Communicating Public Health:
Message Design Strategies to Promote
Awareness and Action to Address Social
Determinants of Health
Jeff Niederdeppe, Ph.D.
Associate Professor
Department of Communication
Cornell University
jdn56@cornell.edu
Join the Conversation: #healthcomm
P1
Collaborators
•
•
•
Sarah E. Gollust – University of Minnesota SPH
Colleen L. Barry – Johns Hopkins SPH
Michael A. Shapiro, Hye Kyung (Kay) Kim, Helen Lundell,
Sungjong Roh – Cornell University
Funding Support
•
•
•
RWJF Healthy Eating Research Program (69173, 68051)
RWJF Health and Society Scholars Program
RWJF Grant to University of Wisconsin Population Health
Institute – Mobilizing Action Toward Community Health
Presentation Outline
•
What are we trying to communicate, to whom?
•
•
•
What are we trying to change?
What are we up against?
Three lessons learned
1. Education and awareness may not be enough
2. Connect messages to broader values
3. Opposing messengers are a challenge
• Some concluding thoughts
Traditional Health Communication
• Focus has largely been on
changing individual behavior,
BUT…
• Behaviors and health outcomes
are largely shaped by larger social,
political, economic environments
• Need different message
strategies, may be at odds with a
focus on individual behavior
Features of Many Health Issues
• Strong sense of personal responsibility for health in
public opinion and discourse
Public Opinion about Factors that
Very Strongly Influence Health
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Personal
Health
practices
Affordable
Health Care
Has Health
Insurance
Income
Education
Where a
Race/ethnicity
Person Lives
Source: Robert, S. A., & Booske, B. C. (2011). U.S. opinions on health determinants and social policy as health policy.
American Journal of Public Health, 101, 1655-1663.
Features of Many Health Issues
• Strong sense of personal responsibility for health in
public opinion and discourse
• Powerful industries promoting health-harming
products, incredible $ resources to fight regulation
For Example…
Features of Many Health Issues
• Strong sense of personal responsibility for health in
public opinion and discourse
• Powerful industries promoting health-harming
products, incredible $ resources to fight regulation
• Wide body of evidence on the influence of the larger
social, economic, physical, and built environment
Ecological Model of Healthy Eating
Features of Many Health Issues
• Strong sense of personal responsibility for health in
public opinion and discourse
• Powerful industries promoting health-harming
products, incredible $ resources to fight regulation
• Wide body of evidence on the influence of the larger
social, economic, physical, and built environment
• Complex mechanisms linking these factors to health
outcomes and behaviors
Factors that Cause Obesity: A Systems View
(105 variables)
Who is the Target of the Message / Campaign?
Public Opinion
(persuade the
opposition)
Public Opinion
(mobilize
issue publics)
Policymaker
Action
Policies To
Create Healthy
Environments
Healthier
Environments to
Improve Health
and Reduce Health
Disparities
What are the Targeted Outcomes for Effective
Communication about Population Health?
What are the Targeted Outcomes for Effective
Communication about Population Health?
1. Increase awareness of health disparities
2. Increase belief that disparities are worth addressing
3. Heighten belief that societal forces and actors cause,
and are responsible for, poor health and disparities
4. Promote support for policies with potential to
improve social determinants and reduce disparities
5. Mobilize action to advocate for social change
Lesson 1:
Raising Awareness is Not Sufficient
Lesson 1:
Raising Awareness is Not Sufficient
• Priming group differences
Priming Group Differences
• Public support for government intervention
depends on type of group difference
– Economic disparities: greatest support
– Racial disparities: least support
• Perceptions of the causes of group
differences matter
– Relates to underlying attitudes about causality,
responsibility, and fairness
– Behaviors vs. social structure vs. genetics
Sources: Rigby et al. (2009); Lynch & Gollust (2010)
Lesson 1:
Raising Awareness is Not Sufficient
• Priming group differences
• Pre-existing awareness and values lead to “biased
processing”
Biased Processing of SDH Messages
Level of Support for Non-Medical
Diabetes Prevention Policies
(higher values, more support)
Proportion Agreeing
"Diabetes Caused by Social
and Economic Factors"
0.45
3.8
0.4
3.6
Democrats
0.35
3.4
Independents
0.3
3.2
Republicans
0.25
3
0.2
2.8
0.15
2.6
0.1
2.4
0.05
2.2
2
0
Control
Social Determinants
Experimental Causal Frame Viewed
Source: Gollust, Lantz, Ubel; AJPH (2009)
Control
Social Determinants
Experimental Causal Frame Viewed
Biased Processing of SDH Messages
• Focus group insight
• Without concrete mechanisms for how SDH produce
disparities, people fill in the blanks with preconceptions
• In response to a chart showing the bivariate association
between education and life expectancy:
“Maybe somebody didn’t go on to school or even didn’t
finish high school but they might have gotten a good
education at home in terms of how to be a healthy person.”
Source: Lundell, Niederdeppe, & Clarke, 2013
Lesson 2:
Connect Messages to Larger Values
Lesson 2:
Connect Messages to Broader Values
• Acknowledge personal responsibility
– BUT…
• Proceed with caution
MALL EXPERIMENT
Insights from Mall Experiment
•
Methods
• 500 participants, 4 conditions, summer 2010
• Michele’s story – environmental and economic
causes of obesity, neighborhood development as
an effective solution
Niederdeppe, J., Shapiro, M., Kim, H. K., Bartolo, D., & Porticella, N. (2013). Narrative persuasion, causality, complex
integration and support for social policy. Health Communication, doi:10.1080/10410236.2012.761805.
MALL EXPERIMENT
Three groups were
exposed to
Michele’s story
about
(1) the causes of
obesity and
(2) neighborhood
development as
one solution
MALL EXPERIMENT
Insights from Mall Experiment
•
Methods
• 500 participants, 4 conditions, summer 2010
• Research Question:
• How strongly should a story emphasizing SDH as
causes and solutions for obesity
• Acknowledge personal responsibility
• To increase complexity of thinking about obesity’s
causes, and
• Maximize support for obesity policies?
MALL EXPERIMENT
Example of Condition Differences
•
High Responsibility
•
•
Moderate Responsibility
•
•
Here, she feels comfortable getting out of the house and exercising
outside – activities Michele sees as tremendously important for improving
her health. This has helped Michele to develop healthier lifestyle habits.
Here, she feels more comfortable getting out of the house and getting
outside. This has helped Michele to have more options for improving her
health – even though following through on them is a challenge.
Low Responsibility
•
Here, she feels more comfortable getting out of the house, even if she’s
not intending to exercise.
MALL EXPERIMENT
Condition Effects on Support for ObesityReducing Public Policies
High
4.2
4.0
3.8
3.6
3.4
3.2
3.0
2.8
2.6
2.4
2.2
Liberals
Mid
Low
Moderates
Control
Conservatives
Niederdeppe, J., Shapiro, M., Kim, H. K., Bartolo, D., & Porticella, N. (2013). Narrative persuasion, causality, complex
integration and support for social policy. Health Communication, doi:10.1080/10410236.2012.761805.
MALL EXPERIMENT
Condition Effects on Intentions to Engage
in Diet and Exercise
4.2
4.0
3.8
3.6
3.4
3.2
3.0
2.8
2.6
2.4
2.2
High
Normal Weight
Mid
Low
Control
Overweight or Obese
Niederdeppe, J. et al. (2013). Effects of emphasizing environmental determinants of obesity on intentions to engage
in diet and exercise behaviors. Preventing Chronic Disease, http://dx.doi.org/10.5888/pcd10.130163.
… BUT Proceed with Caution
• Personal narratives can shift emphasis to individual
responsibility
• Stories about individual children can increase
blame to children for obesity
• Policymakers counterargue individual narratives
unless combined with broader statistics or a story
told about the community
Sources: Barry, Brescoll, Gollust (2013); Niederdeppe et al. (2014b)
Lesson 2:
Connect Messages to Broader Values
• Acknowledge personal responsibility
– BUT…
• Proceed with caution
• Identify novel values related to population health
improvement to reach broader coalitions
Identify novel values (1)
Source: Gollust, Niederdeppe, Barry, 2013
Identify novel values (2)
• Fairness and equal opportunity, not equal outcomes
Source: Lynch and Gollust (2010)
Lesson 3:
Opposing Messages(-ers) are a Challenge
Lesson 3:
Opposing Messages(-ers) are a Challenge
• It can be useful to anticipate and try to offset
counter-arguments from opponents of social change
NATIONAL EXPERIMENT
How tackling opposing arguments can be useful
• Content analysis of arguments used to support
and oppose the tax in public discourse
• Niederdeppe et al., AJPH, 2013
• Public opinion poll gauging response to discrete
pro- and anti-tax arguments
• Barry et al., AJPM, 2013
• In-depth interviews with SSB tax proponents and
advocates in jurisdictions where taxes proposed
• Jou et al., AJPH, 2014
NATIONAL EXPERIMENT
Surveys to Identify Resonant Frames – Pro-Tax
NATIONAL EXPERIMENT
Surveys to Identify Resonant Frames – Anti-Tax
NATIONAL EXPERIMENT
Theoretical Rationale
• Strongest pro-tax arguments focus on:
• Largest driver of obesity (“softening the ground”)
• Provides funds for childhood obesity prevention
• Beverage industry outspends pro-tax advocates by
a large margin; anti-tax arguments resonate strongly
• Inoculation Theory
• Protect from subsequent (persuasive) attack by
highlighting source motives and countering weak
arguments (“industry demonization”)
NATIONAL EXPERIMENT
National Randomized Experiment
• Randomized experiment conducted from OctoberDecember, 2012 using the survey research firm
GfK Group (Knowledge Networks)
• 3,118 completed baseline survey and follow-up
(sent 1-week later and completed within 2 weeks)
NATIONAL EXPERIMENT
Overview of Experimental Conditions
Arm
Approach
Time Period 1
Time Period 2
Arm 1 Control condition
No exposure
No exposure
Arm 2 Control condition
No exposure
Strong con-message 1
Strong pro-message 1
No exposure
Strong pro-message 1
Strong con-message 1
Single message
(not countered)
Single message
Arm 4
(countered at time 2)
Arm 3
Arm 5 Multi-message
Arm 6
Multi-message
(w/repeat pro-message)
Arm 7 Inoculation frame
Arm 8
Inoculation frame
(w/repeat pro-message)
Strong pro-message 1,
strong con-message 1
Strong pro-message 1,
strong con-message 1
Inoculation (weak conmessage with refutation)
Inoculation (weak conmessage with refutation)
Strong con-message 2
Strong con-message 2,
strong pro-message 2
Strong con-message 1
Strong con-message 1,
strong pro-message 1
NATIONAL EXPERIMENT
A Strong Pro-Tax Argument
Supporters of a tax say that sugary drinks may be the single largest
driver of obesity in the United States. More children are obese today
than in previous generations. Rates of obesity have tripled among
children and teens over the past 30 years. Children and teens drink
twice as much soda and other sugary drinks as they did 30 years ago.
Supporters of a tax say drinking a 20-oz soda is equivalent to eating
16 packets of sugar. That’s 240 empty calories in a single bottle.
When people consume sugary drinks, they do not feel full, so they
tend to eat more food. Children who drink sugary beverages also
prefer foods with higher calories, leading to worse overall nutrition.
NATIONAL EXPERIMENT
A Strong Anti-Tax Argument
Opponents of a tax say obesity is a matter of how many calories
people consume, not where those calories come from. A tax on
sugary drinks is arbitrary because it does not affect other unhealthy
foods like donuts, cookies, and candy bars.
Obesity is a complex problem that cannot be solved by focusing on
just one small part of a person’s diet. Sugary drinks account for only
7 percent of calories in the average American's diet. Science shows
that obesity is caused by an imbalance between the calories we
consume through food and drinks and those we burn through daily
activities and exercise.
NATIONAL EXPERIMENT
Inoculation Treatment
Soda companies will try to convince you that a tax on sugary drinks
is arbitrary because it does not affect foods like donuts, cookies, and
candy bars. They will say that they are an unacceptable intrusion of
government into people’s personal choices. They will call them “food
taxes” to try to confuse people.
But sugary drinks are not food – they have no nutritional value. In
fact, research suggests that sugary drinks are the single largest
driver of obesity in the United States. Nobody is telling anyone what
to drink. But, by adding a few pennies to the price of a soda, many
people will choose differently.
NATIONAL EXPERIMENT
Tackling opposing arguments can be useful…
5.50
No exposure
Strong pro-, No anti-
Strong pro-, Strong anti-
Inoculation (Strong pro-)
5.25
5.00
4.75
* Denotes p<.05; **p<.01 vs.
no exposure control
*
4.50
**
4.25
4.00
Scale Midpoint
3.75
3.50
3.25
3.00
*
2.75
2.50
2.25
2.00
Support for SSB Tax Policy
SSB Companies Try to Get Kids to Drink SSBs
NATIONAL EXPERIMENT
… At Least in the Short-Term.
5.00
Baseline
4.75
Follow-Up
4.50
4.25
4.00
Scale Midpoint
3.75
3.50
3.25
3.00
2.75
2.50
2.25
2.00
No exp. t1,
No exp. t2
Strong pro t1, No exp. t1, Strong pro t1,
Both t1,
No exp. t2 Strong con t2 Strong con t2 Strong con t2
Both t1,
Both t2
Inoculation t1, Inoculation t1,
Strong con t2
Both t2
NATIONAL EXPERIMENT
… At Least in the Short-Term.
5.00
Baseline
4.75
Follow-Up
4.50
4.25
4.00
Scale Midpoint
3.75
3.50
3.25
3.00
2.75
2.50
2.25
2.00
No exp. t1,
No exp. t2
Strong pro t1, No exp. t1, Strong pro t1,
Both t1,
No exp. t2 Strong con t2 Strong con t2 Strong con t2
Both t1,
Both t2
Inoculation t1, Inoculation t1,
Strong con t2
Both t2
Lesson 3:
Opposing messages(-ers) are a challenge
• It can be useful to anticipate and try to offset
counter-arguments from opponents of social change
• BUT…
• Strategies to neutralize the opposition may not work
across all social groups
% difference from the no-exposure control
group; †p<0.10; *p<0.05 from OLS regression
Politically Polarizing Message Effects
20.0%
15.0%
15.1%*
14.0%†
12.3%†
10.0%
Significant interaction term
(β=-0.83, p=0.02) for
Republican x inoculation
5.0%
2.9%
Republicans
Democrats
0.0%
Independents
-5.0%
-5.3%
-4.5%
-8.0%-7.6%
-10.0%
-12.3%
-15.0%
Strong pro only
Two-sided
Inoculation
Lesson 3:
Opposing messages(-ers) are a challenge
• It can be useful to anticipate and try to offset
counter-arguments from opponents of social change
• BUT…
• Strategies to neutralize the opposition may not work
across all social groups
• AND…
• It’s not always good to wake a sleeping giant
AND… It’s not always good to wake a sleeping
giant (industry)
Source: Harwood et al., 2005
Some Concluding Thoughts
Also Need to Consider:
Who Delivers the Message?
• Traditional news
Traditional news
• Growing capacity to cover disparities, but
• Covering them is still relatively uncommon
Also Need to Consider:
Who Delivers the Message?
• Traditional news
• Novel messengers
Novel Messengers
• Violating expectations of a source can be powerful
• Partisan labels increase policy support when they
take an unexpected position on a partisan issue
• E.g., Republican endorsing same-sex marriage
• E.g., Democrat opposing abortion rights
Source: Bergan (2012)
Novel Messengers
Military
leaders
speaking to
policymakers
and the public
“When it comes to children’s health and our
national security, retreat is not an option.”
“Retreat is Not an Option: Healthier School
Meals Protect Our Children and Country”
What We Need to Know
• Need more work on the messenger
• Need more work on actions vs. opinions/perceptions
– What are the actions that individuals can take to influence
policy?
Direct Democracy in CA and Other Places…
But Limited Results
The Policy Process is Complex…
Source: Bulletin of the WHO (2006)
BUT Changes in Public Sentiment can
Set the Stage for Changes in Policy
Source: Gallup (2012)
Questions? Comments?
Thank you!
Contact me at jdn56@cornell.edu