key: cord-1032577-12ia0h31
authors: Willen, Sarah S.; Walsh, Colleen C.; Williamson, Abigail Fisher
title: Visualizing Health Equity: Qualitative Perspectives on the Value and Limits of Equity Images
date: 2021-03-19
journal: Health Educ Behav
DOI: 10.1177/1090198121994520
sha: 678fcbb8576ec47db0a8f1757fce4dc578fc5d35
doc_id: 1032577
cord_uid: 12ia0h31

BACKGROUND: Health educators and advocacy groups often use side-by-side visual images to communicate about equity and to distinguish it from equality. Despite the near-ubiquity of these images, little is known about how they are understood by different audiences. AIMS: To assess the effectiveness of an image commonly used to communicate about health equity. METHOD: In 167 interviews with health stakeholders in Greater Cleveland, Ohio, in 2018 to 2019, a commonly used health equity image was shown to participants, who were asked to interpret its meaning. Interviewees included 21 health professionals, 21 clinicians, 22 metro-wide decision makers, 24 community leaders, and 79 community members. RESULTS: About two thirds of our socioeconomically, racial/ethnically, educationally, and professionally diverse sample said the equity image helped clarify the distinction between “equality” and “equity.” Yet less than one third offered an interpretation consistent with the image’s goals of foregrounding not only injustice but also a need for systemic change. Patterns of misinterpretation were especially common among two groups: ideological conservatives and those of lower socioeconomic status. Conservatives were most likely to object to the image’s message. CONCLUSIONS: Equity images are widely used by public health educators and advocates, yet they do not consistently communicate the message that achieving equity requires systemic change. In this moment of both public health crisis and urgent concern about systemic racism, new visual tools for communicating this crucial message are needed.

As the entwined crises of COVID-19 and systemic racism pull the United States toward what may become a genuine moment of reckoning, both population health and health communication strategies are very much in the public eye. Americans around the country, and across the political spectrum, are learning that Black, Latinx, and indigenous people face significantly greater risk of exposure, infection, and death from COVID-19 than their White counterparts (Bowleg, 2020; Devakumar et al., 2020; Gee et al., 2020; Hardeman et al., 2020) . From a public health communications standpoint, this is an opportune moment to take stock of the tools we use to communicate about the causes of health inequities in the United States (Bailey et al., 2017; Geronimus et al., 2006; Hicken et al., 2018; Williams et al., 2019) and the larger goal of achieving health equity.

Specifically, the public health community must ask, Are our current tools for communicating about health equity and inequity-including terms and concepts as well as metaphors, parables, and images (Dorfman et al., 2005; Griffith et al., 2017; C. Jones, 2016; C. P. Jones, 2000; Krieger et al., 2012 )-sufficiently clear and effective? Are they useful in communicating with the general public, or might their power be limited to people of certain political orientations, or to stakeholders in public health and adjacent fields?

In this article, we analyze the effectiveness of one commonly used tool: an image designed to convey the distinction between equality and equity ( Figure 1 ). This image, and others like it, have been used by educators and advocacy groups for nearly a decade to communicate two interlinked messages: First, when people have dramatically different levels of need, simply distributing resources equally will not produce just outcomes. Second, achieving justice and equity requires systemic change. Although equity images are widely employed to convey these paired messages, little is known about how they are understood by various audiences.

We asked 167 individuals of diverse backgrounds and ideologies to respond to the apple tree image shown in Figure 1 as part of a two-phase interdisciplinary research study. We used the image (slightly adapted, as described below) with permission from the Saskatoon Health Region, which developed it in 2014. The image reenvisions a more commonly used baseball image, designed in 2012 by Craig Froehle (2016) . The original image shows three spectators of different heights trying to see over a wooden fence into a baseball stadium. The scenario on the left represents equality. The figures depicted receive the same level of "support"-a single box to stand on-but only two can see over the fence. The right represents an equitable scenario: Each spectator has enough boxes to see the game.

Since its creation, Froehle's original image has been critiqued and redesigned in myriad ways (Cultural Organizing, n.d.; Sippin the EquiTEA, 2018). One variation depicts a racetrack with staggered starting points, and another shows figures of different sizes and abilities riding bicycles adapted to their needs (Robert Wood Johnson Foundation, n.d.) . Another variation, riffing on children's author Shel Silverstein's (1964) The Giving Tree, includes four panels depicting inequality, equality, equity, and-using a system of pulleys and supports to reengineer the tree itself-a desired goal of justice (Ruth, cited in Maeda, 2019; cf. critique by Leong, 2020) . In addition, a revamped version of Froehle's original image became the basis for "#the4thbox," a website, tool kit, and online digital game in which three images labeled "equality," "equity," and "liberation" are paired with a fourth, empty box whose content participants are invited to envision for themselves (Cultural Organizing, n.d.) . In short, images of this sort have come to play an outsized role in conversations about equality and equity, yet we do not know how they are understood by different groups of stakeholders.

We used the apple tree image for this study because it addresses several key critiques of the original baseball image. Whereas Froehle's image depicts three White males, race/ethnicity, and gender in this image are unmarked. Also, some contend that baseball lacks universal appeal, contra ripe fruit. Last, since participants were less likely to have seen the apple tree image, we expected it was more likely to elicit substantive reactions.

Although this image is composed of simple visual elements, the narrative it encodes demands a fair amount of abstract thinking. As we understand it, the image conveys not a single story, but two stories in parallel, bridged by a third, synthesizing narrative that unfolds in four steps:

1. Even if resources (the boxes) are apportioned equally, individuals still have different levels of need and, consequently, different levels of opportunity. 2. The existence of unequal opportunities is unfair or unjust. 3. Justice-or equity-requires the distribution of resources according to need. 4. Achieving equity, and thereby justice, will require change in how the system itself is organized.

The first three messages are clearly encoded in the image, while the fourth-which is arguably the most important from a policy or action-oriented standpoint-is implied but not spelled out explicitly. We were especially interested in knowing whether interviewees' understandings of the image would match these communication goals-and if not, where interpretations diverge. This intended interpretation of the image aligns with prevailing understandings of health equity, itself a "forceful term tending to imply a strong judgment about causality" (Braveman et al., 2011) , as well as the public health field's deep-rooted commitment to social justice (Beauchamp, 1976; Krieger & Birn, 1998) . From an equity standpoint, everyone deserves "a fair and just opportunity to be as healthy as possible" (Braveman et al., 2017, p. 2;  cf. Office of Minority Health & Health Equity, Centers for Disease Control and Prevention, 2020). Unlike descriptive terms such as health disparities, terms such as equity and inequity highlight population-level differences that are, as Whitehead (1992) famously put it, "avoidable, unnecessary, and unjust" (p. 431). Importantly, the language of equity and inequity calls for "special attention to the needs of those at greatest risk of poor health, based on social conditions" (Braveman, 2014, p. 6) . In essence, the logic of health equity is fundamentally about addressing injustice through systemic change.

Do equity images succeed in conveying this message? We assessed the degree to which different groups of health stakeholders recognized and responded to this image, including whether any groups might struggle to understand it, resist its intended meaning, and/or present alternative ways of communicating about equity that merit attention. To anticipate our findings: the image is largely successful in conveying a sense of injustice, but does not prompt discussion of systems change, in part because it "frames" (Dorfman et al., 2005; Entman, 1993; Knight et al., 2016; Viladrich, 2019 ) equity as an individual-level concern as opposed to a systemic or structural issue.

In 2018 to 2019, we conducted ethnographic participantobservation and semistructured interviews with 170 residents of diverse backgrounds and ideologies in Greater Cleveland, Ohio, as part of a larger study of individual perspectives on "heath-related deservingness" (Willen, 2012; Willen & Cook 2016; cf. Viladrich, 2019 cf. Viladrich, , p. 1449 . In most interviews (n = 167), following a discussion about understandings of the term health equity, participants were shown the apple tree image in Figure 1 on a double-sided, laminated page. On the first side, interviewees saw the image without "equality" and "equity" labeled. They were asked to explain the image in their own words and to describe whether they identified with any of the figures depicted. We then displayed the labeled image and asked whether interviewees found it useful in communicating the distinction between these terms.

The sample included public health professionals (n = 21), clinicians (n = 21), metro-wide decision makers (n = 22), community leaders (n = 24), and community members (n = 79). The study was conducted in partnership with a local health and equity initiative in which some interviewees, but few community members, participated (n = 53). As Table 1 illustrates, the community member subsample reflects the demographics of the county in which the study was conducted. Interviewees were recruited through community partners, snowball sampling, and outreach in community venues. Interviews lasted approximately 1½ hours, and participants completed a postinterview demographic survey. The interview guide was developed in consultation with a diverse advisory board of researchers, health professionals, and community advocates.

Interviews were audio-recorded and transcribed for analysis using Dedoose, an online mixed-methods data analysis platform (Version 8.0.35). Analysis proceeded in four stages:

(1) writing of analytic memos for each interview; (2) index coding to divide transcripts into salient sections for deeper analysis (Deterding & Waters, 2018) ; (3) inductive review and iterative generation of an analytic codebook by a team of coders; (4) preliminary coding followed by discussions to achieve consensus around code definitions and resolve coding discrepancies; and (5) completion of coding of relevant interview segments. Since codes are not mutually exclusive, multiple thematic codes could be applied to participant responses.

Drawing on postinterview demographic survey responses, we analyzed patterns of response by socioeconomic status, race/ethnicity, gender, political ideology, interview type (public health professional, clinician, decision maker, community leader, community member), and participation in the health equity initiative. The findings below highlight patterns from two-sided tests of proportions and multivariate probit analyses that control for the above characteristics (p values reported parenthetically). Two-sided tests compare a given subgroup to the sample as a whole (full analyses are available in the Supplemental Appendix).

The 167 interviews we conducted in Greater Cleveland suggest that familiarity with equity images is relatively common, especially-but not only-among individuals in health professions. Many participants reported that the image helped clarify the distinction between equality and equity. Participants also tended to see the scenario depicted as unjust but, importantly, they did not consistently interpret it as a call for systems change. Rather, many interpreted the image as calling for localized or individual, as opposed to systemic, solutions. Others actively pushed back against its message for ideological, pedagogical, or strategic reasons. Interpretations of the image varied systematically by socioeconomic status, political ideology, and participant type, but not by race/ethnicity or gender.

Three quarters of participants were asked directly whether they had seen this image or another like it. Of this group, 61% (76/125) responded affirmatively. Of course, our sample includes some people who are likely to encounter equity images in professional contexts, including both public health professionals and participants in a health equity initiative. Eighteen of the 21 public health professionals (86%) had previously seen either this specific image or another like it. Of public health professionals uninvolved in the health equity initiative, fewer had seen an equity image (70%; 7/10). Only two thirds of community members were asked directly whether they had seen such an image, but among those asked, 40% (20/50) reported that they had, and none were participants in the health equity initiative. In short, public health professionals were especially familiar with equity images (test of proportions: p = .01; multivariate [five-category interview type]: p = .07), but some members of the public were familiar with them as well.

As a first level of analysis, we sought to establish whether images like this one are useful in clarifying the distinction between equality and equity. Of the 86% of participants asked this question (144/167), nearly two thirds (64%; 92/144) said it did, while only 8% (12/144) said it did not. Others were unsure or offered an inconclusive response (28%; 40/144).

Some participants described the images as illuminating, or even indispensable to their own understanding of society. One White public health professional said, "I don't think that I could ever articulate equality and equity until I saw these images," and another reported that "this is a very powerful way to express the difference between the two." Responses like these were common among professionals, with nearly three quarters of public health professionals, clinicians, and community leaders finding the image clarifying, along with just over two thirds of metro-wide decision makers.

For others, especially those with less education or a conservative political ideology, the image was less successful in conveying this distinction, though differences between groups fell below conventional levels of statistical significance. Among those with less than a bachelor's degree, only 55% found it clarifying (18/33; test of proportions: p = .21; multivariate: p = .09). For instance, a Black community member with some college education said the image was "not really" clarifying because, "I don't really hear about equality or equity too much . . . on an everyday basis." Notably, less than half of conservatives said the image clarified the distinction (46%; 11/24; test of proportions: p = .07; multivariate: p = .35).

In addition to distinguishing between these terms, equity images intend to convey two other messages as well: (1) that an equal distribution of resources will fail to achieve equity when people have dramatically different levels of need and (2) that justice cannot be served simply by divvying up resources equally-rather, it requires systemic change. In our interviews, most participants picked up on the first of these messages, interpreting the image as conveying an unjust arrangement. Relatively few, however, perceived a need for systemic change. Alternative solutions proposed included individual effort or hard work, sharing or cooperation, or direct help to those in need.

Seeing Injustice. As Figure 2 illustrates, 74% of participants (123/167) expressed a sense of moral discomfort with the injustice they perceived in the image. Such qualms were exceedingly common among public health professionals (95%; 20/21; test of proportions: p = .02; multivariate [fivecategory interview type]: p = .08), but less common among community members (61%; 48/79; test of proportions: p = .00; multivariate [five-category interview type]: p = .08). Notably, they were least commonly expressed by people who identified as conservative (27%; 8/30; test of proportions: p = .00; multivariate: p = .00).

Changing Systems as the Solution. While recognizing injustice was a relatively common response, fewer than a third of participants (31%; 51/167) saw the image as calling for systematic redistribution or systems change (Figure 3 ). Among those who perceived this message, one Black community leader said that "the most equitable way" would look quite different: "not that people have to reach up, but that all of these apples have fallen off the tree. They're on the ground, and they can be picked up by anybody." Similarly, a White public health professional with a graduate degree described the need for structural change in terms of "building up the boxes or just pulling the branches down." She continued "if there's a reason that we need boxes, then can we fix the reasons so that we don't need boxes?" Public health professionals (43%; 9/21) and metro-wide decision makers (50%; 11/22) were most likely to offer interpretations like these, which were offered much less frequently by clinicians (19%; 4/21) and community members (22%; 17/79), although only decision makers' and community members' responses were statistically distinct (decision makers test of proportions: p = .03; community members test of proportions: p = .02; multivariate [five-category interview type]: p = .69). In contrast, those without ready access to a vocabulary of systems change were especially unlikely to raise these themes. For instance, only 18% of interviewees without a bachelor's degree did so (7/40; test of proportions: p = .04; multivariate: p = .17).

Other Proposed Solutions. Many interviewees pointed to solutions at the individual or communal level that fall far short of full-on systemic change, including (1) individual effort or hard work; (2) sharing, cooperation, or solidarity; or (3) direct help to individuals in need.

In all, 13% of interviewees (22/167) mentioned individual effort or hard work-a theme raised with particular frequency by conservatives (40%; 12/30; test of proportions: p = .00; multivariate: p = .02). One college-educated White conservative interviewee, for example, appreciated that the figures were reaching for the fruit. He supported "giving people a foot up, but . . . not handing it to them." "If this was a picture where it was being handed to them," he explained, "that would be wrong." Notably, more than one quarter of interviewees earning less than $30,000/year mentioned this theme (27%; 7/26; test of proportions: p = .04; multivariate: p = .09).

A slightly smaller proportion of participants (11%; 19/167) pointed to cooperation, sharing of resources, or solidarity as distinct from broader systems-level change. This interpretation was offered more often by low-income participants, including almost a quarter of those earning less than $30,000/ year (23%; 6/26; test of proportions: p = .04; multivariate: p = .04), as compared with just 4% (3/73) of those making more than $100,000/year.

Last, for 20% of participants (34/167), the image suggested a need for direct help to those in need, whether family members, people in one's social networks, or people in general. Conservatives were most likely to offer this response (33%; 10/30; test of proportions: p = .04; multivariate: p = .07). One college-educated White man, for instance, responded, "See, that's what I do for my friends. . . . that's what I do with my whole life. I find somebody who can't reach and I put a step stool under their feet, but they have to reach. You don't reach for them."

Nearly a quarter of participants (21%; 35/167) resisted the image's message or design in some way-albeit for divergent reasons. Of this group, more than two-thirds (69%; 24/35) expressed personal reservations about either the moral or the political implications of the image-including over a third of conservatives (40%, 12/30; test of proportions: p = .01; multivariate: p = .27), as compared to just 8% of liberals (6/79). A smaller number pushed back against the image for a different reason; they suggested the image has limited value as a communications or educational tool. Ten (6%) saw it as oversimplifying, and another five (3%) noted that others had resisted, or would be likely to resist, the image's message or design.

Expressions of resistance from conservatives merit particular attention, since they raise larger questions about the relative strengths and limitations of equity images. One form of pushback hinged on ideas of both dependence and zerosum logic. A college-educated, conservative White community member described the image as "extremely biased," stating that This taller person with only one box doesn't deserve to be punished because the shorter person needs more boxes. . . . Okay shorter person, . . . I'll help you get this box. . . . I'm not gonna give him two more boxes to get to the apple. . . . What can I do to help you build the box? I'll get you some wood, let's build the box. . . . I don't believe in just "oh, let's give you three boxes." . . . They need to figure out how to get to the box.

A very different form of resistance came from another corner: from those who felt the image tells the wrong storyspecifically, that it focuses on inequities between individuals as opposed to deeper inequities in infrastructure. For example, an African American public health professional with a graduate degree explained that No one should have to have a box to stand on to reach an apple . . . they [should] all start off with the same foundation, and the same ability to grow. . . . If you put . . . two plants in the same soil, you know, same amount of water, same sunlight, then you would never have to boost one up. They're just going to naturally grow.

A college-educated decision maker of mixed ethnicity made a similar argument, albeit in spicier language:

Rather than saying "equality versus equity"-where's liberation? Like, why does the tree even have to be that tall to begin with? We should . . . GMO the [expletive] out of trees until they are short enough so that everyone can reach them! How's that?

In short, some conservatives interpreted the "equity" side of the image as an unwarranted allocation of unearned resources, presumably to the detriment of those who work hard. For some public health professionals and decision makers, in contrast, its focus on individuals is misplaced, and the optimal response involves an overhaul of how society is organized in the first place.

As the COVID-19 pandemic wreaks havoc across the United States and around the world, the nuts and bolts of public health practice and communications are squarely in the public eye. Public health officials are household names, and preventive measures, contact tracing, and epidemiological data appear in daily news headlines. At the same time, growing awareness of systemic racism and the risks it poses to the health-and the lives-of Black, Latinx, Asian American, and other U.S. citizens and residents is producing tidal waves of fierce emotion and political response. In this tense moment, we are witnessing a stunning stand-off between what Bellah et al. (1985) call the first language of American values, individualism, and its second language: interconnectedness, interdependence, and community-the core values of public health (Wallack & Lawrence, 2005; cf. Beauchamp, 1976; Krieger & Birn, 1998) .

Many in the U.S. are now ready for tough conversations about the fundamental causes (Link & Phelan, 1995) of health inequities-in relation to COVID-19, police violence, and other issues-and about the urgent if uphill work of advancing health equity (Walsh et al., 2020) . Others actively reject both the basic logic of public health and the "second language" of interconnectedness, at times in favor of a radical individualism that sees such tough conversations themselves as a threat (Exec. Order No. 13950, 2020; NPR Staff, 2020) . In this moment of health crisis and political discord, what tools does the public health community need in order to communicate effectively with the public? Equity images are among the tools public health educators have come to rely on most. But how effective are they?

From one angle, our findings appear encouraging. Images like these are prevalent. Over 60% of interviewees volunteered that they had seen the apple tree image in Figure 1 or another like it. They are also memorable, or "sticky." When asked to explain "health equity" in her own words, one White community leader with a graduate degree anticipated the next portion of the interview, referencing the Froehle image: "You know what's funny? They have burned the image in my mind of the boy standing at the baseball diamond." For many, including 64% of our interviewees, such images are useful in clarifying the distinction between equality and equity.

However, if these images aim not only to demonstrate injustice but also to garner support for systemic change, they are less effective than expected. Nearly three quarters of interviewees (74%) saw the image as conveying an unjust situation. Yet fewer than one third (31%) offered an interpretation involving redistribution or another form of systemic change. Strikingly, less than half of public health professionals (43%) and only 19% of clinicians pointed to systemic change in their explanations. Thinking back to the four-step narrative outlined earlier, the first three steps consistently "land" with viewers, but the fourth-arguably the most important-does not.

In addition, we also found noteworthy patterns of resistance to the messages the image is meant to convey. More than a third of conservatives (40%; 12/30) expressed reservations about the image's moral or political implications, often suggesting that the inequalities depicted should be remedied through private or community-level actions such as individual effort, direct help, or cooperation and sharing. Conservatives were more likely to perceive individual-level problems, and to resist systemic-that is, government-solutions.

A handful of knowledgeable public health professionals, community leaders, and decision makers also resisted the image's individual-level focus, but for different reasons altogether. For them, the image simply fell short of communicating what we define here as its fourth, implicit message-the message that confronting health inequity is fundamentally about systems and structures, not individuals. From this standpoint, a focus on individual limitations or opportunities is the wrong frame at best. At worst, it distracts from the urgent work of raising awareness about fundamental causes and building durable solutions.

We can certainly imagine settings in which images like this one might serve as meaningful catalysts of substantive conversation and reflection-and we suspect the "#4thbox" tool kit mentioned above may operate in precisely this way. Nonetheless, our findings suggest that these images-when presented without opportunities for elaboration or further discussion-invoke what health communications researchers would call the wrong frame (Entman, 1993; cf. Dorfman et al., 2005; Wallack & Lawrence, 2005) or mental model (N. A. Jones et al., 2011; Southwell et al., 2020) . By depicting individuals, they bring to mind common-sense frames associated with what Beauchamp (1976) calls "market justice" values of rugged individualism, self-discipline, limited government, and personal effort. They do not consistently convey the values of interconnectedness, shared responsibility, and appreciation of the role of government that are foundational to public health (Bailey et al., 2017; Beauchamp, 1976; Krieger & Birn, 1998; Wallack & Lawrence, 2005) , and that bolster broader arguments for societal restructuring.

Given that our sample includes 167 interviewees in one metro area, the generalizability of our findings is limited. Also, asking interviewees which figure they identified with may have yielded more individual and less systematic interpretations. In addition, we asked interviewees to offer their interpretations as opposed to introducing the image as a starting point for collective reflection on the image and its meaning. Future research could explore the efficacy of this or other equity images as starting points for conversation-including versions that include alternatives to equality and equity such as liberation or justice. Similarly, it may be useful to investigate the comparative effectiveness of variations that represent and juxtapose communities rather than individuals (e.g., Kinshella, 2016) .

In this moment of widespread awakening to the vast scope and cascading implications of structural racism and other forms of structural injustice, health researchers and advocates need to reflect carefully on the terms, metaphors, and-in particular-the visual imagery in our communicative tool kit. If we aim to communicate that genuine systemic change is required to eliminate health inequities and ensure that all people can lead a healthy and flourishing life, then we may well need to go back to the proverbial drawing board.

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The authors thank the ARCHES Research Team and Advisory Board; Advisory Board members and interviewers Heide Castañeda, Erica N. Chambers, Ronnie Dunn, Katherine Mason, William Tootle, and Ruqaiijah A. Yearby; the leadership of Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga); and research assistants Yuliya Faryna, Mikayla Hyman, Ava Iannitti, Anne Kohler, John Lawson, Anneke Nyary Levine, Noor Malik, Lucy Pereira, Tracy Segall, Julia Tempesta, Shayna Thomas, Mary Tursi, and Brooke Williams.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this research was provided by the Robert Wood Johnson Foundation (Grant No. 74898). The views expressed here do not necessarily reflect the views of the Foundation.

Sarah S. Willen https://orcid.org/0000-0002-0827-0510Colleen C. Walsh https://orcid.org/0000-0002-9560-6835

Supplemental material for this article is available online at https:// journals.sagepub.com/home/heb.