The Public Conversation and the Public’s Health: A Public Health of Consequence, December 2018

The health of populations is ultimately shaped by the social, economic, and political forces that create the world around us—that influence the food we eat, whether we are exposed to violence, and the availability of harmful substances.^1,2 There is little doubt that these same forces are shaped by our norms and conversations about how we wish to live—that shape the choices we make that ultimately influence our health. This is true both at the level of political action and the public conversation.

THE ROLE OF POLITICS

Starting with the former, although, for example, legislators play an important role in setting laws and regulations that give shape to the conditions in which we live, these same legislators are elected—or not—by voters depending on whether they are broadly reflecting the general public’s perception of what is, or is not, a reasonable direction for society to be going. Leaving aside the issue of the disproportionate influence that corporations and other large entities can have on legislators and on the political process, demand for a particular course of action leads, not infrequently, to political actions that shape our world, for better or for worse.³ This extends readily to the area of health. For example, it required a turn in public sentiment—as part of the Great Society Movement—in the 1960s to pave the way for the development of Medicare. Decades later, President Obama was able to prevail in implementing the Affordable Care Act in no small part attributable to the general public finding it unacceptable that so many Americans remained uninsured.⁴

ATTITUDES AND BELIEFS

Three articles in this issue of AJPH make the latter point—how our attitudes and beliefs shape our health—and do so by considering three enormously different issues. Woo Baidal et al. (p. 1659) consider parental attitudes toward sugar-sweetened beverages (SSBs) and the consumption of SSBs by children in the first 1000 days of the children’s lives. The authors found, perhaps not surprisingly, that the children of parents with more negative attitudes toward SSB consumption consumed fewer SSB calories. Importantly, the authors also showed that the children of parents with more positive attitudes were more likely to have higher SSB consumption, providing one simple and effective explanation for the transmission of obesity across generations. This study readily captures the tight link between our attitudes and our behaviors, consistent with decades of research in the field, extended here to the issue of SSB consumption in low-income populations.

The second, very different article, takes us to Afghanistan where Li et al. (p. 1688) studied attitudes toward interpersonal violence in a country where such violence is endemic. They found, again not surprisingly, a high degree of endorsement of violence justification among both men and women, approving of spousal, child-rearing, and educational violence. The authors suggest that a breadth of strategies need to be adopted to minimize violence in Afghanistan, noting that these strong social norms can derail violence mitigation strategies.

The third article on this point, by Shev et al. (p. 1669), looked at the influence of California’s prescription drug monitoring program’s (PDMP) registration mandate on use of the PDMP. Although at first blush this article does not tackle long-held beliefs, it shows, effectively, how even mandating registration of PDMP does not result in easy acceptance, with registration plateauing well short of complete registration. In many respects, registration here was a start toward changing behaviors, but was only partially successful, with established norms standing in the way of deeper change, at least for the time being.

History and these illustrative examples in this month’s issue of AJPH call attention then to the role of the conversations that inform what we do, locally, nationally, and globally, and push us to reckon with the forces that shape these conversations. In many respects, we would argue that as long as these conversations matter to the creation of the conditions in which we live—and it is hard to imagine a time when they would not—we then must grapple with the public conversation and the norms that shape our daily life and patterns. But how do we then inform the public conversation? And how do we best influence it to the end of generating a healthier population?

THE PUBLIC CONVERSATION

We suggest two thoughts that might help focus our approach.

First, we must put the public conversation, at a global, national, and local level, front and center in the work of public health. Unfortunately, this is both far from what we are accustomed to doing and several steps removed from the comfort zone for most of us in public health. At core, this means changing hearts and minds, creating a demand for health that can inform and nurture broader legislative efforts, and encouraging the creation of structures that generate health. This calls for an activist engagement with how we think about health, with creating a world where health is a priority and, as importantly, where we understand that the generation of health will require the creation of a world that produces health. This will require a relentless promotion of the ideas that animate public health, and our engaging all means at our disposal to articulate the narratives that can change the public conversations and set the stage for a world that produces health. This may mean that we encourage narrative and storytelling toward the ends of promoting an understanding of public health and employing the methods of marketing and communications as core tools of public health.

Second, we need to consider the role of norms and the public conversation as central, ubiquitous, and ineluctable drivers of population health, in all aspects of our population health science and in our public health practice. This will require that in our scholarship we engage with the role that the public conversation plays as a cause of population health, influencing the relation between other causes and health indicators. In our practice, we need to remember that well-intentioned interventions may fail if we fail to account for deeply held norms and for public perceptions that stand in the way of the outcome that would improve the health of the public. Going back, for example, to the work of Li et al., it is hard to imagine substantial success against domestic violence in Afghanistan without substantial effort invested in changing a public conversation that tolerates violence as a means of resolving any number of conflicts, and any violence prevention effort simply is bound to underperform unless this underlying cause is also considered.

In sum, our norms and the broader public conversation that influence them are an unavoidable cause of population health. A public health of consequence must recognize this and consider both how we may study and also change such a conversation. Training the next generation of population health scholars and public health practitioners to do just that stands to move us in the right direction.