Tag: health communication

complexityinnovationsocial innovation

The Ecology of Innovation: Part 2 – Language

Idea Factories or ecologies of innovation?

Idea Factories or ecologies of innovation?

Although Innovation is about producing value through doing something new or different than before, the concept is far from simple when applied in practice by individuals and institutions. This second in a series of articles on innovation ecology looks at the way we speak of innovation and how what we talk about new ideas and discovery shapes what we do about it. 

“Language can be a way of hiding your thoughts and preventing communication” – Abraham Maslow

Innovation is one of the few concepts that offers little benefit contemplated in the abstract. We innovate on specific things with an eye to application, maybe even scaling that idea broadly. Humans innovate because the status quo is no longer satisfying, is unacceptable or has changed so we strive to come up with new ways of doing things, novel processes and tools to make the current situation a preferred one.

Thus, we are designers seeking our client, customer and creation through innovation and we do this through our words and actions — our language. Indeed, if one agrees with Marty Neumeier‘s assertion that design is the discipline of innovation and Greg Van Alystne & Bob Logan’s definition of design as “creation for reproduction” then our language of innovation is critical to ensuring that we design products and services that have the potential to reproduce beyond an idea.

Language matters in innovation.

To illustrate, lets look at how language manifests itself in the communication of ideas using an example from public health. In a paper entitled Knowledge integration: Conceptualizing communications in cancer control systems I co-authored with my colleagues Allan Best and Bob Hiatt, we looked at the way language was used within a deep and broad field like cancer control in shaping communications. This was not merely an academic exercise, but served to illustrate the values, practices and structures that are put in place to support communicating concepts and serves to illustrate how innovations are communicated.

Innovation as product

What we found was that there are three generations of cancer communications defined by their language and the practices and policies that are manifested in or representative of that language. The first generation of terms were traced up to the 1990’s and were characterized by viewing knowledge as a product. Indeed, the term knowledge products can be traced back to this period. Other key characteristics of this period include:

  • The terminology used to describe communications included the terms diffusion, dissemination, knowledge transfer, and knowledge uptake.
  • Focus on the handoff between knowledge ‘producers’ and knowledge (or research) ‘users’. These two groups were distinct and separate from one another
  • The degree of use is a function of effective packaging and presentation presuming the content is of high quality.

The language of this first generation makes the assumption that the ideas are independent of the context in which they are to be used or where they were generated. The communication represented in this generation of models relies on expertise and recognition of this. But what happens when expertise is not recognized? Or where expertise isn’t even possible? This is a situation we are increasingly seeing as we face new, complex challenges that require mass collaboration and innovation, something the Drucker Forum suggests represents the end of expertise.

Innovation as a contextual process

From the early and mid-1990’s through to the present we’ve seen a major shift from viewing knowledge or innovation as a product to that of a dynamic process where expertise resides in multiple places and sources and networks are valued as much as institutions or individuals. Some of the characteristics of this generation are:

  • Knowledge and good ideas come from multiple sources, not just recognized experts or leaders
  • Social relationships media what is generated and how it is communicated (and to whom)
  • Innovation is highly context-dependent
  • The degree of use of ideas or knowledge is a function of having strong, effective relationships and processes.

What happens when the context is changing consistently? What happens when the networks are dynamic and often unknown?

Systems-embedded innovation

What the paper argues is that we are seeing a shift toward more systems-oriented approaches to communication and that is represented in the term knowledge integration. A systems-oriented model views the design of knowledge structures as an integral to the support of effective innovation by embedding the activities of innovation — learning, discovery, and communication — within systems like institutions, networks, cultures and policies. This model also recognizes the following:

  • Both explicit and implicit knowledge is recognized and must be made visible and woven into policy making and practice decisions
  • Relationships are mediated through a cycle of innovation and must be understood as a system
  • The degree of integration of policies, practices and processes within a system is what determines the degree of use of an idea or innovation.

The language of integration suggests there is some systems-level plan to take the diverse aspects within a set of activities and connect, coordinate and, to some degree, manage to ensure that knowledge is effectively used.

Talking innovation

What makes language such a critical key to understanding innovation ecologies is that the way in which we speak about something is an indication of what we believe about something and how we act. As the quote from psychologist Abraham Maslow suggests above, language can also be used to hide things.

One example of this is in the realm of social innovation, where ideas are meant to be generated through social means for social benefit. This process can be organized many different ways, but it is almost never exclusively top-down, expert-driven. Yet, when we look at the language used to discuss social innovation, we see terms like dissemination regularly used. Examples from research, practice and connecting the two to inform policy all illustrate that the language of one generation continues to be used as new ones dawn.  This is to be expected as the changes in language of one generation never fully supplants that of previous generations — at least not initially. Because of that, we need to be careful about what we say and how we say it to ensure that our intentions are reflected in our practice and our language. Without conscious awareness of what we say and what those words mean there is a risk that our quest to create true innovation ecosystems, ones where innovation is truly systems-embedded and knowledge is integrated we unwittingly create expectations and practices rooted in other models.

If we wish to walk the walk of innovation at a systems level, we need to talk the talk.

Tips and Tricks

Organizational mindfulness is a key quality and practice that embeds reflective practice and sensemaking into the organization. By cultivating practices that regularly check-in and examine the language and actions of an organization in reference to its goals, processes and outcomes. A recent article by Vogus and Sutcliffe (2012) (PDF) provides some guidance on how this can be understood.

Develop your sensemaking capacity by introducing space at regular meetings that bring together actors from different areas within an organization or network to introduce ideas, insights and observations and process what these mean with respect to what’s happened, what is happening and where its taking the group.

Some key references include: 

Best, A., Hiatt, R. A., & Norman, C. D. (2008). Knowledge integration: Conceptualizing communications in cancer control systems. Patient Education and Counseling, 71(3), 319–327. http://doi.org/10.1016/j.pec.2008.02.013

Best, A., Terpstra, J. L., Moor, G., Riley, B., Norman, C. D., & Glasgow, R. E. (2009). Building knowledge integration systems for evidence‐informed decisions. Journal of Health Organization and Management, 23(6), 627–641. http://doi.org/10.1108/14777260911001644

Vogus, T. J., & Sutcliffe, K. M. (2012). Organizational Mindfulness and Mindful Organizing: A Reconciliation and Path Forward. Academy of Management Learning & Education, 11(4), 722–735. http://doi.org/10.5465/amle.2011.0002C

Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (2005). Organizing and the Process of Sensemaking. Organization Science, 16(4), 409–421. http://doi.org/10.1287/orsc.1050.0133

*** If you’re interested in applying these principles to your organization and want assistance in designing a process to support that activity, contact Cense Research + Design.

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Is Knowledge Translation In Health Too Important to Leave to Health Professionals?

Storytelling

Knowledge translation — and its affiliated terms knowledge exchange, knowledge integration and knowledge mobilization — was coined to describe a process of taking what is known into what is done in health across the spectrum of science, practice, policy and  the public’s health. As health issues become more complex due to the intertwining of demographics, technology, science, and cultural transformations the need to better understand evidence and its impact on health has never been higher. Questions remain: has demand met supply? How are the health professions dealing with this equation?

Translating knowledge

The Canadian Institutes of Health Research (CIHR), one of the earliest champions of the concept of knowledge translation in research, define it as:

a dynamic and iterative process that includes synthesisdisseminationexchange and ethically-sound application of knowledge to improve the health of Canadians (sic), provide more effective health services and products and strengthen the health care system.

These ideas are expanded below:

Synthesis – Synthesis, in this context, means the contextualization and integration of research findings of individual research studies within the larger body of knowledge on the topic. A synthesis must be reproducible and transparent in its methods, using quantitative and/or qualitative methods. It could take the form of a systematic review, follow the methods developed by the Cochrane Collaboration, result from a consensus conference or expert panel or synthesize qualitative or quantitative results. Realist syntheses, narrative syntheses, meta-analyses, meta-syntheses and practice guidelines are all forms of synthesis. Resources related to synthesis are available.

Dissemination – Dissemination involves identifying the appropriate audience and tailoring the message and medium to the audience. Dissemination activities can include such things as summaries for / briefings to stakeholders, educational sessions with patients, practitioners and/or policy makers, engaging knowledge users in developing and executing dissemination/implementation plan, tools creation, and media engagement.

Exchange – The exchange of knowledge refers to the interaction between the knowledge user and the researcher, resulting in mutual learning. According to the Canadian Health Services Research Foundation (CHSRF), the definition of knowledge exchange is “collaborative problem-solving between researchers and decision makers that happens through linkage and exchange. Effective knowledge exchange involves interaction between knowledge users and researchers and results in mutual learning through the process of planning, producing, disseminating, and applying existing or new research in decision-making.”

Ethically-sound application of knowledge – Ethically-sound KT activities for improved health are those that are consistent with ethical principles and norms, social values, as well as legal and other regulatory frameworks – while keeping in mind that principles, values and laws can compete among and between each other at any given point in time. The term application is used to refer to the iterative process by which knowledge is put into practice.

In short, knowledge translation is about taking what we learn and know from evidence, sharing that knowledge with others and assisting them to make useful health choices in practice and policy through KT.

This often involves communicating across contexts, disciplines, and roles between and from scientists, clinicians, policy makers and to the public alike. In a health environment that is increasingly becoming complex, the ability to communicate across boundaries is no longer an advantage, it’s an essential skill. While we may not always have the right language, we can translate meaning through stories.

But if stories are to be effective they need to be valued.

The value of storytelling

I’ve seen health professionals — scientists and clinicians — roll their eyes when you mention storytelling in a work context. It is as if the only legitimate role for stories is to communicate with children (which University of Alberta researchers are exploring as a tool for sharing health knowledge with parents). Yet, it is through stories that most people share what they know in every other context; why would it be different in health?

Perhaps it is the connotation that stories are ‘made up’ like children’s bedtime tales, but one need only look to journalism to find that we’ve been making ‘stories’ a central part of our life every day. We listen to drive-time radio for stories about the traffic conditions, we watch, download and listen to news stories filed by professional journalists and citizen bloggers alike on mainstream media, Twitter, YouTube, Facebook along with myriad sources across the web. Last week we were glued to various sources to learn storiessome of them false — and create stories about the events of the Boston Marathon bombings.

Stories are what conveys multiple information threads and puts it in a coherent context.

Stories are coherence engines.

Valuing knowledge translation

If knowledge translation is important then it should be reflected in research priorities and evidence for its impact on the system across different disciplines. Dr Shannon Scott and her U of A team recently conducted a systematic review of knowledge translation strategies in the allied health professions and found that the field was full of low quality studies that made it impossible to make firm statements on which methods were best among them . That team has recently proposed a systematic review looking at how the arts and visual methods can further contribute to KT in practice, although it likely the same issue with methodological quality might come into play here, too.

What she and her team are doing is looking at the process of sharing stories and, from a research perspective, sharing stories appears to not have been worth investing in scientifically. At least, not enough to generate a lot of studies and good evidence.

One could argue that knowledge translation is still new and that it takes time to generate such evidence. That is partly true, but it is also an easy prop for those who want to avoid the messiness that comes with communication (and its problematic research context), learning from others, and creating more equitable information spaces, which is what knowledge translation ultimately does. Knowledge translation has also been in use for almost 20 years so in that time — even with the most dismal assessment of the length of time it takes to put knowledge into practice — we should be seeing some decent research published.

KT is fundamentally about sharing. Journalists’ are rewarded for sharing — the more they share and the more people who they share with (as measured by readers, listeners, viewers etc..) the more successful they are in their work. Teachers are rewarded for sharing because that means that they are teaching people. Librarians are rewarded for sharing because that means people are checking out books and using the resources in their library.

We don’t apply the same standard to academic research, even though we have some crude metrics to measure reach and impact,  and there is roughly no metric for the degree to which clinicians share among themselves. Maybe this needs to change.

I have scientific colleagues who are fierce in the face of their most strident academic critics and have delivered keynotes to auditoriums filled with researchers that are nearly paralyzed in the face of speaking to the public. This is not fear of public speaking, its fear of speaking to the public.

Should they be? I don’t think speaking to the public should be expected to be enjoyable for everyone, but neither are doing statistical calculations, completing ethics applications, or presenting posters at conferences, but we still expect scientists to do that. We still expect nurses, doctors, psychologists, medical technicians and social workers to traverse complex social problems to talk to their patients in an open and honest way.

Why is it when scientists are speaking to policy makers, clinicians to scientists, policy makers to the public, or any professional to another from another discipline, speciality or division we decide its not critical for them to make the effort?

Why don’t we do the research to support it? 

Why is it OK not to do KT because its uncomfortable, awkward, difficult or confusing?

Declining interest, rising demand

It is perhaps for reasons like this that knowledge translation is so poorly understood and taken up as a focus for research. Looking at Google NGram data (which tracks mention of specific topics in books and publications) we see a steady rise in citations until about 2003 followed by a levelling off. Keep in mind that the leveling begins before social media became known. In the years after Twitter, Facebook and YouTube — arguably the most powerful communications media we have for doing knowledge translation widely (but perhaps not deeply) — there is roughly no sharp increase.

Below are the citations for the terms knowledge translation, knowledge exchange, and knowledge integration  from 1996 (when the Web first started gaining wide use beyond academia and the military) and 2008, the latest year for which there is available data. Note that the numbers reflect general mentions as a percentage of overall terms, so they are relative, not absolute values.

Figure 1: Google NGram Data for KT, KE & KI: 1996-2008

Knowledge Translation, Exchange & Integration NGram

Is there so much other stuff to talk about in 2013 that the relative importance of knowledge translation is diminished?

A look at Google Trend data using the same terms finds that not only are these concepts not growing, their mention is actually shrinking.

Looking at the three terms we see that all three concepts have declined over time. During these years — 2004-2013 — we saw not only the birth of social media, but the rise of Internet-enabled handheld devices to allow knowledge to be shared anywhere there is a data signal. We now have apps and nearly all of the Internets resources in our pockets and we are seeing a decline in the use of these terms.

Figure 2: Google Trend Data for KT, KE & KI: 1996-2013

Knowledge Term Trends

Where to?

So to review: We have a body of evidence in KT that is problematic and incomplete at the same time we have a decrease in use of the terms, while at the very same time we have a sharp rise in available tools and technologies to share information quickly and a continued, steady demand for more information to make decisions for health providers, patients, policy makers and insurers.

Yes, the data presented here are not perfect. But does it not make sense that there should at least be some trend upward if knowledge translation is valued? Should we not see some shift to more research, better research evidence, and greater interest given the tools and scope of communications we have through social media?

This begs the question: is knowledge translation in health too important to leave to health professionals? 

In future posts this question will be looked at in greater depth. Stay tuned.

* Blog has been updated since original post

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Social Media For Researchers

Social Media For Researchers

I recently sat down and chatted with Armine Yalnizyan, a journalist and board member of the Canadian Institutes for Health Research (CIHR) Institute of Public and Population Health (IPPH) to chat about social media for the IPPH about how social tools can assist researchers to do their work, share their learnings, and improve knowledge translation to the community .

Armine kindly referred me to a “rock star social media communicator” but I think we all can play some pretty interesting metaphorical music in our use of social media to assist us with engaging the public. Here is the link to that webinar conversation for those of you interested in understanding more about what social media is and how it works to support the goals of health research more broadly.

knowledge translationpublic healthresearchsocial media

Knowledge Translation Lip (Sync) Service

Dancing for a Cure

Researchers and policy makers wring their hands and wrack their brains at ways to get people to take up the knowledge generated through scientific research and use it for social good and further invention. Some, stop doing this and just make it happen and YouTube and the Internet are showing us how.

Designer, strategist and broadcaster Debbie Millman, host of the Design Matters podcast, signs off each episode with a great quote:

We can talk about making a difference, we can make a difference, or we can do both

It seems when talking about knowledge translation, there is a lot of talk about how to do it better and then there are some who just do it better. McGill University and some of the researchers associated with the Goodman Cancer Research Centre have partnered up with filmmakers, volunteers and a medical supply company to ‘dance for cancer’ as a means of promoting their work and raising funds for cancer research. (The company, Medicom, has offered to donate per click so if you’re interested in donating and being entertained, click the link below).

Besides being catchy (Taio Cruz‘s club hit, Dynamite, is the song that these researchers and cast are dancing to) and well-produced, the video unscores the potential that video and some creative use of the arts can offer the scientific community in showing the world what it does and how it does it. The video shows what life is like (in a singing-and-dancing way) in a lab and showcases some of the people who do it, making them real humans rather than some mysterious “scientists off in the lab”.

They are designing a knowledge translation opportunity that (so far) has been viewed nearly 30,000 times as of this writing. I suspect that number will triple in the coming weeks. When some of the best, most cited research articles in the world are read (viewed) by maybe hundreds of people, the attention of thousands in such a short time should give pause.

Further, of the thousands that view the video, it is safe to say that most are non-scientists. For many, but certainly not all, of the studies we do in public and population health, the audience for this video is almost the same as ours — or at least includes many of the same people. Not all studies or research projects will yield the kind of data that are video-worthy or inspire photosharing, but some are. Many more than we acknowledge. And if we want the public engaged in science, if we want to reach practitioners and inspire policy makers and researchers alike to pay attention to the evidence being generated, this video might offer some suggestions for a way forward.

While you think of that, enjoy the choreography and lip sync skill of McGill’s brave super-translators and support a good cause in the process:

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Complexity, Interaction Design and Social Media

Social Media Targeting for Head & Heart

Social media, like all human activities, involves designed interactions in a complex environment. How we design for this space is as much about the social — and the complexity that results from it — as it is the media.

Yesterday I participated in a webinar on social media strategy hosted by the Program Training and Consultation Centre’s Media Network. The focus was on how public health professionals can use social media to engage their populations of interest to advance health promotion. Examples of how social media is being used were presented from ParticipACTION, the U.S. Centers for Disease Control and my own research group’s Youth4Health initiative to show how these tools could enhance health communications.

What might have caught some of attendees by surprise was the introduction of complexity science concepts and design thinking into the discussion. These terms are not often used in public health, but as I’ve argued many times in this space, they ought to play a much larger role.

The other potential surprise for some might have been the emphasis on relationships, connection and the kind of things that Brian Solis showcases (see infographic above). Solis describes social media as:

Social media is a deeply personal ecosystem that I lovingly refer to as the EGOsystem. As such, there is a “me” in social media for a reason. It is quite literally a world in which we are at the center of our online experiences, a place where everything and everyone revolves around us. – Brian Solis

When a person is at the centre of an experience that is human formed and technology mediated, design is very important. How one engages with others and the opportunities afforded within that environment or EGOsystem is largely a product of design. For example, Facebook provides a great deal of opportunity to bring in your close “friends” into a conversation, but is relatively poor at bringing in strangers. In contrast, Twitter is about bringing anyone into the conversation, particularly strangers. As I like to put it:

Twitter enables you to learn answers to questions you never thought to ask, have conversations you could have never planned, and meet people you never knew existed

In both of these contexts, the manner in which one designs for interactions has a profound influence on what kind of conversations take place. To use Solis’ model above, attention to interaction design qualities of the technological and social space helps amplify the white arrows, dampen the effect of the blue arrows, with an aim of enhancing the power of the red arrow (belevolence).

This attention to these kind of patterns is at the heart (no pun intended) of complexity oriented planning and why social media, design and complexity require mutual consideration in developing strategy. When in complex spaces, the tempo, rhythm, and pattern of information exchange shifts constantly, just like in a regular conversation. So approaching the program from the perspective of a traditional, more linear-focused mindset will inevitably lead to a misalignment between program activities and the outcomes produced.

If you’re expecting to get a firm outcome from a social media strategy, you might be disappointed. If you are looking for surprises, consider more flexible outcomes, then social media may deliver the goods — but only if you design your strategy to suit the complexity of the context. A complex setting is one where there are multiple agents interacting and producing emergent new properties through such interaction. It it therefore fitting that the concept of interaction design be considered in examining how we engage in these environments.

Much of the discourse on social media from marketing and communication leaders hints at these concepts, but doesn’t name them. By explicitly making complexity, design and the social part of social media a focus we can more intentionally create better experiences that will engage our audiences, and in the case of public health, promote health.

art & designcomplexitydesign thinkingpublic healthsocial systems

Art / Design / Science / Literacy

Szonyi Istvan: Man Reading (artist's father)

Literacy has many forms and art is one of the ways in which these forms come together and present some of the best opportunities for engaging diversity in complex social systems.

The relationship between art and science has been long noted by those looking at the history of discovery, and the nature of creativity and human innovation. In theory, the idea that two creative ventures that use different methods and media as the vehicle for expression should fit together is natural. But that is where theory and practice diverge sharply.

From my perspective, art and design are not perspectives warmly embraced within the scientific community. There is much suspicion among scientists about the validity, reliability and practical utility of art and design in solving important problems. Aesthetics may be nice for culture, but science tackles serious things.

Yet, one of the more serious matters for science is the concept of literacy. Scientists have been worried about the inability of people to pick up and understand the basics of how science works and its implications for society, prompting this to become an educational priority for some.

Science literacy can be defined as:

PISA (Program for International Student Assessment) 2006 defines science literacy as an individual’s scientific knowledge and use of that knowledge to identify questions, to acquire new knowledge, to explain scientific phenomena, and to draw evidence based conclusions about science-related issues, understanding of the characteristic features of science as a form of human knowledge and enquiry, awareness of how science and technology shape our material, intellectual, and cultural environments, and willingness to engage in science-related issues, and with the ideas of science, as a reflective citizen.

This definition is highly referential to the concept of science, defined by the Oxford English Dictionary as:

science |ˈsīəns|

noun

the intellectual and practical activity encompassing the systematic study of the structure and behavior of the physical and natural world through observation and experiment : the world of science and technology.

• a particular area of this : veterinary science | the agricultural sciences.

• a systematically organized body of knowledge on a particular subject : the science of criminology.

This term is rooted in the Latin scire, which is to know . If one looks at the first definition on its own, independent of the second definition and conjunction with the most popular applications of the term science, there seems to be little room for art and design. Yet, when revisiting the definition of science itself, the idea of the systematic study of the structure and behavior of the physical and natural world through observation and experiment, a door opens up to some new possibilities.

Design is largely about the study of human situations and interacting with people, ideas, and space to create solutions that emerge within those spaces. Unlike science, which has a focus on observation and understanding, design is about taking such understanding and applying it to problem solving. Milton Glaser describes design as intervention into the flow of events and the introduction of intention into human affairs.

Art is a means of expression and for exploring the intangible and making it so. It is for such reasons that art + design go together so much.

Reading the different definitions of literacy and considering what science, design and art do, it seems to me right that we contemplate the ways in which they come together. Art and design are part of the normative scientific lexicon, but perhaps they should. As the human-centred problems that science aims to tackle become more complex, abstract and intangible — climate change, chronic disease, food security, social inclusion/exclusion and mass migration/globalization — the need to visualize the problems in new ways and create (design) solutions based on science becomes imperative.

The only way this will take place is to have greater literacy on how this can be in order to recognize the opportunities that science, design and art present and the ability to transform that into true positive intention into human affairs.

** Image used under Creative Commons Licence from Flickr Pool, by freeparking. http://www.flickr.com/photos/freeparking/2351767932/

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Health Communication in the Age of Pamphlets

Although social media is all around us, there is a tendency to forget that it is still new and, in the case of public health, very new. What would / did our health communications system look like if it was designed for pamphlets instead of apps, door-to-door visits instead of Facebook, and libraries instead of websites?

I was at a meeting today and caught the phrase “health communication in the age of pamphlets” as a frank, but concerning assessment of how much we rely on models of communication that emphasize written text, paper-based materials, professionals handing them out or information racks as the distribution channel, and authority and fear as the driver.

If we designed our communications systems for pamphlets, we might have a system that looks like this:

1. Public health officials (mostly physicians) would tell the public what was good for them, how to act in case of emergencies, and they would be doing it with confidence.

2. That confidence would come from experience and some evidence and both of those would have largely complete information, or at least good enough information.

3. Messages would be crafted using mostly text in language (almost exclusively English, except maybe French in some cases here in Canada) that was authoritative and technical.

4. Information could be easily found in doctors offices and some public libraries (you wouldn’t want to put too much information in the library because there are no health professionals there).

5. The conditions that caused illness were straightforward, could be diagnosed and treated and that the reasons people got sick in the first place was that they were largely not taking care of themselves.

It seems to me that this system isn’t that different than what we have now.

The only difference is that people have options and that is what they are seeking. They are also seeking relationships,
…are recognizing that illness is caused by social as well as other determinants,
…that their peers and lay helpers have a lot to offer,
…that professionals’ knowledge is limited, but that they are still very important for specific things,
…that they would rather be in partnership with health professionals than not
…there are limits to what we know and that being an informed consumer is an important skill in the world these days
… that there are as many questions as answers.

Information technology, networks, and a newfound sense of empowerment is changing a lot and maybe soon it will change public health communications.