Month: September 2010

education & learninginnovationpublic health

The Art of Public Health

The Art of Public Health Conference: October 1, 2010

Creativity and its close relative, innovation, is everywhere in public discourse. There is a wide recognition that the way we’ve always done things isn’t working for a lot of the problems we face. Reductionist science and the normal science that it is a part of has helped public health out a lot, eradicating diseases, prolonging our lives, made us happy, has enabled us to feed the world (or large parts of it), and provided answers to many of our most vexing questions.

Except many of those diseases, once thought to be slain, are coming back, there is deep concern that our next generation might not live as long as the current ones, wealth hasn’t equalled happiness,  food insecurity is endemic, and we are still taking more than a generation to translate simple knowledge into practice.

Innovation and creativity are needed to see these problems in a new light, which may lead to insights, discoveries and better strategies for taking what we know into what we do. Artists’ and designers live on creativity; it is their lifeblood. Art is the very act of creation and design is doing so with intent, so bringing this world to public health is a natural fit for those seeking ways of addressing the thorny, wicked problems of public health.

This Friday October 1st, the Dalla Lana School of Public Health will be hosting The Art of Public Health conference . Organized by students interested in exploring the intersection of artistic creativity and its application to public health science and practice, this conference will serve to remind and inspire us about the power of art in what we do. Specifically:

The Art of Public Health’ Conference will focus on an emerging and innovative area in public health: arts-based approaches to public health areas, including research, knowledge translation, evaluation and community development.

The conference website reminds us that the very roots of the words within much of what we do are tied to art and creative exploration:

art (arht) noun:  the use of skill and imagination in the creation of aesthetic objects, environments, or experiences that can be shared with others

pub∙lic (pubh-lik) adjective: of, pertaining to, or affecting a population or a community as a whole

health (helth) noun: a state of complete physical, mental and social well-being

art of public health (arht of pubh-lik helth) idea: the use of skill and imagination applied toward the creation of a state of complete physical, mental and social well being affecting a population or community as a whole

For those of you in Toronto, the registration is free and information can be found here. For those unable to attend, the conference organizers have a Twitter feed . Some further details and contributions will also be available through the main conference website and the home of the Youth Voices Research Group.

complexitypublic healthsystems sciencesystems thinking

Complexity and Emergency Reactiveness

This past weekend a fire broke out in a large apartment block in Canada’s most dense and multi-ethnic communities.

The fire, not as large as one could imagine when you hear “6-alarm blaze”, was still far greater in its impact than its size would suggest. As of last night, there remain 1700 people unable to return home. The building’s structural integrity is now in question, which could pose even further problems for a community that is not well prepared to cope with it. Reading through the stories of what happened in the community, which is where much my research group‘s work is focused on, it is hard to imagine how difficult it must be for people living in a modern city to be camped out in makeshift shelters that are propped up throughout the downtown.

One quote from the Torontoist’s coverage points at the cascading set of problems that these problems cause:

“I just want to know what’s going on,” said Romaniuk, a fourteen-year resident of 200 Wellesley Street with long red hair and an accent that was difficult to place. She had arrived home from work last night only to be denied access to her apartment by emergency responders. “At some point I need to get in. I need to go back to work. I have no clothes to go back to work.” She said she’d slept at her cousin’s home, and that she’d do so again tonight, if necessary. For those who had nowhere to go, the Community Centre was filled with cots, draped with Red Cross blankets. Some residents slept at other ad-hoc downtown shelters last night.

Here we see a remarkable dichtomy between the a part of the world where such sites are rare and those parts where such sites are common, perhaps even semi-permanent (PDF). In Toronto, emergency services have done a decent job of handling the crisis and moving quickly to find places to hold residents who are without a home. But what passes for good in these situations is usually a matter of perspective.

The cascading set of problems that these problems cause are usually examples of complexity in action. The interconnectedness between events and the unintended consequences that emerge from simple actions have ramifications that our post-event analyses only scratch the surface upon. They also cause much discussion about the suitability of emergency preparedness plans. Such plans, often designed to help communities respond quickly in a disaster, tend to work well when the parameters are known and the system constraints are reasonably tight. Airplane emergency safety planning is one area. In an emergency, those in a plane have very few options for escape and in those situations where a problem occurs and there is a chance of survival, most of the strategies, imperfect as they are, will do the job of getting people to safety. A plane is a closed system.

Communities are more troublesome beasts. They are open systems and it is virtually impossible to imagine the variety of scenarios that could unfold in the event that a large scale disaster takes place. The aftermath of Hurricane Katrina showed clearly the flaws in both their plan, but also in the mindset that goes into planning in the first place. The mere act of planning is problematic when you consider a complex system.

The Oxford English Dictionary defines a plan as:

plan |plan|
1 a detailed proposal for doing or achieving something : the UN peace plan.
• [with adj. ] a scheme for the regular payment of contributions toward a pension, savings account, or insurance policy : a personal pension plan.
2 (usu. plans) an intention or decision about what one is going to do : I have no plans to retire.
3 a detailed diagram, drawing, or program, in particular
• a fairly large-scale map of a town or district : a street plan.
• a drawing or diagram made by projection on a horizontal plane, esp. one showing the layout of a building or one floor of a building. Compare with elevation (sense 3).
• a diagram showing how something will be arranged : look at the seating plan.

Consider the terms. The first is a detailed plan of what you are going to do. This means having some idea of what the context will be, what the parameters are, and the agents involved. How often can we do this reliably?

The second part, intention, is far easier. This is something that one can develop abstract, but focused sets of ideas about what is to be achieved.

The last part is about as problematic as the first.

Colin Powell had a more realistic, complex view of planning:

No battle plan survives contact with the enemy

Since Katrina and as the potential spectre of a pandemic influenza sits in our minds, public health has been focusing on emergency preparedness. Thinking in complex terms might enable us to get the best of our intentions to gel with what Powell speaks of: contact. The Toronto fire example provides a decent case for planning, but as the unplanned for consequences begin to reveal themselves (lack of ability to work, loss of pets, missing medication schedules, eating nothing but pizza for three days straight to name a few) the strength of this plan will be forgotten. Considering things as complex from the outset means that plans are no longer solid documents, but fluid, adaptive processes that require new ways of engaging this complexity.

I don’t see much of that. But then, I’m too busy planning for other events that are equally as ludicrous (classes, papers, research projects). Perhaps we all would be wise to heed John Lennon:

Life is what happens when you’re busy making other plans.

For those interested in learning more or doing more for those affected by the fire in Toronto, here are some links:

ongoing activities and news:

co-ordination wiki:

fundraising opportunities:

behaviour changeeHealthpublic healthsocial media

Social Marketing, Marketers and Responsibility

Set Godin

Seth Godin, a business and marketing thought-leader and someone I’ve written on before, posed the question on his blog: Are marketer’s responsible for what they promote?

« The power of buttons and being normal

Are you responsible for what you market?

Let’s assert that marketing works.

If it works, then, are you responsible for what happens after that?

If you market cigarettes aggressively, are you responsible for people dying of lung cancer?

I think there are two ways to go here:

1. You’re not responsible. The marketer is like a lawyer representing the obviously guilty client. Everyone is entitled to a lawyer, and it’s up to the jury to decide. The lawyer’s job is to do the best she can, not to decide on the outcome. Market the best you can and let buyers take responsibility.

2. You are responsible. Your insight and effort cause people to change, and without you, that change would never happen.

My take: if you’re not proud of it, don’t sell it.

As I mentioned in a previous post, social marketing in the health sector (not including the ‘miracle cure’ hawkers) tends towards promoting “healthful” things. Yet, even these supposedly healthful activities such as donating to a particular cause, paying attention to certain lines of evidence, or attending certain educational events have unintended consequences. Donations to one charity means that money isn’t going to others. Adhering to certain protocols and procedures means disregarding or not paying attention to others. While choosing to attend certain events takes you away from other activities you could pursue (like your email back at the office, meetings with colleagues, time with family, or attending other events).

While the above example of cigarettes might lead us to an obvious answer to Seth’s question, what about what happens in our knowledge translation activities on the side of health? Do we stop to consider the unintended consequences of our actions, even if they are well intentioned? Systems thinking is one of the tools to help us through this, particularly systems dynamic modeling. On an individual level, contemplative inquiry is another strategy.

In both cases, we need time, care, attention and the capacity to bring this knowledge to light.

One example is with the Transtheoretical Model and Stages of Change theory. When I started getting into the health field Stages of Change was just gaining popularity. A search of PubMed finds nearly 1000 published articles using variants on the Stage of Change concept. In a nutshell, this theory suggests we work our way up to change by planning over time towards a change. Local, provincial/state, and national programs throughout the world have taken this approach to organizing their activities. For a while it seemed that the only way to get funded was to have some accounting of stage.

The problem was, Stage of Change does a lousy job of predicting change in certain behaviours. Robert West and others looked at the evidence and found that in many cases, Stages of Change did a terrible job of predicting whether people would change their behaviour or not, particularly in the realm of addictions. Smokers or problem drinkers might stop “cold turkey” without any advance planning, which isn’t well accounted for by the model.

Yet, the model, so ingrained in the psyche of many health promotion planners and educators, continues to be used widely, blinding us to other options. The unintended consequences of this is that we are often unable (unwilling?) to consider that other models might work. Or, that the models we have don’t work as well as we’d hoped and that maybe we need new ones. By not only putting these ideas out there, but actively promoting them, we are marketing not only products, but ways of thinking about problems and it is here that we get into trouble.

Pride in what you do might avoid the problem’s that Seth Godin in talking about, but when it obscures our vision from considering other options, it might be time to do less social marketing and more social systems thinking.

education & learningeHealthsocial media

Social Marketing/ Social Media Blowback And eHealth Communication Etiquette


Those of us working at that interface between the professional and public worlds of health have to wear many hats. We need to be good at communicating in ways that gain respect within our professional worlds. This position means writing scholarly manuscripts, using technical language (but not always), and synthesizing the work of our peers on one hand, while being able to work within the world of most marketers, which includes reaching the public. That means working within the realm of (social) marketing.

Social marketing is described as:

Social Marketing is a planned process for influencing change. Social Marketing is a modified term of conventional Product and Service Marketing. With its components of marketing and consumer research, advertising and promotion (including positioning, segmentation, creative strategy, message design and testing, media strategy and planning, and effective tracking), Social Marketing can play a central role in topics like health, environment, and other important issues.

In its most general sense, Social Marketing is a new way of thinking about some very old human endeavours. As long as there have been social systems, there have been attempts to inform, persuade, influence, motivate, to gain acceptance for new adherents to certain sets of ideas, to promote causes and to win over particular groups, to reinforce behaviour or to change it — whether by favour, argument or force. Social Marketing has deep roots in religion, in politics, in education, and even, to a degree, in military strategy. It also has intellectual roots in disciplines such as psychology, sociology, political science, communication theory and anthropology. Its practical roots stem from disciplines such as advertising, public relations and market research, as well as to the work and experience of social activists, advocacy groups and community organizers.

Social marketing is about getting ideas out there and in use and within the realm of public health and social welfare programming, we often presume that what we’re “selling” is good in its quality, intent, potential use, and social benefit.

The problem is that most of what passes for social marketing in the health sector is not done by marketers, or even those skilled in health communications, but rather everyday researchers, clinicians and administrators. Certainly there are many large organizations where such skilled professionals do reside, but in the decentralized web of social media, those are drops in the bucket of content.

The result is that many well-intentioned messages get poorly developed and distributed, creating something akin to blowback, a hostile and aggressive form of resistance to the message. I’ve just been witnessing such a case of this with a an organization seeking to promote social innovation that is getting messages sent by people on its online mailing list asking to be removed from it. One of the big reasons for these messages is that these people were never asked to be put on the mailing list in the first place.

I get almost as much spam (or, in some cases, bacn) from well-meaning organizations and individuals hoping to get their message out than I do the usual snake-oil salesmen peddling natural male enhancements, Rolex watches, and “investment opportunities”. The senders of these messages, well intentioned for the most part, are hoping to you’ll “buy” their product, which means adopting their findings into your practice, register for the conference they are organizing, visit their website, or donate to their cause.

This reflects a fundamental lack of knowledge about social media, social marketing and knowledge translation in the modern age. Effective messages are a matter of content shaping and distribution, but also relationship development. When you send out messages unsolicited asking for something — time, mindspace, referrrals, whatever — you are hoping to develop a relationship, even a superficial one, with that person. Treating them with the disdain that comes from throwing content at people without their consent is violating that relationship. It is no surprise that miniscule things like one simple thing like an unsolicited email can unleash some fury among its recipients.

And for those people and organizations who think putting a tiny statement on their registration form or website in 8pt font saying that you must opt out of communications or presuming people want this, I’m sorry but that doesn’t cut it.

Building social marketing on relationships is something that our field needs to build literacy and competence in quickly as the number of these unsolicited campaigns seems to be growing. If we don’t improve our messaging, we’re going to have a lot harder time getting the right people to attend to the right messages or risk having them treat all of what we send with the same care as those messages from some Nigerian Prince in exile.

innovationsystems science

Systems (Science): Sexy and Not So Much

Recently I was discussing what I do with someone relatively unfamiliar to my research, yet in the same field and I described my interest in systems thinking, knowledge translation, and eHealth and how they go together. Somehow in the conversation the term “sexy” was used to describe these fields along with “hot” and “upcoming”. It’s nice to be at the forefront of a field — or three — but it also has some downsides.

One of the downsides is that rigor often gets displaced by enthusiasm. Even fields like knowledge translation, which first emerged in the mid 1990’s (and far earlier than that if you’re willing to consider different terms), is just now evolved to the point where it is widely accepted and supported as a legitimate area of research. There is still much work that calls itself KT that is really just dissemination with a different name, but the concept of KT at least has some respect.

So too, does the idea of systems thinking. With recent special issues in respected journals like the American Journal of Preventive Medicine and American Journal of Public Health and full monographs from the National Cancer Institute, the idea of transmitting systems science from the backwaters of public health to the forefront is close to reality.

eHealth was sexy too, but too much investment matched with too little patience for good evidence quickly burned through much of the potential that consumer-directed eHealth had for making transformative differences on a broad scale. No worry, mHealth is here and that is quickly proving to be as “hot” as eHealth was ten years ago.

The problem is that “hot” and “sexy” terms often presage their demise in respected discourse before too long. I was once told by a senior official with a large health NGO that he’d given up on eHealth because he knew it didn’t work. This was 2002. Most of the best evidence hadn’t been generated yet and already people had thrown in the towel.

Knowledge translation is having its problems too, because the evidence of a shortening from “evidence to effect” is hard to generate. Often, KT requires systems level changes and systems thinking to create the conditions to generate effective KT practice. That suddenly transforms something that is “sexy” into something difficult and much less so in the eyes of those who are responsible for implementation of KT plans.

Systems science as it is applied to health is in greater danger because the scale and scope of change required to generate good evidence is often at a scale that is prohibitive. Take gambling as one potential public health problem. Governments are now deriving enormous revenue from gambling, while the social costs seem to rise with it. So important is gambling to provincial government revenues in most Canadian provinces that the only way to really change is to change the system as a whole. Diabetes care, mental health, and public nutrition and food security are other issues that are complex and of a scope that requires a true systems-level intervention to effectively address. Suddenly, when you speak of connecting the private sector to the public sector, changing regulations, building true KT systems within these areas, supporting public health education and practice, and tackling the social inequalities that are propped up by a current system of organization, systems don’t seem as sexy.

Furthermore, in the case of systems, KT, or eHealth, acknowledging complexity in the way we handle things, and considering problems from a systems perspective, means hard work, different time horizons, and truly working collaboratively across disciplines and settings. That is hard stuff and it sure isn’t sexy.

There are lots of areas within the health system that are not sexy, but few are seen less interesting than issues that were once viewed as sexy, but now not so much. That’s the danger with systems, knowledge translation and eHealth.

innovationsocial media

KTExchange Blog Goes Live

This week sees the launch of the Knowledge Translation Exchange Blog , a welcome addition to the digital discourse on knowledge translation and health. The KT arena, a space that often gets filled with voices trying to push something akin to some aggressive form of dissemination with a fancier name, can really use some of what the Research into Action group at the University of Texas School of Public Health is doing and discussing. It’s about integrating knowledge translation into the very fabric of what we do in the health sciences, public health and clinical practice.

KT is not just an add-on, but something that requires integration into the planning, learning, evaluation and dissemination of knowledge. Surprisingly, this is a hard concept for a lot of people to grasp (or perhaps just a hard concept to apply in practice given how few people actually do it). It is not, as some might suggest, dissemination dressed up. It is about considering knowledge in context and framing potential audiences for that knowledge at the outset, defining research questions that align with the needs of the user, and creating capacity within research environments to develop proposals and do the research necessary to fit with these needs.

This past weekend I was reminded how basic this is to most people OUTSIDE of the health sector, and yet how foreign it is to the health system. I was visiting family and friends and, as often happens in such settings, people ask what I do. In conversation about building bridges between diverse actors the reaction typically is not one of surprise or novelty, but more like “of course”. What captures people’s attention is my work in using eHealth tools like iPhones and social media as the mechanism. While those things are of interest to my professional colleagues, the fact that bridges are being built is what draws the most attention. That’s telling.

Best wishes to the KTExchange team on their new blog and for a field where doing KT may one day not be seen as novel, but an integral part of what we do in the the health sector.

behaviour changedesign thinking

Design and Health: Systems, Substance and Style

Style, Substance and Getting You Where You Want to Go

Does style matter when it comes to your health?

Consider a visit to your family doctor or dentist. Imagine two scenarios that describe what you find at the office.

Picture one office as having old, worn-out tiles on the floor, the tiled ceiling with fluorescent lights; worn and torn magazines that are many years out of date, and a PC running Windows 98.

Compare that with an office that might be streaming live news feeds on a monitor or TV set, is brightly lit with natural light, simply laid out, and office staff allowing you to fill out your information in the waiting room on an iPad.

In both cases nothing is said about the quality of care or professional competency of the physician, yet if you compare the two by their looks it is quite likely that a person is much more likely to judge the quality of service or care by these first impressions.

Marketers and retailers know this well — the effective ones at least — and spend inordinate amounts of resources in refreshing their stores, developing their brand image, and ensuring that there is some consistent experience that is attractive to customers. If the place is attractive to the eye at first glance, it will elicit a reaction that may last for a very long time and colour everything about how you see that store, organization, group or person.  This thesis about snap decision-making and first impressions has been accessibly summarized by Malcolm Gladwell in his book Blink. In short: first impressions last a long time and are very powerful.

It also means that style is not something that we should necessarily dismiss as ‘just’ the aesthetic part of design. Good design is about form, function and overall fit with the environment the product or service operates within. It’s why Apple products are so distinct for example and why they are often held up as a model for good design. Apple tools play well with each other and often with different products too (although Apple is by no means the model for this — consider the fact that you can only run the Mac OS on an Apple-made computer unless you do something quite drastic) .

Consider Lady Gaga, someone I recently discussed along with mHealth. It is fair to say that she would have nowhere near the fans and following were it only for her singing and songs (whatever you think of them). For her, it is about linking those things to a style that she has created along with a system to support that integration of music, video, fashion, marketing, and entrepreneurship. Her style is what connects a lot of people to her, but it is her substance and the systems around her that make people fans.

What if we thought more about style in our work? Imagine a stylish system for health? It’s not just aesthetic or superficial, it just might be essential. Good design is about linking all of them together.