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“Public health awareness” usually refers to campaigns with messages about quitting smoking or eating healthful foods, often aimed at the people who are most vulnerable to health threats. But four public health and communications specialists, Jeff Niederdeppe, Q. Lisa Bu, Porismita Borah, David A. Kindig and Stephanie A. Robert, have proposed a different kind of campaign. Many of the best ways to improve public health aren’t a matter of individuals’ lifestyle decisions. These researchers suggest a campaign instead that encourages voters and policymakers to make political changes that could improve the health of Americans overall.

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Such a campaign might start with raising awareness about social determinants of health. Media reporting tends to focus on individual choices. But the authors write that regardless of their lifestyle choices, Americans experience radically different health outcomes depending on their race and socioeconomic status. Additionally, people’s opportunities to make “correct” choices vary dramatically depending on their resources and surroundings.

Perhaps if voters and policymakers understood this, they might work to make cities more walkable, reduce government subsidies for unhealthy farm commodities, curb the stressful working conditions found in many low-wage jobs, or make other health-oriented political changes.

But how could a campaign convey information about the broader social determinants of health to voters and policymakers? Niederdeppe and his colleagues start with message framing. They cite experiments from the 1990s that presented social issues like terrorism, violent crime, racial discrimination, and poverty either episodically—through case studies—or thematically—through statistics about the scope of the problems.

When it came to crime and terrorism, suburban residents exposed to the thematic framing became more likely to attribute the problems to societal causes rather than individual choices. On the other hand, regardless of which frame they were exposed to, most of the study participants saw racial discrimination as an isolated problem of specific individuals rather than a broader social problem. Disturbingly, thematic framing made people more likely to attribute poverty to social causes, but not if they were thinking about African-Americans. The authors write, “Specifically when viewers were exposed to stories about poor black people, they were more likely to attribute responsibility for poverty to the individual, regardless of the framing condition.”

To more successfully frame public health issues in terms of social problems like poverty and racism, the authors suggest the use of narratives and images. These techniques can help people identify with those affected, engage emotionally, and remember information. But they also have pitfalls. For example, stories and images can evoke guilt, which tends to lead to resentment and can inhibit persuasion.

The authors acknowledge that what they’re proposing is tricky, both because of Americans’ overwhelming individualistic orientation and because the campaign would have to convince powerful people to be concerned about the problems of the less powerful. But they suggest that this kind of campaign is an important complement to messages about what we can each do to protect our own health.


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The Milbank Quarterly, Vol. 86, No. 3 (Sep., 2008), pp. 481-513
Wiley on behalf of Milbank Memorial Fund