Elaine Arkin, Consultant, Robert Wood Johnson Foundation

What Shapes Health?A New Way of Talking About Social Determinants of Health

August 10, 2011

The mission of the Robert Wood Johnson Foundation is to improve the health and

health care of all Americans.

3© 2008 Robert Wood Johnson Foundation. All rights reserved.

There’s More to Health than Health Care

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Area-based measures of poverty and deprivation have been found to be associated with health outcomes after adjustment for individual-level factors. Additional studies have suggested that neighborhood-level variables may also shape the distribution of health-related behaviors, although other studies have found little evidence of area effects.

(Diez-Roux AV. ―Bringing Context Back into Epidemiology: Variables and Fallacies in Multilevel Analysis.‖ American Journal of Public Health,

88(2):216-22, 1998

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“Area-based measures of poverty and deprivation have been found to be associated

with health outcomes after adjustment for individual-level factors. Additional studies have

suggested that neighborhood-level variables may also shape the distribution of health-related behaviors, although other studies have

found little evidence of area effects.”

“Area-based measures of poverty and deprivation have been found to be associated

with health outcomes after adjustment for individual-level factors. Additional studies have

suggested that neighborhood-level variables may also shape the distribution of health-related behaviors, although other studies have

found little evidence of area effects.”

“In the overall population, observed patterns were

clearly consistent with a socioeconomic gradient in

life expectancy at age 25, health status, and activity

limitation due to chronic disease; for these indicators,

better health outcomes were seen at each higher

level of income or education and the confidence

intervals did not overlap.”

“In the overall population, observed patterns were

clearly consistent with a socioeconomic gradient in

life expectancy at age 25, health status, and activity

limitation due to chronic disease; for these indicators,

better health outcomes were seen at each higher

level of income or education and the confidence

intervals did not overlap.”

“Throughout this century, average life expectancy for all persons in the United States has been increasing… but data show that during 1979–89, 45-year-olds with the highest incomes could expect to live 3 to 7 years longer than those with the lowest incomes.”

“Throughout this century, average life expectancy for all persons in the United States has been increasing… but data show that during 1979–89, 45-year-olds with the highest incomes could expect to live 3 to 7 years longer than those with the lowest incomes.”

“If SES effects are due to poverty and its

correlates, one would expect to find a

threshold effect above which SES would

show little or no association with health

outcomes. Studies at both the individual and

aggregate levels challenge this expectation.

An association of SES and mortality occurs

throughout the SES hierarchy.”

“If SES effects are due to poverty and its

correlates, one would expect to find a

threshold effect above which SES would

show little or no association with health

outcomes. Studies at both the individual and

aggregate levels challenge this expectation.

An association of SES and mortality occurs

throughout the SES hierarchy.”

“Through a combination of latent effects and pathways of living, child development affects health, well-being, and competence throughout the life cycle.”

“Through a combination of latent effects and pathways of living, child development affects health, well-being, and competence throughout the life cycle.”

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Where we live, learn, work and play can have a greater impact on how long and well we live than

medical care.

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Ensure that all children have high-quality early developmental support.

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44 Feed children only healthy foods in schools.

33Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods.

22Fund and design WIC and SNAP (Food Stamps) programs to meet the needs of hungry families with nutritious food.

The Commission’s Recommendations

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77

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Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs.

Become a smoke-free nation. Eliminating smoking remains one of the most important contributions to longer, healthier lives.

Require all schools (K-12) to include time for all children to be physically active every day.

The Commission’s Recommendations

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88

1010

99 Integrate safety and wellness into every aspect of community life.

Ensure that decision-makers in all sectors have the evidence they need to build health into public and private policies and practices.

Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating.

The Commission’s Recommendations

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• Qualitative Audience Research

– 6 focus groups with “swing voters” and opinion elites

• Quantitative Audience Research

– National voter poll on messages derived from focus groups

– Two rounds of message-effectiveness testing using online

surveys

• Interactive Messaging Workshop

• Story Development

Message Development Approach

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Democrats Republicans

Imbalance in levels of health is natural.

Equality should be our goal. - Equal distribution of resources - Equal treatment for all - Equal outcomes

We need to “level the playing field”

Equality is unrealistic and unfair. - Tailor the distribution of [limited] resources

to particular needs, not the same for all - Individuals will never have equal outcomes.

Imbalance in levels of health is unjust.

We need to raise the bottom.

Society bears primary responsibility for inequality, thus to fix it requires more change in society than in the individual.

Olsen Zaltman Associates, 2007

Both society and individual choices create disparities, thus social aid must be balanced against individual responsibility.

Democrats Republicans

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Initial Health Status

Initial Health Status

Access to Health Care System

Access to Health Care System

BA

RR

IER

BA

RR

IER

GO

OD

HE

ALT

H

GO

OD

HE

ALT

H

Poor Nutrition

Environmental Hazards

Poor Education

Racism

Poverty

Inadequate Transportation

Less Parental Supervision

Can’t Exercise

Violence

Stress

Lack of insurance

Difficult to maneuver through health care system

Not enough easily accessible facilities

BA

RR

IER

BA

RR

IER

Racial discrimination

Gender discrimination

Discrimination based on sexual orientation

Cultural hesitancy to see a doctor

Language barriers prevent same level of care

Can’t afford some treatments

BA

RR

IER

BA

RR

IER

Democrats

Discrimination within Health Care System

Discrimination within Health Care System

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Initial Health Status

Initial Health Status

Access to Health Care System

Access to Health Care System

Discrimination within Health Care

System

Discrimination within Health Care

System

GO

OD

HE

ALT

H

GO

OD

HE

ALT

H

BA

RR

IER

Lack of money

Lack of knowledge

- Parents less involved

- Poor public education about options

Bad choices

Ch

alleng

esC

hallen

ges

Lack of insurance

Difficult to maneuver through health care system

Cultural hesitancy to see a doctor

CH

AL

LE

NG

ES

CH

AL

LE

NG

ES

Republicans

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% Favorable

Message

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There are often obstacles or barriers that make it harder for some people to stay healthy than others. Providing people resources and information on diet and exercise and creating healthy policies can help people make healthy choices.

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Staying healthy is a personal choice and is determined by individual behaviors such as diet, exercise, not smoking, and getting regular doctor checkups. Anyone can make the right choices to stay healthy if they want to.

From National voter survey, 2011

Follow-up: 2011: National Voter Survey

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Implication for messages

Republicans had negative reactions to the idea of creating equal levels of health:

• Any variation of equal, equality, or equalizing

• Leveling the playing field• Bringing everyone to the same

point or the same health outcomes

• Raising the bar for everyone- Setting a fair and adequate

baseline of care for all- Lifting everyone up

• Giving everyone a chance to live a healthy life

• Letting no person fall through the cracks/ below a decent level of health

Instead, the following terms may resonate more with Republicans and would not alienate the Democrats:

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Using common vernacular that speaks to core values resonated better than academic language

Respondents preferred messages that included action items or examples of ways to get to a solution

What We Learned:

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Messages that referred to disparities based on race or ethnicity fared poorly with all but Black respondents

Respondents related to messages based on America’s core values

What We Learned:

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Respondents related to metaphors/concepts that are ubiquitous—

– Journey

– Connections

– Limited Resources

What We Learned:

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Journey

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Storytelling helps make the connections

Connections

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LimitedResources

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Good health requires individuals to make responsible personal choices and requires a societal commitment to remove the obstacles preventing too many Americans from making healthy choices, even

when their motivation is great.

Pair personal responsibility with social responsibility:

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Start with something most Americans already believe:

The United States is one of the wealthiest nations in the world. We should be one of the

healthiest, but we are not.

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Make the information clear and compelling without oversimplifying:

Break through to gain attention:

Make theories tangible:

Connect with a target audience:

Make it timely and relevant:

Headline what’s most important.

Challenge conventional wisdom with unexpected facts.

Use real stories, analogies and everyday language.

Stories about “people like me” make the connection.

Provide a call to action.

Considerations for Message Framing:

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Our zip code may be more important to our health than our genetic code.

For the first time, we are raising a generation of children who may live sicker and shorter lives than

their parents.

Unexpected Facts:

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Health Disparities:

The health of America depends on the health of all Americans. Despite enormous investment,

America is not achieving its full health potential.

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Health Beyond Health Care:

Health care reform is essential, but improving the health of all Americans requires broadening

our view beyond medical care. We must find ways to enable more people to lead healthy lives

and avoid getting sick in the first place.

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Where we live, learn, work and play can have a greater impact on how long and well we live than

medical care.

Social Determinants:

Robert Wood Johnson Foundation: How We Talk About Health

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Health starts in our families and it’s nurtured in our schools and workplaces, on our playgrounds and in our

neighborhoods. How healthy we are and how long we live depends on many factors, including education, income, our

local communities, whether we smoke, how active we are and what and how much we eat.

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To improve America’s health, we need solutions that look at where people live, learn, work and play to get at the factors that shape health even more profoundly than health care.

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Working together, we can meet this challenge. We can build a healthier America. Improving America’s health

requires leadership and action from every sector, including people who work in public health and health care, education, transportation, community planning,

corrections, private business and other areas. It is time for everyone to work together and build on what we already

know is working.

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Resources Available:

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Message Guides:

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