14 November 2010
Recommendations and Best Messages
1) Engage the public in order to engage public health leaders, business leaders, and elected officials. Leaders are poised for action on this issue, but both top down and grassroots efforts are needed. Public health officials require funding and look to policymakers to make needed changes, and elected officials are looking for greater public support – so we must meet the public where they are on this issue.
2) Start by targeting base supporters (Democrats, women, African Americans, Latinos, and people with post-graduate degrees) and focus on turning these groups into activists using tailored messaging to excite and motivate them to action. That said, all demographic groups are supportive of community prevention, and there is virtually no group that we can't win over.
3) Coordinate efforts by advocacy groups and focus overall messaging on two themes: one based on kids, and the other linking community prevention to personal prevention and invoking urgency. Focus on kids and schools in both our messaging and policy, for which there is broad and strong support.
4) Use the Best Messages. Repeat Them Again and Again. These messages test well with the public:
- Talk about kids, and aspirations for the future. "Kids are our future, and to have a healthy future, we must help our children grow up healthy. [Insert your example or story here. One example: We need to focus on improving nutrition at schools including getting rid of the junk food, make sure healthy fresh food is available at home, and that there are clean and safe parks in every neighborhood where kids can play. It's the least we can do for our kids to grow up healthy.]"
- Link community prevention to personal prevention, which is well understood by the public. "It's important to get preventive care, like checkups, vaccinations, and mammograms—but we need to do more. We need to change the way we eat, move, and interact so that health and prevention become priorities every day and not just when we get sick. [Insert your example or story here. One example: This will help us combat diabetes, heart disease, and obesity, especially for children. These chronic diseases contribute to seven in ten deaths in the U.S. right now, and 75 percent of our current national health care costs. We owe it to ourselves to change this.]"
- Acknowledge the role of individual choices – especially with reluctant audiences. "It's time we step up to the plate and take control over our own lives, by making healthier choices. But we need government and businesses to work with us, not get in the way. [Insert your example or story here. One example: We should buy fruits and vegetables, cook instead of going through the drive-through, and play outdoors with our kids instead of watching television. We'll have more energy and fewer health problems. It is up to us to act, but we need government and businesses to give us information about nutrition, healthier choices on the menu at school and work, and safe places to exercise, so we are able to make good choices.]"
5) Remember that values and beliefs outweigh facts. To move the public, we must connect with their deeply held beliefs about prevention:
- America isn't as healthy as it should be... but America is still the best country.
- Prevention is good because it improves quality of life, and saves money in the long run.
- A person's health is mostly due to their individual choices.
- Personal prevention, like getting an annual exam, is important, and shows that someone is taking responsibility for their own health.
- We're all responsible for making sure kids have a healthy future.
6) Use specific examples of community prevention, because the public doesn't necessarily know that prevention goes beyond things like mammograms and colonoscopies. These examples test well, but you should use examples that relate to your goals:
- Ban smoking from public places
- Make school lunches healthier
- Label packaged foods so that it's clearer which ones contain unhealthy amounts of fat, sodium, or sugar
- Get a discount on one's health insurance premium if a person participates in a healthy living program
7) Tell personal stories. Everyone connects better with a story of a real person. The best stories are told in the first person, by someone who has benefitted. Don't give a long list of facts and figures. One or two well-chosen statistics can sometimes help – but less is definitely more.
8) Keep the drum beat going. Used consistently and over time, these messages will help to convince skeptics in every sector that community prevention is important. Only then will we be one step closer to building a prevention majority in this country.
About Our Research
We know that community-based prevention is important. So why is the public so often unaware of what community prevention1 does for them? And if it's so important, why does prevention funding always get cut when national, state, and local budgets get tight?
To answer these questions, a number of leaders in the prevention community2 conducted public opinion research.3 We tested messages about community prevention that all of us can use to move the public and assist public health officers, business leaders, and elected officials in getting greater support for community prevention.
It is our collective hope that all stakeholders with an investment in keeping the public healthy – from local health departments to the business community and beyond – will use these messages to move decision makers and the public toward greater support. Speaking in a unified voice and using tested messaging, we can shift opinion about prevention away from a focus on individual responsibility and towards an understanding that the community has a role in promoting health.
The following is a detailed summary of our research methods and results. You can also use our short summary that highlights the most important things we learned.
Prevention Leaders Want Action and Need Public Engagement
Public health leaders, business leaders, and elected officials (our "key informants" in interviews) are poised for action on this issue.
There is a high level of engagement and concern, which indicates a great potential for success if all parties become engaged.
- They are well informed on the urgency of the problem and the direction we need to move – especially public health and business leaders and to a lesser extent elected officials.
- They are largely focused on community prevention and tend to name similar areas for community-level interventions, specifically obesity, nutrition, exercise, smoking, and chronic disease.
- They understand prevention to include maintaining health and a healthy society, rather than just health care.
- They vary in what they know, their goals and their definitions of succes.
- Most agree that the current health care system focuses too much on clinical treatment and testing, and not enough on improving health and prevention services.
- All agree that as a nation we need to do much better.
Despite this consensus, prevention leaders across and within sectors lack a coherent shared narrative on prevention
The goals they described included being happier, having a higher quality of life, improving the economy, and reducing health care costs. While these are all worthy goals, they do not tell a shared compelling story about where we are and where we are going.
Part of the missing narrative is the invisibility of previous successes. Most informants can point to prevention success stories including immunization, cleaner air, and smoking reduction. But they see the public taking these for granted and have no shared language linking those improvements to the changes needed now.
These experts agree that real change on prevention must come from the top down and also the bottom up – but there isn't a consensus on who's in charge.
Informants see a need for both top-down and bottom-up approaches for community-level interventions, including national and local policy changes, changing the health system with a paradigm shift, and instigating a social movement.
- A strategic challenge is the question of "who's in charge?" While all these informants are active within their own sphere, they are also waiting for someone else to lead or coordinate something bigger.
- Public health officials require funding and look to policymakers to make needed changes.
- Business leaders want government to facilitate and coordinate efforts, but are also ambivalent about the government's role in regulation, taxes, and mandates.
- Elected officials are looking for greater public support and to media figures to help influence the public.
Informants agree that partnerships are key, and that policymakers, business leaders, and community leaders need to and can work together.
- However, no one group is claiming responsibility to lead these partnerships.
- While some partnership organizations exist, there is a lack of national coordination on efforts and sharing best practices. All would welcome, to various extents, a national effort to coordinate and share best practices across the piecemeal efforts currently being pursued.
Money is a critical factor in taking effective action.
All groups want more resources devoted to community-level interventions, but few have specific ideas on where to get these resources, especially given the current crisis in public budgets.
In this economic environment, the cost savings of prevention are an important part of the narrative. Those who have been successful in achieving and implementing prevention efforts have found ways to directly tie these initiatives to cost savings and job creation and competitiveness.
The tension between individual responsibility and social determinants of health is a challenge moving forward.
While all respondents acknowledge that both are important, greater emphasis by some elected officials and business leaders on individual responsibility leads to different conclusions about the most effective interventions and the role of government in implementing changes.
None of this will work without public engagement and support.
All informants agree on the need to engage the public, learn more about how to motivate them, and understand what it will take for them to participate in and support community prevention with their dollars, votes, and behavior.
The First Lady's child obesity initiative is a visible example of what is and isn't working. While almost all informants mentioned
Both mass media and social media have a role to play. Several informants highlighted the role of media – including news, advertisements, celebrities and
A public relations campaign is not enough. Our work moving forward should not only focus on "prevention messages," but also emphasize a new national narrative that resonates with people's values, hopes and fears. It should engage the public in a fundamental paradigm shift that places a greater national emphasis on community-level prevention.
The Public Is Receptive and Needs to Hear a Shared Message
The American public strongly supports prevention and believes it should be a much higher priority for the country than it is. Americans believe the U.S. is doing poorly on health and prevention, with most giving our health a letter grade of C or D:
Thinking about the people of the United States, if you had to give us a grade, how healthy would you say we are?
The public overwhelmingly supports allocating resources towards community prevention initiatives, described as efforts to make it easier for people to maintain their health and make healthier choices (73% support, 20% oppose). The public believes these initiatives should be a much higher priority than they currently are (see Figure B). Support and intensity are lower when people are asked if they would support these initiatives even if it meant higher taxes, but a solid majority is still in favor with this tougher language (61% support, 34% oppose).
Support for investment in community prevention remains firm and solid after more information and messages for and against it are presented.
The strongest supporters are women, African Americans, and strong Democrats, but other audiences are also generally receptive: African American women (77% strongly support), strong Democrats (66%), African Americans (65%), West women (62%), Latinos (60%), unmarried people with children (60%), post-graduates (59%), Democratic women (59%), and Northeast women (57%). However, there is virtually no group we cannot win over. Somewhat more skeptical groups include Republicans (especially strong Republicans), older men, older non-college adults, independent women, and those who live in the West North Central and West South Central regions—though all support community prevention by a majority, and all groups are reachable on this issue.
While Americans are divided on the dimension of responsibility for health and prevention, the public moves significantly toward the community view of responsibility as a result of information and messages. Moving people on this dimension should be a key goal of public campaigns on this issue. A plurality agree with a statement that we are all in this together and communities can help make healthy choices easier (46%), while about one third (34%) choose an opposing statement that staying healthy is up to individuals. The divide between community (44%) and personal responsibility (36%) is closer when taxes are mentioned. At the end of the survey, 55% agree with community responsibility (47% if taxes are mentioned), and only 22% stick to individual responsibility (32% with taxes). The people who move most towards a community view of responsibility include Northeast women (32%), Northeast whites (30%), non-college educated older women (28%), weak Republicans (27%), and West men (26%).
Americans rate various specific community prevention initiatives, ranging from banning smoking to improving access to fresh fruits and vegetables, extremely high. It is clear there is broad support for specific initiatives, especially those that
Our strategy called "Healthy Schools, Healthy Kids," which draws some of these actions together, strongly stands out as the most popular among both base and persuasion audiences. This indicates that going through schools to reach kids is the most popular approach for addressing community prevention:
"Too many schools have become unhealthy, offering snacks and soda from vending machines as well as unhealthy school lunches to kids. We should limit junk food in schools and make the school lunch menu more nutritious. We should also have physical education classes every day, not cut them, so kids can be active, which helps them be healthier and learn better."
The second most popular strategy is called "Two for One," and acknowledges the tough economy and suggests fiscal efficiency in implementing community prevention initiatives:
"In these tough times, we have to do more with less, and find ways to promote prevention while we do other things. Where possible, every school should have a community garden. We should use our school facilities after work for exercise programs. When we repair parks and streets, let's build playgrounds and bike paths where it makes sense. For minimal cost and effort we can get multiple benefits."
The public also says they are more likely to vote for elected officials if they support these ventures. 66% said they are more likely and only 11% said less likely. Elected officials have little to lose, and much to gain, by advocating for these initiatives.
The Most Powerful Messages Are About Kids, Connect with Beliefs, and Invoke Urgency
The "kids" narrative is the most powerful way to reach both influential voters and the public:
"Kids are our future, and to have a healthy future, we must help our children grow up healthy. We need to focus on improving nutrition at schools including getting rid of the junk food, make sure healthy fresh food is available at home, and that there are clean and safe parks in every neighborhood where kids can play. It's the least we can do for our kids to grow up healthy."
A narrative based on the First Lady's message on childhood obesity that moves smoothly from personal prevention to community prevention, invokes urgency and utilizes facts about Americans' poor health status, also tested very well, even without specific mention of her name. From our focus group research we know that people respond to a few well-chosen statistics. Also significant is that this message connects prevention to health care, tying it to the system we have in place now (and the recent reform legislation):
"It's important to get preventive care, like checkups, vaccinations, and mammograms—but we need to do more. We need to change the way we eat, move, and interact so that health and prevention become priorities every day and not just when we get sick. This will help us combat diabetes, heart disease, and obesity, especially for children. These chronic diseases contribute to seven in ten deaths in the U.S. right now, and 75 percent of our current national health care costs. We owe it to ourselves to change this."
Another powerful message gave the example of Oklahoma City's successful community prevention efforts. This message tested especially well among base supporters:
"Community prevention can make a real difference—like it has in Oklahoma City. People there were among the most obese in the nation, and it was impacting their local economy since employers don't want an unhealthy workforce that misses too many days of work and costs too much. They invested in prevention by making the city more pedestrian friendly, getting local businesses involved, and encouraging residents to exercise more. Oklahoma City lost half a million pounds and attracted new employers. So now they are not only healthier, but their economy is stronger too."
A message that focused on individual responsibility and extended this theme into an argument on why we need broad action including involvement from government and businesses also tested well. This message does particularly well among tougher audiences like Republicans and men, and will be helpful in reaching beyond the base.
"It's time we step up to the plate and take control over our own lives. By making healthier choices like buying fruits and vegetables, cooking instead of going through the drive-through, and playing outdoors with our kids instead of watching television, we will have more energy and fewer health problems. It is up to us to act, but we need government and businesses to work with us, not get in the way. We need information about nutrition, healthier choices on the menu at school and work, and safe places to exercise, so we are able to make good choices."
1Our research shows that the public prefers the term "community prevention" to "community-level prevention" or "community-level intervention."
2Our work group included the AARP, the American Cancer Society, the American Public Health Association, APCO Worldwide, the California Endowment, Emory University, First Focus, the Joint Center for Political and Economic Studies, Mental Health America, the National Association of City and County Health Officials, the National Association of Latino Elected Officials, the National Academy for State Health Policy, Partnership for Prevention, SEIU, and Trust for America's Health.
3Lake Research Partners (LRP) carried out the research from January – September, 2010, with ongoing input from the prevention leaders' work group. They began with 20 in-depth interviews with public health leaders, business leaders, and elected officials nationwide to learn more about the opportunities and barriers that leaders face in trying to accomplish community prevention goals; these leaders were recruited through various contacts known by the members of our work group. LRP then conducted 7 focus groups with randomly selected, influential members of the general public in Los Angeles, Chicago, and Kansas City. As part of their recruitment these participants indicated that they had a leadership role in their communities, such as being small business owners, teachers, volunteers, etc. Finally, LRP carried out a nationwide Web-based poll with 900 randomly selected members of the general public (including a 200-person Latino oversample). The following pages highlight the most important findings of each of these phases of research in turn.