Tag: health communications

psychologypublic healthresearch

Designing for Empathy and Health

Transparent Contemplation

Seeing Inside Others

When does common sense make little sense? How do we sense-make evidence when it seems to make little sense? The answers could lie in getting inside the heads of those we seek to influence and designing our communications for empathy and health.

Evidence in public / health

Last week there was a brief uproar in the mainstream media and on Twitter created by a tweet from Toronto Public Health to their Twitter followers suggesting they contact the producers of the TV show The View and protest their recent hiring of Jenny McCarthy a a co-host. Ms McCarthy is an outspoken critic of childhood vaccinations in spite of overwhelming evidence to show that they generate enormous benefits over the relative and small risk for many conditions and for promoting the falsified science used to prop up the myths that they cause autism (which is her primary concern).

That post led to much discussion, including posts on Censemaking and the Public Health and Social Media blog (reposted here) and Twitter on the challenges of communicating evidence, engaging the public, and the role of public health in these conversations. Watching comedy duo Penn & Teller offer a humourous if angry take on evidence for vaccinations and health might make the risks and benefits obvious, yet this isn’t the case. Why?

It turns out, that some of these supposed obvious connections still don’t impact those who support the anti-vaccination movement. Indeed, evidence from Australian researchers shows that engaging these audiences does relatively little to influence their behaviour. To some, they may be immune to the evidence (pardon the pun).

In a qualitative study of parents on their pro and anti-vaccination beliefs, the authors found a complex mix of beliefs that governed how information was received and processed. For example, expectations of guilt at the thought that a child would fall ill because of something that could have been prevented due to a vaccine or conversely due to a vaccine side-effect were prominent in the findings.

What arose in the dialogue arising from the Jenny McCarthy / Toronto Public Health flurry was familiar territory: health professionals using the moment to logically persuade the public to choose vaccination, hand-wringing over why people fail to believe evidence or why they believe celebrities, the awful use or mis-use of evidence in the media, and gasps of collective frustration at how out of sync public health is in its engagement with the public on these issues.

What was missing was empathy.

Stories trump evidence

The above quote has been uttered many times in public health circles when the use of evidence in health communication emerges in conversation. Journalists know this and that is why they tell stories in their reportage and not “just the facts”. All one needs is a story about the human experience on one side of an argument and all the evidence to suggest it is an anomaly or rare event gets covered over. It’s why we bristle at news stories of violent crimes  and fear for our safety despite wildly declining crime rates throughout countries in the ‘developed’ world.

A Problem of Perspective

Public health professionals — indeed all of us in any field — need to get out more. It’s easy to scoff at the ignorance of people when you have an advanced degree, spend great amounts of time contemplating or generating evidence, see the health effects of faulty reasoning firsthand, and associate with many others who share the same view. It’s obvious what the right course of action is.

But obvious is a matter of perspective. Health professionals tend to design their materials for themselves. Looking at much of what is developed for health promotion and communication with the public, we might make some assumptions:

  1. People are able to read and understand health related materials (and they like to read in the first place)
  2. They like printed materials and learn best from text
  3. They trust scientists, physicians and health professionals for information on health issues above all
  4. Health is something they think about a lot and always want to learn more about issues
  5. The public is invested in carefully weighing evidence claims to make the right choice
  6. Health behaviour change is a linear, knowledge-driven process

There are more, but let’s examine these briefly. I am not going to dive deeply into the evidence for each of these points (that is for another day) rather ask you to consider how true these are in your observations.

I Want to Believe

These are all assumptions and mostly based on a rational, linear model of decision making and behaviour. They are based on a model that correlates knowledge, expertise and authority and assumes that people respond to such authority. It emphasizes the use of media that is appropriate (and historically priviliged) for academic and technical communications, not public consumption.

On that last point, many educated professionals — particularly academics — are shocked to find people that neither need or want to read. Yet, we propel print materials and websites at people in text form to audiences that we imagine value the same things.

When you study health for a living or treat people with health problems you spend your entire day thinking about health. It may come as a surprise to realize that many others don’t really care much about their health until it’s compromised. They aren’t constantly mired in decisions about evidence, long-term implications of daily decisions, or the social determinants of their wellbeing. Health is just another thing to think about among many.

If we are to be better at communicating with our audiences, we need to empathize more and design our messages, media and services in ways that reflect the reality they perceive and the one they live in knowing that might not be the same thing and nor is it necessarily the same one we live in and perceive.

It also means confronting some big questions about what we are doing in the first place.

What is the destination and the journey we wish to take with the public? Do they want to take it with us in the first place? And if not, what might we do to inspire people to want what we have to offer — and do so in a manner that promotes what they want to accomplish, not just what we want them to.

This avoids us taking the approach to dealing with people who don’t speak our language by talking slower and louder as if they are deaf and stupid rather than unfamiliar with our native tongue.

This is the realm of design and empathic design thinking about communications and perhaps its time to start bringing more of it into our work. Maybe then we might not be so surprised when the obvious answers are no longer so.

Photos: Cameron Norman, Joe Ross (used under Creative Commons License via Flickr)

public healthsocial media

Attack on Anti-vac – Toronto Public Health vs. Jenny McCarthy

Yesterday I posted on the story of Toronto Public Health tweeting a call for its followers to voice concerns to the TV show “The View” about the recent hiring of Jenny McCarthy, a prominent anti-vaccination advocate, as its new co-host. Today, Nicole Ghanie-Opondo reflects more deeply on what kind of impact such tweeting really has and the role of public health in voicing its concerns from that of an insider. What should we expect from these Tweets? What really drives change? Why is there resistance to engaging the public and how can we professionally do so in the complicated, messy work that comes with social media engagement? Huge questions to ask and the fact that people like Nicole and her blog collaborator Corey are doing it speaks to how much change potential we can expect. One of the best blog reads you’ll find on this topic.

Public Health and Social Media

I wanted to keep quiet on this issue, being the pioneer and former voice of Toronto Public Health’s Twitter for 3 years…but I think in the spirit of reflection – let’s blog on!

Cameron Norman explains the issue really well in his post ‘Public Health and Social Media: Catching Fire from Small Sparks. Here’s another opinion via Jim Garrow on why governments should have an opinion, as junk scientists do. To sum it up, Toronto Public Health tweeted at Jenny McCarthy regarding her anti-vaccine views and requested The View to change their mind about having her as a host.

2013-07-24 08.17.32 pm

My biased opinion.

I love my public health peeps and especially adored the pioneering and willing spirit Toronto Public Health had in the early days of its foray into social media. Like family, bureaucracy and public health practioners come with their own baggage. One large piece of baggage around public health messaging…

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public healthsocial mediasystems thinking

The Importance of Journalism to Public Health: 10 Years After SARS How Are We Doing?


Risk communication in public health with Julie Leask

If a health scare manifested itself in the world and there were no journalists to cover the story, what would the impact on the public be?

That is a question that lingered with me throughout the start of the 2013 Ontario Public Health Convention (TOPHC) which began with a morning dedicated to improving public health communication. Opening up the conference was a series of linked keynote presentations from a risk communications researcher (Julie Leask); a former newspaper editor, journalism professor and social media advocate (Wayne MacPhail), and one of Canada’s leading health specialist reporters (Helen Branswell).

The Academic’s Perspective

Keynote speaker Julie Leask (pictured above) and her colleague Dr. Claire Hooker (a good friend of mine) have been looking at the ways journalists engage in risk communication with the public on matters of public health from immunization to SARS to understanding the health priorities of professionals. In 2010 they published a paper looking at how the media covers health topics and argued that the health professions need to be aware of how stories are made, communicated and to be an active partner with reporters if they are to have positive impact in moments of health scares.

“It’s too late when the crisis comes up” – Julie Leask speaking on the need for public health to get engaged with the public using social media

In a previous post I wrote about how journalism is the fourth estate of medicine and public health. Journalists are the storytellers that the public listen to and are charged with looking at a problem from many perspectives to develop that coherent narrative that speaks to their audience. These are qualities that most scientists and public health professionals don’t bring to their jobs, nor are they always expected to or even should. As such, journalists play an important role for this very reason.

Nonetheless, the health sector has an uneasy relationship with journalism. Health professionals – particularly researchers — poorly understand the world of journalists and sometimes view the profession with suspicion. Julie Leask and her colleagues have found this to be the case, but argue that it is no reason to shy away from engaging the public using the tools that are comfortable to journalists. She spoke to the invaluable role of specialist health journalists in acting not only as producers of high quality health content in the news, but also guardians against low quality content making into press. In speaking to her research, she pointed out that specialist health journalists help educate their peers and editors on health issues, which are often complex and require more than a passing understanding of context to communicate well, as key gatekeepers for quality in the health landscape.

The Editor’s Perspective

To this end, Wayne MacPhail, a former editor of the Hamilton Spectator,  argued that public health has a near ethical imperative (my choice of term) to be in the social media space to not only promote good health, but counter and challenge myths and misinformation. This isn’t some naive pronouncement that we’ll eliminate the snake oil sales or quackery that proliferates in the public sphere and media, but rather a simple observation that we have no chance of making impact if we are not even engaged in the space at all.

Like Leask, MacPhail says that it’s too late to engage the public when a health crisis comes up and that public health needs to be in the conversation stream before that happens.

The Reporter’s Perspective


Reporting through SARS to today: Helen Branswell

Helen Branswell, a reporter from The Canadian Press, rounded out the panel and spoke frankly about the dwindling resources and rapidly changing landscape in journalism. She was on the front lines of reporting the 2003 SARS outbreak and showed a picture taken during that time of an empty newsroom and remarked how that the scene is the same now only for different reasons (limited budgets due to decreased ad revenue and the related shift to digital information on the web being two such reasons, among others).

Branswell paints a bleak picture of the present and future in many areas of health journalism. Stories are increasingly being covered by general reporters who may treat the story the same as they would a traffic incident, political story, or crime; journalists who are unlikely to know the context and details that are critical to communicating the nuances present in health matters. Interns are replacing some full time or veteran reporters in the newsroom and there are only a handful of specialists in practice.

Pressures from time, budget and competing interests in the newsroom are all contributing to an environment where quality health reporting is threatened.

What Next?

I asked the panel what they thought public health should do to ensure that the healthy stories are reported well and there was little answers. Helen Branswell said, truthfully and somewhat cheekily: “buy newspapers”. She reminded us that we should be paying for the quality content and supporting good journalism in practice if we want it to survive, which is hard to argue against.

But that alone will not do all the work needed to preserve good journalism. I spoke to another conference attendee, a formally trained journalist who is now working with a research firm, about the ways in which journalists have helped other organizations craft their messages and engaging the public citing the Calgary Police Service’s social media team as an example. This pointed to ways in which journalists can make a difference in matters of public health and social services.

Yet, what about investigative journalism? What about the potential conflicts that come from being paid to report on issues that might be critical of the organization who does the paying (e.g., Ministries of Health, Departments of Public Health, Universities and colleges etc..)? This model doesn’t solve that, but it is at least another option.

Yet, the examples from public health taking this challenge of working with journalists up are few. Many still believe that social media is another means of broadcasting, which misses the mark. Others still view social media, journalism, engaging with the public through the media, with suspicion on the grounds that much of the work out there is not evidence based.

But what evidence did we have when SARS hit us 10 years ago? We had lots of epidemiological data on infectious disease, but that was only part of the story. Many of the leading health scientists were adapting their models, creating new ones and only after the disease left did we really have a full sense of what happened. We learned as we went.

This is what social media is all about, too. The lessons from major health events — disasters, outbreaks, and pandemics — parallel social media. It is innovation space at its clearest and thus there is an imperative to view it as innovation space with the tools and lenses that best support movement within complex adaptive system. From a communications standpoint, social media and the tools of modern journalism (and the style of communication they employ) are one thing to consider. Developmental design and evaluation are also among these tools combined with systems thinking.

Linear thinking and action will not work in a complex system and as this panel pointed out, there is much reason to be concerned if we are not prepared to communicate and support those that communicate well in such times when — not if — they come back.

Ten years after SARS how better off are we? And if we are better, how are we communicating that to the public?

knowledge translationresearchsocial systemssystems thinking

The Know-Do Gap in Knowledge Translation Human Resources

Lots of thinking, not as much doing

Knowledge translation is about putting evidence into practice, but what about putting practices into place that support evidence creation and the people who are in charge of this? Until this missing link is addressed, our knowledge-practice gap will not shrink anytime soon.

Knowing is not enough; we must apply. Willing is not enough; we must do – Goethe

There is a widely held, mistaken belief that knowledge translation (KT) is all about knowledge. During my post doctoral work on KT and systems science I came to know just how strongly this view is held and how faulty it is in terms of practice. Spend time observing how people actually generate, share and take in knowledge and you’ll see that the actual content is a small part of the equation. Quality relationships, networks of people working together, and the right systems and environments in place to facilitate interaction of those people and ideas is what moves knowledge into action.

I was part of a review team that looked at the evidence for knowledge translation and how it fit within cancer communications and we found that much of what has been published focuses on content, not context. While good, appropriate and timely content is a necessary factor in KT, it is hardly sufficient if there are no people or environments where that knowledge can be appropriately contemplated, learned and applied. This is knowledge integration and it requires people and systems working together.

The systems part is tricky enough and has received growing attention over the past decade (see the linked paper above for a short history of knowledge-to-action research), but it is the human side that remains neglected. To make matters worse, it is our future leaders who are bearing the brunt of this lack of attention.

Consider three examples that presented themselves to me over the past week:

1. A young, bold, charismatic and clear communicator with all the skills, knowledge and enthusiasm and desire to be a knowledge broker who is working on the latest of a string of one-year contracts for different organizations. How is this person supposed to be effective at building relationships when she has to start over in a new role in a new organizational every 12 months?

2. A knowledge mobilizer who speaks highly of his team and role on an enthusiastic, dynamic project aimed at transforming academic knowledge into useful, usable, and accessible forms for policy makers and how he is going to miss it as his contract is up (because his part of the project was funded for just one year). What is going to happen to his knowledge when he leaves?

3. A knowledge generator and health promoter who brings a talent for engaging the community and building networks between disparate voices and groups contemplates what it means to be told in one breath that her work (and that of her team and their projects) is so highly valued and impactful and with the next breath that the project will not be funded again, because it is only a one-year initiative. Are those networks she helped create going to grow without someone paying attention to the whole and not just the parts?

These are not content issues, they are human resource issues and systems ones. All the wonderful research scientists do and the amazing innovations that clinicians introduce are not going to amount to anything lasting without someone to carry the torch and to pay attention to getting that knowledge into practice. The knowledge-to-action system is too complex, too fast moving, and attentional resources are too thin to expect that all this can be done on its own without some forethought and committed focus on KT.

And KT and the relationships necessary for true knowledge integration are not things that can be compartmentalized and squished into one year contracts.

What Allan Best, Bob Hiatt and the panel we worked with found (as have others) is that the content itself needs systems in place to do support its integration into practice. These are human systems and those are built on relationships, and relationships are contiguous, not arbitrary or episodic. Yet that is how we view these activities given the way we structure projects and roles for people working in KT.

We are starting to pay more attention to the way in which content is created now it is time to pay as much attention to how it is translated in real human terms and create the same kinds of supports for people that we try to do for content. Otherwise, the young leaders I profiled above will leave the system and take with them their enthusiasm, energy and, ironically, their knowledge leaving us with little more than a name (KT).


*** Photo “Thinker” by dirvish used under a Creative Commons License from Flickr

behaviour changepsychologysocial media

Social Media / Social Activism Redux: Can we Learn from Behaviour Change Theories?

What started as a simple column post a column on October 4th in the New Yorker has really turned into a firestorm of discussion over the last few days (reflecting a building crescendo of discontent and plaudits from those on each side of the debate). The latest volley in the debate has come from the founder of Twitter themselves in a piece in the Guardian. In that column, the chief Tweeters remark:

Williams said:

“It was a very well-constructed argument but it was kind of laughable.

“Anyone who’s claiming that sending a tweet by itself is activism, that’s ludicrous — but no one’s claiming that, at least no one that’s credible. If you can’t organise you can’t activate. I thought [the article] was entertaining but kind of pointless.”

They have a good point. But while Gladwell might be too dismissive of the power of tools like Twitter, it is easy to overstep and imply that information is power and having more of it networked leads to activation (something I discussed earlier this week).

Knowing and doing are very different and any analysis of major theories on behaviour change and the evidence, shows a relatively weak correlation between knowing more and doing more. It also shows an OK, but also not a strong correlation.

What does change people’s behaviour? Lots of things — and that’s the problem. The either/or thinking that permeates the discussion of social media is too often simplistic and driven by an interplay of ideas and values that are not always aligned with the evidence or personal experience.

People tend to change for the following reasons:

1. They have information that tells them there is a threat or a problem with the status quo;

2. Others believe that the behaviour should be changed;

3. The person changing actually cares what other people think;

4. That person has the skills and tools to be able to change;

5. The environment is supportive of change and facilitative (e.g. there are policies, procedures, access to resources — including time);

6. There are more pros to changing than cons (and there are more pros to the strategy of change than the cons);

7. A person actually wants to change (they are self-motivated and not doing things because everyone else thinks they should);

8. A person feels capable of making the change at all.

The more of these elements are present, the more likely the change is going to take place and stick. This is a big list and indicates that change isn’t always straightforward, and it certainly isn’t easy.

The revolution most likely will be Tweeted, but whether that is the cause or the consequence is why research on social media and social activism is needed. Otherwise, we will wind up with another chicken and egg problem.


Chicken, Eggs or Social Eggs?


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.