Communicating the Social Determinants of Health - Canadian Council on Social Determinants of Health

 
Communicating the Social
Determinants of Health
GUIDELINES FOR COMMON MESSAGING

October 23, 2013

Canadian Council
on Social Determinants of Health
Communicating the Social Determinants of Health Guidelines for Common Messaging
Également disponible en français sous le titre : Communiquer les déterminants
sociaux de la santé: guide pour la création de message communs
To obtain additional copies, please contact:
Canadian Council on Social Determinants of Health
E-mail: CCSDH.Correspondence@phac-aspc.gc.ca
This publication can be made available in alternative formats upon request.
ISBN: 978-0-9937151-0-5
Preface
This document is based on research                   The CCSDH fulfills its mandate through various
commissioned by the Canadian Council                 activities, including support for the creation
on Social Determinants of Health (CCSDH),            or adaptation of tools to leverage action on
previously known as the Canadian Reference           social determinants of health. Communicating
Group on Social Determinants of Health (CRG).        the Social Determinants of Health: Guidelines
                                                     for Common Messaging is one such tool. In
The CCSDH is a collaborative multi-sectoral
                                                     creating the guidelines, the aim of the CCSDH
stakeholder group established to:
                                                     is to provide individuals and organizations
• Provide the Public Health Agency of                with the knowledge to create effective, targeted
 Canada (PHAC) with advice on matters                messages on the factors that shape health.
 relating to the implementation of the
                                                     The development of this tool was guided
 Rio Political Declaration on Social
                                                     by the Communications Expert Group,
 Determinants of Health, including planning,
                                                     which was comprised of members of the
 monitoring, and reporting; and
                                                     CCSDH Communications Subcommittee
• Facilitate and leverage action on the social
                                                     and communications advisors from various
 determinants of health through member
                                                     CCSDH organizations. The guidelines
 networks and targeted, intersectoral initiatives.
                                                     were conceived as part of a wider strategy
The CCSDH brings together organizations from         to raise awareness and understanding
a wide array of sectors that have a role to play     of the social determinants of health. As such,
in addressing the factors that shape health. The     it is the hope of the CCSDH that they
CCSDH also includes individuals selected on          will be widely shared and used to facilitate
the basis of their knowledge and experience          an expanded conversation about health
regarding policy, research or intersectoral          in Canada.
action on the social determinants of health.

             COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING           i
THE CANADIAN COUNCIL ON
SOCIAL DETERMINANTS OF HEALTH
KRISTA OUTHWAITE,                 JEFFREY CYR                      BEN HENDERSON
CO-CHAIR                          Executive Director,              Representative, Federation
Associate Deputy Minister,        National Association of          of Canadian Municipalities
Public Health Agency              Friendship Centres               and City Councillor,
of Canada                                                          City of Edmonton
                                  ERICA DI RUGGIERO
PEGGY TAILLON, CO-CHAIR           Associate Director, Canadian     RÉAL LACOMBE
President and CEO,                Institutes of Health Research,   Director of Public Health and
Canadian Council on               Institute of Population          Medical Affairs, Agence de la
Social Development                and Public Health                santé et des services sociaux
                                                                   de l’Abitibi-Témiscamingue
KIMBERLY ELMSLIE                  JOEY EDWARDH
(EX OFFICIO)                      Director, Community              KATHY LANGLOIS
Acting Assistant Deputy           Development Halton               Director General, Strategic
Minister, Public Health Agency                                     Policy, Planning & Information,
of Canada                         GERRY GALLAGHER                  First Nation and Inuit Health
                                  Acting Executive Director,       Branch, Health Canada
MICHAEL BLOOM                     Social Determinants and
Vice-President, Organizational    Science Integration              CORY NEUDORF
Effectiveness and Learning,       Directorate, Public Health       Chief Medical Officer
Conference Board of Canada        Agency of Canada                 of Health, Saskatoon
                                                                   Health Region
PAUL BORN                         MARGO GREENWOOD
President and CEO,                Academic Leader, National        HILARY PEARSON
Tamarak Institute for             Collaborating Centre for         President, Philanthropic
Community Engagement              Aboriginal Health                Foundations Canada

ED BULLER                         TREVOR HANCOCK                   LOUISE POTVIN
Elder                             Professor and Senior Scholar,    Scientific Director, Centre
                                  School of Public Health          Léa-Roback sur les inégalités
BARBARA BYERS
                                  and Social Policy, University    sociales de Montréal
Executive Vice-President,
                                  of Victoria
Canadian Labour Congress                                           ANDREW SACRET
                                  JEAN HARVEY                      Director of Policy
CONNIE CLEMENT
                                  Director, Canadian               and Public Affairs,
Scientific Director, National
                                  Population Health Initiative,    Canadian Institute of Planners
Collaborating Centre for
                                  Canadian Institute
Determinants of Health
                                  for Health Information
IAN CULBERT
Executive Director, Canadian
Public Health Association
ii   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
Communications Expert Group
COMMUNICATIONS SUBCOMMITTEE                      EXTERNAL ADVISORS
DEBORAH LYNKOWSKI (LEAD)                         LYNE CANTIN
Former CEO,                                      Former Analyst,
Canadian Public Health Association               Canadian Public Health Association

BARBARA BYERS                                    JIM CHAUVIN
Executive Vice-President,                        Former Director of Policy,
Canadian Labour Congress                         Canadian Public Health Association

ANDREA GABOR                                     IAN CULBERT
Former President,                                Former Communications Director,
Canadian Institute of Planners                   Current Executive Director,
                                                 Canadian Public Health Association
PEGGY TAILLON
President and CEO,                               DENIS GRUENDING
Canadian Council on Social Development           Communications, Canadian Labour Congress

                                                 CHERYL SMITH
                                                 Communications Executive,
                                                 Canadian Public Health Association

                                                 CARL VENDETTE
                                                 Senior Manager, Executive Networks,
                                                 Conference Board of Canada

Acknowledgements
This document is based on work completed         The CCSDH would also like to thank the
in 2011–12 for the Canadian Council on Social    members of the Communications Expert
Determinants of Health (CCSDH) by Provoke,       Group, who provided guidance on the
a communications firm in Calgary, Alberta. The   development of the messaging guidelines.
Council thanks Provoke for their contribution    The important contribution of Andrea Long,
to this project.                                 Policy Analyst, Social Determinants and Science
                                                 Integration Directorate, Public Health Agency
                                                 of Canada, who authored the guidelines, is also
                                                 much appreciated.

           COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING    iii
Table of Contents
Executive Summary .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . vii

1.	Introduction .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1

2.	Understanding the Context for SDH Messaging .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2
         2.1 Views about health and social determinants of health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
         2.2 Values and metaphors.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
         2.3 Implications for SDH messaging. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4

3. Crafting SDH Messages.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
         3.1 Expressing concepts.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
         3.2 Using facts.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
         3.3 Selecting words.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
         3.4 Best practices for communicators.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7

4.	 Conveying SDH Messages .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8
         4.1 Selecting the right tool.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8
         4.2 Priming the audience.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9
         4.3 Audience segments .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9

5.	 Key SDH Messaging Guidelines.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15

6.	Conclusion.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16

References.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17

                             COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING                                                                                                                            v
Executive Summary
Our health is influenced by diverse factors—       ‘social determinants of health’ which may not
not only by medical care and our health care       be widely understood and may not engage
system, but also by our work, our level of         audiences. The abstract concepts that underlie
education and income, where we live and            SDH must be made tangible with concrete
many other things that are together referred       analogies or examples and the judicious use
to as social determinants of health (SDH).         of facts. Messages that evoke images or
                                                   emotion tend to be more memorable, as
Canadians’ knowledge about SDH and their
                                                   are messages shared through stories to which
impact on health is limited. As a result, it
                                                   audiences can relate.
can be challenging to raise awareness about
the importance of economic, social and             Understanding the audience is an important
environmental policies for building a healthier    key to effective messaging. This involves
population. As part of its mandate to facilitate   assessing the values or metaphors that inform
action on SDH, the Canadian Council on Social      the way in which people perceive health
Determinants of Health (CCSDH) supported           and its social determinants. A message that
research to assist member agencies as well as      is consistent with personal values tends to
other individuals and organizations to build       be more convincing than a message that
the knowledge and tools needed to develop          does not align with one’s worldview. Preparing
effective SDH messages.                            the audience by using a fact, image or story that
                                                   they already believe—or that aligns with
The guidelines for common messaging examine
                                                   their values and interests—can also help make
factors that influence audience receptivity to
                                                   messages more compelling. The way in which
SDH messages, the ingredients of effective
                                                   a message is conveyed should be appropriate
messages and considerations for tailoring them
                                                   for both the audience and the context, such
for priority audiences. Findings emphasize that
                                                   as a short provocative statement, a story
effective messaging requires clear and plain
                                                   or a powerful image.
language rather than abstract phrases such as

           COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING       vii
The following table summarizes the key guidelines for effectively communicating SDH:
 WHAT TO DO                                         WHAT TO AVOID

 ü     Use clear, plain language                    û   Technical language or jargon
 ü     Make issues tangible with analogies          û   Abstract concepts or terms
       and stories
 ü     Break down and round numbers;                û   Complex numbers, or large numbers
       place numbers in context                         without any context
 ü     Challenge conventional wisdom                û   Exhaustive documentation
       with one unexpected fact
 ü     Use inclusive language (we, our, us)         û   Creating distance between groups
                                                        (them, they)
 ü     Identify people by shared experiences        û   Labeling people by group membership
 ü     Prime your audience with a fact, image       û   Facts, images or stories that audiences
       or story they are likely to believe, based       may find too contentious or extreme
       on their values, interests and needs             to be believable (even if they are true)
 ü     Leave the audience with a memorable          û   Being forgettable
       story or fact that can be easily repeated
 ü     Use a conversational and familiar tone       û   A clinical or academic tone
 ü     Take the time to understand your             û   Assuming the same message will work
       audience—this includes customizing your          for all audiences
       message by selecting appropriate tools,
       approaches and information
 ü     Prepare your message content and             û   Speaking off the cuff
       presentation
 ü     Focus on communicating one thing at          û   Trying to do too many things at once
       a time

viii   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
1. Introduction
Our health is influenced by many diverse             In Canada, many individuals and organizations
factors. These include the work we do, our           are working to raise knowledge and awareness
level of education, our income, where we             about how SDH factors influence health. This
live, the quality of our experiences when we         tool was developed to help guide them in
are children and the physical environment            their efforts.
that surrounds us.1, 2 Together, these factors
                                                     The guidelines for common messaging examine
are referred to as social determinants of
                                                     factors that influence audience receptivity to
health (SDH).
                                                     SDH messages, the ingredients of effective
Even though research has proven the                  messages and considerations for tailoring them
importance of SDH, public knowledge and              for priority audiences. They will be useful to
understanding about them remains limited.            those who work in health and public health, and
Canadians are more likely to believe their           those working outside the health sector on
health is shaped by the individual decisions         issues related to SDH such as early childhood
they make about smoking or diet and physical         development, employment, literacy and income.
activity, rather than societal factors such as
                                                     The guidelines build on earlier research
their level of income or education.3,4 This belief
                                                     completed for the Public Health Agency
is often reinforced by media coverage that
                                                     of Canada by Wellspring Strategies.5 They are
focus on individual health and health care issues,
                                                     also informed by research undertaken by
medically-oriented messages and public
                                                     the Robert Wood Johnson Foundation (RWJF)
awareness campaigns that emphasize personal
                                                     to develop and test new approaches in
health behaviours.5
                                                     communicating the SDH.6

             COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING        1
2.	Understanding the Context
    for SDH Messaging
The following section briefly reviews               households with income less than $30,000
perspectives on health and what makes people        were more likely to identify income as having a
healthy. It also examines some of the values        strong impact on their health).4 Environmental
and cultural beliefs that underlie these views.     conditions such as air and water quality were
This contextual information will help to inform     considered by a majority of Canadians to
an effective SDH communications approach.           significantly impact their health.3

2.1 VIEWS ABOUT HEALTH AND
SOCIAL DETERMINANTS OF HEALTH                         In Canada, individuals who recognize
Canadians place great value on their publicly         the structural causes of ill health are more
funded health care system and view it as              likely to support policies to address the
a cornerstone of Canada’s social policy               resulting health inequalities. This means
landscape.7,.8, 9 Health and health care              that increased awareness of SDH through
consistently feature as top priorities identified     effective messaging has the potential to
in public opinion polls.10                            contribute to subsequent action.14
Most Canadians also believe they have good
or excellent knowledge of health issues3, 4
                                                    Commonly held cultural beliefs also influence
and often identify factors such as disease and
                                                    how health information messages are received.
illness (e.g. cancer, diabetes) and health care
                                                    Independence and personal autonomy tend
infrastructure (e.g. access to doctors, wait
                                                    to be valued within the North American cultural
times) as key health policy issues.3, 4, 11
                                                    context. Consistent with this, health is often
There is evidence that Canadians are generally      viewed as a personal responsibility and as
uninformed about SDH.3, 12, 13 They are more        something that individuals can control.6, 15
likely to believe their health is influenced by     In general, people also tend to underestimate
individual factors such as smoking, diet and        the role of external factors and circumstances
exercise, and their access to health care           in explaining behaviours, and overemphasize
rather than by social and economic factors          the importance of personal motives or abilities.15,16
such as adequate income, education level,           A moral dimension is often overlaid on claims
employment or social connections.3, 4 When          about health outcomes, implying that healthier
asked specifically about social conditions          individuals have made the “right” choices while
and community characteristics, only one in          those who are less healthy have made the
three Canadians responded that these factors        “wrong” choices.
impacted their health3 (although members of

2   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
2.2 VALUES AND METAPHORS                              It is not one single factor that contributes to
                                                      poor health, but rather a constellation of factors
By their very nature, beliefs about SDH are
                                                      such as housing, food, employment, and health
connected to individual and societal values.
                                                      care. From a system perspective, disparities in
For example, the extent to which a person
                                                      health outcomes are a sign of imbalance which
believes their health outcomes are connected
                                                      needs to be corrected so that equality can
to their income or education may be related to
                                                      be achieved.6
their views on social justice, equality, personal
responsibility and so on. Since people are more       The journey metaphor views the pursuit of good
likely to dismiss or resist messages that are not     health as journey. Just as life itself, journeys can
aligned with their values, it is often challenging    be “fraught with challenge” or “smooth sailing”;
to develop broadly compelling messages.17             some journeys will be “unpredictable” while
                                                      others “focus on a series of steps that, if
Although there is limited Canadian research
                                                      followed, will take you to a predetermined
about the values that influence our view of
                                                      goal”.6 Poor health is framed in terms of a failure
health and SDH, studies by the Robert Wood
                                                      to provide individuals with “a road map of how
Johnson Foundation (RWJF) in the United
                                                      to achieve good health”.6 There is a recognition
States can inform our efforts to develop
                                                      that people must have the opportunity to make
effective SDH messaging in Canada. RWJF
                                                      healthy choices, but also, that they will choose
research explored values related to health
                                                      their own path, which may or may not
and SDH using the concept of deep metaphors.
                                                      contribute to good health. These “divergent
Deep metaphors “reflect the basic structures
                                                      paths” and the resulting imbalances in health
in our minds that organize our perceptions and
                                                      outcomes are natural. In that sense, expecting
shape the sense we make of them and how we
                                                      that everyone can achieve the same health level
react. The feelings around these metaphors are
                                                      is both unrealistic and misguided. The primary
unconscious—an automatic viewing lens that is
                                                      concern is that overall progress is achieved.6
seldom explicitly acknowledged”.18 In other
words, deep metaphors act as a filter, shaping        In Canada, the system metaphor may resonate
the way we understand and make sense of               with those familiar with the complexity of
our world.                                            health and social support systems, such as
                                                      public health practitioners or social / health
The RWJF found that health is often understood
                                                      policy organizations. The journey metaphor may
through one of two “deep metaphors”, a system
                                                      better resonate with those who value personal
metaphor or a journey metaphor. The system
                                                      responsibility or those who are less likely to look
metaphor connects disparate elements into a
                                                      to public policy to address problems. If only
single structure of interdependent parts. Within
                                                      one metaphor can be used to frame messages,
this perspective, all individuals, from the poorest
                                                      the RWJF research suggests that the journey
to the wealthiest, are interdependent. If certain
                                                      metaphor is a better choice because it is less
communities are experiencing poor health,
                                                      likely to offend or distance those who subscribe
then the whole system is affected. Furthermore,
                                                      to a system view.
poor health is understood to be the result of
a “complex and interrelated system of social,
cultural, economic, and biological factors”.6

             COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING           3
2.3 IMPLICATIONS                                      • Validate the role of individual choices for
FOR SDH MESSAGING                                      health and draw attention to broader social
Understanding how Canadians view health                and economic factors.
and SDH as well as the values that help shape         • Affirm the value of individual responsibility,
these views can inform SDH messaging.                  while also drawing attention to the ways
The above discussion on values and metaphors           members of a society are interdependent.
suggests that SDH messaging may be made               • Avoid creating distance between groups.
more effective if we:                                  Do not single out marginalized or vulnerable
• Build on Canadians’ interest in health               populations. Use pronouns such as we or
    and health care to ‘prime’ how they                our instead of they or them.
    receive messages about other factors              • Refer to situations or circumstances, rather
    that influence health.                             than labeling individuals, e.g. use terms such
• Frame messages in a manner that is                   as people living in poverty, people without a
    consistent with audience values.                   home, people with disabilities.

• Frame messages in non partisan language.            • Draw attention to current circumstances that
    Avoid relying on words or phrases likely to        are unfair or not equitable.
    be associated with particular political parties   • Identify the problem and at the same time,
    or ideologies.                                     affirm alternatives and solutions. Emphasize
• Consider the relevance of deep metaphors.            the idea of creating conditions for people
                                                       and society to progress.

4     COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
3. Crafting SDH Messages
The following section provides tips on how           Provide factual context. How and when a fact
to create effective messages about SDH.              is presented is critical, especially when it may
It stresses the importance of making abstract        challenge an existing belief. Placing facts in the
concepts tangible and the appropriate use            appropriate context can help make contentious
of facts and language to engage audiences.           information easier to accept.

3.1 EXPRESSING CONCEPTS
One of the challenges of delivering SDH                A message could state that:
messages is how to translate theoretical               Half of parents in poor neighbourhoods don’t
language and abstract concepts into tangible           feel safe letting their children play outside.
and easily understood concepts. This challenge
                                                       Or it could create an image of the situation:
can be addressed by using plain language and
illustrating abstract ideas through stories or         Many parents feel they are not providing their
analogies. For example, an abstract concept            children with the most basic opportunities to
such as ‘food insecurity’ can be explained by          play outside, but are unable to move because
using concrete indicators and illustrating their       of their job or income.6
implications, as in, “When we don’t have
enough of the right food, it holds us back”.
                                                     Using numbers. Explain large numbers so
3.2 USING FACTS                                      they can be understood. Large numbers
                                                     can lose their meaning in the absence of
Facts are an essential ingredient of effective SDH
                                                     adequate context. If possible, numbers should
messages. They provide critical information to
                                                     be rounded to make them more memorable
inform stories and can lend credibility to claims
                                                     (e.g. 23.6% could be expressed as ‘almost
and assertions. It is important to remember
                                                     one-quarter’ or ‘almost 25%’).
however, that facts must be used carefully if
they are to engage key audiences.                    A number represents a value, but it can also
                                                     express our values.6 For example, stating that a
How many facts? Research shows that one
                                                     program or intervention costs $10 million over
strong and compelling fact can be more
                                                     five years may be of interest to policy-makers,
powerful than a series of facts, particularly when
                                                     but stating that it costs $2 a day for all Canadians
the fact is an unexpected or surprising point
                                                     may be more appropriate to the general public.
that arouses interest, attention and emotion.
What kind of facts? Information must be
believable to the audience. Even if a fact is
correct, it may be doubted if appears too
extreme. It may also lead to perceptions of
‘cherry picking’ data that best supports the
conclusion, which could cause your audience
to doubt the message.

             COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING          5
SAMPLE FACTS                                          • Living in unsafe, unaffordable or insecure
Here are some good examples of how numerical           housing increases the risk of many health
facts can be incorporated into SDH messaging           problems.22
in Canada:                                            • Education is a strong predictor of long-term
                                                       health and quality of life.23
• The poorest 20% of Canadians have more
    than double the chance of having two or more      • There is growing evidence that investing in
    chronic health conditions like heart disease       education is a highly effective step we can take
    and diabetes than the richest 20%.19               to improve health outcomes. One study
                                                       estimates that having quality education
• People living in Canada’s highest income
                                                       available to all could save eight times as
    urban neighbourhoods live about three years
                                                       many lives as medical advances.24
    longer than those in the lowest income
    neighbourhoods.19                                 • Warm and supportive parenting can help
                                                       protect children from the negative impacts
• First Nations youth are over 4 times as likely
                                                       of poverty, including poor health.25
    to commit suicide compared to other
    Canadian youth. The suicide rate for Inuit        • Being unemployed or having a low-paying
    is almost 12 times higher.19                       stressful job can bring on illness and injury.
                                                       A good job can promote better health,
• The likelihood of being obese is influenced
                                                       self-esteem and social contacts. With a
    by our income, education and jobs. Young
                                                       good job, we feel we belong.26
    people from more affluent families have
    more opportunities to be physically active
                                                      3.3 SELECTING WORDS
    and to consume healthier food.20
                                                      Research from the United States has shown that
• Bullying can have a serious impact on mental
                                                      abstract phrases such as ‘social determinants of
    health. Studies suggest that 36% of students
                                                      health’ do not engage audiences.6 Nevertheless,
    in grades 6 to 10 may be victims of bullying.20
                                                      the concepts that underlie these phrases are
• More than one in four lower income                  actually broadly supported, particularly when
    Canadians have skipped meals as a result          they are expressed in concrete terms. These
    of financial concerns.4                           findings can also inform how we communicate
• 25% of lower income Canadians say they have         SDH messages in Canada.
    delayed or stopped buying some prescription
                                                      Using plain, values-driven and emotionally
    drugs because of the economic downturn.
                                                      compelling statements can help craft effective
    Only 3% of Canadians earning more than
                                                      SDH messages. For example, we should
    $60,000 have taken similar action.4
                                                      avoid using labels and refer instead to the
• Canadians living in the most deprived               circumstances that people experience when
    neighbourhoods had mortality rates that           they belong to a certain group. Below are
    were 28% higher than those living in the          some examples of how to use alternate
    least deprived neighbourhoods.21                  language to describe abstract concepts and
                                                      groups adapted from the RWJF.6

6     COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
WHEN TALKING ABOUT ABSTRACT       TRY USING SIMPLE, VALUES-DRIVEN AND EMOTIONALLY
 CONCEPTS OR GROUPS…               COMPELLING STATEMENTS.

Social determinants                • Our opportunities for better health begin where we live,
                                     learn, work and play.
                                   • Where we live, learn, work and play can have a greater
                                     impact on how long and well we live than medical care.
                                   • All people should have the opportunity to make the choices
                                     that allow them to live a long, healthy life, regardless of their
                                     income, education, or ethnic background.
Health inequalities                • Giving everyone a fair chance to live a healthy life.
Vulnerable groups                  • Too many people don’t have the same opportunities to be
                                     as healthy as others.
                                   • People whose circumstances have made them vulnerable to
                                     poor health.
Poverty                            • Families who can’t afford the basics in life.
Low-income workers                 • People who work for a living and still can’t cover basic costs.

3.4 BEST PRACTICES                                 A good communicator should clearly
FOR COMMUNICATORS                                  understand the motivations, needs, values
The messenger will always be a key element         and background knowledge of their audience.
in the communications equation. It is essential    This will help them tell a story or message
that the communicator appears open and             that the audience will understand, remember
eager and uses a familiar and conversational       and retell. A good communicator prepares
tone. If the communicator feels emotion about      message content in advance and pays attention
stories and messages it is more likely that this   to delivery (e.g. gestures, body language),
emotion will be conveyed to the audience in a      structure (e.g. duration, anticipated responses)
compelling and memorable way.                      and approach (e.g. words, visuals).

            COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING         7
4. Conveying SDH Messages
The following section reviews ways to design            The Robert Wood Johnson Foundation
and deliver messages so that they align with the        (RWJF) used a sophisticated research and
specific contexts and circumstances in which            testing process to develop a set of SDH sound
they will be delivered. It illustrates how to select    bites. Some of these messages have been
appropriate tools and engage an audience by             slightly adapted to the Canadian context:
understanding their needs and interests.
                                                       • Health starts—long before illness—in our
4.1 SELECTING THE RIGHT TOOL                             homes, schools and jobs .

Messages about SDH can be conveyed in many             • All of us should have a fair opportunity to
different ways to suit various contexts. Three           make the choices that allow us to live a long,
basic types of tools are outlined below: sound           healthy life, regardless of income, education
bites, stories, and visuals. These tools can be          or ethnic background .
used independently or combined together.               • Our neighbourhood or job shouldn’t be
                                                         hazardous to our health .
SOUND BITES                                            • Our opportunity for health starts long before
Sound bites are 10–20 second short statements            we need medical care .
or tag lines. They can be used on their own or         • Health begins where we live, learn, work
to introduce longer stories. Sound bites should          and play .
convey one key idea in a clear and evocative
                                                       • The opportunity for health begins in our
manner. They should be easy for the audience
                                                         homes, neighbourhoods, schools and jobs .
to remember and repeat.

STORIES                                                VISUALS

Audiences understand and recall stories more           Images are an important element of effective
easily than facts and figures. If an audience can      SDH messages and can include pictures,
relate to a character or a set of circumstances        diagrams, maps or other visual aids. Images
they are more likely to change their view about        should illustrate or reinforce the SDH message
an issue.5 A good story can inspire audiences          and help create a “mind’s eye view” by
and convince them that action is both                  describing a situation or fact in a manner
important and possible.27                              that reinforces the point.

SDH stories should be clear and compelling             Images can create a conscious or unconscious
and if possible, based on real facts. True stories     emotional response. Messages that create
or analogies can help to make the information          strong imagery can be powerful, but be
more tangible and authentic.                           cautious about negative images that may
                                                       distance the audience.

8   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
4.3 AUDIENCE SEGMENTS
 Although medical care is essential for            There are many potential audiences for SDH
 relieving suffering and curing illness, 75%       messaging. CCSDH members selected the
 of the things that can help make us healthy       following four priority audiences:
 are not part of the health care system.16
                                                   • Youth: Of the general public, Canadian
 When we think about health, it’s easy              youth are the prime target because it is
 to assume that it just means eating the            important to influence their understanding
 right food and being active. Health is a lot       of health early to influence behaviour and
 more than that. Did you know that your             outcomes across the life course. Parents are
 education, job, relationships, and where           also targeted as having an important influence
 you live account for up to 60% of your             on youth.
 total health? 27                                  • Professionals: Educators need an understanding
                                                    of SDH because they have the capacity to
                                                    influence youth. Health and public health
4.2 PRIMING THE AUDIENCE                            practitioners are important because they work
It is important to prepare, or “prime” the          at the frontline of the health system.
audiences to receive SDH messages. Audiences       • Sectoral leaders: Business leaders are
may be more likely to believe a message if it       invested in creating and maintaining a
begins with facts or images they already believe    healthy and productive workforce and the
or support. For example, Canadians place great      workplace policies they adopt can strongly
value on their health care system. As a result,     impact SDH. Public sector leaders are in a
they may be more likely to understand and           position to propose and/or influence public
act upon SDH messages that incorporate the          policies and programs that impact SDH.
importance of access to quality medical care.       Many non-governmental organizations
Messages that resonate with existing beliefs        are concerned with issues relevant to SDH,
about personal responsibility and control over      and tend to be oriented towards opportunities
health may help prime audiences to consider         to create change.
other factors that influence health, such as       • Media: Members of the media need an
SDH. See the box below for examples.                enhanced understanding of the non-medical
Prior to delivering an SDH message, it is           factors that influence health because they
important to assess the level of an audience’s      have the potential to share information
knowledge about SDH, and/or health. Do they         widely and to inform public opinion.
believe in myths or common misconceptions?         The following tables draw upon available
A well-informed audience may be better             knowledge about SDH in Canada and list the
able to engage with a complex SDH message.         important “hooks”, “primes” and considerations
Audiences with little knowledge of SDH will        for framing SDH messages for each target
require more compelling and repetitive             audience segment.
messaging, as well as information that
challenges their misconceptions.

            COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING     9
• Hooks are facts or circumstances that may      • Primes are ideas that may help to increase
 serve as entry points to SDH messaging given      audience receptivity to messaging.
 what is known about the knowledge and           • Considerations include other factors that
 beliefs of the target audience.                   may influence the way in which audiences
                                                   are engaged.
CANADIAN PUBLIC: YOUTH

 SDH               Hooks                      Primes                     Considerations
 Knowledge
 Low               • Connecting with          • Health is about          • Long term health or
                     others is an important     making responsible         other outcomes may
                     part of being healthy.     choices—but it is also     not be motivating.
                   • The health of the          about what options       • SDH are linked to
                     natural environment        you have.                  other life experiences
                     is part of what shapes   • Without health,            (e.g. cost of
                     your health.               opportunities for          education, social
                                                life experience            inclusion, (un)
                                                are limited.               employment, etc).

CANADIAN PUBLIC: PARENTS

 SDH               Hooks                      Primes                     Considerations
 Knowledge
 Low               • We want our family       • We teach our kids        • Connect SDH
                     to be healthy.             how to be healthy          to the health and
                   • Family health is           and to take care of        life outcomes
                     about more than            themselves. Now            of children.
                     the health of each         we need to make          • Parents shape the
                     family member.             sure they know             social conditions in
                     The circumstances          how factors such           which their children
                     and environments           as school, jobs            live. Be cautious
                     in which we live           and friends affect         about making them
                     together shape             their health.              feel they may not be
                     our health.              • Without health,            providing an optimal
                                                opportunities for          environment.
                                                life experience
                                                are limited.

10   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
PROFESSIONALS: EDUCATORS

 SDH               Hooks                       Primes                       Considerations
 Knowledge
 Low to            • In the classroom you      • Education influences       • Educators already
 moderate .          are on the front line .     how healthy we are           have many
 Perceived           Students who come           throughout our lives .       commitments
 knowledge of        to school hungry,         • Children know                they must meet
 health issues       without having              that their doctor            in the classroom .
 may be higher .     enough sleep or the         will help them when          It is important to
                     right clothes aren’t        they are sick . They         support them with
                     ready to learn .            also need to realize         easy-to-use tools
                   • Educators have an           that there are other         and messages .
                     opportunity to help         professionals who
                     build a healthy and         can help them avoid
                     productive next             ill health .
                     generation .

PROFESSIONALS: HEALTH PRACTITIONERS

 SDH               Hooks                       Primes                       Considerations
 Knowledge
 Moderate,         • Existing pressures        • Patient care is            • Supportive of SDH
 but focus           in service delivery         critical to a healthy        concepts, but unclear
 tends to be         and the challenges          population, but it is        on actions to take .
 on individual       they create for             not enough . We also       • Recognize there are
 health/medical      practitioners               need to address the          problems in frontline
 care                and patients .              root causes of illness .     service delivery, but
                   • Contribution to           • Enable/empower               systemic change is
                     creating a healthier        patients to make             difficult to imagine .
                     population—one              healthy choices
                     patient at a time .         by creating the
                                                 circumstances in
                                                 which these choices
                                                 are available .

            COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING           11
SECTORAL LEADERS: PRIVATE SECTOR LEADERS

 SDH                 Hooks                     Primes                      Considerations
 Knowledge
 Low, but            • Ill health has a        • You are invested          • Illustrate the costs of
 significant           business cost—it          in the health of your       inaction, e .g . human
 health                results in workplace      employees—it is             capital development,
 investments via       absences and              important that this         cost of treating
 benefit plans,        diminished                investment covers all       instead of preventing
 sick leave, etc .     productivity .            aspects of health .         illness .
                     • Health is a             • Preventing illness        • Potential for long-
                       good investment .         keeps employees             term benefits in
                       Ill health is costly:     at work .                   workforce health,
                       economically,           • Your employment             absenteeism, and
                       socially and              and occupation can          productivity .
                       personally .              influence your health .
                     • Possible links to
                       corporate social
                       responsibility
                       agendas .

SECTORAL LEADERS: PUBLIC SECTOR LEADERS

 SDH                 Hooks                     Primes                      Considerations
 Knowledge
 Varies by area .    • Sustainability of the   • The costs of ill          • Awareness of
 High among            health care system,       health are high .           political timetables,
 health leaders;       growing cost              We need to                  which can
 moderate              pressures .               keep people from            complicate
 among social        • Demographic               getting sick by             prioritizing longer
 policy leaders .      change—aging              focusing on                 term outcomes .
 May be low            population and            prevention .              • General support
 among others .        connection to health    • Enable/empower              for the concept
                       care provision .          people to make              of cross-sector/
                     • Economic costs of         healthy choices             department work,
                       ill health and health     by creating the             but need help to
                       inequality, the cost      circumstances in            see opportunities
                       of inaction .             which these choices         for specific actions .
                                                 are available .           • Jurisdictional
                     • Increasing prevalence
                       of chronic disease      • Health is a                 divisions—clarity on
                       and the long-term         consistent priority         federal vs . provincial/
                       impacts on well-          in Canadian public          territorial/ regional
                       being, productivity,      opinion polling .           roles and policy
                       etc .                                                 levers is important .

12   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
SECTORAL LEADERS: NON-GOVERNMENT ORGANIZATIONS OUTSIDE OF THE HEALTH SECTOR

 SDH                 Hooks                    Primes                      Considerations
 Knowledge
 Varied.             • Health, social,        • Action on SDH can         • Motivated by desire
 It is likely that     environmental and        help to address             to act and a sense of
 many NGOs will        other issues are         inequality (or other        social responsibility.
 have high levels      inter-connected.         issues as appropriate).   • Many NGOs already
 of SDH-related        There are common       • A healthier                 recognize the value
 knowledge, but        elements between         population can help         of change and may
 the language of       these issues             us to achieve other         be oriented towards
 SDH may not           and SDH.                 societal goals.             achieving it.
 be consistently     • Poor health and        • It is a collective        • Need to be equipped
 used.                 health inequalities      responsibility to           with tools given
                       impact other             create the conditions       limited financial and
                       areas of life, such      in which people             human resources.
                       as employment,           can succeed.              • Consider the
                       child care,              This includes               language and
                       volunteering, etc.       conditions that             priorities of other
                     • Health inequalities      support good health.        sectors—problems
                       are costly—                                          and solutions cannot
                       economically,                                        be framed only in
                       socially and                                         health terms.
                       personally.

SECTORAL LEADERS: NON-GOVERNMENT ORGANIZATIONS IN THE HEALTH SECTOR

 SDH                 Hooks                    Primes                      Considerations
 Knowledge
 Moderate            • Existing health        • Medical care is           • Medical care tends to
 to high.              system pressures         critical, but not           be the focus of
 Some NGOs             and the challenges       enough to make              health dialogue.
 are likely to         they create for          people healthy.             Health organizations
 have a stronger       governments,             We also need to             may need tools and
 focus on              practitioners and        address the root            support to extend
 medical care          patients.                cause of ill health.        this dialogue to
 than SDH.           • Public interest        • Preventing people           include SDH.
                       in health and            from becoming sick
                       health care is           is an important part
                       consistently high.       of supporting health.

            COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING     13
MEDIA

 SDH                   Hooks                     Primes                    Considerations
 Knowledge
 Low to                • Sustainability of the   • Connection between      • Timeliness is critical—
 moderate .              health care system,       individual health and     stories need to be
 Primary focus           growing cost              the circumstances         ‘newsworthy’ .
 tends to be             pressures .               that create (or         • Need to make
 medical care,         • Demographic               undermine) it .           SDH tangible—
 stories about           change—aging            • Connections               create a human face
 individual health .     population and            between health            for the story .
                         connection to health      system pressures
                         care provision .          and overall
                       • Economic costs of         population health—
                         ill health and health     build a healthier
                         inequality, the cost      population by acting
                         of inaction .             on SDH .
                       • New research or data
                         on health conditions
                         or treatments .

14   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
5. Key SDH Messaging Guidelines
WHAT TO DO                                       WHAT TO AVOID

ü   Use clear, plain language                    û   Technical language or jargon
ü   Make issues tangible with analogies          û   Abstract concepts or terms
    and stories
ü   Break down and round numbers;                û   Complex numbers, or large numbers
    place numbers in context                         without any context
ü   Challenge conventional wisdom with           û   Exhaustive documentation
    one unexpected fact
ü   Use inclusive language (we, our, us)         û   Creating distance between groups
                                                     (them, they)
ü   Identify people by shared experiences        û   Labeling people by group membership
ü   Prime your audience with a fact, image or    û   Facts, images or stories that audiences
    story they are likely to believe, based on       may find too contentious or extreme to
    their values, interests and needs                be believable (even if they are true)
ü   Leave the audience with a memorable          û   Being forgettable
    story or fact that can be easily repeated
ü   Use a conversational and familiar tone       û   A clinical or academic tone
ü   Take the time to understand your             û   Assuming the same message will work
    audience—this includes customizing your          for all audiences
    message by selecting appropriate tools,
    approaches and information
ü   Prepare your message content and             û   Speaking off the cuff
    presentation
ü   Focus on communicating one thing             û   Trying to do too many things at once
    at a time

          COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING     15
6. Conclusion
The guidelines for common messaging provide      The CCSDH commissioned this document to
guidance on how to effectively communicate       help foster national dialogue on the broad
messages about social determinants of            range of factors that contribute to people’s
health (SDH). They are intended to serve as      health. It is the hope of the CCSDH that by
a tool to help Canadian Council on Social        equipping individuals and organizations with the
Determinants of Health (CCSDH) members           knowledge to create effective SDH messages
and other individuals and organizations to       we can build a broader understanding of health
build, use and share their own SDH messages.     in Canada among diverse audiences. Further
                                                 research exploring Canadian views about SDH
                                                 and the values, metaphors and language that
                                                 provide the foundation for compelling messages
                                                 would also contribute to this goal.

16   COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
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