The one – and only – time I watched the Sound of Music was on its first showing on BBC One on Christmas Day 1978. The songs have become so pervasive though that I suppose it’s no surprise that they come to mind every so often. One in particular seems an appropriate way of capturing the issue discussed by the UK Public Health Network at its October 2019 summit – that of reframing public health. Framing, by the way, describes the way in which a story or issue is communicated.
The issue of how well public health messages are being understood because of the way in which they are communicated is coming under increasing scrutiny. The frequent disconnect between evidence and policy implementation is also being examined. A number of recent initiatives have reported on the results of reframing the language of public health to improve public understanding and to better influence policy-making.
To swap musicals for a minute, it is Henry Higgins in My Fair Lady who points out that “language is the greatest possession we have.” It can win hearts and minds and alienate and patronise in equal measure. That was very much the message behind work presented to the Network that investigated the views of a section of “the public” on regulation in the UK. The results were surprising, given that the sample interviewed were not expected to be supportive of regulation. However, the group demonstrated a very strong sense of fairness and need for (admittedly mostly other) people to play by the same high standards to which they felt they already adhered. They were particularly in favour of protective regulation, surely providing an opportunity here for the public health community to highlight the cuts to workforce that, for example, mean there are fewer people to enforce food hygiene standards. Identifying how the income generated from things like the sugar tax is being used in schools is also likely to win support.
To paraphrase a conversation between Humpty Dumpty and Alice in Alice through the looking glass, one of the problems appears to be whether we are using words to mean what we want them to mean or whether we are making words mean too many different things. Take education for instance. The public health community promotes a good education as being one of the wider determinants of health because future employment can depend so heavily on level of attainment and employment, in turn, affects both the quality of housing and affordability of nutritional food, all of which then contribute to non-communicable disease.
However, investigations by the FrameWorks Institute and The Health Foundation find that the public hears “education” in this context as “education-about-being-healthier” and not the overall level of attainment. The Network learned at the summit that the public isn’t necessarily making links in the same way as current public health messaging might hope or intend. Step-by-step explanations of the chain of causal effects are needed.
Casting health in economic language might be an option. Except that using GDP as a proxy for wellbeing is problematic. GDP was designed as a measure of economic healthiness to help build infrastructure and measures things that are known to decrease wellbeing. There are many alternative indicators but none that grab headlines in the same way as does the UK’s quarterly reporting on GDP. This matters because, as was pointed out to the Network, if measurements are flawed then policy actions have the potential to be flawed as a result.
Of course, Henry Higgins might be proved right that we will never achieve one common language. Maybe that is no bad thing. After all, a key tenet of good communication is to know your audience and reflect their language back in what you say. However, it does suggest that a set of principles is required to encourage consistent public health messaging that takes account of different audiences, whether that involves various sections of the general public or policy-makers across different government departments.
And the Sound of Music song that came to mind? How do you solve a problem like Maria of course, because of the difficulty the Abbey nuns have in communicating with her:
Many a thing you know you’d like to tell her.
Many a thing she ought to understand
But how do you make her stay
And listen to what you say?
The challenge for the public health community is just that. There is certainly much we’d like to say and much more that we’d like to be understood so how do we persuade people to listen? Making a conscious choice to understand how both the general public and policy-makers frame their views of health may be exactly the way to go in order to reach hearts and not just heads or policy desks.