9UNP0113SD_Jeff_Niederdeppe

- 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. 
(applause)