2. The mission of the Robert Wood Johnson Foundation is to improve the health and health care of all Americans.
--Who we are
--We’ll talk about why RWJF developed messages about social determinants of health, the research behind the messages, recommendations for crafting messages, and how the foundation talks about social determinants

3. There’s More to Health than Health Care
3/25/2017
There’s More to Health than Health Care
Social & Economic
Opportunities & Resources
Income
Education
Medical
Care
Racial Bias
Social Status
Living & Working Conditions
in Homes & Communities
Personal
Responsibility
Affordability
--The challenge is to convey—is a simple and compelling way—how all of these factors, interconnected, affect our health.
Neighborhood
Conditions
Coverage
Access
Community
Resources
Working
Conditions
Housing
© 2008 Robert Wood Johnson Foundation. All rights reserved. 3

4. Area-based measures of poverty and deprivation have been found to be associated with health outcomes after adjustment for individual-level factors. Additional studies have suggested that neighborhood-level variables may also shape the distribution of health-related behaviors, although other studies have found little evidence of area effects.
--Where we started—with how the research describes disparities and social determinants.
(Diez-Roux AV. ―Bringing Context Back into Epidemiology: Variables and Fallacies in Multilevel Analysis.‖ American Journal of Public Health, 88(2):216-22, 1998

5. “Through a combination of latent effects and pathways of living, child development affects health, well-being, and competence throughout the life cycle.”
“Throughout this century, average life expectancy for all persons in the United States has been increasing… but data show that during 1979–89, 45-year-olds with the highest incomes could expect to live 3 to 7 years longer than those with the lowest incomes.”
“In the overall population, observed patterns were clearly consistent with a socioeconomic gradient in life expectancy at age 25, health status, and activity limitation due to chronic disease; for these indicators, better health outcomes were seen at each higher level of income or education and the confidence intervals did not overlap.”
“If SES effects are due to poverty and its correlates, one would expect to find a threshold effect above which SES would show little or no association with health outcomes. Studies at both the individual and aggregate levels challenge this expectation. An association of SES and mortality occurs throughout the SES hierarchy.”
“Area-based measures of poverty and deprivation have been found to be associated with health outcomes after adjustment for individual-level factors. Additional studies have suggested that neighborhood-level variables may also shape the distribution of health-related behaviors, although other studies have found little evidence of area effects.”
--Over the past 10 years there has been a lot of research pointing to the need to address social determinants.
--So this is where we started…..

6. Where we live, learn, work and play can have a greater impact on how long and well we live than medical care.
--And this is where we ended up.
--Now let’s look at how we got there.
(Ask: How many of you have seen this messaging? How many of you use it?)
--RWJF focuses on policy and environmental changes to improve health. As SDOH evidence multiplied, we took several steps to address these factors:
Research to inform messaging, recognizing that we needed to translate the evidence into simple, compelling language in order to engage decision makers outside of health.
We also needed the messaging to describe our grantmaking direction, as we began to focus more on SDOH.
-And…

7. --And we convened the Commission to Build a Healthier America and charged the Commissioners with developing recommendations to improve health—beyond health care. We needed clear messaging both for the Commissioners (many of whom were leaders in fields other than health) and to promote their work.

8. Co-chaired by Mark McClellan and Alice Rivlin, Commissioners produced 10 recommendations for improving America’s health…(read on next 3 slides)

9. The Commission’s Recommendations
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The Commission’s Recommendations
Ensure that all children have high-quality early developmental support. 1
Fund and design WIC and SNAP (Food Stamps) programs to meet the needs of hungry families with nutritious food. 2
Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods. 3 4
Feed children only healthy foods in schools.

10. The Commission’s Recommendations
3/25/2017
The Commission’s Recommendations
Require all schools (K-12) to include time for all children to be physically active every day. 5
Become a smoke-free nation. Eliminating smoking remains one of the most important contributions to longer, healthier lives. 6
Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs. 7

11. The Commission’s Recommendations
3/25/2017
The Commission’s Recommendations 8
Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating. 9
Integrate safety and wellness into every aspect of community life.
(Explain that the report with recommendations is available at commissiononhealth.org)
Ensure that decision-makers in all sectors have the evidence they need to build health into public and private policies and practices. 10

12. Message Development Approach
Qualitative Audience Research
6 focus groups with “swing voters” and opinion elites
Quantitative Audience Research
National voter poll on messages derived from focus groups
Two rounds of message-effectiveness testing using online surveys
Interactive Messaging Workshop
Story Development
--Research was conducted by 2 firms, one (R)--Public Opinion Strategies– and one (D) Greenberg Associates--, who helped shape both the research questions and the messages that were tested. ( )
--Note: audiences for testing purposes were identified as R or D or swing to enable them to quickly categorize themselves.
--Note: swing voters were targeted in the research. Ds are more likely to already be supportive, and strong Rs would be more difficult to sway. Swing voters offer the greatest opportunity to broaden the base of support for SDOH.

13. Democrats Democrats Republicans Republicans
Imbalance in levels of health is unjust.
Imbalance in levels of health is natural.
Equality should be our goal.
- Equal distribution of resources
- Equal treatment for all
- Equal outcomes
Equality is unrealistic and unfair.
- Tailor the distribution of [limited] resources to particular needs, not the same for all
- Individuals will never have equal outcomes.
We need to “level the playing field”
We need to raise the bottom.
Society bears primary responsibility for inequality, thus to fix it requires more change in society than in the individual.
Olsen Zaltman Associates, 2007
--Ds and Rs differ in how they view the world.
Note: results here are comparable to those in research we’ve conducted over the past 10 years on the issue of covering the uninsured.
Both society and individual choices create disparities, thus social aid must be balanced against individual responsibility.

14. Discrimination within Health Care System
Democrats
Poverty
Poor Nutrition
BARRIER
BARRIER
Lack of insurance
Racial discrimination
BARRIER
Can’t Exercise
Gender discrimination
Environmental Hazards
Difficult to maneuver through health care system
Violence
Discrimination based on sexual orientation
HEALTH
GOOD
Poor Education
Language barriers prevent same level of care
Racism
Not enough easily accessible facilities
Less Parental Supervision
--Ds see many relationships between root causes of health, access to care and discrimination in the health care system.
Inadequate Transportation
Cultural hesitancy to see a doctor
Can’t afford some treatments
Stress
Discrimination within Health Care System
Initial Health Status
Access to Health
Care System

15. Discrimination within Health Care System
Republicans
Challenges
CHALLENGES
Lack of money
Lack of insurance
BARRIER
Lack of knowledge
- Parents less involved
- Poor public education about options
Difficult to maneuver through health care system
HEALTH
GOOD
Cultural hesitancy to see a doctor
Bad choices
--Rs are less specific in how they see the causes of disparities, and focus on lack of access, not discrimination.
--They are more likely to view disparities as challenges, not stronger barriers, that can be overcome by individuals with determination and some help.
Discrimination within Health Care System
Initial Health Status
Access to Health
Care System

16. Follow-up: 2011: National Voter Survey
% Favorable
Message 35
There are often obstacles or barriers that make it harder for some people to stay healthy than others. Providing people resources and information on diet and exercise and creating healthy policies can help people make healthy choices. 58
Staying healthy is a personal choice and is determined by individual behaviors such as diet, exercise, not smoking, and getting regular doctor checkups. Anyone can make the right choices to stay healthy if they want to.
--The R perspective was upheld in a 2011 survey by the same research team.
--The challenge: to engage more swing voters/people holding more conservative perspectives, while keeping the support of Ds/more progressive voters.
--In order to broaden the base of support for SDOH.
From National voter survey, 2011

17. Implication for messages
Republicans had negative reactions to the idea of creating equal levels of health:
Instead, the following terms may resonate more with Republicans and would not alienate the Democrats:
Any variation of equal, equality, or equalizing
Leveling the playing field
Bringing everyone to the same point or the same health outcomes
Raising the bar for everyone
Setting a fair and adequate baseline of care for all
Lifting everyone up
Giving everyone a chance to live a healthy life
Letting no person fall through the cracks/ below a decent level of health
Understanding the perspectives of both Rs and Ds helps us avoid any language that will “turn off” target audiences, and leads to broadly acceptable ways to frame SDOH.

18. What We Learned:
Using common vernacular that speaks to core values resonated better than academic language
Respondents preferred messages that included action items or examples of ways to get to a solution
--Participants did not connect to “social determinants” but they “got it” about the importance of neighborhoods, education –specific factors that affect health.
--Problems + solutions messages work best.
--Stating and problem alone does not engage—in fact, can turn off the target.
--A solution suggests a way to resolve the problem, and can suggest how people can connect to resolving a problem.

19. What We Learned:
Messages that referred to disparities based on race or ethnicity fared poorly with all but Black respondents
Respondents related to messages based on America’s core values
--Disparities messages were divisive, not solution-based.
--Relating to America’s core values can gain agreement by connecting to something people already believe.

20. What We Learned:
Respondents related to metaphors/concepts that are ubiquitous—
Journey
Connections
Limited Resources
People could quickly grasp messages that connected to concepts such as a “journey” that are commonly used.
--Messages that connect people to the concept click.
--Understandably, people do want to hear about what is feasible, not about solutions that seem to require huge investments.

21. Journey
--Visuals as well as messaging convey that the pathway to good health can be made easier or more difficult depending on social factors….that achieving good health is a journey.

22. Connections Storytelling helps make the connections
--Storytelling makes it real.
--Facts provide evidence but compelling stories make a personal, empathetic connection.
--Both are important.

23. Limited
Resources
--People pay attention when they are told that the US spends more on health care than any other country. But we are not the healthiest.

24. Pair personal responsibility with social responsibility:
Good health requires individuals to make responsible personal choices and requires a societal commitment to remove the obstacles preventing too many Americans from making healthy choices, even when their motivation is great.
--Personal responsibility is an important theme for Rs.
--Start with something people already agree with to get buy in for what follows.

25. Start with something most Americans already believe:
The United States is one of the wealthiest nations in the world. We should be one of the healthiest, but we are not.
--Again, tie to something people already agree with. In this case, loyalty to our American way of life is a core value.
Note: “America” earns more agreement than ”United States.”

26. Considerations for Message Framing:
Headline what’s most important.
Challenge conventional wisdom with unexpected facts.
Use real stories, analogies and everyday language.
Stories about “people like me” make the connection.
Provide a call to action.
Make the information clear and compelling without oversimplifying: Break through to gain attention: Make theories tangible: Connect with a target audience: Make it timely and relevant:
--Added to these findings are these guidelines for good communications.
--Next—we will look at the messages that emerged from the research.

27. Unexpected Facts:
Our zip code may be more important to our health than our genetic code. For the first time, we are raising a generation of children who may live sicker and shorter lives than their parents.

28. Health Disparities:
The health of America depends on the health of all Americans. Despite enormous investment, America is not achieving its full health potential.
--”ALL Americans” is more inclusive than pointing out disparities.

29. Health Beyond Health Care:
Health care reform is essential, but improving the health of all Americans requires broadening our view beyond medical care. We must find ways to enable more people to lead healthy lives and avoid getting sick in the first place.
--This provides a rationale to expand the “health” frame to include social factors.

30. Social Determinants:
Where we live, learn, work and play can have a greater impact on how long and well we live than medical care.
--And here we are again….

31. Robert Wood Johnson Foundation: How We Talk About Health
Next. I want to share our “elevator speech “ at RWJF—how we talk about health.

32. Health starts in our families and it’s nurtured in our schools and workplaces, on our playgrounds and in our neighborhoods. How healthy we are and how long we live depends on many factors, including education, income, our local communities, whether we smoke, how active we are and what and how much we eat.
Point out that we use the ICONS on the bottom of the slide to reinforce live, learn, work and play.

33. To improve America’s health, we need solutions that look at where people live, learn, work and play to get at the factors that shape health even more profoundly than health care.

34. Working together, we can meet this challenge
Working together, we can meet this challenge. We can build a healthier America. Improving America’s health requires leadership and action from every sector, including people who work in public health and health care, education, transportation, community planning, corrections, private business and other areas. It is time for everyone to work together and build on what we already know is working.

35. Resources Available:
--A set of 11 issue briefs on social determinants of health including neighborhoods, work, stress and early childhood. Summarize the research evidence for decision makers.
—A set of 4 storybooks and videos

36. Message Guides: --Two guides to messaging.
--The issue brief summaries the research you’ve just heard about—and includes key SDOH messages.
--The second guide is more comprehensive and also includes subsequent research.

37. New Public Health includes the latest…

38. --The Commission website includes additional SDOH charts, slides, and
--Obstacles to Health, that describes in charts and text the disparities in health both in the US and comparisons between the US and other countries.
--Other resources from the Commission include maps that show differences in life expectancy based on where we live.

39. Connect with Us: What Shapes Health Home: Follow us on Twitter:
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@RWJF
@RWJF_PubHealth