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Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
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5

Why Frames Matter
1

Julie Sweetland, a sociolinguist and the vice president for strategy and innovation at the FrameWorks Institute, shared strategies to promote racial equity through strategic framing.2 FrameWorks is a nonprofit think tank that conducts communications research about social issues.3 Its staff consists primarily of multidisciplinary Ph.D.-level researchers.

Frames matter, Sweetland said. People’s understandings of issues are frame-dependent and communicators need to be selective about what to say, what to leave unsaid, and what to emphasize. How issues are framed has a large impact on the way that people hear, interpret, and act on the different policy proposals that are put forth on racial equity in health outcomes or on any other issue.

METHODS AND MODELS FOR UNDERSTANDING RACE AND HEALTH

One method that FrameWorks researchers use to learn about how people understand social and policy issues is to talk to dozens of people

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1 This chapter is the rapporteur’s synopsis of the presentation made by Julie Sweetland, a sociolinguist and the vice president for strategy and innovation at the FrameWorks Institute, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

2 FrameWorks’ definition of framing is available at http://www.frameworksinstitute.org/sfa-overview.html (accessed July 13, 2016).

3 See http://www.frameworksinstitute.org (accessed June 21, 2016).

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

on the street and ask them about communication aspects of different topics such as criminal justice reform, human services, environmental health, climate change, child mental health, systems of care, the social determinants of health, immigration, and education. People talk on camera for 10 minutes, and researchers ask questions to get their “top-of-mind assumptions.”4 FrameWorks uses other methods as well, Sweetland said, but videos are a useful way to capture how people think and are more interesting to share than long transcripts, particularly when working with interviews from dozens of different people.

Sweetland shared video clips of responses to the question: “What are the factors or conditions that affect people’s health?”5 In the public mind, there are three determinants of health: diet, exercise, and smoking. This suggests two things, Sweetland said: The first is that members of the public are good learners. These three answers have been the emphasis of public health communications for the past 20 years. The second is that to get people to think about population-level outcomes, causes, and consequences, it will take careful framing of the issues. Individualism is the foundational cultural model used by most people in America. Therefore, people do not understand the mechanisms that create, maintain, or reproduce racial inequity. It is a black box for Americans, and they typically fill in that black box with individual-level explanations.

When the topic is race, Sweetland said, Americans appeal to a model of historical progress as represented by a narrative that Martin Luther King Jr.’s dream of racial equality has been fulfilled with the election of Barack Obama, an African American president. More broadly there is a deep narrative that racism was solved in the 1960s and that the policies that supported structural racism were taken care of during the years of the Civil Rights Movement. From an individualistic perspective, the discussion of health disparities can trigger deficit thinking6 about communities of color instead of shifting people’s perspectives.

The public also uses separate-fates thinking to understand social issues, Sweetland said. What this means is that different groups lead separate lives. Similar to what Mindy Fullilove discussed (see Chapter 3) concerning how many people in cities live separately from people with different backgrounds and experiences, Sweetland said that separate experiences lead to thinking that the consequences for one person are not shared

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4 Immediate and without much thought.

5 The video of Sweetland’s presentation is available at the roundtable’s website, http://nationalacademies.org/hmd/Activities/PublicHealth/PopulationHealthImprovement-RT/2016-FEB-04/Videos/5-Sweetland-Video.aspx (accessed May 18, 2016).

6 Deficit thinking refers to blaming people of color (individually or collectively) rather than recognizing that structural factors contribute to health inequities.

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

consequences for all. If the problem is individuals, and the country has already “taken care of racism,” then the problems are in the hearts and minds of a few outlier individuals with outdated views rather than in the ways that we structure our institutions. This assumption can lead to thinking that “the problems of other people are not my problem,” Sweetland said. Separate-fates thinking leads to a sense of fatalism: “It is what it is. It cannot be affected. The poor will always be with us. You can’t change genes.” These opinions shape our policy climate, she said.

Simply telling people the scope of a problem without shifting their cognition, and without providing them with a framework in which to interpret data can backfire, Sweetland said. As an example, she shared the following disparities data: “In 2010, 35 out of every 100,000 white people were serving time in state prisons for drug-related crimes. By contrast, 280 out of every 100,000 African Americans were serving time in state prison for drug-related crimes, though the drug use of African Americans and whites in the United States is roughly equal.”7 If the meaning is not provided to them, the audience will provide the meaning. If the information is not reframed, the audience will accept the pre-frame. Stories that simply say who is affected and how much they are affected should be avoided and should be replaced with stories that are more explanatory, Sweetland said; otherwise, the shift in thinking will not occur. Statistics that are interpreted by a public health expert as indicators of an obvious systemic problem will not necessarily be interpreted the same way by the general American public. Members of the public will tend to rationalize them away in many different ways unless they are provided with some very powerful cues for how to interpret them.

The cultural models that people have available to understand health, such as health individualism, and the cultural models that people have to understand race, such as separate fates and historical progress, do not allow the public to really engage in the kinds of policy thinking that promote racial and social justice, Sweetland said.

REFRAMING COMMUNICATION TO ADVANCE RACIAL EQUITY

Sweetland discussed a range of examples and explanations of how to reframe communication in order to explain inequities in a manner that makes sense to a range of Americans.

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7 The video clip of a couple’s response to this data is available at the roundtable’s website, http://nationalacademies.org/hmd/Activities/PublicHealth/PopulationHealthImprovementRT/2016-FEB-04/Videos/5-Sweetland-Video.aspx (accessed May 18, 2016).

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

Reframing for Racial Equity Strategy #1: Lead with a Value That Counteracts Separate-Fates Thinking

Values are cherished cultural ideals. They orient thinking on a topic and have powerful priming effects. FrameWorks finds that from a framing point of view, the first problem is affirming that there are solutions available and that this is usually a more productive kind of way to engage people in the conversation. Rather than focusing on a problem, which can be overwhelming to an audience, a more effective way to frame is to state that there is a problem and that improvements are necessary, Sweetland said. Framing is not ignoring the problem; instead, it involves calibrating the level of “problemness” with the availability of solutions and focusing on the possibility of improvements having shared benefits. Sweetland offered advice on what to avoid and on the best strategies to advance a message:

Avoid

  • Who is affected and how much.
  • These data speak for themselves—look how bad this is for people of color!
  • This is a problem that affects the vulnerable.
  • This is a moral outrage!
  • The system is broken and sweeping changes are needed NOW!!!

Advance

  • What affects what, to what end.
  • This is a problem with a system that should contribute to a functioning society.
  • Here are the moving parts of the system. The data reveal problems.
  • This is impractical and unsustainable.
  • Improvements are necessary, possible, and will have shared benefits.

Sweetland suggested ways to make the transition from a pre-frame that should be avoided to a frame that advances equity. Leading with values often means not leading with equity. Equity is the mindset, the outcome of communication. The idea is to try to get people to endorse the cue that is put in front of them as to why this matters. Equity may already be a cherished ideal of a group of stakeholders, but, as Natalie Burke discussed (see Chapter 4), it means different things to different people. Instead, tap into values such as human potential and suggest that all people have potential that needs to be available to all communities. Additionally, tap into the value of pragmatism and people’s can-do spirit.

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

Sweetland offered specific examples for how to shift thinking by promoting these values when using titles on slides, graphs, or annual reports. Instead of: “Latest data on early health indicators,” consider “Maximizing potential: How are we doing?” Instead of: “Child poverty, homelessness on the rise,” cue for pragmatism with “Challenges that call us to work harder and smarter.” FrameWorks research studies recommend specific values for specific issues and they are available to the public on their website.8

Reframing for Racial Equity Strategy #2: Summarize Less, Explain More

Across several different studies FrameWorks has found that explanation beats description. Mere description presents the determinants and outcomes and does little to shift public thinking. A mechanistic explanation connects determinants to outcomes through a process. This can have up to twice the effect on people’s support for policies. Framing effects literally shift the perspective, Sweetland said.

Description: The primary factors that shape the health of Americans are not medical treatments but rather the living conditions they experience. These conditions have become known as the social determinants of health. Our health is shaped by how income and wealth is distributed, whether or not we are employed, and, if so, the working conditions we experience. Furthermore, our well-being is also determined by the health and social services we receive and our ability to obtain quality education, food, and housing, among other factors. Health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

Explanation: Our physical, social, and economic environments shape our health. For example, when communities have areas with safe parks and sidewalks, exercise is easier. And when people live near quality grocery stores, it’s easier to eat a healthy diet. Having social support also affects health and wellness by helping people avoid depression and other mental health problems. Poverty makes it difficult to afford good food and decent housing—which we know are basic requirements for health. And unemployment generates severe stress, contributing to mental health problems and placing strain on the body that makes it difficult to fight off illness. The conditions in the communities where we live shape our health and wellness.

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8 See http://www.frameworksinstitute.org (accessed May 18, 2016).

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

The slight change in text is what frame effects are: they are the small differences in what is emphasized and how messages are framed that can lead to large differences in how people understand the kind of narrative that is being elevated. Explaining that the physical, social, and economic environments shape our health is different from what people are expecting to hear when they hear the term health. Connecting poverty to access to food and housing and connecting unemployment to stress and mental health problems explains what is affected and to what end. Sweetland said that this sort of explanation can lead people to be up to twice as supportive of public-minded, progressive kinds of policies than other messages.

Reframing for Racial Equity Strategy #3: Cue Structural Interpretations of Disparity Data

“Naked numbers” will be interpreted through unproductive interpretive models such as “health individualism,” Sweetland said. Order matters. Start with meaning, then numbers, in order to bring the public along: Values first, then disparities data = more powerful frame. When values are used together with data on disparities, it is one of the most powerful ways of making the case for equity, Sweetland said.

FrameWorks has tested three types of messages: (1) just racial, which involves just presenting facts on the disproportionate impact of a problem on people of color; (2) just the value, which refers to presenting a pragmatic, commonsense approach to tackling a problem; and (3) combining pragmatism and racial impact data. Together, pragmatism and data are a powerful way to give people the tools to understand that there is a problem and that there is something people can do together to solve it.

As an example, Sweetland discussed two different narratives regarding data on tooth decay. The first was framed using “evidence of systemic inequality”:

Blacks, Latinos, and Mexican Americans experience nearly twice the amount of untreated tooth decay as their white, non-Latino counterparts. There are stark racial and ethnic inequities that characterize almost every area of life—from education and housing to development and health. Bostonians face very different opportunities and futures depending on their skin color, language proficiency, country of origin, and neighborhood of residence due to structural and institutional racism. (DentaQuest Foundation, 2014, p. 25)

The frame effects of this “disparities drop,” as Sweetland termed it, are that the audience is likely to interpret this as a “You made your own bed” flavor of fairness. Poor outcomes are the result of people making

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

poor choices. Trends by race reveal cultural deficits, not structural deficits. A reframing of this public health information with “fairness across places and pragmatism” leads to this:

When public health officials in Boston realized that some communities were experiencing up to twice as much untreated tooth decay than others, they looked for underlying reasons for the patterns of this chronic disease. It was more common in neighborhoods where employment opportunities were few and access to health care and oral health care was spotty. The Southern Jamaica Plain Health Center took a practical approach to building community awareness of the troubling data among Blacks, Latinos, and Mexican Americans by engaging a team of young men of color to serve as “oral health ambassadors.

The frame effects of this “fairness across places” approach is that it cues a contextual flavor of fairness that the circumstances beyond individuals’ control should be taken into account.

By bringing this issue to light and pointing out ways to get involved with groups working for change, this common-sense approach to a campaign has started an uncommon conversation.

The frame effects of such a pragmatic approach are to reduce fatalistic thinking about racial inequities and tap into an American sense of “can do.” Sweetland emphasized that the point is not to hide race, but rather to make sure that the message is framed in a manner that explains how inequities are more an issue of access and structures before the concept of race is introduced. Discussing equities through a lens of place-based fairness provides people with a context to think more structurally and to take into account the impact of circumstances beyond individuals’ control. The frame effects of using this pragmantic lens are to reduce fatalism and the sense that “it is what it is” and instead to prompt people to think that together “we can take matters into our own hands, roll up our sleeves,” and solve these problems, Sweetland said.

In the research studies conducted by FrameWorks, Sweetland said, the public have some very deeply engrained and well-rehearsed narratives that make it difficult to move a health equity agenda. However, Sweetland said, those preferences are not fixed, but rather they are frame-dependent. The way that people talk about these social issues can open up the “barn raiser” tradition—the collective tradition in American culture—and it is really up to people to shift their communications in order to advance that kind of agenda.

In summary, Sweetland said that there is an untapped or underutilized source of power that people have as change agents, which is intentional framing, conscious framing, and looking at data when framing. At FrameWorks, the focus is on science translation. FrameWorks invites the

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×

public into expert modeling through the use of good communications and helps them become more informed decision makers, advocates, and citizens. Substance absolutely matters, Sweetland said, but substance is framed for good or for ill. Leading with an equity message may not be the way to bring the most people into this kind of movement, but they absolutely can get there. People will support equity. It is a matter of the invitation that they get.

Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 37
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 38
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 39
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 40
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 41
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 42
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 43
Suggested Citation:"5 Why Frames Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/23576.
×
Page 44
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In February 2016, the National Academies of Sciences, Engineering, and Medicine held a workshop in which speakers shared strategies for individuals, organizations, and communities to advance racial and health equity. Participants discussed increasing awareness about the role of historical contexts and dominant narratives in interpreting data and information about different racial and ethnic groups, framing messages for different social and political outcomes, and readying people to institutionalize practices, policies, and partnerships that advance racial and health equity. This publication serves as a factual summary of the presentations and discussions from the workshop.

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