Each month, MATCH Project staff review a wide variety of academic journals to identify recent articles having particular relevance to population health policy, research, and practice. University of Wisconsin Robert Wood Johnson Health and Society scholars and faculty recommend one or two articles to feature on the blog. The complete set of articles is archived here.
News Media Messages and Public Perceptions of the Social Determinants of Health
We connected with Sarah Gollust, PhD, to learn more about her recent research exploring the relationship between media message framing and public perceptions on the issue of type 2 diabetes. Dr. Gollust received her graduate training in health services organization and policy at the University of Michigan and is currently a Robert Wood Johnson Health and Society Scholar at the University of Pennsylvania.
Improving Population Health (IPH): What prompted you to do this research?
SG: I was motivated after taking many courses in graduate school at the University of Michigan in which I learned about health inequalities and the social factors—such as the neighborhoods we live in, our income and education—that influence population health. In every class, I found myself wondering what the general public would have to say about these matters if they knew more about them. Would they be surprised? Upset? Would they be motivated to do more to support public health policy?
I discovered that there was little research in the U.S. on public attitudes and beliefs about health inequalities or how the news media present these issues for the public. So I decided to conduct a study about how U.S. newspapers describe type 2 diabetes and the effects of communicating about the social determinants of diabetes on Americans’ opinions about public health policy. I chose to examine type 2 diabetes for two reasons: it is a leading cause of death in the United States, so developing policies to prevent the disease is critical; and its causes can be portrayed in multiple ways, including strong epidemiological evidence of the influence of social determinants.
IPH: What were your main findings?
SG: In the study, members of the public were randomly assigned to read online versions of hypothetical news articles about type 2 diabetes that differed only in how they described the causes of diabetes. One version stated that behavioral choices influence diabetes, one stated that genetic predispositions influence diabetes, one stated that societal factors like impoverished neighborhoods and access to food influence diabetes, and another used no language about the cause of diabetes.
We observed that Republicans and Democrats responded very differently when they read the same information about the social factors that influence diabetes. Compared to their policy opinions after reading the article without any language about the cause of diabetes, Republicans expressed less support for public health policies to prevent diabetes and Democrats expressed more support for these policies when they read the social determinants article. This “polarization” finding signaled to us that everyone has different values and beliefs about who is responsible for improving health, and that certain ways of discussing these issues will resonate more or less with people’s prior values.
IPH: Did you encounter any unexpected obstacles?
SG: The research itself went quite smoothly, but in discussing the results I’ve discovered that talking about politics can be very tricky. It is all too easy to lapse into using caricatures and stereotypes to portray the two sides of the political spectrum. Even a topic as seemingly politically neutral as diabetes touches deeply felt values and political beliefs, which is important to recognize.
Since I published this work during the extremely politically polarized Congressional debates over health care reform, it received more press coverage than it might otherwise have gotten, but I wanted to be especially cautious to not over-extend the lessons we can learn from this study to the politics of health policy in general.
IPH: What are the implications of this work either for further research or for practice?
SG: With that caution in mind, I do think this work offers implications for future research and practice. First, the study provides an illustration of a phenomenon well-documented in the fields of communication and political psychology, but that has not been a central concern in public health—the idea that political values strongly influence how people process and respond, both cognitively and emotionally, to messages in the media. In particular, this study, along with my other work, demonstrates the important role of beliefs about personal and social responsibility for health in shaping Americans’ opinions about health policy.
Second, advocates, researchers, journalists, and policymakers who want to publicize the social determinants of health and not face resistance from subgroups of the population might consider acknowledging both the roles of individuals (i.e., healthy behavioral choices) and the roles of societal forces that constrain people’s choices. However, these communication strategies should be empirically tested and grounded in theory.
Third, and related to this last point, more research is needed to investigate how the public responds to alternative ways of presenting and framing the social determinants of health and health inequalities, with particular attention to the influence of social and political values.
Showing Calories on Menus Could Make a Difference
Christina Roberto and her colleagues at the Yale University Rudd Center for Food Policy and Obesity have been engaged in both research and advocacy around restaurant menu labeling. In this post, Ms. Roberto highlights her recent article explaining the rationale and evidence for menu labeling legislation and discusses the new health reform law's national menu labeling requirement.
Restaurant menu labeling is a public health intervention aimed at improving poor diet and decreasing obesity. It requires chain restaurants to provide nutrition information (usually only calories, but some places also require information about saturated fat, sodium, etc.) on menus and menu boards so that the information is visible at the point-of-purchase. Restaurants with 20 or more locations are required to provide this information as part of the 2010 Health Care Reform bill.
Menu labeling makes sense. It provides people with information that allows them to make informed decisions about their eating. In the past, people ate at restaurants infrequently, so the occasional splurge was okay. Given how frequently people eat out today, however, the need for nutrition information about restaurant food has become more important. When we eat out, we tend to eat food that is higher in calories, of poorer nutritional quality, and served in larger portions, which promotes overeating.
How effective is menu labeling? Findings have been mixed but promising. One study conducted by researchers at New York University examined the impact of calorie labels among low-income individuals and did not see much of an effect. However, a larger study conducted by the New York City Department of Health observed reductions in calories purchased at several chain restaurants. These two studies looked at different restaurants and groups of people over varying time frames, which might explain the disparate results. Another recent study found that the calorie content of purchases at Starbucks was reduced in cities with menu labels versus those without.
A recent study we published in the American Journal of Public Health involved people we recruited from the New Haven community and randomly assigned to receive one of three menus. Some participants received a menu with calorie labels on it, some received a menu without calorie labels, and the last group received a menu with calorie labels and a label that read: “The average daily caloric intake for an adult is 2000 calories.” Participants then ordered and ate a meal for dinner. We found that people ordered and ate fewer calories when given calorie information, suggesting that providing such information can encourage healthier food choices. In addition, this effect was maximized when people were given a menu which included a statement about recommended daily calorie intake. While our study was lab-based, unlike the other studies described, we actually measured calories consumed and were able to demonstrate a cause and effect relationship between menu labels and reduced food intake.
The menu labeling provision in the healthcare reform law is quite strong. It requires calorie labeling on chain restaurant menus and menu boards as well as on drive-through menus and vending machines. There is also a requirement that a brief statement regarding daily caloric intake be included. In addition, restaurants must provide more comprehensive nutrition information in a brochure upon request. While the restaurant industry initially opposed menu labeling (it sued New York City twice, both times unsuccessfully), the National Restaurant Association supports national standards for menu labeling for a number of reasons.
Chain restaurants that operate in many different cities and states do not want to pay the cost of compliance with different regulations for each jurisdiction. Since this law will preempt local governments from creating their own standards, it will create certainty and uniformity that is helpful to the industry. In addition, the law allows for the error that accompanies routine differences in portion sizes and menu items by requiring restaurants to provide caloric information about restaurant items that is accurate within a reasonable range. Labeling also only applies to standard menu items and does not pertain to special dishes. Given those conditions, we can hope that any remaining backlash will not affect the upcoming Federal Drug Administration rulemaking process.
Christina Roberto, MS, is a doctoral student at Yale Univerity pursuing a joint degree in Clinical Psychology and Public Health.