As public health professionals and students, understanding how to effectively communicate and talk about public health and social issues is very important. This week’s episode is a conversation with Dr. Julie Sweetland from the Frameworks Institute about framing public health communications.

To learn more about this topic, visit:
www.frameworksinstitute.org/
www.phrases.org/

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Anya Morozov:

Hello everyone and welcome back to From the Front Row. Here at the University of Iowa College of Public Health, we love public health. It’s in our name. Most of the time we’re surrounded by other people who also love public health and are dedicated to improving the health of communities. However, sometimes when we actually go into those communities, the perceptions of public health can be a lot different. Many people have never heard of public health or don’t know exactly what it is, or, in recent years, people may associate public health with political polarization, business closures, and other not so positive things. This has consequences for the successes or failures of messaging, public health service delivery, and, ultimately, people’s health outcomes. So what can professionals, students, or you, our listeners, do to communicate public health’s importance to folks who don’t think about it every day? That’s the topic of today’s episode. If you’re a new listener, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside the field of public health.

Anya Morozov:

I’m Anya Morozov, and today I’m in the Zoom studio with Dr. Julie Sweetland. She is a linguist and the senior advisor at the Frameworks Institute. The Frameworks Institute gathers information from experts, the public, policy makers, and the media, and uses that to tell folks like public health professionals how they can talk about social issues in a way that makes sense and that sets the stage for positive change. Welcome to the show, Dr. Sweetland.

Julie Sweetland:

Thank you, Anya. Thanks so much for having me.

Anya Morozov:

Yeah. So as someone with a PhD in linguistics, I’d say you have a pretty unique path. So before we get into the topic at hand, can you tell us how you chose to study such a niche field, and what got you to work at the Frameworks Institute?

Julie Sweetland:

Oh, good question. I mean, I think since childhood I was always interested in languages. In high school I took all the three foreign languages that we offered, and I decided I was going to go off to college and be an Arabic major because I wanted to study something with a different alphabet. So I was always just a word nerd. By virtue of being a language major, I had to take a linguistics class my first year of college and I realized it’s not so much that I love languages. I love language. I don’t want to speak the language, necessarily. I want to think about language. And so that led me to linguistics, which is the scientific study of language. Throughout my career I worked in education and curriculum design, always with the focus on how we can use words to make the world a better place.

Julie Sweetland:

And I’ve ran into the Frameworks Institute, ran into their work, and just fell in love with it. And they were looking for a director of learning, which brought together my expertise in adult education and curriculum design and social justice. And so it’s been really wonderful to be able to take my expertise in how language works, and my experience in teaching and training, and bring both of those to different social causes and social sectors, again, just to be able to use language to make the world go better and create positive change.

Anya Morozov:

Yeah. I’m glad you found a way to combine all of your interests, and yeah, I think sometimes words are underestimated in terms of how much good they can do. So that’s great. So can you talk a little broadly, it’s in the name of the Frameworks Institute, but what is framing and why do you think framing public health communications is so important?

Julie Sweetland:

Oh yeah. So framing is the process of making choices about how we present ideas. So where to start, what to emphasize, how to explain it, what to leave out of the conversation, what to leave unsaid, and all of those choices evoke different associations, different understandings of how something works, and when it comes to social issues, it can affect the way people think about who’s responsible for a problem, what’s at stake, what causes it, what should we do about it? And all of those evoke different commitments and support for different policies. So that’s what we think about as framing when it comes to social issues. I mean, public health has always understood the power of communications, as the field was getting started with its roots in sanitation work and that sort of thing. There were lots of efforts to reach out to the women’s magazines of the time and explain those sorts of changes and show different pictures of the same block in New York city 20 years ago and today, and why that matters.

Julie Sweetland:

So there’s always been an understanding that in order to drive broad population health we need to engage people. We need to engage the public. And right now, framing public health communications, I think, has never been more important. We are really at a point where America is starting to see that our health is all connected, yet still really, really locked in the bedrock belief that at the end of the day what causes health is diet and exercise and lifestyle choices. And so there’s a opening to get people to understand health in a more structural and systemic way, but we can’t take it for granted that we’ll make it through that opening if we don’t frame our way forward.

Anya Morozov:

Yeah. So we try to gear this podcast to a more general audience, and framing can be a higher level thing to think about sometimes. So, for our listeners, do you think framing of social justice issues or public health issues is something that just experts or leaders in public health should think about, or do you think it is relevant to students and people who just want to learn about public health but maybe don’t work directly in it, and if so, how?

Julie Sweetland:

Well, I’m biased, but I do think that the concept of framing is really just a fundamental concept that at any level of education people need to have an understanding of. So I talked to my 11 year old daughter about how different choices in the way we refer to different social groups matters, and how the terms we use to refer to people, understanding that the words we use reflect our beliefs about how the world works, but they also make the world go in some ways. They create what we believe to be true. And so I think that’s important for children to understand. In terms of undergraduates and graduate students, it’s understanding that there is no such thing as an unframed communication. We’re always making some kind of choice about how to present an idea, and so we can leave its effects up to chance, or we can do that intentionally and thoughtfully, and ideally with a grounding and an understanding of what that language does. So I think it’s really relevant.

Julie Sweetland:

And it’s funny, when we founded Framework 22, 23 years ago, we had to spend a lot of time introducing the concept of framing to people, but now it’s a term that gets used a lot. You can turn on the news any day of the week and you’ll hear, especially in political coverage, “This candidate was framing the other candidate soft on crime,” or, “Framing this as a matter of social justice,” and that’s really about the emphasis and the issues we’re connecting them to. So I think understanding that this is always happening, not just in political circles, but that it’s really a fundamental way that communication, especially communication around social issues, works. And so, yeah, I think it’s got some relevance for everyone.

Anya Morozov:

Yeah. It really sounds like it. So in terms of how I heard about you, I actually went to a presentation at the Public Health Conference of Iowa, and you were talking about public health communication traps. And you talked about multiple that people can fall into when they talk about public health topics, and the first one you mentioned was, surprisingly for me, leading with the word health in discussions. So what’s wrong with the word health when we talk about public health?

Julie Sweetland:

Yeah. It’s really about the associations that people bring with the concept. So if we lead with the phrase health, it often just doesn’t work as we expect. First of all, people believe that health happens at the individual level. That it’s about what a person does or doesn’t do, and if an individual is sick or healthy, if they’re sick, that’s too bad for them and they’re family, if they’re healthy, that’s great, but it doesn’t have broader consequences. They also think about the causes. As I mentioned, diet plus exercise equals health. It’s only lifestyle choices. And then people also think that the solution, if we want to get more people healthier, people assume that the best way to influence health outcomes is just to provide those individuals with information to help them make better diet and lifestyle choices.

Julie Sweetland:

So when we frame the goal as health, it’s just too easy for people to fall back on those little picture understandings of health. And we’ve seen this in our own research at Frameworks. When we tested different ways of framing environmental health, if we led with a message that said we really need to protect public health, that had no effect. But if we said we need to make sure that no matter where people live their environment is healthy, that was better. So it was more of a zip code argument. And that said, yeah, people, yes, we should do that.

Julie Sweetland:

And when we looked at research on how to talk about tobacco related health disparities, when we said there’s cancer and lung disease and all these sorts of things that happen, emphasizing negative health impacts that made people less supportive of tobacco control policy. People blamed parents for letting their kids vape or smoke or whatever. But when we said no matter who you are and what community you’re part of, you shouldn’t be singled out for exposure to things that we know are harmful, and that’s more of a justice argument and pointed at the industry, and that led people to public health policy. So in both of those examples, talking about health led people to say, “Well, it’s other people’s problems,” but talking about the health issue in terms of fairness or justice made it more of a public issue. So again, it’s not that you need to run away from the concept of health, but we need to go up a level and give people a bigger ideal to orient to before connecting to that topic of health, just because people have little picture definitions of it in their head.

Anya Morozov:

Yeah. I think, again, within the college, and we talk all the time about this social ecological model where there’s things that influence health at the individual level, all the way to community and policy level, but sometimes it’s difficult to think outside of this college people don’t necessarily conceptualize health that way.

Julie Sweetland:

Yeah. Sometimes we borrow the phrase from the great sociologist, Wright Mills, who talked about awakening the sociological imagination and really getting people to think about that social and ecological level, the policy level. And people can do it. That’s just not where they start. And if we use words that keep them at that individual level, it’s harder to move them to those outer levels.

Anya Morozov:

So framing it as more of a justice issue than necessarily health. Clearly, you’re still going to have to talk about health at some point when you’re presenting public health issues, but framing it in a way of justice.

Julie Sweetland:

That often works. I mean, on other topics, I’m remembering we did some work out in some of the Western states on safer syringe practices, so things like needle exchanges. And a lot of the public health presentations were starting with the health topic or the health threat, so it was blood borne infectious diseases. I was like, “That’s not a title you want to run out into the streets with.” It’s [inaudible 00:12:20] This is pre COVID, but still, it was like, “Oh, that sounds terrifying.” But the bigger idea of public health is ensuring everyone is as safe as can be. That’s just a different level of introducing the topic. But yeah, justice or another higher level principle. Absolutely.

Anya Morozov:

Yeah. Okay. So we’ve touched on health and how to maybe frame things a little differently. What about the language of social determinants of health, which we often use as a catchall term for things like housing, economic stability, education, transportation, and healthcare access?

Julie Sweetland:

Yes. Okay. Critical concept, awful messaging. People really, really are turned off by the phrase social determinants. So this isn’t just Frameworks research, as far back as… I think it was 2010 that Robert Wood Johnson Foundation commissioned some research and concluded that phrase of social determinants consistently tests poorly with everyone, no matter which way you test it. We’ve had similar conversations with folks at the National Academy of Sciences, Engineering, and Medicine. Interviews we’ve conducted at Frameworks looking at that, people who were unfamiliar with the phrase social determinants guessed incorrectly that it had something to do with socialism, and others rejected the idea that society “determines” a person’s fate. People want the idea of free will and agency. I mean, that’s just ordinary public folks.

Julie Sweetland:

When we looked into the way people in health systems on the medical side, healthcare side of health, people who were familiar with the term social determinants of health tended to equate it with risk factors or harmful environments. It was almost like a checklist of what social categories do you fall into that are making you sick, instead of seeing this broader idea that what surrounds us shapes us, and we can design environments to promote good health and fairness across places and health equity. But instead we’re allowing. We’re tolerating environments that are undermining good health. So if I could vote the phrase social determinants of health off the messaging island, I totally would.

Anya Morozov:

Voting it off the messaging island. It would be cool if that was how communications work. You can just vote it off the island. So, if not social determinants of health, what might be a better alternative?

Julie Sweetland:

People never want to hear this, but you probably can’t just replace it with a catchy the three different words instead. It’s a concept that really needs an explanation. I guess it’s not too much longer, one alternative that we’ve tested that makes sense to the public and some of those neighboring sectors, healthcare, housing, transportation, etcetera, is talking about how there are foundations of community health. Really just the sense that it’s a metaphor. It’s a building block idea. That the health of our community is a building that depends on a strong and stable foundation. And then give an example. For example, education relies on the foundation of community health. Students who show up in the classroom, students’ experiences in the classroom matters on what happens outside of school. And then also when kids are healthy, they can learn better. So helping people see one particular determinative health, and explaining that, helps people then start to think about it. So explaining, one, instead of listing the nine to 12 to 16 determinants, depending on which Framework you’re doing, we have found is much better.

Anya Morozov:

Yeah. I like that. And I can see how social determinants, while it’s a term we use very frequently, it can sound deterministic. And I think, yeah, it’s good to explain it in a way that also promotes hope, almost, and shows a way to potentially changing the starting point.

Julie Sweetland:

Yeah, and that possibility of intervening, the possibility of making a difference, is really important. So for instance, particularly when you’re talking about race or racism as a determinant of health, lots of folks are saying let’s no longer talk about race as a determinant of health, let’s instead talk about racism and segregation, those sorts of things, as putting people of different races in different surroundings, that’s what’s changing it. But as to the extent that we talk about race as a determinant of health, what are you supposed to do? Change your race? You can’t do that. What are you supposed to do? Change your gender? Of course, some people can, but most people probably don’t. And so it leaves that possibility of change hard for people to think about. But if you explain the concept that our surroundings can affect our health in many ways because they shape our access to things like nutritious food, clean air and water, opportunities to walk more, that’s more helping people understand the how, rather than a checklist of demographic categories.

Anya Morozov:

Yeah. So shifting the way that we talk about some of these things. Clearly you can’t just cut and paste social determinants of health with something else, and I know I have heard the term social determinants of health probably at least 10 times in the past two days because we use that phrase so often. So, I guess, what would you say are some practical steps to move towards the framing of language that we want, whether it’s towards foundations of community health or moving away from listing off the social determinants. Do you have any practical steps to move conversations?

Julie Sweetland:

I mean, I think change often starts with awareness, and so asking public health students, public health professionals to learn more about framing and issue cause communications. I think public health is very sophisticated in health behavior communications. How is it that we can reach this particular population with information they need to take healthier behaviors or protect themselves from threats? That’s a very sophisticated practice within the field. How do we help America get smarter around the policies and programs and infrastructure we need to have healthy communities for health to be the norm? That is an underdeveloped part of the curriculum, of the research, of the practice. So I think that’s learning, but there is evidence available. So continuing to learn.

Julie Sweetland:

I’ll put a plug in for phrases.org, P-H-R-A-S-E-S, which is an acronym for public health reaching across sectors. That website has a lot of information specifically designed for public health practitioners to communicate more effectively, and it’s posted by the Aspen Institute and supported by de Beaumont Foundation. Frameworks did the foundational research for that, and it’s based on our recommendation. So something like that I think could be built in to public health degrees, but also folks that are already in the field can absolutely access that.

Anya Morozov:

Yeah. And well, if anyone listening wants to look into that, I’ll put that link in the description. So do you have any examples of a successful change in how people have framed a topic in conversation?

Julie Sweetland:

Oh yeah. So, I mean, going back to your point just before about how in the field you use SDOH all the time and we need an alternative. 10, 15 years ago, developmental scientists, folks that study child development and public health outcomes, were talking about allostatic load and how that is often an overload of the body stress system. That phrase was not tripping off the tongue, and it wasn’t [inaudible 00:20:42] the public. We developed an idea of positive stress, stress that helps you learn and grow, tolerable stress, bad things, like when a child might lose a parent, but can be tolerable with the right supports, or toxic stress, when stress is prolonged, severe, and you don’t have the buffering relationships. And toxic stress is now used both in the field and outside the field for the concept of allostatic load. Before this science was introduced, the phrase helped the science catch on. The language and the research go together. They can help each other. I don’t want to suggest just changing the word did all the work, but there was a lot of compelling research.

Julie Sweetland:

Americans are thinking differently about stress. Before it was always and only what doesn’t kill you makes you stronger, and now people really do understand, I mean, we’ve got a shift in consciousness, that too much stress can be a bad thing. It can be debilitating. It can be a real health risk. So that’s great. In another field, education, 10 years ago, we were seeing a lot of rhetoric around back to basics, “Kids can’t read. Kids can’t do math. Let’s get back to basics. Schools are trying to do too much.” And now schools are much more focused, and educational advocates, on telling a story about getting kids ready for the future, talking about the skills we need for the world we will inherit in a world driven by information. And that’s a reframe. Talking about the past, we should go back to whatever they were doing in 1920, to talking about the future. We need to be ready for 2030, 2040, 2050. And so that has changed what people think is appropriate in terms of professional preparation, in terms of curriculum, in terms of all sorts of things.

Julie Sweetland:

So, I think I said 10 or 15 years ago at least two or three times, a true shift in mindset can be accomplished through a shift in framing. What people think is changed by the way we talk about it, but it does take time. It’s very rarely a quick and easy fix, at least on the types of issues and conceptual challenges that we work on at Frameworks.

Anya Morozov:

Yeah. So we’re not going to release this episode and then all of a sudden we use the language that’s more appropriate. It’s going to take a while, but this podcast might help.

Julie Sweetland:

Absolutely.

Anya Morozov:

So thinking broadly again, in your opinion, how do you think the COVID-19 pandemic has shaped the way that people talk about public health?

Julie Sweetland:

Oo. Well, there, you could have a whole podcast series itself on that topic, I think. So I think there’s at least a couple things. One is that people are thinking and talking about public health agencies and public health workers more often than ever before. Nobody knew who the head of the NIH was in 2019. So there’s a higher level of consciousness, and I think, for a lot of folks, a higher level of respect and gratitude. We also have seen higher levels of distrust and even anger at how public health agencies were perceived to respond or not respond appropriately. There’s a higher level of scrutiny and a higher level of distrust. So I think both are true. Lots of folks are more aware and more conscious and grateful than others, and some folks are more concerned, more suspicious, and really more resistant than before.

Anya Morozov:

Mm-hmm. Yeah. So it has gone from this more invisible thing to something that’s on more people’s radar, whether it’s in a more positive light or a more distrustful light.

Julie Sweetland:

Yeah. And I think there’s lots of factors going into that from particular people in office, particular messaging missteps, particular very specific things that happened in specific places or by specific people. The only part of that I feel like we as a public health field can control is the words we use. We can get ourselves as thoughtful and as clear as possible, and just be thoughtful about how things might be misinterpreted, and work really hard to do the messaging in the clearest, most consistent, concise way possible.

Anya Morozov:

Thank you. That’s good advice. So can you talk a little bit about some of the work you’re doing with public health practitioners here in Iowa? I have heard through the grapevine that you’re doing a little more than only presenting at the Public Health Conference of Iowa.

Julie Sweetland:

Yeah. We actually came through the Iowa College of Public Health. We’re partnering with the Institute for Public Health Practice that I believe hosts the Midwestern Public Health Training Center, and so through that initiative we are working with quite a few public health practitioners in Iowa, but also across the MINK region. This was a acronym that was new to me. Missouri, Iowa, Nebraska, and Kansas. So that’s a region within APHA’s region world. And so from those four states, we’ve got, I don’t know, six to eight people from each state, and someone from a couple local health departments in most states, the state health department, a few NGOs in each state, so folks that work on different aspects of the issue, and we’re coming together five or six times, and with some technical assistance in between, but a series of learning opportunities to dig into the framing aspects of different issues.

Julie Sweetland:

So we’re really excited to be working with those folks across six or eight months, I think it is, talking about the issues like building vaccine confidence, talking about this idea of shifting mindsets on what health is to begin with, with some of that language that lands better with the public. So a series of workshops for those folks, and then we’re really excited that those folks will, hopefully in a future phase, become ambassadors to other professionals in their organizations or that sort of thing.

Anya Morozov:

Well, thank you for bringing that knowledge and expertise to the MINK region. I think we’ll all benefit from it. So our last question is one that we ask everyone who comes on the podcast. You can talk about something within the Frameworks Institute. You can talk about pretty much anything. What is one thing you thought you knew, but were later wrong about?

Julie Sweetland:

Again, a topic that could have a lot of entries. Let’s see. I think that I used to think that the way to make an issue simple and understandable for folks who weren’t experts, if you wanted to get people to rethink their belief about poverty or urban education or immigration, that you should tell a heartwarming story, a shatter the stereotypes kind of story, but a really vivid story about what you think this story flips that on its head. And what I have learned is that if you paint a vivid picture that focuses on an individual, you focus people on the individual, and they might listen and they would be compelled, but they don’t always change their ideas about the issue. They’re just as likely to think, “Well, that person is an exception to the rule and they’re special, and if they can pull themselves up out of that problem, so can everyone else.” So the kind of counter stereotype story we think bust stereotypes, but it actually reinforces them.

Anya Morozov:

That is something I also did not know. So thank you for sharing it. Yeah. You’ve given us a lot of interesting ways to think about things today, and I’m really grateful that you took the time to share your knowledge. So thank you so much for coming on the show.

Julie Sweetland:

Oh, Anya, I’m grateful for the opportunity. And I’m also grateful for students like you that are joining the profession, and for everyone that’s doing the work to make society a place where we’re all experiencing wellbeing in all its forms.

Anya Morozov:

And that’s it for our episode this week. Big thanks to Dr. Julie Sweetland for coming on with us today. This episode was hosted, written, edited, and produced by me, Anya Morozov. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.