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Count Me In!

I Introduction

Count Me In! is a new health promotion strategy that highlights the relationship between health and inclusion. It has been developed by the Ontario Prevention Clearinghouse (OPC) with support from the Laidlaw Foundation and the Population and Public Health Branch, Ontario and Nunavut Region, Health Canada.

Count Me In! combines two elements:

1) a bilingual, social marketing campaign with public service announcements (PSAs), posters, and brochures to familiarize the general population with the relationship between the determinants of health and belonging in society, co-developed with the Association of Ontario Health Centres (AOHC); and

2) "count me in!/j'en fais partie!", a bilingual primer and worksheets for community leaders that uses the determinants of health to demonstrate how individuals, families, and communities can develop indicators, strategies, and targets to promote inclusion.

The social marketing campaign will be launched on Community Health Day, April 28, 2004, at the Regent Park Community Health Centre in Toronto. The workbook will be launched in regional meetings with community leaders in the health and social sectors throughout Ontario in the fall of 2004.

II The Challenge of Defining Inclusion in Canada

Although social and economic inclusion is a concept in the European Union, Britain, and Canada, defining the term and its use in population health remains a challenge. The Europeans focus on exclusion and social outcomes and the British have narrowed the definition to focus on employment. (1) Canadian efforts have tried to create a broader approach, based on our experience and the reality of our peoples and communities.

Count Me In! was, in part, designed to create a Canadian definition and framework for inclusion as the basis for a new approach to health promotion. This approach recognizes that individuals, families, and communities benefit from the feeling and the reality of belonging.

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lll A Participatory Approach to the Challenge

Count Me In! used a participatory approach to creating a Canadian definition, combining the expertise of a provincial advisory group with field testing of the concepts, language, and framework in local working groups. The advisory group developed draft definitions and frameworks for individuals, families, and communities to use to influence policy decisions to promote inclusion. The group included social and health scientists and activists and reflected urban, rural, and diverse populations, as well as cultural, First Nations, and official-language interests.

Local groups tested the draft definitions and frameworks through interviews, focus groups, and consultations with their constituents. They were coordinated by Access Alliance Multicultural Community Health Centre in Toronto, Peterborough Family Resource Centre, and Francoscenie in Eastern Ontario and included staff from agencies in the health, social, and cultural sectors as well as people seeking inclusion. The local groups reported back to the provincial group throughout the year-long project and adjustments were made to the draft materials, which were then reconsidered in the field.

The initial definition was developed through a search of the European, British, and Canadian literature and it tended towards the technical, laden with Latinate words from the social sciences. At each of the five meetings through the course of the year, the advisory group began with a fresh consideration of the definition, prompted by further thought and input from the local groups. The language used in the definition and framework became a paramount consideration. As the process moved forward, the language became simpler and less technical. The framework emerged in the same way, draft after draft, from meeting to meeting, in the attempt to create a workable process for community leaders to use in working with inclusion concepts.

The provincial and local groups worked to develop a language that was more appropriate to people seeking inclusion, departing from the technical orientation of the language imported from Europe and described in earlier OHPE bulletins (2). This participatory process yielded a strong, plain-language, easily translated definition and framework for use by our diverse communities.

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IV The Definition of Inclusion

This is the definition of inclusion developed by the project:

A society where everyone belongs creates both the feeling and the reality of belonging and helps each of us reach our full potential.

The feeling of belonging comes through caring, cooperation, and trust. We build the feeling of belonging together.

The reality of belonging comes through equity and fairness, social and economic justice, and cultural as well as spiritual respect. We build the reality of belonging together by engaging our society to ensure it.

The definition departs from early British, European, and Canadian iterations in a number of ways:

* A early, key decision was to remove "social and economic" from the concept of inclusion and to promote a more holistic approach, recognizing the importance of the cultural and spiritual realms as well as the notion of justice and equity. This decision came from the acknowledgment of a number of unique features in our own reality: the vital importance of our First Nations;, our bilingual, bi-cultural origins; our experience with immigrants and refugees; and our pioneering work with people of differing abilities.

* An equally important decision was to embrace the language of "belonging" instead of the language of inclusion and/or exclusion. The local groups advised this from the very first consultations. This was a word and concept that everyone understood, appreciated, and sought.

* This led to the decision to give equal value in the definition to the "feeling of belonging" and the "reality of belonging." Our definition captures the "reality" aspect by highlighting equity and fairness and social and economic justice, as well as cultural and spiritual respect. However, the definition also considers the "feeling" of belonging, drawing from the work of educators to ensure inclusive schools. For example, a recent study by the Centre for Addiction and Mental Health discovered that students in inclusive schools were less likely to report academic and behavioral difficulties and poor mental health, and the 7th Annual Sydney Symposium on Social Psychology in March 2004 heard papers from psychologists from Australia and the United States, exploring the positive health and mental health benefits of the feeling of belonging. (3)

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V The Framework for Inclusion

The framework for belonging in society is the basis of the social marketing campaign and the community leader primer and worksheets. The framework can be illustrated on a chart with columns representing

* the determinants of health;

* specific factors that influence communities in society;

* indicators for individuals, families, and communities;

* indicators for agencies, schools, and governments;

* strategies to promote inclusion; and

* targets for inclusion.

A. Belonging Flows through the Determinants of Health

The feeling and reality of belonging are not experienced in a vacuum. People seeking inclusion experience the feeling and reality of belonging through the precisely delineated elements that determine our health, the health of our loved ones, and the health of society. On their website, Health Canada lists them as follows:

* income and social status,

* social support networks,

* education and literacy,

* employment/working conditions,

* social environments,

* physical environments

* personal health practices and coping skills,

* healthy child development,

* biology and genetic endowment,

* health services,

* gender, and

* culture. (4)

B. Specific Factors that Influence Communities in Society

There are many different kinds of communities in a society. They may form around age, sexuality, geography, ability, faith, status, and/or the experience of racialization. It's important to remember that we all belong to many communities at the same time. Also, we may identify ourselves with these communities or have that identification assigned to us by others in mainstream society.

Specific factors affect communities differently. The more we understand these specific factors, the easier it will be to understand how belonging for communities flows through the determinants of health. Communities will also be able to more effectively identify indicators of belonging and develop strategies and targets to promote belonging.

For example, people who have been defined or stereotyped by others have started to describe this as the experience of racialization. They may be black, but they are not West Indian. They may be Chinese, but they are not immigrants. They may speak Ojibway, but they are not speaking a foreign language. These specific factors influence that community:

* language barriers,

* ethnoracial differences,

* racism,

* immigration status,

* concentration of populations in large urban centres, and

* settlement/adjustment.

For example, a member of a racialized community may face significant language barriers and settlement/adjustment factors in educational settings, such as school and literacy programs. Those factors will have a bearing on the feeling and reality of belonging.

C. Indicators Measure How our Society is Doing in Promoting Belonging

Indicators can be used to track progress towards the goals of helping people realize both the feeling and reality of belonging as individuals, families, and communities. Indicators must

* be meaningful to the individuals, families, and communities; and

* identify policies and practices in agencies, organizations, governments, and schools that help people belong to society.

To be useful, indicators must meet certain criteria. The Healthy City office in Toronto has listed six. Indicators must be

* complete and measure many things,

* readily available for use,

* accessible and meaningful to the public and policy makers,

* sensitive to changes over time and to differences among population groups,

* capable of being used at different levels of aggregation, and

* valid and reliable.

In our example, *access* to ESL interpreters may be seen as in indicator for individuals, families, and communities seeking inclusion. Correspondingly, *the number* of ESL interpreters in the system may be seen as indicator for agencies, organizations, governments, and schools.

D. Strategies and Targets to Promote Belonging

A strategy is a way to move towards a target or goal. A strategy requires that you

* carefully and precisely describe the goal you are trying to reach;

* make sure that goal is within your reach;

* identify the decision makers who could help you reach your goal;

* figure out the shortest path to reaching that goal;

* pull together the necessary resources, including the people you need to help you; and

* focus on the issues and strategies until you reach the goal.

A target is a result that you are able to reach. A target must be clear, precise, specific--we must be able to tell everyone what that target is in order to gather their support to reach it. We want them to say, Count Me In!

In our example, a strategy to promote belonging could involve asking your community health centre to help organize a meeting of those members of the community who would benefit from ESL interpreters. The meeting may propose developing a petition and submitting it to the local school. A target may be to have an appropriate ratio of ESL interpreters to students, so students have easy access.

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VI The Social Marketing Campaign

The Count Me In! social marketing campaign, co-developed with the AOHC, was based on a mid-nineties campaign on the determinants of health. That campaign included television PSAs, posters, and a brochure. In this new campaign, a small team from OPC, AOHC, and Health Canada worked with a creative agency to make adjustments in the original imagery. The original campaign featured a dialectic between negative and positive imagery--those who had access to the determinants moved to better, healthier lives (from negative to positive film or photos). They decided to create a test set of images using only the positive imagery matched with simpler language to explain the determinants. They also tried various tag lines to tie the images and text to inclusion. A composite set was developed and focus tested through a network of community health centres and in the three local sites of this project. After testing and reconsideration, "count me in!" was posed at the tag line in the form of a button and a range of verbs were matched with the determinants of health to tie the campaign together:

* Income impacts health

* Community promotes health

* Employment determines health

* Education improves health

* Equality enhances health

* Environment influences health

The posters and brochure are cast in a contemporary lime and the "count me in!" button is in the same bright, positive colour.

The television PSAs will be distributed through national and regional channels and a set of posters and brochures will be shipped gratis to community health centres and public health units. They may be ordered by contacting the Association of Ontario Health Centres at (416) 236-2538 x222.

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VII The "count me in!/j'en fais partie!" Primer and Worksheets

The Primer is a thirty-page document that explains and elaborates on the definition and framework of inclusion described above. It is meant for community leaders to use with small groups and is written at a Grade 7 reading level to promote easy use by people seeking inclusion. The Worksheets that follow are a guide to help a small group through the process. They share the following headings:

* One: Belonging Flows through the Determinants of Health

* Two: Specific Factors that Influence Groups in Society

* Three: Indicators Measure Belonging in Society

* Four: Strategies and Targets to Promote Belonging

The Primer and Worksheets are still in the process of field testing and refinement and will be completed by the fall of 2004.

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VIII Next Steps

In keeping with the participatory approach used to develop a Canadian definition of inclusion, Count Me In! will use a popular education methodology to introduce this new health promotion strategy across Ontario by sponsoring a series of regional meetings with community leaders from the health and social sectors. Coupled with presentations on the health promotion tradition and strategies for community engagement at these meetings, there will be a demonstration of the workbook methodology that is designed to facilitate an inclusion analysis of the region. This may seed regional inclusion networks, supported by a network of health and social agencies.

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IX Conclusion

Count Me In! is an attempt to connect a new idea with a great tradition. Health promoters in Canada have been in the forefront of introducing such useful concepts as the "healthy community" and the "healthy city" over the last twenty years, along with the broad acceptance of the principles in the Ottawa Charter, including an emphasis on population health strategies. And the current climate is an interesting one for health promotion work. There is much debate, for example, about the racial profiling that seems to be occurring in the wake of the events of September 11, 2001. Exclusion gains currency in such a climate. Over the year-long development of this new health promotion strategy, we heard from the health and social activists involved in the process that this is a perfect time to promote inclusion, to promote a feeling and reality of belonging, as a Canadian contribution to the challenge of our time.

For more information, visit, or contact Michael Fay, project coordinator, at (705) 286-3668 or [email protected].

X References

(1) See OPC's Social and Economic Inclusion Project briefing notes 7 and 8 for more information on the European and British approaches to social and economic inclusion:

(2) OHPE 298.1, An Inclusion Lens (, and OHPE 330.1, The Closing the Distance Project (, have more information on social inclusion concepts and projects.

(2) For more information, we suggest The Critical Role of School Culture in Student Success by DeWit, et al, Centre for Addiction and Mental Health, December 2003, available at as a PDF file and The Social Outcast: Ostracism, Social Exclusion, Rejection, & Bullying, a collection of papers from the 7th Annual Sydney Symposium on Social Psychology in 2004, edited by Williams, Forgas, and von Hippel (

(3) See Health Canada, What Determines Health at