The more I think about knowledge translation’s (KT) ascent in requirements of federal funding applications in Canada, the more I consider the possible Conservative machinations that may be behind it. It’s no secret that the Conservative government’s political influence continues to penetrate deep within Canada’s knowledge creation system, and so, could this be relevant to KT’s omnipresence in Canada? This week, I’ll be writing about the economics of knowledge translation, and how this is compatible with the ruling Canadian Right.
But wait; sure CIHR is pushing towards improvements in knowledge creation, but can we say that CIHR is politically motivated? Well, let’s look at their governance structure. According the CIHR Website (http://www.cihr-irsc.gc.ca), the CIHR is governed by a council of 18 individuals, appointed by the federal cabinet. A cursory glance at their affiliations reveals that several have very frank relationships to health corporate entities, including Pfizer, Caprion Protenomics, and the Richard Ivy School of Business. Most interesting is that there is clearly an effort to create a semblance of impartiality – the deputy minister of health serves in an ex-facto role, and does not have a vote at the table. However, Michael Wilson, who held four cabinet posts under two Conservative Prime Ministers, and whose background is listed as Chairman of Barkley’s Capital Canada Inc., is a full voting member of the board (Canadian Institute of Health Research).
When one considers the key messages of the Conservative Party of Canada, things like productivity, economy, and commerce come to mind. Indeed, the translation of knowledge into commercialize-able formats seems to fit, and is even frankly discussed on the CIHR’s website (Canadian Institute of Health Research). Throughout the world, KT is perceived as an integral component of economic development, with extensive research done around which kinds of academic institutions suite which kinds of businesses, what is required for the process, and so on (Delfmann & Koster, 2012). Over the past two decades, the use of econometrics in governance and decision-making has globally taken centre stage. However, little research into the evidence informing this practice has been presented (Hansen & Muhlen-Schulte, 2012).
So, finally, is this a bad thing? Well, as so many things in KT, the answer isn’t black or white, but a shade of grey. When the discussion focuses on the economic gains of bringing new technologies to market, coordinated strategies for knowledge translation are lauded as important and integral to complex, high risk sectors like healthcare (Stone & Lane, 2012). On the other side of the coin is the soft innovation that occurs within healthcare. Politically motivated, commercialization focused KT can be very selective in what it chooses to translate. While it is well understood (inside the walls of the academy) that uprooting social inequities is integral to improving health, a politicized KT endeavour can undermine this message’s role out to implementation (Muntaner, Chung, Murphy, & Ng, 2012). Considering that the commercialization of information is an important stated goal of the CIHR (Canadian Institute of Health Research), what do we do when what we are trying to translate is a de-commodified good, like public health? (Muntaner, Chung, Murphy, & Ng, 2012).
I recognize, of course, that I am speaking from a biased perspective. The fact that the governance structure of the CIHR has been politicized isn’t necessarily conclusive of the fact that KT is a Conservative ploy. Nor have I presented conclusive evidence of selectivity in the KT process – although, to use an idiom: more research is needed. All the same, I find it important to critically question our assumptions about the politics of any fashion in health. Economic productivity measured by GDP, after all, shouldn’t be the goal of a national health research institute. It doesn’t translate to greater economic equality or, in itself improve health (Muntaner, Chung, Murphy, & Ng, 2012).
Canadian Institute of Health Research. (n.d.). Members of Governing Council. Retrieved November 19th, 2013, from CIHR-IRSC: http://www.cihr-irsc.gc.ca/e/6953.html
Delfmann, H., & Koster, S. (2012). Knowledge transfer between SMEs and higher education institutions; Differences between universities and colleges of higher education in the Netherlands. Industry & Higher Education , 26 (1), 31-42.
Hansen, H. K., & Muhlen-Schulte, A. (2012). The power of numbers in global governance. Journal of International Relations & Development , 15 (4), 455-465.
Muntaner, C., Chung, H., Murphy, K., & Ng, E. (2012). Barriers to Knowledge Production, Knowledge Translation, and Urban Health Policy Change: Ideological, Economic, and Political Considerations. Journal of Urban Health .
Stone, V., & Lane, J. (2012). Modeling technology innovation: How science, engineering, and industry methods can combine to generate beneficial socieconomic impacts. Implementation Science , 7 (1), 44-62.
“I have nothing against diamonds (or rubies or emeralds or sapphires). Gems are beautiful and desirable. To buy or not to buy is an individual decision. But is has to be an informed decision. … I find it unconscionable that the resources of the third world would be exploited for the sake of our vanity, and above all that billions of dollars of corporate profit are built on the backs of workers paid a dollar a day.” – Edward Zwick, Director of Blood Diamond (Amnesty International, 2006)
Drawing links between the thoughtful gifts bought for loved ones, and environmental degradation, human suffering, and death is not something that many consumers enjoy being confronted with. Diamonds and gold are some of the worst offenders. The production and/or extraction and processing of these “symbols of love” have caused and continue to cause immense public health, human rights and environmental consequences (Donahoe, 2008). ‘Conflict diamonds’ have been used by rebel armies to pay for weapons that have killed tens of thousands of people during civil wars in Sub-Saharan Africa. Diamond’s riches largely allude the millions of actual ‘diggers’ and ‘miners’ in developing countries, and foreign “middlemen, diamond dealers, and exporters earn the lion’s share of mining income” (Donahoe, 2008, p. 170) while arguably giving little back to the host country besides environmental damage, forced resettlement, and human rights violations. The same (and much worst) has been said about gold mining. Gold extraction has been linked to many worker deaths, union-busting, human rights abuses pollution, loss of traditional livelihoods, long-term economic problems, and deteriorating public health in local communities (Donahoe, 2008).
How can all this knowledge be translated into the adoption of better, more responsible resource extraction that is known to be technically and economically feasible? The problems are complex and so are the solutions. Legally mandated impact assessment is one way to use this knowledge to inform and influence development related decision making. But this also involves changing the behaviour of powerful corporations with powerful pocketbooks. Targeting consumers is another way to bring about change by urging people to be responsible and informed, and to ‘vote-with-their-wallets’.
‘No Dirty Gold‘ is an international campaign that attempts to raise awareness of the environmental, social, health, and human rights impacts of irresponsible gold mining. It’s goal is to create a gold mining sector that respects communities, workers, and the environment by educating and influencing consumers, retailers and manufacturers, so in turn they will help to influence mining companies to reform ways in which they extract and produce metals. No Dirty Gold employs a variety of knowledge translation (KT) techniques from the IDRC toolkit – social marketing ads mimicking the ads of the World Gold Council (see ads below); storytelling; consumer education through online fact sheets and twitter; and publications – to spread their message and try to bring change (No Dirty Gold, 2013). Edutainment has also been used to raise awareness among consumers of the externalities of their obsessions with bling. Two recent Hollywood blockbusters, Blood Diamond and Avatar, are good examples, the former of which had official support from Amnesty International.
As a researcher and a consumer, I want to learn. Are consumer awareness campaigns like the ones described effective in influencing corporations’ behaviour? What kinds of behaviour change techniques are most useful when attempting to change consumer behaviour in relation to products that do not harm or improve their own health or local environment? Products whose value is heavily based on culture and tradition as well as their ability to confer status? I personally do not desire to buy and/or own diamond and gold jewelry but I do desire to travel in a highly polluting fashion. Do jewellery owners ignore the ‘externalities’ of their purchases in the same way I ignore the environmental impact of my flight record?
Amnesty International. Companion Curriculum to Blood Diamond. 2006. URL: http://www.amnestyusa.org/sites/default/files/bd_curriculumguide_0.pdf Accessed November 19, 2013.
Donahoe, M. Flowers, Diamonds, and Gold: The destructive public health, human rights, and environmental consequences of symbols of love. Human Rights Quarterly, 2008, 30(1):164-182.
No Dirty Gold. The No Dirty Gold Campaign. URL: http://nodirtygold.earthworksaction.org/about_us#.UorjGhZwo20 Accessed November 18, 2013.
The Power of Emotions in Leadership
Public narrative is a leadership practice of translating values into action. It is based on the fact that values are experienced through emotions.
Marcus in The Sentimental Citizen states that it is our emotional system that employs rationality to enable us to adapt to everyday challenges. Therefore, “if emotionality enables rationality, the effort to exclude passion will also undermine our capacity to reason” (2002, p. 7).
According to Marcus (2002), emotions are held to have common qualities: first, emotion arises from hidden and uncertain causes, so unlike reasons and judgements, which can be fully revealed and debated, emotion are problematic. Even if emotions generate good results, we cannot say that they are rational because rationality requires full disclosure. Second, emotions are thought to provoke action without thought, both individually and collectively. Third, emotion is presumed to diminish a full consideration of the intended action, especially as it affects other people. Obviously this focus conflicts with the proper use of reason and justice. (pp. 21-22).
Even in a healthy brain, consciousness awareness does not have full access to the sensory information collected by our eyes, ears, nose, skin, and tongue. The brain receives some 10 million bits per second, of which only 40 bits per second reach consciousness sight (Zimmermann, 1989). Thus emotions have more information about the state of the world, as well as about our own resources than is available to consciousness (Marcus, p. 62-63). The emotions systems know what they know more than consciousness can grasp. Therefore, it is the emotions systems that provide considerable service to consciousness.
Emotions and Neuroscience:
The first important discovery is that the brain has a variety of emotion systems. They share some features but they perform quite different functions. (Marcus, p. 67). They have the following common features:
- Emotion systems have access to the full information arriving to the brain from the five senses, far more information than is represented in conscious awareness shortly thereafter.
- Emotion systems have access to procedural memory and somatosensory stream (information about the body, what and how well it is doing, where everything is, etc.)
- Emotions systems use sensory and somatosensory information to execute a variety of analysis and produce some effects
- Emotions systems use this information to influence procedural and declarative memory, learning and conscious awareness. Hey often influence how and when we rely on conscious awareness.
- Emotion systems generally execute their functions before and in preparation for conscious awareness. (pp. 67-68)
Let’s be back to the public narrative discourse and identify how emotions operate in it. It is a fact that not all emotions encourage action, some of them inhibit action and work as hindrance to start any movement or even encourage the community to join the agent (storyteller/leader).
According to Ganz, (2011) the major “action inhibitor” is inertia (p. 277). Inertia is the resistance of any physical object to any change in its motion (including a change in direction) and emotional inertia is remaining in a particular emotional mood and not willing to change the mood. How to confront with emotional inertia for initiate an action? We can counter inertia with urgency. Urgency can capture our attention, creating the space for new action. Another action inhibitor is apathy; being indifference to the surroundings and having no particular feeling about the subject. One emotion that can overcome apathy is anger (Ganz, 2011, p. 278). Anger arises when somebody sees or feels injustice and unfairness.
Ganz, M. (2011), “Public Narrative, Collective Action and Power” in Accountability through Public Opinion, (Eds.) Sina Odughemi & Taeku Lee, Word Bank. pp. 273-289.
The process of knowledge translation begs us not only to ask the important questions, but also the questions that really matter. In health practice, knowledge translation first appeared as ‘bench to bedside’ or ‘campus to clinic’ (Greenhalgh & Wieringa, 2011), it was also found that “managers and policy makers fail to draw consistently on robust evidence when designing services or allocating resources” (Greenhalgh & Wieringa, 502). The decision and motivations to turn evidence into evidence based policy is contextually based, the facts are always value laden and their application is also affected by the situation. Greenhalgh & Wieringa (2011) highlight a notion that is well documented process, despite good evidence, policy makers are not always inclined to carry out the recommendations. As Lewis (2007) states evidence base medicine and evidence based decision-making have yet to be revolutionary, he acknowledges that evidence should be more influential but this has yet to be a reality.
You would be hard to pressed to find an individual that does not have an opinion on food, we need it, we love it, and it is connected to our most basic human experience. In the words of Wendell Berry, “to be interested in food but not in food production is clearly absurd.” Food is connected to our well-being on so many levels. The state of food production is being challenged by the integration of genetically modified or genetically modified organisms (GMO), the implications of GMO products is not well understood.
Last week the Canadian Seed Trade Association (CSTA) failed to support a resolution about the regulation of GMO alfalfa at its semi-annual meeting. The CSTA is responsible for “representing 128 corporate members engaged in all aspects of seed research, production and marketing, both domestically and internationally” (Canadian Seed Trade Association, 2013). The resolution, brought to the floor wanted to support regulation of growing GMO alfalfa in dedicated areas of the province of Manitoba, whilst other areas could stay GMO free. GMO soy and corn has contaminated the Canadian markets, right of entry to European and Japanese markets have already become inaccessible for fear that we cannot guarantee the purity of that seed (CBC, 2013). Lack of access might not be the only concern, “a growing body of research connects these foods with health concerns and environmental damage” (David Suzuki Foundation, 2013). The fact is that we don’t know the impacts of GMO products, and more importantly the spread of these GMO plants is out of control in most developed countries (Sustainable Pulse, 2013).
Evidence is showing that we cannot control the growing and harvesting of GMO crops, secondly we are not sure of the long-term effects that GMOs will have on our health or the health of our planet. As Jane Barrett, negotiator for SATAWU, recently said “A farmer’s job is to take care of the soil, the plants will do the rest”. We are responsible for the actions that we take; stewardship of the planet is a serious responsibility.
The disconnect in this example is between the lack of action towards regulating something that is possibly harmful to human health, as exemplified by Michie et al. (2005), “[t]he implementation of evidence based practice (EBP) depends on human behaviour” (32). This behaviour is influenced by so many triggers, such as social or economic, and what needs to be highlighted is that regardless of evidence the actions that we take are based in complex systems influenced by so many differing stimuli.
In the field of knowledge translation where we are able to name many practical examples where good evidence is not being applied, in my opinion we need to start asking the more contextual questions, all the theory, frameworks or models are not going to solve our problems. If dissemination is the problem, let us be creative and proactive in developing knowledge translation that is effective in the context that we are trying to consider. When the important questions are asked, it is imperative that we all act with the intention of sharing that knowledge, and that we act in conjunction with the evidence not in despite of it.
Barrett, J. (November 2, 2013). SATAWU Presentation, ITF Youth Climate Change Africa regional meeting, Johanesburg, South Africa.
Canadian Seed Trade Association. (2013). Home. Retrieved from: cdnseed.org
CBC. (2013). Farmers protest introduction of GM alfalfa. Retrieved from: http://www.cbc.ca/news/business/farmers-protest-introduction-of-gm-alfalfa-1.1363280
David Suzuki Foundation. (2013). Understanding GMO. Retrieved from: http://www.davidsuzuki.org/what-you-can-do/queen-of-green/faqs/food/understanding-gmo/
Greenhalgh, T., & Wieringa, S. (2011). Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review. Journal of Social Medicine, 104, 501-509. Doi: 10.1258/jrsm.2011.110285
Lewis, S. (2007). Toward a general theory of indifference to research-based evidence. Journal of Health Services Research and Policy, 2 (1), 1-7.
Michie, S., et al. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality Safety Health Care, 4, 23-33. doi: 10.1136/qshc.2004.011155
Sustainable Pulse. (2013). Spread of GM Crops Out of Control in Many Countries – New Report Retrieved from: http://sustainablepulse.com/2013/11/12/spread-of-gm-crops-out-of-control-in-many-countries-breaking-news/#.UorXP8Skqn8
With over 3,000 delegates in attendance the International Congress on AIDS in Asia and the Pacific (ICAAP) opened with speeches from a number of distinguished delegates in the field of HIV/AIDS. The speakers, although coming from a variety of different regions and backgrounds, championed a common theme: the importance of community leadership and youth involvement in the fight against the HIV/AIDS epidemic. The speakers’ persistence that community and youth groups (commonly referred to as “the next generation”) must lead the movement against the epidemic inspired consideration of several points related to the involvement and potential contributions of youth and community in paving the way toward a zero infection rate. Much research has been conducted on community participation in the research process, growing alongside the recognition of community-based participatory research as a significant part of the research process. However, surprisingly, much less attention has been awarded to the subject of youth participation in driving social change. Particularly, the focus here will be on the potential impact of youth leadership in HIV/AIDS prevention.
The urgent call to action conveyed by the speakers and targeted toward youth groups (among others) to lead the fight against HIV/AIDS is echoed in the literature on adolescent involvement in knowledge translation (dissemination, sharing) related to the HIV/AIDS epidemic. For example, Walsh, Mitchell, and Smith (2002) believe that “youth participation and agency, though often overlooked, is key to any attempt to halt the rising [HIV] infection rates in young people” (Walsh et al., 2002, p. 106). Similarly, Campbell, Gibbs, Maimane, Nair, and Sibiya (2009) maintain that the “involvement of young people is seen as a precondition for successful HIV/AIDS management and has become a central pillar of international AIDS policy” (UNGASS, UNICEF, & UNAIDS as cited in Campbell et al., 2009, p. 94). A pervasive theme of ICAAP11 is youth leadership and advocacy, reflecting Walsh et al.’s positioning of young people as both producers and consumers of knowledge and emphasis on capturing and harnessing youth culture toward a public health objective such as reaching zero infection rate of HIV (Walsh et al., 2002). Also important is the provision of ‘space’ for youth to act (Walsh et al., 2002, p. 110). Although recognition has been given to and steps have been taken toward involving youth groups in interventions advocating for policy change, Campbell et al. (2009) also mention a few barriers to youth participation in HIV/AIDS management: (1) the impact of adults in undermining youth participation, (2) the limited support for youth organizations from external agencies, and (3) the lack of incentives for youth to participate (Campbell et al, 2009, p. 106). Future research in this area should focus on possible methods to overcome such barriers, especially and specifically in the context of HIV/AIDS.
Finally, it is also worth considering the potential role of the knowledge broker in partnerships with vulnerable communities. Conklin, Lusk, Harris, and Stolee (2013) highlight the role of the knowledge broker as “bridge builders” who “link researchers who produce scientific knowledge and practitioners who produce experience-based knowledge with knowledge users” (Conklin et al., 2013, p. 8). (For more on the role and responsibilities of the knowledge broker, please see the resources below.) Generally, research on knowledge brokers focuses on their role in relationships between researchers and policymakers, although it is uncertain whether they can play a contributive part in the knowledge translation/sharing process between researchers-policymakers and members of youth organizations or vulnerable communities.
Dobbins, M., Robeson, P., Ciliska, D., Hanna, S., Cameron, R., O’Mara, L., DeCorby, K., & Mercer, S. (2009). A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies. Implementation Science, 4(1), 23-31.
Russell, D. J., Rivard, L. M., Walter, S. D., Rosenbaum, P. L., Roxborough, L., Cameron, D., Darrah, J., Bartlett D. J., Hanna, S. E., Avery, L. M. (2010). Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: a before-after intervention study. Implementation Science, 5(1), 92-108.
Waqa, G., Mavoa, H., Snowdon, W., Moodie, M., Schultz, J., McCabe, M., Kremer, P., & Swinburn, B. (2013). Knowledge brokering between researchers and policymakers in Fiji to develop policies to reduce obesity: A process evaluation. Implementation Science, 8(1), 74-84.
Campbell, C., Gibbs, A., Maimane, S., Nair, Y., & Sibiya, Z. (2009). Youth participation in the fight against AIDS in South Africa: From policy to practice. Journal of Youth Studies, 12(1), 93-109.
Conklin, J., Lusk, E., Harris M., & Stolee, P. (2013). Knowledge brokers in a knowledge network: The case of Seniors Health Research Transfer Network knowledge brokers. Implementation Science, 8(1), 7-16.
Walsh, S., Mitchell, C., & Smith, A. (2002). The Soft Cover project: Youth participation in HIV/AIDS interventions. Agenda: Empowering Women for Gender Equity, 17(53), 106-112.
There is a need to increase the number of deliveries by skilled birth attendants in Nepal in order to continue reduction of the maternal mortality ratio (MMR) and the rate of neonatal mortality. Researchers have already noted a decrease in MMR which can be attributed to various factors including better roads and increased numbers of health clinics. There have also been more mothers using health services for family planning, antenatal visits, skilled delivery, postnatal visits, and national policy and foreign aid has been directed towards achieving the Millennium Development Goals, one of which is improved maternal health.1 Using a skilled birth attendant for childbirth (defined broadly as a midwife, doctor or nurse trained in safe childbirth techniques) is assumed to be one of the most important factors that can provide optimum outcomes for mothers and their newborns.1
Mothers in Nepal often deliver their babies at home unattended or with a family member only. This is particularly common in rural areas, and even more so in the mountainous areas, even though there may be a medical facility in the vicinity.3 Actions are needed to provide safer birthing environments with life-saving medications and skilled attendants. Mass media campaigns are one of the ways that knowledge brokers promote decisions to use skilled attendance at birth. The following quotation from the Overseas Development Institute’s report on maternal health offers one possible reason for the increasing numbers of parturient women using skilled birth attendants (and in this case, an institutional delivery), being a mass media campaign.1
Previously, we conducted only 40 or 50 deliveries in one year, but last year we had 190. I think there are several reasons for this: the MDGs, more doctors, awareness raising by female community health volunteers and radio and newspaper advertisements.’ – Medical superintendent in the mountain region.1
When mass media campaigns are used, high proportions of large populations are exposed to messages through use of media such as television, radio and newspapers.4 In countries where mothers-in-law and husbands make family decisions around maternity care and place of delivery, it is important to promote messages to all members of the public, not just to pregnant women who attend antenatal visits in a health care facility.3 Mass media messages can be promoted for a short or long period of time, and may be presented alone or linked to other program efforts.4 In order to have the intended benefits, the desired message should be derived from the use of the ‘knowledge to action process’. The knowledge to be presented needs to be selected and adapted to fit the local context.2 Promotion of the messages of health and safety through use of skilled birth attendants should be carefully considered to fit the culture. As the next step in the knowledge translation action cycle, barriers to knowledge use should be assessed. Barriers to changes in childbirth practices may involve geography, finances, gender or social inequities, or cultural norms. If policies are already in place to provide for transportation financing (the case currently in Nepal), then cultural norms may be one of the barriers addressed through mass media. The usual norm is childbirth unattended, but messages can also appeal specifically to the mothers-in-law and husbands to care for parturient women by adopting health-seeking behaviours for birth.
The intervention needs to be tailored to its users and the right media modalities selected. Radio is a mass media available in many rural Nepalese homes, stores, and community gathering places. Radio messages may be the most favorable way to reach the largest number of people, and can be disseminated in the home language or dialect of the community. Successful mass media campaigns can broadcast messages to many people repeatedly over time and at a low cost per person. Newspapers are also common but not all rural people are literate, especially women of childbearing age and their mothers-in-law. It is likely that if all members of the family hear the radio messages in their own language they may begin to discuss the health issue both within the family and within the community. If the campaign is successful, it may make the behaviour change a new cultural norm.
The next steps to see if the mass media campaign is working is to monitor the knowledge use and evaluate the outcomes through inquiry at the institutional and community levels.4
Together with mass media campaigns about the benefits of using a skilled birth attendant, required services and products must be made available. For childbirth, this means a clean and relatively comfortable room for delivery, essential life-saving medications and the ability to make referrals to higher level facilities if more assistance is needed for delivery, such as caesarean section or blood transfusions. A 24-hour availability of skilled birth attendant is also needed, as babies do not arrive on convenient schedules. Policies that are favourable to sustainability of satisfactory maternal health services and supportive to rural caregivers will help improve services and therefore reinforce behaviour changes in the public.
1. Engel J, Glennie J, Adhikari S, Bhattarai, Prasai D, Samuels F. ODI. (2013). Nepal’s story: understanding improvements in maternal health. Overseas Development Institute.
2. Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N. (2006). Lost in knowledge translation: time for a map?
3. MoHP, New Era and ICF International Inc. (2012) ‘Nepal Demographic and Health Survey 2011’. Kathmandu: MoHP, New Era and ICF International.
4. Wakefield M, Loken B. (2010). Use of mass media campaigns to change health behaviour. The Lancet. 376: 1261-1271.
As it has been pointed out, my blog posts over the last couple of months have raised a lot of questions. I thought for this blog post, I should attempt to try my hand at an argument for something I believe in strongly – the ability of art to act as evidence in public health research. All right, so maybe one last question:
This summer I did a three-month practicum in Argentina that was largely focused on facilitating the use of Photovoice in an indigenous community as a way to enable nursing and communications students to share their views on health in their community, especially in relation to Chagas disease. I would need a whole other blog post to expand on that project, but my point here is just to say that my experience with Photovoice really convinced me of its value as a method of conducting health research and translating the findings (that is, engaging in knowledge translation) in an engaging, empowering, and fun way.
Photovoice is a participatory action research method where individuals are given cameras to take pictures of their everyday lives in order to reflect upon issues and concerns in their lives and communities (Foster-Fishman et al., 2005). These images then serve as evidence, often about a specific health problem, presented from the viewpoint of the photographer (Wang and Burris, 1997). In this class, and in many others I have taken, we often talk about the importance of context. I think one of the major strengths of Photovoice is that it inextricably captures context.
Another advantage of Photovoice is that photos tell a story. It is quite cliché to refer to the adage that “a picture is worth a thousand words” when talking about Photovoice, and yet it is true. There is something about a photograph that moves people more than just describing it in words. In his article “Towards a general theory of indifference to research-based evidence”, Steven Lewis (2007) refers to power of the narrative to persuade people and argues that art can have a “subversive and inspirational power” (p. 4). This also relates to Maryam’s presentation last week on Public Narrative and the way that technique relies on appealing to people’s values through eliciting an emotional response. I think a photo can do this too.
Yet in this class we have also had a lot of discussions of the hierarchy of evidence, especially in health research. In discussions of randomized controlled trials and prospective cohort studies, it can seem difficult to even broach the topic on including photographs, drawings, and theatre performances as evidence. At the same time though, people respond to art in ways that they might not respond to data or written reports. We just need to convince them take it seriously.
I am hopeful that this can happen. Boydell et al. (2012) recently conducted a scoping review looking at the way that art-based research is being used to both produce knowledge and disseminate findings. They argue that “[the] growing use of arts-based knowledge creation and dissemination strategies is driving an important shift in our understanding of what counts as evidence, as well as appreciation for the complexity and multidimensionality involved in creating new knowledge” (p. 2). Still they identify gaps in the literature in terms of how arts-based researchers report on the impact of their work and whether these methods should be judged differently than through traditional positivist ways of looking at reliability, validity, and trustworthiness. They also highlight the important ethical considerations that need to be taken into account with this type of research.
Clearly it is not as easy as just believing in the usefulness of art and its impact on people. We need to engage in more discussions of why and how art can have a place in the world of health research. This requires acknowledgement of the ways research has been traditionally conducted and evaluated and a willingness to have more conversations about the ways we think about, value, and critically assess different types of evidence.
Boydell, K.M. et al. (2012). The Production and Dissemination of Knowledge: A Scoping Review of Arts-Based Health Research. Forum: Qualitative Social Research, 13(1).
Lewis, S. (2007). Towards a general theory of indifference to research-based evidence. Journal of Health Services Research & Policy.
Foster-Fishman, P. et al. (2005). Using Methods That Matter: The Impact of Reflection, Dialogue, and Voice, American Journal of Community Psychology, 36(3/4).
Wang, C. and Burris, A.M. (1997). Photovoice: Concept, Methodology, and Use for Participatory Needs Assessment. Health Education & Behaviour, 24, 369.
The Delphi Method is a survey technique that began during the 1940s as a method to obtain expert forecasts about the future of military technology. The Delphi method utilizes multiple rounds of surveys in order to obtain consensus from a group of individuals deemed experts in a particular field. Common group communication failures can be avoided using this method, such as power dynamics or pressure to conform (Jewell 2011) and it promotes in-depth conversation among your chosen experts. While discussing the technique in our class session, some raised the question, who is considered an “expert”? Is it limited to those with high levels of education or more explicit knowledge? One of the advantages of the Delphi method is that it allows the researcher to define the “experts” and thus permits a consideration of what is most suitable in the context of your research question. Experts in the case of the Delphi method are individuals with extensive knowledge on a topic, and therefore individuals with extensive tacit knowledge could be selected as experts, depending on your question.
In order to practice the technique, I facilitated the formulation of a Delphi method survey of recent MPH graduates (within the past 5 years) in a recent class. Using class input we formulated the following 1st round survey questions:
1. What do you see as the 3 most important emerging trends in public health?
2. What areas of public health do you see as having the greatest job growth potential in the near future?
3. What do you believe to have been the single most important factor in attaining your current position (e.g. personal or professional connections, in-depth knowledge of a field, advanced ability in a skill, etc)?
4. Having now entered the workforce, what skill or area do you regret not having enhanced further during your graduate degree?
Completion of the 1st round allowed for a reflection on the use of the Delphi method more broadly. One interesting issue that emerged in our survey was the reluctance of our chosen “experts” to speculate about the future. In our case, as was raised in class, perhaps a more appropriate group of experts would have been higher level professionals in the field or those more associated with career counseling and forecasting. I imagine such a group would be more comfortable providing their opinion on the future, compared to our respondents who felt this was perhaps beyond their scope of knowledge of the field of public health.
Another important point to consider is whether your question would be better answered using a standard survey. When using the Delphi method, it’s important to remember you are seeking the informed opinion of your respondents. In the case of our survey, a question such as #4 would perhaps be better suited for a standard survey utilizing sampling methods that allowed for generalization to the target population. As was demonstrated in a class example (Milat 2012), this might also take the form of reaching consensus about a shared definition (in the case of our example, “scaling-up”).
Finally, the smaller scale and more selective nature of the Delphi method provide an excellent space for open dialogue around your subject of choice. An interesting issue that emerged from the first round and was not addressed in the survey instrument was our definition of “graduate”. As it turns out, 5 out of 13 participants had not completed their final project although they are working full time and finished their coursework. The multi-phase nature of this method allows for a continued conversation around this topic, something that otherwise might have to be postponed until another phase of research if using a standard survey.
Jewell, A. (2011). The Delphi Technique. Available at: http://delphitechnique.blogspot.ca/2011/02/what-is-delphi-technique_13.html
Milat, A.J. et al. (2012). The concept of scalability: increasing the scale and potential adoption of health promotion interventions into policy and practice. Health Promotion International, 28(3).
This summer, while working for the World Health Organization (WHO) Poland Country office I ran in to my first health policy toolkit: The WHO Technical Manual on Tobacco Tax Administration (WHO, 2010). For the purposes of this blog post, I am using the term “toolkit” to refer to practical tools that have been developed to be informed by evidence, and offer assistance to policy makers. In the Knowledge to Action Cycle model, this would represent to “Tools & Products” portion of the knowledge creation triangle (Graham, et al., 2006).
Toolkits are a ubiquitous product in the health policy field. A search of CINAHL using the term “toolkit” reveals over 700 results, with only very few articles discountable as not health policy toolkits. Unfortunately, it seems that there is very little in the way of reviews of the form of writing itself; most articles are simply toolkits offered up for one health aim or another.
Aside from academic searches, several websites host repositories of toolkits available for all types of health policy issues. The website www.k4health.org, represents the web presence for the organization Knowledge 4 Health. Their Toolkits section contains 67 different toolkits ranging in such disparate subjects as mental health and prevention of post-partum-hemorrhage. The WHO also maintains many different policy toolkits, again, ranging in subject from things like sex work to chemical hazard prevention.
Most toolkits, and all the toolkits I’ve reviewed in preparation for this blog post, follow the standard academic format of providing a background evidence section at their beginning. As a pedagogical structure, this explains exactly why the subsequent portions are written the way they are. This differentiates this form of writing from briefings or instruction manuals, which might not explicitly provide a review of literature.
Next, toolkits that I’ve reviewed break down the relevant task into steps or benchmarks that can be achieved by the implementer. In this section, the toolkit becomes much more like an instruction manual, laying out in clear, unequivocal language what must be done. Some toolkits will present these steps in more interpretable ways (ex. (K4Health, 2013)) while others will be focused and very exacting (ex. (WHO, 2010)).
A lack of reviews and evidence around this writing style makes the tool difficult to analyze. For example, should steps be more exact or more general? Which of these approaches should be used in which situation? What’s more, when should this type of toolkit be created, and towards what kinds of ends? Additionally, I wonder about how often these toolkits are used. I have encountered toolkits that come as part of mandated government programs, however much of this work is prepared by researchers and allowed to be passively disseminated. For example, with the www.k4health.org website, I wonder how often those 67 toolkits get downloaded, and more importantly, how often they get implemented. Indeed, even the WHO’s role is one of diplomacy – gently urging it’s member states to adopt the procedures defined in its toolkits.
Despite the prevalence of toolkits in public health practice, there is much research, development and review that remains to be done on this writing style.
WHO. (2010). The WHO Technical Manual on Tobacco Tax Administration. Geneva: WHO Press.
WHO. (2010). Toolkit for Scaling Up Health Innovations. France: WHO Press.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., et al. (2006). Lost in Knowledge Translation: Time for a Map? The Journal of Continuing Education in the Health Professions , 26, 13-24.
K4Health. (2013). A Gorecasting Guide for New and Underused Methods of Family Planning. K4Health.
“Gold – Making an Impact on the World” (WGC, About Gold, 2013). An apt slogan for the World Gold Council (WCG) whichever way you look at it. But the way you look it makes a world of difference.
Recent WCG research reportedly demonstrates the positive role played by ‘responsible’ gold mining in supporting ‘sustainable’ socio-economic development, highlighting in particular the importance of the sector for development in non-OECD host nations (WGC, Advanced by Gold, 2013). Data from 15 WGC member companies on their 2012 expenditures, including payments to suppliers, employees and governments, were combined in an attempt to comprehensively measure how, on a global scale, value generated by the formal gold mining sector is distributed including how much remains within host nations. These findings, along with other recent evidence of the direct economic impact of gold, provide one indication of the economic value created by gold mining and its contribution to national economies (PwC, 2013). This report concludes that gold plays a fundamental role in advancing economic development and the needs of society. Last week, an online news headline for these study findings boasted that, “New research indicates that responsible gold miners contributed more than $55 billion to sustainable economic development in 2012.”
The aforementioned evidence is just one take on the effects of gold extraction and deals with economic impacts at the global and national levels. Other sources provide a very different perspective. Media examples from the opposite end of the spectrum include: “Barrick ignores UN High Commissioner for Human Rights recommendation regarding Papua New Guinea Rapes” (Oct. 28, 2013); “Destruction of Peru’s rainforest by illegal gold mining is twice as bad as experts thought” (Oct. 28, 2013); “Canadian mining company Infinito Gold seeks to extort $1 billion from Costa Rica” (Oct. 10, 2013); and “Romanian gold rush cancelled as protesters defeat Europe’s biggest gold mine” (Sept. 9, 2013).
Research on formal gold mining at a more local level can also point to quite different conclusions about the impacts of gold mines on local economies and societies. Jobs, income and better education were positive effects of the establishment of a gold mine on nearby villages in Mali, but along with these, mining brought land expropriation, environmental degradation and social tensions. Entrepreneurship and diversification of the local economy related to mining projects were minimal (Jul-Larsen et al, 2006). Harmful socio-economic impacts related to the expansion of gold mining in Peru include adverse effects on water resources, livelihood assets and social relationships, resulting in increased social conflict. At the local level, there is weak evidence of any positive effects on Peruvian livelihoods, especially in rural areas (Bebbington et al, 2009). The socio-economic impacts of small-scale ‘informal’ or ‘illegal’ gold mining have also been studied. Evidence from field surveys, airborne mapping and satellite imagery from the southern Peruvian Amazon region links the greatly increased number of small mines – a 400% increase from 1999-2012 – and resultant forest destruction, to global consumption of gold and the dramatic jump in gold price in 2008 (Asner et al, 2013).
So is gold mining contributing to sustainable development or hindering it? How can we best answer this question? Terry Heymann, the WGC’s Gold for Development Manager, argues that “gold, produced in conformance with high safety, environmental and social standards, provides opportunities in the form of jobs, skills, improved infrastructure and tax revenues, but maximizing the development potential of mining requires continued attention and discussion” (WGC, Advanced by Gold, 2013). Population health intervention research offers a meaningful way of contributing to that discussion.
Population health interventions are policies, programs and events that operate within or outside of the health sector and have the potential to impact health at the population level, by generating and shifting the distribution of health risks through their effect on underlying social, economic and environmental conditions (Hawe et al, 2009; Hawe et al, 2013). The intentionality of those interventions, whether inside or outside the health sector, is neutral (Hawe et al, 2009). Gold mining, and any type of resource extraction project, fits into this definition of a population health intervention due to its impact on population health through the environmental, social and economic changes to which it contributes (see the arguably busy causal diagram above for examples). Population health intervention research (PHIR) offers a way of connecting the impacts of mining at multiple levels and on multiple determinants to the actual population health outcomes and health equity, important measures of sustainability. This type of research is necessary if we are to fully understand how gold is making an impact on the world.
To be continued.
Asner, G. et al. Gold mining ravages Peru. Carnegie Institution of Science. Monday, October 28, 2013. URL: http://carnegiescience.edu/news/gold_mining_ravages_perú
Bebbington, A.J. & J. Bury. Institutional Challenges to Mining and Sustainability in Peru. Proceedings of the National Academy of Sciences of the United States of America, 106(41), October 2009. URL: http://www.pnas.org/content/106/41/17296.full?sid=ecb93442-632a-4083-aaf6-04be0359aee1.
Hawe, P. & L. Potvin. What is population health intervention research? Canadian Journal of Public Health, 2009, 100(1):I8-I14.
Hawe, P., E. Di Ruggerio, & E. Cohen. Frequently asked questions about population health intervention research. Canadian Journal of Public Health, 2012, 103(6):468-71.
International Council on Mining and Metals (ICMM). Best practice guidance on health impact assessment, 2010. URL: http://www.icmm.com/library/hia
Jul-Larsen, E. & S. Lange. Socio-economic effects of gold mining in Mali: A study of the Sadiola and Morila mining operations. Chr. Michelson Institute, 2006. URL: http://www.cmi.no/publications/publication/?2340=socio-economic-effects-of-gold-mining-in-mali.
Price Waterhouse Cooper (PwC). The direct economic impact of gold, 2013. URL. http://www.pwc.com/gx/en/mining/publications/mining/the-direct-economic-impact-of-gold.jhtml 2013.
World Gold Council (WGC). About Gold, 2013. URL. http://www.gold.org/about_gold/sustainability/socio-economic/responsible_mining_value_distribution/
World Gold Council (WGC). Advanced by Gold 2013. URL: http://www.gold.org/advanced_by_gold/#impact