摘要：Framing health problems in terms of the social determinants of health aims to shift policy attention to nonmedical strategies to improve population health, yet little is known about how the public responds to these messages. We conducted an experiment to test the effect of a news article describing the social determinants of type 2 diabetes on the public's support for diabetes prevention strategies. We found that exposure to the social determinants message led to a divergence between Republicans' and Democrats' opinions, relative to their opinions after viewing an article with no message about the causes of diabetes. These results signify that increasing public awareness of the social determinants of health may not uniformly increase public support for policy action. Public health advocates have been increasingly promoting the importance of the social determinants of health—the nonmedical, social, economic, political, or environmental factors that influence the distribution of health and illness in the population. Some experts argue that strategically framing health problems in terms of their social determinants could help to turn the public's and policymakers' attention to policies that might effectively improve population health and ameliorate health disparities. 1 – 3 For instance, the World Health Organization Commission on the Social Determinants of Health recently recommended that governments actively incorporate social determinants into their political agendas, making investments in raising public awareness about the impact of social determinants on population health. 4 In the United States, experts suggest that advocates use the media strategically to educate the public and policymakers about determinants of health other than medical care and health behaviors. 5 – 7 The implicit assumption of these efforts is that public and political attention to the social determinants of health will lead to increased support for policy interventions to improve public health. However, the claim behind this call to action has received little empirical scrutiny. 8 Substantial theoretical and empirical evidence supports the conventional wisdom that when the public believes that a health problem results from external factors (i.e., from social or environmental determinants) instead of from individuals' own behaviors or shortcomings, they will be more likely to support social or governmental attempts to address the problem. 9 – 13 Yet, political science research suggests 2 reasons to challenge this assumption. First, if policymakers and the media emphasize a connection between low socioeconomic status and illness, they will draw attention to a particular social group: those living in poverty. Research indicates that attitudes about social groups are powerful influences on public opinion toward health and social policy. When particular populations are highlighted in the media, people draw upon their attitudes and even prejudices toward these populations when making judgments about policies relevant to the problem at hand. 14 , 15 Second, empirical research demonstrates that Americans systematically differ in their underlying beliefs about the major causes of poverty, with Republicans less likely to acknowledge the role of social structural factors in influencing socioeconomic status than Democrats and believing more strongly in personal responsibility for social status. 16 , 17 As a result, political partisans may respond differently to messages about the social determinants of health because of their differing underlying attitudes about those in poverty and the role of personal responsibility. Previous research has demonstrated associations between the public's perceptions of the causes of illness and their policy opinions. For instance, Oliver and Lee 11 and Barry et al. 18 showed that Americans who believed that obesity is caused by an obesity-promoting environment were more likely to support public health policies that target obesity's environmental determinants (such as regulating school concessions or food advertising). Reutter et al. 19 found that Canadians who believed in structural explanations for health inequalities were more supportive of social policies to address poverty than were those who endorsed behavioral or medical explanations. However, each of these studies, by relying on cross-sectional survey evidence, can only demonstrate correlations, not causation. No previous research to our knowledge has investigated the causal impact of messages about the determinants of health on public attitudes toward specific policies. Yet, given the increasing attention to the health policy implications of social determinants, systematic empirical assessment of this relationship is warranted. We designed an Internet-based experimental study to assess the impact of news media messages about the social determinants of health on public health policy opinions. For this study, we chose type 2 diabetes as an exemplar of the social determinants of health. Type 2 diabetes is the sixth-leading cause of mortality in the United States, and racial, ethnic, and class-related disparities abound in its incidence and prevalence. Although type 2 diabetes is commonly associated with health behaviors (in particular, poor diet, lack of physical activity, and concomitant obesity), these risk factors occur within a context of social and economic influences, including neighborhood environments (e.g., food marketing, price of fruits and vegetables, school concessions) that facilitate unhealthy diets and social stressors that can directly affect insulin resistance. 20 , 21 In addition, scientists have recently identified and replicated numerous genetic variants that increase susceptibility to type 2 diabetes. 22 When selecting a particular cause of diabetes to feature in a news article, that is, when “framing” the causes of diabetes for the public, journalists might choose from among a genetic predisposition frame, a behavioral choices or lifestyles frame, a social determinants frame, or some combination. 23 – 25 This selection of a causal frame could affect public support for particular strategies to address diabetes (i.e., regulating food marketing or intervening in schools), because public perceptions of the causes of diabetes would affect what level and type of intervention they view as most effective or appropriate. 26 The goal of our study therefore was to assess the impact of news media framing of the determinants of health—using type 2 diabetes as the example—on public health policy opinions by comparing a social determinants explanation with one that identified genetic predisposition, behavioral choices, or provided no causal explanation. By randomly distributing which hypothetical news article a study participant viewed online, we were able to identify the impact of these causal explanations on participants' beliefs about the social determinants of diabetes as well as their opinions about policies to prevent diabetes. Given potential differences in predisposing attitudes about the social determinants of health between political partisans, we also assessed whether the impact of the news messages depended on the political orientation of the viewer.
