Framing a Public Discussion on the
Social Determinants of Health
Lauri Andress, Ph.D. • June 24, 2009
Which message explains health disparities
the best?
1.
2.
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 highquality 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.
0%
1
0%
2
Do we need a public
discussion on the SDOH?
Depends …
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
Public Policy
Framing the Discussion
The conscious, strategic efforts by
groups of people to fashion shared
understandings of the world and of
themselves that legitimate and
motivate collective action." (1)
Cultural learning
Values
Healthcare Access and Quality
Racial and Ethnic
differences in health
The group that defines the
issue wins the day……………
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.
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
• Demonstrates significant gaps between
the health of wealthy and poor people
When you think about this statement, does it have meaning
for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• Explains the gradient of health along
all socioeconomic levels
When you think about this statement, Does it have
meaning for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• Shows the significant race-based gaps in
health outcomes
When you think about this statement, Does it have
meaning for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• 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?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• The role of social exclusion [social inequality]
in determining health outcomes
When you think about this statement, does it have
meaning for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• The role of circumstances-induced stress as
a mechanism leading to health disparities
between different populations
When you think about this statement, does it have
meaning for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• The importance of both psycho-social and
material causalities in creating disparities
When you think about this statement does it have
meaning for you?
1. Yes
2. No
3. Not sure I understand the statement
0%
1
0%
2
0%
3
A Public discussion looks like this…
Possible 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 don’t 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.
• Certain groups of people are less healthy
because they are socially or economically
deprived.
In general, when you think about this statement do you:
1. Agree
2. Disagree
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• 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:
1. Agree
2. Disagree
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• 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 don’t have the material goods that have been
deemed important in a society.
In general, when you think about this statement do you:
1. Agree
2. Disagree
3. Not sure I understand the statement
0%
1
0%
2
0%
3
• 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:
1. Agree
2. Disagree
3. Not sure I understand the statement
0%
1
0%
2
0%
3
A Quick Review
Our In-House Poll
Social Movements
Agenda Setting
Generating the public discussion…
Features of Social Movements
Method of issue generation
1. Outside initiative- nongovernmental sources
2. Mobilization- government source
3. Inside access- bypass public use legislative process
Mobilizing structures
• The type of structure
• The impact of external opportunities
• Other resources
Individuals
Money
Knowledge
Frames
Technical tools
Process information
Distribute information
Political opportunities
• Openness of political system
• Presence of elite alignments
• Presence of state repression
Framing processes
• The cultural toolkit of a society
• Framing strategies
• Frame packages
• The structure and role of the
media
Generating the public discussion…
Features of Social Movements
Opportunity
Organization
Mediate
Social Change
Frames
Shared Cultural Understandings
Agenda Setting
Mobilizing
structures
Agenda Setting
Issue
Public
Problem
SPIGS
Public
Media
Legislative
Agenda
Agenda Setting
Frames
Narratives
Stories
Claims
Cognitive Models
Image
Tone
Values
Venues
Issue advocates
Policy elites
Public
4 levels
Media
Victory
Policy monopoly
Policy Made
Recognition
Resources
Government
Regulatory
Legislative
Courts
Next Steps
• Using Social movement elements as
framework and the agenda setting model
– The U.K.
– Canada
– United States
• Generally
• Kentucky
• The Future
A Case Study
The emergence of the social
determinants of health on the policy
agenda in Britain: 1980--2003
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….
Results: Political Opportunities
• 1980: Publication of the Black Report
• 1985: Abolition of the Health Education Council
• 1996: SDOH policies, government publications,
and programs after
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%
Results: Issue generation & expansion
Political Opportunities
Period 1
1980- 1996
Issue Generation Method
Outside Initiative
News articles =63%
Period 2
1997-2003
Issue Generation Method
Mobilization Effort
News articles =57%
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
– Elite–level debates
The Media and Framing
By excluding or marginalizing other perspectivesnotably 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.
Results: Framing
• 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.
– 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”.
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
Results: Mobilization Structures
Group
Frequency
Political Parties
11%
Academic Institutions
9%
Government
28%
Parliament, Downing Street
Advocacy Groups, Think Tanks,
Not-for-Profits
9%
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
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.
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
Political Opportunities: United States
• Government intervention
Ronald Reagan (1981) “Government is
not the solution to our problem; government
is the problem.”
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.
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
United States Considerations
• Issue Generation
o Outside initiative- nongovernmental sources
o Mobilization- government source
o 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
United States: Cultural Barriers
Values, Beliefs, and Frames
Poverty
Land of Opportunity
Inequality
Health and Health Care
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]
Values, Ideals, etc. … don’t 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
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
Health: How we think about it in the U.S.?
Healthier
GROUP A
CHOICES
GROUP B
GROUP C
Character, Knowledge,
Culture, Priorities, Values
Less Healthy
Public assumes a different causal story: RIGHT CHOICES
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
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
It’s your own personal responsibility to do what you can to improve
your health and keep yourself healthy ... If I’m going out, [if] I smoke a
lot, if I’m carrying on excess weight or if I have four or five alcoholic
drinks every day – I’m making that decision. That’s my choice, so I’m
hurting myself. I think there’s 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
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…
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
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?
1.
2.
3.
4.
5.
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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3
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4
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5
The Future
Where 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
The End
Lauri Andress, Ph.D.
www.bridgingthehealthgap.com