Communicating the Social Determinants of Health · ii Communicating the Social Determinants of...

Communicating the Social Determinants of Health Scoping Paper

Diana Daghofer Wellspring Strategies Inc. March 15, 2011

Wellspring Strategies Inc. March 15, 2011

2 Communicating the Social Determinants of Health

Acknowledgements This report was prepared for the Canadian Reference Group on social determinants of health (CRG), which is supported by the Strategic Initiatives and Innovations Directorate, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada. The views expressed within are not necessarily the views of the Public Health Agency of Canada. Many thanks go to the numerous groups working to effectively communicate the social determinants of health to a wide range of audiences in Canada and internationally.



Communicating the Social Determinants of Health

Contents

Executive Summary ............................................................................................................. i

1.0 Introduction and Background .................................................................................. 1

2.0 Key Audiences ......................................................................................................... 2

2.1 Policy-makers and Politicians ............................................................................ 2

2.2 Public health practitioners.................................................................................. 3

2.3 Media ................................................................................................................. 4

2.4 Community Groups/Activists ............................................................................ 5

2.5 General Public .................................................................................................... 5

2.6 Additional Audiences of Interest ....................................................................... 6

3.0 Current Positioning of SDH in Canada .................................................................... 6

3.1 Media Coverage ................................................................................................. 6

3.2 Public Understanding and Assimiliation of SDH Message ............................... 7

4.0 Strategies and Approaches to Communicating the SDH Message .......................... 8

4.1 Coordinated, Intersectoral Action ..................................................................... 9

4.2 Advocacy ........................................................................................................... 9

4.3 Communicating for Social Change .................................................................. 10

5.0 Challenges and Barriers to Increasing Awareness of SDH ................................... 11

5.1 Framing the Message ....................................................................................... 11

5.2 Barriers to Media Coverage ............................................................................. 12

5.3 Individual, Political and Corporate Views ....................................................... 13

5.4 Constraints on Advocacy Activity ................................................................... 14

6.0 Potential opportunities ........................................................................................... 15

6.1 Social Media and Public Education ................................................................. 15

6.2 Complexity Theory .......................................................................................... 16

6.3 Promising Approaches ..................................................................................... 16

7.0 Communication and educational tools for key audiences ...................................... 17

8.0 Next Steps .............................................................................................................. 17

Appendix A ....................................................................................................................... 19

Appendix B ....................................................................................................................... 20

References ......................................................................................................................... 25


i Communicating the Social Determinants of Health

Executive Summary

Canada retains a reputation of being at the forefront of health promotion and population health; however, implementation of policies that reflect the social determinants of health (SDH) lags behind many other nations.1 The recent publication of high-profile reports from the World Health Organization (WHO), 2 Canada’s Chief Public Health Officer,3 the Canadian Senate,4 and others have brought the SDH to the forefront again. To make progress on implementing the SDH, support must be built among politicians and policy-makers, public health practitioners, the media, community groups and activists, and the general public.

Gaining traction on the SDH is complex, as the concepts revolve around individual and cultural values. As such, it is important to plan communication about the SDH with a full understanding of the current views of key audiences on issues such as poverty and inequality. Effective communication requires knowledge of potential strategies to reach and mobilize these groups, skill in framing messages in a way that will allow careful consideration of the issues, and an appreciation for the political context in which proposed change will take place.

Psychological research has found that “humans tend to overemphasize individual factors and underemphasize contextual factors when attributing responsibility for others’ actions or dispositions.”5 In other words, people are more likely to blame others for their poor health, than to suggest that social or structural factors may be at the root of ill-health. The human bias towards individual responsibility must be overcome before people can attribute poor health and health disparities to factors beyond individual control, particularly among decision-makers, who tend to belong to the wealthier, healthier demographic.

A great deal of research has been conducted in the US on ideologies that shape peoples’ views of the SDH. V 6 While some research outlines Canadians’ views of the SDH, a more complete understanding may be required to effectively shape messages and strategies to communicate the SDH. The audience profiles in this report provide a starting point for that process.

Target Audiences

It has been suggested that policymakers, opinion leaders and voters should be the primary audiences for efforts to raise awareness of SDH and health disparities, as they are most likely to

1 Manzano AT, Raphael D, CPHA and the Social Determinants of Health: An Analysis of Policy

Documents and Statements and Recommendations for Future Action, Can J Public Health 2010;101(5):399-404. 2 WHO (2008) Closing the gap in a generation: health equity through action on the social determinants of

health. Final report of the commission on social determinants of health. World Health Organization, Geneva. [cited March 9, 2011] Available at http://www.who.int/social_determinants/final_report/en/ 3 Public Health Agency of Canada, The Chief Public Health Officer’s Report on the State of Public Health in

Canada 2008, [online] cited February 19, 2009 from http://www.phac-aspc.gc.ca/publicat/2008/cpho-aspc/index-eng.php 4 Senate of Canada, Subcommittee on Population Health of the Standing Senate Committee on Social

Affairs, Science and Technology, Population Health Policy: Issues and Options, April 2008, [online] cited February 19, 2009 from http://www.parl.gc.ca/39/2/parlbus/commbus/senate/com-e/soci-e/rep-e/rep10apr08-e.pdf 5 Niederdeppe, J., Bu, Q. L., Borah, P., Kindig, D. A., & Robert, S. A. (2008). Message design strategies to

raise public awareness of social determinants of health and population health disparities. Milbank Q, 86, 481-513. [cited March 9, 2011]. Available at: http://www.rwjf.org/files/research/3576.35691.messagedesign.pdf 6 Robert Wood Johnson Foundation, A new way to talk about the social determinants of health (2010). [cited

March 4, 2011]. Available at: http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428

http://www.who.int/social_determinants/final_report/en/

http://www.phac-aspc.gc.ca/publicat/2008/cpho-aspc/index-eng.php


http://www.parl.gc.ca/39/2/parlbus/commbus/senate/com-e/soci-e/rep-e/rep10apr08-e.pdf


http://www.rwjf.org/files/research/3576.35691.messagedesign.pdf

http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428


ii Communicating the Social Determinants of Health

shape health and social policy.v The media and community groups/activists are important influencers of public opinion.

Policy-makers and Politicians - Research suggests that the views of policy-makers have the strongest influence in shaping policies, rather than the views of specific constituencies. The SDH are frequently mentioned in policy documents, but advancing their implementation requires political will and skill to develop broad acceptance.7 Advocates must be able to capitalize on political opportunities, tap into citizens’ ideals and values and mobilize systems to effect change.

Public Health Practitioners – Confusion remains on the part of many public health practitioners regarding their role in promoting the SDH, despite the fact that it has been outlined in a number of reports. Essentially, all point to the importance of practitioners as educators, motivators and activators, in one form or another.8 9

Media – A number of studies have confirmed that media coverage of the social determinants of health is extremely low. 10 11 12 The frequency of coverage on a topic broadly reflects the level and type of discussion being carried out by the general public. In addition, the media can be very influential in shaping the way the public thinks about and discusses health.x 13 According to one researcher, the media tend to reinforce conventional views of health problems and play a large role in determining the legitimacy of various solutions.xiii

Community Groups/Activists - The WHO insists that the success of national efforts to reduce health inequities depends heavily on the extent to which civil society and communities are engaged in the process as autonomous, empowered and involved partners.14

General Public – Canadians are generally uninformed about the social determinants of health.ix x

xii Several studies have shown that most Canadians believe they have excellent or good knowledge of health issues, but tend to focus on disease or illness, health care infrastructure and lifestyle issues when asked about significant health issues.xii They regularly identify the most important factors to maintaining good health as diet and physical activity, as opposed to social and economic conditions. They are an important audience, however, and can play key roles in shaping public discourse through input to the media, involvement in community, professional and activist organizations, and direct challenges to public and elected officials.

7 Andress, L. (2009). Framing a Public Discussion on the Social Determinants of Health. University of

Pittsburgh [cited March 9, 2011]. Available at: www.pitt.edu/~super4/35011-36001/35151.ppt 8 Raphael, D. (2006). The social determinants of health: what are the three key roles for health promotion?

Health Promot J Austr., 17, 167-170. [cited March 11, 2011]. Available at: http://www.who.int/social_determinants/resources/articles/hpjadec2006.pdf 9 Raphael, D. (2008). Getting serious about the social determinants of health: new directions for public

health workers. Promot Educ, 15, 15-20. 10

Hayes, et al. (2007) Telling stories: News media, health literacy and public policy in Canada Social Science & Medicine, Volume 64, Issue 9, May 2007, Pages 1842-1852 11

National Collaborating Centre for Healthy Public Policy, Content Analysis of Media Coverage of Health Inequalities in Canada, 2008, NCCHPP, January 2010. [cited March 14, 2011] Available at: http://www.ncchpp.ca/docs/InequalitiesMediaCoverage_ContentAnalyisis_EN.pdf 12

Canadian Institute for Health Information. Select Highlights on Public Views of the Determinants of Health. Canadian Population Health Initiative. Ottawa (CAN): CIHI; 2005. [cited March 11, 2011] Available at: http://secure.cihi.ca/cihiweb/products/CPHI_Public_Views_FINAL_e.pdf 13

Gasher, M., Hayes, M., Hackett, R., Gutstein, D., Ross, I., & Dunn, J. (2007). Spreading the News: Social Determinants of Health Reportage in Canadian Daily Newspapers. Canadian journal of communication [cited March 14, 2011]. Available at: http://www.cjc-online.ca/index.php/journal/article/download/1724/1844 14

Solar, O. & Irwin, A. (2006). Social determinants, political contexts and civil society action: a historical perspective on the Commission on Social Determinants of Health. Health Promot J Austr., 17, 180-185. [cited March 10, 2011] Available at: http://www.bvsde.paho.org/bvsacd/cd65/social.pdf

http://www.pitt.edu/~super4/35011-36001/35151.ppt

http://www.who.int/social_determinants/resources/articles/hpjadec2006.pdf

http://www.ncchpp.ca/docs/InequalitiesMediaCoverage_ContentAnalyisis_EN.pdf

http://secure.cihi.ca/cihiweb/products/CPHI_Public_Views_FINAL_e.pdf

http://www.cjc-online.ca/index.php/journal/article/download/1724/1844

http://www.bvsde.paho.org/bvsacd/cd65/social.pdf


iii Communicating the Social Determinants of Health

Challenges and Barriers to Increasing Awareness of SDH

If communication about the SDH runs counter to people’s personal philosophies, it may actually increase opposition to action on health inequalities.15 A cultural focus on individualism places the locus of responsibility for health on the choices and behaviours of the individual, rather than societal constraints and policies regarding the distribution of resources.16 As such, carefully segmented and tested messages are required to resonate with the Canadian public, policy-makers and politicians, and make addressing the SDH a priority among enough people to stimulate action. As has been shown in Canada and internationally, the concept of the SDH is not well understood or accepted among many audiences, especially policy-makers outside of the health field. It is important to frame the SDH in politically-neutral language that makes sense to people.vi

Barriers to media coverage of the SDH must be overcome, including a lack of knowledge of the concepts, a perceived difficulty in telling stories that capture the social determinants in tangible, measurable terms, and the perception that the social determinants are not new and therefore not newsworthy. Media have also expressed concern over stigmatizing the poor, unemployed, and less educated in society through reporting on SDH research.

Constraints on advocacy activity among public health practitioners may also hinder support among this important audience. Some have suggested that public consultation in health issues amounts to little more than tokenism, as policy-makers are under heavy pressure to achieve specific national policy targets, and may feel that community involvement slows the process down and results in a loss of control.

Potential opportunities

Several opportunities have been identified as new ways to communicate the importance of SDH directly to the public, including social media.17 Videos,Twitter, Facebook, e-alerts, blogs and podcasts are being used by various groups.

Complexity theory also posits several paths to progress on SDH, including “adjacent possibles” - initiatives that are one step removed from the existing system but show the how substantive change may be possible – and contradictions – capitalizing on the fact that the public is becoming more aware of conflicting approaches to disease. For example, there is great pressure for people to change their personal behaviours to avoid obesity, while at the same time, government policies and program either support or do not interfere with the sale of unhealthy foods.

Some public health organizations are applying the SDH in an effective and engaging way, including the Ontario Public Health Association and the Association of Local Public Health Agencies, the Sudbury and District Health Unit18, the Montreal Health Region19, the Saskatoon Health Region20 and others.

15

Gollust, S. E., Lantz, P. M., & Ubel, P. A. (2009). The polarizing effect of news media messages about the social determinants of health. American Journal of Public Health, 99, 2160-2167. 16

Raphael, D., Curry-Stevens, A., & Bryant, T. (2008). Barriers to addressing the social determinants of health: insights from the Canadian experience. Health Policy, 88, 222-235. 17

Wolfe SA, Federal/Provincial Coordinator of the Canadian Alliance of Community Health Centre Associations (CACHCA), via email communication via SDoH Listserv, January 5, 2011 18

Sudbury and District Health Unit, A framework to integrate social and economic determinants of health into the Ontario public health mandate (March 2006). [cited March 18, 2011] Available at: http://www.opha.on.ca/resources/docs/SDOH-FrameworkDiscussionPaper-March06.pdf

http://www.opha.on.ca/resources/docs/SDOH-FrameworkDiscussionPaper-March06.pdf


iv Communicating the Social Determinants of Health

Next Steps

Effective communications strategies are required to gain traction towards implementing a SDH approach. These strategies may include:21

- Coordinated intersectoral action and community involvement. Communication for Social Change (CFSC) has been identified as a successful process that combines community dialogue and collective action for social change to improve the health and welfare of the community.22

- Advocacy, including media advocacy - working with and training journalists to ‘‘frame’’ news stories to build public support and influence decision-makers and policy-makers

- Effectively-framed messages, in politically-neutral language that make sense to people, as well as provocative statements that highlight the costs of doing nothing

- Stories about successful programs and initiatives (possibly building on the examples provided in Section 6.3 – Promising Approaches).

- Images and graphics that translate research into compelling narratives. - Use of video and social media to reach the public directly.

Further Research Required – Before an effective communication strategy on SDH can be planned and implemented, more detailed information is required on the Canadian context, including detailed information on the views of various groups of Canadians on the SDH, particularly politicians and policy-makers. Language specific to the Canadian social context must be developed and tested with Canadian audiences to create messages about the SDH that resonate with specific groups within society.

19

Bryant, T., Raphael, D., & Travers, R. (2007). Identifying and strengthening the structural roots of urban health in Canada: participatory policy research and the urban health agenda. Promot Educ, 14, 6-11. [cited March 9, 2011] Available at: http://www.hpclearinghouse.ca/pdf/bryant_2.pdf 20

Daghofer D, Beanlands H, Using Neighbourhood Data to Address the Social Determinants of Health Ontario Health Promotion E-Bulletin, 08 July 2010 - OHPE Bulletin 668, Volume 2010, No. 668 [cited March 18, 2011] Available at: http://www.ohpe.ca/node/11458 21

Kelly, M. & Bonnefoy, J. (2007). The social determinants of health: developing an evidence base for

political action. National Institute for Health and Clinical Excellence [cited March 11, 2011]. Available at: http://www.who.int/social_determinants/resources/mekn_final_report_102007.pdf 22

Figueroa, M., Kincaid, D., Rani, M., & Lewi, G. (2002). Communication for Social Change: An Integrated Model for Measuring the Process and Its Outcomes. Johns HopkinsUniversity Center for Communication Programs [cited March 10, 2011]. Available at: http://www.communicationforsocialchange.org/pdf/socialchange.pdf

http://www.hpclearinghouse.ca/pdf/bryant_2.pdf

http://www.ohpe.ca/node/11458

http://www.who.int/social_determinants/resources/mekn_final_report_102007.pdf

http://www.communicationforsocialchange.org/pdf/socialchange.pdf



1.0 Introduction and Background

Marc Lalonde introduced the idea that health depends on a wide range of factors outside of the health care system, with the publication of “A New Perspective on the Health of Canadians”, in 1974.1 While Canada still retains a reputation of being at the forefront of health promotion and population health, implementation of policies that reflect the social determinants of health (SDH) lags behind many other nations.2 The SDH are enjoying a resurgence of late, with the publication of high-profile reports from the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH), 3 Canada’s Chief Public Health Officer,4 the Canadian Senate,5 the Conference Board of Canada,6 and numerous public health and social development organizations. Even as the research base is being solidified, however, health inequities are growing in Canada.7

Knowledge of the SDH among the Canadian public, media, policy-makers and other decision-makers is quite varied. The public are generally uninformed, 8 9 while the number of references to SDH in policy documents suggests that policy-makers are quite aware of the role of social determinants in shaping health. 10 One possible reason for the lack of news coverage on the SDH is lack of knowledge on the part of the media. 11 Among its proposed actions, the WHO CSDH included the need to raise awareness of the SDH among the public, practitioners and decision-makers, to better link health with living conditions.3

Communicating the SDH is, however, a complex undertaking. The WHO Commission takes a very straight-forward approach, and appears convinced that effective communication of SDH messages will provide the catalyst required for actions to significantly improve the health of vulnerable populations. However, by their very nature, the concepts behind SDH are based on

societal values. 12 People’s political and social perspectives will colour how they react to

statements linking health with income, education and other social conditions. Some point out that the political and economic orientation of a nation is a key factor in predicting whether action on social programs is taken, regardless of the strength of evidence behind a particular policy.13 Looking at past efforts of the WHO regarding SDH, analysts suggest that it is not primarily a lack of knowledge that has hampered action on SDH, but rather, political barriers.14

Given the complexity of the situation, it is important to plan communication about the SDH with a full understanding of current thinking of the relevant constituencies on issues such as poverty and inequality. Effective communication requires knowledge of potential strategies to reach and mobilize various groups, skill in framing messages in a way that will allow careful consideration of the issues, and an appreciation for the political context in which proposed change will take place.

This scoping paper attempts to gather some of the background required to plan an effective communication strategy, and point the direction to additional information required before such an effort is undertaken.



2.0 Key Audiences

Before individuals can be influenced on a value-laden issue such as the SDH, a clear understanding of their current views is required. Psychological research has found that “humans tend to overemphasize individual factors and underemphasize contextual factors when attributing responsibility for others’ actions or dispositions.”15 In other words, people are more likely to blame others for their poor health (e.g., Obesity is due to lack of exercise), than to suggest that social or structural factors may be at the root of ill-health (e.g., Poor neighborhoods have few healthy food choices available.). This view is supported by the fact that most research carried out in the fields of medicine, public health, and health communication – as well as most public health initiatives – have been focused on individual behaviours and health care interventions, rather than SDH as the primary determinants of health. 15

The human bias towards individual responsibility may make it difficult to attribute poor health and health disparities to factors beyond people’s control. Some may simply discard this possibility, particularly if they belong to a wealthier, healthier demographic, as many decision-makers do. It has been suggested that policymakers, opinion leaders and voters should be the primary audiences for efforts to raise awareness of SDH and health disparities, as they are most likely to shape health and social policy.15 As such, efforts need to be made to convince those at higher socio-economic levels that supporting people in disadvantaged circumstances benefits everyone, making equalizing efforts within social policy well-warranted, even if it means redistributing their wealth to others.15 Other strategies involve empowering those in lower SES groups to become more involved in the political process and make their voices heard. Various strategies to mobilize voters are addressed in Section 4.0 of this paper.

A great deal of research has been conducted in the US on ideologies that shape peoples’ views of the SDH. 15 16 There, individual responsibility takes the dominant position in health, emphasizing the role of the individual, and shifting attention away from SDH and disparities in population health. While some research has identified Canadian’s views of the SDH, a more complete understanding of various groups’ views may be required to effectively shape messages and strategies to communicate the SDH. The profiles of audiences provided here begins the process of developing a clear understanding of the views of Canadians.

2.1 Policy-makers and Politicians

Note: As much of the research combines data on policy-makers with that of politicians, these two groups are presented together in this paper.

Public policy has been found to have a strong influence on population health outcomes.3 In fact, some research has suggested that the views of policy-makers have the strongest influence in shaping policies, rather than the views of specific constituencies. As such, they are a clear – some say the primary – focus on awareness-raising campaigns on the SDH.

Even so, awareness of SDH does not necessarily translate into policy changes. Advancing the SDOH takes political will and the skills to develop broad acceptance.12 Advocates must be able to capitalize on political opportunities, tap into citizens’ ideals and values and mobilize systems to effect change.

Political leaders are often part of the social elite, and may need to be convinced that the health inequities experienced by those in low SES groups can be markedly improved through social policy.15 Forces must also be in place to “enable, reinforce, or push for change”,17 including



strategies such as community-based social action to bring “grassroots pressure to bear on politicians and the state”.18 Dr. Fran Baum, one of the CSDH Commissioners, suggested that top-down and bottom-up pressure for change are required, and will likely be most successful in countries with high levels of linking social capital, or formalized, respectful and trusting interactions among people from various social institutions. 19

Information, presented in media and language that supports the policy-making process and the political priorities of governments in power, is also required. 13 Of note in the current political climate in Canada, left-leaning parties are more likely to use government policy to address the effects of social and economic inequalities, while conservative governments emphasize personal responsibility and minimize government intervention.13 Economic data may bolster the argument for social policies within the current Conservative government. Unfortunately, there is very little research evaluating the relative costs and benefits of interventions designed to tackle health inequalities.13

In any case, evidence may be sufficient to acknowledge in principle the need for action, but political barriers must be overcome before such action takes place. As the WHO CSDH points out, “…if the political strategy is not well developed, the evidence collection, however scientifically sound, may fail to generate the concrete change the Commission seeks.”14

A series of interviews conducted in 19 European countries with a total of 40 politicians and policy-makers revealed the following regarding their views of SDH:20

- Collaboration on health inequalities between different departments or sectors needs to be guided and supported by measurable targets. ‘Health inequalities’ are too vague to gain political support and often seen as ‘abstract’.

- Health determinants are more readily understood when a direct link to human health can be established. For example, cooperation on environmental and occupational health is more common than in other areas.

- There is great recognition that social factors, education and employment are important determinants of health.

- Working on child and adolescent issues, particularly education, is crucial to addressing socio-economic inequalities, and has the potential to yield concrete and measurable outcomes.

- Some policy sectors, such as finance, justice, internal affairs, safety and security, and foreign policy are more difficult to reach.

A similar survey of Canadian politicians and policy-makers would be helpful in guiding a communications strategy to this group.

2.2 Public Health Practitioners

Public health practitioners have had a long history of supporting the SDH, both as individuals and through their organizations.

The role of individual public health practitioners has been spelled out in a number of reports. Essentially, all point to the importance of practitioners as educators, motivators and activators, in one form or another. These roles are summarized as: 21 22

- Educators – The public, health professionals and the media are generally unaware of the real determinants of health, focusing instead on the healthcare system and individual behaviours. Policy-makers within the health area appear to be aware of the SDH, but their



colleagues in key areas such as finance, human resources, education, public safety, transportation and housing may not be, or at least not to the extent required to translate into policy. Public health practitioners have a role in providing information to the public , the media, policy-makers and decision-makers that respectfully, but bluntly, outlines the evidence that living conditions are the primary determinants of health. It has been argued that education, in itself, will not lead to policy changes in support of the SDH, but will support efforts among other groups to influence the political process and eventually lead to public policy changes.

- Motivators – People are clearly concerned with health and are touched by personal stories. Public health practitioners can build on the evidence linking the SDH with good health to tell the real-life stories they encounter every day, to create a better understanding of the conditions required for health. Compelling stories about the life conditions faced by members of their communities can create vivid illustrations of the impact social determinants of health have on people’s lives, and provide an alternative to the focus on medical and lifestyle factors. Evidence exists that the media, and possibly policy-makers may be influenced by stories told by the people at the front lines of ill-health every day.

Aside from the valuable research, the genuine voices that emerge from community based research may also influence the public and decision-makers. Involving people who live through the very real social and economic disparities that lead to health deficits makes the issue far more immediate, and may equip them to participate in political action themselves. The People’s Health Movement is one example of a successful social movement created in support of health through the participation of those affected.23

- Activators – Ultimately, political action will be required to have a measurable impact on public policy. To support political action for health, it has been suggested that public health practitioners must first understand and participate in the policy-making process; then frame their research such that it will fit within the current political context; and, finally, use that evidence directly in public health advocacy to influence political priorities.13 Going even further, practitioners may want to cultivate networks and relationships with public servants and politicians to influence the policy process.

Public health practitioners are sometimes confused or concerned about their roles in advocacy activities. Some are reluctant to get involved at all, given that the focus of lobbying efforts is often their employers. Some public health jurisdictions, such as Vancouver Coastal Health, have created Advocacy Guideline and Resources to clarify acceptable roles on the part of their staff.24

A neutral role that all public health researchers and practitioners can feel comfortable with is ensuring that accurate, current evidence is available to support the political decision-making process. Clearly written summaries of evidence outlining the impact of social determinants on health can be a vital part of public health advocacy, by providing not only politicians and policy-makers with required background, but also the media, activists and voters with material to raise the priority of SDH among politicians.13

2.3 Media

The news media, in its various forms, has been identified as a significant source of health-

related information. 8 The frequency of coverage on a topic broadly reflects the level and type of discussion being carried out by the general public. The media can also be very influential in



shaping the way we think about and discuss health, and not be mere reflectors of views.8 11 One researcher, Lawrence Wallack writes: “The media tend to reinforce conventional definitions of health problems and hence determine, to a large extent, the legitimacy of various solutions”.11

A more detailed review of the media coverage of the SDH is provided in Section 3.1. It is clear that journalists are an important and largely misinformed audience. Most articles on health and health disparities focus on individual health factors rather than broader SDH.11 News stories tend to describe individual incidents, rather than focus on broader themes regarding health, and often over-simplify complex issues to the level of anecdotal evidence. There are a variety of reasons for this type of reporting, including a lack of understanding of the SDH, the view that they are not conducive to telling news stories, feelings that SDH are not newsworthy, and a fear of stigmatizing low-SES and racial or ethnic minority populations. 15

2.4 Community Groups/Activists

The WHO CSDH said that, “the inclusion of civil society voices is essential to give expression to the marginalized” and “fundamental to the chances of success in closing the gap in a generation”.25 They note that past experience has identified the vital role of civil society participants in designing and implementing SDH policies, going so far as to say that the success of national efforts to reduce health inequities depends heavily on the extent to which civil society and communities are engaged as committed yet autonomous partners; are empowered with knowledge and leadership on SDH; and involved in ongoing monitoring of SDH conditions and policy responses.26 To implement its recommendations on the SDH, WHO set up separate work streams for ‘civil society’ and ‘intersectoral action’.

Addressing the inequitable distribution of power has been identified as essential to reducing health inequities.25 27 In Canada, an active movement exists among non-governmental organizations in support of the SDH, including charitable organizations, such as The United Way, social development agencies, such as the Wellesley Institute and anti-poverty groups like Campaign 2000. Policy institutes like the Canadian Centre for Policy Alternatives and even the Canadian Senate have weighed in on the need to address the SDH.28 They represent all aspects of civil society, from think-tanks and researchers to community activists.

An international example of the success cross-sectoral initiatives can have is The People’s Health Movement, a global network of health professionals and activists, academics and researchers, campaigners and people’s organizations. They have been active advocates in putting the SDH on the global agenda, by using advocacy strategies to promote the SDH as the primary determinants of health.23

2.5 General Public

There is ample evidence that Canadians are generally uninformed about the social determinants of health.8 9 22 At the same time, they are an important constituency, as they can play key roles in shaping public discourse through input to the media (letters to the editor, radio call-in shows, story suggestions, etc.), involvement in community, professional and activist organizations, and direct challenges to public and elected officials.

In fact, a number of processes identified as being successful in bringing about social change note the absolute requirement of public involvement in identifying the problem and working towards common solutions. (These strategies are discussed in Section 4.0.)

Details of Canadians’ current knowledge of the SDH are provided in Section 3.2.



2.6 Additional Audiences of Interest

The medical establishment - The CSDH notes that in the past, medical professionals and institutions have resisted efforts to advance health promotion and intersectoral action, and suggests that gaining the support of the medical establishment poses a significant challenge.14 They noted that health care providers are usually part of the “social elite”, and may resist the redistribution of wealth via government policies. The CSDH also suggests that physicians have a strong interest in maintaining their control over health.

The situation may be somewhat different in Canada, as a number of health care associations publicly support a SDH approach to health, including the Canadian Medical Association, the Canadian Nurses Association, the Registered Nurses Association of Ontario, the Association of Ontario Health Centres, the Chronic Disease Prevention Alliance of Ontario and others.28 In Ontario, physicians, nurses and others have joined forces to form Health Providers against Poverty. The Ontario Physicians Poverty Work Group, part of the Ontario Medical Association, has developed a series of articles for physicians on how to address the SDH. They have also passed a resolution calling for an organizational policy that examines poverty as a risk factor for poor health outcomes.29

The corporate sector – While arguments against increased government support for social programs often come from the business community, concerned about international competitiveness, the Conference Board of Canada has come out in strong support of a SDH approach.6 In 2006, it established the Roundtable on the Socio-Economic Determinants of Health, with a goal to create heightened awareness on what determines health, and to communicate that information to decision-makers.30 It has since announced a long-term communications and engagement strategy - DeterminACTION – with goals to: “simplify the message, spread the message and stimulate action”.

3.0 Current Positioning of SDH in Canada

3.1 Media Coverage

By excluding or marginalizing other perspectives- notably a more political analysis of the origins of illness-as opposed to just the biomedical perspective- the media play a significant part in narrowing the public debate about health, illness, and society. 12

Lauri Andress, MPH, J.D., Ph.D

A number of studies have confirmed that media coverage of the social determinants of health is extremely low. 8 9 31 In a review of health media in 2003, coverage was overshadowed by stories of healthcare (65%), with the physical environment (32%) and personal health behaviours (30%) cited as the main causes of ill health. The only social determinants of health mentioned among the top five topics identified were employment or early childhood, and that, in only 7% of cases, respectively.9 The situation had not improved by 2008, when the Canadian press devoted an average of 7 articles per month to health inequalities.31 Another review sampled articles from 13 of Canada’s largest-circulation newspapers, in both English and French, over an eight-year period, finding that two-thirds of health stories focused on health care, with only about 5% of stories dealing with broader social influences upon health.11

On the bright side, it appears that when the media do cover the SDH, they publish in-depth articles. One review measured “units of information”, a measure of how often an idea or a



subject was found in a document, and found that coverage of health inequalities in 2008 included twice the number of units of information than the average annual coverage over the previous 25 years.31

Among Canadian newspapers, the Toronto Star (13.5%) and The StarPhoenix of Saskatoon (12.2%) printed more articles on health inequalities than any other newspapers reviewed. Interest in the issue in Saskatoon was pegged to a study carried out by the Saskatoon Health Region, and the work staff carried out with local media to generate news articles on health inequities in that city. There appears to be greater interest among francophone dailies, which ranked 3rd and 4th in terms of volume of coverage (Le Devoir - 6.7% and La Presse - 6.4%). Other media produced less than 5% of content each.

What is covered?

The main causes of health inequalities were reported to be poverty (10.8%) and social inequality (10.3%). The media identified the health system’s lack of resources, pointing out that certain social groups have difficulty accessing (5.8%) the health system. In some cases (11.2%), the newspapers stressed the importance of government intervention. International news figured prominently, due to the release of the final report of the WHO Commission on the Social Determinants of Health. Monique Bégin, as Canada’s high-profile representative on the Commission, received high visibility.

What prompts stories?

Triggers for media coverage of health inequalities include journal articles, reports and conferences. One study tracked 10 events related to health inequality, and found that they generated almost half the content studied (43.8%). The Final Report of the WHO’s CSDH produced almost a quarter (23.9%) of coverage alone.

Key informant interviews with Canada’s leading health reporters revealed that scientific journals were an important source of stories. 11 They specific mentioned the following journals as story sources: the Journal of the American Medical Association, the Canadian Medical Association Journal, the New England Journal of Medicine, Science, the Proceedings of the National Academy of Sciences, l’Actualité Medicale, the British Medical Journal, The Lancet, Nature, and the Journal of Medicine. Other sources of stories cited were medical schools, regional health boards, hospitals, non-profit societies, health workers’ unions, doctors, nurses, federal and provincial health ministries, university research centres and interest groups. Readers’ calls, letters and emails were also noted as sources of story ideas. On the other hand, press releases and press conferences were viewed with caution and skepticism, as they appeared to be designed primarily to promote pharmaceutical products.

3.2 Public Understanding and Assimilation of SDH message

As noted previously, Canadians are largely ignorant of the role of social factors in determining health.8 9 22 In a 2005 survey, most Canadians (70%) said they had excellent or good knowledge of health issues, yet when asked about significant health issues, their responses focused on disease or illness, health care infrastructure and lifestyle issues, mirroring the results of previous studies. 9 They identified the most important factors to maintaining good health as diet (cited by 82% of respondents) and physical activity (cited by 70%). When specifically asked about social and economic conditions (like income and housing) and community characteristics (like supportive community), only one in three reported that had an impact on the health of



Canadians. It is clear that Canadians in general consider lifestyle changes as primary to improving health, rather than modifications to the broader SDH.

On the other hand, most respondents to the public opinion survey did identify people who were economically disadvantaged, First Nations and Inuit peoples, the elderly and children/youth as groups who have poorer health than other Canadians. About one-quarter (24%) of respondents did not consider any group as having worse health than other Canadians.

When asked about actions that could improve the health of the population, members of a Citizen’s Dialogue asked for more focus on prevention, education and wellness programs. An equal number of respondents to a survey (21%) suggested that improvements to health could be made through social and economic conditions (like raising household incomes or reducing taxes), and an improved health care system. Other suggestions were increased education (14%) and increased employment levels (10%).

At least one public opinion pollster, Michael Adams, cites evidence that Canadians’ values tend towards a more egalitarian and socially liberal approach that would, presumably, support addressing health inequities through a social determinants approach.32 Of course, views differ depending on individual philosophies. For example, Canadians who believed in structural explanations for health inequalities were more supportive of social policies to address poverty than were those who endorsed behavioral or medical explanations.33

Adams addresses what he refers to as “the myth of converging values” between Canadians and Americans. This issue warrants further study, as much research has been done on the views of Americans on issues of poverty and individual responsibility, and the role these ideologies play in accepting information about the SDH. 16 34 One US research study showed that an SDH message prompted different reactions depending on respondents’ political views.34 People are more likely to resist messages when they do not match their worldviews, so the liberal positioning within SDH messages prompted disagreement or disbelief from Republican study participants, but not among Democrats.

This type of detailed knowledge of Canadians’ views will be important in shaping effective messages regarding the SDH. It has been suggested that increased communication about the SDH may actually increase opposition to action on health inequalities if it runs counter to people’s personal philosophies.34 As such, carefully segmented and tested messages will be required to resonate with Canadians, and make addressing the SDH a priority among enough people to stimulate action.

4.0 Strategies and Approaches to Communicating the SDH Message

While evidence is important to implementing a SDH approach, effective communications strategies are required to gain traction for the issue. It has been suggested that these strategies include:35

- stories about successful programs and initiatives - messages reinforcing the need for civil society to be involved in partnership - intersectoral action and community involvement - provocative statements that highlight the costs of doing nothing - working with and training journalists to promote public health messages - images and graphics that translate research into compelling narratives.



4.1 Coordinated, Intersectoral Action

Given that the SDH are based in a number of sectors outside of health, including finance, employment, education, transportation and housing, communication across sectors is required to align various sectors and social movements towards common action.36 Several intersectoral initiatives address communication and advocacy as part of their plans for action on the SDH. DETERMINE is active in Europe, while the international Global Equity Gauge Alliance, encompasses ten countries in South America, Africa and Asia.

DETERMINE aims to stimulate action to address the SDH and improve health equity in the European Union. Its membership includes over 50 health bodies, public health and health promotion institutes, governments and various other non-governmental, professional and academic organizations and networks from 26 European countries.37

The program’s six priority areas are to develop policy, skills, partnership and leadership, organizational support, an information and evidence base, and to raise awareness and advocate for change. Within its advocacy program, DETERMINE works to:

- Gather compelling information and develop advocacy materials (brochures, web sites, etc.) on SDH, incorporating relevant information for each member country.

- Develop a stakeholder map and an advocacy strategy, including presentations to policy makers, civil society and representatives of other policy areas that impact on health, and media relations and social media strategies.

The Equity Gauge is based on the following three pillars:38

- Assessment and monitoring - to analyze, understand, measure and document inequities. - Advocacy - to promote changes in policy, programs and planning. - Community empowerment - to support the role of the poor and marginalized as active

participants in change rather than passive recipients of aid or help, using a bottom-up developmental approach and encouraging greater accountability of all institutions involved.

4.2 Advocacy

Advocacy efforts work beyond the simple dissemination of information on inequity to “use information strategically and act to change policies to improve the lives of disadvantaged people.”38 The following steps are recommended:

- Inform stakeholders - Effectively and strategically access, compile, and disseminate information, packaged and delivered in ways that are relevant to various target stakeholders.

- Shape public discourse - Bring health equity issues onto the public agenda, especially through the media, with convincing and effective arguments. Develop recommendations for policy and interventions.

- Sensitize organizations and foster coalitions - Convince and enable like-minded organizations to support systematic action for health equity; support capacity-building to facilitate ongoing advocacy efforts; and help form coalitions and networks working for health equity. (Foster community empowerment).

- Influence decision-makers through expertise and social action. Expertise can be imparted directly to policy makers and decision-makers, through participation in governmental advisory bodies and contributions to major reports, and other roles as



experts that can help influence policy. Social action can include challenges to policies or actions that seem likely to lead to greater inequities, and promoting parliamentary and legal action to further health equity.

Government departments and public health organizations are, by their nature, bureaucratic. Bureaucracies tend to be resistant to change, may reject it, or “worst of all, assimilate it in a way that blunts any real impact on the status quo.” 39 As such, at least one case study suggests that change must come ‘from within’ – from public health workers and the community they serve. Starting from a strong evidence base, it cites the need for the “realization that what we are doing now to ‘preserve and protect the public health’ is inadequate, because the social forces that advantage one group of people over another in our society are too deeply entrenched ever to be undone by conventional public health programming and regulation.” 39

Another suggestion is that, when faced with intransigence, organizations should direct more moderate voices to work the ‘‘inside route’’ within government, and target vocal opposition to take a critical role in the media, and attempt to set the public agenda that way.40

Media Advocacy is a particular approach designed to bring the media on-side with an issue. It is “the strategic use of news media to advance a public policy initiative, often in the face of such opposition”.40 Media advocacy efforts ‘‘frame’’ news stories to build public support and influence decision and policy-makers. It requires skill, creativity and planning, but over the long-term, media advocacy has successfully turned the tide on a number of health issues.41

In contrast to education campaigns, media advocacy: - moves beyond information or persuasion to mobilization - focuses on social accountability, rather than individual responsibility - focuses on changing the environment, through policy changes, rather than individual

behaviours - focuses on news media as the communications avenue, sometimes augmented with

paid advertising.

4.3 Communicating for Social Change

Communication for Social Change (CFSC) is a dynamic, iterative process that combines community dialogue and collective action for social change to improve the health and welfare of the community.42 It has been described as a way of “combining the interest-grabbing techniques of communication with the participatory skills of community development,”43 and builds on theories of group dynamics, conflict resolution, leadership, quality improvement, and the network/convergence theory of communication.

The CFSC model works from the premise that, for social change to occur, communication is required that is “cyclical, relational and leads to an outcome of mutual change rather than one-sided, individual change”. 42 It begins with a catalyst or stimulus that provokes dialogue within the community, and includes horizontal versus vertical information sharing, equitable participation, local ownership, empowerment, and social versus individual change. It requires strong leadership, but succeeds only when community members determine what collective action is required to resolve their problem. At the same time, the process increases community capacity for future collective action, leading to a pattern of continual improvement.

This process has also been called ‘facilitated dialogue’, ”designed to elicit, gather, and synthesize the collective wisdom of a group of people in answering a specific question, through the



broadest possible participation and achieving the broadest possible ownership of the resulting decisions.” 39 For success the process must:

- be sustained over time, with consistent participation and decision-making by a core group that eventually expands to include others

- be led by facilitators (and participants) who anticipate and accept that conflict, resistance, and tension are natural and inevitable elements of the process

- be entered into with the clear understanding that transforming public health practice is the ultimate goal.

Note: A model of Communication for Social Change is provided as Appendix A to this report.

5.0 Challenges and Barriers to Increasing Awareness of SDH

A number of variables determine how the SDH are perceived and acted upon in society, which can either facilitate or hinder action. The views of individuals, the political context of the day, the structures and organizations available to mobilize action, and the framing of SDH messages will all affect their acceptance. 44

5.1 Framing the Message

Because the SDH are inherently value-laden, it can be challenging to shape messages in ways that are heard and resonate with the public, policy-makers and politicians. As has been shown in Canada and internationally, the concept of the SDH is not well understood or accepted among many of these audiences, especially policy-makers outside of the health field. The Robert Wood Johnson Foundation (RWJF) in the US recently completed an extensive process to re-frame the SDH in a way that made sense to people and “did not carry political overtones”.16 They assessed language, images and symbols that would bring the message home, seeking to find common language that would “expand Americans’ views about what it means to be healthy”.

The key message they arrived at was: “Health starts where we live, learn, work and play.” The message was well-received by the media and academics, and further refinements ensured that it reflected a range of political perspectives.

Language around the SDH is firmly rooted in a nation’s culture. The work of the RWJF addresses how Americans perceive health, specifically the importance of individual freedom and personal responsibility versus state involvement in creating a healthy society. The lessons from that process provide general guidelines to be followed in developing messages around the SDH. However, language specific to the Canadian social context should be developed and tested with Canadian audiences.

Key lessons learned from the RWJF process and associated research are: 15 16 1. While the concepts behind SDH were understood, phrases like “social determinants of

health” and “social factors” failed to engage the audience. 2. Messages that were presented in colloquial, values-driven, emotionally compelling

language were more effective, particularly if audiences were ‘primed’ with messages they already believed.

3. One strong, surprising fact aroused interest, attention and emotion for maximum impact.



4. Respondents, particularly opinion leaders, preferred messages that identified the problem, but focused on potential solutions, either through examples or as principles that would lead to successful action.

5. Messages that incorporated personal responsibility made respondents more receptive to the idea that society has a role to play in making healthy choices universally available. Messages that present only one side or the other can be easily refuted and may face greater political opposition.

6. Mixing traditionally conservative values with traditionally progressive values presents language that is common to both world views. Combining the notion of personal responsibility (conservative view) with a message about opportunities (progressive view) appeals to a broader audience.

7. Describing disparities based on race or ethnicity can evoke negative reactions and potentially reinforce negative stereotypes. Focus broadly on how social determinants affect everyone (versus a specific ethnic group or socioeconomic class).

8. People understand and recall stories better than facts and figures. While little research exists on the subject, it appears that people are more likely to change their attitudes towards an issue and argue less with its points if they can identify with characters in a story, even if they are from a different social class or race.

9. Images are important in telling the story, creating links between various groups of people, suggesting causes of issues such as poverty, highlighting contrasts in society and creating analogies that people can relate to.

In addition to these general lessons, the US research provides a list of phrases to avoid, and alternative phrases to value-laden statements such as: vulnerable populations, health disparities and poverty. It also emphasizes that issues should be communicated in both economic and human terms, using simple language, specific examples and understandable statistics.

Research conducted with policymakers in the UK confirmed that compelling story lines are not only important to attract public attention. In interviews, senior policy advisors stressed the need for simple, jargon-free messages and emphasized the "value of a good story” to inspire decision-makers with the sense that action on the SDH are not only important, but feasible as well.14 They argued that researchers must be mindful of government timeframes, and should clearly lay out the relevance of the issues to current political concerns. Messages need to be easily communicated and "sellable" to colleagues and constituents.

In Canada, people who recognize the structural causes of health inequities are more likely to support social policies to address those inequalities.45 Clearly, much more research is required with all target audiences to ensure that public health messages about the SDH are tailored to specific groups within society.

5.2 Barriers to media coverage

There have been calls to expand the public’s understanding of health influences since publication of the Lalonde Report in 1974, yet Canadian newspaper coverage of stories about health are still overwhelmingly about health care and personal health habits.11

In interviews, 5 of 12 Canadian daily health reporters cited individual behaviours as the principal factors that determine the health of Canadians, primarily smoking and diet. 11 Only three of the reporters cited socio-economic factors as principal determinants. When asked to name the



central health issues facing Canadians, 11 of the 12 reporters interviewed cited some kind of health care reform.

The reasons postulated by researchers on why Canadian daily newspapers give so little coverage to the social determinants of health are:

- lack of knowledge of the social determinants on their part - a perceived difficulty describing the complicated story of social determinants in tangible,

measurable terms and the concrete “storytelling” required of news reporting - a perception that the social determinants are not new and therefore not newsworthy - an expressed concern about stigmatizing the poor, the unemployed, and the less

educated through reporting on social determinants research.

This latter fear may have some basis in fact, as research indicates that attitudes about social groups are powerful influences on public opinion toward health and social policy. When marginalized populations are highlighted in the media, people draw upon their attitudes toward these populations when making judgments about potential solutions or policies suggested to address the problem.34

Other potential suggestions relate to the structure of our healthcare system and political ideologies. Reporters are used to going to ‘the source’ of stories, which in this case is deemed to be health care institutions (hospitals, health clinics, unions, and professional associations) and people (patients, doctors, nurses, hospital administrators). As a result, the focus becomes health care, and not the factors that keep us healthy. In addition, population health tends to be complex, addressing broad groups of people dealing with a wide range of interrelated causes of health. News stories require a human face to tell the story.

Perhaps the most intransigent barrier to health reporting on the SDH is the fact that they are firmly rooted in societal values. They may run counter to individual reporters’ beliefs or their employers ideologies. Some reporters interviewed as part of one study said they did not believe in the impact of the SDH. At least one prominent Canadian researcher believes the lack of coverage on SDH reflects the political and economic views of the ever-shrinking number of owners of mainstream media outlets.46 He points to the fact that the biomedical and behavioural models of health offer potential for profit for news outlets, which the SDH approach does not. He suggests that proponents of the SDH approach should seek other opportunities, through their public health associations and local public health units, as well as social media and advocacy, to “develop a citizens’ movement to create health-promoting public policy.”

Others are more optimistic, and highlight the need for a structured communications strategy to better inform the public and health journalists about population health research. They point to scientific journals as a key outlet for researchers to promote the population health view in ways that will encourage and support increased reporting on the SDH. A recent project announced by the Canadian Institute for Health Research aims to support improved health reporting in a number of health related areas, including the broader determinants of health.47 The Best Evidence Network, funded with $370,000 over three years, will provide journalists with accessible, credible, evidence-based resources on topics in health policy.

5.3 Individual, political and corporate views

A clear barrier to implementing a SDH approach is the conflict between personal versus societal responsibility. A focus on individualism places the locus of responsibility for health on the



choices and behaviours of the individual, rather than societal constraints and policies regarding the distribution of resources.48 Views across the spectrum are found in individuals from all sectors, including decision-makers. Unfortunately, more conservative views tend to be held among the more powerful and wealthy in society. Those who are most affected by health disparities often have the least opportunity to influences action.15

Capitalizing on support from business organizations, such as the Conference Board of Canada, and spelling out economic reasons for supporting action on the SDH may help demonstrate the value of this approach. Evidence exists to counter common arguments such as: - Economic growth will, on its own, improve everybody’s health. Counter: In 2007, at the end

of a decade of sustained growth (and prior to the most recent recession), the gap in income between Canada‘s richest and poorest people was at its highest point in the last 30 years.49

- The high taxes needed to fund a strong welfare system limit economic competitiveness. Counter: On the Global Competitiveness Index high tax European countries are ranked at or near the top (in 2010: Switzerland 1st, Sweden 2nd, Finland 7th and Denmark 9th)50

- Inequalities are largely the result of poor lifestyle choices amongst poorer people. Counter: Lifestyle practices themselves show a social gradient, suggesting that social and structural factors affect the uptake of healthy and unhealthy behaviours. Wider social conditions need to be addressed alongside efforts to promote healthier lifestyles.51

- The best way to improve health is to invest more in our healthcare system. Counter: The difference between life expectancy in Cuba and in the United States is less than one year, while health care spending in the US per person is almost 25 times as much as Cuba.52

Other messages that may resonate with a corporate audience are: - Given that there is a gradient of health status across the entire range of socio-economic

determinants, addressing health inequities will improve the health of all. - Healthier employees, customers and communities positively affect economic growth. Better

health enables people to participate more actively in the economy and reduces the cost of lost productivity.

- Addressing health inequities has the potential to stem the rapidly increasing use of health services. Easing the demand for services would decrease system cost drivers, reduce pressures on the delivery of health services, and, over the long term, contribute to the financial sustainability of our health care system.53

5.4 Constraints on Advocacy Activity

Employment relationships - While progress on the SDH clearly requires political action, a number of groups are inhibited from carrying on advocacy.40 As previously mentioned, public health practitioners and other government-paid or funded workers may feel constrained against lobbying their employer or benefactor for change. Charitable organizations may be reluctant to take on what could be a very heated debate, and are, by their charitable status constrained by Revenue Canada from carrying on advocacy activities.

Those that can most actively take on the SDH cause tend to be under-resourced community groups.40 One possible solution is that those who feel constrained join, as individual citizens outside their work roles, with advocacy groups.

Among public health practitioners, results of a 2010 survey of public health units showed that virtually all respondents strongly agreed that “community engagement, multi-sectoral collaboration, and support for policy advocacy are appropriate domains of public health unit



activity on the SDH.” 54 However, while they agreed that they had roles to play in increasing awareness of and advocating for policy change on SDH, very few indicated that they had undertaken community education or awareness campaigns. More had participated in community groups or committees, including poverty reduction efforts. Encouragingly, half of respondents noted that addressing the SDH had been identified as a priority in their strategic plans.

When asked about barriers to addressing the SDH, practitioners indicated that they lacked access to local data, human resources, awareness of the public health role, and simple language to talk about SDH with the public.

Poor Quality Consultation - Public involvement has been deemed essential in processes to advance the SDH; however, some researchers question the quality of consultation being carried out.55 They suggest that consultation may be little more than tokenism, as policy-makers are under heavy pressure to achieve specific national policy targets, and may feel that community involvement slows the process down and results in a loss of control.

Consultation processes can also bog down when participants are defined by their needs, as opposed to the assets, capabilities and skills people bring to the table.55 This results in solutions that address particular deficiencies, rather than focusing on the broader issues at hand.

6.0 Potential opportunities

There are significant opportunities for progress, building on the recent high level of activity regarding the SDH, both internationally and in Canada. Mechanisms and approaches to build on are profiled in this section.

6.1 Social Media and Public Education

A number of groups have been making use of video and online media to educate the public about the SDH. In the US, Unnatural Causes: Is Inequality Making us Sick was broadcast on PBS and aired in schools across the country.56 The campaign has created a number of video, audio and downloadable fact sheets for wide public dissemination. It provides details on how to plan an awareness-raising event, including an action toolkit, discussion guide and policy guide. The Unnatural Causes network, ‘Connect Up’, has gathered commitments from hundreds of health and social justice organization working towards implementing the SDH.

In Canada, the documentary Poor No More is being screened across the country, and is trying to educate and engage the public through its online video clips, blog, Facebook page, Twitter and other social media outlets.57 The production is backed by an advisory group of health professionals and social activists.

Similarly, the BC Poverty Reduction Coalition has developed a light-hearted short video, “If the BC government were a basketball player,” pointing out that the province has no poverty reduction goals.58

Anecdotal information exists about the potential of social media tools to shift debate on health issues. For example, Community Health Centres are gaining a following through Twitter, Facebook, e-alerts, blogs and podcasts. They see this approach as providing a greater ability to direct messaging, and move past the traditional gatekeeping function of mainstream media, to reach out to the public directly. According to Scott A. Wolfe, Federal/Provincial Coordinator of



the Canadian Alliance of Community Health Centre Associations, “New audiences are hearing messages about the importance/impact of SDOH, key aspects of health care reform and other issues for which there is an absence of discussion via mainstream media.”59

6.2 Complexity theory

Complexity theory points to opportunities that may exist to promote the SDH as well. Is posits that a number of conditions must be in place before substantial change in an issue is possible. 36 Among them are: - Adjacent Possibles - initiatives that are one step removed from the existing system but

show the how substantive change may be possible. For example, international policies or programs like those of Sweden that promote the SDH.

- Contradictions - The public is becoming more aware of conflicting approaches to disease. For example, there is great pressure for people to change their personal behaviours to avoid obesity, while at the same time, government policies and program either support or do not interfere with the sale of unhealthy foods (e.g. high-fat foods, sugary drinks). The public recognizes the health, social and infrastructure costs of obesity that the public purse must absorb, while businesses that reap substantial profits.

6.3 Promising approaches

Also, a number of public health and social justice organizations have been actively addressing the SDH. Their efforts are summarized below.

Sudbury and District Health Unit (SDHU)60, – This public health unit has been very active in promoting action on the SDH, both to health professionals and the public. It released the report, A framework to integrate social and economic determinants of health into the Ontario public health mandate, in 2006, followed by Social Inequities in Health and Ontario Public Health Background Document, in 2007.61 A number of health units in Ontario are using these resources to guide cross-sectoral advocacy on a range of issues related to the SDH. In addition, SDHU produced two advertisements, in English and French, as part of a long-term community social marketing campaign, to raise awareness of SDH among decision-makers, and to build community support for action to reduce social inequities in health.62

Montreal63 - The Montreal Region Health unit follows an urban health agenda that focuses on: the natural and built environment, the political and social environment, health infrastructure, and social and community infrastructure. It has been cited as one of only a few Canadian health units that embrace a broader determinants agenda.

Saskatoon Health Region (SHR)64 – Beginning with research, in 2005, on health disparities among its citizens, the SHR has focused intensely on addressing the SDH. Among other changes, health services and the health promotion department have been restructured to meet health equity goals; staff has received trained on a SDH approach, such that all programs are viewed through this lens; and health status reports are structured around the SDH. The SHR and its partners established three areas of focus for 2009-2010: poverty reduction, homelessness and supported housing and Aboriginal employment. Having detailed local data, a pro-active partnership approach and active engagement of the media are some of the elements that have led to quick successes.



Vancouver Coastal Health (VCH)65 – VCH follows a population health strategy to orient actions to address SDH. It has also produced an educational video resource on health inequities for the general public, “The New Agenda”. The video features commentary from VCH staff and stories from local residents about how the SDH impact their lives.66

Collaborative Population Health Working Group (Nova Scotia)67 – Three public health units in south western Nova Scotia have banded together to create Redefine, Rebuild, Reconnect: Changing Our Picture of Health. It is an interdisciplinary group whose goal is to create and support local champions of population health. The website provides tools, including a video and blog to help participants exchange knowledge and gather and use evidence on population health strategies.

OPHA and aLPHA Joint Working Group in the Social Determinants of Health68 - This collaboration aims to provide leadership and common messaging related to the SDH health. They promote activities to address the SDH within the mandate of local public health units in Ontario; support the provincial advocacy efforts of alPHa and OPHA; and monitor advocacy efforts and policy changes at the provincial and national level that impact inequities in health. Their focus is applying a SDH lens for the development of public health policy and programming among public health units and the three associated ministries – Health and Long-term Care, Health Promotion, and Children and Youth Services.

Association on Ontario Health Centres - This group promotes an upstream approach to creating health. As previously noted, they have an active social networking approach to getting the SDH message directly to the public, via Facebook, Twitter and other means. Its Urban Health Framework works on health disparities within an urban setting, providing a framework to guide proactive, collaborative responses and approaches for CHCs, based on a SDH approach.

7.0 Communication and Educational Tools for Key Audiences

A wide variety of materials have been created in recent years to communicate or educate various audiences about the SDH. Resources for policy-makers and politicians, public health practitioners, the media, community groups/activists and the general public are listed in Appendix B, with a short description and key audiences identified.

8.0 Next Steps

Effective communications strategies are required to gain traction towards implementing a SDH approach. These strategies should include: 35

- Coordinated intersectoral action and community involvement. Communication for Social Change (CFSC) has been identified as a successful process that combines community dialogue and collective action for social change to improve the health and welfare of the community.42

- Advocacy, including media advocacy - working with and training journalists to ‘‘frame’’ news stories to build public support and influence decision-makers and policy-makers

- Effectively-framed messages, in politically-neutral language that make sense to people, as well as provocative statements that highlight the costs of doing nothing



- Stories about successful programs and initiatives (possibly building on the examples provided above in Section 6.3 (Promising Approaches)

- Images and graphics that translate research into compelling narratives. - Use of video and social media to reach the public directly.

Further Research Required – Before an effective communication strategy can be planned and implemented, more detailed information is required on the Canadian context. This includes:

- Detailed information on the views of various groups of Canadians on the SDH, including how political leanings colour their reactions to information on the SDH

- A survey of Canadian politicians and policy-makers to help guide communications to this group.

- Language specific to the Canadian social context, that has been tested with Canadian audiences to help tailor messages about the SDH to specific groups within society. Given the extensive research carried out in the US on this front, it may be possible to start with the messages developed through The Robert Wood Johnson Foundation16, and build on them.



Appendix A – Integrated Model of Communication for Social Change

Further information is available through the Communication for Social Change Consortium: http://www.communicationforsocialchange.org/.

http://www.communicationforsocialchange.org/



Tool Name and Source About this Resource Targeted Audiences

Policy-makers

Practi-tioners

Media Comm. Groups/ Activists

General Public

Policy and Public Health Practice

1. A New Way to Talk About the Social Determinants of Health (2010) Robert Johnson Woods Foundation (US)

Summarizes four years of research and message development on communicating the SDH in ways that are effective, compelling and persuasive, across all political views.

√

2. Capacity-Building and Awareness-raising To address the social determinants of health and to improve health equity (2009) EuroHealthNet (EU)

This interactive document provides suggested actions to address the SDH, incl. awareness and advocacy.

√ √

3. Backgrounder on SDH, (2005) Canadian Nurses Association

A summary of the SDH and actions that nurses can take.

nurses

4. A framework to integrate social and economic determinants of health into the Ontario public health mandate, (2006) Sudbury and District Health Unit,

Recommendations for public health to mitigate or address underlying SDH as a key domain of public health action.

√ √

5. Social Inequities in Health and Ontario Public Health Background Document, (2007) Sudbury, Northwestern and Simcoe Muskoka District Health Units,

Builds on the Framework above to assist the Ministries of Health Promotion, Health and Long-Term Care and Children and Youth Services to develop and implement a strategy to reduce social inequities in health.

√ √

6. Position Statement on SDoH,(2009) City of Hamilton Example of a municipal position statement to guide local policy.

√ √

7. Deprivation Index (2011) Kingston Community Roundtable on Poverty Reduction

A tool that includes education, food, geography, housing, health and income to measure poverty.

√ √ √

8. Tackling Inequities Through Public Health Practice, A Handbook for Action, (2006) The National Association Of County & City Health Officials (NACCHO), Washington, DC

A handbook to help health practitioners restructure their organizations, culture and daily work to address the root causes of health inequities.

√



http://www.health-inequalities.eu/pdf.php?id=68410efc3dbc18f8b1a0ea0e5e1fa4ef



http://www.cna-nurses.ca/CNA/documents/pdf/publications/BG8_Social_Determinants_e.pdf




http://www.sdhu.com/uploads/content/listings/SocialInequitiesinHealthandOntarioPublicHealth_Jan15-07_Rev_jv_jm.pdf

http://www.sdhu.com/uploads/content/listings/SocialInequitiesinHealthandOntarioPublicHealth_Jan15-07_Rev_jv_jm.pdf

http://www.hamilton.ca/NR/rdonlyres/B9A5AD7E-CB58-4BA3-8F5D-1F5D51A54233/0/Apr27BOH09008SocialDeterminantsofHealthPositionStatement.pdf

http://www.kingstonpovertyreduction.ca/pdf/Roundtable%202010%20Deprivation%20Index.pdf

http://www.acphd.org/axbycz/admin/datareports/ood_naccho_handbook.pdf





Policy-makers

Practi-tioners


General Public

9. Health Inequalities Intervention Toolkit London (England) Health Observatory

Designed to assist evidence-based local service planning and commissioning, including Joint Strategic Needs Assessments.

√

10. The Equity Gauge: Concepts, Principles and Guidelines (2003) Global Equity Gauge Alliance and Health Systems Trust

Describes an "active" approach to monitoring inequities in health, including: assessment and monitoring, advocacy and community empowerment

√

Advocacy

11. Advocacy Guideline and Resources, (2011). Vancouver Coastal Health Population Health

Guidelines outlining the role of public health in SDH advocacy, along with advocacy resources and initiatives.

√ √

12. Advocacy Strategy: Deliberate and Strategic Use of Information to Influence Decision-Making, OPHA

PowerPoint presentation on how to develop an advocacy strategy

√ √

13. Advocacy for public health: a primer (2004) Chapman S, Journal of Epidemiological Community Health

Academic article that outlines the strategic planning required for effective advocacy, including a case study and list of resources for public health advocacy.

√

14. Public health advocacy toolkit (2007). Public Health Alliance for the Island of Ireland

A toolkit that provides a framework for action on advocacy; helps to identify training needs; provides resources for developing skills and competencies.

√

15. Media Advocacy Workbook (2000, possibly updated in 2008). The Health Communication Unit

Outlines a recommended process for media advocacy, with many tips and strategies.

√ √

16. Planning for Media Advocacy, The Praxis Project (US) A non-profit organization that works with local groups to influence policymaking to address the systemic

√ √

http://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesInterventionToolkit.aspx

http://www.gega.org.za/download/gega_guide.pdf

http://www.vch.ca/media/Population%20Health_Advocacy%20Guideline%20and%20Resources.pdf

http://www.vch.ca/public_health/population_health/advocacy/advocacy

http://www.opha.on.ca/resources/docs/generic_advocacy.ppt

http://www.opha.on.ca/resources/docs/generic_advocacy.ppt

http://homepages.wmich.edu/~jbrusk/Advocacy%20for%20public%20health%20primer%20Chapman%202004.pdf

http://advocacy.phaii.org/uploads/docs/toolkit.pdf

http://www.thcu.ca/infoandresources/resource_display.cfm?res_topicID=3&res_sub_topicID=17

http://www.thepraxisproject.org/




Policy-makers

Practi-tioners


General Public

causes of community problems and close the health gap facing communities of color.

Community Engagement

17. Healthy Children, Health Communities – Action Toolkit for Positive Change (2008) - United Nations Association in Canada

This toolkit is part of a community-based research and engagement project to empower children and youth to speak out and take action on their health priorities.

√ √

18. Making Connections – Health is a community affair, (not dated) Social Determinants Partnership (Ontario)

A series of stories describing ways people can create healthier communities, using simple language and engaging graphics.

√ √

19. Promoting Health Equity, (2008) Centres for Disease Control and Prevention (US)

Examples, case studies and resources to help communities address SDH.

√ √

20. Primer to action: Social Determinants of Health, (2008), Health Nexus/OCDPA, Canada

A resource for health and community workers, activists and local residents to understand how the SDH impact chronic disease, and possible actions.

√ √

21. The Equity Channel (Belgium-based) An international collaboration of organisations working to connect people globally for action on the SDH.

√ √ √

22. Public Health Practitioner's Public Engagement Toolkit (2009). DETERMINE - EU Consortium for Action on the Socio-Economic Determinants of Health

Website with tools, guidelines and easy-to-use templates and tools, deemed the most practical and flexible available by partners from Wales, Scotland, Netherlands and Ireland.

√

23. Communities Taking Action The Prevention Institute (US)

A website profiling successful community initiatives aimed at improving health equity, aimed at

√ √

http://www.unac.org/hchc/en/resources/index.php

http://www.unac.org/hchc/en/resources/index.php

http://www.healthnexus.ca/our_programs/hprc/projects/Bkeng.pdf

http://www.cdc.gov/nccdphp/dach/chaps/pdf/sdohworkbook.pdf

http://www.ocdpa.on.ca/OCDPA/docs/PrimertoAction2-EN.pdf

http://www.equitychannel.net/

http://www.health-inequalities.eu/bot_Seite3459.html

http://preventioninstitute.org/tools/focus-area-tools/communities-taking-action-profiles-of-health-equity.html




Policy-makers

Practi-tioners


General Public

demonstrating key steps to creating healthy, equitable environments and inspiring similar action elsewhere

24. The Last Straw! (2007) - A Board Game on the Social Determinants of Health .

A teaching tool to promote discussion about the SDH while helping players build empathy with people who are marginalized

√ √ √

Communication

25. Social Determinants of Health: The Canadian Facts, (2010) Mikkonen, J., & Raphael, D.

A concise, accessible report that presents data on health inequities in Canada, to promote awareness and informed debate

√ √ √ √

26. Poverty and Health, Peterborough County-City Health Unit

Series of resources, including fact sheets and TV ads, to raise awareness and apply the SDH

√ √ √ √

27. Poor No More (2010) – Deveaux Babin Productions A documentary film about Canada’s working poor, designed to build public support to reduce poverty

√ √ √

28. Population Health: The New Agenda (2009) Vancouver Coastal Health

Video featuring health professionals and citizens talking about how the SDH affect health, generally and personally

√ √ √

29. Sick People or Sick Societies? (2008), CBC Radio A podcast that explores the SDH, addressing many of the same concerns as Unnatural Causes from a Canadian perspective

√ √ √ √

30. Unnatural Causes: Is Inequality Making us Sick? (2008) Website summarizing the documentary and providing information, an Action Centre of

√ √ √ √ √

http://www.thelaststraw.ca/

http://www.thecanadianfacts.org/The_Canadian_Facts.pdf

http://pcchu.peterborough.on.ca/PH/PH-SDH.html

http://www.poornomore.ca/

http://mainsite.lemongrassmedia.net/pop-health-the-new-agenda/

http://tinyurl.com/432unj

http://www.unnaturalcauses.org/




Policy-makers

Practi-tioners


General Public

advocacy materials, research, quizzes, video clips and podcasts.

31. Redefine, Rebuild, Reconnect: Changing Our Picture of Health Collaborative Population Health Working Group (Nova Scotia)

A website including a video and blog to exchange knowledge, gather and use evidence to apply population health strategies.

√ √ √

32. Public Ad Campaign - Social Inequities in Health (2011) Sudbury & District Health Unit

Television ads to raise awareness of the role of SDH with the public

√ √ √

Broad-based Resources

33. Social Determinants of Health listserv, York University

An international listserv that provides research, resources, information & discussion for public health and social justice practitioners.

√ √ √

http://www.changingourpictureofhealth.ca/?page_id=80

http://www.changingourpictureofhealth.ca/?page_id=80

http://www.naccho.org/toolbox/tool.cfm?id=1934

https://listserv.yorku.ca/archives/sdoh.html



References 1 Lalonde M. A new perspective on the health of Canadians. A working document. Ottawa: Government of

Canada, 1974. [cited March 15, 2011] Available at: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/1974-lalonde/lalonde-eng.pdf 2 Manzano AT, Raphael D, CPHA and the Social Determinants of Health: An Analysis of Policy

Documents and Statements and Recommendations for Future Action, Can J Public Health 2010;101(5):399-404. 3 WHO (2008) Closing the gap in a generation: health equity through action on the social determinants of

health. Final report of the commission on social determinants of health. World Health Organization, Geneva. [cited March 9, 2011] Available at http://www.who.int/social_determinants/final_report/en/ 4 Public Health Agency of Canada, The Chief Public Health Officer’s Report on the State of Public Health in

Canada 2008, [online] cited February 19, 2009 from http://www.phac-aspc.gc.ca/publicat/2008/cpho-

aspc/index-eng.php 5 Senate of Canada, Subcommittee on Population Health of the Standing Senate Committee on Social

Affairs, Science and Technology, Population Health Policy: Issues and Options, April 2008, [online] cited February 19, 2009 from http://www.parl.gc.ca/39/2/parlbus/commbus/senate/com-e/soci-e/rep-e/rep10apr08-e.pdf 6 Conference Board of Canada, Healthy People, Healthy Performance, Healthy Profits: The Case for

Business Action on the Socio-Economic Determinants of Health, December 2008, [online] cited February 19, 2009 from http://sso.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb 7 Organisation for Economic Co-operation and Development. Growing Unequal: Income Distribution and

Poverty in OECD Nations. Paris, France: OECD, 2008.[cited March 15, 2011] Available at: http://www.oecd.org/document/4/0,3343,en_2649_33933_41460917_1_1_1_1,00.html 8 Hayes, et al. (2007) Telling stories: News media, health literacy and public policy in Canada Social Science

& Medicine, Volume 64, Issue 9, May 2007, Pages 1842-1852 9 Canadian Institute for Health Information. Select Highlights on Public Views of the Determinants of Health.

Canadian Population Health Initiative. Ottawa (CAN): CIHI; 2005. [cited March 11, 2011] Available at: http://secure.cihi.ca/cihiweb/products/CPHI_Public_Views_FINAL_e.pdf 10

Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. Canada: A land of missed opportunity for addressing the social determinants of health. Health Policy (2010), doi: 10.1016/j.healthpol.2010.08.022 11

Gasher, M., Hayes, M., Hackett, R., Gutstein, D., Ross, I., & Dunn, J. (2007). Spreading the News: Social Determinants of Health Reportage in Canadian Daily Newspapers. Canadian journal of communication [cited March 14, 2011]. Available at: http://www.cjc-online.ca/index.php/journal/article/download/1724/1844 12

Andress, L. (2009). Framing a Public Discussion on the Social Determinants of Health. University of Pittsburgh [cited March 9, 2011]. Available at: www.pitt.edu/~super4/35011-36001/35151.ppt 13

Nutbeam, D. & Boxall, A. M. (2008). What influences the transfer of research into health policy and practice? Observations from England and Australia. Public Health, 122, 747-753. 14

WHO, Action on the social determinants of health: learning from previous experiences (2005). Secretariat of the Commission on Social Determinants of Health [cited March 10, 2011]. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf 15

Niederdeppe, J., Bu, Q. L., Borah, P., Kindig, D. A., & Robert, S. A. (2008). Message design strategies to raise public awareness of social determinants of health and population health disparities. Milbank Q, 86, 481-513. [cited March 9, 2011]. Available at: http://www.rwjf.org/files/research/3576.35691.messagedesign.pdf 16

Robert Wood Johnson Foundation, A new way to talk about the social determinants of health (2010). [cited March 4, 2011]. Available at: http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428 17

Green and Kreuter (2005), as cited in Moore, S. (2010). From awareness to action on the social determinants of health. International Journal of Public Health, 55, 521-522. [cited March 9, 2011] Available at: http://www.springerlink.com/content/n24kj884563x27q2/fulltext.pdf 18

Fisher (1999) as cited in Moore, S. (2010). From awareness to action on the social determinants of health. International Journal of Public Health, 55, 521-522. [cited March 9, 2011] Available at: http://www.springerlink.com/content/n24kj884563x27q2/fulltext.pdf 19

Baum (2007), as cited in Moore, S. (2010). From awareness to action on the social determinants of health. International Journal of Public Health, 55, 521-522. [cited March 9, 2011] Available at: http://www.springerlink.com/content/n24kj884563x27q2/fulltext.pdf 20

EuroHealth Net and IUHPE, DETERMINE – an EU Consortium for Action on the Socio economic Determinants of Health, Working Document #3 – Voices from Other Fields (2008, estimated) [cited March 12, 2011] Available at: http://www.health-inequalities.eu/?uid=0161f5af56c7b42804f3e10978de02f5&id=Seite2574

http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/1974-lalonde/lalonde-eng.pdf

http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/1974-lalonde/lalonde-eng.pdf

http://www.who.int/social_determinants/final_report/en/





http://sso.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb

http://www.oecd.org/document/4/0,3343,en_2649_33933_41460917_1_1_1_1,00.html

http://secure.cihi.ca/cihiweb/products/CPHI_Public_Views_FINAL_e.pdf

http://www.cjc-online.ca/index.php/journal/article/download/1724/1844

http://www.pitt.edu/~super4/35011-36001/35151.ppt

http://www.who.int/social_determinants/resources/action_sd.pdf

http://www.rwjf.org/files/research/3576.35691.messagedesign.pdf


http://www.springerlink.com/content/n24kj884563x27q2/fulltext.pdf



http://www.health-inequalities.eu/?uid=0161f5af56c7b42804f3e10978de02f5&id=Seite2574

http://www.health-inequalities.eu/?uid=0161f5af56c7b42804f3e10978de02f5&id=Seite2574



21

Raphael, D. (2006). The social determinants of health: what are the three key roles for health promotion? Health Promot J Austr., 17, 167-170. [cited March 11, 2011]. Available at: http://www.who.int/social_determinants/resources/articles/hpjadec2006.pdf 22

Raphael, D. (2008). Getting serious about the social determinants of health: new directions for public health workers. Promot Educ, 15, 15-20. 23

Narayan, R. (2006) The role of the People’s Health Movement in putting the social determinants of health on the global agenda Health Promot J Austr., 17, 186-188. [cited March 11, 2011]. Available at:

http://www.who.int/social_determinants/resources/articles/hpjadec2006.pdf 24

Vancouver Coastal Health Population Health, Advocacy Guideline and Resources (2008 – est) [cited March 15, 2011] Available at: http://www.vch.ca/media/Population%20Health_Advocacy%20Guideline%20and%20Resources.pdf 25

World Health Organization, Social Determinants of Health, WHO Implementation. [cited March 10, 2011] Available at: http://www.who.int/social_determinants/implementation/en/ 26

Solar, O. & Irwin, A. (2006). Social determinants, political contexts and civil society action: a historical perspective on the Commission on Social Determinants of Health. Health Promot J Austr., 17, 180-185.

[cited March 10, 2011] Available at: http://www.bvsde.paho.org/bvsacd/cd65/social.pdf 27

Raphael, D. (2003 - est). Recognizing the Political Barriers to a Healthy Inclusive Society: The Case of the Social Determinants of Health. Canadian Council on Social [cited March 11, 2011] Available at: http://www.ccsd.ca/events/inclusion/papers/raphael.pdf 28

Raphael, D. (2009). Escaping from the Phantom Zone: social determinants of health, public health units and public policy in Canada. Health Promot Int, 24, 193-198. [cited March 10, 2011 Available at: ]http://www.hpclearinghouse.ca/pdf/phamtomzone.pdf 29

Ontario Medical Association, Doctors Point to Poverty as Major Cause of Illness, July 28, 2008. [cited March 16, 2011]. Available at: https://www.oma.org/Mediaroom/PressReleases/Pages/DoctorsPointtoPovertyasMajorCauseofIllness.aspx 30

Munro D, Determinaction, Conference Presentation, The Conference Board of Canada, October 13, 2009 [cited March 10, 2011] Available at: http://www.conferenceboard.ca/search.aspx?q=Determinaction 31

National Collaborating Centre for Healthy Public Policy, Content Analysis of Media Coverage of Health Inequalities in Canada, 2008, NCCHPP, January 2010. [cited March 14, 2011] Available at: http://www.ncchpp.ca/docs/InequalitiesMediaCoverage_ContentAnalyisis_EN.pdf 32

Adams, MJ, (2003). Fire and Ice: The United States, Canada and the Myth of Converging Values.

Toronto: Penguin Canada. 33

Reuter et al (2002), as cited in Gollust, S. E., Lantz, P. M., & Ubel, P. A. (2009). The polarizing effect of news media messages about the social determinants of health. American Journal of Public Health, 99, 2160-2167. 34

Gollust, S. E., Lantz, P. M., & Ubel, P. A. (2009). The polarizing effect of news media messages about the social determinants of health. American Journal of Public Health, 99, 2160-2167. 35

Kelly, M. & Bonnefoy, J. (2007). The social determinants of health: developing an evidence base for political action. National Institute for Health and Clinical Excellence [cited March 11, 2011]. Available at: http://www.who.int/social_determinants/resources/mekn_final_report_102007.pdf 36

Alvaro C, et al, (2010) Moving Canadian governmental policies beyond a focus on individual lifestyle: some insights from complexity and critical theories. Health Promotion International, Vol. 26 No. 1 37

EuroHealthNet and the International Union on Health Promotion and Education (IUHPE), Menu for Capacity Building & Awareness Raising Actions. September 2009 [cited March 1, 2011]. Available at: http://www.health-inequalities.eu/pdf.php?id=68410efc3dbc18f8b1a0ea0e5e1fa4ef 38

Global Equity Gauge Alliance, The Equity Gauge: Concepts, Principles and Guidelines [cited March 1, 2011] Available at: http://www.gega.org.za/download/gega_guide.pdf 39

The National Association of County and City Health Officials and the Ingham County Health Department, Tackling Health Inequities Through Public Health Practice (2006), ed. Richard Hofrichter [cited March 14, 2011]. Available at: http://www.acphd.org/axbycz/admin/datareports/ood_naccho_handbook.pdf 40

Chapman S, Advocacy for public health: a primer J Epidemiol Community Health 2004;58:361–365. [cited March 4, 2011]. Available at: http://homepages.wmich.edu/~jbrusk/Advocacy%20for%20public%20health%20primer%20Chapman%202004.pdf 41

Media Advocacy (2011). The Health Communication Unit, Dalla Lana School of Public Health, University of Toronto [cited March 11, 2011] Available at: http://www.thcu.ca/infoandresources/resource_display.cfm?res_topicID=3&res_sub_topicID=17 42

Figueroa, M., Kincaid, D., Rani, M., & Lewi, G. (2002). Communication for Social Change: An Integrated Model for Measuring the Process and Its Outcomes. Johns HopkinsUniversity Center for Communication Programs [cited March 10, 2011]. Available at: http://www.communicationforsocialchange.org/pdf/socialchange.pdf



http://www.vch.ca/media/Population%20Health_Advocacy%20Guideline%20and%20Resources.pdf

http://www.who.int/social_determinants/implementation/en/

http://www.bvsde.paho.org/bvsacd/cd65/social.pdf

http://www.ccsd.ca/events/inclusion/papers/raphael.pdf

http://www.hpclearinghouse.ca/pdf/phamtomzone.pdf

https://www.oma.org/Mediaroom/PressReleases/Pages/DoctorsPointtoPovertyasMajorCauseofIllness.aspx

http://www.conferenceboard.ca/search.aspx?q=Determinaction

http://www.ncchpp.ca/docs/InequalitiesMediaCoverage_ContentAnalyisis_EN.pdf



http://www.gega.org.za/download/gega_guide.pdf




http://www.thcu.ca/infoandresources/resource_display.cfm?res_topicID=3&res_sub_topicID=17

http://www.communicationforsocialchange.org/pdf/socialchange.pdf



43

Communication for Social Change: Successes and Challenges in Addressing the Social Determinants of Health (2007). Ontario Health Promotion e-bulletin [cited March 10, 2011]. Available at: http://www.ohpe.ca/node/8966 44

Andress, L. (2006). The emergence of the social determinants of health on the policy agenda in Britain: a case study, 1980-2003. University of Texas School of Public Health [cited March 9, 2011]. Available at: http://digitalcommons.library.tmc.edu/dissertations/AAI3258575/ 45

Moore, S. (2010). From awareness to action on the social determinants of health. International Journal of Public Health, 55, 521-522. [cited March 9, 2011] Available at: http://www.springerlink.com/content/n24kj884563x27q2/fulltext.pdf 46

Raphael, D (2011) Mainstream Media and the Social Determinants of Health. Is it time to call it a day? Health Promotion International (pre-publication version; accepted for publication) 47

University of Manitoba. (2010). Improved Access for Media to Health Policy Research Findings. [cited March 14, 2011]. Available at: http://myuminfo.umanitoba.ca/index.asp?sec=2&too=100&eve=8&dat=3/4/2010&npa=21839 48

Raphael, D., Curry-Stevens, A., & Bryant, T. (2008). Barriers to addressing the social determinants of health: insights from the Canadian experience. Health Policy, 88, 222-235. 49

Yalnizyan A, The Rich and the Rest of Us, The Changing Face of Canada‘s Growing Gap, Canadian Centre for Policy Alternatives, March 2007. [cited February 22, 2011]. Available at: http://www.policyalternatives.ca/publications/reports/rich-and-rest-us 50

Schwab K and Porter ME (2010) The Global Competitiveness Report 2010-2011. Geneva, Switzerland: World Economic Forum, [cited March 17, 2011] Available from: http://www.weforum.org/blog/posts/global-competitiveness-report-2010-2011 51

World Health Organization, Focusing the Equity Lens: Arguments and actions on health inequalities.

Working Group report of the Collaborating Centre for Policy Research on Social Determinants of Health (eds. Povall S, Whitehead M, Gosling R, Barr B), Liverpool, UK, December 2008. 52

110 University of California. Atlas of Global Inequality. Accessed February 2011 at http://ucatlas.ucsc.edu/ 53

Health Officers Council of BC, Health Inequities in British Columbia: Discussion Paper, November 2008,

[cited March 17, 2011] Available from: http://www.phabc.org/files/HOC_Inequities_Report.pdf 54

Joint OPHA/alPHa Working Group on Social Determinants of Health (2010). Activities to Address the Social Determinants of Health in Ontario Local Public Health Units: Summary Report. Association of Local Public Health Agencies [cited March 9, 2011]. Available at: http://www.alphaweb.org/docs/lib_013531606.pdf 55

Jordan et al. (1998) as cited in Kelly, M. & Bonnefoy, J. (2007). The social determinants of health: developing an evidence base for political action. National Institute for Health and Clinical Excellence [cited March 11, 2011]. Available at: http://www.who.int/social_determinants/resources/mekn_final_report_102007.pdf 56

California Newsreel, Unnatural Causes website [cited March 17, 2011]. Available at: http://www.unnaturalcauses.org/media_and_documents.php 57

Langille D, Executive Producer, Poor No More, film and website. [cited March 17, 2011] Available at: http://www.poornomore.ca/ 58

BC Poverty Reduction Coalition, video: If the BC government were a basketball player. [cited March 17, 2011]. Available at: http://bcpovertyreduction.ca/ 59

Wolfe SA, Federal/Provincial Coordinator of the Canadian Alliance of Community Health Centre Associations (CACHCA), via email communication via SDoH Listserv, January 5, 2011 60

Sudbury and District Health Unit, A framework to integrate social and economic determinants of health into the Ontario public health mandate (March 2006). [cited March 18, 2011] Available at: http://www.opha.on.ca/resources/docs/SDOH-FrameworkDiscussionPaper-March06.pdf 61

Sudbury and District Health Unit, Social Inequities in Health and Ontario Public Health Background Document (January 2007). [cited March 18, 2011] Available at: http://www.sdhu.com/uploads/content/listings/SocialInequitiesinHealthandOntarioPublicHealth_Jan15-07_Rev_jv_jm.pdf 62

Sudbury and District Health Unit, Public Ad Campaign, Social Inequities in Health. [cited March 18, 2011] Available at: http://www.naccho.org/toolbox/tool.cfm?id=1934 63

Bryant, T., Raphael, D., & Travers, R. (2007). Identifying and strengthening the structural roots of urban health in Canada: participatory policy research and the urban health agenda. Promot Educ, 14, 6-11. [cited March 9, 2011] Available at: http://www.hpclearinghouse.ca/pdf/bryant_2.pdf 64

Daghofer D, Beanlands H, Using Neighbourhood Data to Address the Social Determinants of Health Ontario Health Promotion E-Bulletin, 08 July 2010 - OHPE Bulletin 668, Volume 2010, No. 668 [cited March 18, 2011] Available at: http://www.ohpe.ca/node/11458


http://digitalcommons.library.tmc.edu/dissertations/AAI3258575/


http://myuminfo.umanitoba.ca/index.asp?sec=2&too=100&eve=8&dat=3/4/2010&npa=21839

http://www.policyalternatives.ca/publications/reports/rich-and-rest-us

http://www.weforum.org/blog/posts/global-competitiveness-report-2010-2011

http://www.weforum.org/blog/posts/global-competitiveness-report-2010-2011

http://www.phabc.org/files/HOC_Inequities_Report.pdf

http://www.alphaweb.org/docs/lib_013531606.pdf


http://www.unnaturalcauses.org/media_and_documents.php

http://www.poornomore.ca/

http://bcpovertyreduction.ca/


http://www.naccho.org/toolbox/tool.cfm?id=1934

http://www.hpclearinghouse.ca/pdf/bryant_2.pdf




65

Vancouver Coastal Health, Towards a Population Health Approach: A Framework and Recommendations for Action, February 2006. [cited March 18, 2011] Available at: http://www.vch.ca/media/Toward_A_Population_Health_Approach.pdf 66

Vancouver Coastal Health , Pop Health: The New Agenda. [cited March 18, 2011]. Available at: www.lemongrassmedia.net/lgm/blog/files/pophealth-the-new-agenda.html 67

Collaborative Population Health Working Group (Nova Scotia), Redefine, Rebuild, Reconnect. [cited March 18, 2011]. Available at: http://www.changingourpictureofhealth.ca/?p=256 68

OPHA-alPHa Joint Work Group on the Social Determinants of Health (2009). Ontario Public Health Association [cited March 10, 2011] Available at: http://www.opha.on.ca/our_voice/collaborations/jwd-sdoh.shtml

http://www.vch.ca/media/Toward_A_Population_Health_Approach.pdf

http://www.lemongrassmedia.net/lgm/blog/files/pophealth-the-new-agenda.html

http://www.changingourpictureofhealth.ca/?p=256

http://www.opha.on.ca/our_voice/collaborations/jwd-sdoh.shtml

http://www.opha.on.ca/our_voice/collaborations/jwd-sdoh.shtml

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