The technique is so familiar it’s practically a cliche: To discourage a particular behavior, make people aware of “myths” that seem to support the behavior. “10 myths about smoking,” “10 common alcohol myths,” “7 myths about the COVID-19 vaccine,” etc. But what if presenting those myths actually encourages or reinforces the behavior health communicators are trying to discourage?

Research suggests that that is exactly what happens.

As Sandro Demaio, one of our contributors for this edition of Inspire conceded, “Ironically, for many years we were communicating many public health challenges in a really counter-productive way, which is kind of frightening. I spent years talking about the myths of non-communicable diseases (NCDs). Well, it turns out that if you talk about myths, it just reinforces the myth and people walk away remembering the myth and not the truth.”

The concept underlying the problem of the “myths” approach is called framing. We spoke to Demaio, CEO of VicHealth, and Mark Chenery, co-founder of Common Cause Australia—a social enterprise aimed at strengthening intrinsic cultural values in Australia—about the power of framing messages.

VicHealth has used framing—or what it refers to as Values-Based Messaging—to communicate about actions required to prevent childhood obesity, the importance of gender equality, and more generally, the role of governments in supporting the health and wellbeing of communities.

Framing 101: A quick primer

Inspire: Sandro, Mark, thank you for joining us. Perhaps you could start with a practical definition for our readers: What is framing?

Sandro: Framing—the way that we communicate and the values that we speak to when we communicate—whether it’s to policymakers, the public, or other healthcare or public health professionals, is fundamental. It can completely change the way the message is received and the reaction that it elicits.

Mark: So, the theory of framing is that when you’re in a different frame—thinking about something from a different perspective—you then reflect on different things, different actors, different situations, different ways of thinking about the problem, different things that you’re wanting out of it. Then different values become relevant.

Inspire: So, you’re interested in understanding the way people think about things in order to move them in a direction, towards supporting a policy or maybe even doing things differently, like adopting a new behavior. OK, so, why does framing matter, why is framing so important? If you know the message that you want to convey, isn’t getting that message out there in a way that is appealing to your audience enough to get their attention?

 

Sandro: Framing allows us to rebalance the way that we communicate and speak to populations, colleagues, and policymakers, but particularly the public. This approach engenders support, not necessarily just through persuasion, but actually through really speaking to the deep core values that we all share. It allows us to maneuver around the politicization of public health challenges by speaking in a way that allows the public to understand and work to support and engage in public health challenges in a meaningful way that resonates and that allows them to see through the noise to where progress can be made.

Ironically, for many years we were communicating many public health challenges in a really counter-productive way, which is kind of frightening. I spent years talking about the myths of non-communicable diseases (NCDs). So, for us the innovation has been really understanding how—in a world of misinformation and a very noisy information landscape—do we really try and cut through that in a way that speaks to and communicates what are fundamentally beneficial opportunities, policy opportunities, that will benefit the vast majority of the public.

Inspire: So, it’s the realization that there’s a better way to communicate, there’s a better way to connect with people that’s going to be more influential, that’s going to have more weight, it’s going to fit in, it’s going to reach them, right? Because it’s not going to trigger a different story or an oppositional idea. It’s going to actually integrate with how they’re willing to see the world or maybe how they already see the world. Is that right?

Sandro: That’s how we see it, and it’s one piece of a bigger puzzle for us; it’s not the only piece, but it’s a very important one. And it presents a very high return on investment for us. We could spend hundreds of thousands of dollars on public messaging campaigns to try and support certain policy outcomes, or partners could, or you might be asking the public to do something, or you might be calling out industry behaviors, but if you’re framing it in a way that is not going to resonate, it could actually do more damage than bring benefit, as we saw over the last 10 years in the NCD space. We’ve tried to talk about social determinants, but I think we’ve talked about them, at times, in a way that became very esoteric and difficult to understand. So, the public disconnected because they saw it as something that’s not tangible.

Perspective matters

Inspire: How does VicHealth help clients understand framing?

Mark: I often start presentations by showing people an illustration of one of the core concepts of framing: bi-conceptualism. People will see a duck or a rabbit in this image – or both.

The idea is that people have the ability to perceive the same information from different perspectives. And it’s really important because your brain is automatically—without you having to tell it to—making different meanings out of what it’s seeing. This is what our brains do—they’re always trying to make meaning out of the world, but it can actually make very different meanings out of the exact same situations or issues or even the exact same sets of facts. So, understanding this is really important because we split all audiences on any issue into three different groups based on our understanding of their bi-conceptualism. So, on any issue you’re going to have:

 

Supporters: These are people who see the issue from your perspective, they very much understand the problem the same way you do; they understand the solutions the same way you do; in other words, they support them wholeheartedly. But they’re actually quite inflexible in their thinking.

 

 

Opposition: These are people who don’t agree with the problem, they do not agree with your solutions, and they are also very inflexible in their thinking. They only see the bird and you try to explain to them that it’s a rabbit there and they just fail to see it.

 

 

Everyone else: In the middle there are persuadable people, and these are the vast majority of people on any issue and they can toggle quite easily between seeing the duck and seeing the rabbit—all you have to do is lead them there—very gently point out that the rabbit is looking to the right and the duck’s sort of looking a little bit upwards to the left. And then they can see it.

Inspire: Our MIYCN work involves promoting breastfeeding, which generally speaking, people support—we don’t hear manufacturers of breastmilk substitutes (BMS) say, “Don’t breastfeed your baby”—in fact, just the opposite. So, we might not see a clear opposition. But more subtly there is opposition. How do you see it—is there an opposition for every issue?

 

Mark: Sometimes there are unhelpful ideas that exist because there are people who strongly believe them and who keep repeating them. I’ve never come across an unhelpful idea that doesn’t have a group of people who have strong adherence to that. They might not be institutionalized, but there’s a worldview going on there. So, yeah. It might not be appropriate to vilify those people because they might be the people that the person you’re talking to trusts the most. But yes, there’s not always an institutionalized opposition, but there’s always an unhelpful world view that is sitting behind the unhelpful stuff that’s going on.

Framing in action

Inspire: OK, so considering how you frame messages has clearly allowed you to engage people on a variety of health topics in Australia. Tell us about the process you use to gain the insights you need for framing.

Mark: So, the very first step in our process is to figure out how our supporters or key advocates think about a particular issue. What are the metaphors they use? What values do they draw upon when they’re thinking about the issue?

So, we’ll do what we call elicitation interviews where we interview at least 15 people working in different areas on that issue who—and the only criteria that we really have is that these people are deeply passionate about it, that they see the issue very much from VicHealth’s perspective—they agree with or they’re all in agreement about the problem, they’re all in agreement about the solutions required. Let me talk to them and understand the patterns in how they’re thinking about the issue. So we ask really fundamental questions.

Then we do a public discourse analysis to look at how people are talking about it in the public. That gives us a sense of the different frames that are out there, and which ones might be useful. This is essentially a gap analysis between the way advocates think about it and the way the public is thinking about it, and which frames bring us closest to seeing the issue from an advocate’s perspective.

Inspire: So, let’s say our focus is on promoting breastfeeding, and we have a two-pronged approach: we’re trying to change policies as well as community perceptions. For example, we’re supporting governments to create policies that prohibit the marketing of BMS to new mothers, and second, to implement community-level advocacy that aims to make mothers aware of the advantages of breastfeeding and the disadvantages of not breastfeeding. Can you give us an example of the kinds of questions you would ask in the elicitation interviews to find the right framing for this issue—promoting and supporting women to breastfeed exclusively for the first six months?

Mark: Well, what I’d be seeking to understand is the way people – who are deeply passionate about breastfeeding and also deeply concerned about the marketing of BMS – think about these issues. What values motivate their concern? What outcomes are they seeking? What do they see as the key barriers to achieving these outcomes and who is to blame for them? And, of course, what solutions do they think are needed to get us to where they think we need to go?

So, I’d start by asking really fundamental questions like, “What is breastmilk?” and “Why do babies drink it?” I’d also ask, “What are breastmilk substitutes?” and “Why do people market it?” I may even ask, “Why do we feed babies?” I’ll also typically ask people to pretend I’m a six-year-old child and explain the problem to me in language a child would understand. Basically, I ask questions we don’t normally ask because we assume the answers are obvious. This then forces the people I’m interviewing to go back to basics and explain to me all the assumptions they are making that inform their sophisticated understanding of the topic. Once I understand which basic building blocks make someone deeply passionate about the cause, my job is to activate those ideas—one way or another—in persuadable audiences.

Framing to motivate behavior

Inspire: Framing is useful in communication, clearly. How does it fit in with an effort to actually change behavior?

Mark: Actually, we’re looking mostly at motivation. We realize that for behavior change it’s not just about motivation. For a comprehensive behavior change strategy, you have to consider: Do people have the skills? Is the external environment or the context facilitating the behaviors we want? And you would look at all of that; you don’t just look at people’s motivation. But in our messaging framing work, it is about that motivation, that one element of the behavior change question: How do we amp up the level of motivation as high as we possibly can through messaging, and that is part of the equation. It’s never the full story with behavior change.

So, to answer your question, if we’re trying to understand the supporters and opponents of the expectation that all women should breastfeed exclusively for 6 months and not use formula, we might start by asking the fundamental questions I mentioned earlier. I want to hear how they really think about it.

Inspire: So, you’re doing a lot of analysis of language. Basically, you’re looking at the way people are thinking about this issue, you’re identifying the main way they look at it, and then you look for these other ways that might be helpful for you to promote it. Is it mainly then about developing advocacy communication? Is the idea that you’re going to try to get people to be more supportive or to advocate for a certain position in policy discussions?

 

 

Mark: It depends on what the objective is. So, for the breastfeeding example—just like the work we’ve done with alcohol policy—in talking to advocates we would be trying to understand how they conceptually think about the issue. And some of the key things that you’re looking at are: What actors are in the frame when advocates talk about the problem? What actors do they focus on? It might be similar to our alcohol elicitation interviews. With alcohol, the key actor that advocates are talking about is industry—it’s all about the industry and all the mischievous things that they do to manipulate people. So it gives me a sense of the values at play. But when they’re talking about the issue publicly, all they talk about is the drinkers. They’re actually focused on different actors when they’re framing the issue publicly to how they think about it themselves. So one of the key shifts that we recommended for alcohol was to bring the industry into the frame. Make sure they’re always front and center when we’re talking about this issue because that is the perspective that gets someone to get angry and say we need to regulate this industry. Whereas, when we’re focused on drinkers, all that’s doing is activating a defensive perspective in the majority of people who do drink alcohol.

Inspire: If we were to find something similar with this issue—such as complaints that the BMS companies are giving out free samples of formula and manipulating mothers to stop breastfeeding—wouldn’t there be a risk of giving these BMS companies more publicity if we make them a focus of our messaging? I’ve heard there’s a reluctance to mention BMS at all because we don’t what to bring attention to them.

Mark: With framing, it’s not “what” you talk about as much as “how” you talk about it. So, if you’re going out there trying to correct BMS misinformation, then no that’s not helpful. All you’d be doing is reinforcing the myths by reminding people of them. But, on the other hand, if the way you frame BMS companies is as profit-focused, then that’s probably a useful thing to say. In fact, it may even help inoculate people against the misinformation peddled by BMS marketers because they’ll be less likely to be trusted. Of course, all this would need to be verified with some message research in order to have confidence that you’re not activating unhelpful ideas and to know your message is actually persuasive.

Inspire: You’ve given us a lot to think about in terms of how we’re using framing, the process we go through to understand people’s motivations, and the audiences we should be reaching or seeking to reach.

In Part 2, we’ll look at the practical application of framing – how the concept is used, including tips and insights to use it effectively. But before we do, we want to hear from you. Have you used framing in your work? What insights can you share about your experiences with framing? Tell us more in the comments below or on Twitter using the #Inspire4SBC hashtag. Thanks for sharing your ideas.