresponsible vs. responsible
• Katz, 2001

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Values, Ideals, etc. dont assume we are all
agreed

• Inequality- Equality- Class
• Natural and endemic to our society
• Life is unfair..
• Potential for upward mobility
• Isaacs Schroeder, 2004 Kawachi, Daniels,
  Robinson, 2005

• on Hurricane Katrina
• Shame on anyone that makes this tragedy
  political, socio-economic or racial. in the
  land of opportunity and personal responsibility
  the individual is ultimately accountable.
• Robert Buckley, Decatur, USA
• BBC web site

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Values, Ideals, Frames, Framing

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

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Health How we think about it in the U.S.?
Healthier Less Healthy
CHOICES
Character, Knowledge, Culture, Priorities, Values
Public assumes a different causal story RIGHT
CHOICES
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Health How we think about it in the U.S.?
CHOICES
HEALTH OUTCOMES
A User-friendly Conceptual Model simple, easy
to understand seems like the whole story A
Moral Model Not just how things do work, but how
they should work outcomes seem fair
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Health In the U.S. -- A Moral Lens

• Q Do you think we as a society owe every person
  some kind of help for being healthy? Is
  something like that a right to have?
• A No. Not as a society, because see a lot of
  times people cause their health problems by the
  way they live.
• Conservative African-American man, age 60

Its your own personal responsibility to do what
you can to improve your health and keep yourself
healthy ... If Im going out, if I smoke a lot,
if Im carrying on excess weight or if I have
four or five alcoholic drinks every day Im
making that decision. Thats my choice, so Im
hurting myself. I think theres too much of
people not taking responsibility for their
actions and just letting it go and thinking,
well, you know, let somebody else take care of
me. Moderate White woman, age 75
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Values, Views, Frames, Framing
FrameWorks Institute

• Health care
• If we spend enough we can get it right!
• Consumer Logic
• Healthcare is a commodity
• Preempts moral perspective
• Not everyone has a right to a given consumer good
• If you want it you work hard to get it or ---
• It was a luxury you couldn't afford.
• Government intervention will not fix problem
• But the government must do something
• Scared for small businesses
• Want poor to help pay for costs but not be too
  burdensome

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Values, Views, etc.

• Where issue is lodged
• State Health Departments
• Local Health Departments
• NIH
• CDC
• Policymakers
• How the issue is framed
• Disparities as racial and ethnic
• Disparities as access
• Disparities vs. inequalities

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

• Early childhood education
• Place-based policies that improve communities
• Racial and ethnic group differences in health
• Economic policies like the earned income tax
• Healthcare access and quality

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The FutureWhere do we go from here?

• Change the conversation
• Framing research
• New narratives
• refined and tested a set of messages
• group of 300 subjects, including including113
  individuals living in Louisville and Jefferson
  County
• Subjects were diverse in terms of age, gender,
  education and ethnicity. They had no special
  expertise in areas related to health. Subjects
• pre-tested with a group of 187 Americans from
  around the country, before being edited and
  refined to the list tested in Louisville.
• The film --- Unnatural Causes
• Low hanging fruit

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