Communicating About Health Equity Comparisons: A Cautionary Note

It’s no secret that communication is key to changing hearts and minds and to motivating action, but we’ve probably all said something that didn’t connect with our audience the way we thought it would. Sometimes the wrong communication strategy can even end up hurting rather than helping a cause.

Research abounds, but awareness does not
With the proliferation of research on health inequalities, how do we communicate information in ways that improve both population health and health equity? Raising public awareness of health inequalities is seen as playing a crucial role in helping to achieve health equity. However, despite the increase in research output, a lack of awareness about various health disparities persists among a significant portion of the public. When CDC issued its inaugural  Morbidity and Mortality Weekly Report on health inequalities in 2011, then-Director Tom Frieden wrote: “Differences in health based on race, ethnicity, or economics can be reduced, but will require public awareness and understanding of which groups are most vulnerable, which disparities are most correctable through available interventions, and whether disparities are being resolved over time.” More recently, the National Academies report “U.S. Health in International Perspective: Shorter Lives, Poorer Health” called for media campaigns to educate the public on how the U.S. lags behind peer nations.

Awareness doesn’t necessarily equal support
When it comes to advancing public health and population health goals, effective communication matters. However, greater public awareness of a public health issue does not necessarily equal greater support for change. Intuitively, it may seem that an educational approach that informs the public about documented demographic disparities will lead to greater public support to fix those disparities, but research suggests it’s not so straightforward. The Institute of Medicine’s workshop “Communicating to Advance the Public’s Health” makes it clear that not all publicity is good publicity. Depending on the way an issue is covered and what aspects are emphasized (i.e., the framing of the issue), drawing attention to an issue can be counterproductive in some cases. It may reinforce group stereotypes and stigmas, particularly for health issues where individuals are often perceived as being responsible for the condition (e.g., obesity, drug use, sexually transmitted diseases). Raising the profile of an issue can sometimes mobilize powerful opponents when there are industries or groups with vested interests. How an issue is framed can also contribute to political polarization.

Based on my own and others’ research, I would urge particular care in highlighting demographic group comparisons. Demographic social comparison frames in disparity messages highlight how different social groups rank or compare to one another in risk or disparate impact. However, there is evidence that there can be unintended effects of using demographic social comparisons in messaging about population health.

Most people don’t think like statisticians when they interpret demographic trends and risks. Instead, risks are often interpreted based on irrational cognitive biases and social context. As a result, the reference groups we choose when we talk about demographic trends and inequalities can influence the public’s health perceptions, even when we present the same facts about risks.

Frames that emphasize racial health disparities tend to underperform alternative messaging in studies with a variety of audiences
Researchers found less public support for federal intervention to fix disparities when Black disparities rather than social class-based health disparities were highlighted. In a separate study that tested the effectiveness of messages about childhood obesity, fewer than half of the participants rated disparities in obesity as a strong rationale for government intervention. The racial disparity frame fared worse than a frame focusing on long-term health effects. Other studies have found that stories of progress and success in overcoming racial inequalities elicited more positive responses among both African Americans and health providers than frames that highlight continued racial inequalities did. Based on empirical research the Robert Wood Johnson Foundation, the FrameWorks Institute, and academic researchers have all urged caution in emphasizing racial and other minority group disparities when communicating about health inequalities and social determinants of health.

What can health equity researchers and advocates do?
Does all this mean racial disparities should never be emphasized? Not necessarily, but it underscores the importance of looking to the literature and assessing audience beliefs and values, or partnering with others who have that expertise. It is worth considering whether a message may prime or reinforce group stereotypes or stigma. It is also worth finding out what kinds of beliefs the target audience holds about the reasons for the disparity and whether they see reducing disparities as a priority and a compelling reason to enact public health policies. Further, it is worth considering what kinds of messages are being sent about how the issue can be most effectively addressed, or whether it can be fixed at all. Finally, for communication campaigns, in this era of social sharing of information and political polarization, it is worth considering what kinds of messages are shared socially and how message sentiment and frames may affect message dissemination. Research has shown that whether an issue is connected to race and racial discrimination is associated with who sees and shares the information on social media.

We all know that the way we say something matters, but it isn’t always obvious how to say it or what to highlight for a particular audience. Different audiences take away different interpretations of the same information based on the communication context and on their own prior beliefs and values. Fortunately, a nascent but growing body of theoretically and empirically based research addresses communication about health inequalities. It can help guide communication efforts and provide potential strategies for communicating to advance health equity and effect social change not only among the general public, but also among  journalists, health providers, and policymakers.