Communicating The Social Determinants Of Health
Communicating the SocialDeterminants of HealthGUIDELINES FOR COMMON MESSAGINGOctober 23, 2013Canadian Councilon Social Determinants of Health
Communicating the Social Determinants of Health Guidelines for Common MessagingÉgalement disponible en français sous le titre : Communiquer les déterminantssociaux de la santé: guide pour la création de message communsTo obtain additional copies, please contact:Canadian Council on Social Determinants of HealthE-mail: CCSDH.Correspondence@phac-aspc.gc.caThis publication can be made available in alternative formats upon request.ISBN: 978-0-9937151-0-5
PrefaceThis document is based on researchcommissioned by the Canadian Councilon Social Determinants of Health (CCSDH),previously known as the Canadian ReferenceGroup on Social Determinants of Health (CRG).The CCSDH is a collaborative multi-sectoralstakeholder group established to: Provide the Public Health Agency ofCanada (PHAC) with advice on mattersrelating to the implementation of theRio Political Declaration on SocialDeterminants of Health, including planning,monitoring, and reporting; and Facilitate and leverage action on the socialdeterminants of health through membernetworks and targeted, intersectoral initiatives.The CCSDH brings together organizations froma wide array of sectors that have a role to playin addressing the factors that shape health. TheCCSDH also includes individuals selected onthe basis of their knowledge and experienceregarding policy, research or intersectoralaction on the social determinants of health.The CCSDH fulfills its mandate through variousactivities, including support for the creationor adaptation of tools to leverage action onsocial determinants of health. Communicatingthe Social Determinants of Health: Guidelinesfor Common Messaging is one such tool. Increating the guidelines, the aim of the CCSDHis to provide individuals and organizationswith the knowledge to create effective, targetedmessages on the factors that shape health.The development of this tool was guidedby the Communications Expert Group,which was comprised of members of theCCSDH Communications Subcommitteeand communications advisors from variousCCSDH organizations. The guidelineswere conceived as part of a wider strategyto raise awareness and understandingof the social determinants of health. As such,it is the hope of the CCSDH that theywill be widely shared and used to facilitatean expanded conversation about healthin Canada.COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGINGi
THE CANADIAN COUNCIL ONSOCIAL DETERMINANTS OF HEALTHKRISTA OUTHWAITE,CO-CHAIRAssociate Deputy Minister,Public Health Agencyof CanadaJEFFREY CYRBEN HENDERSONExecutive Director,National Association ofFriendship CentresRepresentative, Federationof Canadian Municipalitiesand City Councillor,City of EdmontonERICA DI RUGGIEROPEGGY TAILLON, CO-CHAIRPresident and CEO,Canadian Council onSocial DevelopmentAssociate Director, CanadianInstitutes of Health Research,Institute of Populationand Public HealthKIMBERLY ELMSLIE(EX OFFICIO)JOEY EDWARDHActing Assistant DeputyMinister, Public Health Agencyof CanadaDirector, CommunityDevelopment HaltonGERRY GALLAGHERVice-President, OrganizationalEffectiveness and Learning,Conference Board of CanadaActing Executive Director,Social Determinants andScience IntegrationDirectorate, Public HealthAgency of CanadaPAUL BORNMARGO GREENWOODMICHAEL BLOOMPresident and CEO,Tamarak Institute forCommunity EngagementED BULLERElderBARBARA BYERSExecutive Vice-President,Canadian Labour CongressCONNIE CLEMENTScientific Director, NationalCollaborating Centre forDeterminants of HealthRÉAL LACOMBEDirector of Public Health andMedical Affairs, Agence de lasanté et des services sociauxde l’Abitibi-TémiscamingueKATHY LANGLOISDirector General, StrategicPolicy, Planning & Information,First Nation and Inuit HealthBranch, Health CanadaCORY NEUDORFChief Medical Officerof Health, SaskatoonHealth RegionAcademic Leader, NationalCollaborating Centre forAboriginal HealthHILARY PEARSONTREVOR HANCOCKLOUISE POTVINProfessor and Senior Scholar,School of Public Healthand Social Policy, Universityof VictoriaScientific Director, CentreLéa-Roback sur les inégalitéssociales de MontréalJEAN HARVEYDirector of Policyand Public Affairs,Canadian Institute of PlannersDirector, CanadianPopulation Health Initiative,Canadian Institutefor Health InformationPresident, PhilanthropicFoundations CanadaANDREW SACRETIAN CULBERTExecutive Director, CanadianPublic Health AssociationiiCOMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
Communications Expert GroupCOMMUNICATIONS SUBCOMMITTEEEXTERNAL ADVISORSDEBORAH LYNKOWSKI (LEAD)LYNE CANTINFormer CEO,Canadian Public Health AssociationFormer Analyst,Canadian Public Health AssociationBARBARA BYERSJIM CHAUVINExecutive Vice-President,Canadian Labour CongressFormer Director of Policy,Canadian Public Health AssociationANDREA GABORIAN CULBERTFormer President,Canadian Institute of PlannersFormer Communications Director,Current Executive Director,Canadian Public Health AssociationPEGGY TAILLONPresident and CEO,Canadian Council on Social DevelopmentDENIS GRUENDINGCommunications, Canadian Labour CongressCHERYL SMITHCommunications Executive,Canadian Public Health AssociationCARL VENDETTESenior Manager, Executive Networks,Conference Board of CanadaAcknowledgementsThis document is based on work completedin 2011–12 for the Canadian Council on SocialDeterminants of Health (CCSDH) by Provoke,a communications firm in Calgary, Alberta. TheCouncil thanks Provoke for their contributionto this project.The CCSDH would also like to thank themembers of the Communications ExpertGroup, who provided guidance on thedevelopment of the messaging guidelines.The important contribution of Andrea Long,Policy Analyst, Social Determinants and ScienceIntegration Directorate, Public Health Agencyof Canada, who authored the guidelines, is alsomuch appreciated.COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGINGiii
Table of ContentsExecutive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Understanding the Context for SDH Messaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 Views about health and social determinants of health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.2 Values and metaphors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 Implications for SDH messaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43. Crafting SDH Messages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.1 Expressing concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.2 Using facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.3 Selecting words. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.4 Best practices for communicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74. Conveying SDH Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.1 Selecting the right tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.2 Priming the audience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.3 Audience segments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95. Key SDH Messaging Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGINGv
Executive SummaryOur health is influenced by diverse factors—not only by medical care and our health caresystem, but also by our work, our level ofeducation and income, where we live andmany other things that are together referredto as social determinants of health (SDH).Canadians’ knowledge about SDH and theirimpact on health is limited. As a result, itcan be challenging to raise awareness aboutthe importance of economic, social andenvironmental policies for building a healthierpopulation. As part of its mandate to facilitateaction on SDH, the Canadian Council on SocialDeterminants of Health (CCSDH) supportedresearch to assist member agencies as well asother individuals and organizations to buildthe knowledge and tools needed to developeffective SDH messages.The guidelines for common messaging examinefactors that influence audience receptivity toSDH messages, the ingredients of effectivemessages and considerations for tailoring themfor priority audiences. Findings emphasize thateffective messaging requires clear and plainlanguage rather than abstract phrases such as‘social determinants of health’ which may notbe widely understood and may not engageaudiences. The abstract concepts that underlieSDH must be made tangible with concreteanalogies or examples and the judicious useof facts. Messages that evoke images oremotion tend to be more memorable, asare messages shared through stories to whichaudiences can relate.Understanding the audience is an importantkey to effective messaging. This involvesassessing the values or metaphors that informthe way in which people perceive healthand its social determinants. A message thatis consistent with personal values tends tobe more convincing than a message thatdoes not align with one’s worldview. Preparingthe audience by using a fact, image or story thatthey already believe—or that aligns withtheir values and interests—can also help makemessages more compelling. The way in whicha message is conveyed should be appropriatefor both the audience and the context, suchas a short provocative statement, a storyor a powerful image.COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGINGvii
The following table summarizes the key guidelines for effectively communicating SDH:WHAT TO DOWHAT TO AVOIDüUse clear, plain languageûTechnical language or jargonüMake issues tangible with analogiesand storiesûAbstract concepts or termsüBreak down and round numbers;place numbers in contextûComplex numbers, or large numberswithout any contextüChallenge conventional wisdomwith one unexpected factûExhaustive documentationüUse inclusive language (we, our, us)ûCreating distance between groups(them, they)üIdentify people by shared experiencesûLabeling people by group membershipüPrime your audience with a fact, imageor story they are likely to believe, basedon their values, interests and needsûFacts, images or stories that audiencesmay find too contentious or extremeto be believable (even if they are true)üLeave the audience with a memorablestory or fact that can be easily repeatedûBeing forgettableüUse a conversational and familiar toneûA clinical or academic toneüTake the time to understand youraudience—this includes customizing yourmessage by selecting appropriate tools,approaches and informationûAssuming the same message will workfor all audiencesüPrepare your message content andpresentationûSpeaking off the cuffüFocus on communicating one thing ata timeûTrying to do too many things at onceviiiCOMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
1. IntroductionOur health is influenced by many diversefactors. These include the work we do, ourlevel of education, our income, where welive, the quality of our experiences when weare children and the physical environmentthat surrounds us.1, 2 Together, these factorsare referred to as social determinants ofhealth (SDH).Even though research has proven theimportance of SDH, public knowledge andunderstanding about them remains limited.Canadians are more likely to believe theirhealth is shaped by the individual decisionsthey make about smoking or diet and physicalactivity, rather than societal factors such astheir level of income or education.3,4 This beliefis often reinforced by media coverage thatfocus on individual health and health care issues,medically-oriented messages and publicawareness campaigns that emphasize personalhealth behaviours.5In Canada, many individuals and organizationsare working to raise knowledge and awarenessabout how SDH factors influence health. Thistool was developed to help guide them intheir efforts.The guidelines for common messaging examinefactors that influence audience receptivity toSDH messages, the ingredients of effectivemessages and considerations for tailoring themfor priority audiences. They will be useful tothose who work in health and public health, andthose working outside the health sector onissues related to SDH such as early childhooddevelopment, employment, literacy and income.The guidelines build on earlier researchcompleted for the Public Health Agencyof Canada by Wellspring Strategies.5 They arealso informed by research undertaken bythe Robert Wood Johnson Foundation (RWJF)to develop and test new approaches incommunicating the SDH.6COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING1
2. Understanding the Contextfor SDH MessagingThe following section briefly reviewsperspectives on health and what makes peoplehealthy. It also examines some of the valuesand cultural beliefs that underlie these views.This contextual information will help to informan effective SDH communications approach.2.1 VIEWS ABOUT HEALTH ANDSOCIAL DETERMINANTS OF HEALTHCanadians place great value on their publiclyfunded health care system and view it asa cornerstone of Canada’s social policylandscape.7,.8, 9 Health and health careconsistently feature as top priorities identifiedin public opinion polls.10Most Canadians also believe they have goodor excellent knowledge of health issues3, 4and often identify factors such as disease andillness (e.g. cancer, diabetes) and health careinfrastructure (e.g. access to doctors, waittimes) as key health policy issues.3, 4, 11There is evidence that Canadians are generallyuninformed about SDH.3, 12, 13 They are morelikely to believe their health is influenced byindividual factors such as smoking, diet andexercise, and their access to health carerather than by social and economic factorssuch as adequate income, education level,employment or social connections.3, 4 Whenasked specifically about social conditionsand community characteristics, only one inthree Canadians responded that these factorsimpacted their health3 (although members of2households with income less than 30,000were more likely to identify income as having astrong impact on their health).4 Environmentalconditions such as air and water quality wereconsidered by a majority of Canadians tosignificantly impact their health.3In Canada, individuals who recognizethe structural causes of ill health are morelikely to support policies to address theresulting health inequalities. This meansthat increased awareness of SDH througheffective messaging has the potential tocontribute to subsequent action.14Commonly held cultural beliefs also influencehow health information messages are received.Independence and personal autonomy tendto be valued within the North American culturalcontext. Consistent with this, health is oftenviewed as a personal responsibility and assomething that individuals can control.6, 15In general, people also tend to underestimatethe role of external factors and circumstancesin explaining behaviours, and overemphasizethe importance of personal motives or abilities.15,16A moral dimension is often overlaid on claimsabout health outcomes, implying that healthierindividuals have made the “right” choices whilethose who are less healthy have made the“wrong” choices.COMMUNICATING THE SOCIAL DETERMINANTS OF HEALTH: GUIDELINES FOR COMMON MESSAGING
2.2 VALUES AND METAPHORSBy their very nature, beliefs about SDH areconnected to individual and societal values.For example, the extent to which a personbelieves their health outcomes are connectedto their income or education may be related totheir views on social justice, equality, personalresponsibility and so on. Since people are morelikely to dismiss or resist messages that are notaligned with their values, it is often challengingto develop broadly compelling messages.17Although there is limited Canadian researchabout the values that influence our view ofhealth and SDH, studies by the Robert WoodJohnson Foundation (RWJF) in the UnitedStates can inform our efforts to developeffective SDH messaging in Canada. RWJFresearch explored values related to healthand SDH using the concept of deep metaphors.Deep metaphors “reflect the basic structuresin our minds that organize our perceptions andshape the sense we make of them and how wereact. The feelings around these metaphors areunconscious—an automatic viewing lens that isseldom explicitly acknowledged”.18 In otherwords, deep metaphors act as a filter, shapingthe way we understand and make sense ofour world.The RWJF found that health is often understoodthrough one of two “deep metaphors”, a systemmetaphor or a journey metaphor. The systemmetaphor connects disparate elements into asingle structure of interdependent parts. Withinthis perspective, all individuals, from the poorestto the wealthiest, are interdependent. If certaincommunities are experiencing poor health,then the whole system is affected. Furthermore,poor health is understood to be the result ofa “complex and interrelated system of social,cultural, economic, and biological factors”.6It is not one single factor that contributes topoor health, but rather a constellation of factorssuch as housing, food, employment, and healthcare. From a system perspective, disparities inhealth outcomes are a sign of imbalance whichneeds to be corrected so that equality canbe achieved.6The journey metaphor views the pursuit of goodhealth as journey. Just as life itself, journeys canbe “fraught with
Rio Political Declaration on Social Determinants of Health, including planning, monitoring, and reporting; and Facilitate and leverage action on the social determinants of health through member networks and targeted, intersectoral initiatives. The CCSDH brings together organizations from a wide array of sectors that have a role to play
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