On narrative and public health

Some initial thoughts about getting people outside public health to understand the importance of wider determinants in health

Erica Holt-White has blogged about some of the findings from the Health Foundation’s work on how the public understand what makes us healthy. The difference between what public health professionals think and what the public thinks is stark. This is a problem if we’re ever going to get serious about prevention.

Public health professionals tend to think that healthcare is one cause among many of good health, and probably not the most important. We’d point to evidence which suggests that healthcare accounts for only about a fifth of the improvements in life expectancy. We never miss an opportunity to talk about the social determinants of health. These are things like the kind of job you do, how much money you have, or the quality of housing that you live in and they have a big effect on your health.

The public, by contrast, believes “free healthcare” is the most important cause of health. Wider determinants like employment and education, while seen as important, come much further down the list.

When it comes to responsibility for health, public health types are often wary of ‘personal responsibility’. That’s because we recognise that many of the causes of good or poor health — whether genetic, environmental or macroeconomic — are out of our control, especially for people on lower incomes. Even so-called ‘lifestyle factors’, things like smoking, drinking too much, or not getting enough exercise, are probably not completely under our control. For example, someone who lives in an unsafe neighbourhood and has to work long hours or shifts to pay the bills probably isn’t going to be in a rush to go for a run (not safe), or get down the gym (can’t afford it). Calorie for calorie, unhealthy food tends to be cheaper than healthy food. People whose parents smoke are more likely take up smoking. So public health types tend to put more emphasis on the role of government creating the conditions for people to be healthy.

The public, on the other hand, thinks that people are responsible for their own health.

Why it matters

You might say: “Why does it matter that the public doesn’t see things the same way as the public health experts? There are lots of things that experts see differently from the general public — that’s why we have experts. Let them get on with expert-ing. ”

It matters because if the public believes that free healthcare is the best route to better health, then our politicians are likely to believe that too. And if that’s the case, we shouldn’t be too surprised that the public health budget gets cut while the healthcare budget grows ever larger, even if it is a false economy.

It matters because if the public believes that people are most responsible for their own health or illness, then our politicians are unlikely to think that it’s the government’s job to get involved in helping people to be healthy, such as by influencing the price of healthy and unhealthy foods.

And it matters because the disconnect between policy experts and the public might be one reason that expert opinion is held in such low regard in some quarters.

Why are professionals’ views of health so different from the public?

The Health Foundation has been working with the FrameWorks Institute to figure out why this gulf exists between public health professionals. The early findings are fascinating.

The first observation that struck me was this:

“no particular social factors received a very large amount of attention and, critically, none received nearly as much attention as health care…both media and organisational materials mentioned health care much more frequently than any single social factor.”

People outside of the public health bubble can hardly be blamed for thinking that healthcare is the main determinant of health if that is what they are being told, including by the health sector itself.

This seems to be compounded by the predominance of healthcare in discussions about solutions, and the prominent role of healthcare professionals in the public discussion.

The initial findings also suggest that:

“While organisational materials frequently mentioned how social factors can enhance health, the sector did not tell a coherent and consistent story about health creation any more than the news media did.”

So if we want the public to better understand that health isn’t all about healthcare, maybe we should stop telling them that it is, and start telling a coherent story about the wider determinants of health.

Another finding seems more difficult to fix:

“The media focus to a significant degree on individuals’ responsibility for health outcomes, while organisational materials do this but to a lesser extent.”

While the health sector can stop behaving as if healthcare is the main driver of health, it can’t directly address a preoccupation in the media with individuals’ choices. I think this is one reason why it’s hard to tell a coherent story about the wider determinants of health: individual behaviours are a mediating factor between environmental stresses and poor health. It’s all too easy to focus on the tangible behaviours rather than the less tangible structural factors like poverty and deprivation. Part of this might be because we don’t like the idea that we might not be in complete control of our own destiny.

What to do?

Some of this is clearly about the health sector getting its message straight.

But I wonder how many people pay close attention to messages from the health sector. Recently Call the Midwife did a storyline on a measles outbreak. I imagine this reached far more people than routine NHS and PHE communications on vaccines. I wonder if they might be interested in doing something on the wider determinants of health.

A friend suggested that a David Attenborough documentary is needed. It’s a good idea — David Attenborough has been incredibly effective at drawing attention to environmental issues like waste plastics. Hugh Fearnley-Whittingstall touched on some good points in Hugh’s Fat Fight, even if his focus was still on individuals changing their own behaviour.

The Health Foundation held a competition for short stories about what the future of health and health inequalities might look like. I really enjoyed the entries. It felt like a step in the right direction to me.

So thinking about changing the medium might be part of the answer.

There might also be lessons from the science communication literature. For example, don’t assume that if people don’t see things the same way as experts, it’s because of a lack of knowledge.

The ‘deficit model’ is used to describe a model of science communication that sees the audience as empty of knowledge, and all that is needed is for the expert to fill them up, and they will see the importance and beauty of science. It's not a great look, but it still seems to be the model for some of our messages about health: tell the people that smoking is bad, or that exercise is good, and lo, the people shall not smoke and shall take exercise. While there are some things that people might not be as aware of as they should be (antimicrobial resistance), I doubt there are many smokers who don’t know that smoking is really bad for your health. And besides, there are plenty of reasons why knowledge alone doesn’t change behaviour.

Then there’s working with the media. The Science Media Centre has established a good model for getting expert opinion into news articles quickly, helping to challenge dubious or overblown claims. I wonder if there’s a collaboration to be started here.

But real progress takes time. For example, scientists worked over a period of years to shape the narrative around embryo research, ultimately paving the way for Parliament to pass sensible legislation at a time when other countries did not. The public health world may wish to study this example.

These are just some initial reflections. I’m sure there are other ways that the public health world can better get its point across.