Tag: public health

art & designenvironmentpublic health

Design Space in Public Health

EmabarcaderoFountainIf design is everywhere humans are and shapes our interactions in the built environment, which dictates how we interact with the world around us should it not be considered important enough to be a part of public health?

I recently picked up a copy of the architecturally-inspired Arcade Magazine because of its theme on Science, Art and Inquiry. Inside was a piece by Andrew Dannenberg, Howard Frumpkin and Daniel Friedman. The first two are MD’s and the last author an architect and all are from the University of Washington . In that article, they outline a case for why design and public health should go together. The audience for the piece are those interested in architecture.

Indeed, Arcade’s purpose is to “incite dialogue about design and the built environment”. It makes me wonder why we don’t have something that “incites dialogue about design and public health?”.

Yet, I couldn’t help but think that same piece should be published in a public health space. In the article, the authors outline a few of the key areas where design can contribute to public health.

Among the first of these areas is promoting physical activity and the role that design can play in building and planning for spaces that encourage people to move in healthy ways:

Working together with public health professionals and planners, designers can help remedy what urban theorist Nan Ellin calls “place-deficit disorder,” starting with the basics – stairways, sidewalks, landscapes and contiguous urban spaces – which they can compose to attract greater pedestrian use.

Designing for resiliency is another of the areas where good design can benefit the public by creating a solid urban infrastructure to literally weather the storms that come upon us:

Evidence-based design can help reduce vulnerability and enhance the resilience of buildings and infrastructure, but most importantly, the communities who depend on them.

They also look at the role of design in enhancing sustainability and as a means for assisting environmental health while shaping the demand for sustainable products:

Designers possess the unique skills, knowledge and practices to specify the use of benign materials across scales based on life cycle analysis, energy conservation, carbon management, and environmental and health impacts. As designers expand these practices, they educate their clients, inform the public and shift the market.\

Lastly, they focus on how design can contribute to reducing social inequities by drawing on evidence looking at the connections between space and wellbeing for those in low-income neighbourhoods:

Recent studies demonstrate that links between greater access to green space and lower mortality are more pronounced among the poor than the wealthy. Housing initiatives that offer better homes for low-income persons, workplace design that protects workers, and universal design that improves access for activities by persons with disabilities—these practices benefit vulnerable populations and offer designers unlimited opportunities to help foster fuller, healthier lives.

Expanding the discourse of design and public health

It was refreshing to read a ‘conversation’ between public health and design and some taking the issue of space and health seriously from a design point of view. Some, like Emily Pilloton and her Project H design others have sought to use design as a bridge to social wellbeing by looking at space as being about communities and economics. Her video below explains how she has taken a design-driven approach to her work in promoting new sustainable ways to engage her adopted community of Bertie county.

Both of these examples of design in public health take a place-based approach, however there is much that can be done with designing the experience of health beyond place. Jon Kolko’s group at AC4D looked at design and homeless in their book Wicked Problems.  Andrew Shea has looked at the link between graphic design and social good in his book, which is explained further in his TEDX talk below. The design firm IDEO has been working on social good projects now for a few years through its IDEO.org platform and program.

  Bringing public health in

What seems to be missing and that the article in Arcade did and that was bring public health in. Emily Pilloton, Jon Kolko, Andrew Shea and many other terrific socially-minded designers are changing the way the public thinks about public health. Public health needs to be doing this too. It is striking that we have so few public health professionals — Drs Andrew Dannenberg and Howard Frumpkin as exceptions — doing the kind of design-oriented research and publishing in this area. It is ripe and public health and design both need it.

I don’t expect a lot of public health folks read Arcade, but maybe they should. And maybe we should be reading more about design in public health publications too.

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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.

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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 health

Low-profile public health job could mean best candidates won’t apply

If public health is important, should the presumably ‘top job’ in the field in a particular country not be highly coveted? Not if that position is tied to the government’s discretionary decision making. Andrea Hill looks the matter of replacing David Butler-Jones, Canada’s outgoing Chief Public Health Officer, and how there is a real risk the best candidates will not throw their hat into the ring.

canada.com

In the fall of 2009, Canadians were on edge about their health. The country was in the midst of a worldwide pandemic and people were succumbing to H1N1 by the dozens. Health officials begged those who were ill to stay home and thousands of people across the country spent hours in line waiting to be vaccinated.

Through it all, David Butler-Jones did his best to be Canada’s calm, relaxed face of information about the influenza, often referred to as swine flu. The chief public health officer, who had been appointed in the aftermath of the SARS crisis, appeared in regular news conferences to update Canadians about the latest H1N1 cases and the progress being made by national immunization efforts.

“During H1N1, you saw the public health agency and the chief public health officer work as they were expected to work,” said Kumanan Wilson, Canada research chair in public health policy…

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Design (re)Thinking Health Systems

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How might we design health systems to promote health and wellbeing and not just treat illness and disease and manage infirmary and chronic conditions? What if health systems were about health?

If we were to apply design thinking to health systems, what might be do?

In a previous post, I suggested that knowledge translation is too important to be trusted solely to health professionals, partly because they  have largely failed to take up the charge. Taking a step back — a systems thinking perspective — one realizes that to design better knowledge translation, we need to design better health systems.

Julio Frenk, Dean of the School of Public Health at Harvard, believes this too. In a 2010 paper published in PLOS Medicine, Frenk comments on the state of health systems and examines how we might re-think them in light of global health challenges.

Health systems are the main instrumentality to close the knowledge–action gap. To realize this potential, it will be necessary to mobilize the power of evidence to promote change. Yet all too often reform efforts are not evaluated adequately. Each innovation in health systems constitutes a learning opportunity.

Frenk’s article is an invitation to engage in systems and design thinking about health. Both approaches invite pause to consider what the problem is in the first place. For design thinkers, problem scoping is the first step.

For systems thinkers this is akin to setting the boundaries around the problem.

Once we set the boundaries and find the appropriate problem, we then frame it appropriately for design. Problem definition is something often over-looked or under appreciated, but is the core of effective problem solving and design.

If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions – Albert Einstein

Health systems are typically defined in light of professional services and policies aimed at making the sick well. They are essentially illness and disease (sick care) systems.  This conceptualization, still dominant in the professional and policy discourse in many Western countries, places medicine at the centre of health services with the allied disciplines working alongside, but rarely ventures its gaze beyond the institutions of care or the conditions such institutions are designed to treat.

Frenk, writing in PLOS Medicine, suggests its time to expand our view of what makes a health system if we are to truly promote and sustain global health and see three key points as provoking such re-thinking:

First, health has been increasingly recognized as a key element of sustainable economic development [1], global security, effective governance, and human rights promotion [2]. Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector [3]. Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.

In order to realize the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health.

Frenk offers some suggestions:

Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.

First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations. Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.

It’s important to note the mention of the role of the population and its dynamical impact on the system. As populations change dramatically in their composition and form of residency within countries, including a greater movement to urbanization, so too will the myriad factors that influence health systems. The people are the system and thus it will change as populations change. While Frenk lists this as one point of many, it is a radical departure for reductionists or those who see health systems as being about care, not people.

A third expansion of our understanding of systems refers to their goals. Typically, we have limited the discussion to the goal of improving health. This is, indeed, the defining goal of a health system. However, we must look not only at the level of health, but also at its distribution, which gives equity a central place in assessing a health system. In addition, we must also include other goals that are intrinsically valued beyond the improvement of health. One of those goals is to enhance the responsiveness of the health system to the legitimate expectations of the population for care that respects the dignity of persons and promotes their satisfaction. The other goal is fair financing, so that the burden of supporting the system is distributed in an equitable manner and families are protected from the financial consequences of disease.

Frenk’s third challenge is to affirm the very point of health systems at all.

While not explicitly speaking of systems thinking or design thinking, there is much that both fields have in common with Frenk’s argument. Design thinkers might ask: What have we hired our health system to do?

Frenk argues that our health systems must go well beyond just making gains in measured health outcomes towards dignity, respect and social justice.

Finally, we should expand our view with respect to the functions that a health system must perform. Most global initiatives have been concerned mainly with one of those functions, namely, the direct provision of services, whether they are medical or public health services. This is, of course, an essential function, but for it to happen at all, health systems must perform other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.

Frenk did not identify specific solutions, but did pose some key questions for health systems design.

If we were to take this challenge up as designers and systems thinkers, what might we do? Here are some suggestions for inquiry:

  • Consider new definitions of health like the one posed in the British Medical Journal that emphasizes looking at the social and environmental influences on health beyond just the absence of physical symptoms. Further inclusion of a psychology of human flourishing might add to this definition.
  • Map out a new system visually with people at the centre, not professionals or institutions. What does that look like? Tools like a Gigamap might provide the kind of multi-media, multi-sensory visual way to conceive of the interrelationships that make up health system. System dynamic models can help this out as well.
  • Engage people across this system to validate this map and co-create possible future models that could serve to shape discussion at multiple levels and  mobilize civil society to support healthy environments.
  • Create small scale, safe-fail / fail-forward, prototypes of small-scale innovations that can be tested, developmentally designed, and rapidly re-developed as needed to start shifting the system as a whole.

Designing health requires designing health systems. Applying new thinking and envisioning a system that is dynamic, comprised of people and just institutions is a start.

Photo: Bartolomeo Eustachi: Peripheral Nervous System, c. 1722 shared by brain_blogger used under Creative Commons Licence

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Evaluating Health Promotion Social Media Strategies for Public Health Impact

How is social media stacking up?

How is social media stacking up?

I recently spoke at an interactive workshop presentation at the 2013 Ontario Public Health Convention (TOPHC) looking at social media use in public health and the strategies available for evaluating those strategies in practice. The talk was focused on the tools, methods and approaches and the inherent challenges in dealing with a dynamic social communication environment.

Here are the slides from that presentation.

Evaluating Health Promotion Social Media Strategies for Public Health Impact

Image: Shutterstock (used under licence)

public healthsocial mediasystems thinking

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

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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

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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?