Chapter 7. Communicating about health inequalities

Overview

Conveying messages and recommendations about health inequalities is part of an evidence-based approach to advancing health equity. In general, the content of reporting outputs should be based on an accurate interpretation and thorough understanding of the underlying evidence and its implications (see Chapters 18, 22 and 24). Communications should be aligned with the overarching purpose of health inequality monitoring, tailored to the intended audience (i.e. considering their prior knowledge, skills, needs, priorities and interests), and delivered through an appropriate channel – effectively addressing the questions of why, what, how, when and to whom reporting is required.

Designing effective, integrated and coordinated communications requires a strategic approach. The WHO Strategic Communications Framework for effective communications identifies six principles for effective communications, which are relevant to activities across all audiences, including individuals, communities, health-care providers, WHO staff, international organizations and policy-makers. The principles include accessibility, actionability, credibility, relevance, timeliness and understandability (1).

Reporting on health inequalities should be sensitive to the underlying context, and all people should be addressed inclusively and respectfully (2). Reporting should not contribute to or perpetuate stigma or discrimination against certain populations, or lead to further marginalization or other negative consequences, especially among people who are experiencing disadvantage. Meaningful consultation and engagement with affected populations throughout inequality monitoring, including communication activities, can help to attenuate this.

Although communications may take the form of written reports, there are many other compelling ways of communicating information about health inequalities. Increasingly, reporting outputs combine a variety of multimedia elements and interactive components. When possible, members of the intended audience should be involved in the development, including pilot testing, of the reporting outputs.

The objective of this chapter is to facilitate a deeper understanding of strategies to effectively convey key messaging about health inequalities to different audiences. The chapter highlights purpose-driven reporting and reviews considerations for communication with different intended audiences, covering different types of reporting output that may be suited to specific audiences. The chapter offers strategies for navigating challenges that arise when information is scarce, or when inequality evidence is conflicting or confusing, and the content of reporting is anticipated to be unpopular or contentious with the intended audience.

This chapter complements other chapters that address technical considerations for reporting, including the presentation of inequality data (Chapter 23) and the use of health inequality analyses in evidence-informed decision-making (Chapter 24).

Purpose-driven reporting

The overarching purpose of health inequality monitoring is to promote health equity and improve the health of all people. Through regular health inequality monitoring, inequalities between population subgroups can be identified and tracked over time, which helps to inform the development of equity-oriented responses. Reporting should align with this broader vision, with the general purpose of creating knowledge and awareness. The purpose of reporting may also be oriented towards advocacy, sharing information, calls for further research, or programme or policy changes.

A description of the reporting purpose addresses why reporting is being done. Aims, goals and objectives further clarify what reporting is setting out to achieve and how it will do so. Having a clearly defined purpose of reporting can help identify an appropriate audience that is positioned to advance the aim, goals and objectives of reporting. For a given inequality analysis, multiple, complementary reporting outputs may be prepared. Clear goals and objectives for each reporting output should be identified to ensure the output fulfils its purpose and is impactful (Box 7.1) .

BOX 7.1. Examples of aims, goals and objectives corresponding to different health inequality reporting purposes

The following four examples demonstrate different sets of aims, goals and objectives that may be identified as part of health inequality reporting:

• Example 1: the stated purpose of reporting may be to present an overview of the state of inequality in a country over the past decade, with the aim of integrating equity into goals and targets of a forthcoming national health strategy. The goal of reporting may be to show the potential impact of reducing inequalities. An objective may be to calculate and report summary measures of health inequality that show impact, demonstrating how accelerated improvements among disadvantaged population subgroups would benefit the overall situation.

• Example 2: the purpose of reporting may be to provide an in-depth picture of the current state of inequality in the health of population subgroups experiencing disadvantage, aiming to increase awareness about population subgroups that have been underserved by the health system and to redirect resources and programme activities to reach them. A goal of reporting may be to present evidence to inform resource reallocation. A corresponding objective could be to present disaggregated data about health outcomes, funding levels and programme activities.

• Example 3: reporting could be undertaken with the purpose of highlighting where further research and analysis are required. The aim of this reporting may be to produce evidence to better understand the root causes of health inequalities. It may include the goal of identifying existing gaps in data and evidence that need to be addressed. A corresponding objective could be to systematically assess and report data availability for a particular health inequality analysis.

• Example 4: the purpose of reporting may be to compile the latest available global data and evidence about the current state of health inequality in a topic. The aim may be to cultivate a broad understanding of the state of inequality, with the goal of presenting high-level evidence derived from inequality analyses using data from multicountry household health surveys. To this end, the objectives may include presenting the latest state of inequality, tracking changes over time, and discussing the general implications of the findings for policies, programmes and practices.

Aims reflect the ideals of reporting or the desired result in a general sense. Aims direct the construction of goals and objectives.

Goals state what is to be done – that is, a specific desired outcome or result.

Objectives define actions to achieve goals.

Communicating with diverse audiences

Alongside the reporting purpose, consideration of the target audience for reporting is warranted to determine who is best positioned to support the intended outcome of reporting. Ideally, the identified audience has an interest in the topic area and can help achieve the goals and objectives of reporting. In some cases, the audience may be very intentional. For example, reporting may be done to a specific department within the ministry of health or to members of a certain policy advisory group. In other cases, the audience may encompass diverse groups of people across multiple sectors, such as policy-makers, community leaders, affected populations, civil society actors, researchers, scientists and other knowledge users. As a continuation of (Box 7.1), considerations for identifying target audiences for each of the four examples are presented in (Box 7.2).

BOX 7.2. Examples of target audiences corresponding to different health inequality reporting purposes

Building on the examples presented in (Box 7.1) , different target audiences may be positioned to support the specified aims, goals and objectives for reporting:

• Example 1: the aim is to integrate equity into the goals and targets of a forthcoming national health strategy. A relevant target audience would be national policy-makers and others involved in the development of the health strategy.

• Example 2: reporting is focused on informing resource allocation and programme activities to reach populations underserved by the health system. Programme managers would be an appropriate target audience, because their role as managers means they have influence on decisions about resource allocation and programme activities.

• Example 3: reporting highlights where further research and analysis are required to better understand the causes of inequality. This reporting would be appropriately directed to academic audiences such as researchers and people who oversee research funding decisions. These audiences are positioned to act on addressing the identified research gaps.

• Example 4: the reporting output presents the current global state of inequality. Because of its broad purpose, this output could serve as useful background for diverse audiences, including policy-makers, civil society actors, scientists and the general public. Other accompanying reporting outputs may be developed for more specific audiences, such as policy briefs for policy-makers or research papers for academic audiences.

It is important to be familiar with the interests, needs and preferences of the target audience to ensure reporting is relevant and accessible. It is also important to consider the prior knowledge of the audience about the health topic, population, setting, inequalities, and approaches for measuring inequalities (Box 7.3). For example, it would likely be appropriate to include detailed technical content in reports designed for researchers and scientists. Policy-makers or programme managers, on the other hand, tend to value more succinct summaries of results, accompanied by clear and timely recommendations. For general audiences, such as affected populations or community leaders, plain language should be used, focusing on new and relatable insights into the topic area.

BOX 7.3. Learning about target audiences

Acquiring an in-depth understanding of the audience may seek answers to questions such as:

• Are there prevailing biases or misconceptions that should be addressed?

• How do audience members tend to access information?

• What is the technical ability of the audience?

• What type of language (technical or plain) is preferred, and at what level?

• What is the level of digital literacy?

• What are the relevant political, cultural and social influences that affect how audiences interpret and act upon knowledge?

• What are the processes that guide how information is used and shared?

This list is not exhaustive, but it underscores the insights that will enable more impactful reporting.

Having close familiarity with the target audience means relevant information can be included in a way that is accessible to the audience and, where applicable, motivates the audience to take desired actions. To the extent possible, members of the target audience should be involved in the development of reporting outputs, including piloting reporting approaches. Existing examples of high-quality and impactful reporting outputs can be consulted to derive lessons and best practices.

Reporting outputs

There are many types of reporting outputs, which can be tailored to reach different audiences with different types of information. For example, peer-reviewed journal articles and technical reports require more detailed methods and results because they are intended for audiences with more technical expertise. Other forms of reporting, such as policy briefs and nontechnical reports, tend to include a greater focus on the application and use of the findings and may be particularly impactful with audiences such as policy-makers, civil society actors and health advocates.

Multiple reporting outputs may be prepared and used to complement each other. The use of multiple reporting outputs can help to reach broader audiences and cater to members of the target audiences with different preferences in how they access information – for example, some people may prefer to read information, but others may prefer to listen to audio tracks. The use of multiple reporting outputs can help to reinforce key messages and make different types of supporting information accessible.

See Chapter 23 for an overview of the general components of health inequality reporting, including examples and best practices.

Written reports

Written reports are a common reporting output that can be tailored for a variety of audiences and reporting purposes. Reports may be highly technical, containing a high level of detail about the results and the underlying analysis approach. For example, the WHO State of Inequality and Explorations of Inequality Reports are technical reports written for specialized audiences familiar with the topics or analysis approaches (3). The WHO World Health Statistics reports are global annual statistical reports that provide updated information on selected health topics, with disaggregated data where available (4). Academic publications such as peer-reviewed journal articles are another form of written highly technical report with a prescribed reporting structure (Box 7.4) .

BOX 7.4. Academic publications

Academic publications such as journal articles are written primarily for researchers or people with advanced technical knowledge. They are appropriate outputs for reporting technical details about a specific analysis, with a detailed description of the underlying methodology. The organization of an academic publication often includes four clearly demarcated sections:

• The introduction contains relevant background information, explains why the study was undertaken, and states the research question or objective.

• The methods describe how the study was conducted, including details about the population, data sources, health indicator and inequality dimension variables, analysis methods and interpretation. The level of detail should be sufficient such that the analysis approach could be replicated.

• The results present the findings of the analysis and answer the research question.

• The discussion explores the implications of the results and how they fit with the current state of knowledge, and future research directions.

Academic publications that go through a peer-review process have a high level of credibility within the scientific community. There are well-established systems for archiving, cataloguing and searching academic publications.

In some cases, reports may be less technical. For example, reports geared towards general audiences or policy-makers may present analysis findings more generally, emphasizing their practical implications. Policy briefs are written reports that contain focused information about a specific issue. They are prepared to be accessible to nonspecialized audiences that may not have extensive knowledge of the issue. They usually include some contextual information and relevant evidence, but the key features of policy briefs are options and recommendations for follow-up actions and policies. Policy briefs are typically short and, depending on the context, may follow a specific template.

Readability assessments, available online or through word-processing software, can provide an initial sense of the accessibility of the language and style of writing to the intended audience.

Written reports often combine narrative text with tables, graphs and maps. Additional elements such as photographs, personal anecdotes, reference lists and technical appendices can also be integrated, as appropriate. Many institutions have established systems for distributing and archiving written reports, either digitally or in print form.

Interactive displays

Interactive displays present findings digitally, engaging viewers as active participants in determining the information that is presented. Data repositories, platforms and tools designed around large datasets may enable tailored exploration of the data. For example, the WHO Health Equity Assessment Toolkit allows users to select a health topic and customize views according to settings, data sources, dates, indicators, inequality dimensions, and various graph and table types (5). These display types tend to be appropriate for audiences with more advanced technical knowledge (see Chapter 23).

Interactive displays may also be designed for more general audiences. Displays can be integrated into websites and other digital content to highlight key messages, appealing to a wider audience. The use of a visual summary, for example, engages users by presenting information in a predominately pictorial format with interactive components. Visual summaries have been prepared alongside the State of inequality: HIV, tuberculosis and malaria report (6) and the WHO World Health Statistics reports (4).

Presentations

Presentations such as webinars, interviews and conferences can be an engaging way to provide a human connection to reporting. Presentations are most effective when the results are conveyed through clear key messages. They can be particularly impactful when reporting is advocacy-oriented (i.e. asking for a follow-up response or action from the audience). Depending on the format, presentations may include interactive elements such as audience polls or question-and-answer sessions. Recording and disseminating presentations can increase the reach of these outputs.

WHO regularly hosts webinars on occasions such as the launch of inequality monitoring resources and journal special issues. As examples, see the recordings of the webinar for the launch of the step-by-step manual for inequality monitoring in sexual, reproductive, maternal, newborn, child and adolescent health (7), and the webinar for the launch of the 2023 special issue of Vaccines on inequality in immunization (8). These webinars feature remarks by senior members of the WHO leadership team, reflections from technical experts internal and external to WHO, testimonials from members of the target audience, and question-and-answer sessions.

News media

Traditional media content (e.g. articles, commentaries, opinion pieces, and radio and television broadcasts) and social media content (e.g. posts shared through networking platforms) are other approaches to reporting. Videos, factsheets and question-and-answer documents, which may accompany news media, can be effective ways to provide information about inequality to the general public. The ability to track public engagement with content and to interact with the public (e.g. through comment sections and message boards) can help to gauge public interest and tailor information and messaging to the intended audience.

Commentaries and opinion pieces may be written by people directly involved in carrying out monitoring activities (e.g. researchers, analysts, policy-makers or other subject matter experts) to express an opinion, backed by evidence.

Depending on the outlet, traditional and social media content can achieve wide coverage among general audiences, bringing attention to the most important messages. Traditional and social media tend to be appropriate for reporting a limited number of key messages and may direct audiences towards other reporting outputs for further details. For example, WHO and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) used several forms of news media as part of disseminating the findings from the State of inequality: HIV, tuberculosis and malaria report (Box 7.5).

BOX 7.5. Use of news media to disseminate inequality messages about HIV, tuberculosis and malaria

On the publication of the State of inequality: HIV, tuberculosis and malaria report (9), WHO and the Global Fund put out a joint news release to announce the publication and spotlight high-level messages from the report (10). The release was picked up and covered by news media from around the world.

As part of a social media plan, social media assets were created and disseminated through WHO social media accounts on multiple platforms. This included a video clip, which was reposted on the report webpage (11).

The authors of the report published a commentary in a prominent general medical journal to underscore the key findings of the report (12).

Delivering key messages

As described in Chapter 24, the results of inequality analyses, together with other forms of evidence, should inform the development of key messages and recommendations communicated as part of health inequality reporting. When delivering key messages to different audiences, however, challenges may arise when navigating information gaps, conflicting or confusing messaging, and unpopular messaging. Across these scenarios, communication efforts benefit from pilot testing reporting outputs and key messages with members of the intended audience to ensure the messaging is presented clearly and in an effective format. If feasible, working with communication experts may be warranted if the messaging is particularly challenging.

Communicating about information gaps

In some cases, key messages about health inequalities may be derived from information that is incomplete, outdated or of poor quality. For example, a lack of disaggregated data for relevant health indicators and inequality dimensions may leave gaps in the analysis. In some contexts, such as acute emergencies, there may be a high level of uncertainty associated with the accuracy of the data because the situation is evolving and changing, with variable data availability and quality (see Chapter 5).

Aspects of risk communication and community engagement strategies, which are integral to health emergency readiness and response activities, may be relevant when faced with information gaps. A central tenant in such responses is to proactively communicate what is known, what is not known, and what is being done to get more information. The use of regular communication with the public recognizes that people have the right to be informed and community engagement can strengthen involvement in responses (13).

In terms of health inequality monitoring, findings and key messages should not be overstated. Instead, reporting should be upfront about any underlying limitations related to the data and their interpretation. Uncertainty in the messaging should be highlighted by presenting qualitative explanations for general audiences and including statistical measures of uncertainty for audiences with higher data literacy. Accompanying messaging may highlight the need for improved or expanded data collection or strengthened capacity for inequality monitoring. For more on strategies for navigating data scarcity as part of sourcing data for health inequality analyses, see Chapter 15.

Making sense of conflicting or confusing messaging

Conflicting or confusing messaging may be a concern when the direction of inequality is unexpected (i.e. a subgroup that is traditionally disadvantaged outperforms more advantaged subgroups); when key messages do not align with what is happening in other populations or settings; or when there are outliers in the results. Such cases may arise due to variable data quality – in which case, it may be advisable to reassess the data source and analysis to find an explanation.

It might be the case, however, that the messages derived from the data accurately reflect complexities of the situation in the affected population. Delivering key messages that are conflicting or confusing requires attention to ensure adequate context is provided. This includes consulting other qualitative and quantitative evidence and seeking expert opinions to understand factors that may contribute to the observed situation.

For example, global data have shown that the burden of tuberculosis (TB) was higher in men than women (14). It is important, however, to consider the fuller context, recognizing that women face gender-related barriers to TB diagnosis and care and experience greater stigma and discrimination. Women may also lack decision-making power over health and care-seeking decisions (15).

Delivering unpopular messaging

The messaging derived from health inequality monitoring may be unpopular or sensitive with some audiences. For example, messaging may draw attention to the shortcomings of governments, the systemic exclusion or lack of recognition of certain populations, or issues such as misinformation, discrimination or corruption.

Delivering unpopular messaging requires a thoughtful and strategic approach that balances evidence with an understanding of and respect for the perspectives and values of all stakeholders, including the populations represented in the monitoring results and the intended audience for reporting. The main results of inequality analyses should be reviewed with diverse stakeholder groups (including affected populations) to ensure that conclusions and recommendations are relevant and sensitive to gender and culture, and that they do not perpetuate stigma and discrimination against groups experiencing disadvantage. Messaging should aim to balance reporting on deficits and strengths. Reporting approaches that emphasize deficits over strengths should be avoided because this may stigmatize groups in vulnerable situations, reinforce power imbalances, erode trust and credibility with communities, and shift the focus away from the structural factors that underlie inequalities.

References

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