Innovation in Research Innovation in Research & Knowledge Exchange& Knowledge Exchange

Dr. Gina BrowneCASN ConferenceToronto, Ontario

May 8, 2012

Paradigm Shifts in Paradigm Shifts in Knowledge, Methods, Knowledge, Methods,

AnalysisAnalysis… starts with various or diverse notions of what is

known… what causes the known

“… we must depart from habits of mind that have characterized our usual (knowledge and) thinking.”

- Clyde Hertzman

Alternative Philosophical, Knowledge, Governance and Organizational Structural

Assumptions in Health Care Affecting our Thinking

Philosophies:Assumptio

nsLinear & Literal

Integrated Thinking

Health

…within the individual or within the environment…a state…an end

…an interaction between the individual and environment…capacity to respond (Antonovsky)…means to well-being…an indicator

Environment

…single or separate environments…social, natural or socio-economic

…the interaction between the individual and three environments

Community Support

…health care…single solutions…specialized services

…health promotion…network of human assets and resources…holistic services

Knowledge:

Assumptions

Linear & Literal

Integrated Thinking

Determinants of Health

…germ theory…host resistance…single causes

…inequities of social assets…multi-factor…multi-level

Research…process evaluation…what the masses say…limited dissemination

…outcome measured…evidence-based…shared success stories

Governance:Assumptio

nsLinear & Literal

Integrated Thinking

Policy Directions

…built in stages, based on crisis…independent silos…exclusive planning and policy development…hold information…single service provision…red tape, long time planning…always look “inside the box” for “return on investment”

…integrated governance…integrated planning…stakeholder model…knowledge transfer via improved computer technology…integrated service provision…innovative, learn from failures, risk taking…find new partnerships and promote “outside the box” thinking and new unused resources

Funding

…independent silos…shared or lost funding if partnered…return unspent money

…integrated funding…new funding for integration activities…savings held for future activities

Leadership

…directing…regulate and control…government planning…standards (“one size fits all”)

…building trust…guide, hands-off, shared control…self-organization…innovation

Community Organizations:

Assumptions

Linear & Literal Integrated Thinking

Structure

…single, segregated services…isolation, competition…standard…conflicting ideologies within mandates

…multiple, integrated services…inclusion, cooperation, partnerships…diversity…allow organizations to develop to meet the need of local community

Location …regional or provincial …municipal or neighbourhood

Stakeholders

…publicly financed for deficiencies…narrowly defined groups…limited to current health system…feelings of hopelessness…lack of control over work and environment

…community health, social, recreation assets that include resources to reduce inequities…increase in community resources…build the current health system and weave with other systems

Strategy

…primary care…provincial solutions…limited local community capacity…evaluate and criticize…regulation…focus on failures

…community health…local community solutions…build local community capacity…support and encourage innovation…entrepreneurship…focus on successes…recognize that health is not an end to itself, but is the result of improved policy in all other areas (work, environment, education)

Paradigm Shifts in Knowledge, Methods and Analysis… starts with various? notions of causation

Disruptive LinearInteractions or

Curvilinear

“The Tipping Point”

Malcolm Gladwell… sudden effects caused by a few in certain context

Examples:

• 911

• The Arab Spring

• Occupy 99% vs. 1%

• SARS

“Epidemiology”

721-1980’s

Dose/Response

Examples:

• Smoking & Lung Cancer

• Host Resistance

• Antibiotic resistant bacteria

“Human Development”

- Clyde Hertzman

Latent effects, risks interacting with protective factors

Examples:

• Adverse child events and chronic disease 40 years later

Paradigm Shifts in Knowledge, Methods and Analysis… starts with various? notions of causation (Continued)

Disruptive LinearInteractions or

Curvilinear

Criteria:

• Stimulus

• by a few

• occurring suddenly

• in specific context

Criteria:

• Consistent

• Strong

• Specific

• Coherent

• Temporal

Criteria:

• Interactions

• Non-linear

• Self amplifying

• Multiple outcomes

• Depends on meaning given events

Principles of causation in Social Epidemics “Tipping Point”The “boiling” point of massive modern change”by Malcolm Gladwell “Biographies of Mysterious change1. Contagious Behaviour or ideas:

… unexpected properties of things… “sticks”, makes an impact… because of reading , hearing, seeing, thinkinge.g… virus, fashion, crime, technologies

2. Law of the few:… little causes having big effects… geometric progression and out-of-proportion, not… proportional or gradual

3. Both contagion and the few happens in a hurry! Dramatic change “The power of context”

Examples:

1987 1 Million fax machines1989 2 Million fax machines

OR

1990 Cellular phone1998 Everyone has one

Example: Epidemic of Syphilis in Baltimore

1995 increase in S. Rates1. Crack Cocaine: brings in outside

people who take their behaviour home2. Reduced STD clinic staff by ½,

decrease patient visits, decrease outreach

3. Disruptive decrease in public housing: Index people moved

Different Ways of Tipping Growth of drug (stimulus) Growth (transformation) of disease:

from acute to chronic Transport of index people and

behaviours to a new neighbourhood

Extraordinary efforts by a few, change in the agent in certain context.

How can we create positive social epidemics?

Arab Spring? → Contagious message of social justice

sticks Occupy: Tax the 1%? Suddenly “man set

himself on fire”

“… Youth raising the village”

Youth rebels

Arab Spread

Epidemiology: 721 in 1980’s

Criteria for CausationConsistency: different study methods provide

similar resultsStrength of AssociationSpecificity: the precision with which one

component of an associated pair can predict the occurrence of the other

Coherence: the association is consistent with other known facts about the natural history and biology of the disease

Temporal relationship among associated variables: one precedes the other

Reality Is ComplexReality Is Complex

Figure 1: Bioecological Model of the Reciprocal Influences Between Environments on Child Development

ENVIRONMENTS

CHILDWell-being

Achievement- Birth Weight (HBHC)- EDI/KPS- EQAO- Emergency Visits

(10-24 yr. olds) - Special Needs

Parents-Neighbourhood-Family Constellation

Family- Med. Income- CAS- Gov’t transfer

School- ESL- Grade 3, 6, 10- Passing Test

Community- Population Health

and Human Service Utilization

LEGISLATIV

E

REGULATORY POLIC

IES

Causation is a result of the interaction between accumulating proximal and distal risk and protective factors. Therefore, the probability of an outcome is uncertain and unpredictable.

Causation (host resistance) results from a multitude of forces (genetic, biological, psycho, social): “equifinality”

Figure 2 Latent

Pathways

• Exposure causes outcomes that are:  latent (years later); cumulative (add up such as chronic poverty); pathways (one leads to another): poor readiness to learn leads to poor school performance; latent, cumulative, pathway outcomes are coexistent.

Life Course

ENVIRONMENTS

CHILDWell-being

Achievement

- Birth Weight (HBHC)- EDI/KPS- EQAO- Emergency Visits

(10-24 yr. olds) - Special Needs

Parents-Neighbourhood-Family Constellation

Family- Med. Income- CAS- Gov’t transfer

School- ESL- Grade 3, 6, 10- Passing Test

Community- Population

Health and Human Service Utilization

LEGISLATIV

E

REGULATORY POLIC

IES

Cumulative

Causation is non linear… is curvilinear (too much/too little).

Causation is iterative and recursive results from interactive, between repeated, self amplifying exposures to risk (stress) or protective (social support factors) over time: “cumulative” wear and tear, e.g., measured by allostatic load.

Figure 1 Intersection of Diversities can create Vulnerability

Source: Delore & Hubert, 2000

Poverty

Youth

Racial Discrimination

Sexual Discrimination

Mental IllnessPhysical Illness

Figure 3 Latent

Intersections of

Vulnerability Cumulative

Pathway

EarlySchool Age

Adult

Sensitive Periods

Causation is non specific: e.g., exposure to a disadvantaged environment causes multiple outcomes: "multifinality".

Poverty

Youth

Racial Discrimination

Sexual Discrimination

Mental IllnessPhysical Illness

Causation can depend on sensitive periods in growth and development; e.g., bonding and attachment.

Causation results from the meaning of the event and the appraisal/ability to manage in the face of the event; e.g., people endorsing experiences of racism and oppression associated with shortening of chromosomal telomeres - a novel measure of aging.

All the sources and mechanisms of causation happen simultaneouslyi. Interaction of multiple and distal factorsii. In humans with genetic, biological

psychosocial levels of host resistanceiii. Undergoing latent, cumulative and

pathways of causationiv. Non linearv. Repeated self amplifying risks ratesvi. Results in multiple outcomesvii. Depending on sensitive periodsviii. The meaning given events

Changing Assumptions about what is known about causation

Has led to changes in what we know, measure, methods of inquiry and

analysis:

Multi-level Interventions Enhanced Study Designs Multiple Levels of Measurement Multi-level Modeling Analysis

FROM: TO NEW FRONTIERS:

KNOWING …? Learning? Thinking? Creating? Applying?

What and Where? How? Why? When?

About? With?

Patterns/regularities? Exceptions/outliers?

Single causes? Multiple causes?

Order and linear steps of change?

Disruptive?

Psychiatric diagnosis? Sites and mechanisms of dysregulation?

Truths? Harms and goods?

Changing What We KnowChanging What We Know

About METHODS…?

Follow-ups? Timing of measure?

Administering measures? Co-creating meaning?

Eliminating co-interventions and cofounders?

Embracing complexity?

Clinical trials? Longitudinal life course research?

ChangingChanging

INTERVENTIONS…?

Standardization and fidelity to treatment?

Customization tailoring/choice?

Cramming new technology into existing structures (patient portals)?

Customized and choices in technology and therapy?

Single interventions? Multi-level/model interventions?

ChangingChanging

Calculating Sample Size: estimating › For main effects› For interaction effects

ChangingChanging

ANALYSIS…?

Categorical or linear analysis?

Multi-level or hierarchical regression analysis?

Avoiding multi co-linearity? To indexes that combine phenomena (e.g., anxiety and depression)?

Rules of statistics shaping knowledge?

To knowledge shaping statistical methods?

ChangingChanging

OUTCOME MEASURES…?

Achievements? Well-being? Happiness? Gratitude?

Absence of disease?

Costs?

Quality of life?Capacity to respond to

adversity?

Return on investment?

ChangingChanging