Understanding Policymakers’ Opinions Can Help Foster Policy Change

We thank Luangrath and Wen for their response¹ to our article.² We are happy to see that our results have generated reflection on how mayors and health commissioners perceive health disparities.

Luangrath and Wen suggest that the sequencing of survey questions might have biased results because respondents were asked about the fairness of health disparities before they were asked about the impact of city policies on disparities. However, the question about fairness was actually asked after the question about policy impact. Nevertheless, Luangrath and Wen are correct in noting that the way in which questions are asked may affect responses. They speculate about why respondents answered the way they did (e.g., whether funding and structural limitations influenced responses). These are important areas for additional research.

Reflecting on our finding that city policymakers’ opinions about health disparities varied significantly by ideology, Luangrath and Wen suggest that “biased media coverage is not the principal challenge; rather, it is the difficulty of making the case for public health.”^1(p588) We certainly agree that it is of critical importance to make the case for public health in ways that resonate with people who have different ideological positions. This is particularly important during a time of heightened political polarization.^3,4 Consistent with previous research,^5,6 our results underscore the importance of thoughtfully using language and framing to make a compelling case for public health to audiences with different ideologies.

Luangrath and Wen imply that a conclusion from our article is that mayors and health commissioners do not understand the social determinants of health. We do not feel this is accurate. As we note, “city policymakers are more aware of health disparities and the impact of socioeconomic factors on health than the general public.”^2(p639),7 That said, we believe our results show that there is still room for improvement to educate city policymakers about the connections between socioeconomic factors and health.

Luangrath and Wen argue that we “missed an opportunity to explore how government can promote health and the social citizenship rights that flow from it.”^1(p589) Our study focused on characterizing city policymakers’ opinions about health disparities with the goal of informing communications strategies to cultivate political will for government actions that promote health equity. We applaud the Baltimore City Health Department’s health equity approach. We hope that further research about the opinions of policymakers will produce evidence that can help extend this approach to other cities.