Public health workers have to be especially careful with the words they use. With people’s trust and support key to the field’s mission, language can make a critical difference.
“The language we use is more important than we think,” John Kelly, PhD, an associate professor of psychiatry in addiction medicine at Harvard Medical School, told The Nation’s Health. “It’s not about being politically correct or being nice — it’s much bigger than that.”
For Kelly’s field, in particular, words have serious impact and few are immune to their powers, including health professionals. In a 2010 study published in the International Journal of Drug Policy, researchers surveyed about 500 clinicians after they read vignettes containing either the phrase “a substance abuser” or “having a substance use disorder.” Clinicians exposed to “substance abuser” more often agreed that punitive action should be taken, with the two phrases evoking “systematically different judgments.”
Research shows that words and language make a difference in public health, from promoting healthy foods to vaccine education to smoking cessation. In the addiction field, a Massachusetts group has created a glossary to help guide health workers in the language they use to improve health of patients.
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Language sways public views of addiction too. A 2014 study published in Psychiatric Services surveyed hundreds of U.S. adults with questions containing either “mental illness” or “drug addiction,” finding a huge advantage for “mental illness.” For example, 64 percent of respondents thought employers should be able to deny employment to people with “drug addiction,” versus 25 percent who supported the same practice for people with “mental illness.”
“Our language activates these implicit cognitive scripts that give meaning to what we try to convey and communicate,” Kelly said. “That’s why we need a language that unifies the field and reflects more of the true nature and understanding of addiction that’s been uncovered in the last 30 years.”
To fill that gap, Kelly helped create the “Addiction-ary,” a glossary of addiction-related words and terms to help guide providers in their word choices. The Addiction-ary, published by the Recovery Research Institute, a nonprofit that Kelly directs at Massachusetts General Hospital, offers an extensive list of definitions, including information on why particular language is important and how it impacts people’s willingness to seek treatment. Some words, such as “substance abuse” and “addict,” are tagged with a stigma alert.
In general, Kelly said a good rule of thumb is always using person-first language, such as saying a “person with an eating disorder,” instead of a “food abuser.”
“Without empirical basis, this is often viewed as being PC,” he said. “But now we have studies that show it can induce implicit cognitive biases.”
Language, messaging and the right person to relay them have long been a focus of public health study. Beyond the addiction field, public health research finds that words and language make a difference for just about every priority in the field, from promoting healthy foods to vaccine education to smoking cessation. The public health implications of words even led the National Highway Traffic Safety Administration to announce in 1997 it would no longer use “accident” for a car crash, as it implies the event is not preventable. Health and medical groups have enacted word policies as well — for example, both APHA and the American College of Legal Medicine have policies against using “suicide” in reference to physician-assisted death. In short, words matter.
“There’s not any part of the scientific enterprise that does not involve communication,” said Laura Lindenfeld, PhD, director of the Alan Alda Center for Communicating Science at Stony Brook University in New York. “The U.S. public tends to trust science, so we want to help scientists and medical professionals be the best communicators they can be.”
Since 2009, the center has trained more than 11,000 professionals in the science, technology, engineering and medical fields, including public health workers. A pillar of its instruction is improvisation, according to Valeri Lantz-Gefrah, MSA, who leads the center’s Improvisation Program. The center’s technique, she said, is based on the teachings of Viola Spolen, often considered the founder of American improv, who originally developed the method to help build connection and community among the newly arrived immigrants at the settlement house where she worked. Lindenfeld said employing improv helps scientists focus on how their word choices help them connect and relate to an audience — “to share the wonders and joys of science and help create a world that values and uses science,” she said.
In the center’s early days, Lantz-Gefrah said it took time to build buy-in that scientists needed the training, but now scientists are eager to hone their communication skills.
“The words that you say are as important as the way you deliver them,” Lindenfeld said.
In choosing those words, sometimes the best option is to veer away from the health talk, especially when it comes to food.
“I’d say that people’s overall interest in nutrition lately is probably higher, but it’s not always an inducement to try things,” Adam Brumberg, deputy director at the Cornell University Food and Brand Lab, told The Nation’s Health. “The additive effect of giving something a creative name is pretty powerful across a wide range of groups.”
For example, research out of the lab has shown that kids will eat more veggies if they have funny names such as “X-Ray Vision Carrots” and “Tomato Bursts.” In a 2009 study of nearly 400 4-year-olds, researchers found kids ate twice as many carrots marketed as “X-Ray Vision Carrots” than carrots that are not renamed. And the positive effect seemed to persist even after “X-ray” was dropped from the description. The lesson is true for adults too, Brumberg said, with many more apt to respond to descriptors of a food’s benefits — like boosting the immune system or providing energy — than simply labeling an item as “healthy.”
The Cornell lab is involved in the Smarter Lunchrooms Movement, an effort to help schools build lunchroom environments that promote healthy eating. As part of its efforts, the movement offers an extensive list of creative names and descriptors for food, such as “Big Bad Bandit Beans,” “Tasty Tiny Tree Tops” for broccoli and “bone-protecting” milk.
“It’s challenging for public health people — they have so much information in their heads that it can be hard for the rest of us to make use of it,” Brumberg told The Nation’s Health. “But it’s important to remember that perception is often reality, so what people think of something often matters more than the facts in the moment.”
Of course, avoiding certain words can create perception problems as well. In December, The Washington Post reported that the Centers for Disease Control and Prevention had “banned” seven words from its budget documents: evidence-based, science-based, vulnerable, transgender, entitlement, diversity and fetus. The U.S. Department of Health and Human Services and then-CDC Director Brenda Fitzgerald, MD, denied the reports, but the idea earned swift condemnation.
“I think people got angry because the specific words chosen were words so much in the heart and fiber of what public health is,” said Lawrence Gostin, JD, faculty director at the O’Neill Institute for National and Global Health Law at Georgetown University. “These are words that make up the nuts and bolts of what CDC is about.”
Gostin authored an article about CDC’s seven-words controversy in the February issue of the Journal of the American Medical Association, writing that “warning CDC not to use certain words in budget requests may be well-intended, but it sends a political signal that could result in self-censorship — from research and scientific publications to health information.” He said the idea that words like “science-based” and “evidence-based” would be considered somehow inappropriate to present to congressional appropriators signals a much broader problem.
“This is a part of a wider pattern of undermining science and trying to cast doubt on science,” Gostin told The Nation’s Health.
Jay Bernhardt, PhD, MPH, professor and dean at the University of Texas Moody College of Communication, agreed that any limiting of language or speech within agencies, especially CDC, should be cause for concern.
“If CDC doesn’t have the full ability to communicate clearly between scientists, between agencies and with the public, it can’t really accomplish its mission,” Bernhardt, a former member of APHA’s Executive Board, told The Nation’s Health. “Science and evidence first, at all times.”
In his opinion, Bernhardt said one of the best public health campaigns in the last decade is CDC’s Tips From Former Smokers campaign, the first paid national tobacco campaign that featured real people living with smoking-related health consequences. The campaign’s direct language and authentic images worked: Research shows that since 2012, millions of Americans have tried to quit smoking because of the campaign, with at least 500,000 quitting for good. Bernhardt described the campaign as having the right combination of powerful messaging, high-frequency exposure and a clear call to action.
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When it comes to public health communication, Bernhardt said scientific accuracy and credibility should be first and foremost. But after that, he says to go with what works.
“I put a premium on what’s most effective for my audience,” he said.
Then there are the cases in which even the best language only works if the right messenger delivers it. In 2014, the health communications agency Kyne helped launch a campaign aimed at protecting health workers responding to the Ebola outbreak in West Africa, after reports of workers being attacked as they returned home to their villages. David Kyne, MA, founder and CEO, said at the time, there was so much mistrust surrounding the outbreak that health sources such as CDC, the World Health Organization and ministries of health were seen negatively.
Instead, the agency recruited professional soccer players from the countries affected to star in a PSA called “I’m No Hero,” which praised the work of Ebola responders and encouraged trust among viewers. In the ad, the name on the back of each player’s jersey is that of a health worker.
Kyne said the ads were positively received, having a powerful impact among responders who had lost colleagues to the outbreak.
You have to communicate in a language people understand,” Kyne told The Nation’s Health. “If it doesn’t resonate, it’s pointless.” To access the Addiction-ary, visit www.recoveryanswers.org.
- Copyright The Nation’s Health, American Public Health Association
