Communicating health risk in a context of uncertainty

In my writing about criminalisation and HIV stigma I have been strongly critical of the rational-individual ‘model’ (assumption) that underpins the health psychology and economics upon which so much of public health practice is based. I’ve argued we can learn a lot instead from behavioural economics and bounded rationality.

One of the biggest bounds (limits) on human rationality is the finite nature of what we know, especially with respect to what’s likely to happen in the future or about some newly-emerged and previously unknown problem or technology.

Nobel prize-winning research by Kahneman and Tversky (1979) developed ‘prospect theory’, which shows that in economic decisions, rather a lot depends upon how a prospect is framed — in particular in terms of whether it involves possible loss or gain.

There have been some rather clunky attempts to incorporate this insight into health promotion, such as by framing condom use in terms of what someone has to lose. It’s an important insight but it involves translating health behaviour into economic terms, which as Dan Ariely points out has a suppressive effect on social norms like altruism β€” not ideal!

Today and tomorrow, I’m attending the NCHSR Social Research Conference at the University of New South Wales. At this morning’s opening plenary, Alan Peterson from Monash University is presenting on communicating health risk in a context of uncertainty. He argues early framing of risks is influential upon subsequent responses: think about the panic about the high death rate in the early days of H1N1 flu in Mexico.

In all of those cases there was an intention to develop a framing and strategies very early on, with unintended consequences and a need to reframe the issue as it emerged and developed. Experts, particularly scientists, set out to claim the territory and easily achieve media attention. (As a sector, he says, we need to develop our understanding of the media. More on that later.)

Much was done in framing HIV/AIDS that we later regretted: by way of example, Peterson cites the Grim Reaper campaign. (He dates it at 1983/84 and says it was later withdrawn, although I thought it was from much later in the 1980’s and don’t recall anything about it being withdrawn).

I. Risk vs Uncertainty

Peterson suggests ‘risk’ has surpassed ‘culture’ (Williams, Keywords) as the most commonly used word in contemporary political discourse.
In expert discourse, ‘risk’ implies predictable, calculable and controllable; by contrast, ‘uncertainty’ implies unpredictable, changeable, arguable, doubtful.

Talking about risk instead of uncertainty is a claim to power, authority and expertise, which can produce disputes about legitimacy, of which Peterson gives two examples:

  1. In the climate change debate, the IPCC has come under attack for a failure to sufficiently acknowledge areas of uncertainty in the science. Peterson quotes an article headlined “Be truthful on climate: science boss” where UK scientist John Bennett calls for climate change scientists to get better at communicating uncertainty.

  2. Another article titled “DNA under legal microscope” reports that NSW has commenced a judicial enquiry into the use of the DNA in forensic evidence where it is the only evidence linking the accused to the crime.

Peterson goes on to discuss ‘framing’ of emergent problems/technologies in the context of uncertainty, using case studies of stem cell research, genetics research and nanotechnologies.

II. Framing defined

Miller & Riechert (2000:45) “Draws attention to the ways in which claims makers organise facts and claims and ignore others in their effort to shape public discourse and potentially public policy”.

Entman (1993:55) “To frame is to select some aspects of perceived reality and make them more salient in the communicating text, in such a way as to promote a particular problem definition…”

It’s important to note how this framing is different from the framing Kahneman & Tversky describe in prospect theory. It’s not about how framing influences individual decision-making about uncertain prospective gains/losses. It’s about how moral entrepreneurs (to borrow a term from Becker) can frame the debate in terms sympathetic to their claims.

It should surprise nobody to learn that I was a highschool debater, and the advantage of being the Affirmative team is that you get to speak first and define the key terms in the topic. In debating there was at least a procedural rule that your definition had to be reasonable and debatable on both sides; in political discourse there’s no such rule!

As Peterson points out, framing is an ongoing process β€” but early framing is remarkably persistent and a privilege of the first to speak. On a health issue that’s typically going to be a scientist, since that’s to whom the media will turn for quote.

In mid-2009 I gave a presentation at a forum convened by the Australian Research Centre in Sex Health and Society with the title “Clinicians are from Mars, Community workers are from Venus”. It argued that community people (including social researchers) need to get better at doing the media. (After all, we offer the all-important human interest angle).

However, HIV is no longer in any sense an ’emerging’ problem; it has been framed and reframed, and the challenge now is how to perform media and researched accounts of HIV as endemic. One way of framing endemicity is via generational accounts, so I’m curious to hear Yves Calmette speaking later in the conference, where he relates health promotion specifically to Gen Y and social media technologies like Facebook.