# Lesson 5: Social, Cultural, and Environmental Theories II *Companion-podcast transcript • Sarah & Kiffer* *Office Hours episode to listen to after working through the lesson* --- **Sarah:** In September 2022, Newfoundland and Labrador brought in a levy on sugary drinks, at twenty cents per litre. **Kiffer:** And when the premier announced the repeal in May 2025, he cited affordability. The levy ended on July first. **Sarah:** So who was really paying for it? A levy is a flat amount per litre, so for the same drinks it takes a bigger share of a small income. **Kiffer:** That's the cost side, and I take it seriously. Where Sarah and I differ is on who gets the health benefit. **Sarah:** Welcome back to Office Hours. I'm Sarah. **Kiffer:** And I'm Kiffer. We're on Lesson five, Social, Cultural, and Environmental Theories II, and the first question is about encoding. **Sarah:** Question one. When students read that a message has to be encoded for its audience, a lot of them take that to mean making it simpler. Is that what it means? **Kiffer:** It's a common reading, and it leaves out most of what encoding covers. Encoding means putting the information into a code the receiver will read the way you intend. The words are part of the code, and so are the tone, the source and the channel. A short, plain message in a clinical tone can still come across as talking down to people. **Sarah:** Let me try that on a made-up case. A health unit wants long-haul truck drivers to use free blood pressure checks at a nurse's table inside a highway truck stop. Its message is short and plain: high blood pressure usually has no symptoms, so get checked. It goes out on the health unit's website and social media. **Kiffer:** It's simple, and it can still fail at nearly every step. Most long-haul drivers are passing through the region, so few of them follow a local health unit's website or social media. And suppose interviews, also made up, find that many drivers worry a high reading could end up on a record that affects their commercial licence. **Sarah:** Then a simple message about a free check gets decoded as a risk to their job. And the source makes it worse, because a government health unit can sound like one more agency checking up on them. **Kiffer:** Right. Long-haul drivers can be thought of as a speech community, with their own channels and their own code. A redesign starts by researching that code. It might use dispatch messages from carriers and posters at the fuel desk, have a driver who's used the table talk about it, and say plainly what happens to the results. Any promise of confidentiality has to be true before it goes in the message. Then follow-up interviews at the truck stop check how drivers read the new version. **Sarah:** So the message stays about as simple as before, and the source, the channel and the code all change. Now the second half of the question. If a lot of people saw a campaign, did it work? **Kiffer:** Let's work a made-up example. A health authority estimates that twenty thousand adults in its region smoke. It runs a campaign for its free quit-smoking program. A survey afterward finds that sixty percent of adults who smoke remember the ads. Of those, half can say what the program offers. Of those, one in five say they're thinking about signing up. And the program's records show three hundred enrolments in the six months after the launch. **Sarah:** I can already picture the news release. Sixty percent of people who smoke saw our campaign. **Kiffer:** Here's the question for everyone. What share of the region's twenty thousand adults who smoke actually enrolled in the program? Take a few seconds. *(Pause)* **Sarah:** I'll go level by level. Sixty percent of twenty thousand is twelve thousand who saw it. Half of those, six thousand, understood what the program offers. One in five of those is twelve hundred who were thinking about it. Three hundred enrolled, which is a quarter of the people thinking about it. And three hundred divided by twenty thousand is 0.015, or one and a half percent. **Kiffer:** So sixty percent at the first level and one and a half percent at the last. Each level is a real hurdle, and exposure is the easiest level to clear and to measure. Before giving the campaign credit for even those three hundred, I'd want one more number: how many people enrolled in the six months before the campaign. **Sarah:** Say it was one hundred eighty. Then the campaign might account for about one hundred twenty extra enrolments, and only if nothing else changed over the same months. **Kiffer:** Right. One hundred twenty is 0.6 percent of the adults who smoke. Some of the twelve hundred who are thinking about it may still enrol later. An evaluation that reports exposure and stops there tells you very little about behaviour. **Sarah:** Question two. How does a community's push become lasting change inside an organization? I'd like to try this one myself. **Kiffer:** Here's a made-up case. Women from a city neighbourhood with many newcomer families want women-only swim times at the city pool, for religious, cultural and personal reasons. With help from a settlement agency, they collect four hundred signatures and speak at a council meeting. Recreation staff compare three options: a weekly women-only session with female lifeguards, a session at a partner school's pool, or no change. The recreation manager approves a six-month pilot of the first option, paid for with a one-time grant. The Sunday evening sessions are running, and they're full. Here's the question for everyone. In the staged model of organizational change, which stage has the recreation department reached? Take a few seconds. *(Pause)* **Sarah:** The petition and the council meeting are the unsatisfied demand. Comparing the three options is the determination of alternatives. The manager approving the pilot is the decision. And the sessions are running every Sunday and they're full, so the department has reached institutionalization. It's part of the schedule now. **Kiffer:** Let me ask you something about those Sunday sessions. What happens to them when the six months are up, or if the manager who approved them takes a job in another city? **Sarah:** Then nothing has to happen for them to stop. The grant runs out and the sessions end. Okay, I jumped a stage. The sessions have been adopted, and they aren't institutionalized until they stop depending on the pilot money and on one manager. That would mean a line in the operating budget, a permanent spot on the schedule, hiring that keeps female lifeguards on staff, and attendance reported to council every year. **Kiffer:** That's right. Full sessions make a case for keeping them, and permanence comes from budgets, schedules and policy. The gap between adoption and institutionalization is where the factors nobody controls, like a new manager or a budget crisis, do the most damage. In Lewin's terms, the petition helped unfreeze the department and the pilot is the movement. Nothing has refrozen yet. **Sarah:** What strikes me is that the first stage came from outside the department. The unsatisfied demand was created by community mobilization. **Kiffer:** It was, and you can find all three key issues of community mobilization in it. Try them. **Sarah:** The women decided how to define their community, as women in one neighbourhood or as any woman in the city who'd like a women-only swim, and that changes who council thinks it's serving. They drew on capacity that already existed in the settlement agency. And the health issue, physical activity, rides on something the women themselves care about, a swim where they feel comfortable. **Kiffer:** That's all three. Mobilization created the demand, and organizational change is what will make the result last. **Sarah:** Question three. Is a syndemic just several diseases showing up in the same people? **Kiffer:** That's a common misreading of the term. Merrill Singer, the medical anthropologist who coined it in the early 1990s, used it for epidemics that exist together because shared conditions promote them. So the first test is about cause. Is there a shared set of social conditions, such as poverty, housing or exclusion, behind the cluster? **Sarah:** And is there a second test? **Kiffer:** Yes, and it's about interaction. Singer's own work described the epidemics as mutually enhancing. In a 2017 paper in The Lancet, he and colleagues described syndemics as health conditions that cluster in a population and interact, biologically, socially or behaviourally, in ways that make their effects worse. They used comorbidity and multimorbidity for diseases that simply occur together. **Sarah:** Let me test that with a made-up place. In a retirement community, high blood pressure, cataracts and arthritis are all common. That sounds like comorbidity to me. The main thing those conditions share is age, and age isn't a social relationship in the political-economic sense. **Kiffer:** That's the right instinct. To call something a syndemic, you'd need to show social conditions driving the cluster, and the diseases interacting in ways that make things worse. **Sarah:** A well-known recent use of the term shows both. In September 2020, Richard Horton, the editor of The Lancet, wrote that COVID-19 is a syndemic. The virus was interacting with chronic diseases such as hypertension, diabetes and heart disease, and both were clustering in social groups along lines of inequality. **Kiffer:** Horton wrote that the search for a purely biomedical solution would fail, and he called for a larger vision covering education, employment, housing, food and the environment. That's the third step of the political-economic approach. Treat one epidemic without touching the conditions, and the other epidemics stay in place. **Sarah:** That can sound fatalistic, though. If the conditions drive everything, why run an HIV testing program at all? **Kiffer:** Because people living with HIV or hepatitis C need diagnosis and treatment now, and the conditions will take longer to change. Testing and treatment go alongside work on housing, income and access to care, and a program that works only on individuals should be honest about the conditions it's competing with. **Sarah:** Question four. When a program goes unused, is culture the explanation? **Kiffer:** Sometimes, and it's also the explanation people reach for first. Here's a made-up case. A health authority runs a free type 2 diabetes prevention program in a farming community on the Prairies. It's a walking group and a cooking session, on Tuesday afternoons at the health centre in town. Attendance is low, and the program report blames rural culture. **Sarah:** That sounds like culture being used as a catch-all. What did the interviews find? **Kiffer:** They found four things. Many farmers say they're on their feet from dawn to dusk, and walking for exercise is something people in town do. Several older residents say diabetes runs in families, so there's little to do until the doctor finds it. The sessions fall during seeding and harvest, and for many families the health centre is a forty-minute drive. And younger families say they think about exercise and diabetes differently from their parents, and many of them already walk together in the evenings. **Sarah:** So here's a question for everyone. Which of those four findings would keep people away even if everyone in the community thought about health exactly the way the planners do? Take a few seconds. *(Pause)* **Kiffer:** It's the third one. A Tuesday afternoon session during harvest, forty minutes away, keeps out a farmer who agrees with every word of the program. That's a barrier in the setting, the kind that community and organizational change deals with, and time and distance are also a question of who can afford to come, which is political economy. The report filed it under culture. **Sarah:** And the other three are cultural in different ways. The first is about meaning. Physical activity already has a meaning here, and it's work. The second belongs to the ethnomedical system, the answers to what causes illness and who deals with it. And the fourth is the critique that culture is never homogeneous. The younger families think differently from their parents. **Kiffer:** Good, and each finding points to a change. Move sessions to evenings outside seeding and harvest, and closer to home, say at the school gym. Talk about activity in terms that already carry value here, like strength and stamina for the work people do. And since older residents see the family doctor as the person who deals with diabetes, offer screening through the clinic they already use. That fits the program to their ethnomedical system. **Sarah:** None of the findings fit the adaptation reading, though. **Kiffer:** No, and that reading needs care. The best-known adaptation argument about diabetes is the thrifty genotype hypothesis, proposed by the geneticist James Neel in 1962: genes suited to times of scarcity became harmful with a modern diet. In 1989, Neel wrote that the data behind the original version had largely collapsed, though he kept a revised form of the idea. **Sarah:** And there's a Canadian critique of how it's been used. A 2018 paper in the journal Ethnicity and Disease argued that in Canadian health care the hypothesis turned the effects of colonialism, including the high cost of fresh food in the North, into a story about Indigenous genes. So the same check applies to every reading. Before you accept a cultural or a biological explanation, ask whether the setting or the structure explains the pattern better. **Kiffer:** I'd put it that way too. The adaptation reading is a legitimate lens, and it works best alongside questions about price, distance and history. **Sarah:** Question five, and this is the harder worked example. It joins the syndemic idea to a communication plan, and there's a trap in it. **Kiffer:** Here's the made-up case. In one city neighbourhood, depression, type 2 diabetes and food insecurity cluster among adults with low incomes, and a health authority's analysis meets both tests for a syndemic. Clusters like this are studied for real. A paper in the same 2017 Lancet series, led by the medical anthropologist Emily Mendenhall, treated depression and diabetes among people with low incomes as a syndemic. In our case, the shared conditions include low income, unstable housing, no regular family doctor, and often no reliable phone or data plan. **Sarah:** And here's the plan. The authority's diabetes, mental health and food security teams each run their own campaign. To choose channels, they send an online survey to everyone on the community health centre's patient email list. Eighty percent of the people who answer say email and the centre's website are the best ways to reach them, so all three campaigns go out by email and on the website. **Kiffer:** Here's the question. What's wrong with the way the teams chose their channels? Take a few seconds. *(Pause)* **Sarah:** The survey went out through the channel it was testing. Everyone who answered is on the health centre's email list and could answer online, so of course most of them like email. The people at the centre of the syndemic are the least likely to be on that list, because two of the shared conditions are having no regular family doctor and no reliable phone or data. **Kiffer:** That's the trap. The conditions that drive the syndemic also cut people off from the usual channels, so a survey run through those channels can't see the people it most needs to hear from. Eighty percent describes the people who answered, and it tells you very little about the people the campaigns are for. **Sarah:** There's a second problem, too. Three teams means three campaigns. Someone at the centre of the cluster could get one message about blood sugar, another about mood and a third about a food program, from three different sources. **Kiffer:** That treats a syndemic as three separate epidemics, which is the very thing the concept warns about. It also runs into agenda setting. For someone who's short of food and housing, those problems are likely to sit at the top of the agenda, and a message about blood sugar has to compete with them. So how would you redesign it? **Sarah:** I'd write one plan for the whole cluster. Do the formative research where the shared conditions bring people, at the food bank, the drop-in centre and the housing help desk, and ask there how people want to hear about services. Use sources they already trust, like outreach workers and peers. And encode one combined offer that starts with what's already on their agenda, food and housing help, with a blood sugar check and someone to talk to in the same visit. **Kiffer:** That's a good redesign. I'd add one check from the third step of the political-economic approach. A message about the food program helps only if the program has room for the people it brings in, so the help with the shared conditions has to be in place before the message goes out. **Sarah:** Now for the part where we disagree. **Kiffer:** It's about sugary drink levies, like the one Newfoundland and Labrador brought in at twenty cents per litre in September 2022, and who really ends up paying for them. **Sarah:** My worry comes from the structural violence lens. A levy is a flat amount per litre, so for the same drinks it takes a bigger share of a small income. A Memorial University study found that sugary drink sales fell somewhat more in Newfoundland and Labrador than in the Maritime provinces, which had no levy, and one of its authors called the effect small. When the premier announced the repeal in May 2025, he cited affordability, and the levy ended on July first. If the money disappears into general revenue, it can look like a health program paid for by the people with the least. **Kiffer:** I take the cost side seriously. Where I differ is on who gets the health benefit. A price change acts on the structure of choices, which is the level political economy points to. Mexico brought in a tax of one peso per litre in 2014, about a ten percent price increase. A 2016 study found that in the first year, purchases of taxed drinks were six percent lower than pre-tax trends predicted. Households with low socioeconomic status cut back the most, by nine percent on average. **Sarah:** That shows people bought less. Buying less of something you enjoy because you can no longer afford it is still a cost, and purchases are still a step away from health. It's the levels-of-effect problem from question one again. **Kiffer:** That's fair, and purchases are a long way from health outcomes. Still, the Public Health Agency of Canada reports that diabetes is about twice as common among adults in the lowest income group as in the highest. If consumption falls most where diet-related disease is most common, the health benefit may be concentrated there too. Where I land is that a levy can be fair when the revenue goes back to the people who pay the most, through things like school food programs or support for low-income families. That's close to what the Heart and Stroke Foundation recommends. **Sarah:** I'm still more cautious than Kiffer. I'd want the families who pay the most to have a say before a levy starts. But we agree on the practical rule. Before you judge a price policy, ask three things: who pays, whose health changes, and where the money goes. And have an answer to the third one before the policy begins. **Kiffer:** Agreed. It's the follow-the-resources question from the lesson, asked from both ends. Let's pull it together with three things to take away. **Sarah:** First, a message carries more than its literal content. The tone, the source and the channel are all part of the code, and exposure is only the first of several levels of effect. **Kiffer:** Second, check the label you put on a problem. A pilot that's running has been adopted and not yet institutionalized. A cluster of diseases is a syndemic when shared conditions drive it and the diseases interact in ways that make their effects worse. And a barrier labelled culture may turn out to be the schedule or the distance. **Sarah:** And third, the conditions that drive a syndemic also shape which channels reach people. Choose channels with research done where the shared conditions bring people, and check whether the people you reached are the people the program is for. **Kiffer:** If you'd like more practice, go back to the farming community's diabetes program from this episode. Sort the four findings again, then write a short redesign that answers one critique from each of the four theory families. **Sarah:** Next time, it's Lesson six, Multilevel Theories and the Ecological Perspective, where we look at how to hold several levels of influence in a single model. **Kiffer:** Take care, everyone. **Sarah:** See you in Lesson six.