‘Soft power’ for prevention comes from engaging the public with prevention as a science

Professor Penny Hawe, Professor of Public Health, University of Sydney and a member of the Prevention Centre’s Leadership Executive, is a champion for prevention and finding creative ways to get the preventive health message to cut through with the public. She says, “I just want to make prevention science interesting. I want the public to think that population health science, and the thinking that’s behind some of those policies and programs that they see, is clever.”  

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Penny: I just want to make prevention science interesting. I want the public to think that population health science, and the thinking that’s behind some of those policies and programs that they see, is clever.  

Gretchen: Hello there. This is Prevention Works the podcast of The Australian Prevention Partnership Centre. And that’s Penny Hawe, our guest today, here to talk about creative ways to get the preventive health message across and actually bring about a demand for prevention. I’m Gretchen Miller and Penny is Professor of Public Health at the University of Sydney and a member of the Prevention Centre’s Leadership Executive.

She’s also held significant roles in Canada, where she was Markin Chair in Health and Society at the University of Calgary and won the top tier career award of Health Scientist from the Alberta Heritage Foundation for Medical Research, as well as establishing the first Canadian Institute of Health Research Centre at the University. Penny, you want to lay down the surgical glove to what’s become the default mode of prevention communication. So, can you describe the challenge you’re presenting and what’s wrong with the current focus?

Penny: Oh, thank you for that, Gretchen. Well, I think the reason why I want to focus on demand for prevention is that I think up until now, all we’ve really cared about is supply of prevention. So, in my career you know, we went through a discovery phase trying to work out what works and what doesn’t work. And then we moved into the capacity building phase to try and increase supply of what we know does work and scale-up. You know, there’s a whole program of scale-up happening, trying to think about how we supply programs.

But I don’t think we really have penetrated the field of what the public thinks about what we do. In fact, I think we’re very invisible to the public. So, we have to look to ways of making prevention programs and policies, more visible and more accountable, and hopefully more taken for granted, even loved by the public.

Gretchen: And before we go onto your solution, I’d like to break it down a bit. What does the general population think that prevention is?

Penny: Well, I think it’s, and this is not incorrect in many ways, I think they think it’s what they do themselves. So, it’s whether or not they smoke or whether they drink alcohol to access or whether they exercise and all those things, which are not incorrect. I mean, those things matter for sure, but I think what’s invisible to people is how that came about.

And it came about because there’s a preventive health workforce that’s been in place in this country for about 30 years. There are programs and policies in settings, in schools, in hospitals, in local government areas that regulate things like, cigarette sales and alcohol supply. And even the placement of confectionery and supermarkets and all those little things that happen or big things happen, some of them, have been supplied by a health promotion workforce.

And people take that for granted. If you ask someone when they’ve given up smoking, you ask them, how did that happen? And they’ll say, ‘Oh I just gave up, you know, I’ve tried before’. The number of quit attempts definitely predicts whether or not you give up successfully. But the reason why someone ends up quitting is probably due to 30 years of advocacy and policy control and advertising restrictions that have been delivered by this invisible workforce. And what I’m wanting to now do is make the public aware of that workforce and aware of those policies and programs, because I think if they knew about them, they’d think, Oh yeah, fair cop. I think that’s a good idea. But right now, we just literally haven’t turned our mind to that yet.

Gretchen: Yes. And there’s another aspect to that question. What do policy makers think prevention is? And I wonder if you could talk a little bit about the emphasis on the economics of prevention, that perhaps has gone too far?

Penny: Well, I think economics of prevention is really important. I mean, we absolutely have to have our numbers in line. We have to definitely be able to be delivering prevention efficiently and effectively. It has to be cost effective. We have to be able to make a cost benefit analysis, a good argument that for every dollar we invest in prevention, we get, you know, 14 back or 17 back. But I think we can overstate the emphasis of economics and think it’s the only argument, I guess that’s where I come in, when people talk about the value of prevention, I don’t want that to just mean the economic value of prevention. I want people to think beyond that and look at other avenues that we could make prevention mainstream in society, without it just being because it’s an economic investment.

Gretchen: So given that we’re at peak capitalism now and absolutely everything around us can and is regularly given an economic value, what do you want to offer instead?

Penny: Well, it’s not instead it’s as well as, I think it’s really important that, that we, you know, tick all the boxes with the economics. And I think we can do a better as well. I, I think we often evaluate programs just on the single outcome that we funded it for. Like we evaluate an obesity program just in terms of obesity gains or obesity losses, sorry!

But we could also be thinking about the multiple benefits that programs have. And as soon as you do that, then the economic benefit gets stronger. So, there’s still advances to be made in the economics. But the kind of “radical” thing that I want to do, which sounds a bit ridiculous, but it’s, I just want to make prevention science interesting. I want the public to think that population health science, and the thinking that’s behind some of those policies and programs that they see, is clever. I mean, it’s as clever as geoscience. It’s as clever as neuroscience. It’s as clever as astronomy. We’ve never thought about communicating our science just like that and tapping into that – I’m going to say something, a word that might be offensive – nerdy, the nerdy market, that is, the people that love science and love stories and love to hear how things work, how the universe works. Well, we’ve got a population health science story about patterns in populations and stratification and distribution and hierarchy.

And you understand health really differently from studying populations compared to looking down a test tube. But when you talk to the public, most of the public will think that health science is medical science, and medical science is bench science, and bench science is immune systems or synapses, and while that’s true, it’s not the only story.

And once we start shining the light on what we learn about health science, from studying populations, I think people will go, “wow”. And those people vote. Those people vote for governments that bring in policies that look after the health of populations. And I guess what I’ve got in mind here is that there are things that we know are very effective to do, to promote health, like bringing in a sugar tax would promote health. Or restricting the salt in food would promote health. But governments are often reluctant to do those big things because they think that they won’t have public support, that they’re not popular, that there’ll be a backlash. But if the public thinks the science behind these things is as kosher or as decent or as conventional or as familiar and trustworthy as the science behind astrophysics, then why wouldn’t they accept it?

Gretchen: It’s really interesting, actually, because we know that there’s a hunger for understanding health. We’ve seen it with the fascination with the COVID-19 figures, for example, the daily ups and downs. The media is seeing fit to report on that because there is a public hunger to understand what’s going on, not just with you as an individual and what might happen to you as an individual, but also what’s happening around us with our community. And we also know that they’re interested in their own health. They’re interested in their family’s health. We know that from the response to any health story. So I guess it’s about how that story is told. So what’s happening with the way that story is told. And I think that it’s not just about the telling, is it? It’s not just about telling people?

Penny: No. It’s about engaging them directly in the production of the science or the knowledge of the science. I mean, you picked up on contagion. Contagion is one of the, I guess, the easiest population concepts to understand is that you can catch something from somebody else. And you don’t know that from just looking down a test tube. You only know that from looking at a population.

Gretchen: So what can an organisation like The Australian Prevention Partnership Centre, which is a collection of top preventive health researchers and communicators, do to add to their arsenal of addressing the mission of communication?

Penny: Well, I think they can copy methods that mainstream science educators and communicators use. I think there’s some gain to be made by thinking about our science, as a science and engaging citizens in the production of our knowledge. So as citizen science methods, like, you know, people go out and measure water quality and they, you know, count frogs. We could use mainstream science museums as ways of communicating population health science.

Gretchen: The thing about engaging citizens, right? It’s not just that they have something to say and they should be included in a co-creative way, but also that the act of engaging them in the story early on gives some buy into the story. So, they actually then start to have a vested interest because they know how it’s unfolding. You’re not just telling them the story, they’re a part of it. Would that be fair to say?

Penny: That’s absolutely it. And also there’s potential for there to be thousands of them. So, it’s not unusual for the community to be involved in the production of research. We’ve had a history in health promotion of community-based participatory research, going back, you know, 30 or 40 years. But usually, that would be about, say, eight or 10 committed people getting something done with some researchers and there’s plenty examples of that.

Gretchen: But you’re saying that citizen science is a way to involve thousands of people at once, instead. So can you tell us about the pilot project you did which, I think was a proof of concept thing wasn’t it, to test the feasibility of methods that could get thousands of women involved in showing how easy, or hard, it is to keep breastfeeding after they return to work, depending on the presence or absence of breastfeeding friendly policies at work. You wanted more women to keep breastfeeding after the first six months.

Penny: Breastfeeding falls off after that because loads of women go back to work and they don’t have a place where they can express milk and they don’t have a place where they can breastfeed if they want to continue to breastfeed unless they work in some really good workplaces that have already got accreditation with the Australian Breastfeeding Association and they’ve got a nice little room where they can have that happen.

So, by setting up a partnership with the Australian Breastfeeding Association and a website and using their network, we recruited women to do something very simple, which is to take their phone to work and take a photograph of where they will be expected to breastfeed in this workplace.

And so word got out. It was just one single fun thing that you could do is take this photograph, fill out a few ethics forms and information that the university needed of course, and then we could load these pictures up on website and analyze them. And it was quite shocking. I mean, some results were fabulous. But others sent us a picture of a toilet or they send us a picture of a storeroom, and that’s shocking.

What’s good about that though, is that if we had simply surveyed these places ourselves, that information would just belong to us as a group of about, you know, six or eight researchers. But because we surveyed these workplaces through the eyes and ears of those women, that knowledge now belongs to all the participants and it belongs to the partner organisations. So that empowers the partner organisations to fix the problem in a way that it wouldn’t have been under traditional research where, you know, Penny Hawe and Sam Rowbotham and their colleagues collect some data, write it up and then broadcast the results and hope that something happens.

It’s a completely different way of doing the research that changes – has much greater potential for bringing about policy change, because the whole purpose of doing this is to level the playing field. And to make it so that everybody can breastfeed at work if they wish.

Gretchen: So you’re saying that citizen science draws attention to inequities in prevention policy delivery. So that if you’re in Western Australia, you don’t have different prevention provisions to somebody in South Australia, is that what you’re talking about is ensuring that everybody has the same access. And the only way you can do that is for people to actually demand that same access to preventive programs.

Penny: Exactly and for people to even know that are those policies and programs that aren’t equally distributed. I mean, that information could be made available and they could say, heavens, I don’t care. You know, they could decide they literally don’t care.

But once you normalise that information. Once you make it clear that it is an uneven playing field. So, for example, if you want to give up smoking, there’s a 22% increased likelihood that you will be successful in giving up smoking if you’re in a workplace that has got comprehensive tobacco control policies compared to one that doesn’t have comprehensive tobacco control policies. If you’re trying to lose weight and you’re eating takeaway food. Are you eating takeaway food in a legislated area, in a municipality where transfats have been banned in the production of take away food? Do you know that? Or do you not know that? I mean, these are things that make a difference. If people are trying to lead a healthy lifestyle, but some people have got obstacles and other people don’t have obstacles – then yeah, we think – and it’s a hypothesis – but we think that if we put that information out there, and produce that information with people, with communities, that it might lead to the difference.

It has in health care. So for example, in health care, there used to be a time when you got different healthcare, like different cancer treatments, different drugs, different guidelines in different states because we hadn’t worked out a uniform method of delivery, and people did get a different deal. Well, I’m just saying we should be doing that in prevention as well.

Gretchen: And so part of your work has also been about collating the evidence to show how much improvement in health can be brought about just by introducing public policies.

Penny: You know, if you want to reduce diabetes, if you put in cycleways and get people cycling over 15 years, you can reduce diabetes by 20%.

Now, how do we commonly try and reduce diabetes? Well there’s a drug, you can put people on called Metformin and if they take that drug every day for 15 years, it will reduce diabetes by 18%.

And I’ve just told you, that putting in a cycling way can also reduce diabetes by about the same amount, 20%. I think that’s an astonishing contrast. So we’re in the field right now with a survey where we’re feeding that information through to a panel of 2000 people and getting them to tell us what they think is the most likely effect for something. And when we tell them what the real effect is, gathering their response.

They probably don’t realise that public policy can be as important or even more important, more effective. I’m not telling people to come off their drugs. Stay on your drugs, people! What I’m trying to do is show how legitimate these effects are that we can get from public policy.

Gretchen: Okay. So let’s talk a little bit about how you first came up with these ideas of creating a demand for preventive health policy?

Penny: I worked for 10 years in a province that is the oil-rich province of Canada, and they had a nest egg of billions of dollars at that point, millions, at least that they wanted to invest in big ideas to change and improve the province. So transformational ideas. They wanted one in agriculture. One in universities. One in transport. And they wanted one in health. And so myself and Alan Shiell, an economist that I work with were asked to come up with a Big Idea that would transform the health system.

Most of the people that we spoke with talked to us about, okay, well, pick something important, like pick diabetes or pick physical activity or pick mental health. And that made us uncomfortable and we couldn’t work out why. And eventually it was that picking off problems one at a time doesn’t change the system and doesn’t change things over time. It just helps whoever happened to be the lucky people that you pick to invest your money in.

What we realised was that unless you change the dynamics of the system, unless you make people demand the sorts of programs that are going to help them all the time, unless you create demand for prevention and understanding of the population health science beneath it, then, you won’t ever be successful.

So that’s that, that was when we originally came up with that idea that was in 2007.

Gretchen: So, what was the sort of big idea that you presented?

Penny: Well, it’s the one we’re talking about. We’ve got supply of prevention, but we don’t have public demand for the programs and policies that can bring about the change. So we had a four step process. To how we would then bring about a transformation of the system.

So, first of all, it started with the thing that you and I’ve been discussing this morning, which is make people aware of the differential distribution of programs and policies that bring about change, so map those. Show that if you’ve got a parent in a nursing home in Edmonton the success of the falls prevention program up there is 42%, compared to the success of the falls prevention program that’s in Lethbridge, and have a public conversation about that.

People don’t realise that there’s an awful lot of preventive programs out there that are ineffective, but they’re constantly supplied. In that province, there’s a lot of voluntary involvement in provision of prevention programs. And many of the programs that are available at that stage, in the parenting sector, are run by well-meaning people, but with low levels of effectiveness. So, draw attention to the fact that we already have provision of policies and programs, but not all of them are effective. So that’s where the accountability and visibility comes in.

And then we had a series of steps after that on how to transfer the portfolio of programs that you have as a health service provider to one that’s going to be more effective. So, how to build up your ‘blue chip’ programs? How do you replace your ineffective programs?

And finally, part of it was to have an idea of having ‘healthy-strings-attached’ planning policies. So, they were building a huge hospital in Southern Calgary at the time. And everyone knew that a hospital improves health – or they thought so. And the suggestion we made was that what you should instead, is not just build a hospital, but make it so that any of the businesses that want to locate within a certain perimeter around the hospital have to follow healthy-strings-attached planning policy.

 So, they have to sell healthy food, fresh food. They have to have employment policies that are equitable in terms of gender and other aspects of affirmative action. They have to have good policies for the workforce. You know, all those sorts of things that make a difference. So, healthy-strings-attached planning policies.

Gretchen: Before we go on, can you tell me about your engagements with billionaires? Because it sounds kind of funny to us you know, the hoi polloi. But in Canada, the relationship with philanthropists is far less arms-length than it is here. And I wonder how that affected your thinking?

Penny: It really affected my thinking. And I think it was because I came from the University of Sydney where I had, to be frank, got very lazy about how I think about public health because I’d always been surrounded by great thinkers and doers in this field. And I just got on with the business. I didn’t know how to talk about public health. And I was just a researcher. But when I moved to Canada, I had to sort of become those other roles. I had to, sort of, be the Simon Chapman and be the Steve Leeder and talk to the guys that actually wrote the cheques that ran the province.

So, the guy that funded my chair was a donor. And then up until then, of course I’d always thought of donor was someone that gave away a kidney. And this guy was very interested in how I was going to go about the business of promoting population health science, but he didn’t understand it. So, he asked me to explain things to him all the time and to justify things all the time.

And I was almost in contact, you know, on a daily basis. Sometimes twice a week. He would send me questions – problems he was trying to solve in his life. So, he’s an oil guy, in the oil sands in Alberta and in Southern Alberta. They are in partnerships being developed in partnerships with, First Nations and Metis communities. So, these oil companies are, in return for the mineral rights, building schools and building health care services and trying to look after communities. And he would ask me about what might be the best thing that he could do in relation to whatever problem that he was trying to solve.

Gretchen: So in other words, what’s going on here is that you are talking directly to the money and that gave you a kind of accountability. But also, I guess, a grounding with somebody who isn’t a health expert and so might ask you quite unusual questions, and that would give you a different way of thinking?

Penny: Absolutely. And it made me realise that in my own little bubble, you know, like with public health people, words like ‘capacity building’ and ‘co-creation’ and ‘collaborate’ you know, we, we speak to each other using our own words. But as soon as I had to speak to him, he’d say, what do you mean? Or why would you do that?

And it just forced me to think about the principles that I was or should be following, as opposed to just kind of the rules that I always followed. So it was helpful. It was friendly interrogation!

Gretchen: So when you got back here, you partnered with the Australian National Centre for the Public Awareness of Science and you started projects that were much more engaged with the public directly. Can you tell me a little bit about some of those?

Penny: Yeah, well, we started off with citizen science and then we also moved into communicating population health science in a science museum, to see if there are ways of communicating and audiences we could reach through using traditional methods that are used in science communication.

So, Questacon is a science museum in Canberra. People go there and learn about things like how does lightning work? Or, you know, what is quantum physics? So, it’s very much based on exhibits that spark and engage and attract little thumbprints all over them.

And the team that was working on it was students from the Centre for Public Awareness of Science and the designers. We had nothing to do with it. So, we had no control over how the messages were to be presented. We just gave them a briefing. And what they took from the briefing was that they wanted to communicate that it’s harder for some people compared to others to achieve a healthy lifestyle.

And, also that, neighborhoods in particular can be tougher than others in terms of achieving a healthy lifestyle. That if your neighborhood has got loads of alcohol and, takeaway food and hasn’t got a fresh supermarket and it’s got nowhere to go walking, these kinds of things make it harder or easier. And they thought about different ways in which they do that, but they eventually hit on the idea of a kind of a roller coaster that has its up and downs. And they used a marble running through a track to illustrate that depending on where you get on, you get off or you fall off sooner. So that’s sort of like the track to death really. But, in what we’re trying to, was not trying to kill people, we’re trying to give them the longest track that they can have and the healthiest track that they can have before yeah you know, eventually people die. This is, you know, they die, but some people die sooner and from circumstances that are not fair.

And usually we try and communicate that by saying “it’s not fair”. So that’s the traditional way in which we communicate social determinants of health. We try to engage people with the moral argument and the passion and persuade them. But what this did was just literally, you walked up to this exhibit, you could play with it, you could see it. You could get the message and go, “Oh. Okay”.  So, you ended up with the same message. You know, took the knowledge in, but without having to engage with the ideology in some sense.

I’m picking on the word ideology because, yeah, we were talking about me being in Canada earlier. I actually was on the Canadian Institutes of Health Research Institute of Population Health Board for six years. And one moment made a big difference to me. Michael Marmot had produced his Social Determinants of Health W.H.O. report and the guy next to me, who was one of the senior bureaucrats said that it just sounded like “ideology with evidence attached”. And, and that was a Big Moment for me. I thought, how can we communicate the evidence without people thinking they’re listening to ideology?

Gretchen: That is shocking, isn’t it?

Penny: But it was a great challenge because what was great about this science museum exhibit people just came up and played with it. They saw the outcome, they had the conversation with the facilitator and the sense of the penny dropped, but without having to consciously engage in caring, if you see what I mean?

Gretchen: So there was another project that you did, which was Health Minister for a day. What happened there?

Penny: Well, this was literally another idea that came from the professional science communicators. We would be rabbiting on to them one day about the dynamic simulation models that the Prevention Centre is producing. So, these are computer models where you can show policymakers: What different types of combinations of policies bring about health outcomes? What the critical sequence might be of bringing about health outcomes. And you can also show them, well, if you invest in this path, you can’t invest in that path. And this one will be slower in this one will be faster. So, we were talking about how exciting it was that the Prevention Centre was getting into this kind of modeling.

And one of the science communicators said, well, if we, if we could transfer that to the public, by turning that into a game so that the public can engage with those models and start to see what it would be like to be health minister for the day. And this was a wonderful idea because it was back at the time when I think we changed health ministers three times in that year.

So, it was quite a realistic name for the game to be called Health Minister for the Day. And, and the students that got involved in it, we had a team of students for a year and we had a hackathon in Singapore where different students from around the world got engaged in thinking about how to put together a game. And what kind of obstacles you could put in. Because for a game – for someone to play – they have to have a score. They have to be able to compete. They have to have, you know, good days and bad days. And the idea is that, you know, a 13-year-old, 14-year-old, 15-year-old youth. Could stand out the front of parliament and say to Greg Hunt, “you know, I saved 50,000 lives today. How many did you save Greg Hunt?”. So, it’s that type of engagement.

What we wanted people to, just to literally realise is that there are health budgets. There are trade-offs to be made. When you’re investing that budget, there are winners and losers in relation to that budget. There’s obstacles like for people like you, Gretchen, we couldn’t work out whether the media is a good thing or a bad thing! It really depends on what day it is. So, you can complicate the game and make it harder for the health minister to achieve his or her goal. So, that’s actually still being worked with. There’s still a team working on that at the moment. They’ve now got it down to their telephone apparently. So, it’s good.

Gretchen: Okay. So let’s finish off just by talking about how these things not only engage the public, but yes, the media and how you tell the story? Is this a way to bypass that old dualism of ideology, the for and against the relentless economic valuation of every aspect of the way we lead our lives and actually bring the public back in and involve them?

Penny: Yeah, it’s definitely that. And if people are engaged in understanding and producing the knowledge for the story in connecting with the story in different ways, maybe being part of the story, because they have been involved in games or exhibits where they can see it happening, then yeah.

Gretchen: So to bring us to the end of our conversation, can you put what you want in nutshell?

Penny: What we want is popular support for policies and programs that the government puts in place that affects everyone. So that’s a really key message for us. This is why we’re using diverse communication strategies and engagement strategies. It’s not just about people making health decisions for themselves. It’s about creating popular support for governments to implement policies and programs that help everyone.

Gretchen: On that note, Professor Penny Hawe, thanks so much for joining us on Prevention Works. There’s more information on the website of The Australian Prevention Partnership Centre. I’m Gretchen Miller. See you next time.


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