Reframing climate change as a public health issue: an exploratory study of public reactions
Climate change is taking a toll on human health, and some leaders in the public health community have urged their colleagues to provide voice to its health implications. Previous research has shown that Americans are just dimly conscious of the health implications of climate change, yet the literature on issue framing shows that providing a novel frame – such as for instance human health – may be potentially useful in enhancing public engagement. We conducted an exploratory study in the United States of people’s reactions to a public health-framed short essay on climate change.
U.S. adult respondents (n = 70), stratified by six previously identified audience segments, browse the essay and were asked to highlight in green or pink any portions associated with essay they found “especially clear and helpful” or alternatively “especially confusing or unhelpful.” Two dependent measures were created: a composite sentence-specific score based on reactions to all 18 sentences in the essay; and respondents’ general reactions to the essay which were coded for valence (positive, neutral, or negative). We tested the hypothesis that five associated with six audience segments would respond positively to the essay on both dependent measures.
There was clear evidence that two associated with five segments responded positively to the public health essay, and mixed evidence that two other responded in a positive way. There was limited evidence that the fifth segment responded in a positive way. Post-hoc analysis showed that five associated with six segments responded more positively to information about the health advantages related to mitigation-related policy actions than to information about the health problems of climate change.
Presentations about climate change that encourage individuals to consider its human health relevance appear likely to provide many Americans with a good and engaging new frame of reference. Information about the potential health advantages of specific mitigation-related policy actions seems to be particularly compelling. We think that the public health community has a significant perspective to share about climate change, a perspective which makes the problem more personally relevant, significant, and understandable to members of the public.
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Climate change is already taking a toll on human health in the United States  and other nations worldwide . Unless greenhouse gas emissions worldwide are sharply curtailed – and significant actions taken to simply help communities adjust to changes in their climate which are unavoidable – the human toll of climate change will probably become dramatically worse over the next several decades and beyond . Globally, the human health impacts of climate change will continue to differentially affect the world’s poorest nations, where populations endemically suffer myriad health burdens related to extreme poverty which are being exacerbated by the changing climate. As mentioned in a recent British Medical Journal editorial, failure of the world’s nations to successfully curtail emissions will likely lead to a “global health catastrophe” . In developed countries like the United States, the segments associated with population most in danger would be the poor, the very young, the elderly, those already in poor health, the disabled, individuals living alone, individuals with inadequate housing or basic services, and/or individuals who lack use of affordable health care or who reside in areas with weak public health systems. These population segments disproportionately include racial, ethnic, and indigenous minorities .
While legislation to lessen U.S. greenhouse gas (GHG) emissions has stalled in Congress, in December 2009 the Environmental Protection Agency (EPA) moved toward regulating carbon dioxide and five other associated with gases underneath the Clean Air Act, citing its authority to safeguard public health and welfare from the impacts of global warming . The agency discovered that global warming poses public health problems – including increased morbidity and mortality – because of declining air quality, rising temperatures, increased frequency of extreme weather events, and higher incidences of food- and water-borne pathogens and allergens.
This finding comes as a comparatively small group of public health care professionals are working rapidly to higher comprehend and quantify the character and magnitude of these threats to human health and wellbeing . This new but rapidly advancing public health focus has received minimal news media attention, even at internationally leading news organizations such as the New York Times [unpublished data]. It is not surprising therefore that the public also has yet to completely comprehend the public health implications of climate change. Recent surveys of Americans , Canadians , and Maltese  demonstrate that the human health consequences of climate change are seriously underestimated and/or poorly understood, if grasped at all. About 50 % of American survey respondents, for instance, selected “don’t know” (instead of “none,” “hundreds,” “thousands,” or “millions”) when asked the estimated number of current and future (in other words. 50 years hence) injuries and illnesses, and death due to climate change. An early on survey of Americans  demonstrated that many people see climate change as a geographically and temporally distant threat to the non-human environment. Notably, not a single survey respondent freely associated climate change as representing a threat to people. Similarly, few Canadians, without prompting, can name any specific human health threat linked to climate change impacts inside their country .
Cognitive research in the last several decades has shown that how people “frame” an issue – in other words., how they mentally organize and discuss with others the problem’s central ideas – greatly influences how they understand the nature associated with problem, who or what they see as being accountable for the problem, and what they feel should be done to deal with the situation [11, 12]. The polling data cited above [7–9] suggests that the dominant mental frame utilized by most members of the public to arrange their conceptions about climate change is that of “climate change as an environmental problem.” However, when climate change is framed as an environmental problem, this interpretation likely distances lots of people from the issue and plays a role in deficiencies in serious and sustained thesis statement examples for climate change public engagement necessary to develop solutions. This focus can also be susceptible to a dominant counter frame that the best solution is to carry on to develop the economy – spending money on adaptive measures in the future when, theoretically, society would be wealthier and better able to afford them – rather than focus on the root causes of the environmental problem . This economic frame likely leaves the public ambivalent about policy action and works to the benefit of industries which are reluctant to lessen their carbon intensity. Indeed, it is precisely the lack of a countervailing populist movement on climate change that features made policy solutions so hard to enact [13, 14].
Significant efforts have been made in the last several years by public health organizations to raise understanding of the public health implications of climate change and prepare the public health workforce to respond, although as noted above, it is not clear the extent to which public health care professionals, journalists, or most importantly, the public and policy makers have taken notice. In the usa, National Public Health Week 2008 was themed “Climate Change: our overall health into the Balance,” the Centers for Disease Control and Prevention created a Climate Change and Public Health program, and many professional associations assessed the public health system’s readiness to respond to the emerging threat [15–17]. Globally, World Health Day 2008 was themed “Protecting Health from Climate Change,” additionally the World Health Organization has developed a climate change and health work plan, the first objective of which is “raising understanding of the results of climate change on health, to be able to prompt action for public health measures” . Several prominent medical journals have released special issues on climate change and health [19–21], and these along with other medical journals  have issued strongly worded editorials urging health care professionals to provide voice to the health implications of climate change.
An important assumption in these calls to action is that there might be considerable value in introducing a public health frame to the ongoing public – and policy – dialogue about climate change. Since there is indeed solid theoretical basis for this assumption, to the best of our knowledge there is not yet empirical evidence to guide the validity associated with assumption .
The objective of this study therefore was to explore how American adults respond to an essay about climate change framed as a public health issue. Our hypothesis was that a public health-framed explanation of climate change will be perceived as useful and personally relevant by readers, except for members of one small segment of Americans who dismiss the notion that human-induced climate change is going on. We used two dependent measures in this hypothesis: a composite score based on respondent reactions every single sentence in the essay, while the overall valence of respondents’ general comments made after reading the essay.
Our study builds on previous research that identified six distinct segments of Americans, termed Global Warming’s Six Americas . These six segments of Americans – the Alarmed (18% associated with adult population), the Concerned (33%), the Cautious (19%), the Disengaged (12%), the Doubtful (11%), while the Dismissive (7%) – fall along a continuum from those people who are engaged on the issue and looking for ways to take appropriate actions (the Alarmed) to people who actively deny its reality and are looking for ways to oppose societal action (the Dismissive; see Figure 1). The four segments in the center of the continuum are likely to benefit most from a reframing of climate change as a human health condition because, to a greater or lesser degree, they’re not yet sure that they fully understand the problem and are still, if motivated to do this, relatively available to learning about new perspectives.
Global Warming’s Six Americas. A nationally representative sample of American adults classified into six unique audience segments based on their climate change-related beliefs, behaviors and policy preferences.
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Between May and August 2009, 74 adults were recruited to take part in semi-structured in-depth elicitation interviews that lasted an average of 43 minutes (ranging from 16 to 124 minutes) and included the presentation of a public health framed essay on climate change. The recruitment process was made to yield completed interviews with a demographically and geographically diverse group of at least 10 folks from each one of the previously identified “Six Americas” . Four respondents were dropped from this study because of incomplete data, leaving a sample size of 70. Audience segment status (i.e., which one of the “Six Americas” a person belonged) was assessed with a previously developed 15-item screening questionnaire that identifies segment status with 80% accuracy [unpublished data].
To quickly attain demographic diversity in the sample, we recruited an approximately balanced number of men and women, and an approximately balanced number of younger (18 to 30), middle-aged (31 to 50), and older (51 and older) adults (see Table 1). We did not set recruitment quotas for racial/ethnic groups, but did try and recruit a mixture of folks from various racial/ethnic backgrounds.
Table 1 Distribution of Respondents by Age, Gender and Segment.
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To quickly attain geographic diversity, we recruited participants in another of two ways. The majority of participants (n = 56) were recruited – and then interviewed – face-to-face in another of two locations: out-of-town visitors were interviewed at a central location on the National Mall in Washington, DC (a national park situated between the U.S. Capitol, the Smithsonian Museum buildings, while the Lincoln Memorial); and shoppers were interviewed at an “outlet” mall (i.e., discount branded merchandise shopping mall) next to an interstate freeway in Hagerstown, MD. The outlet mall is more than an hour driving distance outside of Washington, DC and attracts shoppers from Maryland, Pennsylvania, and West Virginia, along with visitors from further away that are driving the interstate freeway. The remaining study participants were recruited via email from among participants to a nationally representative survey that we conducted in Fall 2008 . They were interviewed subsequently by telephone, after being mailed a copy associated with test “public health essay” – described below – in a sealed envelope marked “do not open until asked to do this by the interviewer.” As an incentive to participate, all respondents were given a $50 gift card upon completion of the interview. George Mason University Human Subjects Review Board provided approval for the research protocol (reference #6161); all potential respondents received written consent information just before participation.
The 70 study participants resided in 29 states. Using U.S. Census Bureau classifications, 14% (n = 10) were from the Northeast region, 21% (n = 15) were from the Midwest, 40% (n = 28) from the South, and 23% (n = 16) were from the West; state and region were unknown for one participant. In 2006, the geographic distribution associated with overall U.S. population was 18%, 22%, 36% and 23% in the Northeast, Midwest, South and West, respectively .
Data Collection and Coding
Most of the interview was dedicated to open-ended questions meant to establish the respondent’s emotions, attitudes, beliefs, knowledge and behavior relative to global warming’s causes and consequences. For instance, respective open-ended questions asked alternatively if, how, as well as for whom global warming was an issue; how global warming is caused; if and exactly how global warming could be stopped or limited; and what, if anything, an individual could do to help limit global warming. Toward the end of the interview, respondents were asked to read “a brief essay about global warming” (see Appendix 1), that was designed to frame climate change as a human health issue. Respondents were also given a green and a pink highlighting pen and asked to “use the green highlighter pen to mark any portions associated with essay that you feel are specifically clear or helpful, and make use of the pink highlighter pen to mark any portions associated with essay which are particularly confusing or unhelpful.”
As shown in Appendix 1, the one page essay was organized into four sections: an opening paragraph that introduced the public health frame (5 total sentences); a paragraph that emphasized how human health would be harmed if action just isn’t taken fully to stop, limit, and/or force away global warming (i.e., a description associated with threat; 7 sentences); a paragraph that discussed several mitigation-focused policy actions and their human health-related benefits if adopted (4 sentences); and a short concluding paragraph intended to reinforce the public health frame (2 sentences).
When respondents finished the reading, they were asked to explain in an open-ended format their “general reaction to this essay.” (Note: This question was inadvertently not asked of 1 respondent, and so the sample size for analysis of this data is 69.) For every part of the essay they marked in green, they were subsequently asked: “What about each of these sentences was especially clear or helpful to you?” For every part of the essay they marked in pink, they were also asked: “What about each of these sentences was especially confusing or unhelpful to you?”
To evaluate the respondent’s general reactions to the essay we reviewed their individual statements (n = 193), understood to be discrete thoughts or concepts. Based on this review, we iteratively developed eight thematic categories that captured the number of statements produced by respondents. Table 2 defines and describe these themes.
Table 2 Thematic Categories Used to Code Respondents’ General Reactions to the Public Health Essay.
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Two graduate student coders were then trained to code each statement into one of the thematic categories. The coders were also instructed to assess the overall valence of every respondent’s statements – the very first of our dependent measures – rating them as: -1 (entirely negative comments); 0 (mixed, including both positive and negative comments); or 1 (entirely positive comments). Following standard content analysis procedures, we tested inter-coder agreement on approximately 50 statements, making sure that a complete range of possible kinds of coding decisions were required associated with coders. To assess reliability, we used Krippendorff’s alpha [24, 25], a conservative measure that corrects for chance agreement among coders; a K-alpha of .70 or more is considered sufficient and .80 or more is considered excellent. For 7 associated with 8 thematic categories, we achieved a reliability of .80 or higher; “Lack of Evidence or Stylistically Confusing” was the exception, with an inter-coder reliability of https://shmoop.pro.70. After establishing reliability, the two coders then went on to categorize all of those other remaining statements from the sample of respondents.
To code the respondent’s sentence-specific reactions made with the highlighting pens, sentences marked with only green on at least one word were scored +1 (in other words. indicating “especially clear or useful”), sentences marked with only pink on at the least one word were scored -1 (in other words. indicating “especially confusing or unhelpful), and sentences with either no highlighting, or both green and pink, were scored 0. Composite scores were designed for each one of the four parts of the essay – the opening, the threat section, the advantage section, while the conclusion – by summing the sentence-specific scores in the section and dividing by the number of sentences. A composite score for the whole essay – the 2nd of the dependent measures within our hypothesis – was made by summing the sentence scores across each segment and dividing by the number of respondents per segment. Population estimates, that can easily be taken solely as preliminary indicators given the non-probabilistic nature of our sampling, were estimated by weighting the mean values for every associated with six segments according to its prevalence in the U.S. population (see Figure 1).
To check the between-segment differences in our dependent measures – overall reactions to the essay (i.e., valence) and composite sentence-specific reactions to the entire essay – we used the nonparametric Kruskal-Wallis test (see Figures 2, 3). To test if the median response to the essay on each dependent measure was more than zero (i.e., a positive reaction) for our full sample, we used the Wilcoxon signed rank test. Lastly, for both dependent measures, we used the Wilcoxon signed rank test to test our hypothesis that five associated with six segments (the Dismissive being the one exception) would respond positively to the essay; the null hypothesis was that the median score for every associated with five segments did not vary from zero. The Wilcoxon signed rank test is suitable for small sample sizes and non-normal distributions, both of which are the case for at the least some segments within our data.
Average valence of respondents’ general essay comments. The mean valence of respondent comments when asked their general reactions to the public health essay by audience segment and by a national population estimate. Note: 1 = (entirely positive comments); 0 = (mixed, including both positive and negative comments); and -1 = (entirely negative comments).
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Composite essay scores by segment. Scores reflect respondent average values by segment for the difference between the number of times all of 18 sentences were marked “especially clear or helpful” and “especially confusing or unhelpful” with a full range of possible values between 18 and -18. The scores are adjusted for unequal amounts of respondents within each segment by re-weighting values to represent n = 10.
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Post-hoc – after examining the visualized data (see Figures 4, 5 and 6) – we chose to test for 2 possible main effects in the data. To examine the possibility that the essay’s later focus on the public health benefits of mitigation-related policy actions was seen by respondents as clearer and more useful than the essay’s earlier concentrate on public health-related threats, we calculated the difference between the re-scaled (by an issue of 10) average response to both the advantage therefore the threat sections and then used the Wilcoxon signed rank test to test, by segment, whether the median of these differences was more than zero. We then evaluated the entire main aftereffect of the essay – across all segments – using the weighted t-test on the differences with weights corresponding to the frequencies associated with segments in the population.
Essay evaluations by sentence: Alarmed, Concerned and Cautious segments. Sentence-specific evaluations of the public health essay by respondents in the Alarmed, Concerned and Cautious segments and by a national population estimate. Note: Scores reflect the difference between the number of times a sentence was marked as “especially clear or helpful” while the number of times it had been marked as “especially confusing or unhelpful,” adjusting for unequal amounts of respondents within each segment by re-weighting values to represent n = 10. Sentence abbreviations correspond to O = opening section (5 sentences); T = climate change health threat related section (7 sentences); B = mitigation-related policy actions and their health benefits (4 sentences); and C = concluding section (2 sentences). The national population estimate was made by weighting the values for every associated with six segments according to their relative proportion of American adults.
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Essay evaluations by sentence: Disengaged, Doubtful and Dismissive segments. Sentence-specific evaluations of the public health essay by respondents in the Disengaged, Doubtful and Dismissive segments and by a national population estimate. Note: Scores reflect the difference between the number of times within a sentence was marked as “especially clear or helpful” while the number of times it had been marked as “especially confusing or unhelpful,” adjusting for unequal amounts of respondents within each segment by re-weighting values to represent n = 10. Sentence abbreviations correspond to O = opening section (5 sentences); T = climate change health threat related section (7 sentences); B = mitigation-related policy actions and their health benefits (4 sentences); and C = concluding section (2 sentences). The national population estimate was made by weighting the values for every associated with six segments according to their relative proportion of American adults.
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Essay evaluations by section (opening, threat, benefits, closing). Average section-specific evaluations associated with public health essay by respondents in each one of the six audience segments and by a national population estimate. Note: Scores reflect the difference between the number of sentences within each section marked by a respondent as “especially clear or helpful” and those marked as “especially confusing or unhelpful” with those values averaged over the number of sentences per section and rescaled by an issue of 10. Section abbreviations correspond to O = opening section (5 sentences); T = climate change health threat related section (7 sentences); B = mitigation-related policy actions and their health benefits (4 sentences); and C = concluding section (2 sentences). The national population estimate was made by weighting the mean values for every associated with six segments according to their relative proportion of American adults.
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Lastly, to examine for the possibility that the concluding framing section associated with essay was perceived by respondents as clearer and more useful than the opening framing section, we calculated the difference between the re-scaled average response to both the opening while the concluding sections and then used the Wilcoxon signed rank test to test, by segment, whether the median of these differences was more than zero. We then evaluated the entire main effect – across all segments – using the weighted t-test on the differences with weights corresponding to the frequencies associated with segments in the population.