Communicating the social determinants of health

FrameWorks’ research identified four communication challenges that can act as barriers to wider public acceptance of the evidence on social determinants of health.

Challenge 1: Broadening what is understood by the term ‘health’

Participants initially tended to understand health as an absence of illness, defining health primarily by what it is not, rather than what it is. One interviewee said:

‘Good health is never having to go to the doctors. Ironically, good health is never having to use the NHS. I say ironically because of how much I respect the NHS, but if I never have to use it […] that’s good health.’

This also illustrates the strong connection in public thinking between health and medicine. The members of the public interviewed saw health as being a medical issue. They saw doctors and health professionals as authoritative voices on how to maintain health through daily behaviours, and they saw medicine as offering innovative ways to treat illness.

By contrast, individuals who work in the field of social determinants of health spoke of a healthy society as one in which people can experience physical and mental wellbeing, make meaning of their lives and have the sense of control needed to pursue life goals. This difference in the understanding of health leads to different ideas about how to maintain and improve health.

Viewing health as an absence of illness makes it difficult for people to think explicitly about how health might be created, as well as narrowing people’s focus to clinical treatment and individual-level prevention.

Challenge 2: Increasing understanding of the role of social determinants of health

The predominance of the individualistic strain of thinking was illustrated by how members of the public thought about the factors that shape people’s health. They assumed that choices relating to diet, exercise, smoking and drinking alcohol are the primary influences on health. When thinking in this way, people assigned responsibility to individuals for making healthy choices. This led some to assume that when people experience poor health, it is their own fault.

‘Yeah, that “responsibility” word – it starts with you, and it ends with you. Nobody else is responsible for you – nobody.’

Within this strain of thinking was the ‘mentalism’ model – seeing individuals’ choices as primarily determined by their self-discipline and willpower. This way of thinking was also applied by many participants to mental health issues such as depression and anxiety, which were seen as being determined by an individual’s mindset.

By contrast, those working in the field of the social determinants argued that health is a product of societal systems. Individual behaviour, they said, is strongly constrained and shaped by social and environmental factors. As a result, individual behaviours should be seen as the endpoint in a long chain of causes and consequences that produce health outcomes.

Another way that public participants thought about health, linked to the individualistic strain, was the ‘genetic exception’ model: where they could not explain health outcomes through individual choice or willpower, people often turned to genetics or fate to account for these exceptions to the rule.

‘I’ve known people that have never smoked before in their life, but then got lung cancer. So, it’s not one thing leads to another. I think sometimes you’re just a bit unlucky.’

When thinking in the individualistic strain, participants saw health outcomes as being determined either by individual choice and willpower, or by genetics. This led to a sharp distinction between self-inflicted and accidental illness; between the ‘deserving’ and ‘undeserving’ ill.

By placing all the emphasis on personal choice, they saw those who had an avoidable illness (such as lung cancer or obesity) as less deserving of care than those with a genetic illness (such as multiple sclerosis). One implication for communicators is that messages about an ‘NHS crisis’ may reinforce the view that limited health care resources should be targeted at those who are ‘more deserving’.

These results show that there is a big difference between experts and the public in terms of their underlying assumptions about the determinants of health. One of the main challenges for communicators is to shift the public away from individualistic ways of thinking about health and open up space for thinking about the role of social determinants.

Challenge 3: Increasing understanding of how social and economic inequalities drive health inequalities

Advocates of the social determinants of health described deep health inequalities among different groups as being driven by wider inequalities in power, wealth and resources. Public participants did recognise that certain neighbourhoods, cities or countries have better health than others, and so were able to recognise that social and environmental factors can lead to health inequalities. However, the ecological cultural models that people used to explain these differences only provided a partial understanding of how environments shape health, and they often fell back on more individualistic models to explain things.

For example, when thinking about the link between wealth and health, participants applied a health consumerism cultural model, explaining actions in terms of purchasing power. They assumed that wealthier people can buy good health through being able to afford the best foods, gym memberships, housing and private health care.

‘[People with money] might be able to buy the more healthy options. Trying to eat healthily does cost more money than the junk food.’

Public participants also described how social and environmental factors can restrict or encourage certain behaviours – the ‘behavioural constraints’ model. For example, they recognised that a time-consuming job can make it harder for people to eat well or take enough exercise.

However, both the health consumerism and behavioural-constraints models were relatively weak. Participants often defaulted to more individualistic strains of thought, as illustrated by the following quote:

‘I think you always have a choice… And I think anyone on any budget could work a way out to eat relatively healthy food or significantly less bad food.’

A common explanation for health differences between communities focuses on cultural norms. When thinking in this way, public participants assumed that communities or family units set different norms about what is healthy, and that these in turn shape individual behaviour in a way that is almost inescapable. They thought some cultural norms promoted health while others were detrimental to health.

‘There are some people in [working-class] communities that don’t work… I think there’s just a culture at the moment where a lot of people are just after free handouts. It’s unhealthy, and it’s unproductive. I think if you’re not working, you’re sitting around watching telly. You’re just hanging about doing nothing. I think that has a big impact on your health and your life expectancy.’

So while people active in the field of social determinants of health saw health inequalities as being driven by wider inequalities in power, wealth and resources, the members of the public interviewed often explained them wholly in cultural terms. This ‘cultural norms’ model of thought can obscure structural inequities and further contribute to the stigmatisation of ill health. It can lead to health inequalities being seen as resulting from a ‘bad culture’ as well as poor individual choices.

Although members of the public had some productive – and some less productive – ways of thinking about ecological influences, there was a lack of awareness among participants of how racism, discrimination and other types of power imbalances generate health inequalities. People had a sense that discrimination and stigma can be a consequence of certain types of health problems, but they tended not to think of them as a determinant of health, and struggled to understand how inequalities in power might affect health outcomes.

Communicators, therefore, need strategies for bringing a range of ecological models forward in the public’s thinking and deepening the way they think about social determinants to better reflect the full range of ways in which our environments shape our health.

Challenge 4: Generating an understanding of the policy action needed to keep people healthy

When thinking about how health can be fostered for society as a whole, the public participants focused primarily on ‘raising awareness’ and health care. These solutions flowed directly from assumptions about what health is and how it is shaped. When people thought about health as being primarily shaped by individual choice, they saw raising awareness as the obvious solution, because the only thing society can do is provide information for people to make ‘good’ choices. And when health was associated with medicine, health care was the default solution. These patterns were illustrated in one participant’s answer to a question about the role of government:

‘One part is awareness. The other part is the NHS – obviously huge. It accounts for just under a third of all government spending. So, obviously, the government is responsible for that. Anything I can’t do, the government should be responsible for. I can’t install a pacemaker. I can’t set a broken bone. I can’t stitch up a giant gash in my neck.’

By contrast, those working in the field of social determinants argued that the way to create a healthy society is through increased investment in public services that protect and improve the health of the population over the long term. In this view, while the NHS is important, the protection of the NHS budget at the expense of other health-creating services puts the long-term wellbeing of the population at risk.

Communicators advocating for broader public policy solutions to health issues, therefore, need effective ways of explaining how public investment and policy in these areas can lead to improvements in individual health.

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