ISSUE BRIEF 7: MESSAGE
TRANSLATION

Breaking Through on the Social Determinants ofHealth and Health Disparities

DECEMBER 2009

An approach to message translation

Message Headlines – At a Glance
The Social Determinants of Health: “Where we live, learn,
work and play can have a greater impact on how long and how
well we live than medical care.”

While there are richresources—literally
decades of researchand volumes ofscholarly articles—todocument healthdisparities and theimportance of social
determinants ofhealth, much of thiswork has been
unfamiliar to leaders
outside of publichealth and related
fields.

Health Disparities: “The health of America depends on thehealth of all Americans. Despite enormous investment, America
is not achieving its full health potential.”

Background
The Robert Wood Johnson Foundation (RWJF) convened the Commission to Build a
Healthier America (2008-2009) to explore why some Americans are so much
healthier than others and why America is not the healthiest country in the world. The
vision was to impanel a diverse, multi-sector, nonpartisan Commission of leaders toinvestigate the issues and identify solutions, outside of the health care system, toimprove the health of all Americans.
Inherent in this approach was increasing awareness and involvement of leaders
outside of public health and health care—leaders who were likely to be somewhat
unfamiliar with “social determinants.”

Audiences
The primary audiences for the Commission’s work were public policy makers andprivate sector leaders—those with the power to implement the Commission’s
recommendations. These decision makers span the political spectrum and cross
many sectors. To engage these decision makers, the Commission also hoped toengage health organizations, leaders and organizations outside of the health andhealth care sectors and targeted media.

Communication Objective
To raise awareness and achieve greater consensus among diverse leaders about
the social factors that affect health and the need to act across sectors to improve thehealth of all Americans—particularly those who face the greatest obstacles.

The Challenge
While there are rich resources—literally decades of research and volumes ofscholarly articles— to document health disparities and the importance of social
determinants of health, much of this work has been unfamiliar to leaders outside of
public health and related fields. This was particularly true for the public and private
sector decision makers with authority to make changes.

Translating any data for a broad audience can be challenging. Translating the wide
ranging, highly specific and technical information that characterizes the fields ofsocial determinants and health disparities presented a particularly confounding
problem. The complexities were intensified by deeply-held beliefs about the issues
that made communicating across a broad spectrum of stakeholders sensitive as wellas complex.
If the Commission was to accomplish its objectives of reaching, informing andengaging diverse leaders across the political spectrum as a way to make headway
on these long-studied issues, it was essential to:
1. Communicate complex information in a way that accurately reflected theresearch findings in a context that mattered to identified target audiences;and
2. Make the case in a way that appealed to leaders across the political
spectrum and connected with leaders both within and outside of the publichealth and health care communities.

Message Development Approach

The challenge was to
identify how to frame
communications in a
way that spoke to how
people really feel andthink about theseissues—not just what
they openly express.

The research-based approach to crafting messages and compelling arguments thatwould break through to new audiences included:
1. Qualitative Audience Research;
2. Quantitative Audience Research;
3. An Interactive Messaging Workshop; and4. Development of Stories
1.

Qualitative Audience Research to Reveal ―Deep Metaphors‖

The Commission engaged Olson Zaltman Associates (OZA) to gain a better
understanding of the target audiences’ thoughts and feelings about differences inhealth among Americans. The objective was to identify how to frame
communications in a way that spoke to how people really feel and think about theseissues—not just what they openly express.
OZA conducted a series of intense, highly-focused, one-on-one interviews withindividuals who represented the Commission’s target audiences, looking for acluster of “deep metaphors” that would enable the Commission to makefundamental connections with those audiences. According to OZA, these “deepmetaphors” reflect the basic structures in our minds that organize our perceptions
and shape the sense we make of them and how we react. The feelings aroundthese metaphors are unconscious—an automatic viewing lens that is seldom
explicitly acknowledged.
Such metaphors are thought to represent fundamental and widely-sharedconceptual orientations. Identifying a relevant set of these metaphors would help theCommission craft language and create imagery that connected to the underlying
motivations that influence our target audiences’ opinions.
Individuals included in these one-on-one interviews were divided into two sets:
those who identified themselves as Democrats and those who identified themselves
as Republicans. Based on their analysis of information from the interviews, OZA
researchers provided recommendations about the three most salient metaphors that
seemed to resonate best across these groups.
Each of these three metaphors—journey, connection and resources—is described
below, along with an example of how the Commission communications teamincorporated the metaphor concepts in written and visual communications:Page 2



Journey: Journey is often used as a metaphor for life itself, where life is framed
as one long journey including many twists and turns. Journey metaphors canbe used to convey both the unknown nature of some trips, with unanticipateddetours, as well as the predictable outcomes of others, such as knowing that“staying on track” means reaching a pre-set goal or destination.
 The “journey” metaphor was played out in both imagery and words.
For example, the cover of the report issued by RWJF to theCommission as it began its work features a photograph of a car driving
away down a long road, while the report’s title, “Overcoming Obstacles
to Health,” reflects the barriers, or “twists and turns,” that people
encounter along life’s journey.
 The Commission also produced a series of maps displaying often
dramatic differences in life expectancy within defined geographic
areas. Each map incorporated language that referred to the “journey”
metaphor—for example, “A short distance to large disparities inhealth.”Connection: Encompassing feelings of belonging or exclusion, connection isreflected in psychological ownership and shows how things are related to one
another. Lack of connection is reflected in feelings of distance or separationfrom others.
 The “connection” metaphor, which can be particularly effective when it
draws people’s attention to associations they may not have previously
recognized, is reflected in one of the main Commission messages:“Where we live, learn, work and play can have a greater impact on
how long and well we live than medical care. In fact, the connections
are greater than most of us realize.” The Commission also used the “connection” metaphor tocommunicate the long-lasting impact of social determinants:“Problems that surround people early in life create a chain of events
that is often difficult to stop.”Resources: Resources are essential to our survival. We require resources
such as nutrients and water to live and grow. Our family and friends areresources that support us in tough times. Because many valuable resources
are limited, we must use them judiciously.
 The “resources” metaphor—especially wasting resources—playedheavily in the Commission’s messaging. The Commission consistently
highlighted that “America spends more on health care than any othernation, but we are not the healthiest people” and that “America is notgetting good value for its health dollar.”2.

Quantitative Audience Research

The Commission also engaged a bipartisan team of polling firms, Public Opinion
Strategies and Greenberg Quinlan Rosner Research, to conduct a national survey
to gauge registered voters’ perceptions of health differences in the United States.
The survey provided a benchmark level of public awareness and identified potential
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receptivity to changes in public and private sector policies. The survey found:
The majority of voters believe health differences due to social factors in this country
are an important problem that needs to be addressed.
 78% agree that “it is important to make sure health differences between groupsof people in this country no longer exist because of factors such as income andeducation.”1.

A complete report of this survey can be found on the Commission’s Web site at:
http://www.commissiononhealth.org/PDF/14a4f32d-73e8-4f85-820c5a10acf0b022/Commission%20Media%20Kit.pdf

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In addition to personal behavior, voters view social factors such as income,education and environment as having significant impacts on a person’s health.
 82% believe living in a safe neighborhood can have a positive influence on a
person’s health.
 67% believe a higher educational level can have a positive influence on a
person’s health.
 68% believe a lower income can have a negative influence on a person’shealth.
The majority of voters believe government should do more to address healthdifferences in this country due to social factors such as income, education, andenvironment.
 60% believe current government policies are not working to reduce healthdifferences.

Three clusters ofmessages collectively
created theCommission’s
storyline:- Documenting the
problem of healthdisparities- Describing theimportant role ofsocial determinants
in health- Conveying theCommission’s callto action

3.

Interactive Messaging Workshop

With the findings and insights gathered through the qualitative and quantitative
research, along with key health disparities and social determinants researchfindings, the Commission’s communications team led an interactive messaging
workshop with staff experts to craft the Commission’s messaging framework.
The Commission’s messaging framework followed a time-tested communications
formula to: Gain and maintain message control when communicating the Commission’s
purpose and activities; Tell a clear, compelling story about social determinants of health and healthdisparities that would matter to key audiences; and Frame the issue in a way that would sway and engage target audiences.
Three clusters of messages collectively created the Commission’s overarching
narrative: documenting the problem of health disparities in America, describing theimportant role of social determinants in health, and conveying the Commission’s callto action.

Considerations for Message Framing
How do we make the information clear
and compelling without oversimplifying
decades of research?

Headline what’s most important.

How do we break through to gain
attention?

Challenge conventional wisdom with
unexpected facts.

How do we make theories tangible?

Use real stories, analogies andeveryday language.

How do we connect with a target
audience?

Utilize the identified deep metaphors.

How do we make it timely and relevant?

Provide a call to action.

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Results: Commission Messages, At a Glance
Included here is a sample of the Commission’s key messaging, using language
rooted in its research. (The complete set of facts and supporting content is notincluded here.)

Theme One:
The Problem of Health Disparities in America―Why Your Zip CodeMay Be More
Important to Your
Health Than Your
Genetic Code‖- The Huffington Post,
April 29, 2009

The health of America depends on the health of all Americans. Despiteenormous investment, America is not achieving its full health potential.
America spends more on health care than any other nation, but ranks
below many countries on key health indicators like infant mortality and life
expectancy.



All Americans do not have the same opportunities to make healthy choices.
Sometimes, barriers to healthier decisions are too high for an individual to
overcome – even with great motivation.

Good health requires individuals to make responsible personal choices andrequires a societal commitment to remove the obstacles preventing too
many Americans from making healthy decisions.

Theme Two:
The Importance of the Social Determinants of Health
Where we live, learn, work and play can have a greater impact on how
long and well we live than medical care.


Our zip code may be more important to our health than our genetic code.

A person’s health and chances of becoming sick and dying early are
greatly influenced by powerful social factors such as education, income,nutrition, housing and neighborhoods.



There is more to health than health care.

Theme Three:
The Commission’s Call to Action
The Commission to Build a Healthier America will look beyond medicalcare for ways to improve the health of all Americans.


Health care reform is essential, but improving the health of all Americans
requires broadening our view beyond medical care.



We must find ways to enable more people to lead healthy lives and avoid
getting sick in the first place.

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4.

Story Development – Putting a Face on the Issues

In addition to the core message points, and as a way to bring the issues andmessages to life, the Commission developed a series of human interest stories toillustrate health disparities and how social factors influence health.
The stories showcased how nonmedical interventions—school-based programs,
workplace programs, nutrition and physical activity programs—have had a positive
impact on an individual’s or a family’s health. These stories provided content forstory booklets, videos, the Web site, imagery for reports and presentations by
Commissioners and RWJF spokespersons.
thKenyon McGriff, Philadelphia: As a 10 grader weighing
270 pounds, Kenyon knew that his neighborhood’s fast
food restaurants, corner markets and dimly lit sidewalks
challenged his health. An after-school running program
helped Kenyon make healthier food and physical activity
choices with good results.

The repetition of
messages supported
a consistent andcumulative narrative.

Abang Ojullu, Worthington, Minn.: Abang’s young
daughter experienced a major improvement in her severe
asthma when the family moved to a renovated apartment
with air conditioning, exhaust fans in the kitchen andbathrooms, and no mold. Abang says a checkup by thenurse after the move found that her daughter’s lungcapacity had noticeably improved.

Putting the Messages to WorkA key to success was the discipline required to ensure that the Commission,
including staff and Commissioners, used the messages consistently across all
communications to reinforce the Commission’s main themes with target audiences.
The core messages, imagery and stories were used as appropriate in publications,
events, media outreach, stakeholder outreach, Web site content and presentations.
The repetition of messages allowed the Commission to communicate a consistentand cumulative story.

Conclusion
The Commission’s purposeful messaging approach—guided by market researchand public health research findings as well as communications principles and acreative content development process—helped the Commission craft a focusedmessaging framework. The process was central to success and worth the upfront
investment given the challenges the Commission faced in advancing a sensitive andcomplex set of issues among diverse decision makers from across the political
spectrum. The messages were used by Commissioners representing different
sectors and points of view. Given the potential for particular issues related to social
determinants and health disparities to have divided Commissioners, this acceptance
was an important accomplishment—and a measure of success for how the topics
were positioned.

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APPENDIX
From Research Findings to Message Points: Examples of Message Translation
This chart provides examples of the kinds of more technical research findings that were restated for public
consumption in the Commission’s messaging.

Research Findings
If SES effects are due to poverty and its correlates, one would
expect to find a threshold effect above which SES would show
little or no association with health outcomes. Studies at both theindividual and aggregate levels challenge this expectation. An
association of SES and mortality occurs throughout the SES
hierarchy.

Commission Messages

At all income levels, our health falls
short of what it could be.

(Adler NE, Boyce WT, Chesney MA, et al. "Socioeconomic Inequalities in
Health. No Easy Solution." The Journal of the American Medical
Association, 269(24): 3140-5, 1993.)

Through a combination of latent effects and pathways of living,child development affects health, well-being, and competence
throughout the life cycle.
(Hertzman C and Wiens M. "Child Development and Long-Term
Outcomes: A Population Health Perspective and Summary of Successful
Interventions." Social Science & Medicine, 43(7): 1083-95, 1996.)

The early years of life set us onpaths leading toward – or away from– good health.

Area-based measures of poverty and deprivation have been foundto be associated with health outcomes after adjustment forindividual-level factors. Additional studies have suggested thatneighborhood-level variables may also shape the distribution ofhealth-related behaviors, although other studies have found little
evidence of area effects.

Where we live, learn, work and play
can have a greater impact on how
long and well we live than medicalcare.

(Diez-Roux AV. ―Bringing Context Back into Epidemiology: Variables andFallacies in Multilevel Analysis.‖ American Journal of Public Health,88(2):216-22, 1998)

Our zip code may be more importantto our health than our genetic code.

When health risk behaviors were considered, the risk of dying wasstill significantly elevated for the lowest-income group (hazard rate
ratio, 2.77; 95% CI, 1.74-4.42) and the middle-income group(hazard rate ratio, 2.14; 95% CI, 1.38-3.25)…Although reducing
the prevalence of health risk behaviors in low-income populations
is an important public health goal, socioeconomic differences inmortality are due to a wider array of factors and, therefore, would
persist even with improved health behaviors among thedisadvantaged.

A person’s health and chances of
becoming sick and dying early are
greatly influenced by powerfulsocial factors such as education,
income, housing andneighborhoods.

(Lantz PM, House JS, Lepkowski JM, et al. "Socioeconomic Factors,
Health Behaviors, and Mortality: Results from a Nationally Representative
Prospective Study of US Adults." The Journal of the American Medical
Association, 279(21):1703-1708, 1998.)

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Research Findings
Compared with babies born to the most-educated mothers (thosewith at least 16 years of schooling), infant mortality rates werehigher—by as much as 12 deaths per 1,000 live births—for babies
born to the least-educated mothers (those with less than 12 yearsof completed schooling). With few exceptions, infant mortality
rates also were higher—by up to five deaths per 1,000 live
births—among babies born to mothers in the second highest
education group (those with 13-15 years of completed schooling).
Compared with children in higher-income families, children inpoor, near-poor or middle-income families were 4.7, 2.8 and 1.5
times as likely to be in less than optimal health. Even amongchildren in higher-income families, the percent of children withless than optimal health in almost every state exceeded thenational benchmark—3.5 percent—which should be attainable.

Commission Messages

There are substantial shortfalls in
the health of children based on theirfamilies’ income and education.
Children in the poorest and leasteducated households suffer the
worst health outcomes. Even middle
class children and children in thebest-off families are not as healthy
as they could be.

(Egerter S, Braveman P, Pamuk E, et al. America's Health Starts with
Healthy Children: How Do States Compare? Washington, DC: Robert
Wood Johnson Foundation Commission to Build a Healthier America,
2008. Available at www.commissiononhealth.org.)Throughout this century, average life expectancy for all persons in
the United States has been increasing… but data show thatduring 1979–89, 45-year-olds with the highest incomes could
expect to live 3 to 7 years longer than those with the lowest
incomes.
(Pamuk E, Makuc D, Keck K, et al. Health, United States, 1998 with
Socioeconomic Status and Health Chartbook. Hyattsville, MD: National
Center for Health Statistics, 1998.)

A 1998 study revealed dramatic disparities in life expectancy
across U.S. counties overall, and particularly when racial or ethnic
differences were also considered. For example, black men in the
county with the shortest life expectancy for blacks lived only 58
years (well below average life expectancy in many developing
nations), while white men in the county with the longest life
expectancy for whites could expect to live to age 78—two
decades longer.
(Braveman P and Egerter S. Overcoming Obstacles to Health.
Washington, DC: Robert Wood Johnson Foundation Commission to Builda Healthier America, 2008. Available at www.commissiononhealth.org.)

Health shortfalls are even more dramatic when considering thelevel of adult health that should be attainable. At every level of
education in every racial or ethnic group, the percentage of adults
1
in less than very good health exceeds the national benchmark.
In the overall population, observed patterns were clearlyconsistent with a socioeconomic gradient in life expectancy at age
25, health status, and activity limitation due to chronic disease; forthese indicators, better health outcomes were seen at each higher
level of income or education and the confidence intervals did not2
overlap.
1. (Egerter S, Braveman P, Cubbin C, et al. Reaching America’s Health
Potential: A State-by-State Look at Adult Health. Washington, DC:
Robert Wood Johnson Foundation Commission to Build a HealthierAmerica, 2009. Available at www.commissiononhealth.org.)
2. (Braveman P, Cubbin C, Egerter S, et al. ―Socioeconomic disparities inhealth in the United States: What do the patterns tell us?‖ American
Journal of Public Health. In press.)

While America has seen great gains
in improving health overall, someAmericans face much poorer
prospects for good health and longlife than others.

Some Americans will die 20 years
earlier than others who live just a
short distance away because ofdifferences in education, income,race, ethnicity and where and how
they live.

Americans at every income andeducation level should be healthier.
Many people with incomes andeducation above the national
average die prematurely frompreventable health problems. And
for those with limited incomes andeducation, health outcomes are far
worse.

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About the Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and healthcare issues facing our country. As the nation's largest philanthropy devoted
exclusively to improving the health and health care of all Americans, the Foundation
works with a diverse group of organizations and individuals to identify solutions andachieve comprehensive, meaningful and timely change. For more than 35 years theFoundation has brought experience, commitment, and a rigorous, balanced
approach to the problems that affect the health and health care of those it serves.
When it comes to helping Americans lead healthier lives and get the care they need,
the Foundation expects to make a difference in your lifetime.
About the Commission to Build a Healthier America
The Robert Wood Johnson Foundation Commission to Build a Healthier America isa national, independent, non-partisan group of leaders formed in February 2008 toraise visibility of the many factors that influence health, examine innovativeinterventions that are making a real difference at the local level and in the private
sector, and identify specific, feasible steps to improve Americans’ health. The
Commission released its recommendations on April 2, 2009.
Resources on the Commission Web Site:
The Commission’s Web site—commissiononhealth.org—includes a variety ofexamples of how the messaging was used, along with supporting resources
including reports, issue briefs, state-level child and adult health data, fact sheets,
multimedia personal stories, downloadable charts, polling results and blogs.
Credits
Lead Authors
Elaine Arkin, Robert Wood Johnson Foundation
Danielle DeForge, Chandler Chicco Agency
Allison May Rosen, Chandler Chicco Agency
Photography
Courtesy of the Robert Wood Johnson Foundation
Design and Layout
Alex Field, Burness Communications
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