Well, I'll start by saying thanks for the opportunity to be
here and share some of my work that I've been conducting in
the past year and a half or so. The title is relatively
illustrative of what I'm going to be talking about.
And I'm going to focus today on media campaigns and
socioeconomic disparities in health behaviors.
Just to give you a sense of what I'll be talking about today,
I thought I'd start off by trying to make the case--
hopefully that won't happen repeatedly.
I'll try to make the case that smoking cessation presents
a pretty interesting case study in thinking about issues related
to media campaigns and the socioeconomic disparities.
Then I'm going to raise three questions that will sort of
organize the rest of the talk. Then I'm going to present data
from a longitudinal study that looked at SES differences
in response to media messages here in Wisconsin.
Then I'm going to say a few words in closing about a project
I'm very excited about. It's a collaboration
with David Kindig and Stephanie Robert, among others,
here at Wisconsin that focuses on trying to develop narratives
and images for population health messaging.
I'll get into that in a bit of detail.
It's going to keep happening. I thought I'd start off
and just share. I'm sure most folks in the room
already know about Healthy People 2010, but they
sort of outline the nation's health priorities for this
decade. And there are really two goals
that are explicitly stated. The first, pretty
straightforward, is to increase the quality and years
of healthy life, increase health of the population.
And the second goal is to eliminate health disparities,
a rather lofty goal. But I think important to note
that it's placed equally with both raising overall health
and disparities. Now my field of health
communication and in my field, I'd like to make the case
that essentially we focused more on the first issue, increasing
overall health of the population rather than disparities.
I think this is illustrated nicely by a couple of recent
sort of reviews of the literature, Hornick published
a book in 2002 that simply made the case that media campaigns
influence health behavior. And a meta-analytical review
by Leslie Synder and company in 2004 focused on the main
effects of health communication campaigns and behavior change.
But there have been no parallel studies focusing on,
meta-analytic studies, at least, focusing on effects
of campaigns on disparities. Okay, now thinking about
smoking cessation as a case study in disparities.
Why do I think this is an interesting case study?
Well, one, tobacco is the leading cause of death
in the United States. Some estimates say 30%
of cancer deaths are attributed to smoking.
So the public health issues related to smoking
are pretty clear. And I also want to point out
that there are very large SES disparities in smoking behavior
in the United States. And here, presenting data from
I think 2002-ish, on the X axis is listed years of education
in categories. This is just males, but the
pattern is similar for females. And on the Y axis, you have
the percentage who are smoking in the past 30 days,
currently smoking. What we see is that more or less
linear relationship between socioeconomic status measured
in terms of education and smoking rates.
Whereas for those with less than a high school degree, smoking
rates are between 30 and 40% and for folks with some graduate
work, that percentage is less than 10%.
Third, I think it's worth pointing out that media
campaigns have been shown to be effective strategies to increase
a variety of health behaviors and successful adult cessation.
Now in thinking of the overall effect size of these campaigns,
the estimate is R equals 0.05, which in the whole scheme of
things is not a very big effect. But I think it sort of
understates this effect, because what the effect size measure
is essentially the effect per exposure.
And one of the reasons you would do a media campaign
is because you reach a large segment of the population,
you reach lots of folks at the same time.
So even a small effect per exposure, if you get lots
and lots of exposures, it can be quite meaningful.
I think it's worth pointing out that smoking cessation
campaigns are pretty typical when it comes to the average
effect size for media campaigns. So they're on par with sort of
an average media campaign promoting health behavior.
Fourth, I think it's worth pointing out that nicotine makes
cigarettes highly addictive, and raises questions about
the degree to which smoking is a volitional behavior,
particularly among those who have established smoking
over time. And I want to point out that
SES differences in smoking have not always been
as pronounced as they are today. Right here I'm presenting data,
that's a little dated, but on the X axis, we've got year,
between 1966 and 1991. And on the Y axis, the
percentage of women, in this case, but again,
trends are similar for males, who are current smokers.
So in 1966 we see smoking rates here for women without
a high school degree, and here with a sort of triangle, women
with a high school degree. In 1966 these smoking rates
were pretty comparable, between 30% and 33%.
What you see is these lines have steadily diverged over time
to where in 1991, there is a large difference between these
two populations. I don't have the data plotted
here between '91 and today, but these trends have
essentially stayed at about the same distance,
both have declined a little bit, but the disparity
has remained quite strong. Now getting into the sort of
three questions that are organized in this talk.
I want to first present some theoretical conceptual thinking
about how a media campaign might contribute to
widened disparities in smoking. Then I'm going to present
a little bit of summary data on whether this actually happens
in practice. I'll conclude by saying a bit
about how we might go about addressing these problems
and moving forward. So, the field of communication
in thinking about health disparities has focused and
used largely, the knowledge gap framework as a theoretical
framework. And in short, the knowledge gap
says that higher SES populations tend to acquire knowledge
from media at a faster rate than lower SES populations.
And over time, this leads to increased gaps in knowledge.
I think this is a useful view in some perspectives,
but also a quite limited one. Several people have argued that
framing disparities in terms of knowledge gaps really places
the onus on individuals, rather than larger societal problems.
You know, it's just if certain populations did a better job of
gaining knowledge, we wouldn't have these disparities.
This part is not explicitly made in the argument, but has been
imposed as a critique. I think empirically, it's worth
pointing out that knowledge gaps don't explain disparities
in smoking cessation. If you include in a sort of
multi-variant framework, the effect of education and control
for the effect of differences in knowledge, educational
disparities don't go away. Well more recently the Swaneth
at Harvard has proposed a little broader framework, in short, for
thinking about media campaigns and disparities, and proposed
this concept of communication inequality, which, in summary,
refers to differences between population in terms of:
essentially meaningful exposure through a campaign, whether it
be through differences in access communication channels,
media use patterns, or how much attention is paid to various
types of media; second, would be differences in
sort of response and retention of a media campaign, and this is
to say where the knowledge gap fits into this framework;
and third, and I think perhaps most importantly, is the
capacity or opportunity to act on a media message.
I'll talk a little bit more about that.
In thinking what this looks like, I like to think in
pictures and boxes with arrows, so what I've done here is
sort of, beginning with kind of a simple logic model or causal
model of what an effective campaign might do if it
was trying to promote smoking cessation.
Well, you start with a campaign. Here you need a campaign
if you're going to have campaign effects.
And if the campaign is highly successful, it ought to promote
widespread exposure and recall of the messages
across populations. If those messages are
successful, well designed, they ought to lead to changes
in knowledge, attitudes, behaviors, intentions to perform
a behavior. And in the case of smoking,
trial of quit attempts, making an attempt to quit.
But ultimately, the goal for smoking cessation
media campaigns is sustained smoking cessation over time.
You start with a campaign in a series of sort of
largely cognitive processes leading to sustained
smoking cessation. I'm thinking about how media
campaigns might widen smoking disparities
by socioeconomic status. I think it's useful to map on
this sort of concept of communication inequality here.
The first place this causal chain could break down is in
terms of meaningful exposure, high and low SES populations
may differ in their media use patterns, their access
to different types of media, or their attention
to a media message. In health communication, and
in public health more generally, I think we've thought about this
a fair bit, talked about the digital divide, concepts in
social marketing, about reaching targeting populations, and
finding populations within their media use patterns
has been useful. And we've thought of some
fairly good solutions, I think, to these problems.
Conducting formative research with target audiences both
high and low SES populations, understanding media use patterns
and targeting messages, placing them in context
to reach these populations. That's not the only place
the chain can break down. Suppose we do a good job
of targeting and reaching populations,
both high and low SES. There's still a possibility that
those messages will be different in their persuasive effects,
by populations, and that can happen by differential retention
or response to messages by SES. And again we've thought about
this a fair bit in health communication, informed by both
persuasion theory, sort of behavior change theory.
Solutions largely deal with the design of those messages,
trying to develop messages to target beliefs, attitudes
that may be disparate between populations, and try to
essentially persuade folks about the importance
of quitting smoking. But it's this third area
that I think in communication in particular that we've thought
the least about. And this is the idea that
even if a campaign is successful in motivating and promoting
quit attempts among high and low SES populations,
there's still a possibility that they will lead to disparities
in sustained smoking cessation, because we know that high and
low SES populations face far different challenges and
barriers in social environments. Lower SES populations have
lower access to medical care, tend to have higher levels of
stress from social environment, tend to be in neighborhoods
that have lower levels of social capital,
less social resources, etc. And all of these factors
may reduce the likelihood that intentions to quit
actually lead to sustained smoking cessation.
This has been informed, I think, by sociology,
social epidemiology, some of these fields.
The solution here, I think, that's most important,
is really policy change to change these social environments
in which people live and work. In the field of health
communication, I think we've thought a little bit less
about this. The concept of media advocacy
gets at that a little bit. But I think it's an area
that we need to do a lot more thinking about.
That sort of lays out the conceptional model
of how this might happen. Now let's move to the question
of, in practice is there evidence that media campaigns
may widen SES disparities in smoking.
So we'll start with a sort of philosophical question.
What if media campaigns are less effective, equally effective or
more effective among lower SES verses higher SES populations?
If they're less effective, I think it's pretty easy
to understand that that's likely to increase disparities
over time. However, even if a campaign is
equally effective in promoting sustained smoking cessation
for high and low populations, if it's equally effective,
you'll have the effect, essentially, of maintaining
disparities in terms of overall population levels.
If you think about relative risk, if one group is at
a higher risk than the other and you reduce the absolute risk
for both, you're actually raising the relative risk
of lower SES populations relative to higher
SES populations. So really what you'd like to do
is have a campaign, if the goal is to eliminate disparities
to be more effective among lower SES populations.
So what we did, and this was funded by the state of
Wisconsin, was a comprehensive review of literature on smoking
cessation media interventions. We defined media intervention
pretty broadly, any sort of community or large scale
intervention that included a media component.
And we found 139 studies that had a media component and
focused on smoking cessation. We identified, essentially,
45 articles from 29 studies that in one way or another
directly addressed effectiveness by SES.
The first thing I want to point out is only one-third
of the studies made an explicit comparison by SES.
Well, what did we find? We sort of split these
into two categories, one being general population
interventions, which may have had targeted components,
but were ultimately aimed at both high and low SES
populations in promoting smoking cessation.
We found nine that were less effective among
low SES populations; six that appeared equally
effective between high and low SES populations;
and only three that appeared to be more effective among
low SES populations relative to higher SES populations.
Now I want to make a point about these three.
I think these three sort of pro-cases, which we might say
"Okay that's a good thing," were also some of the most
confounded studies, where media was in the context of
larger community interventions, that included tax increases,
other sorts of community interventions.
So the extent to which we can attribute these three studies
to media campaigns per se is questionable.
I also want to make a case that we found evidence of this
sort of causal chain breaking down at each of the three stages
I described in the sort of causal model earlier;
so both in terms of differences in exposure or recall
of a campaign, differences in change in attitudes, knowledge,
intentions and differences in long-term smoking cessation.
The second category was campaigns or media interventions
that were targeted explicitly and exclusively
to lower SES smokers. We found 11 such campaigns
and not a single one produced long-term changes
in smoking cessation, either relative to a control community
or relative to a pre-existing secular trend.
All right, now I'm going to say a little bit about some
original empirical data from a study that I've worked on
here in Wisconsin. I want to acknowledge
Mike Fiore, Tim Baker and Stevens Smith, who were
collaborators on this project. It was funded both
by the RWJ Health and Society Scholars Program and by some NIH
grants for the data collection. The data from this study were
the Wisconsin Behavioral Health Survey, which essentially
featured 452 Wisconsin adult smokers that participated
in two different studies. The Wisconsin Tobacco Survey
in late 2003. And those same respondents
were interviewed a year later in what was called the Wisconsin
Behavioral Health Survey. The response rate for
the Wisconsin Tobacco Survey, 51%, pretty good as far
as RDD telephone surveys go. However, the enrollment rate
among smokers a year later, was quite a bit lower, 29%, and
it wasn't due to lack of effort. There was lots of attempts
to follow up. Some folks had moved, etc.
And we found some pretty substantial demographic
characteristic differences between those who were
followed up and those who were unavailable for the follow-up.
They were older, more likely to be female, higher education,
which of course, is a bit of a problem if the study
is focused on socioeconomic differences in response.
We essentially constrained some variants here.
They were more nicotine dependent and they've made more
past quit attempts. I just want to point this out
and lay it on the table. It is what it is.
I think it's safe to say that these are not representative
of smokers in the state of Wisconsin.
But it is what it is. So to say a little bit
about what's going on in the state of Wisconsin.
There was periodic media campaign activity focused on
smoking cessation between May 2002 and the end of 2003.
I've sort of categorized these messages into two categories.
The first, I am going to call "keep trying to quit ads,"
so if you see "KTQ," that's what that means.
And these ads really had two messages.
They said we understand it's really, really difficult
to quit smoking, but you should keep trying.
And if you keep trying, you'll succeed.
And then the Quit Line number was generally shown at the end
of these messages. These messages were explicitly
designed to target smokers to call the Quit Line
and to promote cessation. A second category of ads were
focused on secondhand smoke, which the primary goal was
really to generate support for smoking bans in Wisconsin.
So they focused on the harmful effects of secondhand smoke,
on children, bar workers, these sorts of things.
Cessation was not a primary goal, but was essentially
a secondary goal. One of these messages from this
set of messages included the Quit Line, but most did not.
In the baseline survey, we asked folks about their recall
of these two messages. The questions were
pretty similar. For the "keep trying to quit"
ads, we asked if they'd seen an anti-smoking ad that showed
several different people talking about quitting smoking and
how smokers should keep trying. 38% of respondents
answered affirmatively, said they had seen that.
And the secondhand smoke ad recall asked about ads
that showed various people talking about the dangers
of secondhand smoke. About 68% reported seeing
that ad. You know, these differences
are actually consistent with the media weight that was given
to each of these campaigns. The secondhand smoke ads
received more gross ratings points, they were on the air
more frequently in higher audience venues.
So this is consistent with the media buy.
When it comes to self-report of media campaign awareness,
I'm always a little bit leery that people aren't that good
at knowing what they've seen and describing, or adequately,
accurately recalling having seen a message.
So we conducted a series of analyses to try to make
the case that-- To see whether these were
really picking up what they were trying to pick up.
So we conducted a series of analyses for convergent
and discriminate validity. Convergent validity says,
is recall of these ads associated with something
you think theoretically it ought to be associated with.
Whereas, discriminate validity says, is it not associated
with something that it ought not to be associated with.
So what I've done here is split these two lines between
"keep trying to quit ads" and secondhand smoke ads.
And in this particular case, I'm looking at the relationship
between recall of the "keep trying to quit ads"
and the secondhand smoke ads, and whether or not
they had heard of the Wisconsin Quit Line.
Remember, that all of the "keep trying to quit ads"
mentioned the Quit Line and only one of
the secondhand smoke ads did. So reasonably we would expect
the "keep trying to quit ads" to be associated with knowing
about the Quit Line. We wouldn't expect, necessarily,
the secondhand smoke ads to be associated.
Here on the left, we have an odds ratio.
One is an odds ratio saying essentially no association
greater than one is subjective of a positive relationship.
What I've plotted here is the point estimate
and the 95% confidence interval for both of these ads.
What we see here is that people who respond, who recalled seeing
the "keep trying to quit ads" were more likely to have heard
of the Wisconsin Quit Line, that's sort of convergent
to the validity evidence. Whereas the secondhand smoke ads
recall was not associated with the Quit Line.
Again, relatively consistent with our expectations
based on the content of the ads. Turn it around.
Let's look at relationship between recall of these ads
and a belief about the harmfulness of secondhand smoke.
This is a relationship between recall and whether
or not someone believes that secondhand smoke is harmful.
And we see the opposite pattern. Secondhand smoke ad recall
positively associated with belief that
secondhand smoke is harmful. The "keep trying quit ads"
not associated. Confidence interval
overlaps with one. Similar pattern for another
sort of reverse coded measure for secondhand smoke.
This is people who disagree with the statement that secondhand
smoke is not dangerous. And we see, again, a positive
relationship, significantly greater than one,
although really, really close for the secondhand smoke ad.
The confidence interval here for "keep trying to quit ads"
overlaps with one. So again, evidence consistent
that these are picking up different things.
Finally one potential confound here is this national Truth
campaign, which some of you may have seen.
It's a large-scale campaign that's in all 50 states.
It's funded by the American Legacy Foundation and
is targeting 12-17 years old, but may have reached
adult smokers in Wisconsin. We are concerned the major
message of this campaign is that the cigarette industry
is bad news; they lie; they cheat; they target teens.
This sort of "tobacco companies lie" kind of encapsulates
the main message of the Truth Campaign.
And what we see is neither of these ad recall measures
are associated with this belief. Although secondhand smoke
is pretty close here. There's some evidence that they
may have picked up something to do with the national Truth
Campaign, although there's no face validity reason to think
that this measure should have, so keep that in mind.
Back to the baseline measures. We focused on education as a
measure of socioeconomic status for a variety of reasons.
It's a nice continuous measure. Income was measured in a series
of sort of categorical questions.
And there was a fair bit of non-response there.
So we focused in this study specifically on education
as an indicator of SES, but not, certainly, the only one.
We controlled for a variety of factors that might confound
the interpretation of any sort of association between
ad recall and outcomes. It includes nicotine dependence,
the number of previous quit attempts, and a sort of
estimate of their baseline self-efficacy to quit.
I also controlled for age, sex, race, their media use patterns,
and as sort of an indicator of the home smoking climate,
whether or not there are rules about smoking in the home,
which is a variable we know to be a pretty strongly
predictive of quitting. All right, those were all
baseline measures. In the follow-up survey,
remember these are all smokers at baseline, we asked
two questions. One, whether they made
a quit attempt in the past year. That would be between
the baseline and the follow-up survey.
42% of respondents indicated that they had made at least one
quit attempt. And then we asked, if they
currently smoked every day, some days, or not at all
at one year. And 13% said, "Not at all."
And we considered those folks to be abstinent from smoking
at one year. So trying to map this
sort of conceptual model onto the analysis here, we really
focused on three hypotheses. The first deals with whether or
not there would be differences by socioeconomic status
in recall of the campaign. And I'm going to
cut to the chase here. We found no differences
in recall between high and low SES populations
as measured by education. The campaign did some targeting
of less educated populations, by where they placed
media campaign messages, so the campaign thought a lot
about this. And I think did a good job
of reaching smokers in the state of Wisconsin equally by SES.
The second hypothesis asked whether there was a difference
in the relationship between recall of an ad
and making the quit attempt. And the idea was whether
we would see lower ad effects on making the quit attempt for
low SES populations, relative to higher SES populations.
And the third hypothesis dealt with--
Okay, among those who made a quit attempt, who were motivated
enough to make a quit attempt during that year, did we see
different rates of abstinence in their ability or opportunity
to turn that quit attempt into sustained smoking cessation
by SES. Analytically, we used logistic
regression models to predict dependent variable.
In this case of the second hypothesis, whether or not the
respondent made a quit attempt at the end of the first year.
The independent variables of interest here were recall
of those two types of ads; education; but essentially
the real focal point here is the interaction between
ad recall and education. Is there a difference
by education in the relationship between ad recall and making
a quit attempt by education? Again we controlled
for a variety of factors that I mentioned earlier.
And for the third hypothesis we focused on just those folks
who had made a quit attempt in the past year,
and predicted abstinence by education.
Was there a difference by education among those
making the quit attempt? Finally some results,
28 minutes in. Here, we're presenting the
relationship between recall of the "keep trying to quit ads"
and whether or not a respondent made a quit attempt
by education. So here on the X axis, we have
three categories of education. Here on the Y axis, we have
the model predicted percentage making a quit attempt
in the subsequent year. What we see here for folks
with a high school degree or less is a trend
toward a negative relationship between recall.
That is, those who saw the ad were less likely to make a quit
attempt after that first year. For some college, we see
essentially no relationship, a slight trend
toward positive relationship. But for folks with a college
degree, we see a trend toward a strong positive relationship
between recall and making the quit attempt.
Now I want to point out that this relationship within
the lower education group is not significant
in and of itself. This relationship is not
significant in and of itself, but the interaction,
essentially the difference between these two bars
is statistically significant. When we split it up
by education, we're talking about 115-120 folks
in each of these categories. We did not have a whole lot
of statistical power to say whether this was truly
a negative relationship. Or, this was truly
a positive relationship. But we can say there were
significant differences in response to these ads
by education. Well, if you move to
the secondhand smoke ad, we see a very different pattern.
And essentially, there's no difference in the relationship
by education, and it's sort of slightly positive,
but not significant. And the interaction
was not significant. So essentially no evidence
of effects of these secondhand smoke ads on quit attempts.
Again, they weren't the primary goal of these ads.
Finally, thinking about this third hypothesis,
let's take folks that already made a quit attempt
and compare by education which groups were better,
had greater opportunities to turn those quit attempts
into sustained cessation. We see a linear, strong,
significant positive relationship.
The more education you have, the more likely you would be
able to turn this quit attempt into sustained cessation.
It's not terribly surprising, but I think it's interesting
that even in the context of a state media campaign, we
see this relationship to where only about 15% of those with
less than a high school degree who tried to quit were abstinent
at one year versus about 35% of those
with a college degree. All right, just briefly I'm
going to state some limitations of this particular research.
As is the case with any sort of non-randomized,
observational study, selection is always a threat to validity.
It could be that folks who saw the ads differed fundamentally
from folks who did not recall seeing the ads,
or reported recall. And this may explain differences
in results by education. Now I think it's worth saying
that we tried to account for as many differences between
these groups as possible, in terms of nicotine dependence,
media use, past quit attempts, their intentions to quit
in the future. So to the extent possible,
we tried to account for these factors.
But it remains a problem in pretty much all
observational research. I mentioned before, some of the
sample problems in terms of losing folks at follow-up,
and measurement limitations in terms of non-response
for the income questions, etc. And third, I think it's worth
pointing out, that we were unable to identify why we see
large differences in sustained smoking cessation among those
with a quit attempt by education.
We would have liked to test for a variety of mechanisms.
Is it difference in access to treatment?
Is it differences in stress? Is it differences in social
environment, smoking culture at work, etc.
By the time we got to this analysis, we were focusing
only on those 42% of our original sample
who had made a quit attempt. So, we're looking at about
200 folks, not a real large sample for testing
these sort of mechanisms here. Now, I want to sort of take
a step back and try to think a little bit--
And I'd love to get some feedback on this from this group
about why we might see SES differences in response
to one type of ad, the "keep trying to quit" ads,
and not for a different type of ad,
the secondhand smoke ads. First, I think it's worth
pointing out that this "keep trying to quit" ad
has two components. One, quitting is very difficult.
And two, with help, you can quit.
But we know that most smokers have tried to quit before.
And we know that lower SES populations
face greater obstacles in turning a quit attempt
into sustained cessation. So, one sort of speculative
explanation is that for lower SES populations,
this sort of part of the message is the most salient, the most
relevant and the most related to their experience.
Quitting smoking is very difficult.
Why should I try? Right?
Versus higher SES populations who may have been around folks
who have had an easier time quitting, may have had greater
success in their previous quit attempts
for longer periods of time, etc. Perhaps this same message
resonates differently for the higher SES populations
to the point where the message there is, you can do it.
It's a motivational message. This is speculative,
and I think worth testing in future iterations of research.
Now the second question came down to the design
of these messages. And there were a variety of ads
that focused on "keep trying to quit," but one of them
was a cartoon-based ad, one of them was a text-based ad,
whereas these secondhand smoke ads were largely
personal vignettes, where they talked to folks,
interviewed real smokers in Wisconsin.
They talked about their own experiences
with secondhand smoke. And we know from the
communication literature that narratives, that exemplars,
examples of people who have encountered problems and
overcome barriers are particularly persuasive.
This led me to wonder whether the fact that
the "keep trying to quit" ads weren't narrative-based largely,
although there were a few, might explain why we see
differences between these ads. In thinking about sort of
the logic of entertainment education, this is a sort of
newer health communication approach to place pro-health
messages in the context of entertainment programming.
The idea is that you get folks who you might not be able
to reach with the sort of informational campaign,
and tie it up in a narrative, and convey messages that way.
Kind of part of the logic that you'd be better able
to reach lower SES populations using this sort of entertainment
education approach. So I think that's another
potential explanation here. Again I am not able to bring
data to bear on this question. And I think these are subjects
that are worthy of future investigation.
All right. Now just going back
to these three questions. How might media campaigns widen
SES disparities in smoking? Well, I think both from the
review and the primary data here in Wisconsin there is some
evidence that differences may occur at this sort of
difference in recall and meaningful exposure.
Although not in the case of Wisconsin, there was some
evidence that this happened in other campaigns
across the country. I think we've shown that
the potential for differences in sort of short-term reaction,
changes in intentions to quit, quit attempts and response
to a media campaign, may be part of the equation here.
I think we've also been able to show that even if a campaign
is successful in motivating high and low SES smokers
to quit, it's pretty clear that lower SES populations
face greater barriers in their social and work environments
in turning those quit attempts into sustained cessation.
And each one of these routes would ultimately lead
to SES differences in smoking for a campaign
promoting smoking abstinence. The second question,
do media campaigns, at least under some conditions,
widen SES disparities. I think there are plenty of
examples in the literature of places that this has happened,
so I think the answer is yes under at least some conditions,
this happens quite frequently. Third, how might we address the
potential for this to happen? And here's where I'd like
to talk about little bit both about some practical
implications of this work and some work that I've been
working on with some colleagues in pop health.
From the research perspective, I think this underscores
the perspective of efforts to focus both on the mean,
essentially the main effects of the campaign.
Is the campaign influencing the behavior in the population?
But also whether that campaign is influencing disparities
by socioeconomic status in this case, but other types
of disparities as well. You notice that I showed before,
only about one-third of the media campaign evaluations
explicitly focused on this disparities question, so I think
from a starting point, more research is important.
From a practice perspective, I think this underscores the
importance of formative research and not just sort of sending
a message out to one or two focus groups,
but in-depth formative research on message,
and potential interpretations of messages and
potential differences in their interpretation
by socioeconomic status. I think in practice, this isn't
always the case in a lot of campaigns.
It certainly happens in some, but I think it's a very, very
important component here. From the research and practice
perspective, I've been thinking a lot more about this, and
Dave Kindig and Stephanie Robert and a couple of grad students
in Journalism School have been very helpful in working
to think this through. How might we develop messages
with the idea of changing policy,
rather than changing behavior? And specifically policy related
to health disparities and social determinants of health.
So I'll just say a few words, before I open it up to questions
about, sort of this project, and I'm very excited about,
again with collaborators in pop health and journalism.
And really, this project is focused on two related ideas
related to population health. Well, some have defined
population health as essentially a focus on social determinants
of health, recognizing the importance of behavior and
healthcare, but also focusing on factors like income,
education, employment and racial discrimination as factors
that influence health, and recognizing that policy
interventions may be the best way to reduce
the social determinants of health and disparities.
And it's again a focus on differences in equal stead, with
focusing on the sort of overall effects in the population.
And we've sort of divined in the preliminary part of this
project, as some message objectives, would be
just to put this on the agenda. To raise awareness of social
determinants of health with folks who are in a position to
have some influence on policy. That may include policymakers,
whether public or private, state or industry,
sort of opinion leaders, or sort of elites, those who
are thinking and working in the area of health policy.
And I think ultimately, the voting public is a sort
of stakeholder here. One of the key goals
of this work is to really frame disparities and
social determinants of health as a social problem,
rather than an exclusively individual problem.
Well, I think this poses some pretty substantial challenges
from a communication perspective.
One, these sorts of populations tend to be sort of on
the upper end of distribution of social determinants
of health. So essentially, you're trying
to persuade and raise awareness of issues that may be
of greater personal concern to different populations,
not the populations that are making policy decisions.
We also know that people have pretty well-established
attribution biases. Something bad happens to you,
to one's self, we tend to think that
it's a circumstantial issue, that it's our social environment
that caused that problem. Whereas, when bad things happen
to other people, on average, we tend to say that that's
that person's-- a fundamental characteristic
of that person. It's been demonstrated
over and over again. It's a fundamental
attribution error that human beings tend to have
in thinking about attributions of responsibilities.
So that plays in here, I think. Public health priorities,
I think, clearly what dominants a lot of the policy talk
is healthcare in fields like health communication
and health education. Individual behavior
is largely the focus. So I think in trying to think
about policy solutions, there's a lot of inertia
focusing on these sort of other issues.
I think it's worth noting that journalistic norms and practice
tend to emphasize individual rather than societal
attributions for problems. There's a really fascinating
study done that I had a chance to read on coverage
of the obesity epidemic. What the study found,
essentially, was that on average, in reporting on studies
that included both sort of social attributions
for obesity, whether it's neighborhoods,
built environments, sort of factors, and
individual attributions of responsibility, behavior,
exercise, diet. The news coverage of these same
studies, which sort of weighed these factors equally
tended to disproportionately focus on the individual blame.
Folks not exercising, not eating right.
So there's a tendency, I think, journalistically to focus
on individuals rather than broader social solutions.
So what we're doing at the moment, and we're sort of
wrapping up this phase now, is trying to say,
is all this literature in the health communication field
and the persuasion from social psychology,
how do you promote individual behavior change?
How do you get someone to do something?
And what we've tried to do is take this literature and
see how it maps onto this topic of how do you raise awareness
about social attributions of problems like income,
education, etc., and raise awareness
of the social determinants of health and health disparity.
Again I think this represents sort of a shift from focus
on individual behaviors to more a policy societal issue.
It's focused on four elements where there's been some research
in communication. And I can talk about this
in greater detail afterward, if you have specific questions.
But one area is the idea that the way a message is framed,
invites different sorts of attributions.
So you think of something like obesity, you can frame it
as a social problem that's caused by differences
in the built environment, access to good quality food,
or you can frame it as people just aren't exercising enough,
or are eating improperly. There's a small literature
on that. Second, there's a literature
in communications suggesting that narratives are
uniquely powerful, particularly in policy situations.
That is, tell a story about a person and all of this has
focused on people trying to get people to change their behavior,
but I think it's possible. There's a little bit of evidence
to this case that you can also develop narratives
that place people's behavior in a social context, that say
here are the constraints on efforts to, in the case
of obesity for example, eat more healthfully
or exercise, etc. We've tried to develop these
narratives that recognize that there's a choice component, an
individual behavior component. But there's also a larger
societal context in which this behavior occurs.
There's a lot of theory, but not a lot of good research
on the use of visual imagery in trying to promote messages
about social determinants of health, and sort of
intriguing literature on guilt as a motivating factor.
There's some evidence that a sort of moderate amount of guilt
can motivate people's thinking about others
and policy solutions that influence others.
Some evidence that you don't want to make people
feel really guilty, because you tick them off.
That causes them to withdraw, so it's sort of a delicate balance.
How do you subtly evoke a minor state of guilt
without it sort of backfiring. So there's some ethical
issues we could talk about, using sort of emotional
types of appeals. Anyway, I'm very excited about
this work, and I would love to turn it over now to you
for questions, comments, etc. Thanks.
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