Monthly Archives: May 2012
Cigarette smoking remains among the most significant and pernicious global public health challenges. On World No Tobacco Day it’s time to consider re-designing our approach to public health and tobacco control in the hopes of meeting this challenge and others like it more effectively.
Today is World No Tobacco Day and offers us an opportunity to take a pause and think about the ways in which we approach tobacco control as an example for public health.
Marketing funnyman Rory Sutherland, and smoker, makes a terrific observation about smoking and its power to promote quiet contemplation in one of his recent TED talks (which is well worth watching for many reasons, only some related to tobacco use):
“Ever since they banned smoking in the UK in public places I’ve never enjoyed a drinks party ever again. The reason… is when you go to a drinks party and you hold up a glass of red wine and you stand up and talk endlessly to people sometimes you don’t actually want to spend the whole time talking. It’s really, really tiring. Sometimes you just want to stand their silently, alone with your thoughts. Sometimes you just want to stand in the corner and stare out of the window.
Now the problem is now that you can’t smoke, if you stand there and stare out of the window on your own you’re an antisocial, friendless idiot.
If you stand there and stare out of the window on your own with a cigarette, you’re a fucking philosopher.”
In this tongue-in-cheek presentation, Sutherland inadvertently hits on a powerful reason to smoke, but not for the reason you might first imagine. It is less about social perspective, but internal perspectives of the self and the opportunity to better acquaint oneself with them.
Sutherland speaks to the perception of others in this talk, but I am more interested in what this act of contemplation — the ‘fucking philosopher’ aspect of smoking for some and why public health sometimes gets it wrong when it comes to tobacco control, but could get it right with mental health with the right design.
Over the past year I’ve made a concerted effort to better understand the motivations and habits of cigarette smokers from the perspective of a designer, not a public health researcher. In doing so I have sought to pay greater attention — as Rory Sutherland does — to the actual experience of smoking. And what I have noticed is the powerful contemplative effect it has on many smokers.
By no means is this a by product of cigarettes, and I certainly cannot endorse their use on health grounds, but one positive by-product of the act of smoking is greater attention to the self in the moment. Sutherland speaks to how a cigarette gives him the license to take time out of a busy party and contemplate, reflect, and gain some perspective that might seem odd or “antisocial” without the prop created by a cigarette.
Strange that we seem unable to develop the same habits and social acceptance of everyday contemplative acts in public, yet fully recognize this as legitmate with smokers even if we question the device used to precipitate the “time out”.
Smokers take breaks throughout the day to engage their cigarettes. Even in cold weather, they will go outside and sit or stand for 10 minutes just to indulge their habit, compulsion or pleasure, sometimes in small groups. This act of smoking provides a sense of community (with other smokers), contemplative space, and a pause from the everyday rush of life. Indeed, as they engage in activities that threaten their physical health they also engage in an activity that is very healthy for their mental well-being.
This is potentially another area that requires further investigation both from a positive standpoint (designing healthy space for contemplative inquiry or reflection) and looking at negative impacts of our well-intentioned efforts to curb tobacco use. While the loss of potential smoking peers has been examined, I could not find any research that examines the loss of contemplative time and its impact on smokers who quit. Doing so firstly acknowledges that cigarette use has benefits, which is problematic for many in public health. It also means getting into a zone of complexity whereby we need to consider how something that is so demonstrably toxic to the human body and others around the smoker can have potentially positive effects in other ways.
From a design perspective, how might we apply the lessons from cigarette use to mental health promotion? How might we design programs, spaces, places, and social conventions that promote the quiet contemplative acts that smokers gain from taking that cigarette break and offer potentially great value to tobacco users without creating harmful effects for others? How can we promote the quitting of smoking without the loss of the contemplative benefits that come with the act of lighting up?
Engaging design, complexity and imagining the systems that influence them both might yield considerable insight into how we manage other public health problems and how we might better promote mental health in the protection of physical well-being.
Social innovation is often about engaging complicated systems like technology (dry) with complex systems like humans (wet). The implementation and evaluation approaches we take must match wet with dry and knowing when we are dealing with each.
If you’ve ever fixed any kind of machinery, you know that a device that’s exposed to the elements is incredibly difficult to maintain. A washing machine or the underside of a car gets grungy, fast.
On the other hand, the dryest, cleanest environment of all is the digital one. Code stays code. If it works today, it’s probably going to work tomorrow.
The wettest, weirdest environment is human interaction. Whatever we build gets misunderstood, corroded and chronic, and it happens quickly and in unpredictable ways. That’s one reason why the web is so fascinating–it’s a collision between the analytic world of code and wet world of people.
Much of social innovation is becoming like this: a collision between the wet world of people and the dry world of technology. It is hard not to be impressed at the technological capabilities we have at our disposal and how they can be put to use to serve humankind. Mobile handsets, low-cost portable computing tablets, social network platforms like Facebook or LinkedIn, or digital common spaces created by tools like Reddit and Twitter all provide incredible means to connect people and ideas together. Stop and think about what we have at our disposal and it is truly mindblowing, particularly when you think how much that’s changed in just 5 years, 10 years or 20 years.
Yet, the enormity of the scale of these tools and their ubiquity can mask their significance and not always for good. Take Facebook, which just launched its IPO and is the current champion of social networks with over 900 million users. It’s easy to forget that Facebook didn’t even exist 8 years ago and now almost one in 7 citizens on this earth have an account with its service.
This could be a tremendous opportunity for social innovation. Yet, it also speaks to the issue of Seth Godin’s wet and dry analogies for design.
Tom Chatfield, a tech writer from the UK, recently blogged about rethinking our social networks. He points to Dunbar’s number, a well-researched figure that estimates the limits to meaningful human relationships to be between 100 and 230. The drive to scale technologies (the dry) to ever-expanding and increasing numbers is problematic if the limits to my ability to meaningfully connect with the networks they create (the wet) are relatively fixed or difficult to change.
It’s dangerously easy simply to gawp and grimace at the sheer scale of the networks connecting us. The numbers are staggering, and offer a powerful index of how much and how fast our world is changing. But we mustn’t overlook the great lesson to be drawn from work like Dunbar’s: the weight of a special few will always outweigh the many, no matter how great the “many” becomes.
Some have argued that Dunbar’s number is a fallacy in the social media world, choosing to rely more heavily on sociologist Mark Granovetter’s work often summed up as the argument for The Strength of Weak Ties . His early research (see link [pdf] for original paper) focused not on the strong ties between people who were close, but the ‘friends of friends’ effects on transmission of information, which is the space where many innovations and novelty comes from in a network.
This confuses the potential innovation and the human capability to connect across large, diverse networks (a technical, ‘dry’ issue) with the quality of the interaction (a relational, ‘wet’ one). Both exist and both will exist, but there is a difference between learning something new and taking it to scale.
Novelty of information and new ideas comes from the intersection created by cognitive diversity in the design process. This is why designers seek to bring people with different perspectives together to explore concepts and generate ‘wild ideas’ as part of an ideation phase. Lots of information can be very useful in this situation and allow designers (social and otherwise) to see things they might miss if they stuck with a narrow band of perspectives. Yet, bringing these ideas to focus, refining them and transforming them into a social innovation that matters to people is far more relational than we give credit for.
Facebook might be great at linking us to ‘friends’ we’ve lost track of, but in applying a model where all of these friends are treated more or less equally, along with all of the information streamed at us through the main feed, our ‘wet’ interactions are made to feel ‘dry’. Drawing the motivation to scale ideas and engage in the efforts needed to make real change happen from such an approach is unlikely.
A recent post from FastCoExist, part of the Fast Company network of sites, by Ashoka changemakers Alexa Kay and Jon Camfield pointed to the barriers and facilitators for making change happen. Among their principal barriers is the need to connect deeper, rather than broader with each other:
How do we learn to be change makers? Much of the art of change making involves soft skills that we absorb from others that model or demonstrate change making behaviors. This means that learning opportunities are limited by one-to-one interactions and by exposure to other change makers. Compared to traditional fields like entrepreneurship, where there are plentiful resources for training, the practice of change making is still far from being widespread.
One of their principles for change reflects the complexity of social change by encouraging and supporting self-organized networks:
Often leaders or institutions promote dependency with a community. But successful change making communities depend on reducing dependence on one anointed leader. Flat networks and peer-based accountability structures are necessary if a community is to sustain change beyond one individual. The need for change communities and networks to be self-regulating is vital for their sustainability.
This is where walled gardens like Facebook are likely to fall down, just as many custom Ning-based communities have fallen into disuse. Create systems that are too bounded (dry) and we risk sucking the moisture from the human elements (the wet) that make real social innovation happen. Our challenge is finding the right balance between the controlled, stable environments that these new technologies afford and the self-organized, emergent and innovative environments needed to implement and scale our initiatives more effectively.
Wet Leaf By Faustas L, via Wikimedia Commons used under Creative Commons License
John Wenger has written on the issue of leadership and systems thinking asking some pointed questions about how leaders can prop up a dysfunctional system inadvertently and how they can also actively serve as agents of change within it. This is the sort of discussions that more leadership training programs and systems thinkers in general could benefit to make the intangible nature of systems real.
Business leaders: when I use the word “culture”, do you screw up your face and say “Love and peace, man”? I’m no aging hippie; in any case, I was born 10 years too late to be part of that movement. Business culture is no wiffly-waffly discretionary add-on. It’s central to effectiveness and business improvement. I do admit a fondness for better communication, greater self-awareness, lots more empathy and way less fear in the workplace (man), but this comes out of a firmly held view that there is huge scope for workplaces to be more humanised, which will have a huge impact on effectiveness. I also have a firmly held view that a real leader is one who seeks to steward the business culture; not find things to measure so they can prove how useless people are. My thinking about “culture” comes out of the intellectual rigour that is Systems Thinking.
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Innovation is at once everywhere and elusive. Understanding what it really is, how to inspire it, and how to avoid losing its real value in the hype might be the biggest and most ironic challenge for innovators yet.
Psychologist, creativity researcher and systems thinker Keith Sawyer recently asked the question: Is innovation just a washed up trend? To support this thesis, he presents the following:
Evidence: The Wall Street Journal (Wednesday May 23, 2012) argues that the term “innovation” is now so widely used, it doesn’t really mean anything anymore–other than a very general notion of “change.” Longtime WSJ reporter Leslie Kwoh says “Businesses throw around the term to show they’re on the cutting edge….But that doesn’t mean the companies are actually doing any innovating.” And then she gives the biggest insult you can give to a trendy business term, in my opinion: she compares the word “innovation” to the washed-up buzzword “synergy.” Ouch, that hurts!
This makes a point. It’s hard not to question the term seeing that it’s almost everywhere. Earlier in the blog he points to how Bruce Nussbaum eventually added an entire section to Business Week on Innovation and Design to match the demand for news on both of those topics. But as Nussbaum himself has written about the term design thinking, the term innovation may also be on shaking ground from over or poor use. Ironically, this all comes at the time when we need what innovation stands for more than ever and the creative problem framing and solving tools that comes with design thinking.
What’s in a name?
The term innovation is generally described as the act of introducing something to new to create positive value. Design is the act of creating something with intent to produce value. It is no surprise that these two concepts go together so well. Design thinking is about applying conscious thought to the act of creating things those products, services, and policies that have value — it is about contemplation and action related to making things that we want and need. These are loose amalgams of definitions that I’ve come across in my research and reading over the past year in support of the Design Thinking Foundations project and capture much of what these words mean explicitly.
However, implicit in this language is a whole other set of values, prejudices and attitudes that extend the concepts beyond the explicit language into something cultural. One of the byproducts of this is found in overuse or adherence to the hype cycle. Now everything is innovative, when really it shouldn’t be. Sometimes what we are doing is working just fine and the need to create something new is unnecessary.
Yet, as change accelerates in many fields and complexity increases, the need to adapt and develop resilience will increase along with it as will the need to innovate in spaces where innovation is not a familiar term. It may not be needed everywhere, but it will be needed in more places more often with increasing urgency as the dynamic complexity of the worlds we’ve created increases. Even keeping things constant will require some adaptation.
To quote from Guiseppe di Lampedusa’s book, The Leopard: ”If we want things to stay as they are, things will have to change.”
What happens next?
But what if Keith Sawyer’s speculation is right and the term innovation is on the way out? What happens next? In response to his concerns about design thinking becoming a shadow of itself in the hands of organizations and practitioners who see it as a quick fix or a blunt instrument, Bruce Nussbaum has sought to explore and further develop a concept called creative intelligence. Having spoken to Nussbaum personally about this, I got the sense that his concerns were less that design thinking itself was problematic, but that the concept had reached a stasis in its application that no longer reflected the dynamic force it once did when he first championed it at Business Week.
It’s hard not to see parallels to innovation. While I agree with Nussbaum’s charge at what design thinking has become, I also don’t think it’s a lost concept (see the debate on the Design Thinking LinkedIn group to see evidence of this). I also think creative intelligence focuses on something different, not replaces design thinking. (Besides, we still have systems thinking, critical thinking and other forms of problem conceptualizing that have endured much debate). The problem is that it is far easier to talk about something than do it and talking too much can burn something out to the ears. Hence the reason catch-phrases never last long. Innovation is at risk and so, too, is design thinking.
Is this adaptive language use or a case of throwing the baby out with the proverbial bathwater?
If not innovation (and design thinking), then what?
The concern with throwing these terms out is that much of what passes for judgement on their worth is based on little evidence of effect. While innovation thankfully has enjoyed much research, design thinking lacks much empirical examples. However, in both cases, when the terms are most often written about or discussed in the media and popular social discourse it is rarely about evidence and nearly always on rhetoric. I am guilty of this, too. I often tweet or refer people to articles from blogs like Fast Company and FastCo Design that write heavily on design and innovation, yet present few empirical studies and lots of opinion.
To this, I point to today’s HBR Working Knowledge update from five scholars who have done much research on innovation and summarize their points quite well, including the idea that not all of us can or will be innovators (from Clayton Christensen).
What is the answer? Is it time to move on or shall we try to invigorate the discussion of concepts like innovation and design thinking with dialogue, evidence and (self-referentially) some innovation and design thinking to advance not only the discourse on these topics, but also their adoption, study and adaptation to help us tackle the complex, wicked and pervasive problems that seem to be growing in our world each day.
Social media is finally catching on with healthcare, public health, and health promotion. With a few recent articles published in the academic literature to rest on, academic health sciences has finally (and I might argue, begrudgingly) conceded that 900+ million users and $100B valuations (Facebook), and thousands of messages exchanged every milisecond (microblogs like Twitter and Sina Wiebo) might have some value for the public beyond entertainment.
If you note how long it took the health sector to start using the telephone as a serious means of engaging their patients or the public, this is lightning-quick adoption. Still, the barriers to adoption are high and the approach to using the technology is scattered. Indeed, just like the start of Internet-delivered telehealth (or cybermedicine (PDF), which has now evolved into eHealth), there is a mad rush to get liked, followed or some other metrics that most health professionals barely understand.
And that is part of the problem.
Meaningful Social Media Metrics
What is a meaningful metric for social media and health? A recently published article in Health Promotion Practice suggested four metrics that are taken from social marketing and applied to social media. These Key Performance Indicators (KPI’s) are:
- Insights (consumer feedback)
- Exposure (media impressions, visits, views, etc..)
- Reach (# people who connect to the social media application)
- Engagement (level of interaction with the content)
These are reasonable, but to to the uninitiated I would suggest a few words of caution and commentary to this list.
Firstly, the insights suggested by Neiger and colleagues “can be derived from practices such as sentiment analysis or data mining that uses algorithms to extract consumer attitudes and other perspectives on a particular topic” (p.162). While not incorrect, this makes the job sound relatively simple and it is not. Qualitative analysis + quantitative metrics such as those derived from data mining are key. Context counts immeasurably in social media use. It’s only in situations where social media is used as a broadcasting tool that gross measures of likes and sentiment analysis work with little qualification.
Even that is problematic. Counts of ‘likes’, ‘visits’, ‘follows’ and such are highly problematic and can be easily gamed. I am ‘followed’ on Twitter by people who have tens of thousands of followers, yet virtually no presence online. Most often they are from marketing fields where the standard practice is to always follow back those who follow you. Do this enough and pretty quickly you, too can have 23,000 followers and follow 20,000 more. This is meaningless from the perspective of developing relationships.
Engagement is the most meaningful of these metrics and the hardest to fully apply. This category gets us to consider the difference between “OMG! AWESOME!” and “That last post made me think of this situation [described here] and I suggest you read [reference] here for more” as comments. Without understanding the context in which these are made within the post, between posts (temporally and sequentially), and in relation to a larger social and informational context, simple text analysis won’t do.
Social Media Evidence: Problems and More Problems
One of the objections to the use of social media by some is that it is not evidence-based. To that extent I would largely agree that this is the case, but then we’ve been jumping out of airplanes with parachutes despite any randomized controlled trial to prove their worth.
Another article in Health Promotion Practice in 2011 highlights potential applications for social media and behaviour change without drawing on specific examples from the literature, but rather on theoretical and rhetorical arguments. An article published in the latest issue of Perspectives on Psychological Science highlights the current state of research on Facebook, which is timely given that its IPO is set for today. That review by Wilson and colleagues illustrates the largely descriptive nature of the field and offers some insight on to the motivation of Facebook users and their online activities, but rather little in what Facebook does to promote active change in individuals and communities when they leave the platform.
The answer to whether social media like platforms such as Facebook ‘work’ as methods of promoting change is simply: we don’t know.
Does social media provide support to people? Yes. Does it inform them? Yes to that too. Does that information produce something other than passive activity on the topic? We don’t know.
In order to answer these questions, health sciences professionals, evaluators, and tech developers need to consider not just followership, but leadership. In this respect, it means creating changes to the way we gather evidence, the tools and methods we use to analyse data, and the organizational structures necessary to support the kind of real-time, rapid cycle evaluation and developmental design work necessary to make programs and evidence relevant to a changing context.
As Facebook launches into its new role as a public company it is almost assured to be introducing new innovations at a rapid pace to ensure that investor expectations (which are enormous) are met. This means that today’s Facebook will not be next month’s. Having funding mechanisms, review and approval mechanisms, a staff trained and oriented to rapid response research, and an overall organizational support system for innovation is the key.
Right now, we are a long way from that. Hospitals are very large, risk averse organizations; public health units are not much different. They both operate in a command-and-control environment suited for complicated, not complex informational and social environments. Social media is largely within the latter.
Systems thinking, design thinking, developmental evaluation, creativity, networks and innovation: these are the keywords for health in the coming years. They are as author Eric Topol calls the dawning of the creative destruction of medicine.
The public is already using social media for health and now the time has come for health (care, promotion and protection) systems to get on board and make the changes necessary to join them.
Over the last two weeks social science researchers across Canada began receiving the decisions from last autumn’s competition for a Social Science and Humanities Research Council (SSHRC) funding award. SSHRC is the principal funder of social science research in Canada, although notably is not in the business of funding heath-related research, which is supposed to be funded by the Canadian Institutes for Health Research (CIHR). [Full disclosure: I currently hold grants from both of these organizations]. The problem is that CIHR was born from a policy and programming body and the former Medical Research Council and has a rather awkward relationship with social science research given its medical focus. It has funded some social science programs, but not in a manner that has enabled social scientists to comfortably explore the range of issues that they might have under traditional SSHRC funding programs, particularly when social issues are not always obviously health issues (e.g., poverty, education) and can easily be dismissed as not being relevant in spite of the evidence that they are. Yet, SSHRC has decided to forgo any funding of health-related projects due in part to the absence of funding to support it when there are presumably options through CIHR or the disease-specific health charities like the Canadian Cancer Society, the Lung Association and others.
Yet, these options are not suitable. In a manifesto entitled “The end of medical anthropology in Canada” a group of leading social scientists painted the picture of the situation in grim terms in University Affairs. Although medical anthropology is the focus of the piece, the authors might as well be speaking for social sciences in general:
Health is inherently social and cultural. SSHRC has always understood this; CIHR, we fear, does not. We face the possible extermination of one of the most vibrant, high-demand and policy-relevant health disciplines, the only scholarly field that places culture at the centre of the analysis of health and that characteristically does so in both national and international contexts. In a multicultural, settler society with a substantial aboriginal population, and in a world where health is at the core of developmental, political and social issues in so many countries, where Canada otherwise wishes to have an impact, does this make any sense?
This brings me back to the beginning of this post and the announcement of the results of the last competition. Looking at the funding numbers released by SSHRC, a discouraging picture emerges. In 2011-12, 37 per cent of all applications in the open competition were deemed fundable, yet only 22.5 per cent were funded. These numbers are similar t0 2010-11, when 36 per cent were deemed fundable and 22 per cent were funded. What is not mentioned in these numbers was the level at which these grants were funded in the first place. I am a 2010-11 recipient of funding from SSHRC — meaning my grant proposal was within the top 22 per cent of all applications for that year — and the amount I received was approximately half of what I requested. That means that I had to take half of my budget and throw it away. So yes, I was successful providing I did either half of the research or found money elsewhere. I did the latter and my pocketbook is none the better for it.
Consider the implications of this change in funding. With one in five projects funded and many of those that are funded at levels well below what was requested the motivation for researchers is one of the first casualties. Researchers know that funding is tight and that it is highly competitive, but few alternative sources for research grants that lay outside of specific disease-focused areas, social scientists young and old are faced with little option. This creates another set of affected parties: students and trainees. Research funding not only supports the scientists themselves in many cases (see my previous posts on this), but those seeking to become scientists themselves or those who seek to get better acquainted with research. In health sciences and policy, this means just about everyone enrolled in such programs.
Now consider all of this in light of a trend towards increasing graduate education numbers. At the academic institution I am affiliated with (like many of its peers), the enrolment numbers are set to nearly double across many of the professional programs associated with health practice and policy in the coming years. Increased demand for training opportunities from the public has created a means for universities to cash in. Of course, what these students will do when they get there is unclear (let alone when they graduate), but it cannot be much in the way of research — at least as it pertains to social science and health. The funding is simply not there to support the kind of broad-based inquiry into the social factors that influence health, illness and well-being anymore. We have, as I call it, reached ‘the Turn’.
The Turn is that point where the system changes irrevocably towards a new direction. It is like a ‘tipping point‘. Dwindling numbers of social scientists working from funding from an institutional budget (e.g., tenure-stream faculty positions) + a doubling of the student cohort * half of the research dollars makes for rather toxic math. The Turn will fundamentally shape the way social science inquiry is done and the kind of questions that get asked. As question foci change, the quality of the research shifts, and the depth of inquiry is reduced, so too will the real impact that social science has on our health.
The gap between what we know, what we do, and what we can do to prevent illness, treat sickness, and promote well-being will grow.
Anecdotally speaking, this trend is not unique to the social sciences, but it is amplified in this domain. Social sciences in Canada and abroad are consistently funded at lower levels than that of basic research (see here for a starting point). But what is interesting is that many of the problems that we face within health require social science knowledge and research to address and social science — from knowledge translation, social network studies, technology adoption, innovation, management, to policy implementation and beyond .
Prevention of disease and chronic illness is often a social phenomenon (e.g., hand washing). Even the act of taking the best of basic science and translating it into practice or policy options (or other scientific research) is a social act that draws on social science research to execute. Social determinants of health are social in nature and require social science to understand their impact. Designing the policy and programmatic interventions that support creating a healthier society also falls to social science research and practice.
What will our health landscape look like without the ability to take what we know and translate it into action? Worse yet, what if we simply are unable to even know what to do because the research and evidence isn’t there in the first place to translate into anything? Without another turn towards something more positive in our research support, we are about to find out.
* Photo Turn the Page by Miaboas used under Creative Commons License from Deviant Art.