Understanding how the public thinks about health

While surveys of public attitudes help us understand what people think about health, they give limited insight into how people think. To broaden our understanding of the social determinants, we need a deeper understanding of the ‘cultural models’ – the assumptions, underlying beliefs and ways of thinking – that shape how people understand messages about health.

The research approach

FrameWorks conducted interviews with members of the public and those working in the field of social determinants of health, including academics, public health professionals and policy makers. Interviews with individuals working in the field of social determinants enabled FrameWorks to capture the ‘untranslated story’ of social determinants – the key ideas that members of the field want those not working in the field to understand or support. By comparing these with the way the public currently thinks about health, as captured by interviews with members of the public, FrameWorks were able to identify the gaps that must be bridged for the public to have a fuller understanding of the social determinants of health.

FrameWorks, in consultation with the Health Foundation, selected interviewees working in the field of social determinants to reflect a diversity of perspectives and areas of expertise. In 13 semi-structured, 1-hour interviews, researchers asked questions and used hypothetical scenarios designed to capture their understanding of what a healthy society is. They used follow-up questions to encourage the interviewees to elaborate on and clarify their answers. The interviews were analysed using a grounded-theory approach, in which researchers identified common ideas and categorised them, allowing themes to emerge from the data.,

Members of the public were interviewed using semi-structured, 2-hour interviews exploring their understanding of health, allowing researchers to capture the broad implicit assumptions and patterns of thinking (cultural models) that people use to make sense of the topic. Participants were selected for interview through a market-research organisation, based on criteria that were chosen to ensure the demographics of the sample were similar to that of the UK population. Interviews were analysed using ‘cultural models’ techniques, which are not designed to identify differences in understanding between population sub-groups, but rather, to identify common ways of thinking. The sample of 36 participants contained enough demographic variability (for example in age, gender, ethnicity, education, political affiliation and income) to ensure that identified patterns of thinking are truly shared across demographic lines.

By analysing these interviews, FrameWorks identified a series of cultural models that underlie how the British public thinks about health (Box 2).

Box 2: Cultural models

Cultural models are common, but implicit, assumptions and patterns of thinking that underlie how people make sense of the world around them.

People may draw on multiple, conflicting models to think about any given issue. Different models may be activated in people’s minds at different times, though some are dominant and used more consistently than others. Understanding which cultural models are most productive, and which are most likely to obscure people’s understanding, is an important first step in developing effective ways of framing an issue.

The cultural models referred to in this briefing are as follows:

  • Absence of illness: defining health as not being ill, rather than as a positive state of wellbeing.
  • Health is medical: understanding health primarily in relation to medicine, doctors and health care.
  • Health individualism: understanding health outcomes as being driven primarily by individual choice.
  • Mentalism: explaining individual behaviour as the result of individual discipline and willpower, or a lack thereof.
  • Genetic exception: using genetics and ‘fate’ to explain exceptions to the rule or cases where health cannot be explained by individual choice.
  • Health consumerism: a belief that money allows people to buy good (or better) health by adopting healthy individual behaviours such as healthier diets or access to a gym.
  • Behavioural constraints: recognising that social and environmental factors affect individual health outcomes by restricting or encouraging particular behaviours.
  • Cultural norms: seeing communities or family units as having accepted standards about what is ‘normal’ and ‘healthy’, and that health outcomes are a result of these.

These cultural models fall into two broad strains of thought:

  • an individualistic strain, which assigns a central role to individual choice and willpower – for example, the health individualism and mentalism cultural models
  • an ecological strain, which sees health, at least in part, as a product of social and environmental influences – for example, the health consumerism and behavioural constraints cultural models.

The research found the individualistic strain to be dominant in public thinking.

More details of the research methods, samples and findings are available in reports by FrameWorks.,

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