Framing Strategies to Avoid Mother-Blame in Communicating the Origins of Chronic Disease

Abstract

Evolving research in epigenetics and the developmental origins of health and disease offers tremendous promise in explaining how the social environment, place, and resources available to us have enduring effects on our health. Troubling from a communications perspective, however, is the tendency in framing the science to hold mothers almost uniquely culpable for their offspring’s later disease risk. The purpose of this article is to add to the conversation about avoiding this unintended outcome by (1) discussing the importance of cognitive processing and issue frames, (2) describing framing challenges associated with communicating about developmental origins of health and disease and offering principles to address them, and (3) providing examples of conceptual metaphors that may be helpful in telling this complex and contextual story for public health.

Evolving research in epigenetics and the developmental origins of health and disease (DOHaD) offers tremendous promise in explaining—at a biological level—what public health has observed throughout its history: that the social environment, place, and resources available to us have critical and enduring effects on our health.^1,2 In particular, this science suggests that our initial vulnerabilities for many chronic health problems, including obesity, cardiovascular disease, diabetes, some cancers, and a range of cognitive and mental health issues, are largely established before and during our first 1000 days after conception, or roughly to the age of 2 years.^3–5 These vulnerabilities result from shocks to our developing bodies—elevated systemic cortisol and poor nutrient flow being among the most studied—that can alter gene expression and physiological “programming.” Such changes also may be passed to offspring.^6–8 Research further indicates that these disease-predisposing alterations are influenced by the environments we are in and the circumstances we experience.^9–12

The potential public health impact of this research is substantial. It suggests that the causes of adult disease take root much earlier than previously understood. Troubling, however, is a tendency recently discussed by Richardson et al.¹³ that in communicating about DOHaD—by definition a phenomenon surrounding gestation and shortly after birth—we often directly and indirectly blame mothers for their offspring’s later disease risk.^13–15 This group of DOHaD and cultural studies researchers also note that this tendency is not new. Scientific language has also historically held women accountable for the adverse effects of fetal alcohol syndrome,^13,16 gestational exposure to crack cocaine,¹³ and autism.¹³ In all cases, it has largely been the mother, devoid of the circumstances in which she exists, held almost uniquely culpable for damaging her unborn child. Yet, as the history of public health and the literature on social determinants of health reveal, behavior—though important—occurs within a larger context. To realize the public health promise of this work and move the research from scientific bench to population-level intervention, we will need to overcome a deeply entrenched problem: the societal tendency to blame the victim.¹⁷

Richardson et al. identify specific risks to women resulting from mother-blame, including stigmatization, scapegoating, and the potential to invite surveillance and regulation during pregnancy.¹³ The additional risk we highlight in this article is the risk to efficacy: in focusing blame on mothers, we may distract from the breadth of other important solutions to be considered.

The purpose of this article is to build on the discussion about how to reframe the conversation and avoid unintended blame by

• (1) Discussing the importance of cognitive processing and issue frames,

• (2) Describing general and specific framing challenges associated with communicating about DOHaD and offering principles to address them, and

• (3) Providing examples, relative advantages, and potential disadvantages for conceptual metaphors that may be helpful in telling this complex story.

It is important at the outset to commit to the same assertion made by others:

[W]e are not claiming that individual mothers never affect their children negatively or that all mothering is desirable. We are concerned with the general indictment of a group—mothers.^18(p2)

It is also important to acknowledge that reframing the conversation does not fundamentally change the deeply entrenched conditions that constrain and adversely define women. Rather, our efforts are to help ensure that communicating this new and promising science does not inadvertently amplify those conditions.

COMMUNICATING DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE

These most recent researchers to assert mother-blame in DOHaD communications call for messaging with an increased emphasis on the role of society in the origins of disease.¹³ But, as we will discuss, the specific language used and imagery invoked in forming such arguments pose unique challenges. We believe that communication tools provided by cognitive, linguistic, and social sciences may be helpful in addressing these challenges. Furthermore, we believe that these tools support translating DOHaD science for population-level application, and effectively telling this story from an “upstream” public health perspective.

Cognitive Processing and Message Framing

Cognitive science reveals that we continuously process all incoming information through mental models, or “frames.”^19–21 We match the cues we perceive to the frames we hold in our minds to understand what we are observing, what it means, how it came to be, and what we think should be done about it.²² As such, frames act as the filters through which we process and understand our experience of the world.^23,24 Our minds have a continuing need to immediately diagnose, organize, and ascribe meaning to all that we take in.^25,26 This need is so primary that if we are not provided a new frame for understanding a given phenomenon, we will find ways to link the new ideas to existing frames.

Frames matter because they tell us what is important about an issue and where to focus our attention.²² They tell us what factors are to be considered within an issue and, usually by abstraction, which are outside it.^20,22 Framing suggests that if we want people to be able to consider specific elements of a problem or phenomenon—particularly when doing so involves introducing a new mental model—we need to include those elements in the explanatory frame. At the same time, we need to be certain not to activate other elements that would functionally preclude that processing.

For example, framing research suggests that when we tell stories through frames that focus attention on individuals, we may limit an audience’s understanding to individual-level causes for and solutions to the problem.²¹ By contrast, when we construct a broader narrative—such as to include the web of activities and decisions that help communities grow stronger—we can expand people’s vision to include systemic causes and potential solutions. This suggests that the initial frame with which we process an issue can be sufficiently powerful that it shapes the range of possibilities we subsequently consider.^21,27

Developmental Origins of Health and Disease Communication Risk

The science of DOHaD and epigenetics represents, for most people, entirely new combinations of ideas and concepts that require novel frames for understanding. This challenges us to provide new mental models that move beyond older disease-causation frames, so that we may help audiences navigate the contours of DOHaD science and consider the breadth of causal factors and prevention options available.

According to dominant Western frames for pregnancy and prenatal development, the pregnant woman is easily understood to be the primary, if not exclusive, influence on her developing child. It is a readily accessible cognitive map, according to which she is cast in 1 of 2 broad roles relative to the developing baby: she can be either “helper” or “harmer.”²⁸ Although both roles draw lines of responsibility for fetal well-being to her, neither frame incorporates the many environmental influences to which she is exposed. As such, this frame may be limiting our collective abilities to consider the full range of options for addressing the origins of disease.

It is important to recognize that, because of the ways our minds categorize and connect concepts, “mothers” will always be included in the concept of “pregnancy.”^25,26 This means that we must also pay special attention to the less readily accessible frames that incorporate the myriad external factors affecting pregnancy.

FRAMING THE STORY OF DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE

We offer 5 communication recommendations to help activate the necessary frames for understanding the ecology of DOHaD. Each is based in a broader principle of effective communication that takes on special significance in efforts to avoid the unintended trap of mother-blame. It is important to note that there is more work involved in framing and message development than can be fully covered here, including examining the critical intersections of messengers, channels, and audiences.²⁹ Therefore, what we present here should be considered first steps in reframing DOHaD communications to include a broader range of causes and solutions.

“Framing-in” Critical Causal Factors From the Start

The role of the mother as the environment of the developing baby is universally understood. What is less considered is that society is also the environment of those babies, through the experiences of pregnant women. Thus, if we want people to consider the influence of social and contextual factors on women’s pregnancies, our core arguments must (1) avoid cueing mothers into the roles of harmer or helper, (2) present societal-level influences clearly and as primary sources of risk, and (3) match level of solution to level of cause.

For example, when we portray causal factors as maternal “choices” (e.g., what she eats, her physical activity level, whether she seeks sufficient prenatal medical care), we exclude from the frame the many contextual factors—often determined by shared societal decision-making—that shape mothers’ actions. Such factors could include whether communities have access to healthful affordable foods, workers are paid a living wage to afford both fresh food and an adequate kitchen to prepare it in, streets are sufficiently lit and safe and facilities are available for regular physical activity, and access to affordable quality prenatal care is broadly ensured. To avoid inadvertent mother-blame, we must articulate a model in which the influences of context on pregnancy are clear.

This is more difficult than it seems. Despite our strong understanding of social determinants of health, our professional and public dialogues about public health problems have often included a mixed pairing of socioenvironmental cause with individual-level solution.^30–32 Avoiding disproportionate focus on mothers will require saturating our discourse with socioenvironmental solutions that match socioenvironmental causes.

Using Metaphors to Cue Mental Models

The terminology that characterizes the science of DOHaD, including “methylation,” “hypothalamic–pituitary–adrenal axis,” “phenotype,” and even deceptively simple words such as “programming,” “risk,” and “vulnerability,” carries specialized meaning that separates those outside the field from deeper understanding of the research. To maximize clarity and demystify new and complex technical information, it is helpful to make use of conceptual metaphor to paint mental pictures of key aspects. Metaphors are powerful in helping people more fluidly process the concepts presented and relate them to existing and relevant mental models.^33,34 Not only does matching to existing, analogous images provide a short-hand mechanism for processing new information, a well-selected metaphor can also extend the emotive meanings associated with it.²⁷ As such, metaphors help to build frames.³⁵

For example, consider the difference between the images of “safety net” and “hammock,” 2 metaphors invoked during national debates about public social services. The first conveys images of something helpful that can protect us when we are at risk for a fall. In the face of danger, a safety net is likely something both wanted and appreciated. The latter, by contrast, conveys images that range from leisure to laziness. Depending on context (e.g., whether others think effort rather than idleness is required), the image of a hammock can evoke feelings of disapproval or disdain.

In the next paragraphs, we offer examples of metaphors that may be useful in communicating the contextual aspects and implications of DOHaD science. Each helps to convey DOHaD’s different mechanisms in highly visual and intuitive ways. We selected or developed these metaphors to address key aspects of the DOHaD story, and assessed each according to standard principles of metaphor analysis to determine its conceptual function(s).^33,34 We then further assessed each metaphor’s main “entailments” (i.e., the primary set of ideas, concepts, and emotions the metaphor contributes) for likely effectiveness in avoiding mother-blame.

Our genes listen to our environments.³⁶

This metaphor can be used in explaining epigenetic influences on health and chronic disease vulnerability. It highlights the power of environmental influences in our development.

Babies “come from” society.²⁸

This metaphor can be used in explaining the influences of social determinants of health on chronic disease risk. It helps to emphasize the relationship between our health, disease vulnerability, and the environments our mothers experienced while pregnant. In addition, it conveys that improving conditions during pregnancy means improving conditions for communities.

Babies are record keepers of societal decisions.⁹

This metaphor can be used in explaining the intergenerational perpetuation of chronic disease risk. It stresses that each society’s decisions today affect population health for generations to follow.

Our health is a car traveling hazardous roads.³⁷

This metaphor can be used in explaining the dual influences of initial health status and environmental exposures on lifetime chronic disease vulnerability. It indicates that there are 2 broad points of intervention in reducing chronic disease risk: we can act at the level of individuals’ health (the “cars”) and act at the level of the environment (the “road”).

It is important to caution that any language—even language that has been evaluated for relative strengths and weaknesses—can have unintended consequences and may not be appropriate for all contexts. For example, in describing genes as “listening” to environments, we do not convey that those environments are the result of shared decision-making and thus also subject to change through collective action. These important points need to be addressed separately. Similarly, in using the “hazardous roads” metaphor, there is danger that we can miscue people to judge how people are “built” by overemphasizing opportunities to act at the level of the “car” relative to opportunities to address the “road.” Special care must be taken across the entirety of the message to ensure that clear focus on intervening at the level of the environment is maintained. (For sample language applying each metaphor, please see the file available as a supplement to the online version of this article at http://www.ajph.org.)

There are many mental images that could be invoked to facilitate understanding of DOHaD science. We offer these as starting points to help work through the scientific complexity while also maintaining focus on DOHaD’s multicausal origins.

Telling Population Stories to Illustrate Condition Complexity

People communicate not only through core argument and metaphor, but also through story. We all understand the importance of stories when we communicate in our everyday lives, but frequently lose sight of that fundamental tool in professional communications. Moreover, when we do set out to tell a story about a community-level problem or one with systemic origins, we often inadvertently do the opposite and tell stories about particular individuals who have experienced the phenomenon being discussed. If we want people to be able to consider broader social context, population impact, and opportunities for societal-level action, we need to tell what Marshall Ganz has called the “Stories of Us” and “Stories of Now.”³⁸ These are stories that (1) describe shared contexts, opportunities, and fates, and (2) call us to collective action to address urgent problems. For example, his model suggests that a story of an individual struggling on her own:

This mother has found it nearly impossible during her pregnancy to get adequate nutrition, because she lives with challenges such as. . . . As a result, she has now taken these personal steps. . . .

is likely to prompt different thinking than a story of collective decision-making and shared outcomes:

We recognize that our future is determined by shared actions taken each and every day. Because of this, members of our community are coming together to ensure that we are investing in affordable, safe, nutritious, and available foods for all children and families. We have started by taking a comprehensive look at all the ways food comes to and is distributed within our community. We have discovered problems, but we have also discovered that they are ones we can fix, as our community and state leaders, businesses, schools, and local organizations work together to create solutions. . . .

Thus, if we want to use stories to help people imagine how social change takes place, we need to be certain that the stories we tell convey examples of shared social action.

Avoiding Elephants

Often in explaining what a problem is, we begin by explaining what it is not. Sometimes we do so in an effort to provide clarification: “This is not a problem of . . . but rather a situation in which. . . .” The problem, as George Lakoff explains, is that in invoking any frame—including those we are raising only to disavow—we are drawing cognitive maps between ideas that cannot be undrawn. In Lakoff’s words, there is no way to say “Don’t think of an elephant” without having an elephant appear in our minds.³⁹ Instead, the unwanted map persists and acts as filter for all that is subsequently perceived.

What this means for communicating about DOHaD is, if we do not want to foster a mother-blame frame, we need to be careful not to raise—or reiterate someone else’s use of—a mother-blaming frame. This sounds deceptively simple, but in practice it runs counter to many of our common communication instincts. For example, when we say:

• “We need to focus on mothers’ diets during pregnancy. . . .”

• “Help her make the healthy choice. . . .”

• “If women experience too much stress. . . .”

• “Her body’s poor nutrient flow. . . .”

or even simply tell the story from the perspective of

• “. . .a woman’s pregnancy. . . .”

we map an understanding of the issue that situates causes and solutions within mothers. If instead we frame the issue around

• “The circumstances in which women are pregnant and in which children develop. . . .”

• “The social and economic pressures facing that community. . . .”

• “Helping society ensure that affordable and healthful foods are accessible to families. . . .”

• “The social circumstances that surround a woman, affecting both her and her developing baby. . . .”

we broaden the cognitive map, inviting consideration of the full complex of influences that give rise to the problem. This larger context includes the mother, but importantly does not first invoke a frame that would functionally impede more inclusive thinking.

Balancing Short-Term Communication Needs and Long-Term Goals

It is tempting to respond to an immediate question or assertion without fully assessing whether the most immediate response might create difficulties for the longer-term message. A frame about behavior that rests solely on the individual and avoids broader context, for example, is generally easier to communicate than one that draws connections to external forces.

For example, “Yes, women should eat XYZ. . . .” is often a more expedient response to an inquiry about women’s dietary patterns than, “If we want families to have healthful food available to them, we must ensure that all communities have the benefit of. . . .” To consistently speak from this broader frame requires careful planning for anticipated questions, continued attention to language used and images invoked, and ongoing evaluation of how messages are received and processed. All of these tasks require sustained commitment to adjusting messages to prevent unintended consequences.

CONCLUSION

Bill Moyers credits American folklorist and writer Joseph Campbell as saying “If you want to change the world, you have to change the metaphor.”⁴⁰ Of course, it is not quite that simple. Language and frames not only influence societies, as we have discussed, but also reflect the cultures in which they develop. As such, changing the frame about responsibility for ensuring the conditions of healthy pregnancy—though important—is only one step toward the significant social change needed to ensure that those conditions are made available to everyone. That said, we do believe the frame and language must change from a primary focus on women to a broader perspective on social determinants, to fully realize the potential of DOHaD science for public health interventions.

A critical step in expanding the frame will be to ensure that our messaging of the science, its implications, and its proposed interventions all allow for broad consideration of the factors giving rise to population disease risk. This begins by recognizing that asking, “What would a woman do today if she wanted to help her baby avoid chronic disease?” is very different from, and much more limiting than asking, “What would our society do and provide if we wanted to be the healthiest place to be born?” In other words, if we do not ask broad and inclusive questions, we are unlikely to get to broad and inclusive solutions.

It is always essential in communication planning to systematically examine reception of messages among different audiences and in varied contexts. Future targeted testing will allow for greater understanding of which messages best suit specific public health needs. It will also be necessary to continue to develop, adapt, and test frames and metaphors as the science and its public health implications evolve. Furthermore, it will be critical as the field works to apply the science for population-level prevention that all messages be fully vetted for unintended consequences in specific applications.

It will also be important to avoid merely shifting blame, and instead maintain focus on addressing the systems that give rise to DOHaD-related risk. For example, although we know that the biological processes at work in DOHaD are universal, we also understand that adult chronic disease tends to aggregate among those who struggle with inadequate food systems, lack of economic opportunity, exposure to environmental toxicants, and marginalization along lines of class and race (among other entrenched social issues). All of these are factors upstream of the nutritional flow and cortisol exposure problems indicated by DOHaD. As such, care will be required in speaking of the relative roles of “community” and “society” in ensuring optimal conditions for pregnancy, to avoid shifting blame to groups currently struggling under limited resources and power.

Similarly, others have observed that epigenetics communication brings the potential for shifting from individual-level blame to “intergenerational blame.”⁴¹ Further work also will be required to avoid moving the spotlight from a singular blame on mothers to an acontextual focus on grandmothers or grandparents.

The unique contribution of public health is to pull back the lens and capture the landscape view on health risks and outcomes. The science of DOHaD offers an opportunity to take this broader view as we translate research to action. The challenge we face is to not only communicate about, but also to invite others into, all that we can see through this more expansive lens. In so doing, we can help to ensure that our approach to the problems this science reveals incorporates the full range of options available to us.