|overview of IDM Best Practices|
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jottings on best practices and:
Note: Best Practices Questions & Answers Parts I-III and V-IX are contained in jottings November 2004 to June 2005; Part IV is contained in the February 2005 reflection.
May 2004: jottings from Barbara Kahan
Research, policy and program delivery: three kinds of practice
It is common to talk about practice, research, and policy, where "practice" refers to program delivery, and only front line workers are "practitioners." I suggest a different view, where research and policy join program delivery in the realm of practice, and researchers, policy makers and front line workers are all considered to be practitioners.
Recognizing research, policy and program implementation as three kinds of practice which are inextricably linked to each other would benefit the health field considerably. It can only be a good thing for researchers and policy makers to have a sense of themselves as practitioners, and for front line workers to expect to have a role to play in research and policy making.
Otherwise we see researchers as producers of best practices for non-researchers, policy makers as identifiers of best practices for specific situations, and program implementers as the consumers or "users" of the best practices that have been produced and identified by others. In this scenario, best practices do not apply to the way researchers or policy makers go about their daily work; they apply only to program delivery. In this scenario, front line workers have nothing to do with research or policy making.
While implicit and explicit guidelines do exist regarding what constitutes the "best" research, it is time to expand these guidelines beyond issues such as accurate sampling, effective interviewing techniques and which statistical tests to use. Are the environmental strengths and challenges influencing a research project identified and addressed? Is evidence of the best way to foster good research team dynamics being applied? How are values reflected in any particular research project? And, what is the best way for researchers to collaborate with policy makers and front line workers to make research as relevant and usable as possible?
In the same way, it is time for policy makers to reflect on what best practices might mean for them. What is the best way for policy makers to collaborate with researchers and front line workers to make policy as relevant and usable as possible? What are the best ways of working intersectorally to make policy? What is the best way to give full consideration to values, theories, evidence, and the political context in making policy?
In addition to applying best practices, it is critical for front line workers to have a major role in developing and identifying best practices. Front line workers can accomplish this by being active "researchers" through ongoing informal reflection, formal evaluation, and collaboration with "professional" researchers. It is also critical for them to become actively involved in policy making through collaboration with policy makers.
In conclusion, I would like to acknowledge the researchers, policy makers and program implementers who already are making efforts to increase dialogue among the three groups and to broaden the concept of practice to include research, policy and program delivery.
best wishes to all,
P.S. Omitted from the discussion above are the populations which researchers, policy makers and front line workers hope to help. Would anyone like to contribute a reflection piece on this?
June 2004: guest jottings from Michael Goodstadt
Lessons for health promotion
The significance of the gap between current thinking and health promotion ideals (expressed, for example, in the Ottawa Charter for Health Promotion) was recently brought home to me. I undertook a small exercise in which I compared my own and my siblings' experiences with best practices. We were interested in identifying similarities and differences in the way in which we conceptualized and operationalized best practices in our respective professional fields. Our professional sectors have included quality assurance in: English Sixth Form Colleges; health care, social services and law enforcement sectors in the United Kingdom and Middle East; private sector companies of many kinds; and best practices in health promotion, public health, and health care in Canada. Our conclusions were:
1. There are many commonalities in the conceptualization and operationalization of best practices across public health/health promotion and other sectors with which we have had experience
2. Some commonalities might be surprising to health promotion practitioners, namely, other sectors' emphasis on:
a. Mission and vision
c. Theories and concepts
d. Internal and external environments
e. Evidence and evaluation
3. There are commonalities among values and theories/concepts across sectors-for example, a focus on social justice and the dignity of the individual.
From this experience my siblings and I drew the following lessons for health promotion practitioners (and for others who are interested in taking a best practices approach to decision making):
1. Be explicit about values
2. Be explicit about underlying conceptual models
3. Give greater attention to the role of organizational and management processes
4. Place greater emphasis on understanding and responding to external environments
5. Place greater emphasis on evaluation and other sources of evidence
6. Place greater emphasis on continuous quality improvement
7. Ensure a balance in the conceptualization and operationalization of best practices
Ultimately, we concluded, best practices in health promotion is the product of optimal decision-making, and exemplary management and organizational processes; best practices in health promotion should give more attention to the conceptual and operational advances being made in the fields of quality assurance and organizational management.
For best practices to become an integral part of health promotion practice, we will need a more complete understanding of the topography of the field of best practices and health promotion. In developing our new maps, we will address many conceptual and operational barriers. However, new initiatives are moving us further into the uncharted regions of health promotion and best practices. In five years, with the advantage of hindsight, we will wonder why best practices in health promotion had experienced so many growing pains. Such is the nature of exploration: we have to navigate many rivers, cross many mountains, and trek through many arid lands. Eventually, as with ancient maps of the old and new world, new maps will reflect our greater familiarity with the vast tracks of land currently designated as terra incognita. It is our belief that, if used wisely, the Interactive Domain Model provides a practical navigational tool that, like the surveyor's theodolite, will help health promotion to chart its best course within its multi-dimensional space, while maintaining its orientation to its preferred compass settings-its values, theories and understanding of the environment. In this way, health promotion will not only be effective, but it will "do the right thing".
take good care,
These guest jottings are excerpted from a longer paper, delivered to 2nd Annual Performance Measurement in Healthcare: Balancing Accountability, Efficiency and Quality of Care (Vancouver, BC, June 2004).
July 2004: jottings from Barbara Kahan
Notes on "understanding of the environment"
Recent questions about the IDM domain "understanding of the environment" have sparked this month's jottings. As many readers know, this domain involves an environmental vision and analysis of selected health and organization issues. In the IDM, environments include social, political and economic structures and systems, and physical and psychological conditions. These exist at group, organizational, community, regional, national, and international levels.
The first question was: Isn't an environmental analysis of health issues too restrictive - for example, does it include epidemiology? The second question was: Why specify an environmental analysis of the organization? These questions led me to re-examine the Model itself: Why an environmental analysis of health and organization issues? Why not just a general analysis of health issues, and why specifically mention the organization at all?
My thoughts as I consider these questions are:
First, none of the domains or subdomains are meant to be used independently. To understand specific issues we need to draw on our environmental analyses and information from other subdomains such as theories and evidence (which may or may not be environmental in nature).
Second, an analysis of health environments adds a depth of understanding not achieved otherwise. Take epidemiology as an example. While it is true that some epidemiological studies do not discuss environmental factors (although many do), the results can lead us to further exploration. For example, if epidemiology links certain behaviours such as alcohol misuse to poor health status, we can use an environmental analysis to ask which environmental factors lead to these behaviours and which environmental factors would support different behaviours. An environmental analysis of health issues moves us beyond a focus on the individual (behaviour and genetics) to include community and societal systems, structures and conditions. With this broader focus we would look at things such as the impact of income inequity on alcohol consumption and its effects, the role of liquor companies, government policies regarding alcohol sale and advertising, the drinking norms for a particular group, accessibility of liquor stores, and effect of community optimism on alcohol use and impacts. In other words, an environmental analysis moves us towards a consideration of the social determinants of health, which encompass economic, political, and social influences.
Third, organizations which understand the environmental factors affecting them are well placed to do their work of addressing health issues. Analysis includes identifying environmental strengths and challenges and identifying strategies to increase strengths and address challenges. Within the organization an environmental analysis might look at work-place health, morale, capacity building, communication, and access to high quality resources. External to the organization an environmental analysis might look at relationships with community members, funding sources and conditions, possibilities for collaboration, policies and regulations, and globalization. I remember vividly the members at one site we worked with who were delighted to realize it was "legitimate" to put effort into making their organization more supportive of their work efforts; they were even more delighted when some of their efforts were successful.
August 2004: guest jottings from Michael Goodstadt
Where is health promotion best practices going?
As I look back on my experience with health promotion and best practices, and forward to the next decade, I am led to a number of conclusions, some of which are encouraging and some of which represent challenges.
First, the field of health promotion is still in its infancy; however; it is managing to pull itself up and stand on its own feet. The past 10 years have witnessed an exponential growth in the quantity, quality and range of theoretical and empirical developments related to health promotion. The field now exhibits greater confidence regarding the meaning of health promotion, how we "do" health promotion, and theory and evidence that guides our practice. We no longer stand in silent embarrassment when faced with the charge that health promotion is mere ideology. We now agree that, while ideology (in the form of our values and goals) is important, we are guided by a significant and growing body of conceptual and empirical knowledge.
Second, health promotion is not a water-tight silo of knowledge and practice. It is an inter-disciplinary field of practice; in this respect it is similar to fields such as medicine, education, public health. Health promotion principles and practice are also making significant contributions to an array of related fields, including: community health, hospital based health care, international health, public health, health education, and chronic disease prevention.
Third, there is a growing interest in best practices in health promotion. Some initiatives have developed best practices frameworks (sometimes building on our experience with the IDM). However, a larger number of initiatives have focused exclusively on evidence of effectiveness in identifying best practices with respect to specific health related issues.
Fourth, health promotion is making advances in identifying the evidence-base for its practice decisions. There are many regional, provincial, national and international initiatives designed to identify, analyze, assess, synthesize and disseminate evidence related to health promotion in general, and interventions regarding health related issues in particular. As part of our Best Practices Project, we addressed the challenge of bridging the gap between research and practice by developing a "Framework for the best practices use of evidence in health promotion," and by compiling an extensive array of relevant resources.
Fifth, in tandem with its growing attention to evidence, the field of health promotion is giving increased attention to the challenges associated with evaluating health promotion initiatives. These challenges have both ideological and methodological roots. On the one hand, there is considerable debate among health promotion practitioners and researchers/evaluators about the appropriateness of traditional positivistic research methods; emanating from this debate is considerable disagreement concerning the appropriateness and value of quantitative and qualitative methods.
Particularly problematic is the growing trend within health promotion to view evidence of effectiveness as the principle criteria for best practices. This perspective is, perhaps, more prevalent in government, public health and among those concerned with chronic disease prevention. However, as the IDM argues, this fails to acknowledge that most decision making (and, more importantly, effective decision making) involves consideration of values/goals, theories/beliefs, and an adequate environmental analysis.
take good care,
These guest jottings are excerpted from a longer paper, delivered to 2nd Annual Performance Measurement in Healthcare: Balancing Accountability, Efficiency and Quality of Care (Vancouver, BC, June 2004).
September 2004: jottings from Barbara Kahan
One of my health promotion beliefs is that building on individual and collective strengths will result in healthier individuals and communities. My question over the last couple of years is how to put this belief into practice in my evaluation work. And so, as I start another program evaluation, I find myself reflecting on strengths, which I define as any positive factor that can be drawn on or built on including:
As I reflect I ask myself why I believe a focus on strengths is so central to improving health. The answer I come up with is based on my own personal experiences and observations of other people. I am more motivated, have more fun, and, as far as I can tell, achieve better results (or, at least, achieve better results more quickly) when I concentrate on what I and others are doing well, the good things I and others bring to a project, and everything I have to be grateful for, than when I am busy worrying - about all the things I am not doing well, about lack of supports and resources, about lack of knowledge and skills. From what I have seen this applies to other people as well.
A focus on strengths, to me, doesn't mean ignoring challenges. Rather, I think, it is a matter of emphasis, order, and linkage. Translated to my evaluation work, this means I should emphasise strengths at least as much as challenges, identify strengths before challenges (it being much easier to face daunting things when people feel strong), and understand that the way to successfully address or moderate challenges is by building on and using strengths. In other words, yes, it is extremely important that an evaluation identify challenges - in the context of strengths.
There are a number of ways in which I am currently trying to integrate a strengths-based approach into my evaluation work. One is, in order to increase overall program strengths, to encourage as much as possible the identification, development and utilization of strengths among everyone who is affected by the program: the people the program is for, staff at all levels, board members, and external supports (including funders, organizational partners, me as the external evaluator). This involves, if the people I am working with agree, including questions about strengths in the evaluation, for example:
Another way I try to focus on strengths is to recognize and use the best of what everyone involved in the evaluation has to offer as we shape and conduct the evaluation and learn from and follow through on evaluation results. An extremely important strength for evaluations is people's first-hand experiences related to the program's processes and activities and the issue the program deals with. People's amazing commitment and dedication and determination to achieving program goals are also extremely important evaluation strengths. Other strengths range from people's common sense to their skills and knowledge. To build on these strengths, I try to gather experiences, perceptions and information about the program from as many groups affected by or involved with the program as possible, and involve as many people in the actual doing of the evaluation as are interested and/or have relevant knowledge and skills to offer. It is difficult to express how much I am impressed, over and over again, with the vast amounts of time and energy extremely busy people are willing to devote to an evaluation because they truly want to know how to improve their program.
In addition, regarding the integration of a strengths-based approach to evaluation, I make every effort to share my evaluation knowledge, skills and enthusiasm so the people I am working with increase their evaluation strengths. It is incredibly satisfying to see people's confidence in their evaluation abilities grow, and to hear someone whisper before the start of an evaluation meeting, "I never thought I'd say this, but I'm actually looking forward to this evaluation!" A major benefit of sharing what I know and feel, I find, is how much I end up learning from the people I am working with, thereby increasing my own strengths.
Finally, in all communications, I am attempting to consciously use language which is phrased positively rather than negatively - which results in having to rewrite things even more than I used to, but is I think well worth the effort.
October 2004: guest jottings from Michael Goodstadt
A health promotion journey
My personal journey in the land of health promotion best practices spans 40 years, beginning with my early encounter with the prevention of cancer. From my review of the cancer field in the early 1960's, I concluded that effective cancer prevention (and treatment) depended on a complex array of individual cognitive, motivational and behavioural factors, embedded in a larger context of socio-cultural values, attitudes, norms, and responses related to cancer, health and illness. Looking back at this early work, I am struck by the consistent thread that has weaved its way throughout my professional career. I have had a consistent interest in finding and assessing evidence concerning the effectiveness of health-related interventions. I have always taken a perspective that extends beyond my original discipline of psychology, to include the broader social sciences. I have always been interested in exploring the contribution of theoretical constructs to programmatic and policy responses to health related issues. I have always been involved in the generation of new knowledge through program development and evaluation, and other forms of research.
The two middle decades of my career were devoted to exploring the jungles of prevention related to alcohol, tobacco, and other licit and illicit drugs. During that time, I undertook many reviews of the effectiveness of program and policy initiatives. I also contributed my own share to the research literature as a result of my program development, research and evaluation.
I have devoted the last 10 years to exploring the larger world of health promotion, especially the effectiveness of health promotion, and contributions that taking a best practices approach might make in enhancing health promotion. During this time, I have been at the Centre for Health Promotion at the University of Toronto. However, I must go back a few more years to make an important connection between my addictions work and my interest in health promotion. In the late 1970's I presented a case to my masters at the Ontario Addiction Research Foundation (they were all "masters" in those days) for organizing our diverse research units under an informal prevention umbrella; this would have included those involved in program development and evaluation, policy development and research, and social and medical epidemiology. My suggestion was summarily rejected-"no one agrees on what prevention means". Within a few years I found myself in a "prevention studies department," and was responsible for mounting a series of professional development courses on the subject of prevention in the field of addictions!
By this time, of course, prevention was being superseded by the emerging concept of health promotion. A milestone in this evolution was characteristically Canadian, led by Marc Lalonde's ground-breaking publication "A New Perspective on the Health of Canadians" . Pushing current conceptual boundaries, Lalonde proposed that the health field can be divided into four broad elements: human biology, environment, lifestyle, and health care organization. This document reverberated around the world. Most jurisdictions recognized the significance of focusing on the complex and inter-related array of health fields, rather than on the two traditional contenders, biology and/or lifestyle. Marc Lalonde's document has been criticized for its conceptual limitations. It has also been blamed for the lifestyle perspective that has characterized the United State's response to health related issues. Nevertheless, "A New Perspective on the Health of Canadians" was a stunning success in two respects: (1) first, it laid the foundation for the further development of thought and practice regarding effective responses to health issues, and (2) second, it put Canada on the international map with respect to health in general, and the prevention of health related problems in particular.
Ensuring that we are using the same map
By 1984, the conceptualization of health and the prevention of health problems was developing at a rapid pace. By 1985, the European Region of the World Health Organization (with leadership provided by Canada) was developing a new ground-breaking framework that would be released to the world at the (First) International Conference on Health Promotion, held in Ottawa in 1986. Appropriately, this framework document came to be known as the Ottawa Charter for Health Promotion . It is difficult to overstate the importance of this document. It has become the touchstone of health promotion around the world, with the possible exception of the United States ; it is the bible upon which "true" health promotion practitioners swear allegiance; it is the starting point for all subsequent WHO policy statements related to health and health promotion; it is the foundation for the development of national health strategies around the world; it forms a key element in Health Canada's concept of "Population Health Promotion" and in the "new public health" . However, it also presents a host of challenges (as well as opportunities) as we attempt to identify, develop and implement best practices in health promotion.
According to the Ottawa Charter for Health Promotion,
"Health promotion is the process of enabling people to increase control over, and to improve, their health." Associated with this definition is an understanding that health is "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity" (WHO, 1946). According to the Ottawa Charter, "Health is a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities."
The Ottawa Charter challenges traditional responses to health issues by arguing emphatically that health promotion "goes beyond lifestyle to wellbeing," and that "Health promotion is not just the responsibility of the health sector." In guiding the development and implementation of health promotion, the Ottawa Charter focused on the "prerequisites for health," that is, the "fundamental conditions and resources for health" , three major strategic approaches , and five action areas. I have tried to summarize these (and other) principles and concepts of health promotion in a single logic model.
Embarking up the river of best practices
By the mid 1990's, I was fully committed to the emerging field of health promotion research and practice. I had explored in detail the developing concepts associated with health promotion. I had emerged from a three year sojourn in the United States to head a new department at the Ontario Addiction Research Foundation committed to "Health Promotion and Prevention, Research and Development"-an organizational experiment whose title contained the seeds of its ultimate failure (no one knew how to, or was prepared to, control a matrix of such competing agendas). In 1994, I migrated painlessly to the Centre for Health Promotion at the University of Toronto. I was able (and willing) to employ my 30 years experience in the prevention sector of health research to two major challenges facing health promotion, namely: (1) the conceptualization of health promotion, and (2) the effectiveness of health promotion practice.
I soon found myself in one of my favourite places, that is, reviewing evidence concerning the effectiveness of interventions; in my new setting, I was concerned with health promotion. It is appropriate that, ten years after delivering the results of this work at a conference in Brisbane, Australia , I should have recently returned from the 18th World Conference on Health Promotion and Health Education held in Melbourne Australia. At this recent venue, I (together with two siblings and a friend) reported on an analysis of commonalities and differences in our experiences with best practices in widely differing public and private sectors-I will return to this analysis later in this paper.
In 1996, the Centre for Health Promotion embarked on what would evolve into a five-year "Best Practices" project, involving myself and Barbara Kahan as co-leaders, in collaboration with a large group of advisors, agencies, and practitioners. Our Best Practices Project was, in part, a response to the zeitgeist, or the spirit of the times, that included: (1) growing emphasis on evidence-based practice in medicine, nursing and other health-related disciplines, (2) growing attention to best practices and quality assurance, especially in the European health promotion community , and (3) growing concern with accountability and effectiveness, especially on the part of government and other funders-this was sometimes expressed as getting the "biggest bang for the buck".
take good care,
These guest jottings are excerpted from a longer paper, delivered to 2nd Annual Performance Measurement in Healthcare: Balancing Accountability, Efficiency and Quality of Care (Vancouver, BC, June 2004).
November 2004: jottings from Barbara Kahan
Best Practices Questions & Answers Part I: For which groups of people, settings, and issues is the IDM approach best suited?
This month's jottings contains the first instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see the report on the proceedings of this event, click here.) Future jottings will contain answers to more questions.
A number of participants' questions related to the fit between the IDM approach and particular groups, settings and issues. I have answered these questions in three sections. The original questions are italicized.
Who is the target group of the IDM (i.e. health promotion professionals, lay people, students)? What setting was the IDM created for: public health, research, community?
These two questions are the easiest for me to answer so I will start here! The IDM is designed to be used with any group of people, in any setting, with any issue. It is a generic approach with a flexible framework for guiding groups through a process which will improve practice. One of the underlying beliefs of the IDM approach is that what works in one situation will not necessarily work in another. For this reason the IDM approach does not dictate the details of how its framework should be applied, but allows each particular group to adapt the approach to fit the specifics of its own membership, setting and issue. It has been used with health professionals and lay people, in community health centres, public health units, and hospitals, and for a number of organizational and health and social issues.
In our experience, the successful application of the IDM approach did not depend on the type of group, setting or issue, but on the existence of the following factors:
Is there a better time (situation) to use the IDM? e.g. a bigger project with more time/resources? IDM seems like it is structured for larger organizational planning/larger projects: Can it be applied to smaller projects/initiatives?
These questions surprised me as I have always assumed the IDM would be much easier to use with smaller projects, at least to start with, because it is easier to coordinate and discuss and sort things out with a smaller group of people than with a larger group - and with the IDM there is a lot of sorting out to do. In fact to date the IDM has only been used with smaller projects (as far as I know).
Some of these projects, however, did take place in the context of large organizations, and in at least one case the impact of the IDM has spread from the smaller project to the larger organization. (See, for example, the presentation by Dilys Haughton in the report on the recent best practices session.)
The fewer the number of people involved and the less complex the initiative the less time will be required to identify the areas of agreement and differences regarding values, theories, beliefs, evidence, and understanding of the environment. While having more people involved could make the task of gathering and analyzing evidence easier, small projects still need to look at what other initiatives are doing and evaluate what they themselves are doing.
I have evaluated a few projects where the whole organization was successfully using an approach similar to the IDM, but these were smaller organizations (small, that is, compared to a large sized hospital or public health unit). It would be ideal to use the IDM approach across a whole organization, whether small or large, but it would have to be phased in as a long-term effort. (I hope some will; I feel confident the results would be worth it!)
Can the model be used for communicable disease in the aspect of health prevention and promotion, i.e. latent syphilis, latent TB, HIV, diseases starting as acute then becoming latent or chronic? Can or has this model been used in promoting healthy cultural relations re. racism/discrimination, i.e. the workplace?
(The response that follows was sent a while ago to the best practices session participant who emailed this set of questions to the website.) Yes, the IDM can be used for communicable latent or chronic disease! The model is generic and based on a "fill in the blanks" approach - practitioners gave a very clear message early on that they didn't want a "one size fits all" approach; this applies not only to how people address an issue but to what the particular issue is. All the IDM "sub-domains" are as relevant to, say, chronic TB as they are to any other issues; that is, for any issue it is important to consider:
While I am not aware of the IDM being used specifically to promote healthy cultural relations re. racism/discrimination in the workplace, I don't see why it couldn't be. It would, again, be a matter of applying the "filter" of the sub-domains to the planning/evaluation/implementation pieces to ultimately figure out who will do what, and when and how will they do it, in order to achieve the particular objectives identified by going through the process.
The IDM can be applied informally without having to refer to diagrams and boxes and computer programs - the important thing is to have the discussions so everything is made explicit and can then be addressed or followed up on. For example, for this particular topic, discussions might cover:
If anyone would like to add any thoughts about the questions above, please email!
Note: Report on the Proceedings from Best Practices At Home and Abroad contains several reports on using the IDM in different settings and with different issues. November's reflection by Hélène Roussel describes the experience of a Francophone volunteer organization in using the IDM.
December 2004: jottings from Barbara Kahan
Best Practices Questions & Answers Part II: Why would anyone want to use the Interactive Domain Model when it sounds so difficult?
This month's jottings contains the second instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see the report on the proceedings of this event, click here.) Future jottings will contain answers to more questions.
The discussion that follows is a somewhat revised version of the response sent to the best practices session participant who asked "why would I want to use this model" when it appears "difficult and time intensive to use and would require additional help?"
For me the most compelling reason to use the IDM approach is because it is a holistic comprehensive approach which provides many benefits for those who understand it and use it in a committed systematic way. (For example, see some of the presentations in the report on the session Best Practices at Home and Abroad, November's reflection by Hélène Roussel which describes the experience of a Francophone volunteer organization in using the IDM, and the IDM Manual section Case Studies.) If we don't use an approach based on the importance to our work of values, theories, evidence, and understanding our environments, I doubt we will ever change anything fundamental in a positive way.
The IDM approach appears difficult only when compared to other approaches which are not holistic or comprehensive. For example, it is simpler to work with an approach which takes a narrow evidence-based approach and ignores the relation of evidence, and practice itself, to values, goals and ethics, theories and beliefs, and understanding of our many environments. These simpler approaches, however, do not accurately reflect the reality of life and will not get us the results required to move forward. The IDM approach to best practices is not harder than any other approach that takes into account a whole range of factors; in some ways it may be easier because we now have a body of experience and a number of tools to assist us in using the IDM approach.
While an IDM-like approach may be difficult for some people, it is not difficult for everyone. Some organizations use an approach to their work which is very similar to the IDM approach, though they may never have heard of the IDM. They base their practice decisions on a wide range of factors - from values to context - because to do so makes sense to them. While this may require more effort than if they based decisions on only a couple of factors, say evidence and resources, they do not find the more complex IDM-like approach overwhelmingly onerous. Despite the effort required they continue to use such an approach because it gets them good results.
When I evaluate an organization using an IDM-like approach, I see that they already have their principles or values identified, they have a specific set of theories and beliefs that they use, they know where to look to find information about what others are doing in their area, they have evaluation processes already in place, they are aware of what is going on in their environments at all levels, they are reflective and questioning in an ongoing way, and they are able to make decisions which fit with their particular values, theories, context, and relevant evidence. The details about values and the rest may be scattered amongst a number of documents (vision statements, annual reports, evaluation reports), but can be readily extracted in order to assess whether practice (processes and activities) is consistent with the other pieces and what changes are required to increase consistency.
It can be time consuming to go through a process of identifying group values, theories, understanding of the environment, and evidence-finding/assessing methods if these pieces are not already in place. But, like building a house, preparing a strong foundation makes a stronger structure, makes future problems less likely, and improves quality of life. And yes, regularly reviewing what we are doing and how to do things better takes time, but is necessary if we are to continuously improve.
Ultimately, learning how to use IDM is not any different from learning other new skills or new ways of doing things for which we have to, at least initially, put out extra effort and perhaps get training. People from sites who have used the IDM have said that as they continue to use the IDM it becomes much easier. And, as one site pointed out, the effort we take to do it in the short term will actually save us time in the long term. (This point, about best practices in general, is also made by Lisa Brownstone in December's profile.) As we are going to be making decisions anyway, we might as well use an approach that encourages critical reflection and takes into account the comprehensive set of factors influencing our work.
If anyone would like to add any thoughts to this discussion, please email!
January 2005: jottings from Barbara Kahan
Best Practices Questions & Answers Part III: How does the IDM address competing, conflicting or shifting values?
This month's jottings contains the third instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see the report on the proceedings of this event, click here.) Future jottings will contain answers to more questions.
One of the participants at the Best Practices session asked:
In the development of IDM, what happens when there are competing/conflicting/shifting values? How would the above be addressed?
I have been very much looking forward to answering this set of questions about values - to me the role of values in practice is not only extremely important but extremely fascinating because of all the complexities involved - the differences from person to person, group to group, situation to situation; how our understanding of values changes over time; the various impacts values can have, depending on other influences.
As individuals and groups we all hold a number of things dear to us - things that we value - which might range from family and good health to material comfort and art. But where values are concerned, life is not always straightforward.
While some values can in most circumstances happily co-exist, occasionally they compete, forcing us to choose one over the other and prioritize our values according to the particular situation or according to our personal or organizational preferences. For example, we might, on the one hand, value having balance in life, and, on the other hand, value getting our work done in a timely fashion. And we might actually manage to achieve both for the most part. Once in a while, however, say when a grant proposal deadline is looming, we might put balance on hold and work flat out to finish the proposal. On another occasion, our child might be sick so we stay home regardless of the work piling up.
Sometimes we work with other individuals or groups whose values conflict with ours - say, for example, one individual or group values a top down decision making structure while the other values a collaborative decision making structure. The values are so opposite to each other they can never fully exist in practice at the same time.
Occasionally our values shift - a value we hold now, either as an individual or a group, might totally change whithin three years.
The IDM Framework assumes that any initiative will experience amongst its members and associates competing, conflicting and shifting values. That is why the IDM approach focuses so strongly on underpinnings, which includes values. The first column of the IDM Framework - criteria and guiding principles - is where an initiative would outline how to deal with issues related to values.
A set of IDM-compatible steps to address competing, conflicting and shifting values are for an initiative's key stakeholders to:
In some cases it may not be possible to resolve differences into complete agreement. However, in the IDM view, it is better for everyone to understand clearly what the differences are than to assume that there are no differences, or to guess wrongly what the differences are. Knowing where everyone stands allows an initiative to move forward with all major players' values in plain sight - rather than bumping into unexpected roadblocks, whose origins often originate (thought we may not realize it) in values-related differences.
This discussion about competing, conflicting and shifting values also applies to goals and ethics, underlying beliefs and assumptions, theories and concepts, and evidence - the other basic components of the IDM's underpinnings domain.
February 2005: jottings from Barbara Kahan
Best Practices Questions & Answers Part V: Is the term "Best Practices" really representative of health promotion values?
This month's jottings contains the fifth instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see the fourth installment, click here.
The question that inspired the most animated discussion at the September 2004 best practices session in Toronto was:
Is the term "Best Practices" really representative of health promotion values? i.e. Best Practices seems more of a medical model or RCT term than a health promotion term.
Some of the concerns raised by participants at this session, at other sessions I have attended over the years, and in the Best Practices Needs and Capacities Scan carried out a few years ago are that, in opposition to health promotion values, the term "best practices" and/or its application:
My response is that yes, absolutely, all of these points could be true, depending on which definition of best practices is used. For example, a narrow evidence based definition which disallowed new initiatives unless a body of evidence demonstrates their effectiveness would indeed discourage creativity. However, a best practices approach with theory as a criterion would allow new initiatives if thoughtful reasons existed for expecting positive results from the new way of doing things.
Or, reflecting on the quantitative-qualitative debate - while it is true that most hierarchies of evidence put quantitative evidence at the top of the heap, this is not true of all best practices approaches. The IDM, for example, states in its suggested guidelines that evidence should be both quantitative and qualitative. In my personal best practices approach, which is based on the IDM, I use quantitative and qualitative data, methods and analysis in the evaluations I conduct.
Qualities such as competitiveness, inflexibility and unattainability are not intrinsic to the term best practices but rather rely on how the term is defined and applied. Take the point about competitiveness - the way I look at it "best" implies comparison but not necessarily competition, with practices ranging from worst (implications of harm being done or making no difference) to best (causing no harm and doing the most good possible in the best way possible, given current circumstances). The comparison for me is not with other groups, but rather amongst the range of practice possibilities, thereby avoiding competition.
I do not think of "best" as the achievement of perfection because that definitely would make it unattainable. All of us are supported in some ways and constrained in others by the nature of the resources, politics, attitudes, and other factors that surround us. After identifying and taking into account current conditions and what this means for what we can and can't do, I think it is important for us to do the best we can. Why do a good job when we can do a better job - and why do a better job when we can do the best job possible, given existing circumstances? And if we do the best job we can given what we've got to work with, then maybe circumstances will change in a positive direction and our definition of "best" will also change...In other words, thinking about doing our best is not setting the bar to some unattainable height; rather, it is understanding what our strengths and limitations are, and doing the best we can with what we have, celebrating our successes rather than worrying about what is impossible for us to achieve - and, in addition, recognizing that circumstances change all the time and therefore our practice must change all the time.
I do admit to a bias - I really like the IDM definition of best practices because it addresses most if not all of the concerns people have about best practices. The IDM definition is based not just on evidence but on values, theories and understanding of the environment, identifies practice as occurring within a particular situation rather than assuming that what works in one place will work somewhere else, and links processes, activities and goals. In other words, what we do and how we do them are inseparable from the outcomes of our programs.
In the end, however, I think it is not important what term we use as long as when we make our practice decisions we do so with as clear an understanding as possible of the whole complex web of factors in which we live.
March 2005: jottings from Barbara Kahan
Best Practices Questions & Answers Part VI: Best Practices Models
This month's jottings contains the sixth instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see previous installments, go to jottings November 2004 on and reflection February 2005. Future jottings will contain answers to more questions. This month's questions are:
1.What other best practices models exist [in addition to the IDM]?
2.What is the consensus (on model to be used) in field to determine best practices?
For most people, an evidence based/what works approach and "best practices" are synonymous. Other best practices approaches, however, also exist. Brief descriptions of the major categories of best practices approaches follow (adapted from the list provided in Best Practices in Health Promotion: A Scan of Needs and Capacities in Ontario by Kahan et al., 1999):
Most current evidence-based approaches include specific steps for identifying evidence and a "hierarchy of evidence" rather than models - for example, see A Proposed Schema for Evaluating Evidence on Public Health Interventions by Rychetnik and Frommer. Randomized control trials (RCTs) generally receive the "gold star" in these hierarchies as being the research design most likely to produce the strongest evidence, sometimes with recognition that RCTs are not always appropriate. One example of an evidence-based approach that does have a model follows:
Better Solutions for Complex Problems. The model described in Better Solutions for Complex Problems: Description of a Model to Support Better Practices for Health (Moyer et al.) is organized into a three-stream loop which connects practice, policy and research through the "world of evidence." Practice, policy and research each has its own set of steps. According to the abstract of this document:
"The model described here defines better practices as plausible, appropriate, evidence-based and well-executed actions associated with processes likely to have the greatest impacts on reducing current and future burdens of disease. The model recognizes that what is 'best' will be subjective, situation-specific, and changing over time. The main components of the model require interactive collaboration between research and practice and are grouped into (1) building on existing knowledge from work done in the past, (2) taking sensible action in the present, and (3) contributing to the wisdom of the future."
The other best practices models that I know of belong to the holistic category. A few of these are described below.
Interactive Domain Model (IDM). The IDM is discussed elsewhere on this website: The IDM approach includes a model, general framework, evidence framework, underlying premise, best practices definition, and supporting resources.
Nova Scotia Best Practices Framework. The IDM is credited as being "an insightful resource" in the development of the Nova Scotia Best Practices Framework. This model's definition of best practices is that "Best practice is a continual process of reflecting on how to improve a systematic examination of health promotion work and uses a process of critical reflection to draw out our collective knowledge of what we know works well." In this approach six units contain components:
Applied to each component are the following questions:
A Model for Developing Best Practices for Interdisciplinary Teams in CHCs/AHACs. In the Association of Ontario Health Centre (AOHC) model, "Best practices aim to (1) adapt practice in ways that suit the particular issue and context and (2) share stories, tools and understanding so that we don't keep reinventing the wheel. Best practices include the incorporation of: philosophy and values, guidelines for practice based on evidence, indicators of positive intervention, and processes of staff, volunteer and community involvement (in design, implementation and evaluation)." (Rishia Burke, Susan Arai, and Shelly Walkerley . Interdisciplinary Team Tool Kit For the Development of Best Practices, Association of Ontario Health Centres)
A description of the AOHC model follows, from the Best Practices in Health Promotion Project 5th Annual Stakeholders' Meeting Report (Jennifer Boyko, 2002 - Centre for Health Promotion, University of Toronto):
The AOHC Best Practices Model, specifically for CHCs [Community Health Centres], "emphasizes the dynamic nature of developing a best practice. The model is based on a series of five dichotomies, namely: (1) outcomes versus processes, (2) standardized practice versus adaptation to community context, (3) patient/participant/community responsibility versus addressing systemic issues, (4) multidisciplinary versus interdisciplinary teams, and (5) guidelines versus practitioner experience and innovation. The tension that can arise between each dichotomy can create barriers to effective practice. However, working through these dichotomies (e.g., by considering what is a 'standard practice' versus 'adaptation') will result in 'best practice.'"
These dichotomies are organized under three categories: Evidence & Evaluation; Adaptations & Advocacy; Approaches to Practice.
A Best Practice Model for Health Promotion Programs in Aboriginal Communities. According to a leaflet about this Australian model, "The model [Royden James Howie] developed uses a community development approach, which seeks to train and empower people from within the communities to promote healthy lifestyles. This 'best practice' model has four key dimensions" which relate to principles of:
In response to the first question, I have briefly described above a few best practices models. My response to the second question is that a consensus on which best practices model or approach to use does not exist. The majority view is that evidence, based on a hierarchy with RCTs at the top, determines best practices. The minority view is that a number of factors determines best practices; evidence - usually broadly defined in holistic approaches - is only one of these factors. Further, some best practices models - such as the AOHC model - were developed within a specific context and are intended for use with a specific population, not for general use. We can, however, learn from all of the models.
Notes:In this month's jottings I use the term "model" to mean a diagram showing the relationships between two or more factors, such as people, concepts, processes, activities, socio-political conditions, or outcomes. Please email if you know of best practices models related to health promotion, public health or population health other than the ones described here.
April 2005: jottings from Barbara Kahan
Best Practices Questions & Answers Part VII: Logic Models and Flexible Frameworks
This month's jottings contains the seventh instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see previous installments, go to jottings November 2004 on and reflection February 2005. Future jottings will contain answers to more questions. This month's jottings discusses two questions. The first question is:
1. Key differences between logic models and IDM: how do/can they fit?
If we define a logic model as a diagram that shows the logical relationships between three or more factors, then the IDM Framework is a logic model designed to help us make sure that there is consistency amongst the three domains of practice, underpinnings and understanding of the environment. We can use the Framework to provide an overview of the three domains, or broken into parts to allow more detail. This website includes a discussion of an IDM Logic Model which shows how to link practice to underpinnings and understanding of the environment through sets of practice-focused objectives for values, theories and other sub-domains.
We can also use the IDM with other types of logic models. The IDM at its most basic level is simply an approach to work which emphasizes:
Any tool that supports this kind of approach fits very well with the IDM. Logic models in particular are very helpful for groups who want to use an approach like the IDM because the construction of logic models demands a great deal of thinking and discussion regarding the pieces they include, and because generally logic models are designed to have an impact on practice - that is, they are not abstract exercises with no daily work relevance.
2. How do you ensure the flexibility of framework/planning to "think outside the box"?
The scenario that prompted this question, presented at the Best Practices at Home and Abroad session, was one where a lawnmower was purchased with a grant - not something one would expect under most funded planning guidelines. The results, however, were extremely positive for that community in a number of different ways.
This is a question that got me thinking. What I have concluded is that part of the answer is to choose flexible frameworks/planning guidelines, ones that are open to considering a number of factors or ways of doing things and that actively encourage thinking outside of the box. For example, the IDM challenges us to think in different ways from our usual about a range of factors, from underlying beliefs and assumptions to organizational and societal contexts (with a lot in between).
Another part is to make sure that we recognize that whatever framework or planning guidelines we choose are tools with limitations for which we need to compensate - no framework or planning guidelines can fully capture the reality of life. Whether in the area of health or any other, life is not easily pinned down or defined - it constantly changes shape, and there is always more than one way of looking at anything. We can use frameworks or planning guidelines and still think outside the box by bringing our own understanding and experiences and vision to our use of them, remembering that the purpose of frameworks or planning guidelines is to help us, not to rule us. In other words, not only do we want flexible frameworks and planning guidelines, we want to be flexible in our use of any framework or planning guidelines.
The last part of my answer on how to ensure thinking outside the box when using frameworks and planning guidelines is to allow ourselves to be both critical and creative in our work - critical by questioning assumptions, and creative by being open to new ideas and ways of doing things. This means accepting that we will sometimes make mistakes - from which we can learn - and that doing things in different ways from the usual will sometimes result in unsuspected benefits.
May 2005: jottings from Barbara Kahan
Best Practices Questions & Answers Part VIII: Evaluating the IDM
This month's jottings contains the eighth instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see previous installments, go to jottings November 2004 on and reflection February 2005. Future jottings will contain answers to more questions. This month's jottings discusses the following questions:
Apart from today's testimonials, have there been studies evaluating the IDM model? By whom?
The answer to the question about whether there have been studies evaluating the IDM is yes and no. In terms of formal evaluation, a process evaluation of the original pilot testing of the IDM Framework was conducted; the report Pilot Testing the Best Practices in Health Promotion Framework describes the results. A process evaluation of the testing of the IDM Evidence Framework was also conducted, but although the results informed the next version of the IDM Evidence Framework these results have not been written up (yet!). The evaluations of the pilot sites' use of the IDM were conducted by the IDM facilitators who worked with the sites - that is, Michael Goodstadt and myself.
In terms of informal evaluation, in the nature of ongoing reflection and review, some of the sites who participated in pilot testing the general IDM Framework or the IDM Evidence Framework have contributed ongoing reports on the impacts - positive and negative - of using the Frameworks and how the Frameworks might be improved on the basis of their experiences. These reports are collected in the IDM Manual section Reports on Using the IDM.
There has, however, been no formal long term evaluation of outcomes for groups using the IDM as opposed to use of other tools, models or frameworks. Such an evaluation would be challenging to do, but could be done if the funding were available. I very much hope resources will be found and an evaluation conducted in the near future because we would learn so much from it. In addition, it would be very exciting! In the meantime, it would be great if any groups out there using the IDM would send me their stories - who you are and what did you use the IDM for, how did you go about using it, what has worked well or not so well in using it, what suggestions do you have for making it easier to use or more effective, what have been the results of using it? These stories could join the original pilot site reports and at some point someone could do an in-depth analysis of the whole collection.
June 2005: jottings from website editor Barbara Kahan
Best Practices Questions & Answers Part IX: Learning about the IDM
This month's jottings contains the ninth and last instalment of answers to questions asked by participants who attended the recent session on Best Practices At Home and Abroad: making health promotion decisions for the best results. (To see previous installments, go to jottings November 2004 on and reflection February 2005. This month's jottings discusses the following questions:
1. How do you go about learning about the IDM?
2. IDM resource when using model for the first time: "Network" available?
3. Is there a website/discussion board that has examples of IDM developed?
4. How can organizations be supported to use IDM (training, funding, facilitation needs)?
Individuals and organizations go about learning and using the IDM in a number of different ways. Learning approaches and supports for using the IDM are briefly discussed below.
Some individuals and organizations develop an IDM-like approach - one which integrates values, theories and beliefs, evidence, and an understanding of the environment (from the socio-political to the physical) into practice - on their own without having heard of the IDM. Other people, when they first hear about the IDM, intuitively understand it with little effort - it immediately makes sense to them.
Most people, however, have a steeper learning curve because the IDM is not the typical approach to practice. It does not focus exclusively on evidence as the most important piece for practice, it emphasizes processes as much as outcomes, and it does not provide ready-made answers. Rather, it encourages people to use the IDM as a guide in developing their own answers, based on their own experiences, situations, and critical thinking.
The two basic options for learning more about the IDM, which can be used singly or together, follow.
a self-guided approach
In a self-guided approach, individuals or groups familiarize themselves with IDM concepts and application by:
At this point no formal Network exists. (Anyone out there want to get one going? That would be great!) Informally, there are a number of people around who are happy to share thoughts and experiences about the IDM. And, one of the main purposes of this website is to further dialogue and connections among people interested in the IDM. The website welcomes your questions, comments, ideas, experiences, people profiles - to email the website click here!
Formal training is another option. The following people (arranged in alphabetical order by last name) are available to provide training in IDM concepts and practice. Note that there might be a range of training approaches and understanding of the IDM amongst them. Contact each of them for these details and others such as availability, cost, language, ability to travel, and whether they prefer to facilitate individually or in a pair.
I do not know of any funding currently available to help support groups to learn and use the IDM. It may be worthwhile to explore individual sources. If anyone comes up with anything, please feel free to share the information by emailing the website!
If any of you have other suggestions for learning about the IDM, or questions about it, please email.
July 2005: jottings from website editor Barbara Kahan
Comments on the Bangkok Charter for Health Promotion
Ever since a couple of weeks ago when I read the draft version of the Bangkok Charter for Health Promotion - see July's Resource of the Month - I have been busy scribbling notes all over my now very creased copy of the proposed document, dragging Evan (my husband) into conversations about it, and reading other people's commentaries on it. Since it's taking up a lot of my time anyway, I thought I would jot down some of my thoughts on it. Rather than list all the details of my critique, I will briefly review what I like best about it and the key changes I would like to see made.
What I like best about the current draft is that it pays some attention to IDM domains. For example, the draft:
My suggestions for revision stem from the two things that bother me the most about the draft Charter. The first is that I don't see an explicitly defined role for me, as a self-employed health promotion researcher/evaluator. Tasks for governments and the business sector are clearly outlined, which is good, but even better would be clearly outlined roles for other key stakeholders, including people like me, community-based organizations and their health promotion staff and volunteers, and community members with no organizational affiliation. At the same time, it would help to indicate who should be responsible for ensuring follow-through on the recommended activities not allocated to government or business.
I am also bothered by the hard-to-pin-down-but-I'm-sure-it's-there top downish attitude towards "community" and community members - which according to the Charter should be supported and empowered and engaged and enabled and mobilized and informed. Yes, the Charter here and there appears to acknowledge the importance of community - but, I suspect, only after communities and their members have been supported, empowered, engaged etc. (by whom is not clear). I would like to see included in the Charter unequivocal statements such as the following:
While I agree that government and business have a strong role to play in building supportive physical, social, economic and political environments, this won't happen to the extent required for long-lasting meaningful change unless people outside of government and business clamour vociferously and take some strong stands. Perhaps the authors of the Charter will add a section analyzing power relationships and their implications for maintaining the status quo versus change... A grassroots social movement which pushes government and business to make real changes is our only hope for achieving a world where social justice and equity - extremely important determinants of health as well as strong health promotion values - are the norm. My final suggestion is to revise the Charter to reflect this understanding.
August 2005: jottings from website editor Barbara Kahan
Balancing work and the rest of life
It's summer, and I hate to work in the summer, and so far I've been working all summer long. Now, at least theoretically, I am on holiday, but in practice, it seems my work is never done and there is always more I should be doing (like updating this website...), and sometimes it feels like I am not really on holiday at all. It is times like this I reread an email that a colleague and friend, Steve Christensen, sent me over a year ago, to remind myself that work is not everything in life. Steve wrote,
As for my pulpit, yes, I tend to preach about balance and health and well-being. I find that this is something that we tend to lose focus of - we get back into our super busy routines, and forget about the really important things in life like taking care of ourselves - which is what our loved ones really want us to do, so we can be around for years and years (to take care of them of course!!). As for how to avoid getting carried away with work stuff on holidays….here's Steve's best suggestions of the day:
- Do not open any programs on the computer that have worked attached to them (like Word). You may play games like Spider or FreeCell for hours & then wonder where the day went. This is called holidays. You're not supposed to care where the day went...
- Avoid checking on work emails or phone messages at work or calling the office to see how things are going. This is work. When you work, you get paid. You are not being paid for being on holidays.
- Write your intentions down on sticky notes. Plaster them everywhere. "I will have balance, I will have balance."
- Develop 5 best practices for having a wonderful holiday and avoiding work, thinking about work, looking at work, or opening up Websites of work.
- And most important of all, make your husband take you to more exotic places on holidays. Yes the last one was wonderful - but then they should all be!!! [This was a reference to the trip Evan and I took to New Zealand and China last year.]
In addition to what Steve wrote, I do try to remind myself about the relationship between an individual's health and work. I don't think the quality of my work suffers because of my lack of balance, because I have never been able to rid myself of that perfectionist habit, but I know that my health does suffer and that means ultimately I end up taking more time off being unwell; it also means I am sure that I will have a shorter work life than I would if I could manage to have more balance.
The last thing I will say is that it is not just Steve's practical advice that helps me in times of stress. Rereading Steve's email always reminds me of the times we have connected on the phone or in person to talk about work, when no matter how busy he is, before we get down to business, he unfailingly asks how I am doing and takes time to discuss my health issues and how to manage my tendency to workaholism. This kind of genuine caring really is great medicine and always makes me feel better. Thank you Steve!
September 2005: jottings from website editor Barbara Kahan
Health promotion and poetry
With Guy Ewing's poem above [September 2005 reflection] and mine below, and the resource of the month a poetry website, this month's website seems to have turned partly into a poetry issue. With a growing acceptance of the power and importance of story in health promotion work, comments such as Maurice Mittelmark's about the knowledge that literature has to offer health promotion (see this month's profile), use of theatre as a tool for better health (I am hoping a friend who is exploring this will write a reflection on this topic for the website), why not poetry as a communication method for health promotion? The poem below is my attempt to explain the connection I feel with the field of health promotion.
Exploration of a world I never knew existed becoming my life's work
The whirling globe draws me in
by the force of its spin,
losing me in a landscape rich
in drama and human idiosyncracy,
covered with mythical mountains to climb
(despite my fear of heights)
deserts, oceans, forests
Bombarded by messages to have a healthy lifestyle
(get fit/eat right, stop smoking/fight addiction)
my radical self gets excited only when I hear
build supportive societies
(share wealth so no one goes hungry,
weave lives with justice and dignity).
I want to fly the sweep of the world's vast contours;
dig down to its molten core;
observe the patterns of its currents and clouds
(seeking truths obvious and obscure:
why things are the way they are,
how to make them better);
join with others to sweep-plant-sing.
It seems to me that sometimes a journal article is the best way to communicate a message, and sometimes a poem is...
yours in poetry and with best wishes,
October 2005: jottings from website editor Barbara Kahan
The Pre-Determinants of the Social Determinants of Health (Part I)
My jottings this month started out as doodles on a piece of paper, progressed to me translating these doodles into a drawing on my computer, then to me printing hard copies of the drawing to use as an example for an evaluaton exercise on environmental influences - and ended in oblivion when I forgot to hand out my nicely printed pieces of paper. It didn't matter, luckily - participants did fine without the handout. But I haven't been able to stop trying to clarify my thinking about what the drawing represents, what I call the pre-determinants of the social determinants of health. My thinking is that if we don't pay attention to the conditions that give rise to income equity/inequity, existence/lack of power and control, high/low status, minimal/extensive social cohesion/support, and all the rest of the determinants, then we will never effectively address them. So - tonight I reincarnated my drawing, revised it yet again, and stuck it on the website, below. Watch this space - my drawing may change a few more times over this month! And visit again in November for Part II of the pre-determinants of the social determinants of health...
with best wishes,
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November 2005: jottings from website editor Barbara Kahan
The Pre-Determinants of the Social Determinants of Health (Part II)
According to the IDM Manual section Using the IDM Framework, the "determinants of health work synergistically and operate on individual, community and societal levels. They include income (individual income and degree of societal income equity); status; education/learning; power/control; social cohesion/support; social, political, economic, psychological and physical environments; individual health-related behaviour, resilience and genetics." Leave out individual health-related behaviour, resilience and genetics and we are left with the social determinants of health. Last month I wrote that if we don't pay attention to the conditions that give rise to the pre-determinants of the social determinants of health we will never effectively address them. To explain my thinking I drew a picture using the example of respiratory health and housing - see last month's jottings - to explore the pre-determinants of two social determinants of health, income and social support.
Whether a home is damp and mouldy or dry and non-mouldy may have an impact on our respiratory health. Income determines whether we have enough money to either fix our home so it is not damp or to move to a different home. In the absence of enough money, social support will determine whether alternatives to living in a damp home exist or not, either through the informal support of family and friends who may loan us money or invite us to live with them in their non-damp home, or formal support from government or agencies who may help us find a healthier more affordable home. To keep things brief, for the rest of this discussion I will follow the example of income as a determinant of a dry or damp home, which in turn affects respiratory health.
Moving from the determinants to the pre-determinants, the first pre-determinant level is the potential that exists in the current environment for a determinant to be positive rather than negative - in this case to have adequate income to ensure a dry home. If we need to increase our income by finding employment, the possibility of finding and keeping a job depends on job availability, the fit between available jobs and our skill and knowledge levels, our health status, responsibilities such as young children or elderly parents to care for, and a number of other variables ranging from having a phone to having a means of transportation to the existence or lack of employment discrimination on the basis of age, sex or race. (Other possibilities of increasing income not explored here are winning a lottery, receiving a substantial inheritance, getting lucky on the stock market, and receiving welfare. The first three are unlikely to happen to most people and the fourth, welfare, is often inadequate to cover healthy accommodation as well as food and other basic needs.)
The second level of income pre-determinants increases or reduces the possibility we will find and keep a job. This level involves the nature of policies and resources related to employment, training and education, health, caretaking, access to phones, discrimination…Are there policies to ensure equity in hiring practices and training for people with special needs? How hard is it to get accepted into a training program? How available and affordable is child care?
The third pre-determinants level is the one which shapes the policies and resources which influence our job-finding finding possibilities - which then increase or decrease our chances of employment and our shot at attaining enough income to live in a dry rather than a damp home. This level involves two different aspects. The first is the nature of officially sanctioned systems and structures. For example, do we live in a society with an economic system where job availability largely depends on the needs of profit-driven large corporations? The second is the nature of the unofficial power and capacities held by individuals, groups and communities. Can we still form work collectives and co-operatives even in a capitalist society?
The fourth level, values and attitudes, determines our political, economic and social systems. For example, what are a society's values and attitudes towards who gets to make decisions: people with a lot of money or education, or people who will be most affected by a decision? How are resources allocated: give people with a high status more than others, or give people the income, food, and shelter they require to meet their needs? Values and attitudes also determine how we use our unofficial power and capacities. For example, do we wait for others to tell us the best way to address our challenges or do we decide for ourselves? Do we follow traditional ways of doing things or are we unconventional?
The fifth level contains all those factors that influence values and attitudes (which determine our system and capacities which determine policies and resources which...). Examples of these factors include geography, culture and history. Living in a harsh climate or a mild one, living in a country that has had constant violent turmoil or one that has enjoyed continuous peace, these experiences and others affect what we value, think, believe in.
To sum up:
Tune in next month for part three of the pre-determinants of health.
with best wishes,
December 2005/January 2006: jottings from website editor Barbara Kahan As a follow up to my October and November jottings, this month I talk about addressing the pre-determinants so that the social determinants of health exist in the positive rather than the negative, for example where people have adequate income to meet basic needs and there is as small an income gap between people in a society as possible. The belief that I think is most important regarding the pre-determinants is this: Each of us, whether we are a front line worker, a manager, a policy maker, a researcher - can positively influence the pre-determinants to at least some extent, by applying the underlying premise of the IDM best practices approach to each of the pre-determinant levels. This means we need to be aware of all levels, discuss them widely, have clarity in our understanding of them, and, individually and with others, regularly reflect on their nature and on the effectiveness of the processes and activities we and others use when working with them. If we do all this we will know better how to influence them positively, and will more likely notice opportunities - for ourselves and for others - to influence them. Even small actions by individuals add up if a lot of people are doing them. It is even more powerful of course to act collectively. Last month I outlined the five levels of pre-determinants from the most immediate to the most distant. This month I discuss the pre-determinants in reverse order. Although I present them as separate levels with a particular order, real life is more complex: while factors like level five's geography affect level four's values (for example, harsh surroundings require greater cooperation), values can also affect geography (for example, valuing profit over the eco-system may allow extensive logging, resulting in deforestation). Or: while systems set the general direction for policies, policies can also change systems. For each pre-determinant I comment briefly on how to influence them. 5th level: factors which shape values and beliefs 4th level: values and beliefs
The Pre-Determinants of the Social Determinants of Health (Part III)
While factors such as geography, culture and history seem like a given, in fact they change all the time for all sorts of reasons. Being thoughtful about them - about how we interpret them, how they affect us, how we might affect them - is important if they are to change for the better. Two examples: a changed understanding of what happened in the past may change what we do in the present; cultures evolve as people highlight or downplay particular aspects, or add new facets adopted from other cultures.
We can make a difference to the determinants of health by making our practice as consistent with our values and beliefs as possible. We can do this by:
December 2005/January 2006: jottings from website editor Barbara Kahan
As a follow up to my October and November jottings, this month I talk about addressing the pre-determinants so that the social determinants of health exist in the positive rather than the negative, for example where people have adequate income to meet basic needs and there is as small an income gap between people in a society as possible.
The belief that I think is most important regarding the pre-determinants is this: Each of us, whether we are a front line worker, a manager, a policy maker, a researcher - can positively influence the pre-determinants to at least some extent, by applying the underlying premise of the IDM best practices approach to each of the pre-determinant levels. This means we need to be aware of all levels, discuss them widely, have clarity in our understanding of them, and, individually and with others, regularly reflect on their nature and on the effectiveness of the processes and activities we and others use when working with them. If we do all this we will know better how to influence them positively, and will more likely notice opportunities - for ourselves and for others - to influence them. Even small actions by individuals add up if a lot of people are doing them. It is even more powerful of course to act collectively.
Last month I outlined the five levels of pre-determinants from the most immediate to the most distant. This month I discuss the pre-determinants in reverse order. Although I present them as separate levels with a particular order, real life is more complex: while factors like level five's geography affect level four's values (for example, harsh surroundings require greater cooperation), values can also affect geography (for example, valuing profit over the eco-system may allow extensive logging, resulting in deforestation). Or: while systems set the general direction for policies, policies can also change systems. For each pre-determinant I comment briefly on how to influence them.
5th level: factors which shape values and beliefs
4th level: values and beliefs
Based on the knowledge that income equity will make people healthier, constantly asking questions - of ourselves and others - will lead to a better understanding of equity-related issues and to practice that is more closely aligned with our values and beliefs. Examples of questions we might ask include: What changes to the economic system will increase income equity? How will a particular policy or program affect equity? Do other options exist that are more likely to increase equity?
3rd level: official systems and unofficial capacities
As individuals and in cooperation with others we have power to influence change in political, economic, health and other systems. For example, in the western world our economic system depends on us consuming more products all the time and using more services all the time. We can trade goods and services rather than buying them, recycle, consume less, share skills and knowledge with each other... Politically we can advocate for changes to official systems and we can create unofficial systems, for example through cooperatives and group volunteer efforts and figuring out what we can do for ourselves on a collective basis if we can't get official systems to meet our needs. If we want systems that support income equity, we have to start imagining what they would look like and how to get them. As individuals and groups we can privately and publicly ask questions that don't have easy answers, such as, what impact if any does a profit driven economic system have on income equity? How can people with low income increase their voice in the political system? Individually and collectively we can stand up against system-related injustices; our voices, alone or together, may well have an impact in changing public awareness and attitudes regarding these systems, leading to change. Building on our unofficial capacities requires creativity, persistence, a willingness to make and learn from mistakes, the ability to work together with others, and the knowledge that we won't get everything that we want, and what we do get will likely not come quickly - but eventually, if we maintain our energy, courage and focus, we will get positive results.
2nd level: policies and resources
In terms of income equity, stuck at the bottom are people who live in disadvantaged circumstances such as welfare recipients and minimum wage earners, often a result of health challenges, few marketable skills, or being part of a group that is discriminated against. Specific policies with adequate resources to support them can soften the edges of a harsh economic system. Examples of policies that would increase income equity somewhat include:
1st level: the potential for the determinant to be positive
This level depends on all the other levels. Good luck to all of us!
with best wishes,
February 2006: jottings from website editor Barbara Kahan
I have been working on evaluations for quite a few years now. This month's jottings summarize my thoughts on the extra benefits, beyond the obvious, that evaluations can bring.
The four most obvious benefits of evaluation are:
Here is my list of the extras that are not so obvious. Whether these extra benefits happen depends of course on a number of variables including the nature of the initiative and the nature of the evaluation.
with best wishes,
March 2006: jottings from website editor Barbara Kahan
Creating New Knowledge for Best Practices Decision Making
Whenever I am feeling like a lone voice in the wilderness I know I can talk to Guy Ewing (see his reflection and profile this month) as we have similar approaches to learning and knowledge. Not that I feel like that lone voice all that often, but there is the occasional situation when I bump into people who think one kind of knowledge is better than any other - often knowledge assessed by level of education (PhD degrees beat Masters degrees, any kind of degree beats a high school diploma…) or by status (the higher people are in an organizational hierarchy the more valid their knowledge). Does it matter? Well, yes, if decisions that affect a group, organization, community are made by people with only one or two kinds of knowledge.
It seems to me there are four basic categories of knowledge sources. For example, we may learn about income as a determinant of health through university classes, through conference workshops and keeping up with the literature, by implementing activities to address it in day to day practice, or by living on an income below the poverty line. In other words, the four categories are: formal education, informal education, work experience, and lived experience. A health promotion, public health or population health decision made on the basis of fewer than all four of these categories is incompletely informed. Each category adds a different dimension to our understanding of any issue - ranging from building on strengths to addressing challenges - and each is necessary to increase the likelihood of success in improving a situation. Rarely does one person have all four kinds of knowledge, making it necessary to have people with a variety of backgrounds involved in decision making.
The times I feel most like that lone voice are when I meet people in influential positions who I thought understood the validity and importance of different kinds of knowledge - and it turns out they don't, at least not as this idea relates to practice. Here is an example related to knowledge from work experience:
In a discussion group I suggest attempts to support best practices should include not just easier access to websites and journals but more opportunities for peers to get together to discuss issues of common interest and share their insights and experiences. The response is: of course mentoring opportunities should be encouraged. I say, well mentors are great, but sometimes it's helpful for people in a non-teaching/non-mentoring relationship to learn from each other. The response: how is that best practices? The discussion limps along… I am not sure I was able at the time to explain properly my view of why that is best practices, but I will attempt it again here: There are other ways of learning than the one-way street to knowledge most of us grew up with (teacher imparts knowledge to student, mentor imparts knowledge to the mentored). One of these other ways is the mutual learning situation that Guy talks about, where new kinds of knowledge emerge from people getting together to share their different kinds of knowledge. This new knowledge, if integrated into practice, will improve our practice.
Many examples of people not understanding the importance of merging different kinds of knowledge relate to the exclusion from decision making of people with knowledge gained from lived experience. While frequently consulted, they are rarely included in decision-making; reasons given for this exclusion include: they wouldn't be interested, they are too wrapped up in their own issues to do broad-based policy, they would be uncomfortable sitting at a table with people with higher education levels… So, decisions continue to be made that dramatically affect people's lives on the basis of limited knowledge. Why not try a learning circle to expand our knowledge? We might find that all sorts of people are more interested in participating than we think, have unrecognized abilities for policy, and can be comfortable if treated respectfully.
with best wishes,
April 2006: jottings from website editor Barbara Kahan
Addressing Income as a Determinant of Health
This topic is very personal to me. Having lived below the low income cut-off for several years when our children were very young, I experienced first hand the stresses of poverty. As I evaluate initiatives designed to assist people living in challenging circumstances, I discover that some people are living in houses with raw sewage leaking in the basement and mould half way up the walls because they can't afford a better place. I tabulate results from surveys showing that in my city parents of young children are going hungry regularly, some once a day. These circumstances make me incredibly angry. How can we, collectively, allow this to happen? Too often people say, even at "best practices" conferences and workshops, that we can't address the determinants of health now because they are too long term. If not now, when? This question leads me to ask, more constructively: how can we turn the negative income situation around? My thoughts about what needs to be in place in order to affectively address income as a determinant of health follow.
We need to look at theory and evidence.
We know that income affects health in two ways:
We also know that many people in Canada do not have enough income to meet basic needs and that the income gap is growing rather than getting smaller.
This evidence provides us with the theory that if we supply everyone with an income adequate to meet basic needs and if we decrease the income gap we will have a healthier society. Our next step is to put the theory into practice, and gather evidence as we go along about which ways of addressing income issues work best.
We need a consensus on fundamental values and beliefs.
The fundamental values for increasing the amounts of income available to bring everyone above the poverty line and to increase income equity include:
Put another way, everyone deserves to have good health, no one deserves to be poor, and being generous enough to contribute to the common good is better than being mean, stingy and materialistic.
In addition to a consensus on the values listed above, important beliefs for addressing the income situation include the following:
We need to understand the environment.
An example of someone who didn't understand the environment with respect to income was Marie Antoinette of "let them eat cake" fame. To avoid her mistakes, we need to look at the environmental influences that shape income-related issues. For example, it is not true that people are on welfare because they are too lazy too work. Evidence shows that welfare rates go down when the economy is better and more jobs are available. In other words, most people will work, if they are able, when the opportunity exists. In addition, some people are temporarily unable to work because of reasons such as illness or having just given birth. Some people will eventually have a better chance of finding work once they receive more education or training. Other people, however, because of chronic disabilities, will never be able to work in a typical unsupported work environment.
To fully understand the environmental influences that shape the current income inequity situation, we need to look at a number of factors, such as socio-economic structures and policies, political systems, general attitudes, discrimination, and methods of change. For example, regarding policies, the Canadian Association of Food Banks' document HungerCount 2005 tells us that no Canadian provinces or territories have minimum wage rates or welfare rates above the Low Income Cut-Off.
In addition, we need to look at the role of other determinants of health. None of the determinants works in isolation; income is no exception. For example, just as people with higher incomes have an easier time getting further education, the reverse is true; people with more education have an easier time getting a higher income.
We need to make our practice consistent with our values, beliefs, theories, evidence, and understanding of the environment.
It is well within our grasp to achieve equity and human dignity. Although optimal health is more challenging, because health depends on the interaction of all determinants of health and individual factors such as genetics, we could significantly increase health levels as well. Following are two examples of practice activities which would be consistent with our underpinnings (values, theories and beliefs, evidence) and understanding of the environment:
We need the political will to change.
No improvement to income issues will occur without the political will, or courage, to make changes. In other words, we need politicians who can act as leaders to bring about an equitable society where everyone has adequate food and shelter, where vast disparities between rich and poor do not exist. We need politicians who will raise welfare rates and minimum wage levels and support community organizing efforts for meaningful change despite the opposition of powerful and privileged groups who want to maintain the status quo.
We also need the anti-poverty groups and the food banks and the social policy think tanks and the community agencies and people like you and me who will continue to advocate for a world without hunger and homelessness, for a world where people share and treat each other with dignity.
p.s. Related to this month's discussion is my series on the pre-determinants of the determinants of health, in the jottings' archives: October 2005, November 2005 and December 2005. See also the comment on this month's jottings.
May 2006: jottings from website editor Barbara Kahan
The Role of Relationship in a Best Practices Approach
Miriam Hoffer's discussion in this month's profile and reflection on the importance of rapport and connection remind me once again of the role of "relationship" in a best practices approach. Over and over I hear in my evaluation work how intrinsic good relationships are to the success of health-related efforts.
In general good relationships are the lubricant that makes programs run more smoothly for program participants, staff members and other key stakeholders. Good relationships involve four key factors: respect for each other, trust in each other, an understanding of the other person's perspective and circumstances, and caring for the other person as a unique individual (again to echo Miriam Hoffer). These ingredients - respect, trust, understanding and caring - result in better reciprocal communication, a feeling of being supported and belonging, and greater motivation to do the best job possible. The benefits of good relationships are numerous: information is more readily shared, conflicts are more easily identified and resolved, cooperation in carrying out common tasks is more forthcoming, resources are more generously shared, and positive energy to do the work at hand is more abundant. The best benefits are the mutual learning that occurs, the growth of individual and group strengths, and, of course, the assistance good relationships provide in reaching goals.
This isn't to say that good relationships are always easy. Conflicts at one point or another are inevitable. Conflict, however, can be positive, depending on how it is handled. Conflict in a good relationship, if approached constructively, might be more aptly termed creative tension - a welcome if uncomfortable challenge which leads to something better than would have existed otherwise. On the other hand, conflict - whether expressed or not - can be disastrous in a relationship which does not include respect, trust, understanding and caring.
All in all I think relationship building is a necessary process for any initiative to pay attention to. Examples of ways to build relationships include:
Based on my own work experience and observations I would say that good relationships, whether they are long term or fleeting, are one of the cornerstones for doing the best job possible. Relationships, in the form of social support and engagement, are also a social determinant of health.
June 2006: jottings from website editor Barbara Kahan
Using the IDM to be flexible and innovative in community change
One of the many things I found myself nodding my head to as I interviewed Mark Cabaj for this month's reflection and profile was the importance in community change of responsiveness to changing conditions and the need for innovation. His comments spurred me on to think about the IDM's role in helping a community project be flexible and innovative. My conclusion is that it can help quite a bit in two key ways.
The first way is through the IDM's definition of best practices, which is not confined, as it is in most definitions, to "what works" or to being evidence based. The IDM definition of best practices includes evidence, but it also includes values and goals, theories and beliefs, and understanding of the environment. In the IDM approach to best practices, in the absence of evidence, or if the evidence is weak or not applicable, theory - whether simple or complex - can be used to try out ideas that have never been tried before. And because practice in the IDM approach is also based on our vision and analysis of social, economic, political, and physical environmental influences, to follow the IDM approach we will constantly check in with our changing visions on the one hand and what is happening in our environments on the other - and will change our practice accordingly.
The second way is through the IDM's underlying premise, that "the quality and value of practice depend on the degrees of awareness, discussion, clarity, and reflection" associated with values and goals, theories and beliefs, evidence, understanding of the environment, and practice itself. In other words, whatever project we work on, if we use the IDM approach we will, on an ongoing basis, examine, talk about, clarify, and reflect on what is going on around us, our current practice, and what effect we are having. As a result of our growing awareness and clarity and our ongoing discussion and reflection we will continually revise our processes (such as building relationships and capacity, making decisions, communicating) as well as our activities.
In other words, if we want to use an IDM approach to help us be responsive and innovative, we need to build in regular opportunities for environmental analysis and visioning, clarification, discussion and reflection - and for brainstorming the best way to revise our processes and activities based on values, theories, understanding of the environment, and evidence when it is of high quality, available and applicable. And sometimes we will have to act courageously and creatively by experimenting rather than being tied to what has been done before.
with best wishes,
July/August 2006: jottings from website editor Barbara Kahan
The role of questions and answers in health promotion, public health and population health best practices
This evening I have been thinking about questions and answers as I try to work my way through the quagmire of issues relating to an evaluation I am conducting where a substantial portion of parents of young children are going hungry every day because of lack of food. I think about the social determinants of health and their impact on quality of life, about the role of different kinds of power in maintaining the status quo or in supporting positive change, about Josephine Pui-Hing Wong's point in her reflection about the connection between the personal and the political.
My ponderings have led me to the conclusion that a good question is more valuable than a thousand low quality answers and more valuable than a thousand answers to the wrong question. And, of course, if I had answers I could trust, that answered the right questions, to me they would be worth their weight in gold.
What do I consider a good question? A good question is one that deals with issues of the highest priority, one whose answer will move us forward in a positive way, one which even if not answered will make us think and point us to areas we need to explore. A good question is one which is rooted in context, and arises out of values, beliefs, theories, and what we already know. A good question is an exceedingly relevant question.
What kind of answers do I consider high quality enough to trust? Answers based on sound data where great care has been taken to ensure its accuracy. Answers based on a combination of quantitative and qualitative methods. Answers based on a complete range of sources.
Given the quagmire of issues I referred to at the start of my jottings, what do I think are good questions for health promotion, public health and population health? I might change my mind tomorrow as I think things through more thoroughly, but at this moment here are my two top questions:
Each question above has a whole sub-set of questions, but these two questions seem to me to provide relevant direction for the best possible practices, which to me includes research, policy making and program implementation.
with best wishes,
September 2006: jottings from website editor Barbara Kahan
Expanding the meaning of health behaviour
Health promotion and public health generally refer to health behaviour as individuals' actions in their private lives, for example regarding diet, physical activity, substance use (alcohol, tobacco, OxyContin, cocaine...), stress management, and use of health care services (medical and dental check-ups, immunizations). I think, however, we need to expand the meaning of health behaviour to include individuals' actions in the public realm, that is our health-related actions in our work, volunteer and political lives.
A general starting point for guidelines regarding health behaviour in our public lives might be the IDM's underlying premise, adapted as follows: In our public lives we are following good health behaviour if:
Examples of ways to address health issues in the public realm follow.
To illustrate health behaviour in public life, here is a summary of mine: I spend a lot of time discussing health-related issues with family, friends and colleagues; when I vote I consider political parties' stands on health-related issues; and I spend roughly two days a month volunteer time on this website to promote best practices health-related information sharing, dialogue and community.
with best wishes,
October 2006: jottings from website editor Barbara Kahan
An IDM best practices analysis of power
Peggy Schultz in this month's reflection mentions "the impact of power on health..." making me think yet again about power in relation to my work and my life. Power is a topic that I think about fairly often, partly because it is a fascinating topic and partly because it affects all of us profoundly in so many different ways. But because it is so broad ranging and complex, I have been sitting here feeling somewhat daunted and thinking I should have chosen something easier to reflect on. But as often happens, the IDM Framework has just given me a starting point - the IDM's domain of "understanding of the environment," with its components of vision and analysis. But first, as the IDM stresses clarity, I will start with my definition of power.
The Ottawa Charter defines health promotion in part as enabling people to increase control over factors that influence their health (Ottawa Charter Of Health Promotion, 1986). To me this definition is about power, which at its best is the ability to participate in making decisions that affect us individually or as a group, rather than someone else making our decisions for us. Power manifests itself in a number of ways - some better than others, depending on our values - ranging from force and persuasion to creativity and example.
vision of power
My vision of the role of power in a healthy community and society is this: Power is accepted as part of life, is understood in its many manifestations, is actively shared, and is used thoughtfully by all of us to enhance quality of life for everyone. We acknowledge the range of "power gifts" that exist - qualities that have the power to influence things for the better, such as the organizational skill of one person, the talent for languages of another, someone else's ability to bring people together. We encourage people to use these power gifts so the rest of us can benefit from them, at the same time as we share our own. And, we provide opportunities so each of us can enhance existing power gifts and develop new ones. And, of course, those people who are most directly affected by a decision are automatically part of making that decision, if they wish. Power sharing does not mean everyone has to be involved in every single decision made - no one has the time for that, and neither do most of us have the interest. It does mean that we should be able to participate in a decision that directly affects us if we want to.
analysis of power
Here are a few of my thoughts about power.
...best practices at the practitioner level has to be built on "reflexivity," that is, our ongoing critical self-reflection on how our social status (related to class, race, ethnicity, education, language, age, gender, citizenship, sexuality, and other sociopolitical dimensions) grant us special privileges and power; how these privileges shape our worldviews and affect the ways we relate to or interact with our clients and each other; and how these power relations affect the health of our clients directly and indirectly...
Power is embedded in every type of relationship - with our partners, friends, colleagues, government. Taking into account the constraints and strengths of our particular context, power is about the control we allow others to have over us and about allowing ourselves to move our world towards a more equitable sharing of power in its many manifestations with others.
with best wishes,
November 2006: jottings from website editor Barbara Kahan
How the IDM fits with other health promotion/public health best practices approaches
This question arose out of a conversation I had with a colleague a while ago: Is the IDM in competition with other best practices approaches? My response was "no" - the IDM is complementary to most best practices approaches. Following are the two main reasons for my response.
First, the vast majority of best practices approaches are evidence based - according to the evidence, what works? For the most part evidence-based approaches focus on ranking the quality of available evidence based on a set of criteria, for example the study design and the size of the study population.
Although evidence is important in the IDM approach, it is viewed as only one factor which interacts with a number of other factors. The IDM is not directive and does not insist groups adopt any specific underpinnings (values, goals, ethics, theories, beliefs, evidence criteria), understanding of the environment (vision and analysis of organizational and health-related environments), or practices (processes and activities). Tools such as the suggested IDM guidelines and the IDM evidence framework are provided only as resources for groups to accept, discard, modify, or completely ignore. The basis of the IDM is that groups will identify their own underpinnings, understanding of the environment and practices - as appropriate for their particular situation - in order to ensure consistency amongst the three domains.
In other words, it is very possible to use an evidence-based approach in the context of the IDM approach, if the selected evidence-based approach is consistent with the rest of the group's underpinnings and understanding of the environment.
My second reason for thinking the IDM is complementary to most best practices approaches - whether they are evidence based, or holistic like the IDM - rests on the notion of critical reflection and continuous improvement. Nothing is perfect and circumstances are never static. As a result, it is important to examine on an ongoing basis whatever best practices approach we choose in comparison to other best practices approaches for potential benefits. For example, the IDM's emphasis on the relationship between processes, activities and outcomes - that it is not just what we do but how we do it that determines end results - might offer an extra dimension to approaches that concentrate on activities and outcomes. Other approaches will provide other insights.
Although I find the IDM extremely useful in my practice regarding planning, evaluation, decision making, and understanding issues - how to further positive change - I still like to explore other approaches when they come to my attention because of what I might learn. I am sure no one will be surprised when I suggest that someone using a non-IDM best practices approach will likely also learn something helpful from exploring the IDM!
with best wishes,
December 2006/January 2007: jottings from website editor Barbara Kahan
Community development for positive change (Part 1)
To me community development is more than a strategy to be used only in some situations; it is an essential ingredient in achieving long lasting positive social, political and economic change. Without basing health promotion, public health or population health policies and activities on a community development approach, we will be stuck with the status quo where a significant minority of people live in extremely challenging circumstances: low income, insufficient food, inadequate housing, fractured social relationships, hopelessness, and serious mental and physical health issues.
This conclusion comes out of a deep frustration I have as a result of participating in and observing efforts over decades to improve quality of life - and health - for everyone. I see occasional improvements here and there but over all the amount of suffering is still huge. At the same time, I strongly believe that the situation would change for the better if we decided to try a different way - a community development kind of way - for geographic communities such as neighbourhoods and communities of interest.
When I talk about community development - or community building, organizing, engagement, mobilization or change, and including community economic development - I mean an approach where community members come together to identify their own priority issues and their own solutions, and work together to implement their solutions. In this kind of on the ground community development approach there may be a role for community-based organizations (CBOs), non-governmental organizations (NGOs) and governments to provide support for community based efforts and to nurture "home grown" community leaders - but not to direct or control.
How does my emphasis on community development fit with my IDM definition of best practices? Reasonably well I would say as it is consistent with my values, beliefs, theories, understanding of the environment and with some of the evidence.
Although community development has many challenges - for example, potential conflicts between competing interests, values and perspectives - it is a necessary approach if we want better health for everyone, not for just a few. I will explore different aspects of community development and change, including its fit with best practices, in more detail in future jottings.
with best wishes,
February 2007: jottings from website editor Barbara Kahan
Community development for positive change (Part 2)
In Part 1 of this series of jottings I wrote that there "may" be a role for CBOs, NGOs and government because, despite good intentions, these organizations are constrained by the nature of a system which is designed to preserve the status quo. Most CBOs and many NGOs are dependent on government funding which comes with strings - necessary when they promote appropriate public accountability but detrimental when they inhibit positive change. Inadequate funding, short time lines, restrictions to program content or method based on inadequate understanding of the issues or situations, and unreasonable expectations all contribute to things staying the same.
At the same time, governments tend to be extremely bureaucratic, think in the short term, and make decisions on the basis of politics rather than the greater good. Needless to say these tendencies impede active community development. For this reason, although I still will be heard to say "governments should do this or that" regarding whatever issue I am obsessing about at the moment, I have come to the conclusion that we shouldn't hold our breath for governments to do whatever it is they "should" do - which even if they did, they could just as easily undo.
This "environmental analysis" of CBOs, NGOs, governments and community change has led me to think that as much as possible communities need to look to themselves to make changes rather than looking to government, CBOs or NGOs - or at the very least fight hard to set the agenda, address change-preventing challenges, work together to advocate for community-friendly policies, and maintain an awareness of all the factors and dynamics at play even when immediate action isn't possible. I know all the challenges that communities - especially disadvantaged communities - face, but even small changes can make a difference, especially from a long term perspective.
with best wishes,
Community development for positive change (Part 3)
Following an IDM process, below I examine the consistency between the practice of community development and my values, theories and beliefs.
Community development fits with my value of power sharing, which involves a number of overlapping areas:
Community development fits with two of my beliefs:
Community development also fits with my theory of social change to achieve better health for everyone. (Health for everyone is another value of mine.) In this theory the social determinants of health play a major role in determining the quality of health, and the social determinants of health are influenced by social, political and economic systems and structures. As long as we continue decision making patterns which exclude many groups of people these systems and structures will remain the same - maintaining a situation where many people experience the social determinants of health in the negative.
Using a community development power sharing approach will begin the process of changing the decision making pattern. The active participation in decisions by all key stakeholders, in particular the ones most directly affected by the relevant situation, will lead to decisions based on a complete set of knowledge and experiences, rather than on the basis of narrow knowledge and experience sets. [see previous jottings re. different kind of knowledge] Although working individually can make some difference, working collectively for collective solutions is much more likely to succeed in making basic changes.
with best wishes,
April 2007: jottings from website editor Barbara Kahan
Community development for positive change (Part 4)
Regarding evidence, over the years I have heard of community development initiatives that have had positive results. And I know that despite the immense efforts and resources that have gone into non-community development initiatives we still have people who are hungry and living in inadequate housing, which directly impacts health status. My very brief search for evidence of effectiveness regarding community development has come up with some positive results but as of yet nothing conclusive - for example, no comprehensive reviews. A more intensive search might come up with more; I will keep looking.
This topic brings up interesting thoughts for me. Because I greatly value power sharing, I would advocate for community development as an approach even without evidence to show that it increased quality of health for everyone - as long as it didn't decrease health. On the other hand, if the evidence shows that it does not lead to changes in the social determinants of health, I would retain my value but rethink my theory of change for better health.
with best wishes,
May 2007: jottings from website editor Barbara Kahan
As some of you know, David Groulx, Josephine Wong and I have been conducting a review of the IDM. Thanks to all those who sent emails and participated in interviews. Although there weren't as many responses as I'd hoped for, they were all of very high quality! And it is exciting to hear from people in different countries - Canada, the US, Ireland, Portugal, Poland... I thought I would share with readers of these jottings some of what people said. (And please note - there is still time to add your comments...)
People used the IDM for a number of purposes, including for planning, evaluation, values clarification, developing a common language and purpose, increasing consistency between underpinnings and practice, and teaching strategic thinking. It appears to have accomplished all of these goals, and also resulted in some unintended benefits. For example, it increased understanding of health promotion for a few people, and helped at least one person make the transition from acute care to community programming. Some people also talked about better outcomes.
The two key challenges mentioned were that, at least at first, it appears overwhelming, and that it is time consuming. Not surprisingly, a common suggestion was to simplify it. Another suggestion was to provide more examples to make it easier to grasp. As a result of this feedback I have been working on an IDM Quick Start sheet and another IDM fan has come up with an excellent idea to help people figure out which parts of the IDM and which resources to use. Look for these new resources on the website soon.
People also mentioned many strengths of the IDM, primarily that it is comprehensive, systematic, reflective, makes things coherent, and that it incorporates values in its process.
People did not always use all of the IDM, instead focusing on the parts that were most relevant for their purpose. The most useful resource in learning how to understand and apply the IDM was talking to someone knowledgeable about the IDM. People also found helpful the IDM Manual, the Coaches' Road Map, the skeleton Framework and Model themselves, the examples, the computer program, and this website.
with best wishes,
June 2007: jottings from website editor Barbara Kahan
Using the IDM for Evaluation
Although I have been busy asking everyone to send me information on their experience using the IDM for the IDM review David Groulx, Josephine Wong and I are conducting, I have not yet sat down to write up my experiences. So I am devoting this month's jottings to reflect on my use of the IDM in evaluations. I will mostly discuss the "value added" aspect of the IDM, as some parts of evaluation work, for example checking to see if there is a logical connection between processes, activities and desired outcomes, are fairly standard with or without the IDM.
I have used the IDM to provide the structure for evaluations related to early learning initiatives and a multi-stakeholder partnership. I am currently using it to develop a community housing plan which contains a built in evaluation component.
I work closely with the initiative's evaluation committee or evaluation liaison person to ensure results which will help the initiative improve its processes and activities in order to achieve better outcomes. It is generally a collaborative process of back and forth. I always suggest using the IDM as the evaluation framework, but I never name it as "the IDM" as the name is not important. Instead I describe the basic IDM approach. Usually I am given the go ahead to use the approach, but in at least one instance my suggestion to include elements such as values in the evaluation was declined as being "too fuzzy wuzzy."
If I have permission to use an IDM approach, after clarifying the evaluation purpose and roles, the first step is to review what already exists in the way of identified IDM elements such as goals, values, beliefs, theories, evidence, vision and analysis of the environments. If any of these elements are not clearly identified and defined, or exist based on input from only some key stakeholders, I work with the committee or liaison to develop qualitative questions about the elements to include in interviews, focus groups, surveys and/or workshop exercises which involve as many key stakeholder groups as possible. If I am working on an outcome evaluation I will also use quantitative methods to gather information about the elements, including quantitative oriented survey questions and file reviews. Once the data is collected, I use the IDM as a framework for the analysis. For example, what are the initiative's values, both implicit and implicit, and is there a match between values on the one hand and objectives, processes and activities on the other hand?
In all cases, whether or not I am formally applying the IDM to the evaluation, I conduct the evaluation as much as possible in a way that is consistent with my own IDM-developed values and beliefs, for example ranging from my power sharing value to my belief that qualitative and quantitative data are both required to obtain a full picture of what is happening.
Evaluation work always involves a number of challenges. For me a key one is that sometimes including the initiative's priority population in more than consultations about the initiative's processes and impacts is not possible during the evaluation. There are many reasons for this - a topic for another jottings!
I have found the structure the IDM provides to be a key evaluation strength. Using its elements of values, beliefs and the rest as a checklist guarantees nothing important is overlooked, and helps organize the information that is gathered in a way that is meaningful.
I have not encountered any negative impacts from using the IDM. Positive impacts include valuable insights into the match between practice and elements such as values and how to increase the consistency between them. Other impacts range from relationship building between stakeholder groups who before the evaluation process may not have even met each other to the development of a set of guidelines for assessing consistency between practice and foundation pieces (values, theories and the rest) and for shaping future action.
with best wishes,
July/August 2007: jottings from website editor Barbara Kahan
Simplifying the IDM
As I mentioned in a previous jottings - on the results of the IDM review - initially some people find the IDM overwhelming. They find it overwhelming because the IDM encompasses many different elements, each of which is viewed from a number of different perspectives and in relation to a number of other elements as part of a whole. Like a tangled ball of multi-coloured yarn, it is difficult to find a beginning point - quite possibly there are many beginning points, one for each colour - and untangling takes time and persistence. So, yes, the IDM is complex, as is life. But as in life there are many ways to constructively deal with complexity, and to use complexity as a strength rather than a barrier. A list follows of some of my thoughts about how to make the IDM appear less overwhelming. Keep in mind that:
I hope all of you have a wonderful summer.
with best wishes,
September 2007: jottings from website editor Barbara Kahan
Momentary Confusion when Applying the IDM
For this month's jottings I thought I would mention another one of the challenges that I find when I use the IDM, which is: I sometimes get confused when I am applying the IDM, particularly between what is theory and what is analysis of the environment, and between what belongs to the evidence subdomain and what belongs to the environmental analysis subdomain. And sometimes when I am writing up results based on the domains I start to think "this is awfully repetitious, isn't this covered already?" But in all these cases I always come to the same conclusion, that it is not surprising if there is overlap and no clear demarcations among the domains - interactivity among the domains is one of the key thoughts behind the IDM, which means it isn't always easy to separate them out.
I find this momentary confusion even between values and practice - if a value is being applied in practice, does that mean it belongs to the values subdomain or to the practice domain? Well, both! And then I also realize that the point is not getting the information into the right "box" but making sure that the information is identified and organized in a way that makes sense to me and whoever else will be using the information - there is no right or wrong box.
with best wishes,
October 2007: jottings from website editor Barbara Kahan
Challenges to Achieving Consistency
One of the challenges to using the IDM identified in the recent IDM Follow-up was the difficulty of achieving consistency. The more I think about it the more I realize that the notion of elusive consistency captures the frustration I have found in using the IDM - although my frustration does not really stem from the IDM but rather the situations in which the IDM is used. To use as an example "inclusion", which is often explicitly identified as a value these days: even when evalution results indicate areas where inclusion could be increased, an increase in inclusion does not often happen very quickly.
There are many reasons for continued inconsistency regarding inclusive practices even when exclusion is identified as an issue. A program's priority population may not want to be included in program decision making or evaluation due to lack of interest, time, energy, confidence, opportunity or support. Also continuity is important to building the groundwork for meaningful inclusion; program participants may change rapidly, and it is often difficult to main contact with program graduates, especially for groups who move frequently.
From the perspective of the program's current decision makers or implementers, a major reason for ignoring exclusive practices is that of scarce resources which do not allow the time required to provide the outreach and support required. In some cases impediments to inclusion in decision making are the assumption that members of the priority population will be uncomfortable relating as peers to staff or boards of directors and a belief that the priority population is unable to think in a meaningful way about issues that go beyond their personal lives.
One reason for continued exclusion that is rarely stated out loud, but which I think plays a part even if unconsciously, is the tendency of power to centralize. My observation is that people who have power are reluctant to share - although often for well meaning reasons. As a consequence, despite the benfits of joint decision making based on a range of knowledge from a variety of perspectives, inclusion which extends to decision-making beyond the immediate level is unlikely to happen unless it is demanded by members of the priority population - perhaps in conjunction with advocates internal or external to the organization.
Speaking of advocates, I have been very intrigued by one of the comments that came out of the IDM Follow-up: that the IDM has a role as an advocacy tool and has already been used as such. Although I often think of the IDM as a "change" tool, I have not thought of it in connection with advocacy and am very excited about this potential use. Explicitly identifying underpinnings and understanding of the environment, and consciously measuring these against actual practice, provides the information required to push for greater consistency among all the domains.
with best wishes,
November 2007: jottings from website editor Barbara Kahan
Using the IDM to Analyze Society
Recently we had a beautiful fall day here in Regina. As we walked through a park near Wascana Lake, crunching leaves and enjoying the blue sky and relatively balmy temperature, Evan (my husband) brought up an IDM application that he had been thinking about. Among other things, Evan teaches sociology classes at the local university and in one class, on technology and society, he introduced the IDM to his students as an analytical tool. He said the students really liked it and that it made sense to them so he wants to try using the IDM again with another class, this time in more depth.
Sociology and other social sciences are very relevant to health promotion because they encompass the social determinants of health and I am always interested in new applications for the IDM. So in this and subsequent conversations with Evan I listened very carefully and thought I would pass on to website readers the gist of Evan's thinking. What Evan is suggesting is that anyone wanting to understand the world could use the IDM to analyze why people act the way they do and why things are the way they are in society.
What Evan likes about the IDM is that it forces us to look at a wide range of variables, rather than the narrow range that most current theories are based on. Some theories have underlying assumptions built into them that may hide the effect of other variables. Although in different situations some variables will be more important than others, the IDM ensures that no important variables will be missed. In other words, an IDM analysis will look at gender, race, class, the physical environment, people's beliefs and other variables, not just one or two.
Evan also said he likes the IDM because it recognizes that values and underlying beliefs and assumptions make a difference to people's actions, though they may not always realize it. The IDM helps identify these values and underlying beliefs and assumptions and their impact. He told me that recognizing the interactivity among the variables, as the IDM does, is key because many things in life are not the result of a direct cause and effect relationship. According to Evan using the IDM helps build a theory to explain what is happening in the world that is truer to life. An IDM-based theory can also contribute to positive change.
with best wishes,
December 2007-January 2008: jottings from website editor Barbara Kahan
IDM Best Practices Website Statistics
The server for the IDM Best Practices Website has a program which collects website statistics. Here are some statistics from August 2005 to end of November 2007. (The website was launched May 2004 but the server used a different program then which collected the statistics in a slightly different way.)
with best wishes,
February 2008: jottings from website editor Barbara Kahan
Fun as a Value
The Suggested Guidelines section of the IDM Manual lists five key values for health promotion and public health: health, social justice (e.g. resource equity), power sharing, the environment, and enrichment of individual and community life.
I suggest adding fun to the above list, to be included in the category of enrichment of individual and community life. I strongly believe that fun is an important value - although I know from past discussions that not everyone will agree with me.
Fun as a value for health promotion and public health may sound frivolous when so many people face so many serious challenges. However, having fun while we address issues does not trivialize the issues, as long as our actions and attitudes are respectful and appropriate to the circumstances.
In my work I am made aware of many painful situations, for example homelessness and domestic violence. As a result many times I feel profound sadness and anger that people have to experience such injustice - as I should; these situations are intolerable. But I find that I do not do my best work when I remain in a sad or angry state for any length of time. Both states exhaust me and interfere in some way with my thought processes. Adding fun to my work helps me cope by lightening the weight I feel, energizing me and brightening my world. Having fun makes me more creative and open to the world. For me, life is easier to negotiate with the occasional fun to balance the pain.
Fun of course is one of those words that has a different meaning for everyone who uses it. What one person considers fun another might find boring or annoying. Here are a few of my own personal examples of the application of fun to my life and work.
I suspect that fun is a much better motivator than fear. It fits with my emphasis on a positive rather than negative approach to life. Certainly for me, fun makes things easier to start and continue doing. Having fun has to be good for one's physical, emotional and spiritual health. I regard fun as an essential ingredient in my work and life in general!
Have a fun February everyone!
with best wishes,
March-April 2008: jottings from website editor Barbara Kahan
Evaluation Thoughts Inspired by Dance Dance Revolution
I have been dancing with Dance Dance Revolution for over a year now. (DDR provides steps on the tv screen in time to the music playing.) Every time I play it I undergo an intense evaluation experience which has resulted in some random thoughts.
with best wishes,
May-June 2008: jottings from website editor Barbara Kahan
Hooray for the Best Practices Community
My recent visit to Toronto has reinforced my belief in the importance of supportive community, regardless of the type. In this case, it is the best practices community that has warmed my heart and created two wonderful events which will have ongoing positive ripples. The events were a workshop on the IDM (Making Work More Meaningful) and an IDM think tank (see this month's reflection for a summary of results). Following is a list of who in the best practices community very generously contributed to the success of these events.
Results were very positive. My only regret is that I didn't have more of a chance to talk individually, or at length, to everyone at both events. I would love to get to know everyone better - a very dedicated, reflective, friendly and energetic group - and look forward to future opportunities to do so. To old friends and new friends - I'm very honoured to be part of such a wonderful best practices community!
with best wishes,
July-August 2008: jottings from website editor Barbara Kahan
Learning from Sudoku about the Importance to Practice of Being Systematic
Sudoko is a puzzle based on a grid divided into nine squares of nine cells each, some with numbers and some blank. The object is to fill in the blank cells so that every square, row and column contains one each of every number from one to nine, with no duplication.
While on holiday a month ago I did two or three sudoku puzzles a day and surprised myself by noticing a connection between doing sudoku and health promotion/public health practice.
I found that when I approach sudoku in a systematic way I am faster and more accurate than when I am haphazard. I find missing numbers more easily. I also find and correct errors more quickly, which is good because I do make a lot of mistakes. In addition to errors of omission, when I miss adding an obvious number, I sometimes make wrong assumptions. That is, I think a certain cell must contain a specific number when actually it could contain two different numbers - an error of faulty reasoning. And sometimes I cross wires, for example I put a number in the wrong cell because my eyes didn't track across the row or column properly, or I mean to enter one number but because I am thinking ahead I enter a different one.
With sudoku it is easy to tell when I have made a mistake - at some point, I end up with two numbers the same in a row, column or square, and one number missing. In health promotion/public health practice, mistakes are not so obvious. Identifying the circumstances, processes and activities that will lead to high quality population health status and health equity is on a totally different magnitude of complexity and challenge.
Yet I have come to the conclusion that the principle of of being systematic is the same - and perhaps even more so in health promotion/public health with the presence of so many more variables and combinations of variables and constantly changing variables rather than a limited number of static and stable numbers.
In my work I am prone to the same kinds of errors I make in sudoku. I sometimes miss the obvious, have faulty logic, and accidentally mix things up. By being systematic, however - proofreading, having two different people enter data and checking the two sets against each other, having key informants review their written thoughts and comments in context to ensure they weren't misinterpreted, going over material with a number of other people to ensure clarity, logic and completeness, and running through a check list of important factors to consider to make sure everything necessary has been considered and fully understood - my results are much better than with a haphazard approach.
It is for this reason that I think a systematic best practices approach such as the IDM can be extremely helpful. The IDM, for example, brings all the important pieces to the forefront for our consideration - how do our values, goals, evidence, and understanding of the evidence fit with our processes and activities? What have we done, what are the results, and what do we need to change to do better the next time around? This kind of a systematic approach provides a solid foundation on which to base our practice decisions.
But - does being systematic inhibit creativity? A question for another time - I'm going to pretend I'm still on holiday and go do some sudoku!
with best wishes,
September 2008: jottings from website editor Barbara Kahan
Being Systematic and Creative
In last month's jottings I asked: Does being systematic inhibit creativity? My short answer is: not necessarily; in some cases it may encourage creativity. My longer answer follows.
Being systematic is the opposite of being haphazard. It generally implies having a list of points to consider or tasks to undertake, rather than taking a haphazard approach, to make sure everything important is considered. It is very easy to overlook one or more of the numerous elements involved in our work unless we have a system or process in place to help us cover all the important details.
Being systematic might inhibit creativity if being systematic is defined as running through a never-changing process or checklist - whether written on paper or in one's head, whether prescribed by an organization or adopted by an individual as a general approach. If deviating from the process or checklist is discouraged, if its contents are narrow in scope, if it is never reviewed and revised, if its underlying assumptions are never questioned - there may not be much room for creativity. A narrow, static process or checklist limits the opportunity for new ideas to emerge because, as useful as set processes or checklists are, they presuppose a certain way of viewing the world and how things should be done. In this way they deter creativity which is about viewing the world in new ways.
However, being systematic might encourage creativity if the process or checklist:
Both being systematic and being creative are important to health promotion and public health work if our work, and the results of our work, are to evolve positively.
with best wishes,
October 2008: jottings from website editor Barbara Kahan
My election platform for improving quality of health and life
Here in Canada an election is scheduled for October 14. My dissatisfaction with the choices presented has spurred me to create a vision and corresponding election platform I would happily support if someone running for office were to present it.
I am basing my platform on a vision of a country where power is shared through activities such as knowledge exchange and capacity building. In this vision, who has power in any particular situation changes according to factors such as who will be most strongly impacted by any decision rather than on status, wealth or personal characteristics (e.g. religion, race, gender, age).
My vision emphasises assets, not deficits. Challenges are recognized in the context of using strengths to address them. Resources are shared equitably so that no one goes hungry or homeless and the gap between rich and poor disappears. We organize the various environments we live in (e.g. political, economic, learning, physical) in a way that supports and balances development of individual potential, contributions to the collective good, and respect for nature and our relationship with it.
Critical reflection is encouraged among everyone from a young age, with respectful discussion and analysis occurring as ongoing activities. As a result, decisions are based on an IDM-like approach which takes into account values, beliefs, theories, evidence, and understanding of the environment. Consideration is given to both short-term and long-term impacts and local and global impacts.
Having a vision is one thing, achieving it is another. The specific planks of my election platform follow.
Many of my proposals relate to the determinants of health, which strongly influence quality of life as well as quality of health. Many people will think my platform naïve and pie in the sky, but I do come from the province which contributed Medicare to the whole country. Lucky for us Tommy Douglas didn't give in to the nay sayers - he had a vision which he fought for, and succeeded in achieving.
with best wishes,
November 2008: jottings from website editor Barbara Kahan
If poverty were a bank...
Within a matter of weeks governments around the world have come up with hundreds of billions of dollars to deal with recent economic issues. My question is: in a time period covering years and years and years, why have they never come up with that amount of money to address poverty? Isn't it a crisis of the most urgent kind that people in affluent countries like Canada and the United States are going hungry and are living in terrible housing conditions? Is it not as hurtful and damaging to a society - I would say even more so - to have a large segment of our population who are not allowed to live in dignity as it is to have banks in difficulty?
So why the explanations that there is not enough money to address poverty when obviously there is? The answer: there is a lack of political will. Because poor people do not have much political clout; because of attitudes that say poor people deserve to be poor; because politicians assume voters care more for their own material comfort than they do for putting the value of equity into practice; because of lack of vision and lack of heart.
I do understand that money alone is not enough to address poverty. But it certainly is a necessary component. I also understand that larger economic issues do need tending to - but perhaps we need to question the basis of an economic system that malfunctions so extremely and even when not in crisis serves only a portion of our population well.
This month's jottings is my impassioned plea to keep economic equity alive as a value and make it a reality. For a more reasoned jottings on the topic of income as a determinants of health, click here.
with best wishes,
December 2008-January 2009: jottings from website editor Barbara Kahan
Thoughts on Terminology
To me, language is about communication - sharing information and expressing ideas and feelings. The role of language in building and maintaining knowledge and relationships is immense. At the same time, language has an enormous impact on our attitudes and actions. The words we use, and how we use them, shape the way we view and approach the world. Unfortunately, the language we choose sometimes has an effect opposite to what we want - when our selected terminology reflects values and beliefs counter to our underlying values and beliefs.
Two examples leap to mind - "intervention" and "target group" (or target population). Both are commonly used in health promotion and public health and both annoy me mightily - because they do not fit with my understanding of what health promotion is all about. Both sound militaristic and aggressive to me, and imply a set of outside "interveners" - who "target" a particular group of people, to do something "to" them rather than "with" them.
Rather than intervention I prefer to use the term "initiative," or activity or program or strategy, depending on the nature of the activities and processes. Rather than target population I prefer to talk about the" priority population."
In my ideal world, activities and processes designed to achieve change grow organically from within the community that makes up the priority population. The role of people working in health promotion is to facilitate and support that process, to be part of a respectful collaboration, not to impose a set of externally-developed practices on the community. The term "initiative" is consistent with this belief.
I would say that the belief underlying the term "intervention" is that professionals and experts are best qualified to decide the nature and priority of the issues and how to most effectively address those issues; the role of "target" population members is limited to deciding whether to participate or not in the intervention, rather than being part of the decision making about which issues to address in the first place and how to address them in the second.
That is why I do not use the terms intervention or target population - I do not want to reinforce a top-down approach to health promotion or public health.
with best wishes,
February 2009: jottings from website editor Barbara Kahan
Searching for a Topic: a non-dramatic mini-mini-drama
Scene: An office on the third floor of a house with a large west-facing window and a view of piles of snow; there are piles of paper on the floor, many books and reports in the bookcases, pictures on the walls, and a variety of knick knacks scattered around the room.
Character: Barbara, editor of the IDM Best Practices website.
Barbara is staring at the screen of her laptop computer. No words are written on the screen. She is talking out loud to herself.
Why do I always wait until the last minute to write my jottings? Now I'm really tired and I don't know what to write about. I mean there are lots of topics I'm interested in and will write about eventually - more about the determinants of health, which is a passion of mine and which I always have lots to say about. Suggestions for using the IDM to develop policy, which would be a very cool thing to do and make a better world. Thoughts on health promotion's relationship to chronic disease prevention, which has personal relevance to me as I seem to have so many chronic diseases. More about terminology, I'm always thinking about words and their meaning. The importance of volunteers - I mean I'm a volunteer, right? I know lots about best practices and volunteerism from personal experience.
But I've been working so hard on this playwrighting course I'm taking from the university here - totally obsessed I'd have to say - that I haven't the energy for much else. Such a different kind of thinking required for left-brain type jottings than for right-brain playwrighting. It's hard to shift from one to the other.
Right now I'm with Emma Goldman sitting on her cloud. Now, Emma Goldman, she was all about the determinants of health, she wanted a better world for people, she understood that people needed adequate income and housing and social networks and all the rest which are all necessary for optimum health. Or am I being a health promotion imperialist when I classify Emma Goldman as a health promoter? No, I think I'm merely recognizing the interconnections in the world, the holistic nature of life.
I think I'll take a health break now. That would be best practices, right?
End of this month's scene.
March 2009: jottings from website editor Barbara Kahan
More Thoughts on Terminology
In my December 2008-January 2009 jottings I mused on how the language we choose sometimes has an effect opposite to what we want, using "intervention" and "target group" as examples of terms which to me reflect values and beliefs contrary to my understanding of health promotion. This month I have been thinking about specific words which in themselves are fine but whose interpretation varies, sometimes in ways that are inconsistent with my particular health promotion beliefs and values. Here are two terms whose interpretations I often reflect on.
That's all for now. I plan to jot down more thoughts on other terms in future jottings.
with best wishes,
April 2009: jottings from website editor Barbara Kahan
Mental Health Issues
I grew up with issues related to mental health/mental illness. My parents, Irwin and Fannie Kahan, and my uncle, Abram Hoffer, were passionately committed to improving quality of life for people with schizophrenia and their families. For example, I vividly remember as a ten year old my mother typing away on her old Underwood manual typewriter the book which became How to Live with Schizophrenia, working extremely hard to put into easily understood language the ideas of my uncle and his colleague Humphry Osmond.
Much of my parents' and my uncle's work challenged the psychiatric establishment, whose answer to schizophrenia was psychotherapy and/or heavy duty drugs. Neither of these approaches did a particularly good job, and the drugs in those days often had major side effects, especially with long term use. However, psychiatrists were resistant to trying a new approach that ground-breaking research in Saskatchewan indicated was very helpful - high doses of nutrients such as niacin - for people in the early stages of schizophrenia. The reasons for this resistance appear to be many, for example: vested interest in continuing with a familiar approach; lack of credibility for a new approach; much more massive profits from drug sales compared to sales of nutrients; flawed replication studies, for example including in the study people with chronic rather than acute schizophrenia; a population which has little political clout. The question this experience raises for me is: What is the best way to introduce new approaches that run counter to conventional wisdom and/or firmly entrenched establishments?
In addition to investigating new treatment approaches, my parents and uncle focused on "quality of life" issues. They tried to change the commonly held negative perceptions of mental illness, which have caused so much needless grief. They emphasized the importance of the environment, for example by advocating for facilities that support positive changes and decrease the possibility of adverse effects - the Yorkton hospital my father mentions in this month's reflection was designed by an architect, Kiyo Izumi, who took LSD to understand how a person with visual disturbances might see the world. As a result, he knew to avoid long corridors which might seem to go on forever and wood with knots in it which might present as faces, and to create cottage type spaces which would be more comfortable for people compared to large impersonal wards. They also fought to increase the rights of people with mental illness, who traditionally have been treated very badly by the criminal justice system.
As well, my parents and uncle understood the holistic nature of health, and that the roots of mental health issues run deep. I remember a conversation I had with my uncle a few years ago. He said that in the days when there was no treatment for schizophrenia except to provide a safe comfortable place with people around who cared, the natural remission rate was higher than it was after the introduction of drugs. An excellent example of the power of the social determinants of health.
Given my family history, it's not surprising that mental health promotion has always been a priority for me. As with everything else, it seems, the answer to improved mental health for everyone lies in a combination of factors, including being open minded about new approaches, learning to build on the positive, and increasing the quality of the social determinants of health.
with best wishes,
May 2009: jottings from website editor Barbara Kahan
Celebrating five years of the IDM Best Practices Website
This month, May 2009, the IDM Best Practices Website is celebrating its fifth anniversary. Starting next month I am planning a retrospective of its past profiles, reflections, jottings and resources of the month. I am also planning to reflect on what new directions to move the website in over the next five years. If you have any thoughts please let me know.
At the moment I am still feeling inspired by the fabulous Leonard Cohen concert I attended the other evening in Saskatoon - anything is possible, including an improved website that, with the usual help from many wonderful people, pops with even more energy and is even more useful! I would like to see:
I would also love to see more participation from website readers. Please feel free to contribute profiles of yourselves and others, to write reflections, and to recommend resources.
In addition - a giant thank you to everyone who has contributed in so many different ways over the past five years. The time, thoughtfulness and support you have given to the website are greatly appreciated.
with best wishes,
June 2009: jottings from website editor Barbara Kahan
Five years of Jottings
Writing monthly jottings forces me to delve deeper into thoughts than I normally would - challenges the logic of my thinking, develops my creativity muscles. It's an excellent reflective and learning process for me, and hopefully of some interest to website readers! The jottings I have written over the last five years fall into the following categories:
Click here to go to the first of a series of jottings that had my brain cells working overtime!
July/August 2009: jottings from website editor Barbara Kahan
Nuclear Power and Public Health
Confused and annoyed, that's me! Because the Saskatchewan government wants to build a nuclear power plant and I don't understand why. Although compared to fossil fuels, nuclear power contributes fewer greenhouse gas emissions to the environment - on a par with hydroelectric and wind power - in the long-term, it contributes way more radioactive carcinogenic waste than any other energy method. So it is definitely not a better energy choice for the environment than fossil fuels. To sort out the issue in my own mind I decided to quickly apply the IDM framework to the topic. As it is my first go-round, the following results are sketchy. As usual with the IDM, it will become more in-depth and reflective as time goes on.
my values (based on IDM suggested guidelines): health; social justice; power sharing; the environment; social connectedness
values underlying nuclear power activities: technology; concentrated decision-making power; high energy consumption
nuclear power proponents:
evidence I refer to:
evidence nuclear power propenents refer to:
Understanding of the Environment
My vision is of a world with minimal pollution or greenhouse gas emissions because everyone consumes energy, food and goods primarily according to need rather than want.
How do we meet the world's energy needs in a way that is least likely to have a negative impact on health and the environment? Is nuclear power a good option to achieve this goal?
Energy requirements throughout the world are increasing due to a number of factors such as increased population, increased desire for consumer goods, increased use of transportation, increased use of heating and air conditioning. The evidence overwhelmingly indicates that extensive use of fossil fuels to provide energy has contributed to climate change, which is an increasingly significant public health issue. Responses to this issue include:
Each alternative energy source has its own negatives, though none compare in magnitude to the potentially cataclysmic consequences of a nuclear accident or the long-term health dangers of nuclear waste. The nuclear industry is better funded, better politically connected, and has more sophisticated public relations than the supporters of alternative energy. It has been suggested that one of the reasons for building a nuclear reactor in Saskatchewan is to provide power for oil sands development in Saskatchewan and/or Alberta; the negative impact of oil sands development on the environment is well known.
Nuclear power produces fewer greenhouse gas emissions than fossil fuels and therefore plays less of a role in climate change. It can produce medical isotopes.
best ways to address the issue
Reducing energy use and increasing energy efficiency is the safest method. It will keep us healthier and the environment cleaner. In my analysis, nuclear energy is not a good option, and the alternatives deserve more consideration.
Build a culture and infrastructure that support energy reduction and efficiency. Redesign the economy so it does not rely on consumerism. Explore alternatives to fossil fuels and nuclear energy.
Disclosure: I have received no remuneration from either the nuclear industry or the anti-nuclear movement in the past or currently. I was a member of SLANAG (South London Anti-Nuclear Affinity Group) in the late 1970s, and a member of RGNNS (Regina Group for a Non-Nuclear Society) in the early 1980s. I have no current anti-nuclear affiliation, although I did recently sign a petition asking the Saskatchewan government not to build a nuclear power plant in Saskatchewan.
Acknowledgements: Sean Sunley and Evan Morris (EcoTech Research), who have been researching the topic of nuclear power and other energy production methods, for information and insights.
with best wishes,
September 2009: jottings from website editor Barbara Kahan
Slow Health Promotion Movement
First there was the slow food movement, followed by slow travel, slow homes, slow cities… I've even seen a reference to slow poetry. Now I'm proposing slow health promotion!
A slow health promotion movement would be extremely compatible with the IDM approach, which emphasizes taking adequate time to build strong foundations for initiatives. Adequate time means allowing enough time:
Like the slow movement in general, the IDM emphasizes quality rather than quantity. Do we want fewer initiatives done well or more done poorly? Do we want to make a meaningful positive impact on population health status by taking the time to explore new ways of doing things with a slow health promotion approach - or continue on the speed-is-of-the-essence health promotion track, constantly trying to do more in increasingly less time?
A frequent criticism of the IDM is that it takes too much time. However, where has the "no time for fundamentals" approach gotten us? To a place where the quality of the social determinants of health is deteriorating rather than improving - for example, the gap between rich and poor is growing. Maybe it is time to step back and slow down so we can think of a better way.
Using a slower but surer approach like the IDM would result not only in greater job enjoyment but better outcomes. Doing things in a rush means we cut corners, rely on methods and approaches that are familiar but not necessarily as effective as they might be, and don't take time to either critically examine how to improve what we've been doing or explore new ideas for doing things.
Doing the "same old same old" has not gotten us very far. Let's try changing from a culture of speed and urgency to one of thoughtfulness, where, before rushing ahead, we ensure every piece of an initiative is the highest quality piece possible and fits well with all the other pieces.
Remember that old saying - a stitch in time saves nine. It's the same for health promotion. If we take enough time at the beginning to set things up the best way possible, we can be assured of fewer mishaps, and better results, down the road.
with best wishes,
October 2009: jottings from website editor Barbara Kahan
Musings on the Physical Determinants of Health
Without question the social determinants of health are incredibly important to people's well being. The physical determinants of health - air, water, soil, and the built environment such as housing - are equally important to people's physical and mental health. (See Bruce Rice's reflection this month for more discussion on this topic.)
We know that people who have higher income, greater control of their lives, and stronger social networks (to mention a few of the social determinants of health) are more likely to be healthier than people who have lower income, less control over their lives, and weaker social networks.
At the same time, people with greater exposure to physical factors such as toxins (e.g. mercury), carcinogens (e.g. asbestos) or irritants (e.g. mould) are more likely to suffer from cancer, neurological conditions, respiratory illness, and other negative health conditions than people with lower exposure.
Some contaminants occur naturally; many more result from industrial wastes or manufacturing practices - that is, from human activity. The obvious conclusion is that a higher quality physical environment is attainable, if the will is there to attain it - as is true to attaining a higher quality social environment.
Which brings us to the common links and the interrelationship between the social and physical determinants of health. Regarding common links, the quality of both sets of determinants depends on what I think of as the pre-determinants to the determinants of health - factors such as: culture, geography and history; values and attitudes; systems and structures; and policies and resources. (For more explanation, see Part I, Part II, and Part III of the pre-determinants of the social determinants of health.)
In other words, social, political and economic factors influence the physical determinants just as much as they influence the social determinants. For example, a society that has policies, systems and structures in place consistent with valuing the physical environment will protect and enhance the environment, in the same way that policies, systems and structures consistent with valuing equity will increase equity.
As for the interrelationship between the social and physical determinants - the social determinants affect who is most likely to experience higher or lower quality physical environments. For example , the people most likely to be exposed to pollution are people with lower incomes, who can't afford to move to more desirable - less polluted - locations, and people with lower education, who are more likely to work in more dangerous workplace environments. The reverse is also true. Physical determinants such as how public space is organized affect social determinants such as social networks.
My point? That it's necessary to understand the interconnections between physical and social determinants of health, and that it's important to address both sets of determinants.
with best wishes,
November 2009: jottings from website editor Barbara Kahan
Make Practice Consistent with Values to Achieve Meaningful Change
I admit it, I get easily discouraged about the lack of progress in the world in achieving better health for all. So I rant and rave, or moan and groan. This month, instead, I will use these jottings as therapy and write down my thoughts about how to increase the chances of improved health for everyone - with my main theme being the need to increase the consistency between practice and values.
First - why do I get discouraged? Because I hear and read, in relation to improving health, about the importance of equity, of high quality social determinants, of community engagement. But - I don't see, at least not on a widespread basis, the corresponding processes and actions that would actually support these important values. That is the major reason that "the more things change the more they stay the same" - the changes that occur are not meaningful ones, at least not when measured against stated values.
One reason for inconsistency between practice and values is lack of clarity about how to translate values, which are abstract, into concrete reality. This lack of clarity is often the direct result of omitting to reflect on the link between values and practice; time is rarely set aside to consider the logical connections between what we value and what we do. So here we have one easy solution - schedule in the time!
In other scenarios, an organization's processes and activities may reflect a totally different set of values than the stated ones, because the "hidden values" have a higher priority to the organization's decision makers. For example, I suspect that the reason governments talk about the need for equity and then take measures that increase inequity is because equity is secondary to other values which are more dear to them, such as - prepare to hear my cynical side talking - "maintaining power" or "status quo" or "individualism" or "cost cutting." What to do about this one? Identify what the hidden values are, and challenge governments on them. "Transparency" is a popular phrase these days - organizations should be called to account if they don't practise what they preach; either they should change what they preach, or change what they practise.
A third reason we might see inconsistency between practice and values is mistaken assumptions among key stakeholders about the degree of consensus regarding the meaning of a particular value. When values are identified but not explicitly defined, people often assume that everyone is on the same page when in many cases they are on totally different pages. This situation leads to people talking at cross purposes, often without realizinig it, resulting in confusion and compromise and a disconnect between practice decisions and values. My suggestion is, of course, that in line with the IDM best practices approach, that all initiatives should involve all key stakeholders in a process of identifying and clarifying key values.
I feel better now, thanks for listening!
with best wishes,
December 2009 - January 2010: jottings from website editor Barbara Kahan
Profile of Users of the IDM Best Practices Approach
What kind of people use the IDM best practices approach to health promotion, public health and population health? My image of IDM users follows, based on my knowledge of the people I know who are using it.
IDM users sound like a pretty impressive group of people to me!
with best wishes,
February 2010: jottings from website editor Barbara Kahan
Evidence-Based Practice and Practice-Based Evidence
This month's jottings are from a discussion paper I prepared for the Canadian Best Practices Initiative (CBPI) Group in August 2008. The discussion of the meaning of practice-based evidence compared to evidence-based practice is included here with the permission of the CBPI and Public Health Agency of Canada (PHAC). The content does not necessarily reflect the views of the CBPI or PHAC. For a list of the documents on which the discussion is based, see this month's Resource of the Month.
The term practice-based evidence was introduced a number of years ago to balance the emphasis on evidence-based practice. The term evidence-based practice is commonly used to mean planning and implementing programs based on research conducted according to rigorous design, methodology and methods. Generally in evidence-based practice a hierarchy is applied, with results from highly controlled experimental designs considered the most trustworthy, followed by results from quasi-experimental designs. Evidence based approaches have traditionally more readily accepted quantitative over qualitative methods. Similarly, the preferred methodology has distinguished between the researcher and the population being researched, with key research decisions made by the researchers.
A number of people have raised issues concerning evidence-based practice, and called for more practice-based evidence to address these issues. The primary issue identified in the literature is evidence-based practice's lack of relevance to a range of practice contexts. Lack of relevance results from three key factors:
In addition to criticisms of evidence-based practice, criticisms of practice-based evidence also exist, primarily regarding lack of rigour and lack of objectivity.
In the view of the literature reviewed, practice-based evidence presents one or more of the following characteristics (not all documents mentioned all characteristics):
None of the authors advocated replacing evidence-based practice with practice-based evidence. Instead, they discussed the two approaches complementing each other or relating to each other in an ongoing cycle of practice (including research). The argument for including practice-based evidence in the cycle is to ensure relevance of research results and increase the likelihood that the resulting evidence will be used.
wishing you all a happy - and healthy!- mix of evidence-based practice and practice-based evidence,
March 2010: jottings from website editor Barbara Kahan
Health Promotion Vision
Vision is a key component of the IDM best practices approach. I haven't thought about vision in a while, bogged down as I've been in the demands of everyday life - trying to meet deadlines, fulfill my volunteer obligations, do my social duties, do the occasional load of laundry, keep up with the dishes, remember to eat, try to fit in exercises...
However every once in a while I remind myself that vision is as important as everything else for all sorts of reasons. Here are three:
I have formulated visions before and I am tempted to look them up to see what I wrote. But I think that like everything else visions need to change to fit with changed circumstances, new knowledge, growing experience. So here is the latest brief version of my personal health promotion vision.
In my vision, society as a whole pays attention to the determinants of health - with positive results. For example, as a society we enjoy income equity, a highly educated population, strong social networks. The benefits are high quality of life.
In addition, people work and live together respectfully and with generosity towards each other, appreciating and building on our own and others' strengths, individually and collectively. We constantly reflect and question, so that our activities and processes are based on a sound foundation, and change as we and the world around us changes. We do our best to make sure that our practice is consistent with our values, theories and beliefs, evidence, and understanding of the environment. We also take time to have fun!
with best wishes,
April 2010: jottings from website editor Barbara Kahan
Choosing Between Qualitative and Quantitative
The terms "qualitative" and "quantitative" are often mentioned in conversation as if they were an "either/or" proposition and debates still occur about which is better for evaluation and other kinds of research. In practice, however, there is a strong overlap between them, and both are important to understand and improve health.
Part of the confusion arises from the fact that in research there are three areas in which to make a choice about qualitative and quantitative: data, data collection, and data analysis.
An overlap occurs when a data collection method is used to collect both qualitative and quantitative data. For example, an interview and a survey could each easily collect both qualitative and quantitative information. Another overlap occurs when a quantitative analysis is applied to qualitative data, for example calculating the proportion of clients who made a particular suggestion to improve a service.
Many research projects use a combination of qualitative and quantitative data, collection methods and analysis methods. For example, I have used the results of literature reviews and in-depth interviews to develop surveys asking some questions which are qualitative in nature and some which are quantitative. I have supplemented the literature reviews, interviews and surveys with focus groups, more in-depth interviews, and reviews of administrative data. My analysis has identified and described common qualitative themes (e.g. related to housing issues), quantified qualitative answers (e.g. the percentage who thought their children were doing better since participation in an early childhood program), and calculated statistics for quantitative answers (e.g. the average age at which people started gambling).
Ultimately the best choices between qualitative and quantitative are those that best suit the question being asked. For example, if the question is how many low income households exist in a city, a quantitative data collection method and analysis is clearly most appropriate. To understand the daily lives of people living on a low income, a qualitative data collection method and analysis is likely best. If the question is why some people have a lower income than others, a mixed qualitative and quantitative data collection method and analysis may be most relevant.
Often research attempts to answer both "how many" and "why and how" questions, requiring a mix of qualitative and quantitative data, data collection methods, and data analysis. In general, if we want a complete picture of an issue, we need both qualitative and quantitative. But, again, the questions we're asking should determine which kind of data, collection method and type of analysis will best suit our purpose: qualitative, quantitative, or a mixture of both.
with best wishes,
May/June 2010: jottings from website editor Barbara Kahan
Something different this month - a quiz! Have fun!!!
Scoring Your Answers
with best wishes,
July/August 2010: jottings from website editor Barbara Kahan
An IDM Analysis of the Physical and Economic Environments as they Relate to Climate Change
In the IDM, understanding of the environment includes all the environments we live in: the physical and the psychological, the social, political and economic. Lately I have been thinking about how the interplay between the physical and economic environments affects the health-related issue of climate change.
I started out my musings by thinking about values - how valuing the physical environment is very common, as is valuing a strong economy. Then I realized that in concrete terms there was a reasonably universal picture of a positive physical environment, but contrary pictures of a positive economy.
Most people would agree that a positive physical environment involves high quality air, soil and water, and a life-supporting balance among all the different elements which interact in the physical environment.
Many people also recognize that the balance necessary for long-term existence of life is now skewed. The green-house gases pouring into the environment are changing our climate and as a result endangering many species of life, including the human species. Already in Saskatchewan, where I live, the level of water in the lakes has decreased over the last fifty years by many feet, a fact which I find shocking. In other words, climate change is, among other detrimental health effects, decreasing the amount of available life-sustaining water.
Agreement is much less wide-spread when it comes to the economy. The description of a positive economic environment varies widely, depending on underlying values, beliefs and assumptions. A insists that a free market is best, B declares that planned is the only way to go, and C praises the benefits of a mixed economy. One group lists the following as characteristics of a positive economy: a strong gross national product, virile corporations with a strong showing in the international marketplace, and some unemployment in order to keep wages low. Another group has a conflicting perspective regarding the desired elements of the economic environment: an equitable distribution of income, networks of local cooperatives, and full employment.
A crucial difference exists between those who see a strong economy as an end in itself ("as long as business profits are high all is well in the world") and those who see it as a means to an end ("let's use economics to achieve a healthier, happier population"). I find myself in the latter group, arguing that we need to thoroughly examine the real-life consequences of any society's economic ideal. For example, our current economy is based on consumerism; however, it is consumerism that is threatening the environment with increased pollution and more green house gases.
The IDM is all about consistency. It seems to me, that in an IDM-influenced world, we would recognize the conflict between the health of the environment and the current view of what a healthy economy is and come up with a different kind of economy, one that is not detrimental to the environment, one that would help ensure a healthy population and the survival of future generations.
with best wishes,
September 2010: jottings from website editor Barbara Kahan
Ignoring the Social Determinants of Health at our Peril, a Mini-Screen Play
Half the screen shows Barbara sitting at her desk talking on the phone. The other half of the screen shows Barbara's friend talking on the phone.
Barbara: I need a jottings topic for September. A topic I can get really fired up about.
Friend: Well then - ta da - Health Promotion and Sports!
Screen fills with image of press release.
Subject: The New Ministry of Health Promotion and Sport
...our new name more accurately reflects the balanced and broad approach of our Ministry's work to date... We have been committed to promoting health... through healthy eating, active living, smoking prevention and cessation, injury prevention, increased participation in sport and recreational activities, and the development of high-performance amateur athletes who inspire us in our quest to develop a culture of health and wellness.
Back to split screen with Barbara and Friend talking on the phone.
Barbara: Ha ha ha ha ha!!!!!
Friend: I hope that's hysterical laughter...
Barbara: It's a joke, right?
Barbara: A balanced and broad approach? There's no mention of the social determinants of health!
Barbara: I mean, it's good if people are able to eat nutritiously and live actively and not smoke and prevent injuries but - sputter sputter sputter.
Barbara: At the same time there's overwhelming evidence of the extremely strong link between the social determinants of health and health status, right?
Barbara: So why not the Ministry of Health Promotion and the Social Determinants of Health?
Friend: You've missed the point, Barbara. It's not actually about health. It's about the upcoming Pan Am Games! They'll use their time and money to prepare for that...
Barbara: Instead of also working to increase income equity, education levels, social networks, capacity building? Instead of increasing housing accessibility and improving housing quality? They're going to limit themselves to an individual approach and ignore a systems approach?
Friend: You got it...
Barbara: Sob sob sob.
Friend: Are you weeping?
Friend: I'm sorry. I was hoping to get you fired up so you could write your jottings.
Barbara: I am fired up about such - such short-sightedness. I'm also weeping. I can do two things at once, even if intuitively they may seem opposed. Too bad the Ministry of Health Promotion and Sports can't do two things at once - focus on the social determinants of health as well as lifestyle issues. Especially since they're integrally linked, not opposed.
Friend: Ah - next month you can write about the case for "and" as opposed to "either/or."
Friend: Is that a smile I hear?
Barbara: I now have September's jottings done, don't I? And my topic for October. Tune in next month everyone!
with best wishes,
October 2010: jottings from website editor Barbara Kahan
The case for "and" versus "either/or"
Address the social determinants of health or lifestyle issues? Focus on policy development or community building? Conduct in-depth interviews or a survey? So many choices! Hey, how about focus on the social determinants of health and lifestyle issues, focus on policy development and community building, conduct in-depth interviews and a survey? Why does it have to be one rather than the other?
In fact, most times it shouldn't be, as using multiple strategies is more effective than using only one strategy. For example, to ensure a home for every segment of the population requires:
Of course, some possibilities I would never include in either my "and" statements or my "or" statements, because I am a passionate follower of the IDM which stresses consistency among all key decision making fundamentals. For example, I would never say "use corporal punishment and/or positive reinforcement in child raising" as corporal punishment is against my beliefs. I eliminate right off the bat any options that don't match my values, theories, understanding of the environment, or the evidence.
In general, I try to change my tendency to think in "or" terms to thinking in "and" terms because it is a more creative, expansive and flexible approach, opening up space for all kinds of new thoughts and possibilities. I try to remind myself that mostly there isn't an absolute right or wrong, that two people with differing opinions can be both right and wrong in different aspects, and that maybe the tension between the two positions will result in something even more effective. I also think an "and" approach is more holistic and less simplistic than an "or" approach, and more accurately reflects the complexity of the world around us.
The two approaches have very different implications for those of us working in health promotion, public health or population health. The book Facilitator's guide to participatory decision-making (Sam Kaner et al., Jossey-Bass, 2007) includes a table illustrating the differences titled
A note to myself is to ask "and" more often: We need this and we need that and we also need -what else? We have this strength to build on and that strength - and what other strengths? Here is one consideration to take account of, here is a second - and what are the third and fourth and fifth considerations? An "and" approach makes me think harder! And better.
with best wishes,
November 2010: jottings from website editor Barbara Kahan
What if we treated the social determinants of health as a priority?
I am imagining that I am a single parent of young children, surviving below the poverty line. To pay the rent for the substandard housing I live in I have to scrimp on food, so sometimes go hungry. I don't have enough education to get a good job. I am so stressed I get irritable and worry that I am being a bad parent. I worry that there is no future for me and my children. I feel depressed, lonely, panicked. And very very tired.
Those of us working in health promotion, public health and population health know that this kind of scenario, where the social determinants of health exist in the negative, are strongly correlated to high risk of mental, physical and social health issues.
The general societal response to the scenario described above is to provide ameliorating services rather than doing our best to improve the social determinants of health. Welfare (which still keeps people below the poverty line), food banks, parenting programs, counselling, while better than nothing, are still inadequate responses to horrific conditions.
People living in these conditions say what is needed and are ignored. Plans are made based on feedback from key stakeholders and these are ignored. Governments make promises and break them. Old programs die, new ones start, the situation continues to worsen. Excuses are made. More excuses are made. The situation continues to worsen.
Essentially we have a situation which works to maintain the status quo. Everyone wants to keep their job even if it is just ameliorating rather than changing unhealthy situations. Paying billions for fighter jets is seen as more important than investing in high quality affordable housing. People living in the most challenging circumstances - with negative social determinants of health - are essentially disenfranchised.
As a society we have enough resources to provide the basics for everyone - if we want to. Good housing, enough food, education, decent jobs, adequate income - these are all within reach if we make them a priority and use our creativity to change the status quo. We can ensure that everyone is influenced by positive social determinants of health if we are willing to share our good fortune (for example, wealthier individuals and corporations pay more taxes to improve the determinants of health over all), emphasize healthy relationships (not just between family and friends, but between neighbours, co-workers, service providers and clients, coalition members...), take the time and energy to advocate for good living conditions for everyone. If we focus on community strengthening, if we take steps to go beyond ameliorating, if we make sure our practice is consistent with IDM fundamentals (values, theories, evidence, understanding of the environments), we will achieve deep-rooted long-term positive change.
If I really were that single parent living below the poverty line, I know I wouldn't feel so hopeless and depressed and exhausted if I had decent accommodation for me and my children, if I had enough to eat. If I were allowed to help identify the issues affecting me and to be part of the solution rather than others deciding what is best for me. If I were part of a truly caring community that realized if one member suffers we are all affected.
with best wishes,
December 2010 - January 2011: jottings from website editor Barbara Kahan
Leading by Example
My concept of leadership has changed over the years. When I was young I thought being a leader meant leaping to the front of a crowd and leading everyone in a charge against the forces of evil (metaphorically if not literally). I thought a leader had to have charisma, that magnetic quality that draws people in and gives power to a message beyond logic or evidence. I thought only a few people could be leaders, and that leadership was not for the likes of introverted uncharismatic types like me.
I no longer think that, but many people still do. For example, a group of us were discussing the differences between being introverted and extroverted. One person indicated she was an introvert, and another person commented, "No, you can't be an introvert, I've seen you show leadership."
Now that I am older, I adhere to the humble rather than the grand theory of leadership. These days I think that anyone who chooses to be a leader can be, including us retiring introverts who consider three people a crowd and whose facility for coherent language deserts us in even mildly stressful situations. Each of us simply needs to choose what kind of leadership matches best with our personality, inclinations and situation. More comfortable writing than speaking? Articles, letters, reports, stories - these all have the power to persuade and move. Enjoy meetings or conferences? Asking questions or making suggestions has the possibility of moving current thinking into new territory.
And anyone, no matter who they are or their situation, can lead by example. For example, conducting practice in an IDM-compatible way - acting on the basis of our values, theories and beliefs, evidence, and understanding of the environment - provides a model for others to emulate.
What does it require to be a leader? Not money, or status, or charisma. It requires only the courage to think for oneself and to take risks. Although people - and organizations - who act in a way that is consistent with what they value and know are not always rewarded, they have the satisfaction of acting with integrity. And whether aware of it or not, they are likely inspiring other people whose lives they touch to also act with integrity.
Ultimately, the "leader within" understands that we cannot predict the future: the amazing possibility always exists that even small actions, if they are based in thoughtfulness, may, down the road, lead the way to larger scale positive change as more and more people follow our example. So we do the best we can given our circumstances, and hope for the best. To me, that is showing true leadership.
with best wishes,
February 2011: jottings from website editor Barbara Kahan
Naming the social determinants of health
My partner Evan is teaching a class on the social determinants of health. He had to decide which ones to cover so I dug up a number of lists - which overlapped up to a point but also contained differences. The questions that popped up in my head from reviewing these lists follows.
My current list of the social determinants of health to consider for their nature and quality follows:
with best wishes,
March 2011: jottings from website editor Barbara Kahan
The role of the medical system as a determinant of health
In last month's jottings I listed community infrastructure (housing, food distribution, transportation, health care services, childcare) as a major social determinant of health. This month I am reflecting on how community infrastructure regarding health care services - the medical system in general - affects health.
I have always had ambivalent feelings about the medical system as a determinant of health. On the one hand, the medical system helps reduce the impact of my several chronic diseases on my quality of life, and keeps me healthier and longer living than I would be if I didn't have access to its resources. Many other people of course benefit in a similar way.
On the other hand, evidence indicates that factors such as income equity and social support are stronger determinants of health than medical services. Primarily this is because addressing root causes of ill health such as poverty and social exclusion are not within the ability of the medical system, and because the medical system has not met its full potential in contributing to health.
In the debate in my head, I always come to the same conclusion: addressing determinants of health such as power, income, education and social relationships is urgent and critical; at the same time, a well-functioning medical system that contributes as much as it can to optimal health for all is necessary. Even if every social determinant of health were of the highest quality possible, medical issues would still exist. And unfortunately we live in a world where the social determinants of health are still in great need of improvement, making the medical system even more essential.
Rather than thinking either that focusing on the medical system can replace addressing the social determinants of health, or that if we address the social determinants of health we don't need to worry about the medical system, we need to work to improve all the social determinants of health - and work to make the medical system as high quality as possible.
The question then arises, what would a high quality medical system look like? To my way of thinking, a high quality medical system would:
with best wishes,
April 2011: jottings from website editor Barbara Kahan
Measuring Health Intelligence
Last federal election I described my personal election platform. This election I propose that we measure the "health intelligence" of political parties by asking the questions below. The answers are ones I think indicate a high degree of health intelligence; feel free to identify your own answers!
Political parties scoring 100 points have a high health intelligence quotient. Anything less requires dedicated learning and greater consistency between knowing and doing on their part.
with best wishes,
May 2011: jottings from website editor Barbara Kahan
Meeting Everyone's Needs
The focus in the recent federal election in Canada on capturing the vote of selected ethnic communities (selected on the basis of their potential to tip the balance in favour of one political party over another - the so-called "micro-targeting") is annoying me (beyond the obvious insincere manipulation) so I decided to try to figure out why. And since the best way I know to clarify my thoughts is to write them down, here we go...
I'm annoyed not because I think people belonging to an ethnic minority are unimportant and don't deserve more attention (especially since I belong to an ethnic minority myself!). In fact I am very aware of the challenging circumstances that face many members of ethnic minorities, particularly Aboriginal peoples, refugees and recent immigrants. Among the challenges they face are communication issues, poverty, discrimination, isolation, difficulties accessing services, and programs that are not culturally appropriate.
I do strongly feel that Canadian society should meet their needs better than is currently the case. To pick out a few groups and ignore others, however, is not the thoughtful approach that I would like to see applied to any societal issues, including health. For one thing, it divides people, accentuating differences rather than commonalities, and states implicitly that some groups are more important than other. For another, such an approach is not effective in achieving over all improvement in our communities because it emphasizes micro-snapshots rather than the whole picture, and isolated pieces rather than relationships among the pieces.
What I would prefer to see is an approach based on the following beliefs:
Applying these beliefs in practice means having a comprehensive plan to make sure everyone has a decent income and shelter and clean water to drink and all the other items mentioned above. It means avoiding a cookie cutter approach by taking into account unique differences. Finally, it means acknowledging, appreciating and making use of the contributions that the wide variety of citizens in our various communities have to offer. That is the way to ensure a sense of belonging and over all improvement.
with best wishes,
June 2011: jottings from website editor Barbara Kahan
Connecting Lifestyle and the Social Determinants of Health
Lifestyle patterns and the social determinants of health are often discussed as if they were separate from each other, when in fact they are integrally linked. Does it matter if they are connected? Yes, because:
Now that I have decided it does matter that lifestyle patterns and the social determinants of health interact with each other, I find myself asking the next obvious question: how do they impact each other?
On the one hand, it is fairly obvious how the social determinants affect lifestyle. For example, low income makes it extremely difficult to eat nutritiously, participate in a full range of physical activities, and control stress in constructive ways.
On the other hand, it is more of a stretch to identify how lifestyle affects the social determinants, but here are some examples:
Lifestyle patterns are often seen as a matter of individual choice, so information about their importance is viewed as the appropriate way to encourage them. I would never downplay the role of information - however, I also think those programs which support positive lifestyle patterns at community and society-wide levels are crucial. What is difficult or next to impossible for a single person or individual family to accomplish on their own is much easier when collectively we have, as the saying goes, made the healthy choice the easy choice, for example by making changes to the way cities are laid out, how food is distributed, accessibility to recreational programs.
The relationship between the social determinants of health and lifestyle patterns is not a "which comes first, the chicken or the egg" question. Clearly, the existence of the social determinants in their positive manifestations makes it easier to develop positive lifestyle patterns. At the same time, facilitating the adoption of positive lifestyle patterns makes it more likely we will achieve meaningful changes to the social determinants, and benefit as much as possible from them. As a society, we need to focus on both the social determinants and lifestyle.
with best wishes,
July-August 2011: jottings from website editor Barbara Kahan
The Individual-System Connection
People, including me, often talk about individuals and systems as if they were two different kettles of fish entirely. Depending on basic philosophy, a person tends to think one of the two has more influence than the other on any particular topic that comes to mind - the state of the world, quality of life, health status...
My natural tendency is to think systems have greater impact than individuals. Economic, political, transportation, educational systems - their configuration affects to an incredible degree all members of a community, region, nation. Is the government elected? Is education free? Are women given the same economic opportunities as men? Do marginalized groups have easy access to transportation? Is inclusion a defining characteristic of a particular system?
It is clear that the answers to these questions have strong implications for how people relate to each other, what their daily lives are like, the health of their communities in terms of issues such as crime rates and employment levels and quality of social networks, and how mentally, emotionally and physically healthy individual community members are.
But when I take the time to examine my assumption more carefully, I always end up with the realization that while systems shape the lives of individuals, simultaneously individuals shape systems. Any system's nature - defined by details such as who can use it, the financial costs and other requirements that must be met before access to it is allowed, how integrated it is with other systems, what premises it is based on - depends on individuals: individuals who make decisions affecting the system, individuals who contribute funds or other resources to develop or maintain the system, individuals who carry out the day to day operations of the system. And, a system's nature also depends on the individuals who use a system, individuals who don't use it, individuals who campaign to change it.
Every individual every step along the way has a choice about how we influence a system. Clearly some people are in stronger positions and better circumstances to exert influence than others, and just as clearly individuals working together collectively have more influence than individuals working on their own. But that doesn't negate the fact that each and every one of us can - and do, whether actively or by default - contribute to maintaining, improving or worsening each of our community's systems.
Doing nothing; or voicing opinions at meetings, on social media, or through emails, petitions and demonstrations. Voting for one political party rather than another. Donating to these non-profit organizations rather than those. Conducting work duties in ways that challenge or maintain the status quo. These are choices we all have, and each choice we make has implications for the quality of the system.
In general, it seems to me, the best way to improve the systems that so dramatically affect us is for all of us, individually and collectively, to follow IDM principles:
with best wishes,
September/October 2011: jottings from website editor Barbara Kahan
Critical Thinking and the IDM
Critical thinking, an essential component of the IDM, involves actively questioning what we and others think, believe, say and do, promotes digging deep beneath the surface, and encourages us to take into account the complexities of life. It is easy enough to reel off a list of values; it is not so easy to understand how to ensure that practice reflects those values - that requires critical thinking. It also requires critical thinking to bring underlying beliefs and assumptions, upon which we often base judgements and actions, to the forefront of our consciousness and make them explicit. Identifying evidence, developing theories, and understanding the various environments we are immersed - these as well require critical thinking.
At the same time as critical thinking is necessary to the IDM, the IDM provides a framework for strengthening critical thinking. It is all well and good to say we need more critical thinking, but not so straightforward to figure out exactly how to think more critically. Built into the IDM template is a checklist of all the important things we need to consider to ensure our decision making is based on sound rather than simplistic thinking. Here are a few examples of IDM-based critical thinking questions:
Taking the time to fully examine an idea, situation or piece of information from the perspective of a comprehensive best practices approach - that is, the reflective IDM -results in better health promotion and public health practices. When we fully engage our brains in the task of identifying and testing every thought, belief, conclusion, piece of information - rather than accepting what we read or have been told or have always thought or done - we will join the ranks of other critical thinkers, who are not always popular but are our best hope for a healthier world.
with best wishes,
November 2011: jottings from website editor Barbara Kahan
The IDM case for identifying similarities and differences
In my more optimistic moments I think that if everyone just sat down and talked together we'd be able to make the world a better place without too much trouble. For the most part we all want the same things, right? Enough food to eat, a roof over our heads, healthy families. And then, of course, I realize that not everyone does want the same thing. Take, for example, family - pretty close, I imagine, to a universal value. Almost everyone thinks the family is important.
Except - ideas differ regarding what a family is, and they also differ regarding how to support families so they can be the healthiest possible.
For some people the conventional configuration of legally wedded mother and father and their child(ren) is the only acceptable definition of a family. Others allow room in their notion of family for single parents, gay and lesbian parents, non-legally sanctioned relationships, polygamous relationships, and/or a range of extended family members.
Even if everyone did have the same definition of family, beliefs for the best way to support families vary widely. Do we focus on strengths, needs, or both? Do we follow an individualistic or collective approach? Which do we think is better: (a) Giving each family a sum of money to spend as they want, assuming that what they need is actually available, accessible and affordable through the free market system? (b) Providing government sponsored universal programs for families? (c) Community building, where people come together on a cooperative basis outside of government and the free market?
It may appear on the surface that we share the same value - in this case "family." But if definitions contradict each other, or visions are on opposite ends of the spectrum, or theories/beliefs differ wildly - what do we do next?
From an IDM perspective, defining similarities and differences is a necessary place to start. In other words, people sitting in a room together isn't such a bad idea after all. We might find more common ground than we expect; we might find our and other people's ideas evolving. We might even find new insights into bringing about positive change.
with best wishes,
December 2011 - January 2012: jottings from website editor Barbara Kahan
Using the IDM as a decision-making tool
I recently developed an exercise to familiarize people with the IDM decision making approach for a friend teaching a university class on the social determinants of health. I thought website readers who have not yet used the IDM might find it valuable to go through a brief IDM decision-making process by applying IDM theory to a concrete situation. If you have a few minutes, here goes!
Imagine you are the minister in charge of post-secondary education in your province/state/country. With the assistance of your department's staff, you are reviewing policies and programs related to the province's universities and technical institutes. The aim is to decide:
As the minister, what kinds of things would you consider when making your decisions? Take a minute to consider this question...
Whether you have written your answers down, or listed them in your head, you will almost certainly find that they fall into the IDM categories of values/goals/ethics, theories/beliefs, evidence, and understanding of the environment. Below are examples of possible answers, organized according to these categories.
education-related environment (socio-political context, economic conditions, geography/climate, infrastructure, psychological conditions)
The next part of the process is to figure out how to ensure that the relevant values, evidence, theories and environmental analysis and vision that you have identified are translated into practice. From an IDM perspective, consistency is key - practice that does not reflect these decision-making fundamentals (values and the rest) will not be the best possible, and therefore will not result in the best possible outcomes. The ongoing part of the process is to constantly review practice and revise it accordingly so that practice reflects, in every aspect, your IDM decision-making fundamentals.
with best wishes,
February 2012: jottings from website editor Barbara Kahan
An IDM Lament about Integrity
Every once in a while I find myself moaning about integrity - most often after reading yet another news article illustrating the lack of it in the political arena. Incensed that the people who are supposed to champion the common good don't, I start muttering to myself that too many politicians, of any political stripe, lack integrity. They put their interests ahead of those of the citizens they are supposed to represent; they put a desire for power ahead of principle. Lack of integrity is bad for our collective health: it results in decisions - on economics, education, social networks and other health-related areas - which may benefit a few and be detrimental to many.
To me a person - politician, educator, health promoter, or anyone else - has integrity when they act according to IDM foundations. That is, they do the best they can at work, home or anywhere else, by basing their actions on what they value, believe and know and by using a critically reflective and comprehensive approach to understand and address issues.
The above sentence was easy to write - but the ideas contained in it are not so easy to put into practice. For example, some values compete with each other in certain situations; we then must figure out which values are of a higher priority to us than others. Evidence may conflict, making it difficult to know what information to use in practice. Contexts may fluctuate so that we continually have to revise our understanding of what is going on and what to do about it. Resources - time, money, skills - may be limited, restricting what we are actually able to do.
Having integrity, however, means not giving up; we do the best possible by acknowledging the challenges, then addressing them directly when we can and working around them otherwise.
Who has integrity? Here is my list (based of course on my particular set of values!):
We can't predict how much difference our actions will make; but acting with integrity increases the chances that we make will a positive impact rather than a negative one.
with best wishes,
March 2012: jottings from website editor Barbara Kahan
The Heartbreak of Not Following a Comprehensive Best Practices Approach
In the pressure cooker of every day life and work it is easy to dismiss the IDM's comprehensive best practices approach as a navel-gazing time-wasting exercise. The IDM does take time - partly because it is a comprehensive approach, which means considering multiple factors and their complex interrelationships; partly because it is a critical approach, which means questioning underlying beliefs and assumptions and accepted orthodoxies; and partly because we are unused to thinking holistically or critically. However, if we want to improve our current situation rather than maintain the status quo, the time would be well spent. For example, inequities, which have a negative impact on health status, seem to be increasing rather than decreasing.
Policies are not abstract words on a piece of paper - they can have a huge effect on people's lives. To illustrate my point about the necessity to take the time to think more comprehensively and more critically, here is one example of a policy direction that breaks my heart. The policy direction I am talking about is encapsulated in the current federal government's "tough on crime" bill which is touted as necessary to make Canadian citizens safer - and by extension, to maintain our physical and mental health.
The bill contains measures such as mandatory minimum sentences - regardless of circumstances - and lengthening sentences for some crimes. But will this new direction achieve a safer and healthier environment for Canadian citizens? Sadly, from an IDM perspective, inconsistencies among values, theories/beliefs, evidence, understanding of the environment, and activities and processes make a happy ending unlikely for this crime-focused direction.
Few people would argue that safety and health are important values. Another value implicit in this crime-focused direction is punishment, which is not a universal value. Given the evidence from other jurisdictions - such as the US, which is moving away from the harsh sentences that filled up prisons because crime didn't actually decrease and people weren't safer - it appears that the government's desire for punishment is trumping safety/health. If I were the government, I would be considering whether in fact punishment is a more important value to Canadians than safety/health.
Perhaps I am wrong - maybe it is not valuing punishment that is behind the proposed bill but the belief that longer sentences will deter people from committing crimes. However, the evidence mentioned above refutes this belief - longer sentences do not prevent crime. If I were the government, I would examine my theories and beliefs and reject those that the evidence does not support.
One heart-breaking aspect of this crime-focused direction is that individuals, families and communities will continue to suffer from robberies, violence and other crimes. We all know that the physical and emotional effects for survivors can be devastating. If health and safety are priority values, shouldn't the government develop evidence-supported policies in line with these values?
Another heart-breaking aspect is that about a third of the prison population is composed of people with mental health issues. When we look at the environment, we see that mental health programs are vastly underfunded, that social conditions linked to some mental health issues are not being addressed, and that incarceration does not help people with mental health issues.
It is clear to me that if we want to prevent more heart-break we need policies based on consistency between values, theories/beliefs, understanding of the environment, and practice.
with best wishes,
April-May 2012: jottings from website editor Barbara Kahan
Small Yet Important
For so many years I was involved in health-related planning, research and evaluation and now that I'm retired I'm not. I can't list any major projects that I'm currently participating in that might influence community health for the better (other than maintaining this website). I had only an instant of panicking, though, worrying that I might not be contributing to something I believe in - because I reminded myself that big is not always best, and small is not always least. And I realized that although my life is going in a different direction, I am still in my own way furthering health promotion. Below is one example of a low cost (virtually no cost) project which, now that I think of it, is definitely health promoting.
Over a year ago I offered, on a volunteer basis, a six week writing course for children ages 10 to 12 in collaboration with the local community association and my local library. The kids and I enjoyed it so much we decided to continue and become a writing club. The library generously gives us space every Tuesday evening to meet (we take a break in the summer) and the community association generously prints Writers' Block?, the club's magazine - its second edition will be out in a couple of weeks, filled with poems and stories and drawings. Working with the kids gives me such pleasure; all of them are wonderful and special in their own unique way. They are energetic, curious, creative, humourous, thoughtful. Spending time with them is a great treat.
Clearly the writing club is good for my health as it makes me feel positive about life. I am fairly certain that it is also good for the kids' health, in that it is fostering a sense of belonging, promoting learning/education/capacity building, encouraging creative and critical thinking, and developing positive group skills.
As you may have noticed, at least a couple of the social determinants of health are listed in the previous sentence. I realize that this mini-project is not working on structural change which is needed to address another major social determinant of health - income equity - but I do think that life is organic and small pieces like this one interact in ways that can't be foreseen with other pieces. And since the kids' writing club is one piece I can work on right now, I will continue, and not worry that it is only a small piece.
with best wishes,
June-July 2012: jottings from website editor Barbara Kahan
Abusing the term "transparency" (Terminology Part 3)
In past jottings I have discussed the terms best practices, knowledge creation, intervention, and target group. This time around the term transparency has been preoccupying me - not because of any difficulties with the concept of transparency, which to me is relatively straightforward and to most people would have a similar meaning. That is, most people would define transparency as being open about any processes that are in play, being publicly clear about goals, sharing any information that is relevant to the particular issue at hand, and fully disclosing any information that is requested. Rather, what's got me in a fury is how the Canadian government is touting transparency as an important value of theirs yet their actions are the complete opposite of what transparency requires - they block access to information, they put out incorrect information, they hide how things are done. I could go on and on. Bahhh!
What this particular scenario highlights for me is that we can define terms until the cows come home, we can identify in great detail how we agree or disagree about our various understandings of a term - but it doesn't matter, it's just wasted energy if one of the stakeholders is not acting in good faith. I very much doubt that the government would define transparency as hiding information, or misrepresenting facts to manipulate reactions, or having secret agendas - but that is what they are doing. And in the process they are disrespecting Canada's citizens, mocking democracy and endangering our health by denying us accurate information on which to base decisions (not to mention excluding us from decision making). On the positive side they have provided me with an excellent example of inconsistency between what is being said and what is being done. The government probably truly believes that the ends justify the means and that the ends they envision are vastly superior to the ends I envision.
But even if I did agree with them about how Canada should be, I know that the ends do not justify the means. I agree with the IDM approach, which emphasizes the importance of being consistent - matching values, theories, evidence and understanding of the environment to practice in order to achieve the best results possible. Having incongruencies between how one acts and what one is aiming for vastly increases the danger of unintended negative consequences. In addition, I strongly believe that if you value something - whether it is truth or justice or transparency - you honour it in practice, not just with words. Our values shape how we define our terminology, and the point of terminology is to clarify our processes and activities, not to obscure. Terminology should be an aid, not a weapon.
The IDM also emphasizes critical thinking, and this situation exemplifies the importance of thinking critically. Because we really can't believe what they tell us. Phooey!
with best wishes,
August 2012: jottings from website editor Barbara Kahan
The good and the bad of writing jottings
Every month (or depending on how busy/tired/lazy I am, every other month) when it is time to write jottings for this website, I moan and groan and feel very sorry for myself. I could be out enjoying the sunshine (in the summer) or curling up in front of the fireplace (in the winter) or catching up on numerous emails or cleaning the house or...
It's not like I do it for the money (it's strictly a volunteer effort) or because my boss is making me (I have no boss) or for the glory (I know my husband, daughter and cousin read my jottings but I have no idea if anyone else does!) or for the fun of it (writing for me is very time consuming and challenging).
So, as I force myself to sit in front of the computer (it seems I do have a boss, which is me), the go-with-the-flow part of myself announces I don't have to do jottings any more - Give it up! Go-With-The-Flow Me says. Life is short, lots of other things to do - banjos to play, phone calls to make, books to read. But Reflective Me always convinces me to do one more jottings. Don't you want to think more deeply than you usually do? says Reflective Me. Don't you want to clarify your fuzzy thoughts?
So, with Reflective Me in the driver's seat (just to mix metaphors a bit), telling Go-With-The-Flow Me soon it will be her turn, I write a sentence or paragraph and then question myself relentlessly: Is that what I really think? Am I wilfully ignoring certain facts? Am I taking account of possibly conflicting ideas? Am I being logical or illogical? Am I making sense??? Often I realize I disagree with what I've written and have to revise revise revise - both my writing and my thinking.
Writing my jottings is hard work. But the reflecting it forces me to do is good. I like the satisfaction of gives me of knowing that my ideas have a sound grounding.
with best wishes,
September 2012: jottings from website editor Barbara Kahan
Listening and best practices
I work very hard at listening because I'm not that great at it. Lectures are a mass of sounds heading in my direction which I can't sort out. At meetings someone will speak for a few minutes and I can't follow the thread of their comments. I'm better in one on one or small group conversations, but even there once in a while I blank out and miss a moment of what someone said. Occasionally I find that I've misinterpreted the intent of what my husband Evan has said to me. Fairly regularly I kick myself (metaphorically speaking) because I ignored internal warning bells - if only I'd listened to myself I would have saved myself some grief. I love music but sadly my attention wanders after a while. I can walk for blocks until I realize I haven't been aware of any of the sounds around me - the traffic or the birds or the wind in the leaves.
In health promotion terms focused listening is imperative if we want our health promotion practices to be the best possible. Really hearing what other people are saying means we avoid mistaken assumptions, don't miss vital information, and strengthen relationships. Listening to our inner voice results in asking necessary questions and acting on important observations. Music can be energizing, inspiring, and lead us to new insight and ideas. Being aware of the sounds around us intensifies our connection to the world outside ourselves.
The good news is that I know my listening limitations and try to address them as best I can. In lectures and meetings I take copious notes because that seems to increase my comprehension, I'm not really sure why. In conversation with people I try to maintain my focus on them rather than on me, and pay attention not just to their words but to things like tone of voice and body language. I try to make myself follow up on those internal mumblings that are telling me to do something, whether the message is simply that it's time to take a break, or, more challengingly, that someone or something needs confronting. When music is playing I try to become part of it, or let it flow into me. As for the sounds of the rain and the breeze and crickets and sirens, I attempt to still myself - quieting those clamouring internal thoughts, turning off the radio, moving away from the computer, putting down my book - and simply listen.
with best wishes,
October 2012: jottings from website editor Barbara Kahan
Understanding inequity among key stakeholders
I sometimes hear myself making statements like "all key stakeholders should be part of planning" for any particular issue and then find my inner ruminater wondering if I really mean that. And my response tends to be "yes - and no."
"Yes" seems the obvious answer because change is more likely to occur if everyone involved is on board. Realistically, trying to implement a decision for which any major stakeholder is excluded leads to serious headaches. More positively, decisions derived from multiple perspectives have the potential to reflect a more accurate and in-depth understanding of all aspects of an issue, and therefore are more likely to achieve the desired result.
"No" as a response, however, has some compelling arguments on its side. Conflicting interests and unequal power relationships are likely to result in decisions that favour one stakeholder group to the detriment of another, and often the favoured stakeholder group is not the one who will be most directly or strongly affected by the decision.
The issue of homelessness provides an example. Key stakeholders include people who are homeless, government social service and housing departments, community groups, and private business (primarily in the form of real estate developers and landlords). It's easy to figure out who has the power in this scenario, and it's not the people who are homeless. While safe, affordable housing in good repair along with support services that assist people to stay in their homes seems like a logical goal, other goals push true solutions to homelessness to the back burner: governments may see keeping tax rates low and keeping influential voters happy as a higher priority; the key mandate of businesses is to make as much profit as possible.
Am I sounding cynical? Well, I am. Bitter experience and all that. But of course it is important not to stereotype. Some governments care about more than maintaining power and some businesses care about more than money. But, sadly, too few.
Eliminating homelessness is actually achievable. We know what needs to be done, and while my inner optimist reminds me that there have been some successful initiatives, we just aren't doing enough on a large scale. Make appropriate policies, allocate adequate resources (the money is there, as bail-outs of banks and the auto industry illustrate). All that's missing is the will. And the will isn't there because people who are homeless are people without power.
The solution? To fight for power equity as hard as we fight for income equity. Although the two often go together, they manifest in different ways. So, yes, involve all major stakeholders. At the same time, however, make sure to understand power relationships and underlying agendas, do as much as possible to increase power for the currently powerless, learn as much as possible from each group, and give most weight to the people who are most affected by a decision.
with best wishes,
November 2012: jottings from website editor Barbara Kahan
The various ways to achieve the health promotion goal of a happy healthy world
I'm one of those people who likes my life to be a cohesive whole rather than compartmentalized. Lately I've been wondering if I have veered from that principle with my latest endeavour. Rather than doing consulting work (planning/research/evaluation) in the area of health-related issues, I've started a small publishing company called Wild Sage Press, whose first two publications are poetry books.
It might seem that this latest passion of mine is far removed from the world of health promotion, public health and population health. But as I think about it I have come to the realization that, even if the link is not obvious, there is a strong relationship between the two worlds - at least, according to the way I perceive life and its workings.
What I believe is that how we do things, regardless of the activity itself, can either harm or promote health. For example, the more cooperatively a workplace is run the better for its workers' health. The further an organisation veers from its values for, say financial reasons, the less it is able to contribute to the health of the communities it belongs to.
So - why do I think the two worlds I inhabit, of health promotion and publishing, are linked? The main reason is that my goals for both areas are very similar. Part of my vision for Wild Sage Press is to "create gifts of word and art that move the world to a place of joy" - and moving the world to a place of joy was exactly what I always wanted to do with my health promotion work. In health promotion as in publishing I see my role as one of contributing to the evolution of healthier communities, because I believe that healthy communities nurture healthy people. In my publishing, as in my consulting, I try to work collaboratively, stay true to my values, allow room for creativity in thought and action...
Although the press is very young, there is already a strong feeling of community associated with it. An incredible number of people have played a role in shaping it, in many different ways. For example, the books are handbound, and handbinding is an extremely labour intensive and time consuming activity. But so many people volunteered their time to help bind the books, it did not feel at all onerous. Except for a few little blips (what would life be without them?) it was actually a lot of fun.
At the inaugural launch many different people came together - writers and publishers and people who love to read; older people and younger people; people who live locally and people who travelled quite a distance to attend - and everyone had a fabulous time. We sat there (or stood - the library ran out of chairs!) listening first to the music (a folk band opened the evening) and then to the gorgeous poetry, and ended with lots of visiting. I think the health-enhancing aspects of people coming together - communally - to celebrate artistry in its different manifestations was very strong that night.
I hope that as people dip into the books and read a poem here and a poem there that they not only find new worlds opening for themselves, but that they feel moved to actively help change the world to a place that is wonderful for everyone. A happy healthy world. And that people realize that the way to that happy healthy world is not just through books, and not just through traditional health promotion activities, but in myriad ways. We are limited only by the extent of our will and imagination.
with best wishes,
December 2012-January 2013: jottings from website editor Barbara Kahan
The determinants of one person's health and well-being
I drew the sketch below in 1997 when I was a student. Surprisingly, I don't think there's anything I would change today. But I am seeingly it differently than I did back then. As I view it now I'm struck by how individual some of the determinants are to me and how others are much more generally applicable. In a third category are factors that I strongly believe are general determinants of health but which many people would discount.
The individual determinants idiosyncratic to me and some others - but not necessarily to the population at large - are things like books, clear vivid blue skies and solitude. Other people might not be so affected by their lack as I would be.
Factors such as having basic needs met, social support/connections, adequate sleep are like motherhood determinants that everyone would agree are important to the health of the world at large.
Probably the most contentious of the determinants I've listed in the drawing below is this one: From each according to their ability, to each according to their need. To me this paraphrase of Marx is simple and fair and heart-warming. This concept as a determinant of health seems a no-brainer to me, but many people will not agree with it because to put that concept into practice would require rejecting capitalism, which emphasises competition and individual economic/social status rather than helping people meet their potential and helping people meet their needs. But which approach will increase social and health equity? Something to think about!
with best wishes,
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