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
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