Understanding Framing of Public Health Issues and Its Relevance in Climate Change Policy Discourse

Policy actions to tackle any major public health threat need different people and sectors to work together. Effective communication is essential to ensure a shared threat perception and coordination of efforts. This can be a challenging task as people and sectors come with their own priorities, resulting in rivalry rather than cohesiveness.[1] Two important aspects of the policy development process are issue definition and agenda setting. Agenda setting refers to deciding which issues need to be taken up at a given time, whereas issue definition refers to how these issues are framed to capture the attention of policymakers, potentially heightening political priority.[2] The concept of framing also applies to people and sectors, especially if actions are required at their end to get everybody on the same plane. What is Framing in Public Health Context? Framing refers to the process by which an issue is presented to people leading to conceptualisation or orientation of their thinking about that issue.[3] Framing an issue goes beyond stating a problem to link it to a value that is dear to them. Framing, thus, evokes deeply held values in people and takes the nature of debate along a value-laden or ideological path.[4] Such values aim to unite people to act for a larger cause and reduce the differences between various perspectives. Public health messages can be framed to highlight either the benefits of engaging in a particular behaviour (a gain or a positive frame) or the consequences of failing to engage in a particular behaviour (a loss or a negative frame), with a gain-frame being more likely to be effective.[5] There are three common value-frames most often used in public health-securitisation, moralisation and technification.[6] Securitisation refers to an issue’s framing as an existential threat, moralisation as an ethical imperative or for a larger societal good and technification – an evidence-based rational decision. While technification appeals most to academic people, it is perhaps the least effective as it only appeals to rationale and not a ‘value’ and so does not evoke emotions. While it is generally recommended that fear should not be used in public health communication, evidence shows that it is effective, especially when jointly done with other efforts.[7] Framing an issue is an inherently political process where vested interests play a role. Politicians, governments, international organisations, civil society organisations and advocacy groups – All try to frame an issue in a way that serves their interests and gets more people behind them. While to start with, there could be multiple framings of the issue, discussions and negotiations can result in the adoption of one pre-dominant framing. Major global players often determine which frames prevail, which may be seen as ‘interference’ in priority-setting processes by national agencies.[6] The example of policy development on safe abortion in Burkina Faso, where abortion is legally restricted and socially stigmatised but also frequent, illustrates this well. Unsafe abortions contribute to a high maternal mortality ratio, and the country’s main policy response has been to provide post-abortion care (PAC) to avert deaths from abortion complications. In general, national decision-makers and doctors opposed induced abortion for social and religious reasons (hence were not amenable to ‘right to abort’) but were convinced that PAC is ‘life-saving care’ that should be delivered for ethical medical reasons. NGOs decided to tactically retract their demand and focus on PAC as a ‘first step’ towards their long-term goal of securing abortion rights.[8] A sort of ‘win-win’ solution. Some other examples of framing include reporting of childhood obesity as an individual-level problem as opposed to a societal-level problem in print media in the United States;[9] use of a moralistic frame of satwik versus tamasic food or an ethical argument rather than a nutrition-based technical argument in India on use of egg in mid-day meals for school children;[10] higher use of public health framing by ideologically liberal and African American US legislators in their opioid use related statements as compared to conservative members who were more likely to use law enforcement framing.[11] The use of the word ‘Sin’ tax on tobacco and unhealthy foods also has religious and moral connotations.[12] The process of prioritising health issues at a global level is complex and deeply political. We can learn from global experiences of successful and not-so-successful framing in public health. Three case studies are discussed below – On human immunodeficiency virus (HIV)/AIDS, non-communicable diseases (NCDs) and tobacco control [Box 1].Box 1: Case studies in framing a global public health issuesWhat Did We Learn from the COVID-19 Pandemic on Public Health Framing? The use of fear (securitisation frame) in framing the COVID-19 pandemic was appropriate and well-founded subsequently, given the devastation it caused. However, the pandemic also saw moral framing, especially in practicing preventative behaviours. Imposition of a moral frame in contexts where the freedom of choosing is itself illusory can result in stigma, as was seen in HIV/AIDS or even during the COVID-19 pandemic. A study showed that emphasising the connection between China and COVID-19, rather than framing the virus neutrally, increased negative attitudes towards Asian Americans and prioritisation of resources for natives rather than immigrants.[25] Government and public agencies should refrain from applying a moral framing to a public health issue and even consider countering it if other stakeholders employ it.[26] At the same time, evidence-based decision-making during the COVID-19 response related to masking, social distancing and vaccination was heavily criticised globally mainly due to the changing nature of evidence, lack of transparency in its use, and poor communication to policymakers and people.[27] What are Its Implications for Framing Climate Change? Climate change, a contemporary phenomenon with unparalleled complexity, has been characterised as a ‘wicked problem’.[28] It has been framed using all the three value frames. The use of the term ‘threats’ by the WHO for climate change is indicative ‘security’ as its pre-dominant framing. Submerging of homes or cities in a flood are the ‘end-of-the world’ scenarios utilised in climate change campaigns to drive the fear factor. Most people do not identify with the doomsday scenario painted above as the probabilities of these occurring are low and in too distant future. Saving the earth for the next generation and focusing on ‘need rather than greed’ use a moralisation frame. However, people may think that solving current problems and having a decent life now are more important for them than securing a distant, uncertain future. Often climate change discourse is done using a ‘moral or equity’ frame. In international negotiations, India takes the stand that developed countries are the one responsible for the status and should do the heavy lifting in mitigation efforts and developing countries should be allowed to ‘pollute’ till they catch-up on the development. However, it allows the same logic to be applied by states and individuals to argue that they need not change as someone else is polluting more and should change first![29] Sharing evidence on increasing temperature of core of earth, rising sea levels, increased frequency of extreme weather events have appealed to the rationalists among the policymakers and people. However, the link between the evidence and the impact on health and life is not well realised. Finally, none of these seem to be very effective. It is time to make ‘health’ central to climate change framing. While climate change has its roots outside the health sector, it is the health sector that bears the brunt of their consequences. A public health framing can depoliticise climate change discourse by offering bipartisan solutions. A public health framed discourse resonates with the public, can support political will, and steer climate change consensus on actions by providing stakeholders with relatable health risks as opposed to the complicated jargon of climate change (e.g. carbon pricing).[30] Public health professionals need the capacity to convey an understanding of health impacts at sub-national levels, the vulnerabilities and disparities within the various populations, the risk perceptions and individual risk assessment approaches, and the complex pathways within which climate change and its related actions impact health. The Lancet Commission on Climate Change and Public Health has strongly advocated for a collaborative approach by emphasising the cross-sectoral drivers of health impacts and public health needs.[31] The framing of climate change primarily as a health problem runs the risk of poor participation of non-health sectors, as seen in NCDs. A study in Ontario showed that public health was regarded as not having a mandate in the climate change decision- or policy-making processes.[32] In India, health did not find a place in the eight missions under the National Action Plan for climate change when launched in 2008 and was subsequently added in 2014.[33] Public health professionals need to better understand the framing of public health issues, advocacy and communication strategies and process of policy development. Further research and understanding of the framing processes can help public health professionals influence the policy environment favourably. If public health professionals want to be an important player in the climate change arena, they need to learn to go beyond generating evidence and using the technification frame.

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