For knowledge translation professionals, knowledge may be the business, but not all the wares are alike. We must make a distinction between explicit and tacit knowledge (TK). The former refers to formal knowledge such as data published in peer-reviewed studies and evidence-based practice guidelines. The latter is informal: unwritten practices or ‘tricks of the trade’ generally acquired through lived experience. It also encompasses less conscious knowledge such as intuition or ‘going with one’s gut’ (Welsh & Lyons, 2001). Yale anthropologist James Scott (1998) makes a strong case for the importance of TK, arguing that it central to the functioning of modern day corporations and states. In its absence, productivity falls and these entities cease to function efficiently. This is well illustrated by work-to-rule strikes: in performing only those responsibilities formally detailed in their job descriptions, employees can reduce an organization’s productivity, which is dependent on informal practices (Scott, 1998, p. 310).
Unsurprisingly, TK also plays a central role in clinical and public health practice. Yoshioka-Maeda et al. (2006) found that public health nurses working in Japan relied on tacit knowledge to plan and coordinate services for clients with complex needs. In doing so, the nurses departed from traditional planning processes that begin with a community assessment, instead allowing problems to emerge from their everyday interactions with clients. Likewise, Kothari et al. (2012) point to an important role for TK in creating or adapting an intervention so that it attends to the local context. Tacit knowledge provides not only contextual information but is vital to accomplishing everyday activities when time and resources are at a premium. Practitioners will rely on past experience to make decisions about personnel (“Is this person reliable?”) and methods (Kothari et al., 2012). Gabbay and le May reported that practitioners in the UK infrequently used evidence-based practice guidelines in their daily interactions with patients, relying instead on ‘mindlines’: “collectively reinforced, internalised tacit guidelines” developed through experience (2004, pp. 1014-1015). However, these engrained habits may also be a barrier to change; it may be hard to convince practitioners to modify engrained habits (Kothari et al., 2012, p. 30).
If TK plays such an important role, how can we manage it to our benefit? Gabbay and le May’s (2004) observed that tacit knowledge exchange took place primarily through interpersonal interactions; the same story emerged from Kothari et al.’s (2012) interviews with practitioners in Ontario. We can encourage such exchanges through promoting and assisting in the development of communities of practice. For a model we might look to Ontario’s Seniors Health Research Transfer Network; there, dedicated knowledge brokers have worked to establish new connections with- and facilitate meetings between practitioners working in the field of seniors’ health (Conklin et al., 2013). We might also take a cue from work done outside of public health. NASA (2013) compiled and published a collection of interviews with individuals who had worked on the space shuttle program. Such an initiative allows individuals to benefit from TK when face-to-face contact is not possible. While these are promising practices, some TK may not be well suited to transfer, as it is often context-specific. Furthermore, there may be certain affective dimensions of TK that we cannot package; lived experience may be essential to knowing or understanding certain phenomena (e.g. managing traumatic experiences).
The lesson for researchers and practitioners is that we must reorient the way in which we evaluate evidence. As the aforementioned studies demonstrate, qualitative inquiry is much better placed to capture the nuances of TK in a given context. In research and practice many accept a specific hierarchy of evidence that privileges formal or explicit knowledge. This hierarchy places randomized, ostensibly generalizable studies (e.g. systematic reviews and meta-analyses) over case studies and those employing non-random samples. If TK plays an essential role in oiling the gears of program planning and implementation, then perhaps the hierarchy of evidence needs reconsidering. While individual case studies are at the bottom of the evidence hierarchy, such a study might provide the crucial “how” or “why” that Riley et al. (2008) find lacking in many program evaluations.
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.
Gabbay, J., & May, A. L. (2004). Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ, 329(7473), 1013.
Kothari, A., Rudman, D., Dobbins, M., Rouse, M., Sibbald, S., & Edwards, N. (2012). The use of tacit and explicit knowledge in public health: a qualitative study. Implementation Science, 7(1), 20.
National Aeronautics and Space Administration. (2013). NASA JSC Space Shuttle Program Tacit Knowledge Capture Project. Retrieved from http://www.jsc.nasa.gov/history/oral_histories/ssp.htm.
Riley, B. L., MacDonald, J., Mansi, O., Kothari, A., Kurtz, D., von Tettenborn, L. I., & Edwards, N. C. (2008). Is reporting on interventions a weak link in understanding how and why they work? A preliminary exploration using community heart health exemplars. Implementation Science, 3(1), 27.
Scott, J. C. (1998). Seeing like a state: How certain schemes to improve the human condition have failed. Yale University Press.
Welsh, I., & Lyons, C. M. (2001). Evidence‐based care and the case for intuition and tacit knowledge in clinical assessment and decision making in mental health nursing practice: An empirical contribution to the debate. Journal of Psychiatric and Mental Health Nursing, 8(4), 299-305.
Yoshioka-Maeda, K., Murashima, S., & Asahara, K. (2006). Tacit knowledge of public health nurses in identifying community health problems and need for new services: a case study. International journal of nursing studies, 43(7), 819-826.
You’ve got all the facts on your side, scientists are affirming your position, and you’ve identified a plan of action that paves the way to social change…but nobody will bite. What’s a person to do?
We’ve discussed the reasons for which the uptake of knowledge into practice isn’t consistent: information is poorly packaged; connections between knowledge producers and knowledge users are weak or non-existent. However, even if we manage to overcome these obstacles, ideology can block the way. It’s responsible for inaction (or poor action) on many pressing issues, such as climate change, poverty reduction, and sex education.
We can characterize approaches to sex education in the US as either comprehensive or abstinence only. Comprehensive sex education generally includes information about contraception use and reducing the risk of transmitting sexually transmitted infections (STIs). The catch is that this sort of sex education is morally objectionable to some people. Specifically, many social conservatives object to lessons that acknowledge or condone sex between unmarried individuals. These values have informed laws mandating abstinence-only sex education; presently, nineteen states have such legislation (Guttmacher Institute, 2013). Unfortunately, abstinence-only sex education fares poorly in terms of reducing unwanted outcomes when compared with comprehensive education (Kohler et al., 2008)
So, what to do? On the issue of climate change, Geoff Dembicki (2013) argues that climate activists need to reframe their rhetoric to better match the way in which conservatives see the world. Advocates for sex education might heed this advice and point to reductions in pregnancies that occur out of wedlock and a reduction in the number of abortions, which touch on two issues important to social conservatives.
Another option is to expand efforts to provide information online. This isn’t uncharted territory; there are already many online resources that provide comprehensive information about sexuality and sexual health. However, current efforts don’t appear to be sufficient. In a recent study of American youth aged 13-18, Mitchell et al. (2013, p. 6) found that only 19 percent of participants who identified as heterosexual accessed information about sexual health online. Of those, nearly half (46 percent) did so purely out of curiosity; an additional 43 percent cited privacy concerns as their primary motivation. What this suggests is that online materials may be of benefit to a wide swath of youth, including those who already receive comprehensive sex education. Taken together with Buhli et al.’s (2009) finding that much online sexual health information is of low quality, this points to an opportunity for public health practitioners to make new efforts to develop and promote online material.
These efforts might involve finding new ways to promote existing websites. Sex educators could attempt to piggyback on popular websites and platforms. The Khan Academy is a popular site that provides series of educational videos on a variety of subjects, many of which have been viewed hundreds of thousands of times. Public health practitioners might look to collaborate with this and other similar websites to incorporate content about sexual health and well-being.
Where resources permit, we should invest in targeted advertising on Google and social media platforms such as Facebook and Twitter. Other efforts could include developing material that requires engagement from the user. Rather then simply present facts, these websites might transform the material into games (see Kapp, 2012 for discussion of the “gamification” of education). Additionally, they might provide mechanisms by which youth could contribute their own content.
I do not believe that more, better quality education alone is enough to ensure good sexual health for all youth. Sex education efforts will not be sufficient if we do not also address problems that pose barriers to sexual health and well-being such as stigma and poverty (Lichtenstein, 2003). However, under the current circumstances, online sex education can play a useful role.
Buhi, E. R., Daley, E. M., Oberne, A., Smith, S. A., Schneider, T., & Fuhrmann, H. J. (2010). Quality and accuracy of sexual health information web sites visited by young people. Journal of adolescent health, 47(2), 206-208.
Dembicki, G. (2013). How to talk to a conservative about climate change. Retrieved from http://thetyee.ca/News/2013/07/29/Conservatives-and-Climate-Change/
Guttmacher Institute. (2013). State policies in brief: Sex and HIV education. Retrieved from http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf
Kapp, K. M. (2012). The gamification of learning and instruction: game-based methods and strategies for training and education. Retrieved from http://library.books24x7.com.proxy.lib.sfu.ca/
Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42(4), 344-351.
Lichtenstein, B. (2003). Stigma as a barrier to treatment of sexually transmitted infection in the American deep south: issues of race, gender and poverty. Social Science & Medicine, 57(12), 2435-2445.
Mitchell, K. J., Ybarra, M. L., Korchmaros, J. D., & Kosciw, J. G. (2013). Accessing sexual health information online: use, motivations and consequences for youth with different sexual orientations. Health education research, Advance online publication.
 The authors note that a much larger percentage of LGBTQ-identifying youth used the Internet to access information about sexual health. They argue that this is because LGBTQ youth may lack other places to which they can turn.
This week’s readings included a call from Glasgow et al. (2012) for a greater community role in the knowledge production process. This necessitates opening up academic research to community participation, as well as including lay understandings and wisdom in our definition of knowledge. The assumption seems to be that if only academics and policymakers were more welcoming then the community would happily meet them in the middle. This may not be the case. Many of the forces that serve to create and maintain health inequities may also place constraints on community participation.
The articles we read this week explore neither what is meant by community participation, nor the ethical and logistic issues inherent in community participation in research. Accordingly, I would like to propose several questions so that we might begin to unpack the idea of community participation.
We might start by asking: What do we mean by community? On which attributes are we basing our definition? The definition of community we adopt should be grounded in the aims of our study or intervention. We might define a community geographically. We may equally refer to imagined communities, such as those based on ethnicity. Furthermore, there is the question of deciding who is and is not part of a community; membership may be decided by self-identification or imposed by others (the researcher, the state).
Having defined a community, we may then ask: Who speaks for these communities? Those who are speaking may not necessarily represent the views of their fellow community members. This leads us to consider whether we are engaging with a diverse cross-section of the community, or simply those members whom we find accessible.
On the subject of engagement: Does our model of community engagement mean placing a greater burden (economic or social) on communities that may already be under considerable stress? Certain communities may not be so keen on working with institutions that have historically played the role of the oppressor (and may continue to do so). Indigenous peoples in Canada have expressed consternation at perpetually being the subject of research (see Castellano, 2004 for further discussion). Indeed, targeting “at risk” communities can prove stigmatizing (Frohlich et al., 2012). Each new publication marking Indigenous communities as unhealthy and each intervention aimed at improving their lot only contributes to widely held stereotypes about indigenous peoples in Canada.
With these concerns in mind, we must pursue mechanisms that aim to temper power imbalances between researchers, health promoters, and community members. This is essential given that many public health initiatives concern communities that society marginalizes.
I understand that for the sake of brevity a journal article cannot examine every pertinent issue in depth. Nonetheless, I find it discouraging that none of the articles we read this week explicitly addressed these issues, even in passing. In the interest of treating community participation in a more than cursory fashion, I suggest we take up some of these questions and explore their implications for research and practice.
Castellano, M. B. (2004). Ethics of Aboriginal research. Journal of Aboriginal Health, 99, 98-114.
Frohlich, K. L., Poland, B., & Sareck, M. (2012). Contrasting entry points for intervention in health promotion practice: situating and working with context. Health Promotion in Canada: Critical Perspectives on Practice, 102.
Glasgow, R. E., Green, L. W., Taylor, M. V., & Stange, K. C. (2012). An evidence integration triangle for aligning science with policy and practice. American journal of preventive medicine, 42(6), 646-654.
In global health we hear the word champion often. Champions can open minds and doors for innovation. They mobilize communities and advocate for change. They can reduce stigmas by providing accurate information and putting faces to silent struggles and years of discrimination. Global health champions helped eradicate smallpox and have given voice and legitimacy to HIV/aids in communities across the world. Champions can be survivors with their own stories to tell, empathetic allies and opinion or community leaders, or even relatable fictional characters. A Cohrene study (2007 as cited in NCCMT, 2011) suggests that using champions is effective approach to promoting change.
According to The National Collaborating Center for Methods and Tools or NCCMT (2011), “A champion is a charismatic advocate of a belief, practice, program, policy and/or technology.”
So how does one go about cultivating champions?
My answer is that there is not a single right answer. It depends on where you are, what you want to do and whose involved. Like anything you have to match the answer to the question. Do some formative research and decipher who is your audience and who and what influence and move them (see some of our previous blog posts about social marketing). Programs around the world depend on various types of champions: some engage communities and local people, some engage survivors and those with personal stories and struggles and some engage or create opinion leaders both real and fictional. In some situations champions can emerge on there own without being involved in a formal program or policy.
For example the dark, humorous but incredibly insightful blog author “Allie’ of Hyperbole and a Half posted “Depression part 2” explaining her experience with depression and strangely enough a piece of corn under her fridge. This single blog post began conversations about mental and depression by simply telling a story and explaining what it was like in a creating and captivating way. It has 5000 comments from the day it was posted, and is referenced by numerous blogs and popular websites including jezebel and reddit. If you need more proof simple google ” depression corn under the fridge”
For those of you who want a more theoretical or evidence based approach you can look into the “champion advocacy model” as outlined by NCCMT. This model looks at the likelihood that a idea or practice is adopted by the population of interest (relates to the diffusion of innovation model). Using a project by Family Health International (FHI) called ‘Network of Champions’ of (NOC which is detailed here), NCCMT argues that aligning individuals whom are already perceived as opinion leaders is more effective in promoting change than less influential individuals who are already aligned with your cause. They also conclude that:
- The influence of a single influence may be limited to a certain level or sphere. Therefore multiple champions should be engaged at multiple ‘points of influence’ to maximize their combined influence while avoiding bottlenecks.
- Any new advocacy effort demands a significant buy in and support from a wide range of stakeholders.
- Incentives and supports for champions can increase likelihood of success, including formal recognition and acknowledgement, technical and financial supports including transport stipends, capacity-building opportunities and skills certificates” (FHI, 2011)
- It is essential that strategies to prevent or address champion fatigue are developed and implemented.
- Any external inter-country networking of a various number of champion based initiatives should be established and maintained on an individual bases.
In addition to these lessons, FHI’s own report on NOC also recommends that you match your champion to the specific activity you want them to do being mindful of their position, influence, time frames and feasibility. You should also encourage champions to build local support networks and internalize the program’s vision to avoid micro managing them (FHI, 2011).
Recently I have been scowering the web for any anti-smoking campaigns targeting seniors. So far I have come up with nothing, and it has been an unsuccessful attempt. So if you do know of any please share them.
But this lack of seniors-focused campaigns got me thinking. Why is it that campaign groups have given up on targeting the older population? Often these groups believe that if an adult has made it to a relatively late stage in their life already then they must be doing something right and most likely a more difficult population to change any health behaviors. However, statistics show that smoking significantly “increases postoperative complications such as myocardial ischemia and infection… Even temporary abstinence from smoking may reduce the risk of these complications and improve surgical outcomes” (Warner, 2005). Any quick glance at Health Canada’s stats will show that majority of patients using our healthcare system are those over 65 years. If quitting smoking prior to surgery can greatly improve their post-op outcomes shouldn’t we be targeting this group to give them the best chance possible?
So far I am still unsuccessful in trying to find a smoking cessation campaign targeting seniors, in the meantime I have come across a few excellent videos that I thought I would share below.
Warner, David. (2005, January). Helping surgical patients quit smoking: Why, when, and how. International Anesthesia Research Society. Retrieved from http://www.anesth.umontreal.ca/3_etudes/documents/Arrettabagisme.pdf
I recently came across a new infographic that I love, and it reminded me to post on here about the importance of data visualization, especially when it comes to getting big messages across very quickly and in very few words. Our brains are visual. We only began reading and writing in the last few thousand years, and even then, it has been a rare gift and privilege for most of that time. However we have been visually absorbing information for as long as we, and our predecessors, have had eyes.
For some great online tools to create your own data visualizations, randing from prezi and pinterest to seal creators and gantt charts, I highly recommend that you check out this presentation: Data Visualization Tools PPT overview review created by Susan Kistler, (the American Evaluation Association’s Executive Director and aea365 blog Saturday contributor). In her words, the presentation covers 25 tools that “help us to merge truth and beauty“. You can download the full slidedeck from the AEA public eLibrary.
The infographic I mentioned (posted below) also reminded me that we, as health promoters are trying to s-p-r-e-a-d information and stop the spread of disease and poor health.
– Sarah Topps 2013
After hearing and reading so much about the Transtheoretical Model and the Stages of Change, I wanted to supplement Tara’s lovely presentation and this week’s readings with an exploration of motivational interviewing. So this post will talk about how motivational interviewing is related to our readings, what exactly it is, how it’s related to public health in general and I’ll leave you with a question to ponder or discuss in the comment section.
How is this related to our readings?
Parvanta mentions motivational interviewing in the text when she differs theory-base methods (stage-based behavioral adoption) from practice strategies (motivational interviewing) and activities/channels (counseling sessions). What this means is that Motivational interviewing or MI, is an intervention that delivers an adaptation of stages of change theory to actually change an individual’s behaviour. MI is not the only way of delivering an adaptation of the stages of change theory. Click here to see another way to deliver a practice strategy informed by the Transtheoretical model.
What is Motivational Interviewing?
MI is an evidence-based counseling intervention that has shown to be effective in treating people with addictions issues (for those interested in the evidence here is an open access journal article full of psychology jargon about MI).
MI is used to ‘move’ people in one stage of change to another by directing the conversation in such a way so that the client (and not the clinician) is the one coming up with the reasons (motivation) to change. Like my title suggests a quick and dirty way to understand MI is that it is remarkably similar to the “reverse psychology” our parents (or at least TV parents) used on us when we were kids.
A foundational concept to MI is that people often get defensive when someone else is telling them why their behaviour is bad and they need to change it. This results in the person putting more effort into justifying their behaviour and why they shouldn’t change than why they should. For this reason, MI places the burden of explaining why a behaviour is bad on the person who is doing it. It is argued that this allows the person to own the behaviour change and their own personal reasons for change. This ownership increases the likelihood of follow through and maintenance of the behaviour change. MI can be compared to traditional ‘intervention’ style, which use confrontation to attempt to motivate people into changing in their problematic behaviours.
Below is a video of Dr. Bill Miller, the creator of motivational interview, talking about traditional addictions approaches, the background and basics of MI.
This is public health course not a course in addictions. Why should I know about motivational interviewing?
MI is now being used for individual behavior change for behaviors like physical inactivity and healthy eating. The Public Health Agency of Canada is now promoting the use of MI techniques by physicians for supporting behaviour change in their patients (as seen in the video overview below). See their website for more videos on using MI techniques for specific behaviours (eg. physical inactivity).
A question for your consideration:
Motivational interviewing claims to be client driven but can also be portrayed as quite manipulative. What ethical considerations do you think are important to be aware of before using MI or any other change theories on the behaviour of others?