IOM_ACM_Final_030515

Communications Report:
Social Determinants of Health
Literature Review and Environmental Scan
Andrea Mooney for the Institute of Medicine
March 2015

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Table of Contents
3 Part 1: Typology and Literature Review
4 Introduction
4 Equity
5 Investing in prevention outside of medical care
6 Communicating about shifting investments
7 Communications Strategy: Media Advocacy
8 Communications Strategy: Knowledge and Attitudes
11 Communications Strategy: Social media
11 Communication Considerations: The Weight of Existing Political Ideology
12 Conclusion
13 Part 2: Environmental Scan
15 Introduction
15 What is being communicated about the social determinants of health in general?
17 What is being communicated about the relationship between socioeconomic
disadvantage and life expectancy?
20 What is being communicated about the impact of various environments on health
status?
20 Neighborhoods and health status
22 Built and natural environments
25 What is being communicated about how health behaviors are impacted by social
circumstances? (Nutrition, physical activity, tobacco and drug use)
31 What is being communicated about how school and education impact health?
32 What is being communicated about how literacy and early life development
impact health?
34 What is being communicated about the future of health care models?
36 Conclusion
37 References

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Part 1:
Typology and Literature Review:
Population-Based Health Communication and
Social Determinants of Health

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INTRODUCTION
The purpose of this literature review is to provide an overview of existing research and
information relating to health communication messaging about health disparities, health
equity, policy, and a shift in investment from clinical care to prevention, social services,
and increased quality of life.
Research shows that targeting audiences as specifically as possible, strategically framing
messages based on political ideology, and garnering public understanding and support for
the improvement of environmental and social equality may contribute to policies that
address health disparities. For example, one such research article considers the need for
public support for prevention, and notes that the kind of prevention needed should happen
entirely outside of the doctor’s office and hospital. The authors suggest that Congress and
the Obama administration, as well as insurers and consumers, should acknowledge the
support and resources needed to produce evidence based preventive care coordination,
outside of clinical reach (Thorpe, 2010).
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Equity
In 2010, Wakefield and colleagues examined mass media campaigns pertaining to
various health behaviors—including tobacco, alcohol and illicit drug usage, heart disease,
nutrition, physical activity and family planning—and found that often, campaigns
addressed behaviors that audiences did not have the resources to change (Wakefield,
2010).
Researchers underscore that the availability of and access to relevant services and
resources are necessary in order for people to change their behaviors, and suggest that
creating supportive policies could provide the relevant access, thus discouraging
unhealthy behavior and encouraging healthy behavior. The authors write, “Pervasive
marketing for competing products or with opposing messages, the power of social norms,
and the drive of addiction frequently mean that positive campaign outcomes are not
sustained” (Wakefield, 2010 p. 1268). With greater and longer-term investment,
researchers argue, extending campaign effects could be more successful in enabling
frequent and widespread exposure over time (Wakefield, 2010).
Marmot et al. suggest that health inequities—lack of access, information and beneficial
infrastructure—are more than just health inequalities, but rather are due to
underdeveloped social policies and programs, unfair economic arrangements and unfair
politics. The authors also argue that structural determinants can improve only with
combined efforts of parts of society outside of the health sector, such as governments,
businesses and local communities (Marmot, 2008).
Media writers, producers and journalists are starting to produce communication pieces
that publicly recognize the topic of health inequity. Though it has been traditionally

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simpler to write stories based on singular behavior change, health journalists have begun
highlighting the determinants of health disparities. Rhiannon Meyers, reporter at The
Corpus Christi Caller-Times wrote a yearlong series entitled, “The High Costs of
Diabetes.” In it, she chronicled a more in-depth view of the condition for a low
socioeconomic population in Texas, and how one’s home, income and environment made
it nearly impossible to treat and prevent diabetes. Meyers spent days and nights with her
interviewees, attending medical appointments with them, staying for dinner and joining
their pre-sunrise morning jogs. Throughout, she found that the basics of treatment and
prevention—exercising, understanding nutrition, accessing healthy food and affording
any food at all— were near impossibilities for many of them, and she explicitly states her
worry about emphasizing the clinical and seemingly “non-compliant” individuals, when
so much relies on environment:
“How do you exercise when your neighborhood doesn’t have sidewalks and you
don’t feel safe walking around outside? How do you count carbs if you don’t
know how to read nutritional labels? How do you worry about your diabetes when
there are so many other, more pressing concerns: How to pay rent, keep the
electricity on, buy dinner? And there’s no way the doctor in the span of a 15-
minute appointment could’ve seen all of these barriers their patients faced.”
(Gorenstein, 2014 and Rhiannon, 2014).
Eli Saslow, writing in the Washington Post, chronicles a similar plight in Hidalgo
County, Texas, where most families who live on food stamps, but without access to
grocery stores, are feeding their children potato chips, Cheetos, Red Bull and instant
soups on a regular basis. Some do not have refrigerators and are afraid to be outdoors
after 4 p.m., and most have diabetes and high cholesterol. Ultimately, their enduring
poverty and surrounding neighborhood factors impact their health a lot more than their
choices. They do not have the information to know what a healthy choice is, the
resources to access the good choice, or the financial freedom to make the good choice
(Saslow, 2013).
Investing in prevention outside of medical care
Changes in resource commitment could positively influence prevention of some common
health conditions, thereby reducing medical costs, and improving population health
outcomes. McGinnis examined the lack of attention to health promotion, in comparison
to the heavy focus on health care investments, and notes that “Approximately 95 percent
of the trillion dollars we spend as a nation on health goes to direct medical care services,
while just 5 percent is allocated to population wide approaches to health improvement”
(McGinnis, 2002).
According to the authors, 40 percent of deaths could be modified by prevention efforts,
which include social circumstances and environmental exposures, while only around 10
to 15 percent of deaths could be avoided by better access to (or higher quality of) medical
care. Furthermore, medical care has a limited impact on the health of populations, and
larger population impacts have been made from changes in sanitation, food supply and
family size (McGinnis, 2002). Improved diet and physical activity rates, for example,

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could help prevent cancer, heart disease and diabetes, among other long-term, costly
conditions (DHHS, 1988).
Though some may view them as unrelated to health, social factors, such as education,
social ties and income inequality, strongly determine health outcomes. While poverty
accounts for around 4.5 percent of mortality in the US, (Galea, 2011), education also
heavily influences mortality. Education increases both social and economic resources
(Zimmerman and Woolf, 2014), and adults with the lowest levels of education endure
death rates more than twice as high than individuals with the highest levels of education
(NCHS, 1998). Employment and income factor in as well; as income inequality rises, so
does the death rate of the poor (Wolfson, 1999). Similar connections can be made for
environmental hazards and preventable injury and mortality. Improved safety and
structural design of roads and worksite conditions could save approximately 7,000 lives a
year (Hoyert, 2001).
One example of investment in non-medical interventions, combined with media
campaigns, is a community-based prevention marketing (CBPM) program called
“VERB™ (It’s What You Do).” The program’s framework combines community
organizing with social marketing to create a physical activity promotion plan to
encourage “tweens”—younger adolescents ages 9 to 13—to try new types of physical
activity over the summer months. Ultimately researchers found that if school officials
adopt marketing schemes to encourage students to be active (while de-emphasizing
health impact in messaging), then students will be more likely to master new skills,
incorporate healthier habits into their social lives, and thereby reduce their risks of
negative health outcomes in the long term (Courtney, 2010).
Communicating about shifting investments
In examining message design strategies for raising public awareness about investing in
the social determinants of health, Niederdeppe et al. consider the fact that there is simply
more research available on the effects of behavior change and health care interventions
than on the social determinants of health, so current research naturally yields more
interventions on behavior change and in increasing access to medical care, rather than on
changing social determinants of health. The authors urge population health advocates to
frame messages that continue to acknowledge the weight of individual health decisions,
but only in context to the social factors that set the stage for long-term outcomes
(Niederdeppe, 2008).
The authors also suggest that most mass media channels are much more likely to use
situational events and episodes to create more attractive narratives, since social
determinants of health are less conducive to storytelling, and seemingly less newsworthy.
Continuing to use single narratives without the context of their contributing social factors
could potentially perpetuate the notion of blaming individuals for their own poor health
outcomes (Niederdeppe, 2008).

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In contrast, communicating more widely about those social determinants may help
influence policies: If policymakers believe that people’s health is more dependent on
their own decisions, they may be more likely to support behavior change initiatives—but
if policymakers (and their constituents) believe that people’s health is more dependent on
their social surroundings, they will be more likely to support initiatives that improve such
determinants. Ultimately, the authors emphasize that strategically framing messages so
that health is seen as part of a social whole will ultimately shape how the general public
views responsibility for health (Niederdeppe, 2008).
In response to the large discrepancy between spending on medical care and spending on
prevention, McGinnis et al. note that a double standard exists when considering such
funding. They question why, for investment in medicine, all that is needed is proven
safety and efficacy, while for investment in prevention, payers require direct short-term
outcomes (despite outcomes being long-term in nature,) an abundance of cost
effectiveness data in order to obtain buy-in. For medicine, none of these obstacles apply.
The authors go on to suggest that prevention is inherently more complex than situational
medical care, and therefore may require a more complex stream of funding (McGinnis et
al., 2002).
Communicating clearly about the relationship between health outcomes and social
circumstances may be critical to creating changes in political priorities. McGinnis et al.
also argue that, “A focused, engaged public needs to understand the payoffs to healthier
lifestyles and improved social conditions that reduce stress and improve well-being. Also,
people need to be convinced that interventions to change lifestyles and social conditions
are available and not too burdensome” (McGinnis et al., 2002).
The authors also emphasize a significant distinction between health financing agendas
versus health care financing agendas. Though prevention efforts may only save money
some of the time (hence, the prevention paradox), they state that it is crucial to show how
shifting our funding priorities to quality of life and the health status of populations will
ultimately produce direct, long-term returns on investment, and start elevating the status
of quality of life as a significant value indicator. Better understanding of how social
marketing interventions can work at the population level may be useful in furthering such
communication objectives (McGinnis et al., 2002).
Communications Strategy: Media Advocacy
Often, health communications campaigns aimed to change individual behavior produce
little to no evidence. Sometimes this can be due to poorly chosen behavioral objectives,
messages or exposure, but it can also be due to the theory that individual targeting will
successfully resonate. Hornik et al. suggest that campaigns should instead diffuse to
institutions and organizations first, and then to individuals, since effects may operate
through critical social or institutional pathways. These messages may also take a
considerably increased amount of exposure and require a multi-channel approach before
creating observable change. The researchers also highlight the importance of specifically
identifying a target audience in order to achieve the best results (Hornik et al., 2003).

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By subdividing audiences based on demographics and social context, message efficiency
can be improved and effectiveness can be increased. Aiming messages at government,
organizational policy makers and opinion leader audiences will likely help to influence
behavior more readily. To that end, media advocacy might be the most sustainable route
for public health groups and their partners, given its emphasis on policy-related solutions
outside of individual responsibility. A media advocacy strategy should include a strategy
with policy options, a media access agenda, strategic debate points, and framing issues
around societal responsibility (Hornik et al., 2003, and Atkins and Rice, 2013).
A complementary goal, however, must be to strengthen the public’s belief that policies
are the best method of implementing change. Above all, the researchers emphasize that
“Beyond the predominant focus on individual beliefs, campaigns must address important
social problems involving community and collective benefits. What are the relative
influences of individual differences versus social structure on the problems motivating
communication campaigns?” (Atkins and Rice, 2013).
Communications Strategy: Knowledge and Attitudes
In reviewing contextual approaches to how the news media influence consumer
knowledge, perceptions and opinions, the Dart Center for Journalism and Trauma at
Columbia Journalism School summarized implications for journalists and researchers.
This fact sheet showed that framing dictates most things, including attitudes towards
responsibility, and can also lead to decreased feelings of blame toward individuals and
increased criticism of social conditions (Tiegreen & Newman, 2008).
A study by Coleman and Thorson investigated a similar topic, and found that when news
stories about crime are framed to include more contextual information about how crime is
actually a public health issue, readers were more likely to agree that “education and
community involvement in prevention programs were more effective in reducing crime
and violence than prisons” (Coleman & Thorson, 2002).
Lundell, Niederdeppe, and Clarke assert that communicators seeking to create messages
about social and environmental health indicators face challenges that pertain to
knowledge, attitudes and framing. Many people believe that the most important
determinants of health are medical care and individual responsibility. After conducting 12
focus groups about views on health causation and disparities, the authors found that
individual behaviors and personal responsibility dominated most discussions, and that
participants had very limited knowledge on how policies could address health disparities
(Lundell, Niederdeppe, and Clarke, 2013).
Since messages about personal responsibility and health have been shown to polarize
groups, the authors suggest composing messages that promote policy positions in a way
that is carefully designed to resonate with both political groups, without alienating either.
The focus groups confirmed that people placed a high value on individual factors, and

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one participant stated that emphasizing social determinants of health actually
disempowered the poor. Nonetheless, both groups identified parents, schools, employers,
communities, the health care industry, government and society leaders as responsible for
improving the health of the people for whom they are responsible. Especially for
conservatives, this responsibility aligned mostly with people in direct leadership roles
(Lundell, Niederdeppe, and Clarke, 2013).
In 2010, the Robert Wood Johnson Foundation (RWJF) launched a bipartisan effort to
understand how Democrats and Republicans viewed health disparities, to ultimately
develop a campaign that would move the issue forward without alienating either group.
Using the ZMET®: Foundational Principles of Emotion and Cognition, they focused on
human thinking and emotion in the subconscious, as well as how metaphoric thinking
becomes the basic mental process of how we understand meaning. Essentially, this theory
posits that metaphors are the gateways to the subconscious (Christiano, 2010).
Using this framework, Christiano’s findings showed that Republicans tended to view
health as a “journey,” upon which poor health arises from choosing bad paths. They also
said that since both the personal and social journeys are unpredictable, the emphasis
should be on adaptability. Democrats viewed health as a breakdown of a system that
considered social, cultural, economic and biological factors, and believed that changing
just one of these factors would not be enough to create success. In addition, they believe
that inadequate resources make a successful “journey” harder. Lastly, they also believe
that Americans should have a “right to health” (Robert Wood Johnson Foundation and
Christiano, 2010).
Another large difference between the two sides of the political spectrum is both parties’
views on balance: Republicans want to “raise the bottom” without changing the status of
those in the upper half, while Democrats articulate it as “evening the playing field”—
changing both sides to achieve equality. The authors of the Robert Wood Johnson
Foundation report suggest that this information could be useful to political decision
makers and their constituents, but are uncertain about whether they should each receive
their own message (Christiano, 2010).
After using this information to reframe messages for six focus groups, the authors found
that 84 percent of Americans tend to view their health as something largely under their
own control, and for which they have to take personal responsibility, but after being
exposed to effective messages, the percentage of focus group participants choosing social
factors as influences on health increased by 31 percent. However, the traditional phrasing
of “social determinants” tested poorly in each phase, and was more successful when
presented in colloquial, emotionally compelling, value-driven language. Christiano also
recommends using one strong and compelling fact that arouses interest, and offering
potential solutions to any problem that is presented in a campaign. Health communicators
should also find a way to incorporate the role of personal behavior and mix traditionally
progressive and conservative views, while focusing on how social determinants impact
all Americans versus specific ethnic or socioeconomic groups.

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The following messaging recommendations are taken directly from the Robert Wood
Johnson Foundation slides (Christiano, 2010).
Proxy statements that work at multiple levels:
1. Health starts long before illness, in our homes, schools, and jobs.
2. Your neighborhood or job shouldn't be hazardous to your health.
3. All Americans should have the opportunity to make the choices that allow
them to live a long, healthy life, regardless of their income, education, or
ethnic background.
Vulnerable populations:
1. Too many Americans do not have the same opportunities to be as healthy
as others
2. People whose circumstances have made them vulnerable to poor health
3. All Americans should have the opportunity to make the choices that allow
them to live a long, healthy life, regardless of their income education or
ethnic background
4. Our opportunities to better health begin where we live, learn, work and
play
5. People’s health is significantly affected by their homes, jobs and schools
Health Disparities:
1. Raising the bar for everyone
2. Setting a fair and adequate baseline care for all
3. Lifting everyone up
4. Giving everyone a fair chance to live a healthy life
5. Unfair
6. Not right
7. Disappointing (e.g., Americans should be able to do better, not let people
fall through the cracks)
8. It is time we made it possible for all Americans to afford to see a doctor,
but it is also time we made it less likely that they need to
Messaging guidance:
1. Less is always more
2. Use complementary–not competing–data
3. Context is king
4. Specific examples matter
5. Do not let numbers be forgettable
6. Break down big numbers
7. The value in a number is in its values
8. Imagine why someone might cry foul
9. Overall messaging rules still apply
(Robert Wood Johnson Foundation, 2010).

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Communications Strategy: Social media
Social media is becoming a helpful way to disseminate messages, but its goals should be
targeted and extremely specific, or its effectiveness will be difficult to measure. An
article in The Nation’s Health details social media’s potential to segment and reach new
populations, particularly in emergency outbreak situations, such as the H1N1 virus, or a
salmonella-related recall. As mentioned, knowing and segmenting the audience is
paramount (Donya, 2009).
Segmenting audiences down to more homogenous sub groups will make a
communications program more effective, and allow campaign managers to use resources
more wisely. In the CDC’s Social Marketing Basics microsite, the importance is
described: “A program developed for the general public will likely not be really effective
for any one person or group. But, by tailoring your efforts to a particular segment, you
can greatly improve your effectiveness because you can use the programming,
communication channels, and messages that are most relevant to your segment. This way,
they are more likely to be reached and more likely to pay attention, creating a more
effective program” (CDC, n.d., p.18).
An Ogilvy white paper discusses social media in its relation to emerging majorities who
suffer from poorer health outcomes and face less access to health care services than
Whites due to either financial hardships and/or growing costs of health care. The authors
conclude, “If social marketing is truly about protecting and improving the wellbeing of
others, we must identify ways to reach and engage those who are not actively seeking
public health information through the Web. Perhaps giving providers and consumers an
equal share of voice in the development of public health messaging and interventions ill
help us overcome this challenge. Social marketers will undoubtedly be using social media
technologies to seek and find the answer” (Hughes, 2010).
Communication Considerations: The Weight of Existing Political Ideology
Predisposing political views strongly impact how consumers understand and process
messages, and contribute to their opinions about causation of health disparities, and what
can be realistically done to solve such issues.
Gollust and Capella examine how predisposing political orientation impacts a consumer’s
resistance to messages about how social and economic factors influence health
disparities. In the study, researchers presented messages about the causes of health
disparities to 732 Americans. Those who placed a high value on self-reliance and
personal responsibility responded best to messages about personal responsibility, and
such messages produced the least anger and counter arguing among Republicans (Gollust
and Capella 2014).
An earlier paper examined the effects of messages about childhood obesity, and public
attitudes toward whether or not obesity’s health consequences justified an obesity

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prevention policy. After stratifying by political ideology and comparing the groups’
attitudes toward obesity prevention, researchers found that respondents agreed that the
potential consequences on military readiness, bullying and health care costs were enough
rationale to implement an obesity prevention policy. Conservatives in particular rated
military readiness highly. Researchers concluded that framing obesity consequences in a
way that relates to the values of the audience can help achieve public support for
prevention policies (Gollust et al., 2013).
A major concern in health communications campaigns has been the garnering of public
support for health policy change. Traditionally, conservatives are more likely to assert
individual explanations for health outcomes, while liberals consider societal and
environmental issues as factors. Previous studies have shown that though someone’s
existing liberalism or conservatism typically stays consistent over time, singular
judgments about politically sensitive issues can be altered based on the depth with which
receivers (or readers, consumers) process the messages. Essentially, the more mental
resources they spend on an issue, the more likely they are to consider situational and
contextual factors that contribute to the issue (Lee et al., 2013).
Given this, Lee et al. hypothesized that an increased depth of mental processing could
increase the consensus about societal explanations of obesity, thereby leading to support
for obesity-related policies. The researchers investigated a random sample of American
adults and read stories to them about societal and individual causes of obesity. The longer
participants spent on the study, the more likely they were to support policies to reduce
obesity—a typically liberal position (Lee et al., 2013).
Findings suggest that liberals are more likely than conservatives to relate obesity with
societal causes, but that greater depth of processing is associated with a higher likelihood
of policy support regardless of political affiliation. Essentially, Lee et al. found that the
more time an audience spent learning about (and/or processing) an opposing view point
or a new idea, the more likely they were to understand and support it. These findings are
most relevant to political moderates. The authors also suggest that spending more thought
on messaging around obesity should increase support for policy interventions to prevent
obesity (Lee et al., 2013).
Conclusion
We are in the early stages of learning what works best for communicating about social
determinants of health.
There are important things we do know, like how crucial audience segmentation, and
specific messaging are. We know that learning more about our audiences’ political
ideologies can help communicators frame messages that avoid alienation, and can help
encourage complex thinking about public health issues. We know that changing beliefs
about social determinants of health, so that people appreciate the relationship between
social circumstances and health behaviors, is an integral first step to effective messaging.
We also know that strategically including multiple sectors like governments, businesses

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and institutions, as well as properly addressing both upstream and downstream audiences,
may be more effective in creating change.
We also know a fair amount of what does not work—aiming blanket messages at large,
un-segmented audiences, and failing to craft messages that fit their psychographics. But
we do not know about gold standards, or surefire ways to create change through
communication, in part because the burden of proof is simply more difficult for
prevention than it is for medicine, but also because each audience and behavior pair
requires its own strategic framework. Health communications campaigns sometimes fail
to produce evidence about prevention or behavior change, possibly due to the long-term
nature of prevention outcomes; lack of evidence about what creates sustained behavior
change; lack of rigor in segmenting audiences both demographically and
psychographically; and failure to create messages that resonate more deeply with each
audiences’ core values.
While there are a plethora of communications activities discussing social determinants of
health, there are far fewer rigorous designs and evaluations that would clearly show
ingredients to success.

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Part 2: Environmental Scan
A review of which organizations are communicating
about social determinants of health, and how

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INTRODUCTION
Social determinants of health are gaining more attention as the “causes of the causes” of
death become clearer to medical professionals, researchers and the public (Braveman and
Gottlieb, 2014). Various institutions around the country and the world are communicating
more directly about social determinants of health, and are using web sites, videos,
television, fact sheets, online tools, academic research papers, stories, reports and
advocacy campaigns to reach a wide array of audiences.
This environmental scan considers the factors that make up the social determinants of
health, and showcases which organizations are talking about those factors, and the
communications channels they are using. Formal evaluation information is included
when available.
REVIEW
What is being communicated about the social determinants of health in general?
As more organizations, institutions and research centers begin to highlight the
significance of social determinants of health, information is presented in a wide range of
channels with varying audiences and purposes. While some communications tactics point
upstream to mobilize decision makers, others focus downstream, on educating
consumers.
A product of the U.S. Department of Health and Human Services, Healthy People 2020 is
a set of national health promotion and disease prevention goals for the country to be
achieved by 2020. Its 2010 launch materials in explicitly emphasize social determinants
of health, and the website healthypeople.gov is intended to educate the public about its
leading health indicators, which include determinants such as environmental quality,
education, employment, safe homes and neighborhoods, and access to preventive services
(Healthy People 2020, 2010).
Though its audience includes more than just the general public, Healthy People 2020’s
online materials are written in plain language for better public understanding. Its website
explains that, “Poor health outcomes are often made worse by the interaction between
individuals and their social and physical environment,” and gives examples of these
determinants, like social norms, exposure to crime, transportation options, public safety
and segregation. It expands to include physical determinants like the buildings people
live in, the schools and recreational settings nearby, exposure to toxic substances and
even things like trees, parks and benches, and provides an example of how millions of
people in the United States live in areas where air quality puts them at a higher risk of
asthma symptoms (Healthy People 2020, 2010).
Another source for information on the social determinants of health is the Virginia
Commonwealth University’s (VCU) Center on Society and Health, an academic research
center that studies how social factors impact health status. Its website identifies decision-

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makers and change agents as its primary audiences, and states that its mission is to
“answer relevant questions that can move the needle to improve health of Americans and
present our work in formats and venues that are useful” (VCU Center on Society and
Health, 2014).
The Center uses online materials to draw connections between society and health,
highlighting the relationship between social stresses like food security, housing,
education and income, to health results like life expectancy and disease. It aims to
“produce communication materials and conduct public outreach to help the public,
policymakers, change agents, and the media “connect the dots” and appreciate the health
implications of social factors outside the clinic,” and to “provide decision-makers with
objective facts to help inform policy decisions, including health impact assessments
concerning upcoming decisions.” The Center identifies policy as a large focus of its
communication efforts, since traditionally considered “non-health” areas like
environment, housing and transportation eventually impact the health of the community,
and can be improved by political means (VCU Center on Society and Health, 2014).
A primary message in the Center’s communication efforts comes from its Education and
Health Initiative, supported by the Robert Wood Johnson Foundation. The initiative,
launched in 2012 to raise awareness about the connections between education and health,
published a report entitled “Healthcare is Necessary, but not Sufficient.” The brief uses
data from Kaiser Permanente to illustrate that even among people with the same access to
health insurance, less educated people endure worse health outcomes and shorter lives,
and shows that this pattern is not unique to the United States; in other developed
countries, including the United Kingdom where there is universal health care, the same
disparities exist. It underscores that, clearly, health care alone is not powerful enough to
improve the health of the nation (VCU Center on Society and Health, 2014).
A similar message is threaded through the acclaimed four-hour PBS documentary series,
Unnatural Causes. Drawing attention to the root causes of health and illness, the series
aims to reframe the debate about our nation’s health status among differing social strata.
“Health care can deal with the diseases and illnesses,” says Ichiro Kawachi,
Epidemiologist at Harvard School of Public Health, “But a lack of health care is not the
cause of illness and disease. It’s like saying that since aspirin cures a fever, that the lack
of aspirin must be the cause of the fever” (PBS, 2008).
Kawachi addresses the argument of individual behaviors on health, by stating that, “Our
ability to avoid smoking and eat a healthy diet depends, in turn, on our access to income,
education, and what we call the social determinants of health” (PBS, 2008).
An organization devoted to these very principles is the California Endowment, which
promotes the building of healthier communities by supporting evaluation and research to
create change. Its Health Happens Here campaign tackles issues like housing, obesity,
school attendance and youth violence, and encourages residents of California to enroll for
health insurance through the Affordable Care Act (ACA). It also aims to increase the
capacity of residents to improve their communities (California Endowment, 2014).

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A 2011 article in the American Journal of Public Health, entitled “Moving Upstream:
The Role of Health Departments in Addressing Socioecological Determinants of Health”
argues that it is the responsibility of public health departments to address these issues,
“even ones that appear to be outside the immediate domain of public health, but
powerfully influence the community.” The authors identify risk factors for tobacco, diet
and exercise, housing, educational programs, and neighborhood safety as issues of social
justice, which need to be urgently addressed.
(Scutchfield and Howard, 2011).
What is being communicated about the relationship between socioeconomic
disadvantage and life expectancy?
The World Health Organization (WHO) has developed a Commission on the Social
Determinants of Health, and emphasizes the relationship between them and life
expectancy. One of the Commission’s communications tactics highlights data that show a
connection between socioeconomic disadvantage and life expectancy, while also creating
a call to action: Its 2008 “Closing the Gap in a Generation” report, shows that in some
countries, like Japan and Sweden, the average female will live more than 80 years, but in
some African countries, she will live fewer than 50 years. It goes further to say that even
within economically stable countries, life expectancies plunge based on socioeconomic
position and social gradient (WHO, 2008).
The report uses this data to support three recommendations for closing the gap:
improving daily living conditions for girls and women; tackling the unfair distribution of
power, money and resources by addressing inequities about the way society is organized;
and third, measuring and understanding the problem and impact by developing health
equity surveillance systems, routine monitoring systems, and more frequently sharing
evidence and training both policymakers and health care providers about health equity
(WHO, 2008).
These statements call attention to how life expectancy can be greatly impacted on a
global level. On a more local level, the World Health Organization considers a similar
relationship between life expectancy and socioeconomic levels in the United States.
A case study from the WHO details how social determinants of health impact life
expectancy in Utah, and provides concrete lessons and recommendations about how to
communicate about these issues in order to raise more awareness and improve conditions.
Entitled “How Can We Get the Social Determinants of Health Message on the Public
Policy and Public Health Agenda?” the case study details the dichotomy between Utah’s
healthiest and unhealthiest residents, living mere miles away from each other. Research
goals included creating a visualizable community profile for Utah’s social determinants
of health; determining the level of perception and awareness of these issues among
policymakers and health care providers; and building partnerships to inform, engage and
strengthen community capacity (WHO, 2011).

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Researchers presented the following research lessons about communicating information
about health disparities, like the case in Utah, to policy makers:
 Communicate contextualized and actionable data. Policy makers and the general
public need simple, precise, accurate, easy-to-understand, easy-to-learn,
visualizable information.
 Frame the message according to local needs (What’s wrong, why does it matter,
what should be done about it?) The data are available, but how we present it is
paramount. Data should be directed at the appropriate audience, always in the
context of social determinants, and in a language that the public can easily
understand.
 Keep repeating the message. Since there is a fatalistic (assuming the poor are
simply destined for poor outcomes) and polarizing (based on political ideology)
mindset toward changing these factors, messages should be repeatedly deployed
and disseminated (WHO, 2011).
One uniquely important factor in life expectancy is income, as synthesized on the Center
on Society and Health’s website, which simplifies the issue by communicating that
essentially, people who make higher incomes live longer, and are more likely to work
jobs that have fewer occupational hazards, better health insurance benefits and work
wellness programs. More affluent people are also more likely to live in safer homes and
neighborhoods, and are more likely to have the ability to afford and access gym
memberships, healthy food, and safe transportation to reach doctors and hospitals (VCU
Center on Society and Health, 2014).
The Center also recognizes that people who make higher income may have begun life at a
more beneficial starting point. For example, they may have been born into an affluent
family, afforded better opportunities for healthy environments that fostered better
biological results, and experienced a higher emphasis on education and career
development (VCU Center on Society and Health, 2014).
Health disparities, or differences in health status, along lines of race or ethnicity, are
discussed in depth in academic literature, but less so among the general public. Despite
race issues’ prominence in the news in 2014, there are few public messages about the
health differences between whites and non-whites. David R Williams’ paper, “Miles to
Go Before We Sleep: Racial Inequalities in Health” addresses this very issue. Williams
quotes W.E.B. Du Bois, writing:
“Over 100 years ago, Du Bois ([1899] 1967) lamented that: ‘the most difficult
social problem in the matter of Negro health is the peculiar attitude of the nation
toward the well-being of the race. There have . . . been few other cases in the
history of civilized peoples Williams 287 where human suffering has been viewed
with such peculiar indifference’ (p. 163)”

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Williams argues that better research is needed to identify effective communication
strategies that raise awareness about racial disparities by increasing public knowledge
and political buy-in (Williams, 2012).
Though not a solely a communications effort, the Centers for Disease Control and
Prevention (CDC) has established the Office of Minority Health and Health Equity,
which has a microsite on the larger CDC website where it discusses its mission to
eliminate health disparities for vulnerable populations, defined by race/ethnicity,
socioeconomic status, geography, gender, age, disability status, risk status related to sex,
and gender. Within this microsite, the CDC also provides written resources such as
Disparities and Inequalities Reports, a “Conversations in Equity” blog, and a Health
Equity Matters e-newsletter (CDC, 2014).
Among the Robert Wood Johnson Foundation’s many efforts to address health equity and
improve the lives of all Americans, including those in vulnerable populations, two stand
out for their online communication. The Commission to Build a Healthier America is a
nonpartisan group of leaders from private and public sectors who issued a 2014 report
entitled “Time to Act: Investing in the Health of our Children and Communities” (RWJF,
2014).
In it, the authors make recommendations for improving America’s health, and say we
must:
 Invest in the foundations of lifelong physical and mental well-being in our
youngest children
 Create communities that foster health-promoting behaviors
 Broaden health care to promote health outside of the medical system
(RWJF, 2014).
The RWJF’s related effort, Culture of Health, communicates similar values in the
American Journal of Preventive Medicine. In the article, authors list four action
dimensions to “provide an integrated perspective on what it takes to achieve population-
level health and well-being.”
They are as follows:
 Action Dimension 1: Social Cohesion and Shared Value of Health: This action
dimension discusses how health is a shared value, and how social network theory,
community resilience and community development help improve the health of
populations.
 Action Dimension 2: MultiSector Collaboration to Build Health
Partnerships: This underscores the importance of building partnerships across all
sectors to truly improve health status, between hospitals, health care institutions,
education institutions, governments, businesses and communities.
 Action Dimension 3: Improving Equity and Opportunity for Health Choices
and Environments: This section draws connections between how the
environment people live in impacts their individual behaviors and capacity to
make healthy choices.

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 Action Dimension 4: Improved Quality, Efficiency, and Equity of Health and
Health care Systems This section highlights the notion that in order for our
health care to be more effective, it must more deeply integrate preventive services
and systematically include cultural competency and community involvement
(Plough, 2014).
The paper concludes with a compelling call to action for those in leadership positions to
actively find opportunities for change, and to help create new norms and expectations,
make a commitment to diversity, and make difficult but necessary choices about resource
allocation (Plough, 2014).
What is being communicated about the impact of various environments on health
status?
Neighborhoods and health status
Neighborhoods are a unique factor in shaping health status, because they determine
access to transportation, safe recreation, grocery stores, and exposure to crime. The
Center on Society and Health uses research to create website content that concisely and
simply explains the relationship between neighborhoods and health status. It dedicates a
portion of its website to discussing research from Zimmerman and Woolf, explaining that
neighborhoods often determine its residents’ proximity to opportunities like jobs and
education, as well as determine their risk for experiencing violence and chronic stress,
which are linked to unhealthy behaviors like the consumption of drugs, tobacco and
alcohol (VCU Center on Society and Health, 2014 and Woolf and Zimmerman, n.d.).
These communication tactics encourage decision makers and policymakers to understand
the interactions, particularly among different races and ethnicities, while also
encouraging them to help identify opportunities for multi-layered solutions that improve
access to good jobs and education, and that strengthen community development
initiatives (VCU Center on Society and Health, 2014).
In a 2008 report entitled “Promoting Health Equity: A Resource to Help Communities
Address Social Determinants of Health,” the CDC presents several case studies that
address local health disparities based on social determinants (CDC, 2008).
One poignant case study in the report, from Tulane University in New Orleans, Louisiana
focuses on reducing youth violence in a particularly violent neighborhood. Project
BRAVE, a school-based intervention in Louisiana that uses stories as a way of
communicating about neighborhood violence is summarized in the report. The goal of the
program was to reduce violence by changing how children learn about violence in
elementary, middle and high school. The strategy was simple: Students were encouraged
to share stories about violence that they either witnessed or experienced, and work with

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public health researchers and artists to analyze, write, edit and present their stories (CDC,
2008).
In the last step of the program, students worked with artists to combine their stories into a
play entitled “Inhaling Brutality, Exhaling Peace,” which was performed in a local park.
The plot of the play centered on a murder that happened in another nearby park, and after
the performance, the audience voluntarily stayed to discuss how to organize community
efforts to prevent further violence (CDC, 2008).
The California Endowment’s Health Happens Here program employs a similar tactic
through the art of storytelling and art in order to communicate about social determinants
of health in neighborhoods and communities. In October 2014, it hosted “The Power of
Stories, Building Healthy Communities Statewide Convening,” at which residents, youth,
and community stakeholders gathered to perform and view videos, art and live
performances that encourage community change in terms of social well-being and
cohesion, physical and mental health, education, and the economy (California
Endowment, 2014).
Health Happens Here also dedicates a section of its website to changing the fate of
neighborhoods in order to change the health of its residents. It uses three topics—junk
food and drinks, walk and play, and safe streets—to communicate its messages. First, it
emphasizes the particular harm that “junk drinks” like soda do to the health of children,
and how having fresh water available can help combat the habit of buying soda through
vending machines. It also encourages local governments to use zoning powers to make
healthy eating and drinking more accessible and attractive (California Endowment,
2014).
Secondly, its “Walk and Play” effort advocates for sidewalks, bike paths, and other parts
of the built environment to promote physical activity. Lastly, its “Safe Streets” section
talks about investing in solutions that prevent crime and build stronger communities that
“hold kids accountable for misconduct, but help them learn from their mistakes so they
can grow into responsible adults.” The site also stresses that there are underlying health
issues that plague our prisons and jails, and that future California leaders need to be
educated on health issues that impact all aspects of the state’s population (California
Endowment, 2014).
Health Happens Here created an award-winning video for a communications campaign
called “Transform” to heighten awareness about how simple transformations of
neighborhoods could positively impact residents’ health (California Endowment, 2012).
In the video, a run-down neighborhood becomes a lively, healthy place. Liquor stores
turn to grocery stores, vending machines to water fountains, and abandoned lots into
parks and swimming pools. "Did you know how long you live depends on where you
live?" asks the narrator. The ad's purpose is to inspire viewers to shift their definition of
health from conventional thinking (doctors, diets, hospitals) and toward a shared

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responsibility for improving the health of California by improving the places where
people live throughout the state (California Endowment, 2012).
Another innovative communications tactic funded by the California Endowment and
created by the Prevention Institute, is the Tool for Health and Resilience In Vulnerable
Environments, or THRIVE, a web-based model that helps users “understand and
prioritize the factors within your own community that can help improve health and
safety.” It helps answer questions about how communities impact residents’ health, what
people can do to address those factors, and where they can find more helpful resources.
The tool takes the user through a prioritization exercise displaying issues of equitable
opportunity, people, and place, and aims to “help close the health gap that divides health
outcomes between the general population and racial and ethnic minorities” (Prevention
Institute, 2003).
Built and natural environments
Within the scope of neighborhoods, housing and health go hand in hand. The Center for
Housing Policy and the National Housing Conference launched the Housing
Communications Network in 2010, in an effort to make the issue of affordable housing
more visible. “The network of housing policymakers and communications professionals
is designed to promote affordable housing as a positive force in American communities
and raise it to a first-tier issue on the national agenda,” says the Center’s website
(National Housing Conference and Center for Housing Policy website, 2010).
The site is also home to publications that discuss a variety of topics under the same goal
of identifying and meeting housing challenges in the United States. Relevant topics
include housing affordability, housing and children, housing intersections (like housing
and education, or housing and health) and sustainable communities, among others
(National Housing Conference and Center for Housing Policy website, 2010).
One specific example of the Center for Housing Policy’s communication tactics is a 2011
research summary entitled “The Impacts of Affordable Housing on Health,” directed
toward professionals involved in housing policy. The paper details how affordable
housing may improve health outcomes by freeing up family resources for food and health
care, reducing stress, positively impacting mental health, and limiting exposure to
allergens, neurotoxins, and other dangers. It also goes further to say that affordable
housing can improve chronic conditions by providing stability, and reduce certain forms
of risky behaviors. The paper goes on to show that affordable housing can also reduce
crowding, thereby preventing infectious diseases from spreading, and improving physical
and mental health. By using green building strategies in affordable houses, residents can
reduce monthly energy bills and limit unsafe environmental hazards that lead to
respiratory illnesses, particularly in children (Center for Housing Policy, 2011).
Another organization using websites and digital collateral to communicate about the
relationship between health and housing is the U.S. Department of Housing and Urban

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Development. Its Healthy Homes Program, aimed to protect families and children from
environmental hazards like lead, mold, carbon monoxide, pesticides and radon utilizes its
website, written in plain language, to explain each of these hazards to the general public.
It also provides grants to those who are developing low-cost methods of hazard
assessment, evaluating effectiveness of Healthy Home interventions, building local
capacity to educate residents, and delivering public-education programs (US Department
of Housing and Urban Development, n.d.).
The California Endowment aims to create healthy homes for California residents. In a
2013 article for Environmental Health Perspectives, entitled “Health Impact Bonds: Will
Investors Pay for Intervention?” Rebecca Fairfax Clay appealed to readers about the
preventable nature of asthma, and how using the market might help improve asthma
incidence and outcomes. The author discusses how Fresno, California suffers from a 20
percent pediatric asthma rate, and is the first U.S. community to test a care funding
strategy to reduce treatment costs and provide financial incentive to investors (Fairfax
Clay, 2013).
Fresno’s proposed health impact bonds would “step in where governments often do not,
by supporting efforts to reduce emergency department visits and hospital stays related to
asthma.” The pilot included 200 children with asthma, who received early preventive care
in 2013, which included home visits to assess asthma triggers and create solutions to
replace carpets, remove dust, mold and pests, monitor medication compliance, and
suggest healthier behaviors, like not smoking around children. This communication tactic
is targeted to an already-invested audience – the readers of Environmental Health
Perspectives—and raises awareness of how innovative investments like these can
improve the lives of hundreds of children in a single community (Fairfax Clay, 2013).
A national media advocacy campaign about the environment made news in 2011 when
the American Lung Association (ALA) partnered with ad agency GMMB to reframe an
environmental issue as a public health issue. At the time, the Environmental Protection
Agency’s standards on power plant carbon pollution included new protections to help
reduce smog, which leads to childhood asthma attacks and complications for those with
lung disease. Some members of Congress claimed that the new standards would be too
costly to install, and challenged pollution’s true impact on respiratory illness. The ALA,
backed by environmental coalitions, and with the help of GMMB, released a campaign
directed at Congress with the goals of getting Congress’ attention, energizing the public,
and maintaining the EPA’s control of the Clean Air Act (GMMB, 2014).
The strategy employed creative design to demonstrate the public health risks of inaction,
and used the imagery of a red baby carriage at the steps of the Capitol and near a power
plant to bring a sense of urgency to the debate over clean air. The ALA released three
television advertisements featuring a wheezing, coughing baby, tucked into a carriage,
abandoned on the steps of the Capitol and ignored in the busy halls of Congress to
visually show the harmful effects that weakening the Clean Air Act would have on the
health of children. The campaign also included digital ads and print audio cards that
played the sound of a wheezing baby, and delivered the cards to 535 members of

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Congress. The launch of the campaign included a press release, press conference, and a
microsite (GMMB, 2014).
The campaign’s goals were reached, maintaining the EPA’s standards for protective
measures. The campaign went on to win two Reed Awards for Best Television Spot of
the 2011 Cycle and Toughest Television Advertisement, as well as a Bronze Telly Award
for regional TV and multi-market cable for a non-profit (GMMB, 2014).
A vitally important environmental determinant of health is climate change. George
Mason University’s Center for Climate Change Communication developed a brief to
inform public health professionals about how to effectively communicate about climate
change. Entitled “Conveying the Human Implications of Climate Change: A Climate
Change Communication Primer for Public Health Professionals,” the report speaks
directly about the fact that the health of Americans is already being harmed by climate
change, and is likely to get worse. Dangers include illness and death from extreme heat,
extreme precipitation, vector-, food- and water-borne diseases, and respiratory diseases.
The authors state that public health professionals have an obligation to effectively inform
the public on these risks (Maibach et al., 2011).
The report discusses research that shows that when it comes to viewing climate change,
Americans are divided into “six Americas:”
“On one end of the continuum is a group of people who are worried, involved and
supportive of policy responses to global warming (13%), and on the other end is a
similarly sized group of people (12%) who are completely unconcerned and
strongly opposed to policy responses. Three of the segments (totaling 65%) are to
varying degrees concerned about global warming and supportive of policy
responses, two (totaling 24%) are unsupportive, and one is largely disengaged
(10%), having paid little attention to the issue. This disengaged audience includes
a disproportionate number of people from low-income households many of whom
are likely to be members of vulnerable communities” (Maibach et al., 2011).
These segmentations are useful for social marketing and other targeted health
communications campaigns. The report also suggests strategies for effectively
communicating about climate change. For example, the authors urge readers to frame the
issue as a human health problem rather than an environmental problem, and localize the
issue as much as possible. Emphasizing the immediate health benefits and creating “win-
win” scenarios that emphasize positive information is also important, such as making the
connection between urban reforestation to reduce heat deaths and illness, or showing the
health benefits of walking and cycling rather than driving a car. The authors note that it is
effective to highlight non-climate related benefits too, like how walking to work is good
for one’s heart health and weight (Maibach et al., 2011).
Four main points are critical to any message about climate change, the authors argue:
1. Climate change is real and human caused.
2. Climate change is bad for us and for our community in a number of ways.

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3. We need to start taking action now to protect the health of our community’s
most vulnerable members — including our children, our seniors, people with
chronic illnesses, and the poor — because our climate is already changing and
people are already being harmed.
4. Taking action creates a “win-win” situation for us because, in addition to
dealing with climate change, most of these actions will benefit our health too
(Maibach et al., 2011).
The four points illustrate the pillars of good communication, which the authors
summarize: Use techniques that capture attention, keep messages as simple as possible,
use emotion and stories, and make your points in an unexpected manner. The points also
illustrate how important it is to underscore the feasibility of change, and the large impacts
that individuals can have on the population as a whole. By framing the situation as
realistic, changeable, and helpful, the communicator can harness the power of positive
ideas in attractive ways that may appeal best to each segment’s readiness for change.
The authors urge organizations and institutions to post information to their websites, use
regional meetings to create news attention, and issue coalition statements that frame news
coverage (Maibach et al., 2011).
What is being communicated about how health behaviors are impacted by social
circumstances? (Nutrition, physical activity, tobacco and drug use)
Predominantly vocal in the fight to improve the state of pediatric obesity in the United
States, First Lady Michelle Obama has championed the Let’s Move campaign, in
partnership with the White House’s Obesity Task Force. The initiative uses web materials
like health education pages and videos, paired with media placements and visibility
events to garner attention and communicate healthy information to the public
(letsmove.gov, 2014).
A few main communications pieces significantly relay the initiative’s message. First, the
Let’s Move website aims to communicate to the general public, using imagery, colors
and plain language for readers to learn more about the epidemiology of obesity, and how
to change their diets and physical activity levels in order to live more healthfully. It also
contains a vast amount of health education information by topic, and videos of the First
Lady engaging her audience in the importance of eating well, drinking water instead of
sugary beverages, and exercising safely. Readers are also able to download and re-use
“columns” written by Ms. Obama to use in their own blogs, newsletters and
communication pieces (letsmove.gov, 2014).
Also on the website is the Obesity Task Force Report. Tasked with reviewing every
policy and program relating to childhood nutrition and exercise, the Task Force issued a
report in 2010, which aims to empower parents and caregivers to make smart nutrition
choices for their household. It also breaks down the situation with school food and
competitive foods, discusses physical accessibility and affordability of food, and the

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under-appreciated relationship between hunger and obesity. Lastly, it discusses school-
based approaches to physical activity, and improved community recreational areas to
promote better physical activity (Obesity Task Force, 2010, and letsmove.gov, 2014).
Additional strategies include initiatives such as “Let’s Move: Cities, Towns and
Countries,” for which local elected officials can register to achieve five healthy goals for
their respective areas, and “Let’s Move Faith and Communities” which urges faith-based
neighborhood organizations to promote healthy living for children and communities
(letsmove.gov, 2014).
Let’s Move has had several successes. In December 2010, President Obama signed into
law the Healthy, Hunger-Free Kids Act, which helps schools offer healthier meals to
millions of students. It has also reached an agreement with brands like Walgreens,
Supervalu and Wal-Mart to offer healthier food selections within communities that do not
have healthier alternatives. In addition, Disney announced its dedication to Let’s Move,
stating it would “require all food and beverage products advertised, sponsored, or
promoted on various Disney-owned media channels and online destinations and theme
parks to meet nutritional guidelines that align with federal standards to promote fruit and
vegetables and limit calories, sugar, sodium, and saturated fat by 2015” (letsmove.gov,
2014).
Also working toward better foods in schools for children is the Pew Charitable Trust. In
partnership with the RWJF, it operates the Kids’ Safe and Healthful Foods Project, which
provides nonpartisan analysis and evidence-based recommendations on policies that
affect the safety and healthfulness of school foods (pewtrusts.org, 2014).
A November 2014 report with RWJF and the California Endowment, entitled “Serving
Healthy School Meals in California,” details healthy lunch requirements, and equipment,
infrastructure and training needs.
Three policy recommendations from the report include:
 Recommendation 1: Federal, state, and local governments should prioritize
funding to help schools upgrade kitchen equipment and infrastructure.
 Recommendation 2: Nonprofit and for-profit organizations interested in
improving children’s health, education, school infrastructure, and community
wellness should consider assisting schools in assessing the need for and feasibility
of enhancing infrastructure and acquiring the necessary equipment.
 Recommendation 3: Students’ nutritional needs should be considered in the
master plans developed by district leadership that guide capital improvements.
School officials and local policymakers should work collaboratively with school
food service directors, parents, and community members to identify and
implement strategies that meet equipment, infrastructure, and training needs (Pew
Charitable Trusts, 2014).
As a part of The National Institutes of Health, the National Heart, Lung, and Blood
Institute (NHLBI) creates health education programs to help lower the risk and
consequences for heart, lung, blood, and sleep disorders. The programs partner with

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private-sector organizations and other government agencies, and are developed based on
scientific findings, learning theory, behavior change, and social marketing best practices
(NHLBI, 2014).
Its communications and health education initiatives include the Community Health
Worker Disparities Initiative, which helps health workers plan, run and evaluate
successful programs within communities, while catering to specific cultural groups. Its
website includes implementation strategies, evaluations, lessons learned, and success
stories for health workers to use to their advantage (NHLBI, 2014).
The website also offers downloadable health education materials catered specifically and
separately to African Americans, Asians, American Indians/Alaskan Natives,
Hispanic/Latinos, and Pacific Islanders, including lesson courses on heart health, flip
charts and picture cards, recipe books, and age-appropriate booklets about physical
activity. These materials are meant for trained health workers to use with their
community members (NHLBI, 2014).
In addition to downloadable materials to use with patients, NHLBI provides an online
resource for starting a community program, entitled “Start to Finish: Your Toolkit to Plan
and Run a Heart Health Program” which consists of a step-by-step process on how to
work with a community to change its behaviors and health risks (NHLBI, 2014).
One popular television personality dedicated to improving childhood nutrition is chef
Jamie Oliver. In partnership with the Center for Science in the Public Interest and its
annual Food Day, the Jamie Oliver Food Foundation launched a Food Education
Campaign in 2013 to promote food education and cooking classes in schools across
America. "This is a chance to start talking about how food education should be an
integrated part of the school curriculum," said Oliver, in a press release about the
initiative (cspinet.org, 2013).
The Center for Science in the Public Interest has historically voiced its strong position on
health and environmental issues, and works particularly to eliminate the marketing of
unhealthy food to children on television, in restaurants and online (cspinet.org, 2014).
Another television-based effort is HBO’s Weight of the Nation, which sheds a new light
on obesity as a severe public health problem requiring a national response. The project
contains a series of four documentary films, a three-part HBO Family series, 14 short
films, a social media campaign, a companion book, and a nationwide community-based
outreach campaign, as well as a child-based Weight of the Nation in 2013 (HBO, 2014).
Omnipresent on most health issues that plague our nation, the CDC recognizes that
children are uniquely susceptible to the marketing of junk food and sugary beverages (as
well as other unhealthy temptations), and has created an interactive website called “Body
and Mind,” completely catered to children. Its pages, filled with cartoon images and plain
language, explain to children through games, stories and quizzes how to spot advertising
that is targeted for them, and how to make healthy, safe decisions. Among other games

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on the site, “Ad Decoder” is a one that helps kids learn how “ads try to manipulate” them,
and “Dining Decisions” helps kids learn how to make healthier choices about food. The
site also has printable activity cards for kids to learn more about sports and activities like
yoga and martial arts, which can be done in the safety of one’s home (cdc.gov/bam,
2014).
The Prevention Institute’s Strategic Alliance for Healthy Food and Activity
Environments began in 2001 to improve nutrition and physical activity opportunities for
California residents, and focuses particularly on reframing the public debate on eating
and physical activity—moving the issue away from personal responsibility and toward
the role that corporate and government practices can play in improving the health of
communities (eatbettermovemore.org, 2014).
One of the Institute’s most innovative efforts is ENACT, a digital tool designed to help
improve nutrition and activity based on seven environments: childcare, school, after-
school, community, workplace, health care and government. Created for organizations,
coalitions and communities who want to improve the health of their members, ENACT
allows users to complete an assessment online, to find tailored strategies on how to
engage partners and begin to plan and implement actions for moving forward within their
organization or community (eatbettermovemore.org, 2014).
As a part of the Academy of Nutrition and Dietetics, the “Kids Eat Right Campaign” is
aimed at educating families, communities, and policymakers about the importance of
quality nutrition, and hopes to mobilize its members to participate in childhood obesity
prevention efforts (eatright.org, 2014).
The campaign’s website provides members with the information necessary to become
organized leaders on obesity prevention, and help children meet nutrition requirements.
One communications tactic uses members and volunteers to disseminate weekly
messages, shopping ideas, cooking tips and recipes through their social media accounts
(eatright.org, 2014).
Physical activity, which is often influenced by one’s neighborhood and surroundings, is
another social determinant of health discussed widely in academic literature, and in
initiatives like First Lady Michelle Obama’s Let’s Move campaign. To demonstrate the
significant relationship between one’s neighborhood surroundings and levels of healthy
physical activity, one 2012 study examined the associations between the densities of
available parkland in neighborhoods, and levels of physical activity.. Researchers found
significant, a positive correlation between park density and physical activity, and a
negative correlation between park density and being above normal weight. Their
conclusions urge for the development of stronger park systems in urban areas to improve
health outcomes in individual at-risk communities (Mudd, 2012).
A similar study tested associations with twice-weekly park-based afterschool programs
with levels of obesity in Hispanic youth. After pre- and post-testing measures of body
mass, waist circumference, skinfolds, cardiovascular fitness, and blood pressure,
researchers found significant improvements for cardiovascular fitness in participants,

29
suggesting that routine physical activity afterschool programs could set children on
healthier fitness trajectories (Wiersma and Rubin, 2012).
Another individual health behavior often defined by social factors is the use of drugs and
tobacco. The country has seen various national campaigns, with some success and some
failure. Successes have come mostly from tobacco campaigns.
One such success is the CDC’s Tips from Former Smokers campaign, which features
former smokers living their daily lives, and offering advice on how to work around often
gruesome health consequences of tobacco exposure, like shaving around stomas and
covering up breathing aids. The campaign’s goals were to build public awareness on the
immediate health damage that smoking and exposure to smoke cause, and to encourage
smokers to stop smoking around others, and ultimately quit. It primarily targeted smokers
ages 18-54, and used the following key messages:
• Smoking causes immediate damage to your body, which can lead to long-term
health problems.
• For every smoking-related death, at least 30 Americans live with a smoking-
related illness.
• Now is the time to quit smoking, and if you want help, free assistance is available
(CDC, 2014).
In 2013, The Lancet published an article evaluating the campaign, noting that it
motivated 1.6 million smokers to attempt to quit, and estimates that 100,000 U.S.
smokers will “remain quit” as a result of the campaign. It also estimates that 6 million
nonsmokers talked with friends and family about the dangers of smoking (CDC, 2014).
Similar in effort is the Food and Drug Administration’s “The Real Cost” campaign,
which aimed to educate at-risk youth ages 12-17 who have smoked fewer than 100
cigarettes about the harmful effects of tobacco, and reduce initiation rates. Ads show
young people succumbing to the “real costs” of cigarettes. One ad shows a young man
paying for a pack of cigarettes by pulling his teeth out, and another shows a girl signing
away her freedom with a contract to spend her money and her time the way her cigarette
wants her to. Launched in February 2014, over television, radio, print and online, the
campaign will continue to air in 200 markets until 2016 (FDA, 2014). Its key messages
include:
• Loss of Control Leading to Addiction: Reframing addiction to cigarettes as a loss of
control to disrupt the beliefs of independence-seeking youth who currently think they will
not get addicted or feel they can quit at any time.
• Dangerous Chemicals: Depicting the dangers of the toxic mix of chemicals in cigarette
smoke to motivate youth to find out more about what's in each cigarette and reconsider
the harms of smoking.
• Health Consequences: Dramatizing the negative health consequences of smoking in a
meaningful way to demonstrate that every cigarette comes with a “cost” that is more than
just financial (FDA, 2014).

30
The campaign’s evaluation methods will include a longitudinal study design following
the same youth over time, and will assess changes in tobacco-related knowledge, attitudes
and beliefs, as well as behaviors (FDA, 2014).
Most recently, the Legacy Foundation’s “Finish It” campaign was released in 2014 to
directly charge youth with the responsibility of “finishing” the cycle of smoking. In light
of the progress made in recent decades, the campaign highlights victories in Florida,
where smoking rates went from 15.7 percent to 7.5%, a record low. It also hopes to reach
the 91 percent of teens who do not smoke by calling out celebrities who smoke as
“unpaid spokespersons” for big tobacco, and asks teens to join the movement using their
social media accounts (Legacy Foundation, 2014).
Less successful communications campaigns have centered on drug use and drug abuse
prevention. One example, the National Youth Anti-Drug Media campaign, had goals to
educate youth to reject drugs, and convince occasional drug users to stop. Targeted
toward young Americans, particularly African Americans and Hispanics, advertisements
aimed to increase resistance skills and self-efficacy, improve education about positive
alternatives, and educate about negative consequences of drug use (Hornik et al., 2008).
In a 2008 article in the American Journal of Public Health, researchers examined the
effects of the campaign, and found that through June 2004, the campaign was unlikely to
have had favorable effects on youths, and challenges the usefulness of the campaign
(Hornik et al., 2008).
Similar results were found for Drug Abuse Resistance Education, a program that used
police officers in schools all over the United States to talk to students about resisting
illicit drugs. After much evidence showed that the program was actually ineffective,
researchers in 2004 conducted another review to test for efficacy, and found that there
was not even a statistically small effect, and recommend that future efforts use alternative
techniques to create more substantial results (West and O’Neal, 2004).
Many researchers have conducted evaluations of drug resistance campaigns, with varying
results. In 1998, White and Pitts found that school-based interventions can help increase
knowledge and change attitudes (White and Pitts, 1998), and Tobler et al. found that
some in-school prevention programs can reduce substance use, but only short term. The
ones that were successful in reducing substance abuse were interactive programs where
students learned and practiced drug refusal skills, receiving immediate, in-class feedback
(Tobler et al., 2000).
Researchers Mrazek and Haggerty assert that a potential weakness is that some in-school
drug prevention programs are aimed at all students, whether they are at a high risk or not,
which can undermine the effects of a program, further highlighting the importance of
proper audience segmentation (Mrazek and Haggerty, 1994). Other researchers, such as
Wynn et al., investigated how mediators impacted the success of in-school prevention
programs, and found that social norms and social acceptance were significant mediators
in a program’s success (Wynn et al., 2000).

31
However, comparing the effectiveness of programs has its statistical limits. In a 2002
systematic review of such programs, Cuijpers says, “A major problem in this research is
that many different interventions have been used, with differing formats, targets, targeted
substances, age groups, and theoretical models. There are also large difference among
studies in design, evaluation methods, and measurement of substance use, and the results
rely mainly on self-reported drug use, which is not always reliable” (Cuijpers, 2002).
What is being communicated about how school and education impact health?
Education is becoming a more visible social determinant of health, and discussed by
some of the most influential public health organizations. The Center on Society and
Health dedicates a section of its website to education, and underscores that Americans
with fewer years of education have poorer health outcomes than their more educated
peers. They clarify that though life expectancy has increased over time, it has recently
begun to decrease for people with fewer than 12 years of education. Among whites with
less than 12 years of education, life expectancy falls by more than three years for men,
and more than five years for women (VCU Center on Society and Health, 2014).
The Center on Society and health also details the impact that increased investment could
make on these statistics. It states that even a 1 percent increase in Americans who attain
some college education could save around $1.3 billion per year in medical care for
diabetes alone (VCU Center on Society and Health, 2014).
The California Endowment champions efforts to communicate to the public how
education impacts the health of California’s residents. Aside from making schools
healthier places by improving their food and beverage selections and promoting daily
exercise at school, the foundation also creates communications opportunities for parents,
students, and community leaders to talk about their visions for their school’s success,
while ensuring that new funds are used to support achievement for students who need it
the most (VCU Center on Society and Health, 2014).
It also makes school more accessible to its students, by working with communities to
build safe routes to school, and increasing access to parks, gyms and other facilities for
nearby exercise. Lastly, it prioritizes the social-emotional health of students by promoting
conversations about mental health, increasing access of mental health services for
students, and helping students who need discipline learn more responsibility and respect,
rather than to solely use punishment (VCU Center on Society and Health, 2014).
The Robert Wood Johnson Foundation has created multiple communications materials
surrounding the relationship between education and health. In partnership with the Center
on Society and Health, the foundation published a website, a video, and a brief under the
common title “Education: It Matters More to Health than Ever Before.” The website acts
as an introduction to the concept, the brief and the findings, and gives the reader three
important take aways: First, that people with less education live shorter, sicker lives;

32
second, that the disparities are even more prominent among white women; and lastly, that
investing in education saves both lives and dollars, since more education leads to higher
income, and therefore better access to healthy food, safe homes and better health care
(RWJF, 2014).
The six-page brief, published in January 2014 with the same title, quickly gets to the root
of the messages about saving lives (by reducing the prevalence of chronic disease),
saving dollars (by preventing illness and reducing medical costs) and the importance of
understanding racial disparities. The purpose of the brief, as stated on its cover, is aimed
at “helping those working in education and those working in health understand the
connections between the two” (RWJF and VCU Center on Society and Health 2014).
Another issue brief from RWJF and the VCU Center on Society and Health, entitled
“Why Education Matters to Health: Exploring the Causes,” provides an overview of the
causes of the relationship, starting from very early in life. The three primary connections
identified are that education creates opportunities for better health; poor health can put
educational attainment at risk (reverse causality); and that conditions throughout people’s
early lives impact both their health and their educational prospects (RWJF and VCU
Center on Society and Health 2014).
The authors also identify and explain the health benefits of education, which include
income and resources (better jobs, higher earnings, resources for good health), social and
psychological benefits (reduced stress, social and psychological skills and social
networks), the knowledge and skills of health behaviors, and likelihood of living in
healthier neighborhoods (RWJF and VCU Center on Society and Health 2014).
What is being communicated about how literacy and early life development impact
health?
An enormously impactful determinant of lifelong health is a child’s early development
and introduction to numeracy and literacy. Many organizations recognize the
significance, and a few have championed the subject.
The Annie E. Casey Foundation is dedicated to helping at-risk children improve their
educational, economic, social, and health outcomes by investing in areas such as
transforming child welfare systems and reforming the juvenile justice system. As a part
of its KIDS COUNT project, the foundation publishes a data center and annual data book
on its website, which provides data on child wellbeing over time. These data books rank
states on child wellbeing in four domains: economic, education, health and
family/community (Annie E. Casey Foundation, 2014).
In 2013, the foundation published a policy report chronicling how important the first
eight years of life is to a child’s educational future, overall health, and wellbeing. Based
on research showing that due to lack of coordinated efforts, most children in the United
States are not cognitively on track by the time they are eight years old, the report makes a

33
case for an integrated solution that will meet the developmental needs of children
younger than eight (Annie E. Casey Foundation, 2013).
Its policy recommendations suggest:
 Providing more support for parents so they can effectively care and provide for
their children
 Increasing access to high-quality, integrated programs for children from birth
through age eight, beginning with investments that target low income children
 Developing comprehensive, integrated programs and data systems to address all
aspects of children’s development and support their transition to elementary
school and related programs for school-age children
It concludes by urging the federal government to work with states to create better systems
for success (Annie E. Casey Foundation, 2013). By targeting upstream audiences like
policy makers, these communications tactics aim to elevate the issue of youth literacy and
cognitive development to a higher national priority.
Similar in goals is the Clinton Foundation’s Too Small To Fail initiative, which aims to
“help parents and businesses take meaningful actions to improve the health and well-
being of children ages zero to five, so that more of America’s children are prepared to
succeed in the 21st century.” It also works to promote new research on the science of
children’s brain development, as well as early learning and early health, by using social
media and other technology to communicate with parents, caregivers, and others on how
to best commit to action and measure efforts (Clinton Foundation, 2014).
Too Small To Fail’s various communication channels include videos, press releases,
microsites, blog posts and reports that are digestible for the general public. Poignant
videos from President Barack Obama, Former Secretary of State Hillary Clinton, Senator
Bill Frist, and Cindy McCain appeal to parents, encouraging them to talk, sing and play
with their children each day in order to build vocabulary and stimulate early brain
development (Clinton Foundation, 2014).
On the Clinton Foundation’s blog, Hilary Clinton published a 2013 post, entitled
“Closing the Word Gap,” detailing in plain language the concept of early development,
and introducing the Too Small To Fail initiative’s strategic roadmap report, entitled
“Preparing America's Children for Success in the 21st Century.” The report emphasizes
recent research findings that early childhood development not only directly impacts long
term productivity and success, but also contributes to the country’s economic wellbeing
(Clinton Foundation, 2014).
Too Small to Fail’s collaboration with Univision Communications Inc. announced an
expanded effort to improve learning for Hispanic children by promoting more inclusion
of fathers, grandparents and other caregivers, as well as providing 100,000 Hispanic
families with resources, tools, and early literacy, digital content and interactive text
messages, mobile apps and community events. One such digital tool is the website,
talkingisteaching.org, which provides parents with topics, images, and suggestions of
how to interact with their child. For example, a page displaying a school bus prompts the

34
parent to ask their child what color the school bus is, what sound the school bus makes,
and presents an opportunity to sing “The Wheels on the Bus” (Clinton Foundation, 2014).
Thirty Million Words, an innovative collection of online tools, is a project established by
the University of Chicago School of Medicine, which highlights the fact that children
who start out ahead, stay ahead. Its solution to this problem is a parent-directed program
that combines education, parental interaction and multimedia to help parents help their
children learn. The technical side provides linguistic feedback from weekly recordings of
the child’s language environment, and helps parents track personal goals (University of
Chicago School of Medicine, 2014).
The program is being implemented for individuals (to facilitate relationship building),
groups (to build social capacity), and through social media (for additional access to
resources). After completing a randomized control trial of the Thirty Million Words
Curriculum, with the case group receiving the curriculum, and the control group
receiving a nutrition intervention, results show that participants using the Thirty Million
Words curriculum significantly increased their talk and interaction with their children. In
the future, the curriculum will expand to day cares and child centers (University of
Chicago School of Medicine, 2014).
A program that directly pairs the concept of health care and early literacy is Reach Out
and Read. The nonprofit promotes literacy using face-to-face conversations in pediatric
primary care settings to “prescribe” books to children and parents to read together. The
program has been recommended by the American Academy of Pediatrics, and now serves
more than 4 million children and their families annually. Results show that families who
participate in Reach Out and Read, read together more often, and participating children
enter kindergarten with larger vocabularies and stronger language skills. Children who
are involved with Reach Out and Read also score higher than their non-Reach Out and
Read peers on pre-school vocabulary tests (Reach Out and Read, 2014).
What is being communicated about the future of health care models?
Evidence shows that while health care helps people be healthy, it alone cannot provide
the fostering and prevention that populations need to lead long, healthy lives. Emerging
health care models that incorporate social determinants of health into their structures may
be a more effective method of health care.
The Institute for Alternative Futures, which works with organizations to create healthier,
more socially responsible futures, published a 2012 report entitled “Community Health
Centers Leveraging the Social Determinants of Health.” In it, authors present a vision of
health centers that move beyond clinical services, and increase their focus on the social
determinants of health to provide a higher quality of care. They go further to explain that
in most cases, community programs that work to improve social determinants of health
happen in response to a problem that occurs again and again, and is eventually brought to

35
leadership. Often, these attempted solutions are under funded, under staffed and under
evaluated (Institute for Alternative Futures, 2012)
To combat this issue and pave the way for more effective, coordinated preventive care,
the report recommends that community health centers develop and implement a
systematic processes that regularly identify community needs, and foster partnerships
with organizations that make programs easier to run and more sustainable to afford and
maintain (Institute for Alternative Futures, 2012).
The report also provides communications strategies to begin this process, and state that,
“Rather than telling others that they need to be concerned about health, repackage health
messages into ideas and language that take into account the concerns and priorities of
other sectors, promoting cross-sectoral coalitions” (Institute for Alternative Futures,
2012).
Communication strategies to implement this recommendation include:
 “Using terms or phrases that translate across sectors, such as ‘livability,’
‘sustainability,’ ‘community resilience,’ ‘equal opportunity for health and
wellbeing for all,’ ‘national strength,’ and ‘community health and wellbeing’
 Using media such as videos to share stories related to the SDH as told by non-
clinicians, policymakers, politicians, and others
 Taking advantage of particular opportunities or apertures in messaging to
heighten relevance and impact. For example, in discussions on the Federal
Government and budget cuts, there is an opportunity for messaging about
economic implications for communities, CHCs, and the health care system, as
well as about how addressing social justice, disparities, and the workplace
actually creates a vibrant, local economy that contributes to the national economy,
thus presenting health as a vital economic input” (Institute for Alternative Futures,
2012).
One health care model that employs these strategies to respond to socially-related health
issues is Health Leads. The organization considers social determinants of health as a
standard part of quality care, and aims to improve health as much as it manages disease
(Health Leads, 2014). Health Leads conducts health communication at the face-to-face
level, interacting to patients in a way that is informed by cultural, linguistic, and health
literacy considerations.
Its website says: “When patients and their families seek medical care, they often face
critical challenges in their lives at the same time – they have little food, they have no job,
they struggle to keep up with bills for gas and electricity. With Health Leads, doctors and
other health care providers are able to ask their patients: Are you running out of food at
the end of the month? Do you have heat in your home this winter?” (Health Leads, 2014).
Health Leads works through a network of clinics and hospitals that allows providers to
prescribe resources—like heat or food—and employ students, called Health Leads
Advocates, to work with patients on attaining these resources. They also work with health

36
care providers to “ask the real questions” to get to the root of patients’ health problems.
In 2013, the organization connected more than 11,000 patients with these necessary
resources. An overview report states that in 2013, 92 percent of its patients had either
secured a resource they didn’t have before, or said that the information they had been
given empowered them to secure the resource on their own (Health Leads, 2014).
In order to communicate their vision, Health Leads publishes reports and videos on its
website. Its cofounder, Rebecca D. Onie also delivered a 2012 TEDMED talk share
Health Leads’ story, and urge others to recognize the importance of integrating the social
determinants of health into the way we live and organize health care systems
(TED.com/talks, 2012).
Conclusion
Health inequities are responsible for many long-term negative health outcomes, and these
messages are gradually becoming more prominent in academic research and the media.
Research indicates that focusing investment more in prevention, addressing health
inequities through social improvement could help advance population health outcomes
and reduce preventable deaths while also reducing financial weight we place on clinical
care. Despite data supporting the efficacy of prevention efforts, there is a large gap
between medical care spending and social spending to improve quality of life.
The more the public supports the idea that health outcomes rely on social indicators like
education, employment, environment and physical neighborhoods, the more likely
policymakers will be to support initiatives that address social determinants of health.
Studies show that American conservatives place a high value on individual responsibility,
and public health communicators should be aware of existing political ideology when
trying to emphasize social determinants of health. Framing messages to show how
individual choices are relevant to present social circumstances may be a helpful strategy
in generating support and funding for prevention efforts.

37
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