Well, I'll start by saying
here and share some of my work thanks for the opportunity to be
the past year and a half or so. thThe title is relatively in
illustrative of what I'm going
And I'm going to focus today to be talking about.
socioeconomic disparities oin health behaviors.d
Just to give you a sense of what
I thought I'd start off by I'll be talking about today,
hopefully that won't happen trying repeatedly. case--
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
Then I'm going to raise three questions that will sort of
organize the rest of the talk.
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
and images for population on tryihealth messaging.ratives
I'll get into that
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
sort of outline the nation's Healthy People 2010, but they
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
And the second goal is of the population.
a rather lofty goal. to eliminate health disparities,
that it's placed equally But I think important to note
and disparities. with both raising overall health
communication and in my field, Now my field of health
that essentially we focused more I'd like to make the case
overall health of the population on the first issue, increasing
I think this is illustrated nicely by a couple of recent
sort of reviews of the
a book in 2002 that simply made the case that media campaigns
influence health behavior.
by Leslie Synder and company And a meta-analytical review
effects of health communication campaigns and behavior change.
But there have been no parallel studies focusing on,
meta-analytic studies, at least,
of campaigns on disparities. focusing on effects
smoking cessation as a case study in disparities.
Why do I think this is
Well, one, tobacco is the anleading cause of deathy?
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.
pattern is similar for females. And on the Y axis, you have
the percentage who are smoking
currently smoking. in the past 30 days,
linear relationship between Wsocioeconomic status measuredss
in terms of education and smoking rates.
Whereas for those with less than
rates are between 30 and 40% a high school degree, smoking
work, that percentage and foris less than 10%.graduate
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
the estimate is R equals 0.05, effect size of these campaigns,
things is not a very big effect. which in the whole scheme of
understates this effect, because But I think it sort of
is essentially the effect what thper exposure. measure
And one of the reasons
is because you reach a large you would do a media campaign
you reach lots of folks segmat the same time.tion,
So even a small effect
and lots of exposures, per exposure, if you get lots
I think it's worth pointing iout that smoking cessation
campaigns are pretty typical
effect size for media campaigns. when it comes to the average
an average media campaign Sopromoting health behavior.of
Fourth, I think it's worth
cigarettes highly addictive, pointing out that nicotine makes
the degree to which smoking is a volitional behavior,t
particularly among those
over time. who have established smoking
SES differences in smoking And I want to point out that
as pronounced as they are today. have not always been
that's a little dated, but Right here I'm presenting data,
between 1966 and 1991. on the X axis, we've got year,
percentage of women, And on the Y axis, the
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 high school degree. with a sort of triangle, women
were pretty comparable, In 1between 30% and 33%.tes
What you see is these lines have steadily diverged over time
to where in 1991, there is a
two populations. large difference between these
here between '91 and today, I dobut these trends havetted
essentially stayed at about the same distance,
both have declined a little bit,
has remained quite strong. but the disparity
three questions that Now getting into the sort of
I want to first present some are organized in this talk.
about how a media campaign theoretical conceptual thinking
widened disparities in smoking. Then I'm going to present
a little bit of summary data
in practice. on whether this actually happens
about how we might go about I'addressing these problemsit
and moving forward. So, the field of communication
in thinking about health
used largely, the knowledge gap dframework as a theoretical
framework.
says that higher SES populations And in short, the knowledge gap
from media at a faster rate than lower SES populations.
And over time, this leads to
I think this is a useful view incin some perspectives,dge.
but also a quite limited one. Several people have argued that
framing disparities in terms
the onus on individuals, rather othan larger societal problems.
You know, it's just if certain
gaining knowledge, we wouldn't populations did a better job of
This part is not explicitly made have these disparities.
imposed as a critique. in the argument, but has been
pointing out that knowledge Igaps don't explain disparities
in smoking cessation. If you include in a sort of
multi-variant framework, the
for the effect of differences effin knowledge, educationalrol
disparities don't go away.
at Harvard has proposed a little Well more recently the Swaneth
thinking about media campaigns broader framework, in short, for
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
media use patterns, or how much attention is paid to various
types of media; second, would be differences in
sort of response and retention
to say where the knowledge gap of a media campaign, and this is
and third, and I think perhaps fits into this framework;
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
was trying to promote camsmoking cessation.it
Well, you start with a campaign.
if you're going to have Hercampaign effects.aign
And if the campaign is highly successful, it ought to promote
widespread exposure and recall
across populations. If those messages are
successful, well designed,
in knowledge, attitudes, they ought to lead to changes
a behavior. beAnd in the case of smoking,orm
trial of quit attempts, making an attempt to quit.
But ultimately, the goal
media campaigns is sustained for smoking cessation
You start with a campaign smoin a series of sort ofme.
largely cognitive processes leading to sustained
smoking cessation.
campaigns might widen I'm smoking disparitiesmedia
by socioeconomic status.
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,
to a media message. In health communication, and
in public health more generally,
a fair bit, talked about the I think we've thought about this
social marketing, about reaching digital divide, concepts in
finding populations within targeting populations, and
has been useful. their media use patterns
fairly good solutions, I think, And to these problems.ome
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.
those messages will be different There's still a possibility that
by populations, and that can in their persuasive effects,
or response to messages by SES. hAnd again we've thought abouton
this a fair bit in health communication, informed by both
persuasion theory, sort of
Solutions largely deal with the design of those messages,
trying to develop messages
that may be disparate between populations, and try to
essentially persuade folks
of quitting smoking. about the importance
that I think in communication in particular that we've thought
the least about.
even if a campaign is successful And this is the idea that
quit attempts among high in motivating and promoting
there's still a possibility that and low SES populations,
in sustained smoking cessation, because we know that high and
low SES populations face far
barriers in social environments. different challenges and
lower access to medical care, tend to have higher levels of
stress from social environment, tend to be in neighborhoods
that have lower levels
less social resources, etc. And all of these factors
may reduce the likelihood that intentions to quit
actually lead to sustained
This has been informed, I think, by sociology,
social epidemiology,
The solution here, I think, that's most important,
is really policy change to
in which people live and work. change these social environments
communication, I think In the field of health
about this. wThe concept of media advocacys
gets at that a little bit.
that we need to do But I think it's an area
That sort of lays out a the conceptional modelt.
of how this might happen. Now let's move to the question
of, in practice is there
may widen SES disparities evidence in smoking.campaigns
So we'll start with a sort of philosophical question.
What if media campaigns are less
more effective among lower SES effective, equally effective or
If they're less effective, verses higher SES populations?
to understand that that's likely I think it's pretty easy
over time. to increase disparities
equally effective in promoting However, even if a campaign is
for high and low populations, sif it's equally effective,
you'll have the effect, essentially, of maintaining
disparities in terms
If you think about relative of risk, if one group is ats.
a higher risk than the other
for both, you're actually andraising the relative riskrisk
of lower SES populations
SES populations. relative to higher
is have a campaign, if the goal Sois to eliminate disparitiesdo
to be more effective
So what we did, and this was among lower SES populations.
Wisconsin, was a comprehensive funded by the state of
cessation media interventions. review of literature on smoking
pretty broadly, any sort of We community or large scaleon
intervention that included
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
The first thing I want by SES.
of the studies made an explicit comparison by SES.
Well, what did we find? We sort of split these
into two categories,
interventions, which may have onhad targeted components,on
but were ultimately aimed at both high and low SES
populations in promoting
We found nine that were less effective among
low SES populations;
effective between high six that appeared equally
and only three that appeared and low SES populations;
low SES populations relative to be more effective among
Now I want to make a point to higher SES populations.
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
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
sort of causal chain breaking down at each of the three stages
I described in the sort of
so both in terms of differences in exposure or recall
of a campaign, differences in change in attitudes, knowledge,
intentions and differences
The second category was campaigns or media interventions
that were targeted
to lower SES smokers. We found 11 such campaigns
and not a single one
in smoking cessation, either produced long-term changes
or relative to a pre-existing relative secular trend.ommunity
All right, now I'm going to say a little bit about some
original empirical data from
here in Wisconsin. a study that I've worked on
Mike Fiore, Tim Baker and Stevens Smith, who were
collaborators on this project.
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
in two different studies. adThe Wisconsin Tobacco Surveyd
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.
among smokers a year later, was quite a bit lower, 29%, and
it wasn't due to lack of effort.
to follow up. Some folks had moved, etc.
And we found some pretty
characteristic differences substantial demographic
followed up and those who were between those who were
They were older, more likely unavailable for the follow-up.
which of course, is a bit to of a problem if the studyon,
is focused on socioeconomic differences in response.
We essentially constrained
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.
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
smoking cessation between May 2002 and the end of 2003.
I've sort of categorized these
The first, I am going to call me"keep trying to quit ads,".
so if you see "KTQ,"
And these ads really had two messages.
They said we understand it's really, really difficult
to quit smoking,
And if you keep trying, but yoyou'll succeed.rying.
And then the Quit Line number was generally shown at the end
of these messages.
designed to target smokers These messages were explicitly
and to promote cessation. A second category of ads were
focused on secondhand smoke,
really to generate support which the primary goal was
So they focused on the harmful for smoking bans in Wisconsin.
on children, bar workers, effthese sorts of things.ke,
Cessation was not a primary goal, but was essentially
a secondary goal. One of these messages from this
set of messages included the
In the baseline survey, we Quit Line, but most did not.
of these two messages. asked folks about their recall
pretty similar. For the "keep trying to quit"
ads, we asked if they'd seen
several different people talking an anti-smoking ad that showed
how smokers should keep trying. abou38% of respondents and
answered affirmatively, said they had seen that.
And the secondhand smoke ad recall asked about ads
that showed various people
of secondhand smoke. talking about the dangers
that ad. About 68% reported seeing
are actually consistent with You know, these differences
to each of these campaigns. the The secondhand smoke adsven
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
I'm always a little bit leery that people aren't that good
at knowing what they've seen
accurately recalling and describing, or adequately,
So we conducted a series having seen a message.
the case that-- To see whether these weree
really picking up what
So we conducted a series they were trying to pick up.
and discriminate validity. of analyses for convergent
is recall of these ads Convergent validity says,
you think theoretically it ought to be associated with.
Whereas, discriminate validity
with something that it says, is it not associated
So what I've done here ought not to be associated with.
"keep trying to quit ads" is and secondhand smoke ads.ween
And in this particular case,
between recall of the I'm"keep trying to quit ads"hip
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.
the secondhand smoke ads We wouldn't expect, necessarily,
Here on the left, we have toan odds ratio..
One is an odds ratio saying essentially no association
greater than one is subjective
What I've plotted here of a positive relationship.
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
based on the content of the ads. with our expectations
Let's look at relationship Turn it around.
and a belief about the between recall of these ads
This is a relationship harmfulness of secondhand smoke.
or not someone believes that between recall and whether
And we see the opposite pattern. secondhand smoke is harmful.
positively associated Seconwith belief thatecall
secondhand smoke is harmful.
not associated. TheConfidence intervalads"
overlaps with one.
sort of reverse coded measure Simfor secondhand smoke.her
This is people who disagree with
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
overlaps with one. for "keep trying to quit ads"
that these are picking up So agadifferent things.istent
Finally one potential confound
campaign, which some of you here ismay have seen. Truth
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 bad news; they lie; is that the cigarette industry
This sort of "tobacco companies thlie" kind of encapsulatesns.
the main message
And what we see is neither of the Truth Campaign.
are associated with this belief. of these ad recall measures
is pretty close here. There's some evidence that they
may have picked up something
Campaign, although there's no face validity reason to think
that this measure should have,
Back to the baseline measures. so keep that in mind.
measure of socioeconomic status Wfor a variety of reasons. a
It's a nice continuous measure. Income was measured in a series
of sort of categorical
And there was a fair bit questions.
So we focused in this study specifically on education
as an indicator of SES, but not,
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
estimate of their baseline quit attempts, and a sort of
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
which is a variable we know to be a pretty strongly
predictive of quitting. All right, those were all
baseline measures.
remember these are all smokers In the follow-up survey,
two questions. at baseline, we asked
a quit attempt in the past year. One, whether they made
the baseline That would be between
42% of respondents indicated and the follow-up survey.
quit attempt. thaAnd then we asked, if theyne
currently smoked every day, some days, or not at all
at one year.
And we considered those folks to be abstinent from smoking
at one year.
sort of conceptual model onto the analysis here, we really
focused on three hypotheses.
not there would be differences The first deals with whether or
in recall of the campaign. by socioeconomic status
cut to the chase here. And I'm going to
in recall between high and low We found no differences
as measured by education. The campaign did some targeting
of less educated populations, by where they placed
media campaign messages,
about this. soAnd I think did a good jobt
of reaching smokers in the state
The second hypothesis asked whether there was a difference
in the relationship between recall of an ad
and making the quit attempt.
we would see lower ad effects on making the quit attempt for
low SES populations, relative to higher SES populations.
And the third hypothesis
Okay, among those who made a dealt with--
enough to make a quit attempt quduring that year, did we seeed
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
In this case of the second dependent variable.
respondent made a quit attempt hypothesis, whether or not the
The independent variables aof interest here were recall
of those two types of ads;
the real focal point here is the interaction between
ad recall and education.
by education in the relationship Is there a difference
a quit attempt by education? between ad recall and making
for a variety of factors Again we controlled
And for the third hypothesis that I mentioned earlier.
who had made a quit attempt we focin the past year,e folks
and predicted abstinence
Was there a difference by education.
making the quit attempt? by education among those
28 minutes in. Finally some results,
relationship between recall of Here, we're presenting the
and whether or not a respondent the "made a quit attempt ads"
by education. So here on the X axis, we have
three categories of education.
the model predicted percentage Here on the Y axis, we have
in the subsequent year. What we see here for folks
with a high school degree or less is a trend
toward a negative relationship
That is, those who saw the ad were less likely to make a quit
attempt after that first year.
essentially no relationship, For some college, we see
toward positive relationship. But for folks with a college
degree, we see a trend toward a strong positive relationship
between recall
Now I want to point out that and making the quit attempt.
the lower education group thiis not significanthin
in and of itself. This relationship is not
significant in and of itself, but the interaction,
essentially the difference
is statistically significant. bWhen we split it uprs
by education, we're talking about 115-120 folks
in each of these categories.
of statistical power to say We whether this was trulyot
a negative relationship.
a positive relationship. Or, this was truly
significant differences Bin 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
but not significant. slightly positive,
was not significant. And the interaction
of effects of these secondhand So essentially no evidence
Again, they weren't the primary smokegoal of these ads.pts.
Finally, thinking about this third hypothesis,
let's take folks that already made a quit attempt
and compare by education
had greater opportunities to turn those quit attempts
into sustained cessation. We see a linear, strong,
significant positive
The more education you have, relationship.
able to turn this quit attempt the more likely you would be
It's not terribly surprising, but I think it's interesting
that even in the context
see this relationship to where of a state media campaign, we
less than a high school degree only about 15% of those with
at one year whoversus about 35% of thosenent
with a college degree.
going to state some limitations of this particular research.
As is the case with any sort
observational study, selection of non-randomized,
It could be that folks who saw is always a threat to validity.
from folks who did not the ads differed fundamentally
or reported recall. And this may explain differences
in results by education.
that we tried to account for Now I think it's worth saying
these groups as possible, in terms of nicotine dependence,
media use, past quit attempts,
in the future. their intentions to quit
we tried to account So tfor these factors.ble,
But it remains a problem
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.
pointing out, that we were And third, I think it's worth
large differences in sustained unable to identify why we see
with a quit attempt smoking by education.ng those
We would have liked to test for a variety of mechanisms.
Is it difference
Is it differences in stress? in access to treatment?
environment, smoking culture Is it differences in social
By the time we got to this at work, etc.
only on those 42% anof our original sampleng
who had made a quit attempt.
200 folks, not a real large So, sample for testingbout
these sort of mechanisms here.
a step back and try to think Now, I want to sort of take
And I'd love to get some a little bit--
about why we might see feedback on this from this group
to one type of ad, SES differences in response
and not for a different the "keeptype of ad,quit" ads,
the secondhand smoke ads. First, I think it's worth
pointing out that this
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
face greater obstacles SES populations
into sustained cessation. So, one sort of speculative
explanation is that for lower SES populations,
this sort of part of the message
relevant and the most related is thto their experience.most
Quitting smoking
Why should I try? is verRight?icult.
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.
resonates differently for the higher SES populations
to the point where the message
It's a motivational message. there is, you can do it.
and I think worth testing in This is speculative,
Now the second question futcame down to the designrch.
of these messages.
that focused on "keep trying And there were a variety of ads
was a cartoon-based ad, one of them was a text-based ad,
whereas these secondhand
personal vignettes, where they smoke ads were largely
interviewed real smokers talked to folks,
They talked about their own experiences
with secondhand smoke.
communication literature And we know from the
examples of people who have thatencountered problems andars,
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,
differences between these ads. might explain why we see
the logic of entertainment In thinking about sort of
newer health communication education, this is a sort of
messages in the context of entertainment programming.
The idea is that you get folks
to reach with the sort of winformational campaign,e
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
education approach. usiSo I think that's anotherment
potential explanation here. Again I am not able to bring
data to bear on this question.
that are worthy Andof future investigation.cts
All right.
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
Although not in the case and meaningful exposure.
evidence that this happened of Wiin other campaigns some
across the country. I think we've shown that
the potential for differences in sort of short-term reaction,
changes in intentions to quit,
to a media campaign, may be part quit attempts and response
I think we've also been able of the equation here.
is successful in motivating to shigh and low SES smokersign
to quit, it's pretty clear
face greater barriers in their that lower SES populations
in turning those quit attempts social and work environments
And each one of these routes into sustained cessation.
to SES differences in smoking woulfor a campaignead
promoting smoking abstinence. The second question,
do media campaigns, at least under some conditions,
widen SES disparities.
examples in the literature of places that this has happened,
so I think the answer is yes
this happens quite frequently. under at least some conditions,
potential for this to happen? ThiAnd here's where I'd likethe
to talk about little bit
implications of this work and some work that I've been
working on with some colleagues in pop health.
From the research perspective,
the perspective of efforts I think this underscores
essentially the main effects to focus both on the mean,
Is the campaign influencing the behavior in the population?
But also whether that campaign
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
from a starting point, disparities question, so I think
From a practice perspective, more research is important.
importance of formative research I think this underscores the
a message out to and not just sort of sending
but in-depth formative one or two focus groups,
and potential interpretations reof messages andge,
potential differences in their interpretation
by socioeconomic status.
always the case in I think in practice, this isn't
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
in Journalism School have been and a couple of grad students
to think this through. very helpful in working
with the idea How mof changing policy,sages
rather than changing behavior?
to health disparities and Asocial determinants of health.
So I'll just say a few words, before I open it up to questions
about, sort of this project,
again with collaborators and I'm very excited about,
And really, this project in pop health and journalism.
related to population health. is fWell, some have defineddeas
population health as essentially
of health, recognizing a focus on social determinants
healthcare, but also focusing theon factors like income, and
education, employment and racial discrimination as factors
that influence health,
interventions may be and recognizing that policy
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
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.
whether public or private, That may include policymakers,
sort of opinion leaders, state or industry,
are thinking and working or sort of elites, those who
And I think ultimately, ithe voting public is a sort.
of stakeholder here.
of this work is to really frame disparities and
social determinants of health as a social problem,
rather than an exclusively
Well, I think this poses some pretty substantial challenges
from a communication
One, these sorts of populations tend to be sort of on
the upper end of distribution of social determinants
of health.
to persuade and raise awareness So eof issues that may beying
of greater personal concern to different populations,
not the populations that
We also know that people are making policy decisions.
attribution biases. Something bad happens to you,
to one's self,
it's a circumstantial issue, we tend to think that
that caused that problem. Whereas, when bad things happent
to other people, on average,
that person's-- a fundamental characteristic
of that person. It's been demonstrated
over and over again.
attribution error that human beings tend to have
in thinking about attributions
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
tend to emphasize individual journalistic norms and practice
attributions for problems. rather than societal
study done that I had a chance There's a really fascinating
of the obesity epidemic. to read on coverage
essentially, was that on What the study found,
that included both average, in reporting on studies
for obesity, sort of social attributions
built environments, whetsort of factors, andds,
individual attributions of responsibility, behavior,
exercise, diet. The news coverage of these same
studies, which sort of weighed
tended to disproportionately these factors equally
Folks not exercising, focus not eating right. blame.
So there's a tendency, I think, journalistically to focus
on individuals rather than
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
how do you promote from social psychology,
How do you get someone individual behavior change?
And what we've tried to do to do something?
see how it maps onto this topic of how do you raise awareness
about social attributions of problems like income,
education, etc.,
of the social determinants and raise awareness
Again I think this represents of sort of a shift from focusy.
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,
But one area is the idea that ifthe 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.
in communications suggesting Second, there's a literature
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.
to this case that you can Theralso develop narrativesdence
that place people's behavior
here are the constraints in a social context, that say
of obesity for example, on eat more healthfullyase
or exercise, etc. We've tried to develop these
narratives that recognize that
individual behavior component. there's a choice component, an
societal context in which Buthis behavior occurs.er
There's a lot of theory, but
on the use of visual imagery not a lot of good research
about social determinants in tof health, and sort ofges
intriguing literature on guilt as a motivating factor.
There's some evidence that a
can motivate people's sort thinking about others guilt
and policy solutions
Some evidence that you don't that influence others.
feel really guilty, because you tick them off.
That causes them to withdraw, so
How do you subtly evoke a it's sminor state of guiltlance.
without it sort of backfiring.
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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