Tag: health promotion

complexityeducation & learningemergencesystems sciencesystems thinking

Storytelling, Sense-making, and Systems Thinking

Making sense of life through storytelling

I teach a class on systems thinking perspectives on public health. This past week we discussed the role of narratives and storytelling as ways to learn about systems and how to organize diverse information and how to make sense of it all.

For those working in systems thinking and complexity science within a public health context, there is much to be excited about in terms of opportunities, much less to be excited about when it comes to knowledge synthesis. That is, there isn’t a lot out there to synthesize when someone wants to study a problem from a systems perspective. Particularly if one is looking for clues as to what kind of evidence can inform decision making. Indeed, a great deal of the problems that systems thinkers face in many fields have no substantive body of evidence to support decision making.

And even if there was such a body, complex systems are often so dynamic that evidence becomes hard to apply because the contexts in which that knowledge is generated is so particular. Even on the same subject, a study of complexity or system dynamics might only provide guidance on ways to approach other problems, rather than prescriptive strategies. That’s complexity and systems for you.

But knowing that doesn’t mean that we can’t look at the problems in some depth. Those looking to take on systems problems tend to find two main questions (challenges) starting out: what are the boundaries of the system, and how does all the information within those boundaries fit together?

To answer these questions, I had my class consider the story of their problem. As part of the course, each student is asked to concentrate on one subject of personal interest and last week I asked the class to consider the story of the problem that they are wrestling with in their research and health promotion work. These public health problems include issues of workplace wellness, HIV/Hepatitis co-infection in prisons, healthy fathering, the application of design to health, youth engagement, environmental sustainability and resilience and more, so there is much to talk about.

Storytelling suffers from being that thing you did as kids like the photo above or something you do for fun, but isn’t widely considered a valid tool for exploring complex systems. It is this myth that I sought to dispel in my class, because when you start telling the story of system, remarkable things happen and much sense can be made from relatively little information.

I started off with some reference sources from the always interesting and insightful Dave Snowden, drawing on two of his earlier papers on narrative and organizational strategy. Dave’s written extensively on this topic, including role that paradox plays in stories, with many other resources found here. What this did was frame the issue not just of one of stories, but large and small narrative patterns that shape the way that people understand the system they are in.

In the case of the students in my class, they are all dealing with subject material for which there is little material on systems thinking to use as a start point. For most of them, they have little idea of where they are within that system relative to the problem at hand. Storytelling provides an opportunity to cover a lot of ground and organize the information that we already know about a system into a manner that allows us some sense-making opportunity. Sometimes there are large stories and grand narratives to which they belong, but often it is the small exchanges or micro-narratives that we work with. Both provide much fodder for systems thinking.

What makes a story is a coherent organization of information, characters, a plot, tension or conflict, a setting and a point of view. With these elements one starts to provide the context and boundary conditions for imagining a system and thus, the foundations for a model of it.

This can be done through long-form narrative or something simple like a haiku (in fact, one of the learners in the class wrote a series of haikus on her topic).

When you write out your story, notice what gets included and what does not.

  • What emotions are present (if any)?
  • Is there any reliance on past knowledge (or evidence)?
  • Are there characters that are more prominent and, if so, why?
  • What is the tension or unresolved conflict in the story?
  • Why was the setting chosen and what limits does it impose?
  • Are you avoiding parts of the system in storytelling intentionally? Or, are you choosing to tell the story in a manner that hides or obscures parts of it you feel uncomfortable with?

These are some of the questions that a systems thinker can ask of the story that is produced, and the answers provide insight into what the system holds, how its organized, and how you as an agent of inquiry and change intend to influence it. The goal isn’t to create the best model or the right model, for neither of those exist. What is about is creating appropriate, useful models. And as George Box famously said about models:

All models are false. Some models are useful

All stories are fiction, but for systems thinkers, some stories are useful.

** Photo from the New York Public Library via The Commons Flickr pool . No copyright exists.

behaviour changehealth promotionpsychologypublic health

New Year’s Resolutions: If You Must…

We Resolve To No More New Years Resolutions! (CC - Meddy Garnet)

The holiday season now takes a shift away from the goodies and rich foods that start with Hanukah and (almost) end with Christmas. There’s one last big day left*: New Years Eve/ Day.

* In Canada, Australia, New Zealand and the UK we have Boxing Day today, the day when all the unsold merchandise for Christmas goes on sale and people do silly things like camp out overnight on Christmas Night so they can get a deal the next morning. It’s just like Black Friday in the US.

People often wake from the sugar-induced near-comtose generated by all the treats on Boxing Day to realize that their new holiday pants fit tighter than expected, that the number of wine bottles in the recycling are hard to count, and that the return to everyday life that comes after the holidays might not be as jolly given the absence of any holidays to look forward to. Add to that the myriad “year in review” lists and recaps on television, print and the Internet and its quite natural to want to make a New Year’s Resolution.

The answer to that is: don’t do it. They don’t work and the whole thing is one big fallacy.

But evidence never stopped people from doing things before — even physicians and scientists — so if you must make them, here are some recommendations from a person that teaches a graduate level health behaviour change course on how to be a little smarter about goal setting:

1. Be specific. Declaring that you’re going to be healthier in 2011 isn’t providing much to go on. Does that mean that you’re going to eat better? And if so, what does that mean? A big mistake is that people keep their goals too general and thus, never really know if they’ve acheived them. One rubric to use is the S.M.A.R.T system for goals. S.M.A.R.T. refers to goals that are Specific, Measurable, Achievable, Realistic and Time Framed. The closer you can adhere to these, the more likely you are to achieve them.

2. Keep quiet. There is a school of thought that suggests that advertising your goals to the world (make them public) is a strong way to motivate change. The thinking here is based on theories of social norming and pressure that suggest that the fear of letting others down will motivate you to succeed. That might have some currency, but it paradoxically fails for reasons that have little to do with others and much to do with our brain. Research from NYU psychologist Peter M. Gollwitzer and his colleagues (PDF) found:

When other people take notice of one’s identity-relevant behavioral intentions, one’s performance of the intended behaviors is compromised. This effect occurs both when the intentions are experimenter supplied and when they are self-generated, and is observed in both immediate performance and performance measured over a period of 1 week. It does not emerge when people are not committed to the superordinate identity goal.(p.616)

Some other resources on this are available here. This isn’t to say that you can’t share aspirations with people, but when you declare you’re going to do something out loud ( following S.M.A.R.T) and get feedback from others, your brain starts to imagine that you’ve already accomplished the goal and is already diminishing your motivational fire.

3. Do it for yourself. Another reason these publicly stated goals might cause problems is that often we announce goals that we want to believe in (or believe others approve of), rather than those we want for ourselves. A large body of evidence suggests that we’re much more likely to do things that fit with our self-concept and values than those that challenge or complicate it. Self-determination theory is the foundation for this concept. Author Daniel Pink wrote an accessible piece on this in his recent book Drive. This can be applied broadly or more specifically. For example, with regards to weight loss, there are a lot of options to assist that from changing the food you eat and the way you eat (not dieting, which is a far larger fallacy than New Years Resolutions and persists even more) to exercise. Perhaps running on a treadmill is something that bores you to tears, so try a group dance class instead. If you’re not a fan of salads, try doing more with beans, oatmeal, nuts, fruit or smoothies. There are lots of ways to get the same place, but choose the things that you really like first.

4. Be social and connect. Even if you’re not announcing your goals to the world on YouTube or doing all the things you want to do first, it is still important to be social. Research on social networks and health show remarkable links (pun intended) between our social networks and our health behaviours. Smoking, obesity and mental health are all enhanced by having strong social networks (however you connect — this isn’t just about Facebook or Twitter). Building strong connections with people can offer so much benefit in terms of keeping you healthy, informed and “human”.

5. Help yourself by helping others. If you want to reach your goals, try helping others reach theirs. Working with your friends and family to support them in reaching their goals can actually strengthen your own resolve. Communities of practice are groups of individuals that are motivated to support each other in solving particular problems that often fall outside of traditional lines of work, discipline or problem domain. These collectives are often self-organized and volunteer-oriented and because of that, they capitalize on many of the aforementioned points. Find a community of people tackling the same problems and offer your assistance and wisdom. In doing so, you might find that you start to work through your own challenges and issues. Research on complex systems shows that small, incremental changes over a long time will produce much more stable change than radical upheavals at once.

New Year’s resolutions are problems because they often set us up for failure. Perhaps the one resolution that you will want to follow this year is to skip the resolution altogether and commit to doing something small often and enjoying yourself and those around you while you do it.

behaviour changecomplexityemergencepublic healthsocial systems

Change as a Social Movement: Lessons for Mental Health?


My colleague Laura O’Grady recently blogged about her reflections on the HIV / AIDS movements and how far its come in 25 years and how much further it has to go. With the 2010 world AIDS conference having recently wrapped up in Vienna, it is worth considering how something that was virtually unknown 30 years ago (AIDS) has become arguably the most high profile health issue on the global stage.

One of the touchstones of progress has been the way that HIV-related stigma has eroded over time. It still has a ways to go as the picture above illustrates*, but focusing on the positive aspects, its easy to see that change has come through the HIV / AIDS movement:

One of the most important shifts in the AIDS movement was the legitimacy and status of those infected. How many remember the Four H club: homosexual, hemophiliac, Haitian and heroin user? The shift away from this stigmatizing labeling was a slow process. A handful of people publicly disclosing their status, many (e.g. Ryan White, Rock Hudson, Elizabeth Glaser) because they were forced to so. No doubt this helped bring a face to the disease. But there was still much stigma, especially centred around transmission. Camps between those who “got it the right way” (e.g. by transfusion) separated themselves from others who engaged in behaviour considered deserving of certain death. It was a great time for the “holier than thou” crowd.

Dr. O’Grady makes the distinction between getting HIV “the right way” and those that might have “deserved” it because of their choices. I couldn’t help but read this post and consider the parallels to mental health and the role that stigma plays in governing our interactions with the various conditions and people who wrestle with such conditions. Although much has been written about how to change behaviour related to HIV risk (here, here, here and here for examples), the focus of change is too often directed at individuals. Individual change is a necessary, but not sufficient condition for population health improvement and one of the more weaker forms of intervention. Studies looking at individual-level change rarely account for even half of the variance in change explained using traditional models. Systems change is where it is at for true impact and HIV / AIDS shows this more than anything. A movement is needed and even then, it is slow going.

Mental health is a puzzle. On one hand, the absence of any clear ‘mode of transmission’ has always made mental health a more insidious and mysterious problem to wrestle with. Historically-rooted myths have abounded about ‘catching’ mental diseases, but that largely subsided in the 20th century and was replaced with a true individual-focused model. This new approach put blame on the individual, or the family, as the root cause of mental illness. This new vision for mental health stopped short of placing those individuals in a context and thus, ignored the role that factors such as work demands (or under-employment or unemployment), poverty, racism, social support, gender inequity, access to services and other social determinants play in contributing to mental wellbeing.

What we are now learning is that the brain and society are both complex adaptive systems, suggesting that the moods and thoughts emerging from such systems might best be understood from the lens of complexity science and systems thinking. If this is the case, then the entire issue of mental health needs re-thinking in how we address the problem. Taking a systems approach leads to very different strategies and questions about where mental health problems emerge from and how they are best addressed. It also means that we’re all responsible, whether we like it or not.

HIV/ AIDS, even though the disease mechanisms are now well known and indicative of a complicated process, the social context in which AIDS exists is truly complex. There are the myriad overlapping issues of fear of the others, gender inequality, homophobia, racism, poverty, geo-political discrimination, the community vs. clinic debate among many others that make tackling HIV a challenge because the context is so varied and global.

Like HIV  / AIDS, we need a movement in mental health because of the same issues. The challenges of understanding mental health in a globalised and multiculutural climate were eloquently discussed on TVO’s The Agenda with guest Kwame McKenzie from the Centre for Addiction of Mental Health in Toronto. He pointed to the research that shows how conditions that are more commonplace in North America such as depression have no parallel in some cultures. Just like HIV, the way in which depression is understood and treated is vastly different from place to place, even within Western countries that are often thought to be similar.

Movements occur when diverse actors come together under a common (but not always unified) banner to advance issues of shared importance. Like HIV/AIDS, there are great divisions within the mental health community about certain definitions and approaches to addressing the problem, but there is also widespread areas of agreement and a shared desire for a plan. Is now the time? It might be worth considering what HIV / AIDS community did to serve as lessons for those of us striving to advance mental health promotion.


behaviour changehealth promotionpsychologypublic health

Is Public Health Modeling Good Behaviour?

Could Public Health learn from this?

Take a break. Life is too short to work all the time. All work and no play makes us dull and boring.

All good stuff — right?

If so, then it must be good for those of us in public health too, right?

Apparently not.

Over the past two days I’ve been attending the annual Canadian Public Health Association convention being held in Toronto and if there is one thing that I’ve learned: we are not taking our own recommendations to heart. Literally.

Stress, particularly that associated with work, has been associated with all kinds of chronic conditions and is a contributing factor to coronary heart diseasemetabolic health, and overall increased risk of cardiovascular mortality.

And from an informal survey of my peers, there is a lot of stress out there among those of us in public health.

Today I met with some colleagues to discuss ways in which information technology could help this problem and make life easier for us. The discussion produced some ideas on what tools could help public health professionals work better and more efficiently in the 21st century, but what stoked the most discussion was speculation that these tools simply place a Band-Aid on a larger problem of work overload.

We aren’t working better, we are working too much and that is what needs changing. Indeed, technology may be making things worse.

For example, email — once a tool that helped us correspond with more people, faster, with less effort — was held as a perfect example of a symptom and cause of stress:

“I get 450 emails a day. This is insane. The only time I get a break is when I’m on an airplane and now they want to introduce the Internet into the cabin! Last time I had my inbox under 100 was 1998” – Full Professor and medical doctor

“I’m not even important and I get 80 messages a day — and classes aren’t even in session right now; it’s the summer!” – Assistant Professor

“I feel like I’m back in school” – Public health official referring the problem of having to respond to emails in the evening when he’s at a conference during the day, just like when he was a student in lectures all day.

“If I don’t answer an email the moment I get it, the chance it will never get responded to is high. I miss very important things that way. I get so much email I can’t manage it all — and I keep getting more” — Senior public health leader

“I feel guilty just taking three days off to spend with my family on a trip. Getting away (to where I can’t access email) is the only way to truly get a break” — Associate Professor

The CPHA conference started on Saturday for those attending pre-conference workshops and continues all week. For those who are using the time to actually attend the sessions (and not sneak off to their hotel room or the business centre to catch up on email — those without Blackberries that is) and maybe socialize with their peers have a mountain of email awaiting them back at the office.

That is email that falls on top of the web-searching, meetings, research. We in public health argue strongly for the need for strong evidence-based research to guide our work and that all public health trainees be training in methods to critically examine the research to make good decisions. The truth is that few have the time to read things in any depth at all.

“I’ll bet the number of people who actually want to critique or critically appraise a research article is very low. They just want to be told what to use and why” — Public health researcher commenting on the public’s and public health professionals’ interest in contributing to the development of knowledge through things like wikis or collaborative writing tools.

We speak of stress as if it is something for others. Systems change is implored, yet considered something ‘academic’ in practice. Leadership is called for, while few choose to truly lead, by example at least.

So are we modeling good behaviour and if not, are we undermining our own credibility in the process? If not that, are we simply undermining our own health and wellbeing?*

* I write this having learned that a particular leader who I greatly admire suffered a massive heart attack recently and recall hearing the news and not being surprised at all, which made me very sad.

No work tonight (writing this blog is something I enjoy). Mazel tov!

eHealthhealth promotioninnovationpublic healthsocial media

Mobile Health Promotion and Web 3.0

Telephones of the Distant Future by Catmachine.

This week the MaRS Discovery District in Toronto is hosting NetChange Week, which describes itself as being “A week exploring tech for change” .

(follow comment on Twitter using #ncwk).

Yesterday’s focus was on mobile technologies and the ways in which they’ve been used to promote health and facilitate fundraising and knowledge development with non-profits. A series of innovations and novel forms of engagement were proposed, most notably in the area of sexual health.

Toronto Public Health presented work on a sexual health promotion program that uses proximity marketing through Bluetooth technologies. Health promoters with TPH go into the (mostly) gay community, particularly bars and clubs, wearing monitors that allow people to opt-in to receive Bluetooth-transported messages directly to their phones. The messages, contained in a GIF format so they can be viewed at a later time, provide a discrete way to deliver sexual health information specifically suited to the gay population.

Another similar program came from Black Cap, which has sought to engage the black community in Toronto through a variety of sexual health programs aimed at men who have sex with men and youth. The latter program involves a group of youth opinion leaders / health promoters who use text messages and their personal social networks to spread positive health messages in the community. Thus far, the program appears to be creating a buzz and leading to some action.

A third presentation from Lisa Campbell Salazar, a health promoter working with TakingITGlobal (among others), presented her research on youth and mobile technologies. Although the survey was not all focused on health issues, they certainly provided highlights (details of the survey can be found here).

One of the most salient findings from this survey was that mobile tools provide youth with a safe, accessible way to offer peer support to one another and connect in real time in situations where their health risk behaviour takes place. As TPH Health Promoter Michelle Hamilton-Page said in her presentation:

No one who is coming up to our booth is having sex at the moment, they need information for later when they are. Mobile phones provide a means to do that.

This is the bottom line for mobile technologies and health promotion. It provides support where people are — literally and figuratively — rather than where we wish them to be. Where we wish them to be are in places where we don’t have to work too hard to reach them (or are not complex): clinics, traditional media spaces, office buildings. Traditional media is usually passive, it can be crafted in boardrooms and office buildings, with little need to actually engage the community your trying to reach*. It is harder to do that with mobile messaging (although there are examples where this works in practice — TPH’s messages are crafted in advance, but the way they are delivered by an ambassador in the community adds that customized component that is part of the message. Black Cap’s youth opinion leaders custom craft their own messages on the fly using guidelines).

*- although even traditional media tries to solicit input before deploying things into the field.

Traditional, developer-designed, limited-authored websites (Web 1.0) allowed us the opportunity to broadcast messages in new ways to an enormous population. Social media enabled people to not only take part in a conversation, but initiate and re-create dialogical spaces and express themselves in ways that transcend text to pictures, video and other creative media (Web 2.0). Mobile technologies combine both of these earlier phases and enable conversations to take place where people are physically situated, freed of wired connections (Web 3.0). Here, the concept of ‘web’ is truly a network, a spiderweb of connections that are poised to promote health and engage the public in new ways.

It is here that the future of health promotion,  and public health more broadly, lies.

A Web of Digital Health Promotion

behaviour changecomplexitydesign thinkingemergencesocial systems

Wayfinding in Complex Systems

Where am I?

One of the more taken for granted aspects of human life is knowing where you are. You probably have a clear sense of what you’re reading this on (e.g., laptop, mobile device), where you and that device are situated (e.g., home, office, sidewalk cafe), and where that situation is located in the world (e.g., city, state, country). In some of these settings, this could be viewed as a simple issue where there are clear markers, conventions and shared realities that dictate where you are. If I say “I’m at my desk at home” that conveys a very clear sense to those who know me about the physical space I’m in and where that space is located.

Online, things are a little more tricky because the locations are not tethered to something physical, only addresses that point to some server that presumably brings to Yahoo!, Google, WikipediaBBC News, the Journal of Medical Internet Research, create your own Star Wars movie, or wherever you’re intending to go. As diverse as these sites are, you still have some idea of where you are and where you’re going. The space in all these settings is defined by markers such as addresses, navigation bars, and the limits of the screen you’re using whether it be a 24 inch monitor, an iPad or a handheld phone. This is more complicated. So while I might be visiting the JMIR site, I could be on many of the hundreds of articles published, the author area, the editorial pages or somewhere linking between them. If I have multiple browser windows open, I could actually be at two places at the same time. But in each case, we can deduce through some effort about where I am.

Social systems, particularly those with multiple overlapping layers of organization (individuals within teams within organizations within communities) are complex. Understanding where someone is within that system provides only a partial sense of where a person really is. Consider social networks. Below is an example of a social network taken from a paper I published in 2006 with Tim Huerta that looked at the Web Assisted Tobacco Intervention community of practice.

Web Assisted Tobacco Intervention Network

Social networking maps are very useful for illustrating to people where they might fall within a social cluster, but more importantly, it also shows where others fall in relation to themselves. So while we’re obviously familiar with who we know, we might be less familiar with who knows us, and almost completely ignorant of who those we know are familiar with. These secondary connections are commonly referred to as weak ties, popularized by the work of Mark Granovetter. Often the most powerful changes come from mobilizing these weak ties — in large part because the further away from the starting point you go, the more diverse the elements are that you engage. Engaging diversity, creates conditions for new patterns of behaviour to emerge and thus, innovation, learning and change.

It sounds pretty simple: map the network, find the connections, exploit those connections and (shazam!) you have change (e.g., knowledge translation! healthy behaviours!). Unfortunately, as a phrase often attributed to H.L. Mencken suggests:

For every complex problem there is a solution that is neat, simple…and wrong.

Social networks are gaining in popularity. Recent mass-market books by Nicholas Christakis and James Fowler and the newly released book by social network scientist Albert-Laslo Barabasi have (or will) accelerate this. But what is missing from the discussion of social networks is place and theories of taking these complicated visuals and translating them into strategies for navigating complex environments. Maps of social networks are great as a start, but they actually offer little practical advice on where to go or even where you are in terms of knowledge space. Yes, you see where you are relative to others in a graphical representation, but social networks for collaboration are layered with organizational bureaucracy, likes and dislikes, technological and time constraints that are easily forgotten about when one maps out connections on chart or PowerPoint presentation.

In other words, social networks are treated as complicated, when really they are complex in the manner in which they are negotiated. Wayfinding is considerably more complex when one considers the reality of trying to navigate through a social network to get something done. Just as design thinking might be viewed as a stance, its value goes beyond seeing things different towards actually producing new things that have value. Likewise, social network maps provide us with a stance for viewing the social landscape differently, but offer little in understanding how to traverse that landscape.

For knowledge translation and public health, better wayfinding in complex, rather than complicated systems is the next step in the journey towards navigating a path to health.

behaviour changedesign thinkingenvironmenthealth promotionpublic health

Thinking: Why the Word Matters to Systems and Design


When I was applying for funding to do a post-doctoral fellowship I struggled with the term “systems thinking” as an identifier as I frankly thought it to be a rather silly term. After being awarded a CIHR post-doc in Systems Thinking and Knowledge Translation I still felt I ought to use another term — maybe complexity science or complex adaptive systems would be better — but thinking? It seemed rather unprofessional or scientific to me. But as I dove deeper into the science of systems and struggled to expand, re-learn or un-learn many of the ways I’d grown accustomed to approaching problems I found myself in admiration of the term. Indeed it was about a way of thinking about things, not just studying them.

The same can be said for design thinking, another term I’ve come to admire that I found equally goofy the first time I heard it. Yet, like systems thinking, the more I’ve embraced this school of thought the more potential it has. Design thinking is predicated on the not-so-obvious recognition that nearly everything we come into contact beyond our fellow humans and pets is designed. Whether it is the computer you use, the streets you walk on, the clothes you wear, or even the curriculum you follow in school, it is all designed. Therefore, if we want to make the world a healthier, more creative, innovative and just place approaching it through the lens of design thinking might be useful.

Indeed, this past week I attended a lecture by Henry Hong-Yiu Cheung from the design firm IDEO who spoke on his application of design thinking to his work and the concept of designing systems at scale. As the concept name suggests, this is about fusing design with systems, although I would argue that the level of systems thinking IDEO applies is not matched to the level of design thinking. But then, they are a design firm first.

I’ve been spending much time imagining what our a health promotion and public health system would look like if driven by systems and design thinking? Larry Green has argued that systems science provides a means of facilitating practice-based evidence emergence alongside traditional evidence. Allan Best and others have posited that systems thinking can improve dissemination in health promotion and facilitate knowledge integration.

Building on the work of Green, Best and others, I’ve argued that health promotion is a systems science and practice, however few have said the same about design thinking. My colleague Andrea Yip and I are looking to change that by exploring ways in which design thinking can inform the way we approach public health and health promotion. If the fit isn’t obvious, consider how the design of the places you live, the products you use, and the communities you inhabit shapes your behaviour and choices. Architects have long known how to create spaces that attract people to them, keep them moving, or drive folks away. John Thackara notes that 80% of the environmental impact of any product is determined at the design stage and Andrea and I are interested in whether designing for health might enable us to better influence the impact of our communities, organizations and practices to improve health.

Our first challenge is to change the thinking behind how we approach the problem in the first place. And just like with systems, there is much education to be done to convince people why these twin styles of ‘thinking’ are worthy of consideration in social innovation, public health and health promotion.