Why we need a new story about health
Almost every aspect of our lives, from our jobs to our homes, our access to education and public transport to whether we experience poverty or racism, impacts our health and ultimately, how long we will live. These factors are often referred to as the wider determinants of health.
In the public and political debate about how to improve health in the UK, the wider determinants are often left out or misunderstood. People think of health in highly individualistic ways; it’s the food we eat and how much we exercise.
This is a problem for those of us who want to address the widening inequalities in health across the country. When people struggle to see how jobs, homes, hardship and discrimination link to health, they are less likely to support, and demand, the policies and actions that are needed to start addressing these issues.
What is framing?
Framing is making choices about what we say and how we say it. Choices about:
- what we emphasise
- how we explain an issue
- what we leave unsaid.
These choices change how people think, feel and act.
Unlike a set of key messages, frames can be used and adapted to a variety of different contexts; enabling us to tailor communications for different audiences and channels while continuing to talk about our issue in a consistent way.
5 recommendations for boosting action on health
At a glance
- Show why it matters: lives are being cut short
We need to open our communications with inequalities in life expectancy and the fact that too many lives are being cut short. What we say first is the most important part of our communication. It sets the scene and gets remembered.
- Harness the power of explanation
Most people fail to understand how the world arounds us, shapes our health. We can increase understanding by using a building blocks metaphor or taking a deep-dive explanation into one of the wider determinants of health.
- Show change is possible
People feel fatalistic about the possibility of change when it comes to health. We need to show change is possible by building solutions into our communications early and being explicit that we can make a difference.
- Use certain arguments with caution
Part of telling a powerful story is in knowing what to leave unsaid. Where possible, avoid talking about the economic cost of the wider determinants of health, or that we should act on the wider determinants of health to protect the NHS, and avoid leading with the pandemic as these arguments have been shown to decrease support for policy changes.
- Use data to strengthen your story, not to tell it
Data doesn’t speak for itself, and naked numbers can reinforce unhelpful ways of thinking. Help people make sense of facts and figures by putting them in context; with metaphor, explanation and by showing why they matter.
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Show why it matters: lives are being cut short
To increase support for policies and action on the wider determinants of health we need to start by showing why this is important. To do that, be clear that this is a matter of life and death.
Presenting the wider determinants of health as a matter of life and death conveys a stronger sense of urgency and importance than focusing on health and wellbeing in general. Wellbeing is always a matter of degree – life and death aren’t. When we make the issue about inequalities in life-expectancy and the facts that lives are being cut short, people take notice.
How to do it
- Lead with the fact that lives are being cut short to establish why health inequalities matter
- Then explain the causes of health inequalities
TIP: Avoid adding complexity with concepts like “disability-free life expectancy” or “healthy life expectancy” as few people understand what they mean.
TIP: To avoid leaving people feeling that nothing can be done, balance the urgency of this tone with clear solutions and a message that change is possible
What does it look like?
Before:
“The Social Determinants of Health have an important influence on health inequities. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.”
After:
“Right now, in parts of the UK, people are dying years earlier than they should. When we don’t have the things we need, like warm homes and healthy food, and are constantly worrying about making ends meet, it puts a strain on our bodies, resulting in increased stress, high blood pressure, and a weaker immune system.”
Different audiences
There are lots of different ways we can flex this frame when we are speaking to different audiences and our own communication style. When we’re speaking to the media, we might want to dial up our tone and be more emotive. When we’re speaking to a commissioner, we might want to dial down the tone and be more measured. The frame provides a scaffolding, which we can flex up and down:
Dial down:
“Some people are dying earlier because…”
“Life expectancy isn’t the same across the UK…”
Dial up:
“Right now, too many people are dying younger than they should…”
“Lives are being cut short by…”
When communicating directly with people who are likely to be personally experiencing the conditions described consider whether of not it is appropriate to use the frame ‘lives cut short’. If not, lead with the building blocks metaphor instead. Always assess who the audience is and whether they are likely to be living the reality being described before deciding how to open.
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Harness the power of explanation
People’s inability to understand why and how the world around us effects our health are two of the biggest challenges for communicators.
Without this understanding, people default to the idea that ‘it’s just the way things are’. Or that problems are too big and complex to be tackled. And when we don’t provide enough explanation, people fill in the gaps with narratives that already feel familiar to them- like ‘it’s up to individuals to make better choices’.
Explanation is a powerful way of bringing people with us – it increases understanding, and that helps to increase support for change.
There are two ways evidence shows we can increase understanding of the wider determinants of health through explanation:
- metaphor
- ‘deep-dive’ explanations.
Use a ‘building blocks’ metaphor to explain the role of the wider determinants of health
The ‘building blocks of health’ metaphor is a powerful way to increase understanding about how a healthy society is shaped by the wider determinants of health.
Research from FrameWorks found that when we compare the process of building a healthy society to constructing a sturdy building, we can increase people’s understanding of the wider determinants of health, health inequalities, and the need for change.
How to do it
- Compare building a healthy society with that of constructing a sturdy building
- A thriving community needs all the right building blocks in place: jobs, homes, education, community connection.
- Explain health inequalities by talking about building blocks that are missing, or weak, and need replacing
What does it look like?
“To create a society where everybody can thrive, we need all the building blocks of health in place: stable jobs, good pay, decent homes, and community connection. But right now, in too many of our neighbourhoods, blocks are missing. It’s time to fix the gaps.”
Do use the metaphor to talk about what creates a healthy society
When we talk about the building blocks of health, we’re talking about the wider determinants of health. Remember, one building block = one wider determinant.
Each block is one of the things needed for good health, such as good jobs, decent and affordable homes, access to a good education and public transport.
Don’t use the metaphor to talk about what creates health for one individual alone
Research shows that this metaphor increases understanding and builds support when we use it to talk about what societies or places need for good health. It’s not about focusing on what only one person needs to be healthy.
What this looks like
‘To create a healthy society, we need all the building blocks of health in place. Things like stable jobs and good pay.’
Do use the metaphor to bring in solutions
Use the metaphor to show something can be done to improve health.
Use it as an opportunity to talk about solutions. People see building blocks as modular: they can be rearranged, replaced, added, and mended to strengthen the structure of a building. This reminds us that systems are designed by humans, which means they can be redesigned, even if this is one block at a time.
Don’t use the metaphor to represent health challenges
Don’t describe health challenges, like air pollution or low pay, as a building block of health. Instead, we can use the metaphor to talk about building blocks that are missing, weak or crumbling, and introduce solutions by talking about replacing these blocks or fixing the gaps.
What this looks like
“Good work that pays enough is one of the building blocks of a healthy society. When it’s missing – when we don’t have enough to get by – this can create chronic stress and lead to ill health. One way to strengthen this building block is to raise the national minimum wage.”
“In too many of our communities, blocks are missing. To prevent people from dying earlier than they should, we need to fill the gaps and make sure everyone has access to a stable job, decent home, and a good education.”
Do talk about a building
The ‘building’ in this metaphor helps people to think about health collectively, so stick to talking about a building. Use concrete and tangible examples of the building blocks of health to increase understanding of the factors that make a difference.
Don’t talk about building a house or use a shorthand
We associate houses with individuals, which makes it hard for us to think of health in wider society. And don’t be tempted to use ‘building blocks’ as shorthand or turn it into an acronym. T
What this looks like
‘Thriving communities need all the right building blocks of health in place, including decent homes and affordable transport. Erosion of these building blocks causes instability in people’s lives and increases their risk of poor health.”
Do talk about strong building blocks that work together
The image of building blocks helps people see how multiple factors interact to shape health. Any building is made up of multiple blocks which work together for the structure to hold up. This helps people see the need for an integrated approach to health and focus on the need for strong building blocks to create good health and wellbeing in society. Use the metaphor to explain how, when these are firmly in place, they interact to give people stability and opportunities in their lives.
Don’t leave your building blocks standing alone
If your work focuses on a specific wider determinant of health – say accessible transport – talking about strengthening that one block is a good starting point. Then bring in the building as a whole. All the blocks need attention to preserve the integrity of the building, and we need people to see the wider context of what shapes our health.
What this looks like
“Reliable, affordable and available transport supports the other building blocks of good health, such as connecting us to work and public services.”
“Accessible transport is an essential building block of health in our towns and villages. We need this building block securely in place alongside other building blocks like decent homes and good jobs.”
Do extend the metaphor to explain health inequalities
The building blocks metaphor helps people understand that we need all the right blocks in place to build a healthy society. We can explain inequalities in health by showing that in some places, too many blocks are missing. Or we can show how discrimination is causing the blocks to crumble.
Don’t use the building blocks of health metaphor for everything
You can extend the metaphor and it’s flexible, but it can’t – and shouldn’t – cover everything. Nor should you use it for anything other than the wider determinants of health – it’ll become confused.
There are additional ways we can tell a story about the wider determinants of health, such as a step-by-step explanation including words that show cause and effect: because, this leads to, this means.
What this looks like
“Right now, across the UK, some people are dying earlier than they should because the building blocks of health are missing or broken where they live.’ ‘When it comes to the building blocks we all need for good health – access to education and a home, a job that pays enough to cover the bills, being part of our community – experiencing racism can wear away at every block.’ ‘Enough income is essential for good health because this can unlock access to the things that help to keep us healthy, like a decent home. Not having enough money can cause poor health because it restricts our options, making it hard to find a warm, affordable home that will help keep us healthy.”
Use a ‘deep-dive’ explanation to explain the role of the wider determinants of health
In a ‘deep-dive’ explanation, we need to focus on just one of the wider determinants and explain fully how and why it effects our health.
How to do it
- Explain how and why your issue happens.
- Explain it step-by-step using language that signals cause and effect: ‘because’, ‘this leads to’, ‘this results in’, ‘this means’
- You don’t have to include every way the wider determinant effects health – just pick out a couple of key points.
TIP: A deep-dive explanation about jobs or housing is a particularly effective way to increase understanding
TIP: Talk about chronic stress to explain the impact of hardship or discrimination on our health
What it looks like
Instead of just asserting that when people have insecure or irregular work it leads to poorer health, explain how like this:
Cause: When people have insecure or irregular work
Step 1: It means that it is harder to afford decent housing.
Step 2: Living in cold, damp homes, can result in respiratory problems and other health issues.
Step 3: Constantly worrying about having enough money to pay the rent can also lead to chronic stress, anxiety, and depression.
Consequence: Leads to poorer health.
Solution: Improve job security
TIP: Deep-dive explanations help point towards your solutions. When writing one, start by thinking of the solution you want, and then explicitly building steps which link to your solution.
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Show change is possible
How to do it
- Talk explicitly about the fact that we can change this.
- Show the urgency of the situation but don’t leave people at the crisis – show it can be fixed, and how.
- Talk about solutions often and build them into communications early
TIP – Use the 2:1 ratio – for every dose of urgency and crisis in our communications, we need to include at least two doses of “we can fix this”.
TIP – Add specific, concrete solutions whenever possible to make the steps needed feel more tangible.
What does it look like?
“By increasing the minimum wage, we can prevent lives from being cut short.
Increased income means that we have what we need to heat our homes, eat healthily, and don’t have to constantly worry about making ends meet.
As a result our bodies produce fewer stress hormones which means lower blood pressure and a stronger immune system.”
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Use these arguments with caution
Sometimes what we leave unsaid is just as – or even more – important than what we do say. This is because there are ways of talking about an issue that can decrease support for what we’re trying to achieve. When it comes to talking about health there are three ways of talking about the issue to avoid where possible:
- making an argument about the economic cost of the wider determinants of health
- arguing that we should act on the wider determinants of health to protect the NHS and,
- focusing on the COVID-19 pandemic.
In situations where these arguments can’t be avoided, the below offers ways of using them will help to minimise harm.
Economic costs
Our research showed that making an economic argument for why people should support action to address the wider determinants of health can backfire. Describing the issues in terms of their effect on the economy, or cost to the NHS, risks triggering blame towards people experiencing poor health, and taps us into individualist thinking.
If you need to provide economic evidence in your work, the below outlines a way to do that.
TIP: Avoid economic or monetary frames wherever possible. If you do need to provide economic evidence in your work, avoid leading with it.
How to do it
- First, lead with the impact on people. Messages that focus on the economy can be seen as commodifying human beings, which makes them immediately unpalatable.
- Lead with why the issue matters (lives are being cut short) and then expand people’s understanding of what health is and the factors that shape it before adding your economic evidence. Without this explanation, economic arguments are likely to just fuel individualistic thinking.
What does it look like?
Before
“Ill health in ‘left behind’ areas costs England £30bn a year, says report.
“Economy would get a major boost if people in most-depriced regions were as healthy as those in rich areas.”
After
“Lack of investment in ‘left behind’ areas is costing lives.
“People in poorest regions are dying years earlier than those in rich areas, with a cost of £30bn a year.”
The NHS
Messages which focused on the NHS as a reason to address the wider determinants of health are, at best, unpersuasive, and can even backfire – making people less likely to support policies and action addressing the wider determinants of health.
Where possible, avoid making the NHS a central part of your argument about why we should act on the wider determinants of health.
TIP: When you do need to talk about the NHS, explain how it should fit within a broader system of support.
How to do it
- Remind people that the NHS was never meant to go it alone and it was always intended to be part of a broader system of support addressing jobs, housing, education, and public transport.
- Explicitly mention people’s attachment to the NHS. Talk about “the NHS we all value and rely on” and how it’s there for us “from cradle to grave”.
- Avoid making the NHS a central part of your messaging.
What does it look like?
Before
“The NHS today is under tremendous pressure to continue to deliver a service that is effective, accessible, equitable and sustainable. Improvements in life expectancy at birth might be stalling for the first time since the introduction of the NHS in 1948.”
After
“The NHS we all value and rely on was never meant to go it alone. It was supposed to be part of a wider system supporting people from cradle to grave; with decent jobs, pay, homes and education. To make sure the NHS can keep helping us in the way it was intended to, we need a broader system of support that can help all of us to thrive.”
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Use data to strengthen your story, not to tell it
Stats don’t speak for themselves. We can help people make sense of facts and figures by putting them in context; with metaphor, explanation and by cuing why they matter.
How to do it
- Lead with why this matters: lives are being cut short.
- Explain the causes – you can do this through using the building blocks metaphor or by using words that link cause and effect (because, this leads to, this results in, this means etc)
- Make numbers easier to understand by placing them in a familiar or relatable context. For example, you might compare numbers of people to populations of a city: ‘that’s the same number of people as live in Greater Manchester’.
What does it look like?
Before
“Life expectancy for females is 10.2 years longer in the least deprived areas compared to the most deprived areas in Scotland. For males that difference increases to 13.5 years.”
After
“Right now, people in our poorest neighbourhoods are dying over a decade earlier than their peers. When we don’t have what we need to heat our homes, buy healthy food and are constantly worrying about making ends meet, it can lead to chronic stress, poor health and lives being cut short.”
Order of communications
Persuasive stories have three key ingredients. They need to:
- Show why the issue matters
- Explain what it’s about
- Show we can fix it
When communicating about the building blocks of health, use this sequence:
- Lives cut short
- Explanation (building blocks metaphor and/or step-by-step causal explanation)
Lives cut short establishes why the issue matters before anything else. It should be human and specific — not a statistic on its own, but a statement that people in some parts of the country are dying earlier than they should, paired immediately with an explanation of what is causing it. Never leave lives cut short without explanation — without it, people conclude this is just the way things are and nothing can be done.
Explanation follows the opening. The building blocks metaphor gives people a picture of how multiple conditions work together to shape health — name the blocks concretely (warm homes, fair pay, green space) and show how missing or crumbling blocks lead to poor health. Step-by-step causal explanation goes deeper into one building block, showing how it affects health through a chain of cause and effect. Use language that makes the chain explicit: because, this leads to, this results in, this means.
Solutions must appear early and often — not as an afterthought at the end. Show that the building blocks can be repaired, replaced, and strengthened, and that decisions made by people can make a real difference. Aim for a ratio of at least two parts can-do to one part problem. Leaving people at the crisis without a route forward produces fatalism.
When communicating about a tool, process, or programme, establish the human stakes — what this means for people’s health and lives — before describing what the tool is or does. Leading with the instrument rather than the human consequences loses the audience before they are engaged.
Collective language
Use we/us/our rather than they/their where possible, to position the communicator as part of the community.
What works, and what doesn’t
The research shows that certain words and ideas work better than others when talking about the wider determinants of health. We need to keep using these words and ideas to tell our stories.
| Embrace | Replace |
| Lead with the fact that lives are being cut short. | Make the argument about helping people to live longer, or about improving health and wellbeing. |
| Talk about life-expectancy, lives being cut short or people dying earlier than they should. | Terms like disability-free life expectancy or healthy life expectancy. |
| Use a building blocks metaphor to explain the role of the wider determinants of health. | Talk about the wider determinants of health without explaining how or why they affect our health. |
| Talk about solutions often and be explicit that we can create change. | Focus only on describing the problem and talking about crises. |
| Explain how the NHS was never meant to go it alone but be part of a broader system of support providing jobs, homes, and education. | Focus on addressing the wider determinants of health to reduce the strain on the NHS. |