In this article, we articulated communication challenges associated with raising awareness of and mobilizing action regarding SDH and health disparities. To address these challenges, we presented data on narrative and visual message characteristics disseminated by two national SDH awareness initiatives in the U.S. In this section, we explore implications of these findings.We begin by discussing the communication implications of our narrative findings, which we couch in the context of limitations of our analysis. We did not test the persuasive impact of these narratives or theory related to narrative persuasion. However, this analysis serves an important purpose. As part of efforts to study the persuasive impact of narratives about SDH and health disparities [30
] in contexts such as HIV/AIDS and other infectious diseases [41
]; chronic diseases such as diabetes [20
]; and obesity [21
], our analysis is positioned to describe features of these messages and help determine what facets could potentially lead to desired outcomes. In particular, it draws on relevant theory to argue that choices these and future campaigns make in communicating about SDH and health disparities using stories, such as the type of health determinants, health outcomes, and policy interventions highlighted, has important implications for convincing citizens and other stakehlolders that (1) SDH contribute significantly to adverse health outcomes and disparities; (2) responsibility for addressing SDH rests both in individual behavior as well as social (i.e.
, governmental) policy; and (3) there are policy solutions to tackle these issues that warrant and need support. Relevant theoretical perspectives include framing of issue responsibility, individual exemplars, and other domains.
Also, we focused on The Commission and Unnatural Causes,
which were, to our knowledge, the only two large-scale, US-based campaigns that were strategically designed to communicate the importance of SDH as of 2009 (when we conducted the analysis). Although other, non-US based initiatives such as the World Health Organization’s 2008 report titled Closing the Gap in a Generation—Heath Equity through Action on the Social Determinants of Health
] have also been published and gained well-deserved notoriety, they did not feature narrative evidence. To the extent initiatives similar to The Commission or Unnatural Causes
are produced in the future (such as the 2012 HBO documentary Weight of the Nation
), which explored behavioral and social-structural factors driving obesity in the US), research could compare them with our sample.
Our analysis suggests several opportunities and challenges for using narratives to communicate about SDH and health disparities. Communication scholars have written extensively about the “right” formula for a “good” (i.e.
, persuasive) narrative, citing factors such as a coherent plot with a clear beginning, middle, and end as well as engaging characters [17
]. We view the health issues faced by protagonists in the narratives as a key element of story plot. Both initiatives emphasized generic and specific health issues, with the former (using examples indicative of generally “poor health”) comparatively more numerous. In terms of the latter, cardiovascular-related conditions such as heart attack and stroke were prominently emphasized; these conditions are among the the leading cause of death in the US [42
] and worldwide [43
]. To our knowledge, existing research on the design and testing of persuasive SDH messages have not given as much attention to types of health issues to which SDH relate. Future research should examine whether it is desirable to highlight connections among SDH, health disparities, and health outcomes through attention to specific or general conditions (or both). Such research may draw on the concept of identification: the extent one is able to imagine being, behaving like, and empathizing with a character in a story; it is an important determinant of narrative persuasion [18
]. We suggest that the ability of narratives to raise awareness of and mobilize policy support around SDH and health disparities may depend, in part, on the extent people can “identify” with the health conditions that are argued to shape/be shaped by these factors. Both generic and specific health issues may have advantages and disadvantages. For example, narratives that employ specific isssues could be effective in conveying awareness because they touch on potentially well-known conditions and causes of death. A generic focus on “health” could allow campaigns to stress that conditions where people live, work, and play shape overall well-being.
Another important story element is SDH themselves: arguably the “villains” preventing protagonists from achieving good health. Both campaigns focused on SDH that have received considerable attention in health policy discourse and are particularly salient in the public vernacular: income/poverty/wealth, neighborhood context, and workplace/housing-related issues. For example, a 2007 national survey [25
] found that 78% of Americans agreed that “it is important to make sure health differences between groups of people in this country no longer exist because of factors such as income,” and 82% felt that “living in a safe neighborhood can have a positive influence on a person’s health.” However, there was comparatively little focus on other SDH like racial discrimination, education, and social support, and survey research suggests that these examples are less salient than their aforementioned counterparts. Robert et al.
] found that less than half of Wisconsin adults believed that neighborhood safety (41.9%), quality of housing (33.2%) and education (33.7%) have strong effects on a person’s health. Education ranked lower in awareness than one’s environmental surroundings. Overall, SDH garnered less awareness than factors like personal health practices (i.e.
, diet and exercise) (84.6%), health insurance (75.3%), and access to affordable health care (69.8%).
SDH advocates do not simply seek to show that social, political, economic, and environmental factors are important drivers of health; they also strive to communicate that health is substantially more complex than an individuals’ willpower or health care coverage alone. SDH may not be created equal in terms of the extent they endanger public awareness or concern. It is possible that some SDH are more likely than others to conjure feelings of personal responsibility and deficiencies as opposed to an appreciation of social-structural considerations [46
]. For example, education can involve beliefs about the availability of quality schools and/or that an individual simply needs to work harder to learn. The former arguably represents a structural factor while the latter speaks to personal motivation. These beliefs, moreover may also impact public views on who is responsible for addressing these health determinants; people may be less likely to support government policies to address SDH if they believe that those determinants have roots in personal deficiencies, can be overcome through behavior change, or serve to stigmatize certain groups. Research suggests, for example, that emphasizing negative health outcomes or disparities among lower socioeconomic groups is viewed, at least by some individuals, as reifying that “lower status” individuals cannot improve their health [30
Finally, nearly half of narratives described strategies to address SDH impacts, of which most (21 out of 28) came from The Commission. A potential explanation may be the contrasting advocacy approaches among the two organizations. The Commission issued a variety of recommendations for addressing SDH, many of which also appeared, in some form, in the narratives. In contrast, Unnatural Causes
featured a separate advocacy component. A page on the film’s website (http://www.unnaturalcauses.org/what_you_can_do.php
) described how organizations could use the film to educate, organize, and advocate for change. The idea was that the film would raise awareness of SDH and their consequences, while later advocacy efforts would focus on changing them. Since our analysis focused on the film, we likely did not capture all potential interventions that factored into this broader advocacy strategy.
SDH researchers and advocates have stressed the importance of offering solutions, especially within narratives, to issues involving connections among SDH, health outcomes, and health disparities [1
]. The strategies mentioned in the narratives we examined tended to be a combination of self-driven decisions and externally-driven interventions. These findings reflect a larger debate about the role both of personal responsibility, including health behaviors, and structural factors in shaping health outcomes and disparities and serving as components of persuasive messages. There is a complex, mutualistic relationship between the two. Health behaviors are, in part, consequences of structural factors [48
]; for example, lack of convenient food markets in one’s neighborhood can undermine the ability to make healthy food choices. Consequently, SDH-themed messages may need to acknowledge the role of personal choice and healthy (or unhealthy) behavior; the role of “external” structural factors; and how programs can help change these behaviors through attention to those factors. Public health organizations and researchers have begun using a “mixed” approach that acknowledges both personal responsibility/behavior as well as SDH [12
]. Preliminary results point to the ability of such an approach, especially when couched in narrative terms, to increase audiences’ belief that societal actors (such as the government) are responsible for tackling SDH and subsequent health outcomes (such as obesity [21
]); increase support for policies targeting SDH and health disparities [49
]; and reduce the likelihood that people counter-argue the message that behavior and external factors synergistically affect health [22
In addition, scholars are also examining the role that existing predispositions play in how people react to such information. For example, political ideology is an important moderator of persuasive effects of SDH-themed narratives, with liberal audiences less likely to counter-argue intended messages and conservative audiences more skeptical about how SDH shape health outcomes (as opposed to health behavior alone) [20
]. There is ample opportunity and necessity to expand the audience pool from citizens to policymakers, given that public support for SDH policy is most effective with policymaker buy-in. Research is beginning to explore policymaker perceptions of health determinants and disparities, especially in the context of specific issues like obesity, as well as views on appropriate and feasible policy solutions [50
]. Narrative-based information using a “mixed” approach discussed above may be particularly effective as part of policy briefs [51
]. These briefs summarize what is known about SDH and health disparities and what can be done to combat adverse health outcomes. The challenge advocates and researchers face relates not only to the political ideology of individual policymakers but also that they tend to be of a higher socioeconomic and health status compared to the rest of the population (and, thus, may feel no personal stake in health policy) [12
Overall, the synthesis of the individual and the social-structural is challenging: emphasizing SDH without overlooking personal responsibility and promoting responsibility without taking a “blaming the victim” approach. The success of interventions that stress both may hinge, in part, on clearly explaining how a given strategy can produce a certain (presumably health-enhancing) outcome: in other words, not just explaining how/why SDH shape health outcomes and disparities but also how/why an advocated solution “works” to improve health. Recent research suggests that people may be skeptical of a “black box” description of SDH-themed interventions included in narratives such as those used by The Commission and Unnatural Causes
. For example, they may believe that the situations portrayed do not happen in “normal” life [30
]; that the solutions are not replicable elsewhere; or that insufficient attention was afforded to how the outcome(s) came to be. Clearly delineating steps through which behavior change, in concert with external policies, achieve positive health outcomes is an important narrative element and warrants future research.
Our analysis of visuals present in the two campaigns likewise has several limitations. We concentrated on specific sections of website and film that contained still images such as charts, graphs, and maps. We did not code moving images within Unnatural Causes
, which can involve factors such as camera angle and editing [34
]. Moreover, scholars could build on this study by focusing on SDH-themed visuals that have been featured in more recently produced programs, such as HBO’s The Weight of the Nation
. Nonetheless, our analysis is positioned to describe image features, such as types of variables represented and juxtapositinons used, and help determine what facets could potentially lead to desired outcomes by drawing on relevant theory. Many of the 90 maps, graphs, and charts featured information about a specific health outcome either in isolation or, more frequently, in combination with other variables including SDH and demographics. However, image juxtapositions featuring two visuals side-by-side were relatively rare. In terms of persuasive appeal, all three appeared to invite causual interpretations. Compared to other types of persuasive impact, causal interpretations seem the most plausible for SDH; both The Commission and Unnatural Causes
emphasized how poor health outcomes are a function, at least in part, of SDH. Moreover, the focus on relationships involving two or three variables belie challenges associated with describing complex interactions among factors that shape health outcomes and disparities. Visual representations of health determinants, while potentially helping synthesize complex data into relatively easy-to-understand formats, can missrepresent multivariate relationships by focusing on a few variables at a time [37
]. Initial research in this area suggests that unlike narratives, images are not as able to effectively portray causal relationships between SDH and health (i.e.
, why education status might be related to health). As a result, people may speculatively discuss why these relationships might exist and what other variables may be missing from the equation. Future research should therefore explore the persuasive effects of SDH-related narratives both with and without accompanying visual evidence. It is possible that narratives could illustrate broader trends offered by visual evidence presented in graphical and other forms.