Framing a Public Discussion on the Social Determinants of Health

1. Framing a Public Discussion on the Social Determinants of Health Lauri Andress, Ph.D. • June 24, 2009

2. Which message explains health disparities the best? • The Health Environments we live in have important effects on health outcomes, and are defined by everything from the availability of decent paying jobs to decent housing to a good education and high-quality preschool. • African-Americans tend to be less healthy than Whites, due to how the body is affected by the day-to-day experience of having lower status. As they are treated slightly differently from other people, the brain and body automatically respond as they would to a threat, in ways that can cause serious health damage.

3. Depends … Do we need a public discussion on the SDOH?

4. Assumptions & Assertions • Social determinants of health [SDOH] are related to public policy. • Making public policy in democracies involves politics and competing values. • Advancing the SDOH takes political will and skills. • Requires agreement on ideas and policy initiatives

5. The conscious, strategic efforts by groups of people to fashion shared understandings of the world and of themselves that legitimate and motivate collective action." (1) Public Policy Framing the DiscussionCultural learning Values Healthcare Access and Quality The group that defines the issue wins the day…………… Racial and Ethnic differences in health It is about keeping healthcare costs down……. Social Justice • Fundamental human needs of autonomy, empowerment, and human freedom…… • The opportunities for full social engagement. • Opportunities for people to craft a life they value. • Without relief from social inequality and poverty plus empowerment, improvements in health inequalities will not be achieved.

6. We want a public discussion that does the following … • Demonstrates significant gaps between the health of wealthy and poor people • Explains the gradient of health along all socioeconomic levels • Shows the significant race-based gaps in health outcomes • Presents the science deemed important by experts • The meaning of the gap between U.S. healthcare spending and outcomes when it comes to health • The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.) • The role of social exclusion [social inequality] in determining health outcomes • The role of circumstances-induced stress as a mechanism leading to health disparities between different populations • The importance of both psycho-social and material causalities in creating disparities • Offer a believable causal story that is different from the • Right choices model • Health care access model • Individual behavior model • Offers solutions that imply policy venues that improve health and reduce disparities • Emphasizes intersectoral policies that fight the deepest roots of the social determinants of health

7. Demonstrates significant gaps between the health of wealthy and poor peopleWhen you think about this statement, does it have meaning for you? • Yes • No • Not sure I understand the statement

8. Explains the gradient of health along all socioeconomic levelsWhen you think about this statement, Does it have meaning for you? • Yes • No • Not sure I understand the statement

9. Shows the significant race-based gaps in health outcomesWhen you think about this statement, Does it have meaning for you? • Yes • No • Not sure I understand the statement

10. The unexpected factors that have important effects on health (economics, neighborhoods, housing, education, racism, etc.)When you think about this statement, does it have meaning to you? • Yes • No • Not sure I understand the statement

11. The role of social exclusion [social inequality] in determining health outcomesWhen you think about this statement, does it have meaning for you? • Yes • No • Not sure I understand the statement

12. The role of circumstances-induced stress as a mechanism leading to health disparities between different populationsWhen you think about this statement, does it have meaning for you? • Yes • No • Not sure I understand the statement

13. The importance of both psycho-social and material causalities in creating disparitiesWhen you think about this statement does it have meaning for you? • Yes • No • Not sure I understand the statement

14. A Public discussion looks like this…Possible messages that we need to transmit… • Certain groups of people are less healthy because they are socially or economically deprived. • One of the best investments we can make is to improve living conditions of people at the lower end of the economic scale. Investments in everything from better housing, to good daycare to job training and school loans result in better health in a given community and fewer health disparities among groups of people. • The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because • you are different or • because you don’t have the material goods that have been deemed important in a society. • We need to consider more carefully public spending oriented to closing the gaps in terms of rights and opportunities.

15. Certain groups of people are less healthy because they are socially or economically deprived.In general, when you think about this statement do you: • Agree • Disagree • Not sure I understand the statement

16. One of the best investments we can make is to improve living conditions of people at the lower end of the economic scale. Investments in everything from better housing, to good daycare to job training and school loans result in better health in a given community and fewer health disparities among groups of people.In general, when you think about this statement do you: • Agree • Disagree • Not sure I understand the statement

17. The chronic anxiety felt from living daily with the sense of social inequality that you cannot participate in “normal” life leads to significant health consequences and group differences in health – either because you are different or because you don’t have the material goods that have been deemed important in a society. In general, when you think about this statement do you: • Agree • Disagree • Not sure I understand the statement

18. We need to consider more carefully public spending oriented to closing the gaps in terms of rights and opportunities. In general, when you think about this statement do you: • Agree • Disagree • Not sure I understand the statement

19. Our In-House Poll A Quick Review

20. Agenda Setting Social Movements

21. Generating the public discussion…Features of Social Movements • Method of issue generation • Outside initiative- nongovernmental sources • Mobilization- government source • Inside access- bypass public use legislative process • Mobilizing structures • The type of structure • The impact of external opportunities • Other resources • Individuals • Money • Knowledge • Frames • Technical tools • Process information • Distribute information • Political opportunities • Openness of political system • Presence of elite alignments • Presence of state repression • Framing processes • The cultural toolkit of a society • Framing strategies • Frame packages • The structure and role of the media

22. Generating the public discussion…Features of Social Movements Opportunity Organization Mobilizing structures Mediate Frames Shared Cultural Understandings Social Change Agenda Setting

23. Agenda Setting Legislative Agenda Issue Public Problem SPIGS Public Media

24. Agenda Setting

25. Next Steps • Using Social movement elements as framework and the agenda setting model • The U.K. • Canada • United States • Generally • Kentucky • The Future

26. The emergence of the social determinants of health on the policy agenda in Britain: 1980--2003 A Case Study

27. Conservative Government 1980 to 1996 Before the 80s Great discontent Declining economy Inflation out- of-control Weak economy The 80s- Thatcherism Smaller government Privatization Weakened unions MUD Early 90s Economic recession High unemployment New Labour 1997 to 2003 Shift to the “right” Rhetoric Fiscally prudent Stakeholder Society Responsibility Equality of opportunity Inequalities Pledge to address SID RED -discreetly Poverty for children Education Minimum wage Results: Political Context Political opportunities open the way for political action….

28. Results: Political Opportunities • 1980: Publication of the Black Report • 1985: Abolition of the Health Education Council • 1996: SDOH policies, government publications, and programs after

29. Results: Issue generation & expansion • Temporal Element • Longitudinal Study • Issue generation & expansion • Long-run societal changes affect policies across the entire political spectrum • Changing institutional features help make sense of the issue generation tactics • Period One-1980 to 1996 • Issue Generation Method -- Outside Initiative • News articles = 63% • Period 2-1997 to 2003 • Issue Generation Method -- Mobilization Effort • News articles = 57%

30. Results: Issue generation & expansion

31. Results: Framing • Grand debate and discussion on social class & inequalities • Poverty vs. The gradient • Distinctive cultural toolkit • Inequalities frame package • Media corresponds to official concerns • A linking mechanism • SPIGS & policymakers • Did not alter lay perceptions • Elite–level debates

32. The Media and Framing By excluding or marginalizing other perspectives- notably a more political analysis of the origins of illness-as opposed to just the biomedical perspective- the media play a significant part in narrowing the public debate about health, illness, and society.

33. Inequality, Health & Government British Social Attitudes Survey since 1983 40% of coded solutions call on Govt. 48 frames identified- 20 on inequality Most frequently identified inequality frame: Government allocation of resources to address poverty and social inequality. Most frequently used catch phrases related to inequality were: “Division between rich and poor”; “gap between the rich and poor and/or reduce the income gap between the rich and poor; “health inequalities and/or health and inequalities”. Most frequently evoked image associated with inequality was: “Rich and poor divide”. Results: Framing

34. Results: Framing • National Familiarity with Poverty & Inequality • Extensive lay and scientific publications • 95% of the news articles in the sample discussed, analyzed the results of, or invoked popular writings or scholarly reports to support a discussion on the SDOH. • History of advocacy for health linked to inequality in Britain

35. Results: Mobilization Structures

36. Summary: Results & Observations • Positive political opportunity • Distinctive cultural toolkit • Inequalities framing package • Historical discussion on social class and inequality • At the public level • Among expert society • Mobilization Structures

37. Telling Stories: News media in Canada To what extent do Canadian newspapers cover issues embedded in health policy documents? • “Health” News stories = 4732 • 13 daily Canadian newspapers • Healthcare = 65% • Physical environment= 13% • Socio-economic environment = 6% • Personal health practices = 5% • Scientific advances = 4% They rarely report on the socio-economic influences that are frequently cited in the research literature as being most influential in shaping population health outcomes. Telling stories: News media, health literacy and public policy in Canada Social Science & Medicine, Volume 64, Issue 9, May 2007, Pages 1842-1852 Hayes, et al.

38. Social Determinants & the United States • Achieving broad public acceptance of the social determinants issue will depend upon: • Political opportunities • U.S. ideals, and values regarding: • Poverty • Inequality • Health • Health care • Mobilization systems • A constituency • Where the issue is lodged Framing: How the issue is lodged The images and symbols used to communicate the issue

39. Political Opportunities: United States George Bush The terrorist attacks in 2001 led to the creation of the Department of Homeland Security, the Patriot Act, the federalization of airport security, an expansion of money-laundering rules and federally subsidised terrorism insurance. Stock market collapse led to the Sarbanes-Oxley: act oversees corporate governance and accounting standards. Ronald Reagan (1981) “Government is not the solution to our problem; government is the problem.” • Government intervention 2007 International survey by Pew: American support for free markets had edged down from five years earlier. Americans, traditionally fonder of the free market than the rest of the world, became less so with arrival of the financial crisis – Americans souring on unconstrained capitalism. Government v market in America: The visible hand May 28th 2009 | INDIANAPOLIS AND WASHINGTON, DC From The Economist print edition

40. Issue Generation • Outside initiative- nongovernmental sources • Mobilization- government source • Inside access- bypass public go to legislative process • Where issue is lodged • State • Local • Regulatory bodies • Academic –research institutions • NGOs • Community organizations • Courts or Policymakers • How the issue is framed for e.g., • As racial and ethnic problem • As health care access & quality • As social injustice United States Considerations

41. Values, Beliefs, and Frames Poverty Land of Opportunity Inequality Health and Health Care United States: Cultural Barriers

42. The Welfare State = Poverty • Who should we help? • How does it impact personality, families, labor market? • What are the limits of social obligation? • Who provides in time of need? • Market principles vs. social justice • Bootstrap • Land of opportunity • Irresponsible vs. responsible • [Katz, 2001] Values, Ideals, Frames, & Framing

43. Values, Ideals, etc. … don’t assume we are all agreed … on Hurricane Katrina “Shame on anyone that makes this tragedy political, socio-economic or racial. … in the land of opportunity and personal responsibility the individual is ultimately accountable.” Robert Buckley, Decatur, USA BBC web site • Inequality- Equality- Class • Natural and endemic to our society • Life is unfair.. • Potential for upward mobility • Isaacs & Schroeder, 2004]; [Kawachi, Daniels, & Robinson, 2005

44. Values, Ideals, Frames, & Framing • Health: How do we think about it in the U.S.? • Healthcare access problem • Healthcare cost problem • Behavioral explanations • Genetic • Cultural problem: racial and ethnic groups • Socio-structural

45. GROUP A GROUP B GROUP C Health: How we think about it in the U.S.? Healthier Less Healthy CHOICES Character, Knowledge, Culture, Priorities, Values Public assumes a different causal story: RIGHT CHOICES

46. Health: How we think about it in the U.S.? CHOICES HEALTH OUTCOMES A “User-friendly” Conceptual Model: simple, easy to understand – seems like the whole story A Moral Model: Not just how things do work, but how they should work – outcomes seem fair

47. Health In the U.S. -- A Moral Lens Q: Do you think we as a society owe every person some kind of help for being healthy? Is something like that a right to have? A: No. Not as a society, because see a lot of times people cause their health problems by the way they live. Conservative African-American man, age 60 It’s your own personal responsibility to do what you can to improve your health and keep yourself healthy ... If I’m going out, [if] I smoke a lot, if I’m carrying on excess weight or if I have four or five alcoholic drinks every day – I’m making that decision. That’s my choice, so I’m hurting myself. I think there’s too much of people not taking responsibility for their actions and just letting it go and thinking, well, you know, let somebody else take care of me. Moderate White woman, age 75

48. FrameWorks Institute Values, Views, Frames, & Framing • Health care • If we spend enough we can get it right! • Consumer Logic • Healthcare is a commodity • Preempts moral perspective • Not everyone has a right to a given consumer good • If you want it you work hard to get it or --- • It was a luxury you couldn't afford. • Government intervention will not fix problem • But the government must do something… • Scared for small businesses… • Want poor to help pay for costs but not be too burdensome…

49. Values, Views, etc. • Where issue is lodged • State Health Departments • Local Health Departments • NIH • CDC • Policymakers • How the issue is framed • Disparities as racial and ethnic • Disparities as access • Disparities vs. inequalities

50. Low Hanging Fruit In an effort to form a healthy equity policy strategy which has been found to be the most responsive to the US cultural toolkit based on framing research? • Early childhood education • Place-based policies that improve communities • Racial and ethnic group differences in health • Economic policies like the earned income tax • Healthcare access and quality