Archives - Reflections




May 2004: Reflection by Jan Ritchie, PhD
Associate Professor, School of Public Health and Community Medicine,
University of New South Wales, Sydney, Australia

In teaching the core course "Health Promotion" within the largest Master of Public Health program in Australia, I have each year introduced my class to the Interactive Domain Model since I came in contact with it and its innovative creators in early 2001. Being privileged to spend a sabbatical period at the University of Toronto in that year allowed me to attend a workshop run by Barbara and Michael where I could attempt to apply it to some aspects of my work. I sent the following set of comments back to Barbara once I returned to Sydney:

First, I believe that linking values tightly into a practice model is a marvellous step forward. I am convinced that the art and science of health promotion brings conventional, clinically-trained health professionals face to face with different values to those they have absorbed in their basic training, which has more often been within a biomedical model. Health promotion as we know it challenges new practitioners towards values clarification and hopefully development of new values. Enhancing this process by getting them to be explicit in stating the values that underpin their practice in this different field is brilliant!

Second, setting the practice in context by including the environment as a routine component of planning is also excellent. We know that the reason RCTs rarely work as a way of assembling evidence in health promotion is because, by their very nature, well-controlled trials are expected to show results while stripping interventions from their contexts, and being applicable across the board. Once you do this, you lose the intrinsic usefulness of a health promotion intervention as you expect similar results in a range of contexts ­ which just doesn't happen. So again, getting practitioners to be explicit about environmental aspects is also a great step forward.

Third, I really like the way the boxes encourage the model user to start with the ideal, then consider the current situation and develop the practice as a way of moving forward to attain the ideal. This focus on the positives rather than the usual epidemiologically-based plan of starting with negative problems is again most progressive.

In that original communication of 2001, I then went on to say I was anticipating having difficulty in using the Model in my health promotion work in Pacific island countries. I believed at that stage that the requirement of the Model to complete the series of checkpoints and boxes in a logical manner would be a difficult thing for my Pacific colleagues to undertake, given their tradition of oral history through narrative.

Now in 2004, I can very happily report that it is very possible to use story as a foundation and translate narrative into the components of the Model. Thanks to my exposure to the IDM, my Pacific colleagues and I are further along the way towards best practice in health promotion in their island countries.


Click here to read a profile of Jan Ritchie.


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June 2004: Reflection by Guy Ewing, adult literacy worker and researcher, Toronto, Canada
Communicating Anew

Having worked for many years in adult literacy programs, I am struck by how difficult it can be to take ideas out of one discourse (mode of discussion) and put them into another. One example that sticks in my mind is the lawyer talking to one of my students. The lawyer said, "That's habeas corpus." My student looked blank. In a patient, helpful tone of voice, the lawyer repeated slowly, "You know, ha-be-as cor-pus." It didn't help. Another example that sticks in my mind is a doctor trying to explain to an elderly man with a Grade Four education the advantages and disadvantages of various treatments for osteoporosis. For a person who had never read a science textbook, his explanations made absolutely no sense.

Those who read this website develop many of their ideas about health in discourses involving written language. Your learning may involve speech as well a written language, but your speech is supported by texts, and your speech borrows from the specialized vocabulary and dense syntax of these texts. When you try to explain ideas developed within these discourses to people who are not accustomed to them, you may run into trouble.

Say you are discussing a health concept with a person who cannot read basic health information, let alone the kinds of written material on health that you are accustomed to reading. This is not an unlikely scenario; according to the International Adult Literacy Survey, at least 25% of Canadians have difficulty reading basic health information. Without reflection on your part, this communication will be mainly you talking and the other person pretending to understand.

A little reflection can go a long way to improving the situation. If you start such discussions without assuming that the person you are talking with reads what you read, or could read what you read, you will be able to step outside of the discourse you are used to. You will draw on words and ways of using words that can be understood. Paying attention to the other person and leaving openings for the other person to ask questions and articulate his or her own ideas, your natural ability to shape communication to the needs of the participants will begin to take over.

Reflection can make all of the difference. What makes communicating outside of an accustomed discourse possible is knowing that you must. Once you have grasped this, you can muster the linguistic resources to communicate effectively.

Of course, such communication requires humility and respect. If you think that you are dumbing down your speech, or if you do not expect intelligence from people with less education than you, your attempts to communicate will come across as patronizing baby talk. One has to have faith that robust ideas can be communicated in plain language, and that, even without education, most adults are capable of complex thought.

If, like me, you are lucky enough to find yourself having extended discussions about health with people who do not get their ideas from books, you might even find yourself involved in a new discourse about health, one with little support from texts, yet strong.

Guy's definition of best practices: In communication, best practices are practices which give equal value to communicative needs of each participant.

To read another reflection by Guy Ewing, click here.


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July 2004: Reflection by Brian Hyndman, Health Promotion Consultant, The Health Communication Unit, University of Toronto, Canada
The Concept of Best Practices in Other Disciplines:
How does Health Promotion Compare?

Guy Ewing's thoughtful reflection piece on adult literacy illustrated the challenges of adopting ideas from one discipline to another. I thought it would be interesting to further explore this challenge by examining how the concept of 'best practices' is defined by other disciplines.

There's certainly no shortage of material for comparison purposes. A Google search of the term 'best practices' yielded over seven million hits from a diverse range of topics. These include:

What struck me about most of these knowledge repositories was the absence of explicitly stated criteria guiding the identification of 'best practices' within a given field. That is to say, the reader was expected to rest assured that the stated best practices in widget making did, indeed, reflect best practices in widget making, since only credible experts in widget making would take the time and effort to compile the necessary information.

And in cases where such criteria were provided, the underlying assumptions, theoretical underpinnings and critical considerations were nowhere to be found. While the Google search expanded my horizons about the state of evidence-based practice in fields outside of my own, I was left with little understanding of why many of these practices were deemed to be 'best.'

As a relatively small and powerless discipline nested within a much larger sector, health promotion has never enjoyed the luxury of resting on perceived credibility. Nor has it enjoyed the benefits of setting its own standards of evidence: the merits of health promotion continue to be judged by the standards of evidence conceived by the medical care sector (e.g., randomized control trials).

The result is a status quo that does not do justice to the values underpinning health promotion practice. In a recent article on the evaluation of community-wide health promotion interventions, Hawe, Shiell and Riley (2004, p. 1562) lament the current imbalance that invariably occurs when:

"policy makers weigh up 'best buys' in health promotion. At present they often have to compare traditional areas like asthma education (which usually come with randomized control trial evidence) with community development (which is usually supported only with case study evidence). The more conservative, patient targeted interventions backed by randomized controlled trials generally win hands down."

As an alternative, the authors suggest an evaluation design that standardizes the process and function of a health promotion intervention rather than the individual intervention components. This would allow for interventions to be tailored to existing community conditions, which has the potential to improve effectiveness. Under this approach, best practices could be viewed as 'evidence of fit' between the theory or principles of the intended change process, the components of the intervention and the community conditions affecting the intended outcome.

This is exactly the sort of critical examination that needs to take place in order to develop standard of evidence and best practices that are compatible with the realities of health promotion practice. The IDM model is an important resource for furthering the evolution of best practices in health promotion, and I encourage its use by practitioners, who, like myself, are tired of having the standards of 'effectiveness' imposed by outside forces.

Reference: Hawe, P., Shiell, A., and Riley, T. "Complex interventions: how 'out of control' can a randomized control trial be?" British Medical Journal 328: 1561-1563, 2004.

Brian's definition of best practices: Practices demonstrating the ability to learn from experience (both your own experience and the experiences of others).


Click here to read a profile of Brian Hyndman.


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August 2004 Reflection by David Rosenbluth:
Thoughts about best practices and health from a social services perspective

David Rosenbluth is Director of Research and Evaluation, Department of Community Resources and Employment, Regina, Saskatchewan, Canada.

defining best practices
Best practices isn't a language that we use in social services in the same way it is used in health promotion areas. What I encounter in my work, which focuses on the social determinants of health, are two concepts. First, the question of "what works?" is asked a lot in socio-economic areas such as manpower and poverty reduction. Second, on the health administration/public management side of things, is the notion of evidence-based decision making.

Both "what works" and evidence-based decision making are similar to best practices but have nuances that are slightly different. When I think of best practices I make a distinction between effective programs or practices and "best" programs or practices. Effective practices are programs, policies, or activities that have empirically been shown to lead to policy outcomes of interest; best practices are effective practices that are in tune with the values and ideologies of the organization or environment in which you are developing policy. A lot of policies or programs are potentially effective but you wouldn't apply or implement them because they assume a different values base or come from a different ideological stance than the one from which you're operating. The fit wouldn't be good.

The importance of "fit" for best practices is illustrated in the area of employment and training for people on welfare, where now there is good empirical literature about 15 years old. Here the early question was, "What works for people on welfare: is it employment or is it training?" Well, it's actually both. And, as people working in the area delved deeper into the issue, the question moved from "what works?" to "what works for whom?" It had become obvious that different sub-populations need different things or respond differently to different programs.

Early learning and care/early childhood, an area that Saskatchewan and all other provinces are starting to emphasize more, provides another example regarding the importance of "fit." If one wants to base policy and programs on effective practices in this area, you have to sift through a tremendous amount of existing research. In doing so, one has to have a critical eye not only for the quality of the work - which findings are credible and which aren't - but also for the context in which the programs have been operating. What is their values base, and how do they fit with other programs in the same service environment? I am interested in different models of how you approach that and pull the different strands together.

best practices and the quality of evidence
Regarding the above-mentioned critical eye for assessing research quality, I have questions about what constitutes credible evidence to which I don't particularly have answers. The current environment in government - which has been fuelled by best practices approaches - assumes a certain approach to research and evidence. What counts as credible evidence tends to be more rigorous empirical work - quantitative analysis and larger scale surveys - which is where a lot of my training has been. But it strikes me that a lot of the questions and outcomes that people are asking about perhaps lend themselves more to qualitative sorts of analysis. These, however, are the kinds of studies that tend not to be given a lot of credence by treasury boards and policy-making bodies. In my own mind I am less certain about what things are credible or not - I am less certain than I used to be about the nature of evidence.


This reflection is based on an interview with website co-editor Barbara Kahan.

Click here to read a profile of David.


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September 2004 Reflection by Eric MacIntyre:
Using the IDM Best Practices Computer Program

Erica MacIntyre is Health Planner with the Grand River District Health Council, Ontario, Canada.

My exposure to the IDM Best Practices in Health Promotion, Public Health, and Population Health has been over the past several years during the pilot phases while a health planner with a district health council. In addition to taking part in the early workshops sponsored by local health promotion practitioners, I have "tried it out" in various sample scenarios. I continue to look forward to finding an appropriate initiative and group of practitioners with which to further explore the benefits the IDM Best Practice Framework in a health promotion planning process.

Until then, I have chosen to reflect on another aspect of the IDM initiative that I am arguing is a "best practice" within the array of health promotion best practices the IDM presents. This best practice is the IDM Best Practices Computer Program. I have piloted the software and see its potential to overcome some of the challenges presented by the IDM "big picture" approach. The IDM Best Practices Computer Program is available at http://www.idmbestpractices.ca/idm.php?content=resources-idm#program.

The term best practice is traditionally associated with quality improvement processes in the business sector and defined accordingly. One such definition is, "A best practice is a business function, process, or system that is considered superior to all other known methods...a best practice is widely known to improve performance and efficiency in a specific area. Successfully identifying and applying best practices can save money, eliminate redundancy, and enhance organizational effectiveness (see http://www.dod.mil/comptroller/icenter/learn/bestpracconcept.htm). In my experience the right software for the job at hand can encourage increased effectiveness, improve efficiency, enhance quality, and improve team communication.

One of the challenges I experienced in using the hard copy version of the Framework was retaining a mental image of the linkages across the various columns, or dimensions. The use of the software made this easier. For example, my seniors' health framework was now broken down into more manageable pieces. At any point I could return to the whole to assess the coherence of the points input into the program. Hence, the adage "garbage in - garbage out" cannot be escaped even with this tool.

Some suggestions to make your experience easier are: try the software out initially with a smaller issue or program, or one that you (your group) are more familiar with. In working with a group connect an LCD projector to your computer. Big screen projection of the work-in-progress will perhaps stimulate discussion (you can read it!) or allow for focus on a particular dimension such as the values or ethics points at the opportune time. There were numerous "help" screens in the program which provide hints and definitions when you need them to improve consistency of approach.

Once you have a draft document in a printable format you can share it and engage in a more complete discussion with your team members or other stakeholders. There will be some minor editing and formatting required, but the time and effort for transcription will be reduced (and finding a volunteer to take this on will be easier!). Communication about the complex ideas each member of the group is trying to convey to others engaged in the exercise is potentially enhanced. Updates to the framework based on the feedback you receive will be easier.

There are legitimate reasons to use more traditional tools such as flipcharts, paper forms, and sticky notes. For example, some health promotion practitioners may feel that the use of a computer and software is a barrier to group interaction. The more technical approach may not be acceptable to all groups. In keeping with best practice the practitioner in conjunction with group members (where applicable) can decide whether the software is the right tool.

The IDM approach to health promotion is intended to generate productive tension so it is best to avoid creating unnecessary negative conflict. It may be wise to approach the use of the software cautiously in the following situations: those where not everyone is comfortable with computers or have equal levels of expertise; where the technical capacity or equipment may present problems; or, alternatively when the use of the software threatens to become the primary challenge of the group rather than creating the substance of the Framework.

Time will tell whether the software application will provide the superior and consistent results expected from a best practice but it certainly appears promising from my introduction to its merits.

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October 2004 Reflection by Anne Lessio:
Beyond Evidence

Anne Lessio is Manager of the Heart Health Resource Centre, Ontario Public Health Association, Toronto, Canada.

What works? How can we, in health promotion and chronic disease prevention use our limited resources in the most efficient manner to achieve our ultimate goal of improving health? What are the crucial elements that need to be present in an effective community-based program? These are the questions I usually ask myself when I consider "best practices."

Health promotion and chronic disease prevention are incredibly complex, involving the determinants of health, overlapping risk factors, people's lifestyle choices. There are no simple answers about what works and certainly not a "one size fits all" solution. Yet chronic disease is the leading cause of preventable death, illness and disability. Consequently, with the aging population the occurrence of chronic disease will only increase. It is imperative that we use our limited resources - human, financial and material - to adopt interventions that have been shown to be effective.

My next thought is what is "effective"? One way of defining "effective" is to consider well-designed studies with vigorous evaluations objectively demonstrating an intervention's outcomes. That is the scientific strength of evidence of the intervention. However, we cannot be limited in health promotion and chronic disease prevention only to those interventions for which there exists strong evidence of effectiveness. We need to consider those interventions that have the potential of being effective in a particular community.

A model for identifying community-based best practices that I have come to appreciate and use was originally developed in the mid-1990's and published by Dr. Roy Cameron (Cameron et all, 2001). It has been refined over the years, as the model has been used for repeated international scans and literature reviews of best practices in chronic disease prevention.

The model assesses practices according to two levels of criteria: Effectiveness (or strength of evidence) and Plausibility (or evaluation and program content attributes). The effectiveness criteria relate to the scientific evaluation of the intervention and consider study design, selection bias, treatment of cofounders, etc. Interventions with well-designed evaluations showing positive outcomes and a strong strength of evidence are designated as "Best" practices.

If there is insufficient evidence or no evaluation data, the intervention is assessed according to the Plausibility criteria. This criterion considers the potential of an intervention being effective based on its evaluation attributes (formative and process evaluation) and its content attributes (grounded in behaviour change principles with behavioral objectives). When an intervention is judged to have a strong or moderate plausibility it is designed as a "Promising" practice. The most recent revision of the plausibility criteria was influenced by other approaches to best practices including the IDM.

A third set of criteria, Practicality criteria, was originally incorporated into the model. This set of criteria is no longer used to categorize an intervention as best or promising, but rather is now being considered as forming the basis of a toolkit to be used by service providers and practitioners in determining which best or promising practice would best fit with their community.

My appeal for the model is that it identifies not only the gold star RCTs as best practices, but also identifies the home grown Ontario population-based promising interventions that would otherwise have been eliminated because of the lack of evidence of effectiveness. Using this model, the Health Behaviour Research Group identified over 100 best and promising practices in chronic disease prevention. This is a very exciting project and one that I hope will support practitioners in identifying what will work in their communities.

On another note, during a one-year secondment with Health Canada working with the National Best Practices Consortium, I was exposed to numerous concepts, definitions, ideologies and methodologies in relation to "best practices" embraced by those working in the field across our country. This diversity adds richness to our discussions about best practices; however, it also creates fragmentation and a lack of consistency. One of my goals is to support a movement towards a common understanding, if not a common definition, of best practices.

Definition of best practices
My conceptualization of best practices incorporates the contextual nature of community-based interventions along with a notion of using information currently available rather than waiting for the "best" information available. I came across the following definition of best practices last year and have adopted it: "Best available practice or policy based on available evidence for a specific group under specific circumstances to achieve an identified aim."

Reference
Cameron et al (2001), Linking Science and Practice: Towards a System for Enabling Communities to Adopt Best Practices for Chronic Disease Prevention. Health Promotion Practice (2)1, 35-42

Click here to read a profile of Anne Lessio. In addition, Report on the Proceedings from Best Practices At Home and Abroad: making health promotion decisions for the best results contains a presentation by Anne Lessio on best practices.


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November 2004 Reflection by Hélène Roussel:
IDM Experiences of L'ACFO-TO, a Volunteer-Based Organization

Hélène Roussel is a volunteer board member with Association des communautés francophone de l'Ontario - Toronto, Canada. She also works with Centre ontarien d'information en prévention/Ontario Prevention Clearinghouse.

IDM training workshops
As part of my health promotion consulting work at the Ontario Prevention Clearinghouse I have co-facilitated, with my colleague Christiane Fontaine, the French-language day and a half workshops for practitioners interested in using the Interactive Domain Model (IDM) approach to best practices in health promotion. The workshops were part of the "Meilleures pratiques en promotion de la santé" project whose mandate was to adapt the IDM academic approach into a more user-friendly approach for use within a Franco-Ontarian context.

It was a challenge to do the training without having a finished example of the application of the Model. It became clear that we needed to develop an example of the Model used in a setting close to the Francophone community. Although the participants (mostly front line workers) were very enthusiastic about the IDM, they did not feel empowered enough to use this approach without their managers' approval. They would have appreciated the presence of their managers at these training workshops. Another downside is that the Model needs to be facilitated by someone who is quite familiar with it. More support and training is needed since most practitioners have felt that a day of training isn't sufficient for proper application of the Model.

Aside from public health and community health centre workers, some other participants felt that such an organized approach as the IDM, which is so much based on consistency, is too much for them and is better suited to bigger organizations. However, the Model has now been used for several months with good results with a volunteer-based organization of which I am the Vice-President. Our experience using the model showed that not only can it be applied successfully to a small grassroots organization, but can also become a very effective tool to help with organizational development and even partnership development.

Using the IDM with Association des communautés francophone de l'Ontario - Toronto
The Association des communautés francophone de l'Ontario - Toronto (ACFO-TO) has a multi-cultural membership. Volunteers come from a variety of places - Ontario, Québec, European Francophone countries, African countries, and Caribbean islands, and practice a variety of religions. L' ACFO-TO is an emerging grassroots French-language organization, which has no paid staff at the moment and is completely volunteer based.

Last June, the board of directors of L'ACFO-TO agreed to adopt the IDM for the purpose of strategic and programme planning. We knew that the IDM was the model for us. Unlike a logic model, the IDM allowed us to review our foundation as well as to be strategic with a good environmental scan section. Being such a culturally diverse group of people, we have found the discussion around values, beliefs and ethics to be quite interesting. For example, agreeing on a value of inclusion was easy. Of course everyone wanted inclusion; the harder part was when we started asking ourselves as a group, what does it mean exactly? How are we going to walk our talk? We realized that the value means something completely different to different participants. This created very exciting discussions that served the purpose of letting go of our personal agenda around the value and helped us shape organizational values in a consensus manner.

The major strength of the IDM is the fact that it requires consistency. We have found this to be quite a challenge, especially in Step One of the Model. While this step refers mostly to strategic thinking, most volunteers are in general a lot more comfortable with action thinking. As a matter of fact, many didn't know how to be strategic. The experience allowed us to expose our volunteers to strategic thinking and because of that, it was an excellent learning process. The IDM definitely kept us on track with consistent thinking.

We also spent a lot of time on ethics, which some participants had never thought of. The discussion helped us create awareness around the issue of building a solid organization, with transparency, accountability, etc. as part of its foundation. Many volunteers didn't think of the organization in that light.

The IDM made it easier to be consistent when developing overall objectives for each committee. Although we still have some work to do to complete all the boxes of the IDM, we are using the IDM as a reference tool at each committee meeting. It is a work in progress and a very organic working tool as far as we are concerned. The definition work we did with the IDM has provided the base to present our work in the community; the Model will continue to remain the blueprint of where we are going. We plan to use it in an organized manner throughout the year to demonstrate to funders that we are functioning with consistent thinking as well as with our future partners on projects. We feel that taking the time to discuss values, ethics, beliefs, theories and evidence based data with our potential partners will bring our partnerships to a much stronger bond and commitment. The IDM is a very appropriate tool for this purpose.

In the process of restructuring the organization, the IDM has proven to be an effective tool that has helped strengthen our vision. The whole IDM process helped bringing everyone involved into play. Often in an organization the environmental overview is done by high level managers and the board; it is very positive that the Model allowed everyone to be part of strategic thinking. Although at first the Model seems complicated, we have found it to be based on common sense.

Hélène Roussel
Vice-President, ACFO-TO
hroussel1111@hotmail.com

Note: Report on the Proceedings from Best Practices At Home and Abroad: making health promotion decisions for the best results contains a presentation by Hélène Roussel on best practices.


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December 2004 Reflection by Joan Roberts:
A reflection on my discovery of a new kind of organization

Joan Roberts is a trainer and consultant in Toronto. She specializes in customized solutions for collaborative processes having difficulty.

Prior to becoming a independent consultant in the late 90's, I worked in many different capacities with numerous large groups. These groups usually formed to deal with a complex social problem, ranging from the lack of affordable housing to preventive disease strategies and local economic development. By the mid 90s, I was aware of the importance of using a neutral facilitator to help a group develop a common vision. In group after group facilitators and consultants were hired to lead the visioning process. Up to two days might be devoted to such work. The end result was printed up in fancy vision brochures. But many processes did not live up the promise envisioned. I pulled out my hair in frustration trying to figure out what was supposed to happen after the vision is complete. Who makes it all happen? How? What do you need in terms of structure to make the vision happen? What the consultants neglected to educate me and their clients about was that there is a lot more to think about in creating a mechanism for large scale change than just the vision!

To stop my hair pulling habit, I went back to school to do a Masters Degree in Organization Development. I found some answers there and learned many large system intervention techniques, mostly more visioning techniques, but still the hair pulling continued. There was so much emphasis on the vision or a plan. When I asked what happens next, I was told by esteemed leaders in the field that the folks know what to do next. "Lets not undermine their confidence trying to tell them what to do," many said.

Do you remember or know the meaning of the term "cop out"? I felt the advice I got was just that -a cop out. My heart would break when I witnessed great people in processes that went nowhere. I was beginning to hear people in the field say that multi-stakeholder processes just don't work, yet at the same time many funders were making partnerships mandatory. This resulted in a lot of sham processes that came together to secure funding - and for little else.

After I finished school, I decided to assemble what I learned with what I did in the field. I asked myself, what did it really take to make large systems change happen? I gave myself free rein to use whatever I learned in my earlier studies and my experience in politics, health promotion and grass roots organizations. I did further research on the concept of trans-organizational systems and multi-domain theory. I finally became confident enough to state that I was not working with large groups but trans-organizational systems (TS), or, in lay terms, the kind of multi-organizational systems everyone was calling alliances, coalitions and partnerships. I developed the material into a successful workshop and now a book called Alliances, Coalitions and Partnerships Building Collaborative Organizations.

What is a Trans-organizational System (TS)?
TSs are functional social systems, composed of individual member organizations, that work together to have impact on broader social societal systems such as health, education and social services but can also exist to provide services or products in a more efficient and effective manner than possible with only one organization. They are able to make decisions and perform tasks on behalf of their member organizations, although members maintain their separate organizational identities and goals. TS members remain accountable to their organizations of origin. TSs are a response to a turbulent environment, where a single organization cannot effect desired change by itself.

What kinds of work do these organizations do?
Organizations manage knowledge to achieve desired results - knowledge being a critical mass of information, looked at through the lens of experience and critical thinking, which enables us to predict and control something.

Organizations are comprised of knowledge specialists and generalists who manage the interface between knowledge specialties. Bits of knowledge by themselves are sterile. They become productive only if welded together into a single unified body of knowledge. To make this transformation of knowledge possible is the task for the organization, the reason for its existence, or its function. In other words, the work of the organization is to add value to incoming information gleaned from its workers, its customers/clients and its environment, and then transform this into the output of a service or product. If there is no value added to or transformation of the knowledge, then there is no work output and no authentic organization.

A trans-organizational system manages knowledge too. It must be managed in a similar fashion to any organization comprised of specialists. But with TSs, the member organizations hold the specialized knowledge and participate in the process as the voices of the knowledge specialists. The specialist knowledge is not necessarily the knowledge of an academic field or profession but can also be the voice of lived experience by a particular constituency. It depends on the problem set that is motivating the formation of a TS.

The TS must bridge those specialist identities and accountabilities of member organizations in order to produce new knowledge that can purposefully adapt to the turbulent environment.

Take note! If you are in a multi-stakeholder process that does not make decisions (transform knowledge) by developing a plan and then executing that plan you are just sharing knowledge and networking for the benefit of your home organization. When your group adopts a decision making process and then uses it to make decisions you are on your way to becoming a TS and making change.

The TS Development Framework as a Best Process
Little has been written on the "how to"s of this new type of organization. Although some theory has been in existence since the middle of the 20th century, little has tied it together. In my book and workshops I present a development framework initially developed by Thomas Cummings in 1984. For the health promoter this can be a major tool in which to begin one's organizing. As many health promoters are saying these days - we need best processes not best practices.

From my experience and the enthusiastic reception I have received in workshops, this development framework is a best process, taking the best thinking from marketing and human service needs assessment (Phases 1 and 2) to the incorporation of knowledge resources through member selection (Phase 3). The framework continues to build on the most recent innovation in tools from the fields of social psychology to focus a system on collective goals (Phase 4), then proceeds to an understanding of the design principles of organizations and a model of organization effectiveness involving the processes of governance, trust-building and work co-ordination (Phase 5), to the final phase of organizational evaluation (Phase 6). This framework is not a linear process and an intervener can enter at any stage and cycle though the stages as needs arise.

Joan Roberts' book, Alliances, Coalitions and Partnerships: Building Collaborative Organizations, has just been released by New Society Publishers. For more information see www.joanroberts.com and December's Resource of the Month.


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January 2005 Reflection by Joan Roberts:
From Best Practices to Best Processes

Joan Roberts is a trainer and consultant in Toronto. She specializes in customized solutions for collaborative processes having difficulty. This month's reflection is a continuation of December's reflection by Joan Roberts, A reflection on my discovery of a new kind of organization.

My take on the topic of best practices and best processes is that best practices need to be distilled into best processes or models so that the audience can determine what is important and can be replicated for their situation. Unfortunately, in my humble opinion, what most academic disciplines do is determine the best strategy to address an issue or problem set. (As well, academics put themselves in the role of decision-maker rather than decision influencer, which is the role of health promoters.) Yet, they rarely look at the underlying process of strategy development - whereas I feel it is the process of strategy development that is the best practice, process or model that should be held up for dissemination. What I frequently see in health promotion is a recount of the story of what was done, without lifting out the steps or framework that can be applied to many different issues.

For instance, I see this in advocacy efforts for tobacco and substance control. Hardly anyone ever outlines the basic steps for developing an advocacy strategy and/or how to develop a message, the principal tool to achieve the advocacy objectives. And, of course, I find it is the same with coalition building, governance, policy development and program development.

Saying all that, however, the development of logic models was the best "best process" I came across in health promotion! It helped clarify a lot of my muddy thinking. I work in a lot of different service delivery systems and I find that health promotion is often the farthest along the path of best process identification.

How would I determine what is a best process? Well, academia ranks models and other things by using a peer critique approval process. If your model survives the close scrutiny and criticism of the learned you pass into the realm of the "best." I have been through a peer review and it is very lengthy. However, in the field of health promotion, a lot of the practices of health promoters do not interest many academics in health promotion because they rightly belong to other fields like community development and marketing.

I recently sat down with a multi-stakeholder group from another sector outside health to come up with their best practice for strategic planning (a process required regularly under legislation) that we could distill and disseminate in a training program. As a group we examined a lot of their models in current use for strategic planning, distilled the practice common to each stakeholder, engaged in a good honest discussion about what could work in situations with minimum resources, and agreed to a simple model for their best practice.

I then went away and developed user friendly tools for each step in the model. This group will then review each tool until satisfied. Once this group is satisfied I will test run the training for the best practice with a reference group of prospective users. The feedback from that session will be incorporated into the training and the first session will be rolled out soon after. The cycle of feedback and development continues with the delivery of each training session because no best process is ever complete or finished but is always a living and changing work in process.

In this instance, the multi-stakeholder nature of the decision making group gives the selection of the best practice credibility and legitimacy to facilitate the adoption of the best practice throughout the sector.

note: For information on Joan Roberts' book, Alliances, Coalitions and Partnerships: Building Collaborative Organizations (New Society Publishers), see www.joanroberts.com and December's Resource of the Month.

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February 2005 Reflection by Debbie Bang: Best Practices Questions & Answers Part IV

Debbie Bang is Manager of the Consumer Health Information Service and of Womankind Addiction Service, St. Joseph's Healthcare, Hamilton, Canada.

Debbie Bang's reflection contains another 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. In addition, click here to go to the list of past jottings, some of which also contain answers to

How can we take [the IDM] back to our work - is there a short cut?

What the IDM model reminds us to do is ensure that the program or approach we are planning emerges from the organization's values/mission/vision. If the organization has not clearly articulated their values/mission/vision or if it is for a new project then the first column of the IDM Framework is a great place to start. The other short cut is to use the Framework as a reminder to include, or at least touch upon, each of the domains when planning.

How can I sell the IDM to my manager?

Tell your manager that the IDM is based on theory and best practice, has been peer reviewed, written about in the literature, presented at conferences nationally and internationally, used and appreciated in a number of settings for a variety of reasons, and, most importantly, it makes sense and provides structure to our health promotion planning.

When the group you are working with is not mandated to discuss the values/vision/underpinnings domain: how can we overcome this?
How do you get buy-in to a values-based approach -funders, etc.?

The argument to emphasize here is that if the group does not ground its work within values/vision of the organization, the planning and/or work will not fit with the mandate. The group may not need to re-invent but they should at least review the mission/values/vision before beginning the work. Otherwise, in my opinion, the time is wasted.

How can we show that the IDM model is applicable to other sectors beyond health?

Begin the discussion with someone not in health, find the common language, and I think that you will find that the IDM model is quite applicable.

notes: Report on the Proceedings from Best Practices At Home and Abroad: making health promotion decisions for the best results contains a presentation by Debbie Bang on her experiences using the IDM approach to best practices. Click here to read a profile of Debbie Bang.



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March 2005 Reflection by Rishia Burke: Great Programs - best practice versus good practice

Rishia Burke is a community researcher and evaluator in Burlington, Ontario, Canada.

I have spent a fair bit of time in the past while doing evaluation work for a number of community-based children and youth focused programs. I have seen some good programs and then I have seen some great programs. I have been thinking about what makes a great program. In other words when does a program utilize best practice versus a good practice?

Programs that use best practices are based on a solid foundation. First that foundation should be grounded in the values or principles that guide the program. For example, a youth program with an anticipated outcome of youth leadership development needs to engage youth in planning, implementing and evaluating the program.

Great programs have done their homework. They have a plan for integrating evidence to guide the work to develop the program (evidence for the program idea). Next they have evidence on how to best run that program (what is the best approach and what types of activities will be most effective) and finally they gather evidence to ascertain how effective a program has been (or evidence of outcomes).

Community-based programs using best practices will consider a range of evidence to answer those questions. That evidence is comprised of a combination of evidence sources such as research from the literature and/or relevant reports. For example what does current research say about whether or not it is important to engage youth as leaders. If the answer is yes, then what does it say about the best approach to engaging them?

Another source of information comes from your own evaluations. You may have conducted a survey within another program and heard that the local youth would like to have more opportunity to help plan their own programs, or they may have told you that they would like to take on a certain community issue that effects them. Other indicators include local evaluation information from other agencies, for example a shortage of volunteer opportunities for local youth, or a community safety evaluation that lists youth needs for leisure time.

A final source of information will come from your own knowledge of the community. What have youth been telling you when they stop by for a chat? What concerns or issues have their parents mentioned to you? What are people saying at the collation you sit on that addresses youth issues? May be there was is a recent report in the local new paper about a community issue that just begs for youth input and involvement.

The key will be considering and compiling the range of information as well as the evidence for all phases of a program - from the planning phase through the evaluation. The result - a program where you know why you are doing it, you feel confident in how best to run it and you evaluate the program so that you know how to make it even better the next time!

Reference: Burke R., Johnson, S & Arai, S. (2001) Unpacking Evidence In Health Promotion, Association of Ontario Health Centres, Toronto, Ontario.

Click here to read a profile of Rishia Burke.

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April 2005 Reflection by Hélène Gagné: Using the IDM in Practice Without Naming It

Hélène Gagné is a senior planner in the Prevention Unit, Division of Preventive Oncology, Cancer Care Ontario (CCO) in Toronto, Canada.

You can use the IDM with colleagues without specifically naming it and still get the same results. Some people are not interested in frameworks but the IDM can facilitate partnerships with others - if it does the trick why not use it?

In my own work, the IDM pushes me to ask different questions of my colleagues - to know if we are using a common language, are we defining the research questions or issue statements the same way. It has forced me to have a systemic approach - having the IDM in mind helps me make the links.

If you are reluctant to use the IDM in its complete approach you can still use elements of it to frame your initiatives and thinking. It is hard to keep the whole Framework in mind but it pushes you in the early foundation part regarding values, beliefs, theories and practice. For example, CCO as an advisory body to the government on cancer issues focuses significantly on evidence - but evidence based on which values and for whom, and what do we intend to do with the evidence? These questions could be answered in various ways depending on how you look at the information and from which perspective.

Right now I act as a liaison with CCO staff working on breast and cervical cancer screening programs and external stakeholders interested in using the inclusion approach to increase participation rates of marginalized women in screening programs. Studies on participation rates in screening programs have identified specific barriers to participation such as lack of access to physicians, transportation, babysitting, literacy. The usual approach is to fix the program to make it more accessible. But based on work that I'm doing with the Ontario Inclusion Learning Network, I now realize that inclusion looks at different assumptions. We have to go beyond fixing programs - though that is good too - to get the perspectives of women who are not being reached, to find the reasons they have not shown up which may be beyond the program. This is consistent with the IDM and useful in guiding the project.

I also use the IDM as a way to have a dialogue with colleagues from various disciplines and frame questions/issues. Although our work is based on the same action plan with the same targets and goals our interpretation is sometimes different because of the different perspectives. It is a good tool for asking questions you would not normally ask. Where do values come from, what's the theory base, which theories are you using - these are not always explicit.

Another way I use the IDM is as a checklist to see if I have covered the main elements of my initiatives - the IDM can act as a reminder of the values that you expressed in your programs and their meaning. For example the Cancer 2020 action plan has a set of principles - i.e. optimism, accountability, focus on population health, evidence based, precaution, integration and collaboration, and strategic use of resources. But it is hard to always keep them up front. We have to remind ourselves of these values and ask, "What does that mean in practice?"

This reflection is based on an interview with website editor Barbara Kahan.


Click here to read a profile of Hélène Gagné, which includes her definition of best practices.


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May 2005 Reflection by Evan Morris: Self-Confidence and Research

Evan Morris is a self-employed consultant with EcoTech Research Ltd, in Regina, Canada. He also teaches at the University of Regina and at SIAST (Saskatchewan Institute for Applied Science and Technology).

I recently did some work for a national organization that works with farmers on issues such as water safety and soil quality. This experience made me realize that individuals or teams can conduct important research even if they have limited backgrounds in research.

I met several small teams of individuals who were working on different applied research projects. None of them were professional researchers or academics. What was very impressive about these teams was the sense of self-confidence that these individuals had about doing research. They were very open about what they didn't know, but lack of knowledge or experience was not a barrier for them. They learned from each other's experiences, from reading, and when necessary by hiring consultants from private industry or from academia to teach them the technical skills that they needed.

Their relationship with these experts was interesting. When they needed help with learning how to operate a new piece of lab equipment, or with learning a new technique, they were happy to hire experts in the field. However, these teams controlled their own research agenda. Experts were hired to allow them to reach their goals, but these experts did not tell them what the research program should look like. The team members had enough confidence in their own abilities to determine which research goals were important to their projects and to learn the skills required to do the research.

The confidence they had in their abilities to do research was a great capacity. When they needed experts, they used them to build up their own abilities. As the teams gained more experience, they were able to help each other out more.

I have been thinking about how what I observed in this work situation would apply to other groups. The important thing for teams and individuals is having confidence in their abilities - to identify their own research goals and to learn research skills and knowledge as required. This allows them to use experts when needed while keeping control over their own research program.

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July 2005 Reflection by Anne Luke: The Spiral Dance: Aligning Values, Principles and Beliefs in a Regina Preschool

Anne Luke is Executive Director of the Regina Early Learning Centre (Canada).

Best practices at the Regina Early Learning Centre is essentially a circular process. Matching beliefs, values and principles to practice means constantly reviewing progress in a cycle of plan, do, reflect, re-do and so on.

The Early Learning Centre is a child and family development centre offering a range of programs for children, prenatal to school entry, and their parents. The preschool is the longest running program. It was started in 1977 by a small group of parents and me, an educator, who were aware that low income families were largely excluded from accessing existing early childhood programs because of financial and transportation barriers. In addition, no culturally relevant programs existed off-reserve for Aboriginal parents and their children. Anthropologist Margaret Mead has said that a small group of people can change the world. In 1977, the small group of mostly Aboriginal parents and me were determined to change the small piece of the world we occupied by establishing a collaborative preschool which would blend parents' hopes and dreams for their children with thoughtful pedagogical practices.

The underlying principle guiding our thinking and action was one of social justice. This principle was based on observation and experience that society marginalizes some people. In the case of the Early Learning Centre parents, most were marginalized by racism and poverty as a result of culture contact and ongoing colonization.

As we planned how and what the preschool would look like, two values were inherent in the process. These were mutuality (understood as the willingness to influence and be influenced), and respect (understood as the willingness to take others seriously). These values, although underpinning all activities, were not publicly named until later when the Centre participated in a program assessment and development process conducted by Dr. Mary Cronin in 1995. Prior to this time I was reluctant to talk about the "touchy feely" stuff; it seemed too personal.

Looking back, I'm not sure why I was so reluctant to voice these principles. I think it was because the concept of the Centre was a personal response to perceived societal injustice, an awareness of the great divide between those who have and those who have not, and the tendency of mainstream society to blame victims as the architects of their own misfortune instead of the ill-conceived socio-economic policies. As well, I have always been a believer in the old saying that actions speak louder than words and that the "touchy feely" stuff could be left unsaid. Whatever the reasons, it wasn't until Dr. Cronin was conducting her study of the Centre in 1995 that she winkled these core values out of me.

Now it is common (and a sign of best practices) to name values and ensure actions flow from them, but back in 1977 when I was inviting parents to join me in creating better opportunities for their children, it was essential that my approach be low-key and as non-intrusive as possible. In addition, to ensure the relationship between me and the parents was a true partnership, it was essential that we needed each other and that a deliberate "planned helplessness" was built in. In other words, what I had to offer was my sense of social justice, my professional expertise in early child pedagogy and my desire to learn and work in partnership with the parents. In turn, the parents had the knowledge of their children, enormous personal strength in the face of overwhelming odds such as poverty and racism and their hope that their children would have a better start in life and more success in school than they themselves had had. By putting these together, we built an effective, mutual relationship with the good of the children as the common goal.

The concept of supportive relationships didn't end there; the same principle was applied to the curriculum. Building a relationship of trust with the children and helping them build relationships with each other and with the world around them became a key pedagogical approach. The curriculum was built on the children's exploration of the carefully prepared materials in their environment. Children were encouraged to choose what they wanted to play with and the teacher's job was - and still is today - to support and extend the child's explorations, encourage curiosity and a sense of wonder, in a warm supportive environment. At a later reflection, the belief that learning best occurs in the context of supportive relationships was also named.

To ensure that the activities of the Centre remained rooted in community based principles, certain practices were established. These were:

As well, a determination to offer only the best possible programmes to the children required a practice of ongoing learning, research, and reflection on how to adapt and implement new learning. Thus began the cycle of assessing and enhancing our approaches and practices, a process of constant renewal and excitement.

Over time, the Centre grew in size and scope. Today it offers Parents As Teachers (PAT) and KidsFirst Home Visiting programmes, family literacy (Come Read With Me; Aboriginal PRINTS - an acronym for Parents' Roles Interacting with Teacher Support), community kitchens, family support, health and social programs as well as the preschool programme. All parent programmes are supported by transportation and child care. (More information about the Early Learning Centre's programmes can be found by accessing our website at www.earlylearning.ca).

New programmes required new strategies to avoid slippage between principles and practice. Structures were put into place to ensure their continued alignment. Some of these structures were:

In 1997, the Early Learning Centre was invited to participate in a national study of how children best learn language and cognitive skills. As part of its program enhancements, the Centre preschool staff introduced the High/Scope strategy used in the Perry Preschool, Ypsilanti, Michigan, of plan/do/review in the classrooms. The strategy was refined to plan/do/reflect as teachers gained more insights into documenting the children's work and using the work with the child as a tool for reflection with its subsequent lead into more meaningful activity. In this way, teachers took an idea and made it their own, adapting it to the context of the Early Learning Centre.

The focus on beliefs, values and principles in a cycle of plan, do, reflect, re-do has resulted in a number of excellent outcomes, not just on the children's development, but on the parents. Studies conducted on the Early Learning Centre show that children consistently improve in all developmental areas as a result of their positive experience. Parents state they learn confidence and competence in supporting their children's development and learning. As a result of their involvement with the Centre, some parents returned to school to complete their high school and went on to study at university. Some are now teachers. Staff turnover is low because, although wages are unfortunately low, job satisfaction is high. Most of all, children, parents and staff know their ideas are taken seriously and that their input is valued.

Today, there is much talk of quality programmes. In the early learning and child care field, "Quality" is one of the QUAD principles of the proposed national early learning and child care system. (The other three principles are: Universally inclusive, Accessible and Developmental.) Quality is elusive; it is context and culturally bound. A quality-measuring tool commonly used in Canadian early childhood programmes is the Early Childhood Environment Rating Scale-Revised (ECERS-R), but this is a basic scale. At the Regina Early Learning Centre, quality is seen as a constant process. It is based on parent, child and teacher goals, continually revisited and reflected upon to ensure that practices are based on what we know from research and experience and on the understanding that, as we co-construct knowledge, these practices will be modified and changed in a continuous spiral dance.

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August 2005 Reflection by Joan Roberts: The Tango and Best Practices

Joan Roberts has her own consulting company, Joan Roberts Consulting, in Toronto (Canada).

Argentine tango is a way to live in the moment while engaged in physical activity. I fell in love with Argentine tango when I saw the musical Tango Argentina but I was a young mother then and life didn't allow me to go out and have fun except in a family kind of way. I've been at it now about six years. The Argentine tango teaches me a lot about communication - it's all non-verbal communication, you really have to stay in the present moment to receive that communication from your partner, they transmit the communication through the body. It's the most complex social dance. There are even Tango Zen classes - it's very meditative. Dancing with your partner you have to decide what to do in that moment, you have to pay attention, your mind can't go off or you make a mistake. While I'm dancing the whole world is blocked off.

I've been trying to develop a better communication through tango workshop. Dancing Argentine tango - making an instant partnership for three minutes - is the same thing as my work. It's about communication and creating adaptive responses. Tango is about improvisation and the impromptu choreography we do is about filling empty space and that's what we're doing in multi-stakeholder work. We go into the empty space between governments and organizations, collectively deciding how we're going to use that space, taking steps into it, filling it with new collaborative projects - things outside of the partner organizations. And that's what we do in tango - there's a dance floor and empty spaces, we lay claim to that space, dance in it, do particular moves. I get my best ideas for work through tango, it improves my creativity. Again, it's process.

This reflection is based on an interview with website editor Barbara Kahan.

Click here to read a profile of Joan Roberts. To read a two-part reflection by Joan Roberts, click here for part 1 and here for part two.

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September 2005 Reflection by Guy Ewing: Teachers

Guy Ewing is an adult literacy worker and researcher in Toronto, Canada.

At the Appreciative Inquiry workshop, Jean asked one of the participants, in an interview, if there was anyone that she had admired as a young person, a teacher or a mentor, who would be proud of her literacy work. When Jean asked this, I tried to think of such a person in my early life, before I became a literacy worker. I couldn't. It seemed to me that there was no one in my boyhood or young adulthood who would be proud of my literacy work, or even understand it. I began to think about the teachers at the boys' boarding school that I attended, who tried to "make men out of us." To them, my belief that the love and hope that I share with my colleagues in the literacy movement is a powerful force in the world would have seemed naive and childish. I wanted to tell them that they were wrong, that the dreaming naivete of children that they tried to stamp out of their students was wiser than their "manly" approach to life. I thought that they might understand if I used a dramatic piece of evidence for the power of love and hope, the story of a group of children in a Nazi concentration camp who lost their parents but who were able to survive, both physically and emotionally, by loving each other and keeping their collective hope alive. So I wrote this poem to my teachers, a few days after the workshop, to affirm the belief in the power of love and hope that has been an essential part of my experience as a literacy worker.


Teachers

Under your tutelage,
I left the dreaming places
of my childhood,
became a man.

But I have
gone back.

How childish,
you would say,
to think that,
holding hands
with those I love,
I can surround
the darkness,
make it shrink until
its sides rejoin,

that songs
can silence fear.

If you were
still alive
I would tell you
how six children
of the Holocaust,
holding hands
in the dark
night
loving each other,
singing songs,

kept each other
alive,

died in old age,
dreaming of childish hands.


To read another reflection by Guy Ewing, click here.





October 2005 Reflection by Alison Stirling: Perspectives on Best Practices

Alison Stirling is a health promotion consultant with the Ontario Prevention Clearinghouse in Toronto, Canada.

I went back to graduate school to try to find my own best practice, to learn how I was using health promotion and to make resources in the field as available and accessible as possible. I didn't know how to do it more effectively, I needed a chance to look at organizing and exchanging knowledge and resources; I needed to step back and understand it instead of just going out and doing it. My decision to be in constant learning and reflect on what I'm learning and how it affects practice is my best practice.

When I think of best practices I come back to what Brian Hyndman said [see his reflection/profile - add link], that best practices is learning from the experience of others - basically, understanding what you know already and what it's based upon, and then how to use that to determine what's the best course of action. It is that sort of reflection and learning that I've used all my working life. I worked as a popular educator before, which was based on reflecting and learning from experience before you act - not something we always take the time to do.

I used to have trouble with the term "best practices" - I assumed it was "better" or "best," and I didn't know what was "better" or who was judging "best." But I have come to a realization that it's our own determination of better or best that matters. Standards are good, but in terms of practice it's both an individual and collective agreement. This relates to what I've been studying in classification theory - which "warrant" or authority of collected published documents represents a field or subject? Would the Ottawa Charter for Health Promotion and 5 other key documents represent an authority or warrant defining the field? There are different kinds of warrants. For example an organization's published mission or goals could be an institutional warrant. What I'm struggling with is a viewpoint warrant that captures what determines best practices in health promotion, a collective agreement about the substantive nature of field. To find this you have to read everything, look for common themes, look at settings, determinants, strategies.

Best practices is integrated into my perspectives of health promotion - I reflect on beliefs and theories, analyse a context and situation and what we already know ("evidence" and knowledge base), and then act. "Best practice" should be what we individually and collectively know to be best, based on that combination of foundations, context and practice.

The IDM definition captures much of my thinking about best practices, that is, the meld of theory and practice of health promotion values, intent/goals, knowledge/evidence ("evidence" as test result vs. accepted knowledge), and context. Or - what we know, what we believe and how we act should be a constantly reflective, learning, acting spiral - and only when we combine the three can we achieve the "best" in our practices.

To read a profile of Alison Stirling, click here.

This reflection is based in part on a contribution by Alison Stirling and in part on an interview with website editor Barbara Kahan.

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November 2005 Reflection by Nancy Dubois: My Interpretation of Best Practices

Nancy Dubois is a Health Promotion Consultant currently working on the development of a "Best Practices System" for Canada with the Centre for Chronic Disease Prevention and Control with the Public Health Agency of Canada.

I come primarily from a practitioner's standpoint so I think of a "best practice" as a program and not a specific activity or a broader strategy. The program would be one in which people can have confidence that it has had or is likely to have the desired results in a context which is as similar to theirs as possible.

Two General Observations

  1. As knowledge develops, ideally, so should practice. As exciting a time as this is for health promotion in Canada, this constant development of knowledge regarding "what works" presents challenges to people trying to make decisions based on this evidence. Outlined here are a number of realities that I identify as those facing practitioners, researchers and policy-makers regarding taking a "best practices" approach to their decisions, which usually focus on the allocation of resources. How can these people make the best use of the scant health promotion resources available?
  2. Overall, I believe these decision-makers are fundamentally trying to select the option that will have the greatest impact while using resources wisely. Therefore, I suggest that most people do "buy into" the notion of "best practices". However, the second observation is that when trying to take this approach, one is often overwhelmed. It is no easy task to identify what is, in fact, the best course of action.
  3. The following are my reflections on why I believe this is a challenging process in practice:

      What is meant by "best"?
      Within a system (government, a public health agency, a workplace), when a value is placed on searching for the evidence behind a possible option it is not clear what "level of evidence" will be acceptable. Must an intervention have been examined using the rigour of a Randomized Control Trial (RCT) in order for it to be judged "effective"? Organizationally, this decision of an acceptable level of evidence needs to be made. What does "best" mean to your organization? This is often a decision that has not yet been made.
    1. Do partners share the same value of best practices?
      Many health promotion initiatives are undertaken as a collective and it is likely that not all members place the same value on this evidence-based approach. Although I think more and more sectors and organizations are identifying the need to discover the best practices on any given topic early in the planning process, there are still individuals driven solely by innovation and community development. This reflects the need to balance the science with the community context.
    2. How does one access the best practices?
      I would suggest that there are four scenarios each of which brings its own challenge. When searching for best practices in a chosen topic area it is not uncommon to discover:
      a) A Needle in a Haystack
      - The individual practices are scattered hither and yon with no compilation, synthesis or summary
      b) The One Stop Shop
      - A compilation of many practices are gathered together in an orderly manner and there is likely also a synthesis.
      - This might also be known as "the Gold Mine"; but should one look for more than just the one?
      c) The Black Hole
      - When not even Google turns up anything. Maybe the topic is so new or the search is so specific that there really is little to find.
      d) The Floodgates Open
      - A prolific number of summaries, catalogues, compendiums and programs abound - now what?
    3. Is the label "best practice" warranted?
      In a recent (2003) review process I led for Health Canada, specifically in the area of chronic disease prevention and control, dozens of different assessment systems and subsequent labels were used to denote best practices. These included "recommended, promising, model, best and better." Short of reviewing the assessment criteria used within each system to understand what their label means, the best bet may be to rank confidence in the program based on the credibility of the source. For instance, The Cochrane Collaboration and CDC's Guide to Preventive Health Services are safe bets, although there are certainly others.
    4. How does one communicate best practices to fellow planners?
      Once the research is done and the results have been found (assuming one didn't end up in the "Black Hole"), those findings have to be conveyed to fellow planners. The question arises as to how best to synthesize the findings and share them with colleagues within organizations, community partners and other stakeholders in a manner that informs without overwhelming. This is even more challenging when I might be working with people who don't share the same value for this type of evidence.
    5. Not everything one looks for is available
      Typically, I find two gaps in many "best practice" scans conducted:
      a) Health communication, social marketing campaigns, and policy/system interventions are not often included. This may be deliberate in the scan parameters or it may be because these initiatives:
      - may not have been evaluated in the first place
      - may not have been written up and published in the peer-reviewed literature
      - are not as prolific as "programs"
      - are so specific to the local context that transferability is not relevant.
      b) A particular program may be designated as a "best practice" and yet the details required to replicate it in a specific context are nowhere to be found. The people involved in the initial development to whom one might turn for assistance may be long gone as well, especially if the program was part of a short-term grant. Information related to the costs and cost-benefits of the program are especially lean.
    6. What can be changed about the program while still preserving the elements that make it a best practice?
      I refer to this as the "integrity" of the program. If there is access to the actual assessment results and one can see how the program scored on the various criteria used in determining it as a best practice, some insight will be provided into the specific areas that scored well and therefore should likely not be tampered with.

    So, with all of these questions it is no wonder that people struggle with "translating science into practice." I will close my reflections with this observation of how I see decision-makers trying to work with best practices. Perhaps you will see yourself somewhere in this mix:

    1. Tow the Line: We have adopted a principle of evidence-based practice and only undertake initiatives that follow principles or actual programs of best practices. We begin our planning with a search for what works.
    2. Line of Best Fit: We generally know where we are headed. We search for "close" best practices and change elements of the programs to best suit our context.
    3. The Retrofit: We know what we want to do so we will search for best practices that justify our approach.
    4. The Ostrich: It takes too much time to uncover what works elsewhere. We will proceed with what our community has identified as needed.
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    December 2005/January 2006 Reflection by Mary Martin-Smith: Creativity and Best Practice

    Mary Martin-Smith is a board member of the Canadian Public Health Association and of the Community Health Nurses' Association of Canada. She lives in Regina, Canada.

    This is my own personal soap box on best practice - if people only look at the literature there is potential for a lack of creativity. Yes, go to the literature to get ideas, but then you need to add a twist of what's going to work to get best practice in our community. By the time something is published and evaluated it's old practice - if you only do what's in the literature you are perpetuating what happened in the past versus meeting the needs of the present. You need to inject some creativity when you work with communities, it is the only way to come up with new best practices.

    I'll give you an example. When I worked in Ontario in the early 1990s on breast feeding, we knew that moms stopped breastfeeding within the first three months and hardly anyone breastfed for very long. What the literature said was that support from people like husbands and mothers was important in getting over the two week hump. We had a hunch that it was more than family support, it was mothers - this was the 1990s - who were tired off being told to feed their babies in the bathroom or somewhere else. We knew moms hated being kicked out of restaurants or malls just because they were nursing.

    We put that information together, stirred the pot, and came up with the concept of baby friendly places. If we'd stuck with what the literature/evidence at the time said, that support people are key in the first three months, we would never have got to the concept of baby friendly environments. Yes we went to the literature, yes we knew the theory of supports for moms, but we needed to stir the pot with a new twist to create a new best practice.

    This lesson had a profound impact on my thinking of best practices - that's where my bias is coming from about too much reliance on the literature. When you explore further and put a creative twist on it you come up with something different. This breast feeding approach is now best practice across the country. We were the first to do it as part of a baby friendly community. We never wrote it up, we presented at conferences, and it spread by word of mouth. There are so many best or better practices going on in the field than are in the literature - who has time to write them up?

    For me creating best practice is about creating environments that say "go for the gusto" - it's the "dare to dream" scenario. I don't mean without critical thinking and a sound rationale for doing something - but the danger is over reliance on an academic approach where you start only by looking at what's worked in other places. This results in too much plunking program X into community Y. It doesn't work like that, people need to be more sensitive in listening to communities to find what's going to work. Communities are different from each other, they have different value systems, power structures, resources. You can't plug a program from community A into community B and expect it to work exactly the same.

    I also don't think you can do best practice without risk taking; more profound learning occurs from understanding what doesn't go well than always looking at what does. If you want to get to best practices you need to have a culture that supports risk taking. I have been fortunate in my career to be in situations where it was safe to take risks. Going back to the breast feeding project, we could have bombed - but I knew that it was safe for me and my team to take this risk and whatever happened people would say that's okay, what did you learn, and how are you going to apply that learning?

    In all my work there's not a lot I can take credit for - I've always been part of a team who has had the freedom to dream about how things could be done differently. Different perspectives around the table, different venues, an environment that says it's okay to think differently and have a vision and go for it, these are all important to best practice. For me creating best practice is about trying to find that balance between what the literature says, what we know about the community, and what happens if we add this new component - that creative twist.

    This reflection is based on interview with website editor Barbara Kahan.

    Click here to see a profile of Mary Martin-Smith.



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    February 2006 Reflection by Henriette Kok and Gerard Molleman: Best Practice in Europe

    Henriette Kok is a senior health promotion specialist for the Municipal Health Service (GGD West Brabant) in Breda, Netherlands. Gerard Molleman is Director, Centre for Knowledge and Quality Management at the Netherlands Institute for Health Promotion and Disease Prevention (NIGZ), Woerden, Netherlands.

    In 2004-2005 the first phase of the project "Getting Evidence into Practice" (GEP-project) co-sponsored by the European Commission was executed. The project is a collaboration of most national Health Promotion Institutes across Europe (for instance NIGZ (Netherlands), KTL (Finland), VIG (Belgium), SNIPH (Sweden), HAD/NICE (England), INPES (France), Health Scotland, Health Switzerland and others). One of the objectives is to develop a consensus based quality assessment tool (QA-tool) and guidelines for implementation of evidence, so that the existing evidence base can be transferred into practice. This resulted in the EQUIPH, the European Quality Instrument for Health Promotion.

    The first step in developing this assessment tool was an inventory of QA-tools that already exist in and outside Europe and are used to increase the quality of health promotion projects. The Interactive Domain Model (IDM) Check In Forms Tool was included in this study.

    The comparison of existing QA-tools was executed to obtain a clear view on the dimensions used and on the different methods for quality assurance. 17 Tools met the criteria to be acknowledged as QA-tool in health promotion projects. They were analysed on content, technical and scientific aspects. Furthermore, the quality criteria or indicators were qualitatively analysed through content analysis.


    Results
    The 17 inventoried QA-tools are located in 8 countries of which 3 are outside Europe (Canada, USA and Australia). The tools are broad in scope. They can be used in the broad field of health promotion and in every type (e.g. research, development, implementation, execution, coordination) and phase (e.g. analysis, planning, implementation, evaluation, continuation) of a project. The tools take different forms. Some use a scoring form to assess quality (11), others use a different approach like checklists (3), a questionnaire (2) or worksheets (1). The type of scoring in tools using a scoring form varies from dichotomous (yes/no) to point scales ranging up to five point scales. The number of criteria to be assessed ranges from 17 to 119 with an average of 45 criteria.

    The qualitative content analysis and subsequent synthesising, followed by two Delphi rounds with partners and experts resulted in EQUIHP, the European Quality Instrument for Health Promotion (http://subsites.nigz.nl/systeem3/site2/index.cfm?fuseaction=Pages.showPages&code=419&code2=420). The EQUIPH tool consists of 10 clusters. These clusters are:

    1. Basic assumptions
    2. Project management, subdivided into: 2a) leadership, 2b) planning & documentation, 2c) capacity and resources, 2d) communication,
    3. Participation and commitment/involvement,
    4. Analysis,
    5. Target group,
    6. Objectives,
    7. Intervention,
    8. Implementation, diffusion/dissemination,
    9. Evaluation, and finally,
    10. Sustainability.

    Comparison of IDM with the EQUIPH
    IDM is really an outlier in this review. IDM is based on the CQI approach in quality assurance and stresses the regular review of core elements in health promotion projects. In contrast to the other tools, the IDM tool pays much attention to the underpinnings (values, theories and beliefs, and evidence) of health promotion projects. IDM contributed 56% of the cluster Basic Assumptions in the final list of criteria of the draft version of the European tool.


    Reflection on the IDM Best Practices website
    The IDM Best Practices website is a useful information resource for HP professionals. It goes beyond a checklist, as it contains a lot of articles on quality improvement and best practices. Also the IDM Manual for Best Practices in Health Promotion can be downloaded which stimulates the implementation of the IDM working procedure by HP professionals.

    The website was most useful for the European project "Getting Evidence into Practice" as we could have direct access to documents on the topic of capacity building (e.g. the road map for coaches and the scan of needs and capacities in Ontario).

    The project can use this information for the 2nd phase, foreseen in 2006-2007, which is aimed to assess the existing capacity to apply the tool in the participating European countries (needs assessment). For more information on the GEP project see its website - click here.

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    March 2006 Reflection by Guy Ewing: Learning Circles and Creating New Knowledge

    Guy Ewing is an adult literacy worker and researcher in Toronto, Canada. He is involved in a national project on learning circles and teaches classes at Ontario Institute for Studies in Education related to linking research, theory and practice.

    Learning circles create opportunities for people in the community to learn together without regard to anyone's educational history or ability to use language - these are places where people bring to the circles different kinds of knowledge to negotiate new kinds of knowledge. For example, in Nova Scotia a fisheries group has fishermen and people interested in fishing policy. In this group people with university backgrounds might bring knowledge of statistics to the discussion while fishermen who may not have a high school education bring knowledge of the ways of the fish and ecology of the ocean. Together they can negotiate new knowledge because statistical models that researchers do may ignore important information which fishermen have, and fishermen might be helped with projections that mathematics can bring if it is based on correct information.

    Some of the groups that we've been working with are Indigenous healing groups that have been bringing their traditional knowledge to the table. In some of the other groups when health has come up it doesn't come up in a way that assumes a medical model or knowledge of that model, it doesn't assume everyone is conversant with the medical model in any of those discussions. Someone's understanding of health may be from their own experience.

    The principle of the learning circle is that everyone's knowledge is respected, no one's is better than others'. This is different from our society where we have imported a hierarchical model from European culture which assumes that people will gain knowledge from a teacher rather than everyone coming together and learning. Not that our culture prevents it, some people are in tune with that approach and get together and do just that, and it is a little bit romantic to say Indigenous people sit down and automatically know how to do this and others don't. But traditionally this approach is strong within Indigenous culture, and it isn't within our culture. For example, literacy workers' don't get government funding because their knowledge is disrespected - for a couple of reasons. The Harris government disrespected anyone they thought were politically opposed to them, they didn't respect the knowledge because they didn't respect the world view the knowledge came out of. Other people in the bureaucracy, who may be quite progressive in politics, don't respect literacy workers' knowledge because they believe in "expert" knowledge.

    One of the crucial things that we have found about learning circles is that they're exploratory - people come together with the goal of exploring certain kinds of questions - there's no pre-determined idea of what's going to be accomplished. It's different than a group coming together for a specific end. Learning involves opening up possibilities so there needs to be that kind of openness. The university attitude - "we have knowledge and we're going to apply it to your situation and everything will be better" - demoralizes people, it suggests that they don't know anything.

    What led me to this place [of the importance of taking into account a variety of kinds of knowledge, as happens in learning circles] was when I started as a volunteer tutor at Parkdale Project Read in the 1980s. I came to that with a lot of formal academic knowledge. I had a PhD in linguistics and an Ontario Teaching Certificate. I had ESL [English as a Second Language] qualifications. I had a background in teaching in the school system. But when I started tutoring I realized that the people who worked in the literacy program - the paid staff and the volunteers - had a different knowledge than I did and theirs was more useful. That really got me thinking about the relationships between different kinds of knowledge - I'd spent years collecting this academic knowledge, and I didn't need it for this important work of learning language. It got me quite confused at first - for a while I rejected my linguistics background.

    What's happened to me ultimately - now I try to use my academic knowledge as a support to others, for example to bring what I know about research to people trying to link research and practice.

    This reflection is based on an interview with website editor Barbara Kahan.

    For a profile of Guy Ewing, click here. To see past reflections by Guy Ewing, click here and here.



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    April 2006 Reflection by Larry Hershfield: Development of the Situational Assessment Tool Catalogue

    Larry Hershfield is Manager of The Health Communication Unit, Centre for Health Promotion, University of Toronto, in Toronto, Canada.

    As "chief cook and bottle washer" at THCU, I concern myself with the design, development and delivery of a host of services and products.

    I am particularly pleased with the development of our Situational Assessment Tool Catalogue for a number of reasons. Workplaces are very important places not just as a setting for health promotion activities but because they are important determinants of our health. And although there are many keys to successful initiatives, having a good handle on the actual situation at individual and organization wide levels is very critical.

    Many elements come together in such a complex product, and I will offer brief reflections on just three: the end-user experience, the review process, and the tradition of best practices.

    Intermediaries (our end-users) are facing a host of challenges and our job is to help them be more effective. Emulating some recent ads, our claim at THCU (sometimes referred to as "Tools for Health Created by Us") is that WE visited hundreds of websites and documents so that YOU have to visit only one! Thus the SAT catalogue is an important tool for content management, in a world where people have too much information already. Thus we hope the information architecture and interface is truly, madly and deeply user-centred, user-friendly. We thank the many people who reviewed the product and assisted in usability testing.

    Behind the scenes, we also relied entirely on online tools and online training/conferencing to manage and capture the review process. Believe me, the reviewing task is not easy - there are a lot of considerations in judging evidence of effectiveness, feasibility and plausibility! And there is a lot of information (formerly contained on paper) to manage, in various forms, in various drafts, at various times. So I am particularly proud of THCU's contribution to managing the review process in a particularly efficient way.

    I am also pleased that we were able to draw upon an evolving tradition of best practice methodologies. This time around, we did not focus on changes to this methodology, though each time a group uses it, we gain increased understanding of what the criteria really mean in the real world.

    Now that we have the basic machinery in place to maintain the reviews, and produce products and services, we look to further innovation next time out.

    Note: for a further description of the "intermediaries" mentioned in this reflection, click here.

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    May 2006 Reflection by Miriam Hoffer: Nutrition and Beyond

    Miriam Hoffer is a dietitian at Health Watch at Women's College Hospital in Toronto, Canada. She is the author of the book Fuelling Body, Mind and Spirit: A Balanced Approach to Healthy Eating (Sumach Press, 2003).

    My main goal when I see people in my office is to make them feel comfortable. Eating habits are very personal and people get defensive when talking about them. I try to make it safe for them. I don't use words like "good" and "bad" or "right" and "wrong." Instead I talk about "more nutrients" or "more balance." I don't talk about junk food but refer to them as "foods not on the food guide". When I close my door and we are alone, I can talk about almost anything. Sometimes what we talk about has very little to do with eating at all.

    With new patients I have a set nutrition 101 talk. I follow Canada's Food Guide to Healthy Eating. With returning patients I try to find something about that person that I can celebrate with them. Once they are relaxed I may bring in something like "Are you getting enough calcium?" but I don't always talk about nutrition. Nutrition habits are hard to change, behaviour change takes a long time - I'm not going to change it in 20 minutes. If I can establish a rapport and make them feel better about themselves that's a health benefit. If there is anything I think the person would be interested in that would relate to their physical, emotional or spiritual health I bring it in. I focus on the women and their personal experiences and try to build up their self esteem because people who feel better about themselves want to eat better.

    My current interest is the language of eating. Eating is usually associated with negative things. It is something that takes up time people don't have or it is an activity that will make them fat. People talk about ways to get around eating or almost apologize when they actually do eat. Food becomes "filling" or a meal will "last me for hours" while eating becomes a way to stave off hunger with the least amount of food people can get away with. I want people to change from a negative to a positive way of thinking about eating. I want them to celebrate eating as a way of taking care of themselves and flooding their bodies with health. I tell them that building a strong body is similar to building a house. By putting the best quality food into our bodies we create a body of strength; if we use poor materials by eating nutritionally poor food, we run the risk of ending up with a straw house. "Which house do you want to be in when the big bad wolf comes?" I ask them.

    I introduce my different approach to eating in many ways. I tell them I am switching to a different television station, or I tell them that "we're looking out different windows" and I want to "tell you the picture of your eating habits that I see out of mine." People are quick to find fault with their eating habits and I want to emphasize what is good. I use "add on" teaching. "Take away" teaching is the norm. I never say don't eat this or that. Instead I say "maybe you can eat a little bit more breakfast." People feel bad when they eat something they think is bad - I tell them "it's all right to eat chocolate, as long as you've finished your meal." Permission is an important thing - I give permission for them to start over and not worry about what they did yesterday.

    The weight thing gets in my way, it's so destructive, so negative for women - a trap they get into. Most are horribly weight centred - I try to get them eating for health, not weight. I don't remember when I started reading about weight and health but I do know that within days of working at Health Watch I didn't want to weigh anyone anymore. It was unhealthy for the women because they got agitated and I'm pretty sure their blood pressures went up, and unhealthy for me because I had to dodge flying objects as the women started flinging off heavy shoes, clothing, belts and jewellery so they would weigh less when they stepped on the scale. I did a lot of reading and really liked the Health at Every Size movement. This is a non-dieting approach to health that I promote with my patients. I truly believe that eating for weight is usually counterproductive to eating for health - people don't learn healthy eating patterns, all they learn is to eliminate foods. The medical director of my clinic was very supportive of the non-weighing of patients.

    Not only is eating personal but everyone eats - I can't set myself up as an expert. The women who come are amazing people. I feel it's an equal exchange, I learn from them as much as they might learn from me. They teach me ways to live life that encompass many facets of healthy living.

    This reflection is based on an interview with website editor Barbara Kahan.

    For a profile of Miriam Hoffer, click here.



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    June 2006 Reflection by Mark Cabaj: Contributing to Community Change

    Mark Cabaj is Vice President of Tamarack Institute. He lives in Edmonton (Canada).

    I don't feel like I'm changing the world anymore, I feel like I'm making the best contribution I can at a time when our society is at the cusp of realizing our problems are technical and social. There are people who understand that there are different ways of doing things, all you can do is contribute as much as you can and sometime the systems will reach a tipping point, I don't know if we've reached that yet or not.

    We are trying to shed the industrial paradigm of solving the world's problems through human services. Because of this paradigm and mind set our machinery - training, resources - is set up for fractured responses to joined up problems. However few real outcomes have much to do with the human service way out of problems. We all know the upfront case for joined up problems needing joined up solutions, but our systems aren't designed for this - funding and political systems aren't supportive of this work. Even when work is done well on the ground, we are still swimming up stream. Projects are short term and siloed, and there is not enough time for organizing. The pulls and pushes are so powerful we don't know how to organize differently, we just get pulled in and the next thing you know we're dealing with the old fractured way - feeding the machinery, keeping busy.

    The Stacey matrix is helpful when thinking about community change. It includes two dimensions - clarity on cause and effect for issues, and the degree of agreement on how to address the issues. You can have high or low clarity, and high or low agreement. For example when there are a lot of interrelated causes making cause and effect unclear, that's technically complicated, even though people may agree how to proceed, say through relentless experimentation. When issues are technically clear but there is disagreement about what to do, that's socially complicated. A living wage bylaw is not difficult technically but is socially complicated - there are millions of way to deal with that. When an issue is technically difficult and there is difficulty getting agreement, often because there are multiple stakeholders with differing interests and power bases, that is a complex problem.

    With complex problems conflict is unavoidable. If you look at social change, for me it's all about conflicts and tensions and how you get people to shift their perspectives and values. A whole bunch of things come into play, there's that interdependent dance. It's good not to ignore tensions but to flesh them out and work on small things first if it's too dangerous to work on the larger areas. Sometimes it's extremely counterproductive to go for a home run if you create an environment where players can't come together again. In one city I'm thinking of, the question is, can you have enough opportunities where well intended people in human services and community members who want to be involved in shaping their futures can talk about the issues together? This is the art part - over time creating an environment where the scope of intervention is greater and greater. The problem is this takes a long time to do and coalitions don't want to take the time.

    I don't think you can always resolve conflicts; sometimes it's worth making a statement. For example in one city Vibrant Communities brought conflicts into the open and normalized the conversation around living wage, which had generated lots of tension.

    When I look at situations where change hasn't happened as hoped, from the distance of an observer I don't feel grief because there's a story there that we can learn from. There are many stories and many levels, there never will be just one story. Things not working out is not a defeat.

    There are examples from Vibrant Communities of comprehensive and multi-sectoral approaches to different issues like early childhood development, safety, urban Aboriginal issues. From these we can take core principles and learnings and evaluation results and figure out how these work in other settings. Phase two is coming out of the laboratory.

    I just spent a third session with Michael Quinn Patton on developmental evaluation. Developmental evaluation is dynamic, a natural fit for complex multi-stakeholder situations where means and ends are not always clear, for example there may be a description of poverty or neighbourhood revitalization but conditions change so means and ends are continually redefined. Developmental evaluation is an overall process to help people be clear and ready for evolution. It is the job of an agent of change to create an environment where that happens.

    This reflection is based on an interview with website editor Barbara Kahan.

    For a profile of Mark Cabaj, click here.



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    July/August 2006 Reflection by Josephine Pui-Hing Wong, RN, MScN: What constitutes best practices in public health?

    Josephine Pui-Hing Wong is Health Promotion Consultant, Planning and Policy, Toronto Public Health, and Community Researcher and Consultant, Hong Fook Mental Health Association. She is also a doctoral student with the Social Science and Health Program, Department of Public Health Sciences, University of Toronto.

    The following is my personal and professional reflection on best practices and does not represent the views of any of the above affiliated organizations.

    When I was invited to write a personal reflection on the topic of best practices, the first thing that came to my mind was - the "personal" is necessarily the "political." Therefore, I like to begin with the words of C. Wright Mills:

    Know that many personal troubles cannot be solved merely as troubles, but must be understood in terms of public issues - and in terms of the problems of history making. Know that the human meaning of public issues must be revealed by relating them to personal troubles - and to the problems of the individual life. (C. Wright Mills, 1959, The Sociological Imagination, page 226)

    "Best practices" is a complex concept. At the risk of being simplistic, I would define best practices as policies, programs, services, activities and actions that are equitable, inclusive, responsive and effective. There are many ways that we can talk about best practices. Perhaps one interesting way is to highlight and challenge some of the myths about best practices.

    Myth #1- Best practices are objective and apolitical
    When public health practitioners gather to discuss best practices, the discussion often focuses on the "objective" application of evidence to program planning, implementation and evaluation. While evidence-based practice is important, it is only one component within best practices. Moreover, evidence-based practice is neither objective nor apolitical (but that is a topic of another debate).

    Having worked in the public health field for more than 15 years, I argue that all practices are "political." By "political," I mean that public health programs and services are shaped by myriad social and political forces. Some of these forces are more explicit (e.g. board of health debates on budgets; citizen reactions towards no-smoking by-laws, etc.) whereas others are much less visible (e.g. prevailing economic policies at the international, federal and provincial levels; neo-liberal and neo-conservative ideologies; systemic discrimination embedded in our everyday life). Thus, if we were to achieve best practices, we must come to recognize that everything we do is political. We need to acquire increased competency in understanding the political economy of health and health care; we also need to develop critical analytical skills that enable us to address public health issues in the contexts of globalization, market economy and increased health inequality. For example, effective public heath nutrition programs must go beyond individual or group education to address the issues of food access and food security.

    Myth #2 - Commitment and devotion of frontline practitioners will lead to best practices
    In recent years, training workshops and conference presentations on best practices and cultural competence have burgeoned. The majority of these professional development activities target frontline practitioners; hence, they reinforce the myth that best practices are located at the frontline level. Evidence suggests that best practices are outcomes of concerted efforts of stakeholders at multiple social and political levels: the macro- (federal, provincial and municipal governments, interest groups), meso- (public health units, health organizations/agencies), and micro- (practitioners, community members, clients) levels. For example, a number of health units and health organizations in Ontario have engaged in efforts to integrate access and equity principles into their programs/services. Their efforts are reflected in the establishment of internal access and equity programs, the formation of diversity and health practitioner networks, and the occurrence of numerous local and international conferences on diversity and health equity. However, without policy changes and resource commitment at the macro- and meso- levels, inclusive or best practices will remain a "mirage," as reflected in this frequently heard comment - "We want to make our programs accessible, but we don't have the budget or resources..."

    Myth #3 - Good intention equals best practices
    Over the years, I have met many colleagues who are committed, hard-working and full of good intentions. Yet, some of their efforts are less than effective in meeting the changing needs of our increasingly diverse, globalized and economically polarized populations. As public health is a field dominated by middle-class and specialized health professionals, we cannot assume that the values and interests of public health practitioners are aligned with those of their diverse client populations. Thus, 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. If social justice and equity are key elements of best practices, then reflexivity is an essential ongoing process.

    Best practices are personal!
    As C. Wright Mills argued, personal troubles and public issues are one of the same. In this sense, best practices are also personal. Over the years, I have come to recognize that my public health practices are inseparable from my personal practices. When I vote for a specific political party during an election, I am essentially advocating for a specific political ideology and supporting a specific set of public policies that have social and material implications for different groups in our society. Thus, for me, best practices are both processes and outcomes; they cannot be left at my doorstep at the end of the day. Best (or worst) practices constitute part of our "being."

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    September 2006 Reflection by David Groulx: Using a best practices approach

    David Groulx is a public health nurse with Sudbury & District Health Unit in Ontario (Canada).

    I may have reflected on my practice in the past but using the IDM best practices approach stressed the importance of reflection on my practice in public health - it made me think about my values and beliefs when addressing issues. I found that going through the process of self reflection with the IDM was a source of self rejuvenation, reminding me why I'm in public health.

    My involvement with the IDM also provided some insight into how to break down barriers that may be affecting an issue. If you understand social and economic structures and know how to address those appropriately you can begin to identify how to break down barriers such as financial constraints.

    I have been thinking about best practices in general, how people use that word and what they mean by it. From my experiences, people tend to think of best practices as specific to a project or simply as evidence-based practice, but it's much deeper than that. For me, best practices includes a critical reflection, exploration and understanding of one's own values and beliefs, health promotion concepts and practice, and one's organizational values, vision, goals and practice and the impact that all of these factors have within one's practice.

    I would encourage individuals to take the time necessary to do the reflective practice as I previously mentioned. Without that examination, reflection and exploration of your own practice one can not comprehensively address the health needs of the community. "Health for all" will not be attainable and values such as inclusivity will fail to be present in practice. The best practice approach is not one to be expedited but one to be thoroughly explored.

    I truly believe in the IDM approach to best practices. It is my opinion that health promotion strategies would be enhanced if we as practitioners conscientiously applied this process in our practice.

    This reflection is based on an interview with website editor Barbara Kahan. For more information about David Groulx, see this month's profile.

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    October 2006 Reflection by Peggy Schultz: Inclusion & Health - What Is a Best Practice?

    Peggy Schultz is a health promotion consultant with Ontario Prevention Clearinghouse in Toronto, Canada.

    An inclusive society creates both the feeling and reality of belonging. Belonging makes us and our communities healthy too. Over the past year, OPC [Ontario Prevention Clearinghouse] has worked with community partners to convene forums on inclusion and health (www.count-me-in.ca). We know that the determinants of health interact to exclude or include us and there is a current focus on how to apply the ideas of inclusion to population health.

    We can oversimplify what we mean by inclusion if we do not address historic and root causes of oppression. We tend to talk in terms of "we" and "they" with assumptions about a mainstream or a norm that should include people who are marginalized and excluded...so that they become part of some "norm." While a best practice framework indicator is that of involving all stakeholders, who decides who is excluded? A best practice must help us reframe so that people and groups themselves determine how they are excluded and how they might want to be included. And, a best practice approach must help us move beyond the term of "inclusion" to express the impact of POWER on health.

    Privilege manifests itself in many places and in many ways; we make judgments and are also judged so that we isolate or are isolated. We fear difference, or, more so we fear "the other." Stress, ill health, injury, isolation, death are linked to individual and collective powerlessness, hopelessness and insecurity. Exclusion is embedded consciously and unconsciously in many layers of our lives, workplaces, families and communities.

    Over time, resistance and conflict through thoughts, feelings and actions build up not only in our organizations, communities and societies but in our own bodies and their very human cells! Our self protection is shaped through our experiences with power. Beyond debate and open conflict or silence and hopelessness, where do we create conditions so that we begin to talk openly about this impact of power? Health promoters often work within a frame of community development to build spaces of trust and respect. We begin at individual, organizational or community levels to support change.

    Currently, we look for ways of fostering strong dialogue - conversations that matter - that have heart and meaning. I mean dialogue that is "not just more talking"; it is an invitation to actually "be with one another." It may be that a best practice is to actually change the conversations we are having so that we listen and hear each other - we speak to our differences not away from each other. This may seem naive in today's world - and, yet dialogue and deliberation open up spaces for health beyond old patterns of exclusion.

    For a profile of Peggy Schultz, click here.

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    November 2006 Reflection by Lisa Brownstone: Benefits of Personal Experience

    Lisa Brownstone, MSc has her own consulting business, Brownstone Consulting, in Regina, Canada.

    Both of my children have a Fetal Alcohol Spectrum Disorder (FASD). I'm also a member of the Regina FASD Network, on the board of the FASD Support Network of Saskatchewan, and have a number of contracts including working on a collaborative model of community housing supports for people with FASD.

    The biggest difference when paid to work on a cause where you have direct experience is passion - the level of passion that you bring to the work and the ability to take those intense feelings and channel them in a positive way. It means you can take your life experiences and translate them into the larger society - generalize them out - and then take the work experience and narrow it to your own personal situation. I've been able to take what I've learned from my children in terms of living with FASD and use that knowledge professionally, and I can take what I've learned through reading and talking to experts across Canada and translate that to my parenting and the discussions I have with my children and setting up their lives in a positive way. It's a two way street that works nicely.

    When working on an issue that affects your personal life, you're in for the long term. My own personal hope is that supports and policies get put in place so that I can pull back from the work and go back to being a mom. At this point I'm doing the work because if those most affected don't advocate, then changes won't happen. I think it's pretty compelling for funding bodies and policy makers to put a face to family and also to have that same family have a background in community development, health promotion, and research, with the ability to do the homework that leads to that greater understanding and movement in the community.

    The challenges of being personally involved are being able to properly channel negative emotions, e.g. anger with funding bodies - they don't get it, they don't supply the supports. Keeping a check on that personal anger and developing patience and understanding affects long term change. Also, you live and breathe the personal and the work. There isn't any boundary, which can result in burn out and exhaustion. You have to keep a pulse on yourself and be able to pull out and find that balance of work, play, family, personal growth.

    Another challenge is that you're constantly in a position of making the private public. It's a thin line for your family and yourself especially with something that's so laden with judgement as FASD, where people talk about "poor parenting" and "why don't they just change their ways" and those kinds of things. Respect for your family's privacy is of course an issue; whenever I'm presenting publicly I've always asked my children's permission - children who are now young adults - to talk about their lives.

    In my case I'm lucky that I've worked with many disabling conditions and so had that framework to understand my children. I was working in the area of cognitive disabilities before my oldest was diagnosed and I think that helped. It's not to say you don't sometimes get your perceptions clouded or affected by the grieving and anger that comes along with having kids with disabilities but it's also that the personal does bring a very different kind of understanding and that's an important part of the picture. You're living the life, so, for example, as a professional, if someone comes to your door and says they're a parent that's exhausted and this and that is happening with their child, you have some understanding as a parent and as a professional. Living the exhausting years of not being able to sleep because of emergency phone calls and other stresses means you have a much different understanding. This is not to say that people who don't have the understanding shouldn't work in the area - everyone has a place - but so do people who are living the experience.

    I would say that I bring passion to any work I take on but that certainly it's up a notch with FASD, and the determination to be part of making a difference is a lot stronger.

    Lisa Brownstone, in her profile, notes that her best practices definition "includes developing programs, developing community, evaluating, research that's done from the bottom up, using available knowledge to build the best models possible."

    This reflection is based on an interview with website editor Barbara Kahan.

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    December 2006/January 2007 Reflection by Warren Linds: Facilitation Planning and Spontaneity

    Warren Linds is Assistant Professor of Applied Human Sciences at Concordia University (Montreal, Canada).

    Two colleagues and I just worked with three different classes on diversity. Each one was completely different and we had to adapt our plans, both in advance and on the spot. One cannot go into a workshop with a prescribed plan - one can plan but one has to be prepared to change. Sometimes when I am in an exercise I let the exercise develop into something else.

    But some people don't like that. They want a plan to follow. I do give them an outline at the beginning. That was a trick I learned from a student who I was working with. He (and he was pretty linear) said that it didn't matter whether you followed the plan, but it gave participants security to know the objectives of the event or workshop and a general plan of what was going to happen.

    It was interesting the other night leading a class on Leadership in small groups. Some students were leading the class and I had the sense that a great exercise activity runs itself - that you can set it up and create situations and conditions for participation or empowerment but once something starts it is out of your control.

    I like the term occasioning to describe the role of the facilitator in such a process (Davis, B., Sumara, D. and Luce-Kapler, R. Engaging minds: Learning and teaching in a complex world. Mahwah: Lawrence Erlbaum Associates, 2000). Complex engagements such as learning involve a lot of adjustment, compromise, experimentation, errors, detours, ahas, and surprises. In this process "things and events fall together in complex and unexpected ways" (page 144 in Davis et al.). The role of the facilitator is not to control the process, but to create the conditions where those we are working with can adapt activities, respond, perform, play, improvise, plan and vary. For example, the facilitator might instigate a task and then the group or community adapts and interprets it for themselves. Occasioning means the facilitator provides a focal point and purpose, i.e. provides occasions for learning and engagement.

    I am asked how can you be trained to be spontaneous? Here are two things I try and do:

    1. Immerse yourself in whatever approach you do, i.e. find the time or opportunity to be a participant as a participant...feel the work from the inside. Don't always be an outsider. Participate in a training workshop run by others.
    2. Always try a new activity or exercise when you are leading. Keep it fresh. Don't let things become stale.

    People get into this idea that there are only two choices of working together:

    1. authoritarian (i.e. directive and dictatorial - keep to the plan)
    2. laissez faire which means no leadership and everything is amorphous and vague and dynamic and ever changing

    There is a third way, though, which involves a process of collaboration and negotiation with the group "on our feet" that isn't just at the level of the verbal, but in noticing the non-verbal and embodied clues that are part of the response of the group to a facilitator's directions.

    I think keeping to a plan and having a structure is good, but sometimes it needs to change. The question is, how do we know when to change? Here is something I wrote in my doctoral dissertation, which was on facilitation:

    How mindful are we as facilitators of the ways in which we respond verbally and kinaesthetically to what happens around us?

    • Do we have an approach to workshop leadership that recognizes the primacy of relationships, the braiding of language and the shifting emotional states in our behaviour?
    • How can we open up the possibilities for learning reflective and mindful awareness so that others learning facilitation may access and develop their intuitive and embodied abilities?

    An Australian facilitator, Martin Ringer writes that:

    Once facilitators have a sound grasp of active listening, assertiveness, models of group development, tools for facilitation they will be in a stronger position to focus on building their capacity to work directly on unconscious, intuitive and systemic aspects of groups. Concurrent focus is fine, but the emergent aspects of groups tend only to fully make sense once the empirical aspects are understood. (From The facile-itation of facilitation? Searching for competencies in group work leadership. Scisco Conscientia 1999: 2(1),1-19.)

    Ringer feels that we should first of all learn "how" to do this, through basic technique and skill development. He is saying that basic skills are somehow separate from other aspects of knowing, and we must "understand" these skills first of all. Yes, skills are important; but I am also interested in exploring these skills through embodied and mindfully aware reflection.

    This reflection is based on a written Skype interview with website editor Barbara Kahan.

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    February 2007 Reflection by Helen Thomas: The importance of organizational support for best practices

    Helen Thomas is Associate Professor with the School of Nursing, McMaster University (Hamilton, Canada), and a clinical consultant with the City of Hamilton Public Health Services for the Public Health Research, Education and Development (PHRED) Program.

    One of the dilemmas regarding evidence in a best practices approach is that there are areas for which there is no answer - so the question is, how does one generate an answer over time? People need to be methodical - review the literature, find a model, develop a program, test the feasibility, tweak it and then methodologically test it.

    But we don't do that - programs, especially in public health, are determined at a regional level and those decisions are made by management people, so front line people think they don't have much input into the decisions. They get told what they're to do so there is no room for that methodical approach, no discussion about getting from x to y and what about z. Using a methodical approach could be a very useful capacity building exercise. But you can't do it at the front line level, you need to do it at the organizational level, to give people time to read and think.

    If we want to use a best practices approach then we need to start intervening with deliverers of service organizations. Some front line workers do some very creative things but they do them in spite of organizational constraints. If we want best practices we need an organization conducive to that. That's a huge order, huge education required, and people need time. To assess the current evidence I think there's probably a real issue about skill development, and getting people to even think about it this way.

    In some organizations, there is a disconnect between management and the front line. The front line workers don't have the autonomy they need to make programming decisions nor are they consulted. Managers make the decisions and that's a huge problem. People on the front line understand the context and the community values and that's an important piece that gets missed. For example the nurses that work on the school team are the experts related to the context of individual schools. One size does not likely fit all, so unique program characteristics may be required in different schools. Another thing, there is a need for many practitioners to begin to look at the group as a whole, not individuals. In best practices in health promotion you're talking about the whole community.

    We also need to emphasize the importance of evaluation, allow 10 to 15 percent of the program budget - but when you say that everyone's eyes glaze over. Many people don't value evaluation. We need to find, in organizations, more rigorous ways to evaluate interventions. If evaluators are called in at the appropriate time, if they are given appropriate resources - this is a policy direction to emphasize with governments. That way, over time we would develop the answers to questions for which there is no current evidence.

    Another organizational issue is that health promotion and public health overlap tremendously but they are not set up to work very collaboratively. That's an efficiency problem as well as a problem when you start looking at best practices approaches. They sometimes work more at cross purposes than together; maybe they are in competition for the same dollars. If we find some way to get health promoters and public health practitioners going in the same direction that would be a useful system thing - if their work were complementary instead of working in different corners.

    People don't want to talk about organizational issues because they're challenging, but they're at the root of problems. It's like trying to feed the poor. Many are willing to donate food or open food banks, but few can see that the root problem is poverty and to change that requires government intervention so we don't have as many poor people.

    This reflection is based on an interview with website editor Barbara Kahan.

    Click here to read a profile of Helen Thomas.


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    March 2007 Reflection by Peter Jones: Hodges' model: A 21st century aid to support health promotion practitioners

    Peter Jones is a Clinical Specialist with NHS Care Records Service Project/Informatics at Lancashire Care NHS Trust based in Preston, Lancashire, UK.

    Health issues involve complex messages that must not only be received, but understood and integrated into thought and, crucially from a health promotion perspective: action. Hodges' model can help health promotion practitioners and their audiences increase their literacy regarding these messages. There are many forms of literacy: the 3Rs, emotional (with social, spiritual), information, health and visual - and Hodges' model encompasses all of them. Hodges model is simultaneously gifted with several qualities:

    • Accessible (to students, teachers, parents, curriculum and policy developers);
    • Inexpensive (in theory and practice);
    • Easy to learn and use;
    • Culturally neutral;
    • Suited to individual and group use;
    • Can prompt the curiosity of those not given to focus and think critically, but -
    • Potentially complex to challenge and extend inquiring minds.

    While not a universal panacea Hodges' Health Career - Care Domains - Model (h2cm) has enormous potential generally, but especially in health promotion. H2CM provides a framework upon which any situation can be mapped, capturing what I have termed the holistic bandwidth of health, social issues, and emotional life. The model can act as an aide memoir and reflective tool which practitioners can use to chart, compare, discuss and debate their journeys and experiences.

    The best way to explain Hodges' model is to review the questions Brian Hodges originally posed, translated into health promotion terms. To begin, who do health promotion practitioners work with? Well, first and foremost individuals of all ages, races and creed, but also groups of people, families, communities and populations. Then Hodges asked: what types of activities - tasks, duties, and treatments do practitioners carry out? They must always act professionally, but frequently according to strict rules and policies, their actions often dictated by organizational or program requirements such as routine documentation and budgeting. If these tasks are classed as mechanistic, they contrast with the times when practitioners give of themselves, comfort, develop empathy, rapport and engage in program delivery. This is opposite to mechanistic task and is described as humanistic. Putting this together Brian Hodges arrived at figures 1 (left) and 2 (right).

    Hodges' model provides a multi and interdisciplinary template, a coastline for discovery, while the context defines the topography - the landmarks. The model also provides a crossroads. Some practitioners may have prior experience of a particular domain, but no one has an all-encompassing knowledge of all.

    The table below shows Hodges domains as a grid, with three coloured threads denoting how specific health promotion programmes overlap across knowledge domains and contexts. The themes represented are pregnancy, drugs, and emotional (mental) health, the use of colour is intended to show associations, as well as differentiate. Although, to some extent this is subjective some concepts span domains, such as 'life chances' and 'peer pressure'. A concept such as, 'stress' can be manifested psychologically and physically. The underlined items are general.


    Health and the environment are like two pearls threaded on a fine cord called quality of life. Hodges' model highlights the pearls and the cord. Using the model - whether formally on paper, or cognitively as an aide-mémoire - assists practitioners to listen (actively), integrate, apprehend and act in order to do the best job possible.

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    April 2007 Reflection by Hélène Roussel: Using the MDI/IDM

    Hélène Roussel is a health promotion consultant with Centre ontarien d'information en prévention/Ontario Prevention Clearinghouse (OPC). She is also a volunteer board member with Association des communautés francophone de l'Ontario - Toronto, Canada.

    Note: MDI stands for Modèle des Domaines Interactifs, the French-language version of the IDM, Interactive Domain Model.

    You have to put a bit of energy into understanding the MDI but once you understand it it's so complete. Using the MDI to plan our activities has forced us to be a lot more solid in how we approach things, more rigorous.

    People who use it need to understand this - and this should be put in big, big letters - we don't have to use all the squares in the Framework. If groups are not ready to talk about theories or values or evidence, if they are not strategic, leave them alone and come back later. Sometimes doing things by trial and error helps us learn to be more strategic. I look at the MDI as more of a guide than as an end in itself. The reason we have been so successful in using it at the grassroots is that we don't let it bog us down, we use what we can in our own way. For example in the case of a project on partnership building we concentrated on three or four squares and that's fine, it's enough to give us a good basis to create a common language.

    Some people have a hard time with the model because they don't have a reflective practice, they are into action and seldom take time to reflect on what they are doing. It's nothing to do with the model, they would resist anything that would require them to reflect. But in health promotion we have to have a reflective approach so we don't constantly chase our tails and miss the boat.

    The MDI is unbelievably powerful. It forces us to integrate planning and evaluation. It brings us to that place where every time we create an objective we ask ourselves how will we demonstrate that we have achieved this. We are forced to think about evaluation from the beginning. It also helps us evaluate things like values and beliefs - to see whether what we do is based on values, the values are not just on paper. For so many organizations the values and what they do are disconnected. There's a gap, and often they let the gap go because they don't have that reflective practice. The MDI is powerful because it allows people to grow within the organization. It reduces the gap between the walk and the talk - it provides integrity.

    The MDI allows people to come to a common reality. For example, if we want to be inclusive - what does it mean to be inclusive, where are we at right now, where do we want to be. It's okay not to be perfect - but is it okay to not be inclusive for the next two years because we need to develop the expertise, and then in the third year when we have the capacity we can be more inclusive? We need to discuss all of this. All of this stuff is very fascinating, I love this model.

    Seriously, I love this model. Even though I'm using it quite a lot I don't grasp every single aspect because it's quite complex - but at same time quite simple. It's been to me a very good way of creating synergy within a group - it brings people onto the same wave length and so creates a basis that supports the decisions we're making.

    This reflection is based on an interview with website editor Barbara Kahan.


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    May 2007 Reflection by Catherine Macpherson: Using the IDM for Health Coaching

    Catherine Macpherson is Product Manager for the LifeWorks division of Ceridian. She lives in Ann Arbor, Michigan.

    I like the [IDM] model - it's not step by step, it's more like a web. It makes everything come together, at least it did for us [at Leade Health, recently acquired by Ceridian]. We had a number of pieces we were working on and the IDM was the web that connected everything for us. When we talked about developing a practice we would look for our evidence, our experience, what else do we need. We were able to use what we learned from the IDM in decision making and in other ways.

    The process brought the entire company together through a common purpose. At meetings on best practices development I saw a lot of people get excited about the work we were doing. Maybe they were working in finance or IT [information technology] and instead of their task being only about numbers or coding it all came alive for them, they knew what we were there for. The communication about the practice invigorated everyone and brought everyone together. It was an enlightenment, the light bulb went off - everyone understood what we were doing.

    I'm still using the IDM in product management. When I develop a product I'm looking at evidence, underpinnings, if it fits our company's values. We're continuing to do ongoing research regarding effectiveness - health coaching itself is new, out for only 10 years, there's not a lot of research about the best way to coach. Since we've been in the business as long as anyone else [Leade Health initiated its first health coaching program in 1997], we have a database of 40,000 people who have gone through programs. We are analyzing the data and finding trends. We are looking at why some coaches are more effective than others - did they have better motivational interviewing techniques, were they more empathetic? We are going to start listening to calls, parse out the competencies, help everyone be competent.

    Using the IDM definitely improved our outcomes. It helped us fine tune our designs, enhanced our coach training through developing competencies, brought us together. I feel like we were doing a lot of things before but we didn't understand these were part of a best practices approach, the IDM helped us put it together and have a cohesive approach, it helped us add more good and best practices to what we were already doing.

    I like the fact that the IDM isn't a one size fits all approach - you can use it to fit your company, what you're doing. It takes into account your own experience.

    This profile is based on an interview with website editor Barbara Kahan.

    June 2007 Reflection by Anne Luke: Best practices and early learning three decades later

    Anne Luke is the founder and former executive director of the Regina Early Learning Centre in Saskatchewan, Canada.

    working from an individual and collective values base

    In my interactions I try to live out my ideals, values, principles - social justice, respect, mutuality. Right from the start [of the Regina Early Learning Centre] my idea was to change the dominant ways of behaviour towards marginalized and colonized people and act according to a code for social justice. It was my responsibility to learn about the causes of poverty, alienation, racism. It was not an easy road - in those early years I felt very alone. But when I named my principles many years later to staff, it was liberating - people said "that fits with our beliefs too, that's how we want to live our lives." That was so liberating for me, it was just amazing - it was like I had this secret inside myself that I wanted to work but didn't want to impose. When it became collectively owned it was "wow!" - together we can relate these principles and values to how we work with children, families, each other, the larger community. Sometimes we have setbacks and then we look at where things broke down, and we have our code to measure it against and we try again a different way. This code has kept me going for nearly 30 years.

    using a transformative approach

    Someone who came to observe at the preschool once said, "This is so good, you're going to get them ready for school." And I said, "What we need is for school to be ready for children." I had a hard time explaining that we were more about affirming who the children are and what they can do and joining with them in their life's journey - we were not about grooming them so they could do numbers and sit in a desk. It was more transformational - not so much changing the individual as changing the system. That's a bit grandiose when you think about working with three and four year olds - of course they change and grow. But what's important is that we change their expectations. They see themselves as creative and competent and when they go into school they have high expectations of what adults should be doing.

    We don't see children as being small and defenceless. If we see the world from their eyes we can see so much, rather than thinking they're not important till they're reading, talking, producing.

    One thing I've discovered from my reading is about people like Paulo Freire who did all that wonderful work in South America - we're not just a Regina preschool but part of a larger vision, whether it's gay rights or food for the hungry or votes for women. We're part of a movement that seeks justice, a transformation of larger systemic approaches that are not concerned with human development, that are concerned with holding onto power. My instincts are to be on the side of people oppressed and take a stand. I think it was Pope John 23rd who talked about standing in solidarity with those who don't have rather than shoring up those who do have.

    impact of using a best practices approach

    The impact on children of using a best practices approach at the Regina Early Learning Centre is that they learn to see themselves as learners. They also improve their language and cognitive skills - maybe not always up to where they would be if they had been born into more advantaged circumstances. But very importantly they see themselves as learners, as part of a group, and that they are powerful people with something to contribute. For example, the Scyther Café project the children created epitomizes how children problem solve. They recreated what they saw happening in the world - they made their own tables, they played café, they learned so many things. They created things of beauty that could be enjoyed by themselves and adults. It illustrates how when you do best practices with children the results are amazing.

    For parents, using best practices has resulted in a sense of belonging, of community that they've built in addition to a safe trustworthy place for children. Centre parents have a strong sense of community, identity, ownership.

    The impact of using a best practices approach on myself is that it has provided a code to live by - a way of being in the world that is respectful - resulting in impacts that are not always measurable. It's an alternate away of being and living and seeing. What more could a person ask for?

    This reflection is based on an interview with website editor Barbara Kahan.


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    July/August 2007 Reflection by Rishia Burke: Using the IDM with a Community Health Centre

    Rishia Burke is a community researcher and evaluator in Burlington, Ontario, Canada.

    The organization that I have used IDM pieces with is a community health centre in the City of Cambridge (Langs Farm Village). The organization operates within a neighbourhood setting serving and working with families and individuals within those boundaries. The work focuses on health care, health promotion and prevention with services areas that include a clinical practice, a youth and teen service area, an early years team, a resource centre (providing employment supports), adult services programming (focus here include seniors programming, multicultural programs, and women), and volunteer services.

    I have used the IDM model in part through the logic model and evaluation work that I have been doing with the organization.

    Before I start the logic model process I work with staff to identify underpinnings - we talk about the assumptions behind their work, why they do their work and what they hope their work is accomplishing. I ask the team to identify the principles that are critical to them as they do their work.

    We then relate those principles to the organizational strategic plan and its underlying principles. (e.g. providing opportunity for individuals to grow in their strengths is important in the way that we do our work and/or we want to look for and foster community leadership in the process of doing our work - Strategic Plan direction of capacity building).

    I ask staff to think about what outcomes a program might have and why those outcomes might be achieved. We talk about what indicators they believe they have of those outcomes. In doing this we are able to look at the value of anecdotal story. I find when working with a variety of organizations staff often validate their work through stories that are related to them by participants. There is value in those stories; however, I also find that when you have a conversation about this we often challenge the story if it is weak and/or identify additional sources of separate evidence to substantiate the outcome.

    We will also look at the literature to see how well assumptions about outcomes are supported; that literature is then used for the development of outcomes in the logic model and indicators in the evaluation framework.

    I believe that an underlying approach in the IDM model is the on-going nature of developing best practices. A large part of the message to staff is that:

    • Evaluation is part of your front line practice - it is not this separate thing that we do at the end of something; the benefits of embracing that is the associated motivation for needed changes to process, a source of pride and satisfaction for a job well done when outcomes are revealed.
    • The planning, implementation and evaluation cycle never ends! One stage feeds the next!

    The strength of using these elements of the IDM approach is that we are able to develop a solid foundation of understanding as a team before we move ahead to a logic model and all the other subsequent steps. The conversation in itself is a bit of a team building exercise.

    Each team at Langs Farm Village will identify some slightly different underpinnings because of the nature of each team's work. However, all of the teams to date have identified the importance of capacity building, leadership development and community engagement in their discussions.

    As mentioned earlier the groups have been able to tie their team level work to the organization's strategic planning work so that they can see how their team's work related to others and to the organization as a whole.

    We will continue with this process until the entire organization's service area logic models have been completed. We will also use discussion about principles and values when conducting other work - most recently when working through a re-design of the organization's leadership development model.

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    September 2007 Reflection by David Groulx: Using the IDM - An Individual Perspective

    David Groulx is a public health nurse in Ontario.

    Type of Organization, Location, Main Focus (Issue and Population)
    I am a registered nurse who has worked in different public health departments and was fortunate to be involved in two pilot phases of the IDM model. Public Health in Ontario Canada is delivered by 36 separate/ independent Health Units/departments. These health units deliver programming addressing the population health needs of the various districts. To guide the work that public health practitioners engage in, the Ministry of Health for the province has set prescriptive programming requirements that must be met by all health units within the province. The topics that are addressed within this mandated include chronic disease and injuries, family health and infectious diseases. It is this document that focuses much of the work done in Public Health across the province. As I am a health practitioner practicing in health promotion my involvement and focus of initiatives focussed on chronic disease prevention. I will describe my involvement in utilization of the tool not in as much to address a particular health promotion initiative but more in terms of the actual experience of utilization of the tool and various components within itself. My involvement began with the initial pilot testing phase. This initial pilot phase involved the testing of the IDM model theoretical constructs and framework and how these would be interpreted and understood by practitioners. I was also involved in the pilot testing of the evidence framework (translating research to practice). The questions that were identified by staff in the pilot testing phase of the evidence framework included:

    • What characteristics do recreational facilities have to have to increase an adults (ages19-55) ability to take control over increasing their physical activity levels.
    • In what ways can we encourage schools to adopt a comprehensive school health approach in order to improve the health and learning of school aged children.
    • In what ways can we increase the # of public places with supportive breastfeeding policies in order to empower women ( increase awareness, increase confidence, take actions) to breastfeed in public places.

    The health promotion values that were identified to correlate with the questions posed included optimal health for all, social justice, community empowerment, ecological respect and sensitivity and joy. Support for involvement in both pilot testing phases were supported at senior administrative level as well as middle management and staff. The IDM model was introduced in both pilot testing phases by both Barbara Kahan and Michael Goodstadt, both authors of this contemporary approach to best practices in health promotion.

    Strengths/Challenges of Using IDM
    The factors or correlates relating to our health are not linear and are extremely complex and multi-dimensional. It is therefore necessary when addressing a particular issue that one understands the different contextual spheres that exist relating to a particular issue. This model guides individuals to navigate through this inherent complexity and multi-dimentiality. It allows for the identification of all the information necessary to guide health promotion practice for a given field that is best suited for a given population.

    A second strength that can be noted includes the ability of the model to facilitate self reflection and examination of one's own personal beliefs, values, and ethics and the environmental context in which these interact. Furthermore it allows and facilitates discussion within and amongst organizational members on the varying viewpoints on their individual, team and organizational values, goals and ethics. In addition there may be variances in how one interprets the environment and the IDM model allows for identification and examination of these differences. These discussions are often absent in the examination of an issue yet inherently impact on the decisions practitioners make relating to addressing public health issues.

    The utilization of the evidence framework assists with and gives insight into how to break down barriers that may be affecting an issue. For example in understanding the social and economic structures that exist one can begin to identify how to break down barriers such as financial constraints. Furthermore the utilization of this framework allows for a systematic approach to incorporating research into practice as well facilitates justification and validation of the value for utilization of qualitative research as this type of research may be more reflective of the values held within health promotion. In addition the utilization of the evidence framework assist with "making the case" to middle and senior management regarding need for focus on or resources allocated to a particular public health problem.

    One of the most important strengths of this model is its portability. The IDM framework allows for the variations in values, ethics, goals, and environments that can be seen across cultures, organizations, and individuals, locally, nationally and internationally.

    Interestingly enough the characteristic intrinsic to the innate strength of the model was also the largest challenge with utilizing this tool at the time of pilot testing. This model, like many other models, is complex reflecting the realities in which we as human beings live work, interact and function within our societies. Unfortunately practitioners themselves may be unable or unwilling to work through such complex models in favour of more simplistic linear approaches, focussing in on, or addressing one aspect of the solution to a particular health promotion issue. I would speculate that this occurs as this approach would require less time on introspective, retrospective and prospective thought and analysis and would focus more on action toward program development and implementation. The IDM model in my opinion does not facilitate that immediate need for "action" and this may be difficult for some practitioners.

    Furthermore, as humans have varying values, goals and ethics, as well as understanding of theories, evidence, and their environment, there exists the potential for conflicting ideas on what would constitute "best practices" between individuals, teams or even between organizations within a community. This conflict has the potential to delay implementation of health promotion practices until such conflict is resolved.

    Finally, after the pilot phases of the project, access to expert support in model interpretation was diminished lending to the discontinued use of the model. At the time of the pilot testing there were no supplemental tools developed as there is today, nor were there identification of expertise to facilitate model utilization as there currently exists.

    Results of Using IDM (Re. Organization and/or Health/Social Issue)
    My participation in the IDM best practices model occurred early in my career in public health. In this infancy stage of my career I had a different view of what "best practices" are. I can truly say that my involvement with the project has had an impact in the way in which I look at the conceptual notion of best practices. There is significant variance in my initial understanding and definition to best practices compared to my current understanding and definition. My current understanding is much more broad and inclusive. It does not only focus on the best evidence but how this information interacts with all the other domains. My involvement in the pilot phases has strengthened my belief in the importance of reflection on my practice in public health. It has made me think about my values and beliefs when addressing issues and has lead me to more critically examine the environment when addressing an issue.

    Furthermore, the utilization of the Evidence Framework assisted in defining search parameters and conducting a literature review such that only the literature that reflected the health promotion values was identified and reviewed.

    Moreover, reflection on the theoretical constructs that the practice of health promotion and public health are based upon had proven to be quite invigorating, reengaging and reenergizing as a participant in the pilot phases.

    Note: The experiences and opinions expressed are those of the author and do not necessarily reflect those of other participants in the pilot phases or the organizations where this author was/is employed.


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    October 2007 Reflection by Evan Morris: Evaluating a Government Partnership Using the IDM

    Evan Morris is a self-employed consultant with EcoTech Research Ltd, in Regina, Canada. He also teaches at the University of Regina and at SIAST (Saskatchewan Institute for Applied Science and Technology).

    I recently carried out a process evaluation of a collaboration consisting of several provincial, territorial and federal health departments. During the first month I spent a considerable amount of time reading project documents and interviewing participants. I also spent a lot of time thinking about how to pull all the information together. It finally dawned on me that the IDM Framework could be applied to evaluating projects as well as for planning. Once I determined to use the IDM Framework for the evaluation, the remainder of my evaluation work was straightforward; the IDM provided a road map for my analysis of the processes involved in this project.

    The IDM is a useful tool for carrying out both outcome and process evaluations. An outcome evaluation tries to determine if the project activities led to the desired project outcomes, while a process evaluation determines if the processes supported the outcome activities. The diagram below shows how I used the IDM in my process evaluation.

    I determined what the activity objectives were, what the process objectives were, and whether or not the process objectives supported these activities. A measure of the success of the processes was whether or not the planned activities took place, and how well they were carried out.

    At first I was tempted to limit my evaluation to how well processes supported activities, and this is a common practice in process evaluation. However process and activity objectives aren't selected in a vacuum. They are the result of a number of factors, including power relationships between collaborators, resources, theories of social change, values, etc. An understanding of these factors makes it possible to determine what project goals were chosen, and what processes were applied. If we can determine how these factors affect our goals, activities and processes, we can provide extremely useful information for other groups or collaborations that are planning projects.

    The IDM is a complete logic model, and contains many domains and interactions. At first I was somewhat overwhelmed at the idea of applying the entire model to the process evaluation. However, several extremely useful discussions with Barbara Kahan convinced me that I did not have to apply the entire framework to the evaluation process. The IDM practitioner can select to use portions of the framework depending on the situation. Some of the IDM domains are categories such as values/principles/beliefs, theories, evidence, resources, structures, etc.

    I analyzed my data based on the domains shown in the diagram below. One of the main strengths of the IDM is that it includes values and principles as major determinants of both processes and goals. It was clear for this collaboration that the values and principles of the participants had a great influence on the processes and successful activity outcomes of the group. In fact values and structures were the most important determinants of group processes.

    Before I began my evaluation I read a number of publicly available evaluation of other collaborations and partnerships. Most collaborative health-related projects involved partnerships involving different types of groups, such as health agencies, community groups, government agencies and academics. In many cases there are unequal power relations between the partners. Typically one partner has greater control over resources, such as funds, facilities, personnel and level of expertise. When such collaborations fail, it is often because these power differences result in partnership processes that become competitive, turf protecting, and antagonistic.

    The collaboration I was evaluating was fairly unique in that the partners consisted of representatives from several government jurisdictions. Power relations were fairly (but not completely) equal. If a partner felt that their views were not being heard, or that they were not benefiting form the partnership, they could easily have dropped out of the collaboration.

    Based on their values, the partners decided early on to create process and outcome objectives that included the following:

    • All partners benefit from the collaboration
    • Decision making is by consensus
    • All jurisdictions, regardless of how small, are included in decision making and project activities
    • There is a sharing of resources
    • There is mutual accountability

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    November 2007 Reflection by Dave Hedlund: Terminology Regarding the Determinants of Health

    Dave Hedlund is Executive Director, Mental Health and Addictions Services, Regina Qu'Appelle Health Region (Canada).

    When people who are familiar with the field of population health promotion talk about the determinants of "health" we mean a set of things that covers a broad spectrum of personal and community characteristics. There are a number of lists of the determinants, all of which overlap. "Health and well being", "quality of life" or "successful communities" are terms people have sometimes used in their attempt to make sure the broader concept of health is understood when it's used this way.

    To many people outside the formal health system, the term "health" doesn't communicate well what the people using it in the broader sense actually mean. I think if we are to be successful in establishing a broad-based priority emphasis on determinants of "health and well being" in our communities, many sectors other than health need to be involved-simply because so many of the determinants are well within the spheres of influence of one or more organizations and groups not part of the health service systems. To effectively develop a common approach, we should consider using language that means more to more people, and is less specific to the health service sector.

    The concept of "sustainable communities" is fairly detached from most professions, as is "quality of life", or even "health and well being". I'm not sure that these are necessarily the best terms either, but at least they are not limited by the impression that they are some profession's particular language.

    As progress is made on the determinants agenda we know some communications expertise will be needed to help move the agenda forward. This could help to ensure there is as much understanding and buy-in as possible created for something that is of such great importance to everyone.


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    December 2007-January 2008 Reflection by Rosanne Glass: Innovation and Best Practices in Education

    Rosanne Glass is executive director of policy, evaluation and legislative services for the government department Saskatchewan Learning.

    I'm always drawn to the innovators doing cutting edge work. I try to learn from and with them. Often the status quo is not acceptable. I don't like change for the sake of change but I take very seriously change for the betterment of society.

    Although something might work at another level or in a different context, when it is applied to the local context it has to be open to a level of innovation. One of the limitations of a system is the degree to which it can be responsive. It's simply harder to change things more quickly in a larger system. And sometimes risk taking is not allowed nor is it acceptable. Although much true innovation happens outside of the system, there are exceptions. For example I call Nutana Collegiate in Saskatoon an incubator of innovation.

    Nutana Collegiate was one of the first high schools to seriously integrate social, health, and justice services with schooling. That school had many highly vulnerable students struggling with a number of complexities in their lives such as addictions, poverty, and many who were teen parents. The school was on the verge of closing in the 1990s but they had a creative staff and a strong leader in the principal - they took one last, strong effort. To my knowledge, Nutana was one of the first high schools to take youth engagement as seriously as they did. They really talked to the students, and really listened to them. They asked: what will it take to keep you in school and what do you need to help you be successful? The students talked about their home lives, their family lives, the issues they were grappling with outside of school. They talked about the kinds of supports they needed including addictions counselling, financial help, mental health services, child care...

    The administration worked with the school board which supported them. They accessed some additional staffing, including Aboriginal Elders in the school, and used the facilities differently. They showcased successes, built serious relationships with service providers, had social workers and other service providers on site. A lot of the students didn't have parental support, in some cases they were the parents. Services available to students ranged from parenting education and counselling to nutrition and other health supports.. Students weren't penalized if they had to leave school to pick up welfare cheques or deal with other personal issues. The school year was organized differently, into shorter blocks of time. The students needed shorter bursts of school to have some success. If they finished one of these shorter blocks they got a credit, rather than losing credits if they couldn't get through a whole semester.

    The school administration and staff tried different approaches and built on what worked. They always talked with the students. When government workers, community members or politicians came to visit, the principal and teachers would always say "talk to the students"; it was the students who would showcase the school. It was so affirming, what school should be like, and not just for vulnerable students. A basic premise is: Don't do anything related to youth without engaging youth. The same principle applies to whatever group you're working with, whether it's parents, youth, Aboriginal people. No one wants things done to them. It's a basic respectful basic practice to work with people.

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    February 2008 Reflection by Josephine Pui-Hing Wong: Politics and Best Practices

    Josephine Pui-Hing Wong is a doctoral candidate with the Social Science and Health Program, Department of Public Health Sciences, University of Toronto.

    I was excited to see that the IDM named "politics" as a significant domain in best practices. Very often, whether we work in a small or large organization, we hear remarks like, "I feel that I cannot do anything because of the bureaucracy" or "we can't fight the system." Yet, members seldom want to talk about practice challenges and barriers in the context of politics. Many perceive politics as something remote and separate from their work or the way they practice. However, I believe we may be able to bring desirable changes if we stop shying away from the idea of politics and start to discuss issues in the context of the social and political forces that influence our organization's culture, decision-making processes and practices.

    Looking at life from both the professional and personal perspectives, I know that I do not exist in isolation from others in the community, in Canada or in the world. Canada's domestic economic policies are closely linked to its international policies and vice versa. Over the last three decades, neoliberal ideologies in Canada, the UK and the US have dismantled our social welfare system, resulting in increased social and economic disparity, child poverty, increased homelessness, etc. In Toronto, during the 1990s, when ordinary citizens were told that government cutbacks were essential due to global economic recession, the median income of the 12 poorest neighbourhoods dropped by $6,800 while the median income of the 12 wealthiest neighbourhoods increased by $11,400. A lot of the public discourses on tax cuts, economic constraints and individual responsibilities serve as smoke-screens to conceal increased social inequality and to transfer blame to the most vulnerable individuals and groups in our society.

    I think one of the worst outcomes of neoliberalism in advanced capitalist societies like Canada is that it promotes an individualistic culture that leads to collective short- sightedness on what a healthy society consists of. I personally do not see individual liberty as true freedom. In fact, I do not believe that humans can truly survive as disconnected individuals - not physically, not emotionally, and not spiritually.

    When we do not take collective actions to address issues related to our environment, social equality, community safety, food security, and global equity, etc., we are collectively exposed to risks that can lead to increased incidence of cancer, new communicable diseases, community deterioration, and terrorism. More importantly, individualistic practices will ultimately compromise our capacity to remain fully "human."

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    March-April 2008 Reflection by Nina Jetha: Comments on Best Practices

    Nina Jetha is the Lead of the Canadian Best Practices Initiative, in the Public Health Agency of Canada's (PHAC) Evidence and Risk Assessment Division, Centre for Chronic Disease Prevention and Control.

    Working in this area has made me more aware of why quality assurance, evidence-based decision making and best practices have become important guide posts for public health action at a time when public health system performance is under increased scrutiny. As well, increased emphasis on ensuring effective public health practice requires a number of efforts designed to increase the capacity for evidence-informed decision making. But we know that information alone will not result in change so incorporation of best practices and evidence into routine decision making in public health organizations requires capacity building and organizational learning focused on developing communication strategies, enhancing knowledge and skill bases, creating supportive infrastructures, and allocating funding for implementation support. There is no doubt that innovative public health interventions such as those on the Portal are turning people's lives around. There's been tremendous progress in improving Canadians' health and reducing health disparities among some groups - and it's thanks to the effectiveness of these interventions.

    Another impact that this project had on me - I now understand the importance of partnering to reduce inequalities of health and improve over all health and well being of Canadians. We can't do it alone. We at PHAC are very appreciative of the active support and engagement that this process has received from experts across the country. We're all working towards common public health goals.

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    May-June 2008 Reflection by IDM Think Tank Participants: Thoughts from the IDM Think Tank

    Top photo above: Catherine MacPherson (Ann Arbour)
    Group photo seated: Rishia Burke (Burlington) and Barbara Kahan (Regina)
    Back row, from left to right: Peggy Schultz (Toronto); Caroline Wai (Toronto); Debbie Bang (Oakville); Ralph DiClemente (Atlanta); Dave Groulx (Sudbury); Nancy Dubois (Scotland, Ontario); and Hélène Roussel (Toronto).

    On March 19, the day after the IDM Best Practices workshop Making Work More Meaningful, a group of IDM "alumni" and the workshop's guest presenter participated in an IDM "think tank." Nancy Dubois, a consultant with the Health Communication Unit (THCU), Centre for Health Promotion, University of Toronto, facilitated the think tank. THCU provided financial support for Nancy's time. Health Nexus (formerly the Ontario Prevention Clearinghouse) provided space and refreshments.

    IDM assets & challenges

    Participants identified a number of IDM assets and challenges. Examples of assets include: people with first hand experience of the IDM, representing a wide range of expertise and perspectives; supportive organizations; a substantial number of English and French language resources. In addition, the IDM influences positive short and long term change, and its values/underpinnings base is unique among tools/models/approaches.

    Examples of challenges include: lack of funding for IDM development and activities; organizational pressures such as time; and a perception that the IDM is too complex to use. A challenge as well as a strength is the IDM's diffuseness, that is, it can be seen as everything to everybody.

    IDM audience

    The day's discussion identified three key groups with potential interest in the IDM: students (a community's future directors and managers); users (e.g. program decision makers and implementers in different sectors); and organizational gate keepers (such as senior management, who have the power to support implementation of the IDM).

    IDM uses

    Participants came up with many potential uses for the IDM in addition to its traditional applications of planning/evaluation and organizational development. Examples of suggestions include: assist with accreditation; guide community based Participatory Action Research; apply to environmental risk/hazards investigations; and help screen funding applications.

    Increasing IDM uptake

    Increasing uptake of the IDM was a constant theme throughout the day's discussions. Ideas to increase use focused on resource and dissemination opportunities. The key resources that participants discussed were people and funding. Participants identified the following key dissemination pieces: continuing IDM development (materials, processes, monitoring results); marketing; and education/training.

    One suggestion for IDM development was to introduce a measurable progression into the IDM; that is, quantify the IDM by attaching numbers to the framework bubbles, which would allow people to assign different scores in worksheets and track priorities over time. Examples of ideas for written materials include: a trouble shooting feature (e.g. how an IDM underpinnings focus can help if a group has trouble finalizing its goals for next year); an "at a glance" version of the IDM; an underpinnings document; more journal articles; an IDM textbook; a map of the IDM in relation to different models/tools/approaches, noting complementary areas and relative strengths and challenges.

    The discussion on marketing the IDM emphasised the need for a strong simple message about the benefits of the IDM, i.e. "How can the IDM help you?" One participant identified four key words to promote the IDM: collaboration; innovation; accountability; sustainability. There was general agreement that emphasizing the IDM's underpinnings feature, a major gap in other tools, is important in promoting the IDM.

    One participant talked about "branding" and the need for recognition of, and a positive association with, the IDM. Possibilities for a new name were discussed, and the importance of credible groups adopting or endorsing the IDM was mentioned.

    Suggestions of education/training opportunities include: IDM workshops for skills enhancement, change management, etc.; on-line learning module; and introduction of IDM into more health promotion/public health academic programs.

    IDM action plan

    The action plan at the end of the day listed activities such as: explore funding possibilities to further develop IDM processes and materials and provide IDM education and training; write underpinnings piece; map IDM in relation to other models, theories, tools and approaches; develop a trouble shooting guide; and investigate opportunities with other organizations.

    Think tank conclusions

    Think tank conclusions were that clarifications, updates, and re-packaging of resources would benefit IDM dissemination. Successful IDM dissemination depends on those updates as well as purposeful prioritizing of those who have decision-making influence. The IDM fills a gap in current thinking, approaches, and trends in a variety of places in provincial and national health promotion and public health scenes. The IDM has the capacity to augment or complement other current frameworks, approaches and models.

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    July-August 2008 Reflection by Ana Lúcia Ferreira de Mello: Using the IDM for Action-Research

    Ana Lúcia Ferreira de Mello lives in Florianópolis, Santa Catarina, in southern Brazil. She is a collaborative professor at the Federal University of Santa Catarina, School of Dentistry, teaching undergraduate students Public Health Dentistry. She also works as a private clinical dentist, and is a volunteer dentist for three long-term care institutions for elderly people. She has a degree in dentistry (1998), a Masters Degree in Public Health Dentistry (2001), and a PhD in Nursing (2005). In addition she is a Geriatric Dentistry specialist (2003). In 2006 she started a PhD in Public Health Dentistry.

    I am really excited about developing my thesis project research utilizing the IDM as a methodological approach for action-research. It will take place in Antonio Carlos, a small city near Florianópolis, which has a high percentage of elderly people, a high life expectancy, and a high human development index. The general aim of the research is to develop best practices of oral health care for the elderly population of Antonio Carlos.

    I am just starting to apply the best practice approach in my academic work. However, I am really excited about the possibility of finding some interesting results, of giving people (and myself) a chance to think about their current practices, and time to reformulate those practices that they believe are necessary to change so they are better in future.

    I wonder if the application of the IDM framework to action-research will be capable of making the difference in Antonio Carlos city: reorganizing oral health services to promote health and better lives for the elderly people of this community. As a structured framework, the IDM best practices approach joins contemporary concepts of planning, empowerment, popular participation, compromising, accountability, knowledge management, quality management, epidemiology, comprehensive attention (includes promotion, prevention, treatment, and rehabilitation), equity, complexity, governance, social justice, and so on. Moreover, I always believe that health promotion is an important foundation/referential, maybe the best, for actions in public health in a country like Brazil, with a lot of socio-economic disparities.

    I think that oral health care of the elderly is a difficult issue to treat. All the rigid concepts of evidence-based dentistry, in spite of having a lot of important contributions, cannot be directly applied to this population. Some adaptation needs to be done. From a public health point of view, this segment of the population in Brazil constitutes a heterogeneous group, in which we find gradations of health conditions, dependence levels, family arrangements, socio-economic conditions, access to health services, etc. And to understand this scenario and provide qualitatively better oral health services, considering the legal framework of the Brazilian Nation Health System, is really challenging.

    Because of this, I believe that the oral health care of the elderly, as a complex phenomenon, will have in the best practices approach an orientation and a theoretical-practical referential useful to researchers and health professionals.

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    September 2008 Reflection by Valerie Overend: Promoting Change for Women Working in Trades

    Valerie Overend is Executive Director of SaskWITT (Women in Trades and Technology). She is also a part-time WITT Facilitator for SIAST (Saskatchewan Institute for Applied Science and Technology), and a free lance consultant.

    I give women the technical tools for working in trades; they also need a lot of social tools to work in a construction setting. But that's not all it takes to get them in, there's a barrier - there has to be give on the other side. When I meet with employers they say "just teach them to be pig headed and stubborn and we'll take them," they want the women to change. The women say "we'll change, just tell us what to do." But I know it's not enough to teach them to swear and wear red plaid shirts, although I do teach them that. Most of them are tenacious and it still doesn't work - the workplaces are not good for women. Most women are not saying the workplaces need to change, they say "we're happy to adapt." It's women like me who have been around for a long time who are saying "the workplace has to change." And, to be fair, we are starting to see these changes as employers begin to realize women's potential.

    The best payoff for me comes with knowing that the people I've worked with now have tools they can take home and use, that they report back that they used the tools, that they changed. Everyone can change if they see a reason to change. Sometimes all that's needed is challenging someone to change because what they're doing isn't working -"try this way." There's always a logic - you can give me all the arguments you want about why women can't do this and I'll say, "what about the women who do?" Or, they'll say "women hate construction" and I'll say "no they don't, I love it! You're wrong, you need to change your assumptions." Sometimes I hear, "I hired a woman once and she didn't show up one day so I'm never hiring another one" - I say "listen to what you just said, you expect all women to be perfect and men don't have to be? Men always show up?"

    I'm not saying employers will go out and hire a woman tomorrow, it's not that simple, but I have had people say "Okay, I'll hire the next woman who comes in the door and try her out for two weeks." I give them the tools to be able to change their hiring practises simply by adjusting their attitudes.

    The skills I teach women are life changing. Say I teach someone to fix a leaky tap which has been dripping for six months and her husband keeps saying he is going to do it but he's really busy and he'll need a whole weekend and need to get all sorts of supplies. This woman goes home, fixes the leak and comes back and tells me, "I did it even though my husband told me not to because the water would be all over the house - I did it anyway." It's not just about fixing the tap - it increases her self esteem, it increases her ability to take her life into her own hands and guide her into the future. It's amazing that fixing one leaky tap can do that because it's not about the tap, it's about taking the decision to do it herself. Most women who come to me are ready for that - they come to me, I don't go to them. So I think that I can claim that one action can change their life. I don't think that's a naïve claim. Logically you think it should take more than that - but they've already done the field work and they're ready, they're on the path. It's so rewarding. For me it's about the personal capacity building.

    This profile is based on an interview with website editor Barbara Kahan.

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    October 2008 Reflection by Caroline Wai: Reflecting on Best Practices

    Caroline Wai is a health promotion consultant with Toronto Public Health.

    defining best practices

    How to define best practices is a loaded question. There's a whole dialogue around whether it should be "best" or "better" practices. When you consider the evidence, the setting, the particular population, the initiative - will we ever be able to say what's a best practice, for who, and when? I'm still struggling with that. A few years ago people would have talked about best practices or an evidence based approach, but now there's a questioning going on, what do you mean by that.

    The IDM has a nice framing of actions and processes, it does a good job of identifying the elements that a best practices approach should include. It's very difficult to say in health promotion "that's a best practice." It's more about the approach than having a list. I like the IDM's emphasis on being explicit, with "what do you mean by that" as part of the approach.

    impact of using best practices approach

    Using a best practices approach can't help but change the way you think as you reflect, particularly on the IDM pieces. Some of the underpinnings that the IDM talks about are subtle, they're not at the front of our thinking until we become aware of them through using a best practices approach like the IDM. Otherwise they are easily missed and might not get included in our planning. It is easier for people who see themselves in the underpinnings to justify why they want to do activities. They can see their work there, where they belong. This kind of process brings an organization together and makes it more consistent, at least on paper.

    My particular shift around best practices has been a recognition that it's not enough to say we want to do best practices. We have to document it, have it on paper so we can refer back to it. At some point the group has to hash out what its definitions are, core values, how to approach something. These have to be documented - you don't always have the same people working on a long term project, and, in addition, how can we talk about best practices unless we can reflect on what's happened in the past?

    three suggestions for implementing a best practices approach

    Always question. When you think you're culturally competent or have covered everything off, be humble. A best practices approach is about questioning ourselves. When we start thinking we're the experts is when we run the risk of not following a best practices approach. What have we missed? How has the population changed and what does that mean for how we approach the population? How has technology and how we receive information changed - if we want to do a communication campaign, is social marketing the best method? What about the hierarchy of evidence - who set up that hierarchy, does it fit with a health promotion approach, how does it work with complex issues like delivering health promotion programs in a high needs population? We need to question that traditional evidence-based approach, and ask what is the best way get the evidence that shows that an initiative is or isn't the best for the population we are working with.

    Keep fundamentals in mind. It is easy to lose sight of core principles in health promotion unless they're in the foreground when we're planning programs. If we list the elements of our best practices approach and then look at what we did, it often doesn't match - but if we plan from the beginning with a values base our practice would better reflect our organizational vision, values and beliefs - regardless of external pressures such as funding criteria. A best practices approach also focuses on remembering who our population is, who the programs are for.

    Use a best practices approach. I really think people should read through a lot of the material on the IDM Best Practices website. The IDM helps you question and helps ground you in your core values and principles.

    This reflection is based on an interview with website editor Barbara Kahan.

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    November 2008 Reflection by Chris Beingessner: Project Based Learning in an Inner City School

    Chris Beingessner is a teacher at Scott Collegiate, an inner city high school in Regina, Canada.

    The dinner theatre project

    Last year we worked with 60 of our students to develop and present a dinner theatre. I got a grant for a local actor and dramaturge to work with the kids. The kids wrote the collective based on their life experiences. In the play, newscasters read found poems taken from news stories about North Central, their neighbourhood. The poems were juxtaposed with previously untold narratives that gave a different picture from the one the media shows. Three boys wrote a hip hop song about North Central, highlighting some positives, and the need to be strong to survive. The show was inspired by the MacLean's article, but went beyond, into an examination of the local media as well. [MacLean's, a national magazine, labelled North Central as Canada's worst neighbourhood in 2007]. But it was also a critique of the media, which sensationalizes things that happen, and dehumanizes the residents of North Central with its news coverage.

    The students specialized in either food preparation or drama. The dinner theatre was linked to several classes. In entrepreneurship class they organized the marketing of the show. In the computer class (information processing) they designed graphics, a website, and mail merged the fundraising letters. English was the core class that tied all the other ones together. There were also drama and commercial cooking classes. In the end, the whole evening was wonderful. The kids were empowered and they saw that their stories (and in the case of the marketers, cooks, and servers, their work) was valued.

    We provided the students with food throughout the day. If they weren't there at 9:00 we phoned them, and if they were late we helped them catch up before sending them to their class. Because kids need structure, they need to know what to expect - especially when they come from backgrounds like our students - we gave them a list of 10 things they need to do to pass.

    project results

    Participating in the dinner theatre project gave kids a sense of belonging and purpose. They came to school because they were doing something that they perceived was important and that other people were counting on. Teachers knew their names and there was built-in time to interact - visit and catch up. That sense of belonging is very important; it builds a sense of pride and self respect.

    Very concretely, our kids with addiction problems see that if they're hung over or drunk it's hard to get anything done. If it doesn't matter to anyone else, be it a teacher or classmate, there's no negative to getting drunk or being hung over. However, the kids were engaged with the dinner theatre project; they took care of themselves so they could be there the next day. When I talked with students after, they said, "We were doing something, there was a reason for me to get up in the morning. If we didn't, we'd be letting someone down."

    Student attendance is an indicator. Usually at Scott the beginning of the year starts at 70% attendance and drops gradually down to as low as 20% by the end of a quarter (half of a semester.) With our project, attendance dropped from 70% to 50% and leveled there. There are socio-economic factors that get in the way of attendance that we, as teachers, cannot affect.

    Another benefit was that the project was engaging for staff as well as students. This is something not often quantified or qualified. Staff felt valued, supported, part of a team - just like the students.

    best practices for project based learning with students in inner city schools

    • In the 1920s John Dewey was saying that education had to relate to real life and 90 years later it still doesn't. It may not matter in more affluent communities where supportive parents are the norm - however, in a neighbourhood plagued by poverty and the effects of residential schools, this support isn't always there. We have to do something to engage the students. If we want to engage youth, we have to make it real.
    • Student ownership is key - the topic has to be something they want to learn about, with some inquiry involved.
    • The project should be empowering, build social teams, and provide structure so the students know what to expect.
    • The project should result in some kind of product that they're always working towards, otherwise it becomes trivial. It's also important to provide a chance to publicly display or showcase the product.
    • We first need to meet basic needs, for example by providing food. If they're hungry how can they learn? We need to acknowledge emotional and physical needs. We need to meet students where they're at, for example, by making sure they have the prerequisites for something we're trying to teach them.
    • Teachers must set aside the idea that they're the experts, and act as facilitators as opposed to lecturers. They have to be willing to throw everything out - realize that "a lot of things that we've been doing don't work." That takes a lot of courage.
    • You need to have cohesive staff who work well together on the same project - that's maybe one of the hardest things to accomplish. But you need a strong team, with all of the teachers committed to the project.
    • Teachers need to find something they're passionate about. If you're not passionate, be prepared for it to flop.

    This reflection is based on an interview with website editor Barbara Kahan.

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    December 2008-January 2009 Reflection by Gary Roberts: Practitioner insights and the knowledge base

    Gary Roberts is a consultant in Ottawa, Canada.

    For the most part the clients who hire me to identify best practices recommendations don't include the practitioner perspective in the process; it may be because there is no commonly accepted methodology for doing that. However, involving practitioners would be a more solid basis to declare best practices from.

    Guidelines for obtaining practitioner insight in a valid and reliable way would be of real interest to me - to ensure that the best of practitioner reflection is brought into the knowledge base in a structured methodical way - in a way that is critical and rigorous. I know different routes to doing that but how do we know which way is best? Is anything that any practitioner says to be accorded the status of insightful? If not - on what basis do we accord something the label of insightful?

    What I would wish for is a methodology that provides some trustworthiness to it - where the user of the methodology could be confident that the findings and outcomes could be trusted, and which have some level of credibility attached to them.

    What would that methodology look like? It would include at least some reflection and self-examination regarding the values and attitudes that practitioners bring to their work or their advice, so that the findings could be presented in reference to that. Perhaps it would also include guidelines or measures of "insightful practitioners" to increase likelihood of drawing from the best available thinkers in a field.

    I'm fairly regularly involved in drawing on practice insights and I am conscious of the amorphous nature of this work, which requires a fair amount of judgement on my part. I would benefit from some guidance on how to draw on practice insights in the best way possible.

    This reflection is based on an interview with website editor Barbara Kahan.

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    February 2009 Reflection by Z. Sonia Worotynec: Developmentally Appropriate Practices

    Z. Sonia Worotynec is the www.immigrantchildren.ca blogger. She lives in Kitchener, Canada.

    The way I understand best practices comes out of my early childhood background. Developmentally Appropriate Practices or DAP is an important principle that we teach emerging practitioners. I think DAP is best practices.

    The notion behind DAP is that when you're working with a child you have to consider all the different aspects of that child. You have to look at their age. Is the activity or lesson or book age appropriate? Is the child old enough to grasp what you're asking them to do? The second component is whether the activity or lesson or book is "developmentally appropriate." This is not about age but that particular child's developmental level. An Early Childhood Educator may set up an activity for a group of three year olds, believing the activity is age appropriate, but within that group of three year olds, there may be one child whose developmental level is below her peers and another child whose developmental level exceeds that of her peers. You need to know the particular children you are working with, not just what a three year old can or can't do, according to whatever textbook. You need to work with children where they're "at" and it's your job to learn about each child.

    The third piece - and an increasingly important piece - is "culturally appropriate." Early childhood practitioners need to see the child in the context of that child's life - their family, community, background. Is the activity something the child will be familiar with? Frightened by? Curious about? What about the parents? What reaction would they give? Is the planned activity something the family can get behind or is it something too "Western" and unfamiliar and, therefore, maybe you need to check in with the parents.

    You have to incorporate all three of those components in your work with that child. I see a strong parallel between DAP and best practices. And, by the way, a best practice in working with adults too!

    In general best practices involve being flexible, responsive, creative and respectful of where people are at, of where they want to go, and of how they want to get there. As people who work with family and children we will have ideas of where we want them to go but have to be respectful of their wishes and beliefs. We have to be open to learning about cultures other than our own, about issues important to cultures other than our own, about what's going on in the world.

    This reflection is based on an interview with website editor Barbara Kahan.

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    March 2009 Reflection by Dayna Albert: Understanding and Applying Best Practices


    Dayna Albert is Manager of the Ontario Public Health Association's Towards Evidence-Informed Practice (TEIP) Project. She lives in Toronto, Canada.

    I find the term "best practices" somewhat problematic - it gives the impression that one simply finds, adapts and implements somebody else's program. TEIP began as a project to promote the dissemination and uptake of best practices. As we learned and evolved, we understood that finding and adopting best practices was not the magic bullet. We changed our name to Towards Evidence-Informed Practice to reflect a continuous improvement approach to the development of effective health promotion initiatives.

    TEIP's preferred definition of best practices is:

    The best available evidence for a specific group, under specified circumstances, to achieve an identified aim. (Dr. Paul MacDonald, U Waterloo)

    This definition emphasizes the relative and transitory nature of a best practice. What is best in one context, at one point in time may not be best outside of that context.

    We can gain ideas and insights from a "best practice" but there are many limitations which should be acknowledged. For example, many effective local programs exist but they will never be recognized as a "best practice" due to the nature of the evaluation resources that are required to achieve that designation. We need mechanisms to share the learnings from our own communities, which may be more relevant than many "best practices."

    Best practice information tends to focus on program evaluation information and to a lesser extent, program content - the WHAT of program planning. What is currently missing from the mainstream conversation about effective health promotion is the concept of the "best processes" or the HOW of effective health promotion. The TEIP Program Assessment Tools (teip.hhrc.net) consist of 19 criteria derived from best practices research which focus on the HOW - how to strengthen community-based program processes.

    Finally, people looking for best practices tend to consider only academic literature evidence soruces. TEIP recommends consulting a range of evidence to inform health promotion programming, of which "best practices" and academic literature are but one source. In the public health context, there are many limitations to purely academic evidence - it needs to be supplemented with local needs assessments, evidence from recognized sources of grey literature and practice-based experience.

    I believe it is important to be grounded in health promotion values, a strength of the IDM Best Practices process. For example, the newly released Ontario Public Health Standards require health promoters to address the needs of priority populations rather than provide equal service to all. This requires a change in values as well as a change in approach. It moves public health back to its roots. Where are we most needed and how do we work with priority populations? Our values will influence how we do this. We haven't yet integrated values into the TEIP Tools in a consistent way. My goal is to learn from the IDM approach and to incorporate a values clarification process as the 20th TEIP Program Assessment criterion.

    Let me share a small story of how values interact with health promotion. In one TEIP community staff were sincerely working to address food skills in low income families. They came to recognize that going into this with preconceived value judgments such as "we are the experts, here to give you knowledge" needed to be challenged. Eventually, they learned from the evidence that they could achieve better results through working with their intended audience as equal partners, by offering peer training and peer mentoring opportunities. If right at the beginning they'd been guided to reflect on their value judgments they may have recognized the need to modify their approach. Identifying and challenging one's values and assumptions are critical to working with priority populations.

    At TEIP we say we have to walk the walk, and we do. We're into welcoming feedback and evaluating everything we do. The first thing I say to workshop participants is: Your input is very valuable to us; feel free to criticize us. I relate this back to my karate training when I was younger - if you don't get criticism you can't grow. We actively seek feedback and involve communities in the design of our tools. We've always had community representation on our advisory committee. They're involved in planning evaluations. I've become an even stronger proponent of considering the needs of the community. It's all about community needs, community fit, and whether what you're doing is effective. A lot of it is reflection - looking to external and internal sources of evidence.

    Programs should never be static, staying the same for the next 20 years. Society changes, evidence changes, funding changes, needs change. A program should be a work in progress, always striving for continuous improvement, using whatever tools can help you. This is my vision of a best practices approach.

    This reflection is based on an interview with website editor Barbara Kahan.

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    April 2009 Reflection by Irwin Kahan: Guiding Principles for Successful Mental Health Promotion


    Irwin Kahan is a volunteer lecturer at the Toronto retirement home where he is a resident. He worked in a variety of positions during his career, including as a member of a team researching LSD, member of the team which initiated research on the use of high doses of nutritional supplements to treat schizophrenia, Executive Director of the Saskatchewan Branch of the Canadian Mental Health Association, and the founding Executive Director of the Canadian Schizophrenia Foundation (CSF). He is the father of website editor Barbara Kahan.

    • My main guiding principle is very simple - if you help somebody, you're also helping yourself. The more you do for other people the more you do for yourself. I realize that many people feel lonely, left out of things - if I can get them involved in something, when I have a successful session, I feel pretty good.
    • You have to look at health as a unit, take everything into consideration - mental, physical, social - all of these tie in together. You can't separate them. The importance of the holistic approach, which includes mental health, is important, and has been neglected too long.
    • People have to see the other person's point of view.
    • Having a sense of belonging fills an emotional need.
    • People need to feel they are worthy, that they have been successful in some areas. I tell people, "Be thankful for what you've done for society - don't neglect the idea that you have participated and contributed a great deal." This thought makes people feel happy.
    • A positive attitude is important to mental health. When people think to themselves, "I should have done this" or "if only I'd done that," they're at war with themselves; they say "I'm not good." If you have such an attitude you're going to be unhappy, it will affect your general health.
    • The blaming idea is a very bad one. When I worked with the CSF I'd start my speeches telling about the psychiatrist who said schizophrenia is always the mother's fault. I'd then explain that schizophrenia is a disease and you can't attribute blame for it to anyone. It's no fault, like car insurance. It was amazing to go out and talk to people who had a relative who was schizophrenic or depressed. They were very happy to see someone taking a different approach, saying it wasn't the family's fault.
    • One of my principle ways of thinking is that you shouldn't denigrate the schizophrenic, that they're terrible people or dangerous.
    • People will support you if you have an idea of a better way. The current treatments of tranquillizers and psychotherapy don't deal adequately with the problem. That's what we tried to do, find a better way - find a successful treatment.
    • We need to work with and support people who have imagination, people who are dedicated. If we do that we'll have a much better society.
    • Research is very important. To find the causes, the cures. Suppose they spent as much on mental health issues as they do on cancer - they would come up with more answers.
    • Curiosity is important. I sometimes read palms - I have great fun doing that. I have a square palm - I'm curious about everything - how does this work, why are they doing that that way? Curiosity keeps you alert which is good for mental health. Research shows the active minded people are less likely to develop Alzheimer's.
    • Focus on the message. One of the highlights in my career was meeting a number of times with Tommy Douglas when he was Premier of Saskatchewan. One time Douglas was to speak ahead of me at the opening of a rehabilitation centre in his constituency riding. I said to him, "I'm nervous speaking right after someone of your stature has spoken." He said, "Don't think about you, think about your message."
    • Practise social action. The first thing is to identify the problem, then get people interested and working with you. Then, work with the government, apply pressure.
      I don't mind saying I applied a lot of pressure on government during my career. For example we wanted a cottage style psychiatric hospital in Yorkton and the government refused. I went to meetings in different towns in the area with paper and envelopes and stamps and said, "Write the Premier [a different premier from T.C. Douglas]." The Premier said to some of us later, "I answered the first ten letters personally, the next twenty-five my secretary answered, and after that we didn't bother." Within two weeks they'd started building the hospital. However, the hospital would have been more successful if it had followed a holistic approach.
      We also fought hard to have schizophrenia viewed as an illness, not a crime - rather than being sent to jail, schizophrenics should go to healing institutions.
      When the government decided that they wanted to close the big hospitals down they kicked everyone out but they got some terrible foster homes where people were maltreated and made sicker. We tried to do something about that - it was a real mess. We hammered at the government for that.
      One of my fellow residents said during a discussion, "Don't bother with the government - let them do their job and leave us alone. Don't challenge them to do things - because it always costs money." I said, "The MPs [Members of Parliament] are our servants and we have to check to see they're doing a good thing. If we leave them to their devices we're going to have a troubled government. We have to look after things and make sure that they don't stray from the straight and narrow."

    This reflection is based on an interview with website editor Barbara Kahan.

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    May 2009 Reflection by Nikki Clelland: Working Interculturally


    Nikki Clelland is a National Health And Medical Research Council (NHMRC) PhD Scholar at the Menzies School of Health Research. She lives and works in Darwin, capital of the Northern Territory, Australia.

    Before coming to the Northern Territory, I hadn't worked extensively with Aboriginal people. Up here Aboriginal and Torres Strait Islander peoples make up about one third of the population - so my core business has been Aboriginal health. Over this time, I've made such close friends with Aboriginal people and my work has now become more of a personal journey - I constantly reflect on insuring that everyone benefits from this research, not just me.

    I consider what my work adds to the professional development of others. I'm pursuing a PhD, getting more educated, maybe more job opportunities - so could I be contributing to greater disparities? I have two close friends who I bounce my ideas off of - am I doing things the right way? My processes, I hope, are transparent, and building the capacity of the people I'm working with. I'm learning so much from them, I hope they learn something from me.

    For me there's two things for doing best practices - the first is to listen, the other is to challenge your assumptions. You come with a lot of preconceived ideas and knowledge based on your own experience. Other people also have their own experience and way of doing things so the only way you can do best practices is to listen and challenge your own assumptions, rather than following the whole one size fits all approach. If you listen to people you have a solid starting point. Groups bring their own concepts of best practices and evidence - your way may not work for other people. That's what I've learned.

    In our work we've used IDM concepts like values, ethics, principles - they're what underpins health promotion generally but especially Aboriginal health promotion.

    My involvement in a best practices approach in Indigenous health has enlightened my understanding of health promotion. I am very excited about the potential of quality improvement methods in health promotion. Over time I hope our research can contribute to the development of a CQI model in health promotion that health care providers can utilise to improve their practice and thereby improve the wellbeing of Aboriginal and Torres Strait Islander peoples.

    This reflection is based on an interview with website editor Barbara Kahan.

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    Click here to read the reflection that contains the above diagram, and the comment that Health and the environment are like two pearls threaded on a fine cord called quality of life.

    June 2009 Five Years of Reflections


    Welcome to the IDM Best Practices Website Magical Mystery Tour! Why Magical? Because of all the special people whose profiles and reflections are on the website - people who possess the magical qualities of passion, creativity and reflectiveness in such quantities that they cause amazing things to happen - invaluable programs, frameworks, networks... The resources listed on the website are also pretty magical, in that they have the ability to help us change things for the better. Why Mystery? Because of all the mysterious places these magical people and resources take us to - wonderful ideas and insights that cause us to reflect on things and wonder about things that may never have occurred to us otherwise. [See also archives for profiles, jottings and resources.]


    Below are examples of quotes from five years of reflections. These quotes illustrate the diversity and the liveliness of thought of the contributors. Click on the quote to go to the full reflection.

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    July/August 2009 Reflection by Meldon Kahan: Using an Integrated Approach to Address Addictions


    Meldon Kahan, a physician, is Medical Director of the Addictions Medicine Service, which is part of the Department of Family Medicine, St. Joseph's Hospital, in Toronto, Canada.

    Currently there is little in place for secondary prevention to help doctors identify addictions. Even though we've seen the problem get worse over the years, very little has been put in place to help doctors or the general public deal with opiates. At the same time, there is nothing for cannabis users other than scattered treatment options. There are very few youth-oriented treatments. There are few public health messages regarding the dangers of cannabis.

    A number of things have to happen to address opiate addictions. There has to be pressure on pharmaceutical companies to have more accurate advertising. There has to be a change in physician prescribing habits through use of guidelines. There has to be better availability of treatment, including the use of methadone and buprenorphine - which is new and safer than methadone.

    For cannabis - there has to be better education of the public around its dangers, especially for adolescents where it can lead to psychosis and has very serious social implications in terms of school and work performance and mood. We need to insure that people using cannabis are not put in jail, which is counterproductive, but that they do have access to treatment.

    Health professionals have to ask everybody about substance use, don't make assumptions - and try to do something if possible. Interventions do work, no question. Family members have to realize that they have enormous influence. If someone has a drug problem, they're much more likely to quit from concern by a family member than from concern by their doctor.

    In my practice I explain health consequences, I use motivational interviewing techniques to gently let them know of consequences and strategies for cutting down. I help them build on supports, for example their family and friends, and behaviour strategies for staying away from it. I involve them in formal treatment if they're willing to go to addictions treatment.

    Best practices in the addictions area would mean better integration of prevention and treatment. A large part of the public seek treatment for one thing or another through their primary care provider, or they go to emergency centres - an opportunity for prevention to take place. Rather than having public health campaigns divorced from health care, we need a better integration of health messages between treatment and prevention systems. If the two systems remain separate we're going to miss a lot of opportunities. One major challenge for prevention protocols or initiatives is to make sure they're tied in with the health care system.

    Treatment and correcting the determinants of health are both required. You can't expect people to get better on treatment without good housing, and you can't expect good housing alone to work without treatment. You need an integrated approach.

    This reflection is based on an interview with website editor Barbara Kahan.

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    September 2009 Reflection by Ralph DiClemente: Ethics, Back to Basics, and Other Topics


    Ralph DiClemente is a Professor at the Centre for AIDS Research, Rollins School of Public Health at Emory University, in Atlanta, Georgia, US.

    Ethics

    I'm teaching a class for doctoral students on grant writing and research ethics. From my standpoint, coming up with less than an adequate design is an ethical issue, just like coming up with an analysis that's not adequately powered is an ethical issue. You run subjects through a study with very little hope of finding an outcome because there aren't enough subjects - why put them through that? Poor design and poor power go together. I see it a lot.

    Everyone thinks power is based on the number of people recruited to study, at the baseline; really it's on follow up numbers. How many people do you lose over time - you may start with 500 but end up with only 400. It's the number of people left in the study, not the people who entered it. That's a very simple thing but you don't see it in books.

    Back to basics

    It's very important to go back to basics; if I have anything to say, it's go back to basics. In the field I see more advanced use of statistical techniques, which is good; the problem becomes use of high powered statistical techniques for low powered situations, trying to compensate for methodological weaknesses by relying on high powered statistical methods. That's a shortcoming; people should focus on high quality rigorous methodology. I see that in students, who always want the most au courant stats package, with the most sophisticated techniques. But it's best to go back to basics, to what's the best and most appropriate research design rather than worrying about the statistical approach which will compensate for methodological weaknesses. I can't tell you how many people have done weird statistical things so I'm not even sure what they're reporting on, it's some transformed version of the data, it's difficult to interpret. It's more exciting to run numbers; the boring but elemental piece is a robust methodology, rather than using statistics as a crutch to compensate for poor design.

    An appropriate use of design is fundamental and shouldn't be a matter of convenience. It may be more convenient to randomize shelters rather than the individuals in a study of homeless kids, but the kids move from shelter to shelter and there are different issues such as ethnicity which is related to risk - it would be much better to randomize the kids. It may be more inconvenient to do best practices but you get more understandable data. If you deviate from what seems like the most appropriate design you need to document why you're deviating.

    People are much more interested in content as opposed to methods - in what you find as opposed to how to do it. But people need to go back and focus on fundamentals rather than skipping them.

    Qualitative research

    The strength of qualitative research is often sold short. People don't fully understand how important it is or how to apply it. I see a lot of mixed method designs - the qualitative piece is usually weak. People like qualitative methods because they're rich, you get to ask people questions and get involved, but often they're done in a superficial way. The most common conduct is to conduct two focus groups, analyze them, draw some inferences - people think "if I just touch base with 8 or 10 or 12 people and see what they said I'm on to something." That's not enough people, and the analysis needs to look deeper. If you just look at it, eyeball it, you miss a lot of potential common elements that emerge if you run analytic techniques using packages for qualitative analysis such as NUD*IST. The information is often not collected in the right way, involves a limited number of people, and the sweeping generalizations are made which aren't warranted by the limited analysis or data.

    Adaptation, translation and dissemination

    The whole issue of adaptation, translation and dissemination is going to become a key issue not only in North America but in places like Africa where chronic disease has reared its ugly head, impacting on morbidity and mortality, in addition to infectious diseases and malnutrition. We could export interventions that were developed in North America - but are they appropriate for those cultures, which are very heterogeneous. There may not be the time or resources to develop intrinsic programs from within the country; it's quicker to look externally at programs that could be adapted. Unfortunately, we don't do a good job at looking cross-culturally, not even in our own society. Unlike medicine, where penicillin will work across age, sex and culture, interventions targeted for people 50 years old aren't workable for young people, interventions for young girls are not optimal for men, programs developed for black people may not work as well for white people. We have to pay attention to social, demographic and cultural differences.

    There are restrictions for every study you read, the intervention can only be used for this population, not others. We have to address that issue if we want to take programs that are evidence based, where the data demonstrates their effectiveness, and move them from the population where they were developed into another population. There are no good systematic approaches for taking interventions and adapting and translating them for other populations and then disseminating them efficiently so they reach the broadest audience. We are starting to do that, but we need to do a whole lot more, if want to impact health on a population level rather than just small groups here and there.

    This reflection is based on an interview with website editor Barbara Kahan.

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    October 2009 Reflection by Bruce Rice: Link between Health and Urban Design


    Bruce Rice is a Senior Policy and Research Analyst with the Comprehensive Planning Branch, Planning and Sustainability Department, City of Regina, Canada.

    There's a lot people don't realize about how the built environment affects lives and behaviour - not just that it's nice to have parks to look at - the streetscape and parks and even the cultural element are important for mental as well as physical health, for supporting a positive state of being. Our environment gives us messages - the layout of the streets, how houses are designed, can people see each other? It gives us signals about what's important in a community. Our oldest communities, the ones with the fully mature urban forests, were designed as liveable places. Their grid system is one of the best for safety and neighbourhood cohesion. The grid system is based on a more pedestrian type of society, where people take care of each other. It's almost an ideal form in terms of the bones of a place where people would want to live.

    There are three aspects of housing as it relates to health. One is the physical aspect - what the space is like, how crowded it is, age and condition, type of heating and ventilation - all that is related to health. For children a home can be either a very good place or part of their health problem. Children in their developmental years are very sensitive to the quality of the housing they're in.

    A second aspect is the nature of amenities - how close is the housing to shopping centres, to schools. This is why gentrification happens - the house may not be worth that much but there is a lot of value associated with the fact that you can walk to work, that you're close to amenities. A house is not just a building. It includes the neighbourhood and services around it.

    The third aspect is economic. Whether you have affordable housing or not really affects you overall, how well you're doing. There's a direct correlation between income and health, and housing policy can influence poverty rates. For example the rate of seniors who are poor in Regina dropped from 39% to 14% because there was a lot of seniors' housing built in the 1970s and because of pension changes. Seniors' housing programs were as much a response to poverty and isolation as they were a response to pure housing need. Regina's low housing costs also resulted in a high rate of home ownership for seniors. In other cities a lot more seniors are living in apartments. The rent goes up but their income doesn't. We can't take it for granted, but the dramatic decline in seniors' poverty rates in this city is proof that social programs and housing programs do work. Affordable housing contributes not just to health but to the independence of people.

    This reflection is based on an interview with website editor Barbara Kahan.

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    November 2009 Reflection by Bruce Rice: Applying best practices to work


    Bruce Rice is a Senior Policy and Research Analyst with the Comprehensive Planning Branch, Planning and Sustainability Department, City of Regina, Canada.

    reflection and evaluation

    Corporately we do a lot of reflection, for example in planning sessions. And lot of the programs I'm involved in have evaluation cycles - is it working, do we need to change it? Outputs versus outcomes is a big issue - you can do as much work as you want but did you change something for the better? When doing planning, it's important to build in evaluation and follow up - right from the beginning and all the way through.

    working with community

    One of the things I try to do is maintain relationships with the communities I'm working with - test out their ideas, and bring new things to them.

    You do have to be on the watch when asking community members what they think - is what they say reality based? For example, lots of time people think nothing is going on in their community when actually a lot is. A classic example is that most health information is disease oriented, there's almost no information the impact of the good prevention programs that exist. It's the same with housing - there's not enough recognition of the good things that are happening in communities. We have to really recognize what those are.

    You also have to watch for attitudes that people internalize. For example, seniors assume that changes in their activity level or health are due to aging and so a lot of treatable health conditions go undiagnosed. One of the clearest examples is fear of victimization - there's a huge difference between people's fears and the victimization actual rates. You always have to consider if you're dealing with perception or an actual event.

    looking for gaps and opportunities

    I strongly believe in the importance of looking at data and information that other people don't see. I look for gaps, what's missing in the way a program is being designed, or an opportunity that is being overlooked. When you get down to the fine grain in neighbourhoods you can see where the deteriorated conditions are - and in some neighbourhoods you can also see opportunities, such as a really good distribution of parks which you can push further. I look for what other people aren't seeing. People tend to talk about what they're familiar with, not about things they haven't seen before. I also think about the people who can't speak for themselves and ask whether the data or my own experience is trying to tell me about an issue that isn't "on the table."

    quantitative and qualitative

    It is helpful sometimes to quantify something; that tells you the relative importance of one issue versus another, where is the need greatest, how many people are we talking about. However I am less quantitative than I used to be. More and more I trust the community - community is almost always ahead of government in seeing needs.

    engagement

    I try to engage more people in programs - it's a best practice to share it around, to make an active effort to engage people in the work. If people are involved in a project they're going to buy into it, and when have to sell a best practice, a pilot, you've got a bit of a support base for it. In general, making linkages with other people and departments is important.

    qualities of people you work with

    If you're working with consultants on a project, it's really important to choose someone who's going to deliver something that's beyond the basic requirements, someone who will move things forward. Also, you want to be working with people who are creative and have the passion to push things through when the going gets tough. Part of this is building knowledge about the project so that people feel it's worthwhile and understand it enough to take it through all the hurdles you're going to encounter along the way.

    communication

    Communication around best practices is really important - like doing presentations. Part of our responsibility is to report to the public; we need to be aware of our educational role.

    thinking broadly

    If you have a suggestion, think big - what would happen if we expanded the scope of this? If you're thinking of a neighbourhood, what would happen if the program was provided across town? The whole point of best practices is that it's not a one-off. It's something people can use as a model, either replicating it or incorporating it into already existing programs or infrastructure.

    This reflection is based on an interview with website editor Barbara Kahan.

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    December 2009 - January 2010 Reflection by Kerry Robinson: Best Practices Snippets


    Kerry Robinson is Manager, Knowledge Development and Exchange, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada. She lives in Ottawa.

    documentation

    In Canada, it seems we don't have a public health culture or working environment where people document and share what they're doing. Time is a major factor for everyone. Maybe public health organizations need to do more work flow analyses to realize that some of our time on admin is not really helping us with our bottom line, enhancing public health. If organizations better documented evaluations and practice learning and shared it with others we could all learn from them. If each organization only published one well documented effective (or ineffective) practice or program they have implemented - do a good evaluation and share the story and the learning - that would be a huge contribution to public health and best practices. We would have fifteen or twenty thousand more practices out there to inform our public health decisions. Right now, the Best Practices Portal is searching and searching to even find twenty or thirty Canadian best practices because practitioners are not documenting their innovative program experience and learning. And the ones that are documented are hiding in unpublished reports, often not posted on web sites. Why is it that there are registries for clinical trials and systematic reviews, but no registries for large public health program or policy evaluations.

    long-term evaluation

    Most practitioners don't have time or support to do evaluation. Most public health organizations may not have the resources or continuity to do long term evaluations. Most research and government funding in public health does not allow for long term follow-up more than five years. Yet everything we know about health promotion and chronic disease prevention shows that behaviour, environment and health/disease changes take time. We need to have more realistic expectations for what our evaluations can show us and also more commitment and investment in multiple and related interventions and documentation of their combined impact over time to inform long term public health efforts. This is not easy to do, but we know that the mostly process and widget counting evaluation exercises of all of the small projects and activities we do in public health is not likely going to give us the evidence or marker of progress that we are really searching for.

    evidence informed vs. evidence driven

    All practitioners say, "Yes, evidence should be an integral part of decisions, but other things go into decisions." We know that funding, politics, community dynamics and priorities, partnerships, values and organizational interests all come into play in public health decisions, policies and programs. This is all legitimate; practice should be evidence-informed, not evidence-driven.

    producers-users dichotomy

    That producers and users dichotomy in the world of knowledge transfer is unhelpful. We're saying that practitioners are also producing evidence, researchers are also users. The well of evidence and knowledge is going to dry up soon if we're waiting for researchers to identify all the answers on what works in public health promotion.

    Unfortunately, we haven't done a very good job of bridging connections and relationships between public health practitioners and researchers, of linking grad students to public health programs that would benefit from research and evaluation support. The Schools of Public Health and Masters of Public Health Programs will help with this, but I think public health systems and governments could do a better job of trying to create more formal relationships between universities and public and community health organizations.

    barriers

    There's no easy bridge to incorporate evidence into practice, whether it's us as a national agency, or at the provincial and regional levels. There are time barriers, political barriers, culture, and technical, but the sunny side is that in general practitioners and policy makers have an appetite for evidence and knowledge that can help them do their work.

    natural experiments

    Traditionally there has not been much support for intervention research in public health. A large majority of the research in health was clinical and laboratory, not population or public health. What is often published in public health journals is still discovery research, documenting public health problems - burden, scope, patterns, population and environment interactions. That work is important, but insufficient. We need to look at all the natural experiments happening across Canada, of innovative policies and programs and support them, document the learning and their impact, harvest and disseminate all of the best practices and processes happening out there.



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    February 2010 Reflection by Bobbi Soderstrom: Evidence and research from a midwife's perspective


    Bobbi Soderstrom is a registered midwife on leave of absence from the Midwifery Group of Ottawa, where she is a partner. She is currently Director of Insurance and Risk Management, Association of Ontario Midwives. She is also Associate Professor Emeritus, Midwifery Education Program, Ryerson University. She lives in Ottawa.

    I think often in the fields of medicine or health care, while we have the evidence, the evidence is only the evidence to date; it may be the best we have, but next year it may change because we learn something more - and what was a best practice may not be any more. We need to be humble in accepting any doctrine about what is the best in any given time period.

    In addition, can different type of practitioners interpret evidence in the same way and come up with the same best practice? Often they can't. It's similar to statistics, it's all in how you interpret the numbers. You can't help but interpret evidence with your own lens or bias.

    I feel quite strongly that as many midwives as can should get involved in doing research that looks through the lens of midwifery. It's so much easier to have a body of knowledge specific to a profession if its members are engaging in research. We are getting to the point in our profession where we have an increasing number of highly educated members who understand evidence and are engaging in research. There are midwife researchers around the world, but it behooves us to develop research in our own communities. There are geographical and historical differences and differences in the way midwives practise in various jurisdictions.

    There are several different levels from which practitioners view evidence. One is to read a journal article about a piece of research, based on the ability to analyze evidence and make an individual decision - does that make sense in practice? Another is interpretation from a group of people who look at what the evidence is saying and write it up as documents, review articles, a meta-analysis, or written clinical practice guidelines.

    There are considered to be different levels of evidence, from anecdotal to expert opinion to randomized and double blind clinical trials. There's some criticism about the very high level clinical trial approach - that those kinds of clinical trials may not take into consideration some of the more human results of those trials. It may be one thing to say, "so many babies were saved," but did it look at the effects on families? They don't consider widely enough all of the implications; not that the researchers wouldn't want to, but they can't do everything. We have to understand the limitations of research.

    There are some good tools that practitioners can use to help work through how good evidence is; but there's a lot of subjectivity in how to judge the goodness, the perfectness - how rigorous the research is, how much value to place on outcomes based on that research. It's important to use individual and professional values in judging research that's done.

    This reflection is based on an interview with website editor Barbara Kahan.



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    March 2010 Reflection by Kerry Robinson: Suggestions for following a best practices approach


    Kerry Robinson is Manager, Knowledge Development and Exchange, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada. She lives in Ottawa.

    When beginning a project, I start with understanding needs and assets, who are the stakeholders, what is happening already, what do we need, and I look for evidence and literature to inform what we should do. Unfortunately, there isn't much evidence for what a national public health agency should do, not many published evaluations of national strategies or initiatives - so I look internationally and nationally at what others are doing - benchmarking - combined with stakeholder consultations to choose the priorities that our partners are interested in working on with us.

    What I suggest for any organization interested in taking a best practices approach is to take it one step it a time. Choose one activity or aspect of practice and look for comprehensive criteria for effective practice, see how you stack up, look for the evidence. Once you find it, though, it's not a simple process of telling you what to do - it may be conflicting, or answer different questions than you are asking. Talking to a few colleagues, interpreting it together, is helpful.

    Try to identify targeted steps for change over a period of time. If something you thought was effective turns out not to be, rethink how you're doing things, digest the findings with the group, look at what you can change in the short and long term.

    Don't try to change every practice or program all at once but take a piece at a time. Be as comprehensive and rigorous as possible in that one area, then use that learning, apply it to other areas and share what you have learned with others.

    This reflection is based on an interview with website editor Barbara Kahan.



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    April 2010 Reflection by Bobbi Soderstrom: Relationship of Midwifery to Population Health


    Bobbi Soderstrom is a registered midwife on leave of absence from the Midwifery Group of Ottawa, where she is a partner. She is currently Director of Insurance and Risk Management, Association of Ontario Midwives. She is also Associate Professor Emeritus, Midwifery Education Program, Ryerson University. She lives in Ottawa.

    There's an obvious - or not so obvious - notion that relates midwifery to population health: when you have a healthy beginning, you're more likely to have a healthy continuum. Midwives champion maintaining the normal - minimizing interventions and therefore keeping things as normal as possible. Midwives do use interventions when required for health and safety; but so often women have interventions during labour and birth because of the way standards of practice have progressed without clear evidence of the benefit to mothers and babies. The fewer the interventions, the sooner the recovery from the challenges of childbirth, and the sooner the family is able to progress as a healthy unit.

    The healthy family unit should function right from the time of birth. But some interventions interfere with the ability of women to bond with their babies, others may separate mothers from the baby's father. We have some really clear examples of how some interventions interfere with population health. There's good documentation of what happened up north when women were - and still are in many areas - flown out of their communities so they could have access to a hospital rather than staying in their own home communities. As a result the children left behind are without their mother; there are all kinds of effects and concerns, not just physical but emotional, exacerbated by how we interfere with the family dynamic. On the other hand, maintaining normal as much as possible can contribute to the health of a community.

    Midwives have an uninterrupted relationship with the family from the beginning of pregnancy to six weeks postpartum. This allows a lot of opportunity to promote breastfeeding, healthy interaction with their children, that kind of thing. An advantage to the kind of service midwives are providing is extended appointment time, lack of feeling rushed, providing the opportunity for education that relates to promoting health in the family, in terms of the whole thing they're embarking on - not just pregnancy and birth, but raising children, keeping everyone healthy. Midwives offer a beginning for how a family can reflect on their health.

    In circumstances where some things are not normal, the midwife can maintain a normalcy for the other aspects of care, so the woman can still enjoy as much as possible what is part of the normal progression of being a mother.

    This reflection is based on an interview with website editor Barbara Kahan.



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    May/June 2010 Reflection by Lawrence W. Green: Paying Attention to Generalizability


    Lawrence W. Green works with the University of California at San Francisco. He is a Professor in the Department of Epidemiology and Biostatistics, School of Medicine, and Co-Leader, Society, Diversity and Disparities Program, at the Helen Diller Family Comprehensive Cancer Center.

    What's lacking in academic research is attention to external validity. [External validity pertains to how generalizable study findings are to other situations. Internal validity uses rigorous design and methods to ensure the accuracy of the study findings in attributing the effect to the cause or intervention.] The peer review editorial preference of journals for tightly controlled RCTs [randomized controlled trials] squeezed external validity out of research in favour of tighter internal validity and worked against the relevance of most research to most practitioners.

    In collaboration with Russell Glasgow, Ed Tricket, Penny Hawe and others, I've met with groups of editors of journals to get them to pay more attention to external validity. As a result several journals have changed their guidelines for authors, asking authors to give more description of the population, the circumstances.

    I'm always in search of examples from practice or programs or policies in real time, with real people in real places, to complement my interpretation of the controlled trials that dominate in the literature.

    When I was Director of the WHO Collaborating Center on Tobacco Control for the Office of Smoking and Health at CDC [US Centers for Disease Control], we produced a document called Best Practices in Comprehensive Tobacco Control. That document became one of CDC's all time best sellers - because we modelled best practices by highlighting the successes of two states. People paid more attention to that than to all the previous decades of RCTs.

    Drawing from the experience of real practice in real jurisdictions can be a powerful way of communicating what works, and more credible to other practitioners working in real jurisdictions, than scientific evidence from RCTs. I'm always looking for evidence from evaluation of real programs and policies - "natural experiments" - to complement what comes out of RCTs.

    This reflection is based on an interview with website editor Barbara Kahan.



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    July/August 2010 Reflection by Bobbi Soderstrom: Best practices from a midwife's perspective


    Bobbi Soderstrom is a registered midwife on leave of absence from the Midwifery Group of Ottawa, where she is a partner. She is currently Director of Insurance and Risk Management, Association of Ontario Midwives. She is also Associate Professor Emeritus, Midwifery Education Program, Ryerson University. She lives in Ottawa.

    Anything I do - documents I prepare, advice I give, investigating, workshops I give - has to take into account my best practices point of view: is care going to reflect the best care that can be provided at this time? This includes looking at the evidence after it's gone through my interpretation lens. Best practices are part of what midwives do, and what we as an association promote - the question is, best practices in whose eyes? Different practitioners read evidence differently, through their own lens.

    Best practices also means asking myself - am I or others in a position to say it has to be done this way and no other way? What are the options? What are the pros and cons of each choice? Is the best choice to do nothing? Who should be making the decisions, who has the decision making power? These are questions that hopefully I regularly challenge myself with.

    To follow best practices, you want to keep abreast of the latest literature and research, you want to interpret it through your and your colleagues' own view, keeping in mind the values of your profession. The midwifery lens is the importance of using a non-authoritative approach to help clients make decisions based on knowledge provided to them, and then constantly re-evaluating the decisions in the light of new evidence, new thinking, different clients and their needs.

    The thing about best practices is that you have to be very careful to recognize that they change. What's best in one set of circumstances may not be best in another. And we shouldn't lose sight of the fact that the educated experienced professional has the background, the development, the experience of their own knowledge to have insight into complicated circumstances - they have good judgement. The word judgement is important here. I don't think best practices should replace judgement, but be an adjunct. As a society we need to champion and respect judgement.

    This reflection is based on an interview with website editor Barbara Kahan.



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    September 2010 Reflection by Kara DeCorby: Using Evidence in a Best Practices Approach


    Kara DeCorby holds a clinical faculty appointment and is a Research Coordinator with the School of Nursing, McMaster University, Hamilton, Canada.

    My hope is that practice will align well with the best available evidence. A best practices approach should use an appropriate process for reviewing and synthesising information. Evidence from research is one part of a model of evidence-informed decision making that includes other sources of information - there are a number of pieces to the puzzle. For important decisions regarding the health of individuals and the health of populations it is important to consider research evidence along with other available and necessary information such as resources, the values of the population, and the local setting.

    I would encourage those who are thinking of this approach or have already started using it to think about a variety of questions. What constitutes the best evidence, what does best practices mean - what does it mean to you, what is appropriate within your practice? What can the evidence tell us - keeping in mind that identifying what doesn't work is just as important what does work. Ask those same tough questions when applying a program or service to a population as are asked when identifying the best treatment for disease.

    Using the evidence pyramid, developed by Brian Haynes, is useful. At the bottom of the pyramid are single studies and at the peak are system-level studies. You can learn most when you move away from single study findings to syntheses of a number of studies - meta-analyses or systematic reviews. I would encourage people to start at the top of the pyramid and find the most highly-synthesized evidence available for their question. In some cases, however, the topic may not lend itself to system level study, or maybe no evidence at that level is available. In that case, you will need to try synopses of single study evidence, and failing that, single studies.

    Using evidence can be a huge time saver, it makes work more efficient. We know in public health that time is a scarce resource so taking the time to use evidence effectively is a great tool.

    This reflection is based on an interview with website editor Barbara Kahan.



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    October 2010 Reflection by Debora Abood: Health Determinants of the Aboriginal Population


    Debora Abood is Social Service Programs Manager with the Victoria Native Friendship Centre in Victoria, Canada.

    The backdrop for the current health determinants in the Aboriginal population is the post-colonization legacy of residential schools and attempted genocide. There's an inextricable link between the historical context of Indigenous Peoples across Canada and the current social and health issues that people are facing.

    The historical context of the Indian Act, residential schools and the sixties scoop [when a large number of Aboriginal children were taken into government care and then adopted out to non-Aboriginal homes] have left an impermeable imprint on the issues that people are currently struggling with. There is an Indigenous belief that it will take seven generations to shift at a fundamental level the legacy that was left. Within that legacy we're dealing with all of the post-traumatic realities of people who have experienced extreme emotional, spiritual, mental, physical and/or sexual violence. That's the backdrop. Many of those issues have become inter- and multi-generational, as is true in any other place where colonization had such a profound devastating impact.

    I believe that many cultures would not have survived the impact of this experience. The fact that Aboriginal People are beginning to thrive is a statement about their tenacity and strength. The resiliency of Aboriginal People is amazing. Many members of the Aboriginal population are thriving, despite numerous barriers.

    Because we are a social service agency, however, we have more exposure to the individuals and families who are struggling. We see how the symptoms of that colonial legacy show up in the part of the community that we provide services to. For example, Aboriginal people are still disproportionately represented in institutional settings across the board. The rate of Aboriginal children in the care of the British Columbia Ministry of Children and Family is higher than it's ever been and correctional facilities are still disproportionately filled with people of Aboriginal descent. Other symptoms show up in things like what dominant culture calls mental health issues, addictions, homelessness, physical issues like type 2 diabetes, heart conditions, obesity. FASD [Fetal Alcohol Spectrum Disorder] is also a huge piece in our community.

    I reject the term "mental health issues." It pathologizes the human response to an inhumane condition, pathologizes the individual human experience - says there's something wrong with the individual. It lacks the social and political context of what attempted genocide does to people. It makes me wild - Canadians are one of the first to take a stand when heinous crimes take place anywhere on the planet, yet in Canada it's still about blaming. Although there's that level of healing that has to happen for the individual, there also has to be healing for the family, the extended family, and the community, in order to address the social and political implications of what happened. For example, addiction is a symptom of the larger societal condition, yet addiction gets identified as the issue. People drink to soothe their pain. I do not believe people are born into the world with a vision to become an addict, it's often a response to the multi- generational historical context.

    Determinants of Aboriginal health also include poverty, education and housing. In the urban community people do not have access to adequate and affordable housing. Systematic racism is also a huge determinant.

    Perhaps the largest health determinant is the loss of cultural knowledge, practices and language, a result of residential schools, which inhibited people from having a direct link to their cultural history or community of origin. Residential schools, the Indian Act, the sixties scoop, were all intended to disconnect Aboriginal people at every level from their spiritual, physical, mental and emotional being. In the urban setting people's experience is often one of dislocation, loss of identity, and lack of a sense of belonging.

    It is natural and normal for people to learn what it is they have lived, and then to live what it is they have learned. Such is the cycle of children growing up in violence. Although we are never responsible for what we were taught as children, as adults we must take responsibility for our own behaviours. The cycle of violence is a health determinant that we continue to struggle with - to find a holistic approach to healing. Indigenous cultures, like most old cultures, approach life and living from a holistic perspective that includes entire family and community systems. Unlike North American culture, which is individualistic, the fabric of these cultures is consideration for the collective.

    This reflection is based on an interview with website editor Barbara Kahan.



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    November 2010 Reflection by Debora Abood: Using Best Practices to Address Racism


    Debora Abood is Social Service Programs Manager with the Victoria Native Friendship Centre in Victoria, Canada.

    If we're working with a culture that isn't the one we grew up in, the first step in a best practices approach is to challenge our own inner world and face possible internalized racism, deconstructing that to the best of our ability. That's an ongoing process, not an event. We have to understand that we're not responsible for what we were taught or learned, and at the same time we must find the courage to navigate our own fear and guilt to face our own shadow, to create a better world. As responsible adults we have to face what we learned and were taught and see if that serves us in the way we wish to be in the world, and the way we wish the world to be.

    I am ever mindful and conscious of my own personal process of deconstructing my internal racism. What gave me permission to move forward with it was that I understood I wasn't a bad person, that I wasn't to blame for what I was taught in history class or from television.

    I feel very privileged and honoured to have been a part of working with the Aboriginal Community for so many years. I feel blessed and very grateful - there's lots for all of us to learn from those old ways. The anguish and the suffering is only what's on the top layer for those people who have been on this earth for countless generations.

    What gives me hope is when I see those strong young people. On Aboriginal television I was watching an awards show a while ago, they were asking the young children, "Who are you going to be when you grow up?" They would say, "I'm proud to be Indigenous." Pride is so important.

    I really believe that the change we seek in the outer world has to be congruent with our inner world; both worlds have to match. One of my favourite sayings is from Albert Einstein - "Problems cannot be changed from the same consciousness that created them." If you're not part of the solution then you really are part of the problem, even if you're silent. All it takes for evil to thrive is for enough good people to do nothing. Wound into that belief is my profound, passionate desire for us to caretake the planet that gives us life.

    This reflection is based on an interview with website editor Barbara Kahan.



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    December 2010 - January 2011 Reflection by Cheryl Woelk: Relationship of Peace Building to Health


    Cheryl Woelk is working towards her Masters of Education degree at the Eastern Mennonite University in Harrisonburg, Virginia, U.S., and a graduate certificate from the Centre for Justice and Peace Building.

    In a holistic view of health, peace is very important. We talk in the peace building program about healing trauma - how trauma results from violence, and affects the health of the community for generations. Violence doesn't have just an individual localized effect. Violence - not just physical violence but structural violence - such as political or economic policies which keep certain groups of people in poverty or without a voice (e.g. multinational corporations employing child labourers), or even cultural violence which means attitudes and behaviours of oppression towards another group are ingrained in a culture (for example, genocide and continued racism towards Aboriginal peoples in North America) - has a huge effect on emotional and physical health for generations. That is why it is important to stop cycles of violence and promote healing from previous wounds of violence and conflicts. In societies with high rates of violence there are higher rates of suicide, substance abuse, physical and sexual abuse and other community issues.

    If conflict is going on, people don't have access to things they need for basic health and safety. For example, I was in East Timor in 2007 when there was violence around the election. Although there was an abundance of food being produced in the area where we were, vegetables couldn't be transported from the rural areas to the city because routes were intentionally blocked due to the conflict. People had to eat mainly rice for a number of days until the violence eased up.

    I think that in society and communities poverty and major health issues have to do with larger systemic issues not related to resources or medicine but to the stability of the region. In my peace building courses people talk about how the state of health of a society is a flag for violence and conflicts - if health is poor, conflicts are likely going on which are leading to the structural violence of poverty and inadequate access to health care.

    That is why it is important to learn that there are alternative ways to respond to conflict rather than continuing those cycles. Everyone experiences conflict - it is natural. There's nothing wrong with conflict in itself, if we didn't have it we wouldn't have change. Conflict doesn't have to be violent, hurtful, harmful. How we respond can provide us with opportunity for change, growth, coming closer to people, a better community.

    If people can be less afraid of conflict, they will find it easier to start practising a healthier way of dealing with it. There is a basic tendency to run away from conflict because it is hard. I try to practise with [my partner] Scott. We grow and learn from it, we grow closer to each other, our relationship is better for it.

    Conflict is not innately bad - what's important is how the conflict is dealt with. My first response is to avoid it - but after that, I think I want to go towards it to learn more about the other person and grow for myself.

    This reflection is based on an interview with website editor Barbara Kahan.



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    February 2011 Reflection by Cheryl Woelk: Power and Peace Building


    Cheryl Woelk is working towards her Masters of Education degree at the Eastern Mennonite University in Harrisonburg, Virginia, U.S., and a graduate certificate from the Centre for Justice and Peace Building.

    When planning some kind of intervention, making some kind of change, the power differential is important to pay attention to. It can derail the process if only one voice is getting the floor, if only one voice is getting heard. You can design a process to empower voices that are less powerful, there are a variety of different tools to use. For example, groups can meet separately, with third party negotiators working to make sure each voice has an equal amount of time. A big thing is - key stakeholders need to be involved from beginning to end, not, "We've heard their voices once, now we don't need to anymore."

    With a large scale social dynamic, if people's voices aren't heard, there are non-violent ways to leverage power for groups that don't have formal power, by using other kinds of power. One kind of power I think is fun is nuisance power - making things uncomfortable, being persistent. Some people have moral or ethical power, they can speak to those kinds of issues. There are multiple sources of power that can be used.

    The two kinds of power most people recognize are the formal authority kind of power and the power of force - if someone has power it's because they can force you to do something, or they have a formal role like government official or teacher. Martin Luther King, however, used all kinds of power which were more powerful than the legislation kind of power. He used moral power, the power of relationships, power through numbers of people, nuisance power.

    As a result he contributed to transforming society. There are still lots of areas that need to change more though. Laws have changed but culture change takes much longer and more concentration. People's attitudes and mindsets take generations, that has to happen on an ongoing basis, it's not just one movement and that's it.

    Recognizing the many kinds of power is really important. For those who are used to seeing force and legislation as the only kinds of power, other kinds of power can be really disturbing. In my classes we talk of power "over" or "for" or "with" people. It makes a difference - if I'm in a position of formal authority, am I using power over or for or with?

    Power is not a pie that's divided but is in relationship with other people. Depending on the dynamics of the relationship, certain aspects of power can be pulled out that can ultimately make change happen. Every situation is going to be different in that way, but we do need to pay special attention to power, making sure voices are heard, that people feel safe.

    This reflection is based on an interview with website editor Barbara Kahan.



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    March 2011 Reflection by Heather Wood: Working with clients who live in challenging circumstances


    Heather Wood is a registered midwife with Access Midwifery & Family Care in Victoria, Canada.

    When I first came to Victoria there was a feeling by some that, as a community of practitioners and service agencies, we were not doing a good job with women with social complexities. People got together to provide integrated supports for people with substance use problems. We are getting closer to establishing HerWay Home, a wrap-around support agency for pregnant women using substances. HerWay will have a drop in centre, addressing issues related to food, housing, childcare, health and medical care. We are that kind of agency, advocating for that kind of low threshold access to care.

    Sometimes, even if someone doesn't say, you know they're struggling. You can extrapolate from knowing they're not working to how challenging food security must be for them, and then get the resources in place. We try to consider the clients' needs. For example, sometimes clients need to go to the hospital for a consultation or to have a test for fetal well being. We'll inform the hospital that the client should have a food voucher or a taxi voucher or whatever's needed. We know agencies that have clothing exchanges. We try to have diapers available for those who don't have money. We try to get freebies like shampoo, these are small ways to help people out.

    Being able to share information is helpful. One client wanted to know how long street drugs stay in urine or blood - I found that information and provide that information when people ask. If that awareness about the implications for you and your health if you're using cocaine helps them be motivated to reduce their use, good for them. One hundred percent of people coming in - whether they're using or not - are very concerned about their fetuses. For a lot of people, if they were already thinking they needed to cut down or stop harmful behaviours, pregnancy brings them to the point where they may be even more motivated to do that.

    The approach we take obviously integrates physicial health in pregnancy, but that's only a component of each woman who sits in front of us. If we look only at whether the baby is growing, giving the appropriate number of kicks, then we are looking through a very narrow lens. We are ignoring evidence that depression in pregnancy has implications for the baby, alcohol use has implications for the baby.

    If you take more of a health based approach, that will reduce the harms for the women and baby. One harm is separating the mother and baby. People using substances in pregnancy are at increased risk of having their baby removed at birth - there are enormous harms that come with that for the baby, the mother, the partner. The ripple effect is astounding and quite well known.

    We don't take the approach of abstinence. We aim for more understanding of addiction and appreciation of the complexity of life circumstances - we take a harm reduction approach, such as what's the least harmful way of using the substance, or providing information about needle exchanges, or getting into treatment those who are interested in doing that.

    To implement a harm reduction approach, there are things that can be put in place involving midwives, counsellors, probation officers, social housing - having that group come together to provide supports to have the best outcome which is, ultimately, a woman having a stable place to live and having her baby with her.

    Rather than telling someone they need to change, we try to walk beside them as they try to change. Some of the questions we might ask are: "Do you have a phone?" "If you phone this agency will your partner support you or will that cause a blow up?" About First Reach at the Y, a great program but which does not include housing for partners, "Is that a type of social housing that you could consider - or is it more important that you stay with your partner and look at other lower income housing that allows you and your partner to stay together?" Having to choose between baby and life partner - that may be an untenable choice.

    We try to help with advance planning and thinking, not just having resources like a crib and clothes but a drug-free environment for the baby and a plan if drug use becomes problematic - having another place for baby to be during that time.

    I find it remarkable how open people are with us - relationship is everything. If you're straight up with people about what they can expect from you, what you can and can't provide, they're respectful of that. You can work successfully with that, rather than hiding information from a client. Relationship and rapport is huge.

    This reflection is based on an interview with website editor Barbara Kahan.



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    Photo by Kaloozer (Mark Richardson),
    taken September 27, 2009 in College Station
    where Charles Ridley works; downloaded from
    flickr.

    April 2011 Reflection by Charles Ridley: Working to be Competent


    Charles Ridley is a professor in the Department of Educational Psychology at Texas A&M University in College Station, Texas.

    Very few practitioners are trained to be observant, look for dynamics, let alone make an intelligent interpretation of what's going on in a person's psychological system. It's not because practitioners are mean spirited or have disrespect for their clients - my argument is you have a lot of people who are credentialed but they're incompetent, in the sense they're not able to deliver the best practices, because the best practices have been in many ways not defined by the professional community.

    I will concede that psychologists have a more difficult challenge than some other fields. For example, physicians can measure blood sugar, other physical indicators - our indicators are more abstract, more qualitative. That does not get us off the hook to strive the best we can to have demonstrable outcomes.

    We have started by asking the wrong question, we have the wrong ordering of questions. The question that applied psychology has historically focused on has been, "How do we help people change?" Therefore we have numerous theories - psychoanalytic, behavioural, cognitive, client centred... Truly we have gained a lot of information, but the focus of our major therapeutic orientations remains, how do we help people change? I argue that's the wrong question. The fundamental question is - what is therapeutic change? Then the question after is, how do people change? And the third question should be - how do you facilitate therapeutic change?

    We've gone the wrong direction - not enough on how people change, the nature of change. The goal of the scientist is to explain, control and predict natural phenomena. But so far we can't explain therapeutic change. We have lots information in, but it is far from being synthesised and put into a scientific framework, because the majority of research has been on the wrong question - how do you help people change - rather than, what is the nature of change?

    The reality is that in 2011 we are still wanting to define what is "competent." There's been lots of discussion in the last ten years - a competency movement - however we are, in my opinion, far from articulating what it means to be really competent. We have a lot of information, a lot of research, theories. But at the end of the day the question must be asked - how can we demonstrate, have evidence, that what we do as a community of professionals, does in fact lead to positive outcomes, to positive change? At the end of the day, how can we demonstrate that all the activities we engaged in made a noticeable difference in the life of the consumer?

    I suspect that when we get a better handle on the fundamental question over time the walls are going to come down between the various camps of psychotherapy orientations because we'll have a more unified theory of change. I say the walls will come down because the whole purpose of theory is that it's a preliminary statement of truth, of reality - when we do scientific research, it will separate the truth from the untruth.

    More and more the right questions are being asked - but we have a long ways to go in providing the right answers. We are making progress, but the answers we have right now are at a rudimentary stage. It's exciting and frustrating - but I allow my frustration to be a source of inspiration rather than being a deterrent. What I envision - I hope I'll be a part of it - I envision a meta-theory of therapeutic change; that's what I would really like to see happen.

    This reflection is based on an interview with website editor Barbara Kahan.



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    May 2011 Reflection by Maria Hendrika: The Role of Values and Beliefs in Best Practices


    Maria Hendrika is Executive Director of Regina Transition Women's Society, which runs Regina Transition House, a 24 hour safe shelter for women and their dependent children fleeing any form of abuse. She lives in Regina, Canada.

    Violence is such a common issue. We wish it wasn't so. We all know of someone who has been abused - be it our mothers, aunties, daughters, friends, co-workers or neighbours. I want to see violence reduced - that's my commitment and my staff's commitment. That commitment colours our values and influences how we do our work. One of my staff says, "Every time I'm dealing with a client I think, how would I want my daughter to be treated if she were in this situation?"

    Our family has had a number of family members who have required extensive medical care. We have seen them being treated very well and not treated well when receiving services. That experience renews my commitment to give the best service possible to women and children when they come to Transition House. Our clients are vulnerable, can't always speak for themselves and deserve the best care at all times.

    Best practice is values based in my mind. What is underlying the work I do? It's respect for clients, commitment to seeing violence reduced in the community, it's honesty - it's a whole lot of things. A few years ago our staff participated in an exercise to identify our values. We came up with HEART which is short for:

    Honest, open, non-judgmental and empathetic communication.
    Empowerment of women and children.
    Absolute right to self-determination and safety.
    Respect for diversity and dignity of all individuals.
    Teamwork and consensus decision-making.

    I believe that we can't meet our mission without living the values that we've defined; underlying these values is compassion and a heart-felt commitment to working towards safety for all women and children.

    In our line of work, compassion is vital. I don't care how skilled someone is - if they don't have compassion, this is not the right workplace for them.

    As a condition of working at Regina Transition House, all employees and board members are required to abide by the Values of the Society. It is not unusual however to have individuals interpret values, vision, mission and goals differently.

    It's helpful to start a meeting with remembering our values - posting them on walls - or as a check-in, asking, what do they mean to you? Everyone will not see them in exactly the same way, but will hear how others see them and hopefully we will find common understanding. It is a process and it does take time.

    Slight differences in interpretation can give you depth - but major differences can interfere in consistent service delivery.

    When there are major differences between values and behaviour I will use that as a teaching moment - "Can you tell me how your behaviour with this client demonstrated that value?" If the conflict between behaviour and values continues there are procedures for discipline.

    Human resource management is the most challenging part of my job - it can be the most rewarding and the most distressing.

    I am very fortunate. Good people who are committed to our cause come here to work and volunteer. I have a great staff team and a wonderful board of directors.

    Sometimes values conflict, and that's an interesting challenge in best practices. For example we are mandated (just like anyone else in our community) to report suspected child abuse. In situations where women are taking children back into a situation where they may be in danger we are mandated by law to report. We are also providing a service for women - we want to keep Transition House a place of refuge that the community sees as a safe haven. In the past, staff have been concerned about women in the community seeing us as the long arm of the government.

    Would women still come in? Would women trust us if we reported as required?

    To address this situation we try to be as transparent as possible. We tell our clients at intake that there are limitations to confidentiality. We tell them that if we notice certain things that lead us to believe children are in danger we will have to report to child protection services. If we do have to report we try to do so with the woman in the room so that she has heard the same information as the intake worker.

    We always have to remember that women have limited choices but their children don't have any. We have to stand up for children and hopefully we will be able to do so in a way that still supports mothers.

    I am happy to report that we have maintained our credibility regarding child protection issues and women using the shelter by being supportive of our clients, informed as to their wishes and striving to maintain transparency in our work.

    We can all utilize best practices to get where we're going - we don't need a specialized degree to get there. People are scared of anything that sounds academic - often they are already using best practices without realizing it. Best practice is values based and it is how we achieve the outcomes we want. Best practice is really just common sense.

    This reflection is based on an interview with website editor Barbara Kahan.



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    Diedre Desmarais with her grandmother in the 1950s.

    June 2011 Reflection by Diedre Desmarais: Conditions Contributing to Poor Health of Elderly Métis people


    Diedre Desmarais is completing her doctoral dissertation in the Department of Political Science at the University of Regina, and will be joining the University of Manitoba as an Assistant Professor and Director of Aboriginal Access and Focus programs in Extended Education in July, 2011.

    Being colonized people makes the problems of the Métis more intense. For instance, my Dad grew up in Lebret, a small Métis community. He didn't have much of an education because Métis people couldn't go to school.

    "...by 1910 the federal government excluded Métis and non-status Indian children from their schools, limiting their responsibility to the education of treaty or status Indians. The provincial government also refused to accept responsibility for their education. With few exceptions, Saskatchewan education in the early 20th century excluded the Métis..." - excerpt from Métis Education by Sherry Farrell Racette in the Encyclopedia of Saskatchewan

    My Dad helped his dad on the farm, then did farm labour on other farms. He was in the army for two years, then got married and picked up work here and there. There was an element of racism; he worked at this job but after 30 years of service he only received $36 a month for a pension.

    My generation of Métis people has done a little better because we're better educated, we finish grade 12 for the most part - for me, I was driven, I always knew what I wanted - that's not usual either, you don't get very many people who give up everything to get a degree. But it was important to me.

    The effects of colonization include bad health. My whole family was scourged with tuberculosis. My grandmother, who was a potato picker, died at 63. We're not different from other people, but our whole life we've had to contend with racism. A lot of people don't realize what it's like - unless you've been followed around in a store because they think you're going to steal something, you don't understand it. That's part of how we live - that's the effect of colonization.

    I don't hear of many health initiatives for Métis here - there's Eagle Moon, Four Directions - there's those little pieces but not a lot. If you're sick and in hospital and don't speak the language, it's tough. For example, I met Helen, who was over 90, when my Mom was in hospital - Helen couldn't connect with anyone because she was a Cree speaker. There's a real need for culturally specific care. Spiritually, some Aboriginal people want to have their own elders come in, have sweet grass available - those are the kinds of things we need. Being in a hospital and not having access to sweet grass - even the smell is important when you're dying. Theoretically we live in this multicultural society - we should be accommodating those aspects of our society.

    Many Métis grandmothers are raising their grandchildren - a second family. A lot of people in my father's generation are getting very little pension, living on a low income. I had a meeting during the summer with a group of elderly people who get together regularly to do bead work, eat soup and bannock, and talk. I asked, "What is the greatest issue that you want to share that's a problem?" They wanted more housing projects so that their family doesn't move in on them. There's so much going on with our elderly people that's negative, I think it's the tip of the iceberg, it's huge.

    The social determinants of health are things like education, income, background. For our Aboriginal elderly people, education is not good, income is not good. How many Métis people in their fifties are in the workforce? How many Métis elderly own their home, and if they do, how do they maintain it - shovelling snow, yard work. The determinants of health impacts Métis people tremendously, and they'll feel them more as they age.

    This reflection is based on an interview with website editor Barbara Kahan.



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    July-August 2011 Reflection by Lawrence W. Green: Best Practices and Professional Judgement


    Lawrence W. Green works with the University of California at San Francisco. He is a Professor in the Department of Epidemiology and Biostatistics, School of Medicine, and Co-Leader, Society, Diversity and Disparities Program, at the Helen Diller Family Comprehensive Cancer Center.

    It's important to train and support practitioners to exercise good professional judgement in systematically assessing the needs of the population. This has been my message since the 70s when I developed the Precede-Proceed model, which uses a systematic set of steps to assess the local situation. It starts with a social diagnosis, then epidemiological diagnosis, behavioural and environmental diagnosis, and continues on. Only once you have been through these steps can you identify best practices.

    Sackett, who along with Haynes brought the evidence-based medicine model to Canada from England where Archie Cochrane developed it, never said it was their intention that evidence-based medicine should replace professional judgement; it should be blended, used in complementary ways.

    Most evidence is derived from studies not based on populations or circumstances identical to most local situations, so you need to adapt - that's where professional judgement comes in. It's a process, not an intervention, that constitutes practice.

    An emphasis on applying interventions with "fidelity," with all its moral overtones, implies that if it doesn't work it's the practitioner's fault - whereas it's probably the fault of the intervention not being the right fit with the population and circumstances.

    We need to train practitioners and planners to look critically at evidence from the viewpoint of their knowledge of the population they're working with - to bring their professional judgement to differences in setting, community, family, culture, history, circumstances.

    Rigorous testing helps us understand the mechanism of how an intervention worked, but the form needs to vary as we take it from one setting to another, that's where professional judgement comes in. Professional judgement has to be strengthened with good training. We need to train students to use a systematic process to assess a situation before they adopt a program or intervention from some foreign place. I would like to see more training on the best process for formulating policy, developing systematic diagnosis of the ecology - not parachuting in shrink-wrapped interventions that have to be applied with "fidelity" without some attention to the form of interventions that may need to be changed.

    Inevitably practitioners have to develop some interventions on their own, or elements of their program, from scratch. That's where theory comes in particularly usefully. There are never enough tests from other places to fill the cells of the matrix of population types, by setting types, by time, by culture.

    I don't pretend that I have more than the broad outlines for the issues and approaches. A lot of things have to be worked out in their details as we go forward.

    This reflection is based on an interview with website editor Barbara Kahan.



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    September/October 2011 Reflection by Jaime Traynor: Defining Best Practices


    Jaime Traynor is a home visitor with the KidsFirst program at the Regina Early Learning Centre in Saskatchewan, Canada.

    For me, best practices means drawing on material that's out there, whether it's research or existing programs doing positive things or experts in the field I can talk to - and working with the people for whom the programs are created, so that it's not top down, but figuring out together what parts make sense, what's working.

    When I volunteered in Uganda I tried to be familiar with the most current information about HIV and sexually transmitted infections. To share the information most effectively, I tried to get a sense from the people in the programs what the level of their knowledge was, and then tailor the information in a way that made sense, for example going into more detail about parts that were most relevant to them. In Uganda this often meant focusing on things like condom use and mother-to-child transmission. Information sharing sometimes involved changing language based on their vocabulary or level of fluency in English.

    In terms of knowledge among the village as a whole, while they had an understanding of a variety of health-related topics, there were often misperceptions. For example, if a woman got HIV it was frequently assumed it was her fault, that she'd been promiscuous; there was also misinformation about modes of transmission. To find out about their perceptions I'd get the teen girls to talk a bit about what HIV meant to them, how they thought people got it. We also created a question box where they could ask questions anonymously, which turned into a great way to discuss issues they weren't comfortable raising face to face. The local midwives at the Centre, who all had deep ties within the community, were also a tremendous resource.

    I think a big thing in best practices is meeting people where they're at - which is a more time intensive approach - rather than just jumping in with the information. You need to take the time to understand their level of understanding, what kind of information they're looking for, what to share, how to share it, what are the most practical tools to do that. In Uganda I tried to get away from lecturing. I used videos, slideshows, pictures, diagrams, and activities that could convey the message.

    The key things I learned in Uganda were the importance of adaptability and flexibility, not assuming things, taking the time to understand the situation rather than being in a rush to get things done - less on producing things to show and more on relationships.

    I have often found that smaller organizations tend to be able to be more flexible and more effective at serving the needs of their clients. In government the overall goal may come from a similar place, but because much of government is so many steps removed from families, or because large bureaucracies like to standardize, they try to create the same rules and guidelines for everyone, even though people don't fit nicely into little boxes. In a program it may be easier to have everything the same across the board but in reality it doesn't work that way. You need some kind of discretion to change things to suit the individual situation.

    This reflection is based on an interview with website editor Barbara Kahan.



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    November 2011 Reflection by Heather Wood: Asking about violence in the lives of pregnant women


    Heather Wood is a registered midwife with Access Midwifery & Family Care in Victoria, Canada.

    When I first started midwifery, the standard antenatal form asked for information such as a person's demographics, due date, a little bit of personal detail about diet, exercise, and more recently a section on alcohol use, substance use, social support, financial situation, housing - and one little tick box at the bottom for intimate partner violence. Just a tick box - not even any room for writing. I heard from many of my fellow students and sometimes from registered midwives that the box was left unticked because it wasn't discussed at all. The feeling was, I guess, that the person sitting opposite seemed so middle class or settled - no, it couldn't be that they suffered violence - that it seemed disrespectful to ask them about that.

    There seems to be an incredible awkwardness among the students we teach around exploring life complexities that may (and generally do) impact on pregnancy and family life. Sometimes it's because of not knowing what to do with the information. They're not trained counsellors. I myself don't blink about talking about violence and substance use. There are often disclosures. I know the community resources, supports that can be put in place quickly.

    Maybe the environment we have helps people feel more comfortable being open about it. We have the usual clinic space with many rooms. In the large open waiting room there are community bulletin boards, brochures on Transition House, posters saying "no means no," First Nations art work, a basket with healthy snacks so that people can help themselves to juices and granola bars in case they're hungry.

    A practice may be clinically sound but there are other ways of causing harm like being disrespectful or not recognizing the potential for violence in a client's life, not recognizing the level of support that's needed. It's one of those things, if you don't open up that door you'll never know. It's amazing how people do want to talk about it.

    This reflection is based on an interview with website editor Barbara Kahan.



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    December 2011 - January 2012 Reflection by Mark Crawford: Defining Best Practices for the Unemployed Workers Help Centre

    Mark Crawford is Executive Director/Advocate, Unemployed Workers Help Centre, a Saskatchewan community-based organization. He lives and works in Regina, Canada.

    We have a worker's point of view. We're a labour based organization, we represent that to a certain extent in the way we approach things. Our practices encapsulate respect for people, accountability, credibility, and honesty in our operation.

    For accountability it's important to track your client statistical base, so that you prove that you're doing what you say you're doing. Control and budgeting is critical for non-profits with external funding and donations - you have to be able to account for every dollar to avoid causing consternation with any funders. Regarding credibility, it's important to be careful about the quality of financial statements and proposals. If you are making projections about outcomes, be sure that the projected outcomes are likely.

    We are straight up on everything, we don't colour anything, we disclose everything. As a result we have a good working relationship with the Employment Insurance Commission, they trust us. That's very advantageous to us.

    Regarding best practices you just have to stick with it and find the formula that works. those best practices - integrity and the rest - develop over time. We've developed the tools, we're good at what we do because of our interviewing skills and from knowing the legislation and the case law. We know what we're doing, we have the fundamentals of being able to do analysis and apply the analysis. That all comes from experience, gives you the required nuances to do well. It's a step by step process that you have to follow. I think over the years we've developed very good practices - steps to follow which will result in a satisfactory conclusion. You get a lot better at it over time.

    We do the best we can under the circumstances. It's not a perfect system - sometimes things don't turn out. You don't always win an appeal or get someone their benefits by advocacy, but we do our best to ensure that people are treated fairly by the system.

    This reflection is based on an interview with website editor Barbara Kahan.



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    February 2012 Reflection by Molly Moss: Using Circle of Courage Values in a School Setting

    Molly Moss teaches French Immersion kindergarten at Ecole Connaught Community School, an elementary school, in Regina, Canada.

    We use the Circle of Courage in our school. The Circle is related to the medicine wheel in its structure and is based on First Nations' values. It comes from Larry Brendtro and other educators who wrote a book called Reclaiming Youth at Risk. The Circle has four areas: belonging, generosity, independence and mastery. There is overlap among all of them, for example acting generously without being prompted shows independence. It's a wonderful set of values or goals - the whole school uses it.

    To me, belonging means feeling safe here, knowing what to expect, having friends here, it's a friendly place. I make sure students know the names of the other kids in the class, I welcome parents into the classroom, make sure my students know the routines and are comfortable with them - most kids really relax once they get that down.

    Generosity focuses on listening, paying attention to show you care, sharing your time, stopping to help someone, sharing your space - don't butt into line. Generosity can be letting someone use your markers or sharing your snack. I want children to know that generosity is making other people feel good and important. It relates to respect - that's a really big thing, developing a sense of other. When children are generous I make a big deal out of it; if children listen to me I'll tell them how they make me feel important. I lay the groundwork all year.

    Independence is about initiative and making good decisions on your own. Independence in school means knowing what to do, when to do it, and doing it without guidance. Following routines without reminders shows independence. It overlaps with generosity - if you bump into another child, don't say "sorry" and run off, but stop and ask if you can help without an adult telling you to do that. When students understand something and do it by themselves that's independence; when they experiment to solve an academic or social problem without asking that's independence. If they know when to ask for help that's also independence. If you're fearful to even try the climber you're not independent; if you climb to the top and wriggle around unsafely that's also not independence because it's showing poor judgement.

    Mastery relates to learning and effort. Children who spend two minutes on a project will not reach the same level of mastery as children who spend twenty minutes on it. They won't remember, won't be able to relate it to other things. That's why I insist on a certain amount of time - if a child comes up to me and says they're done after two minutes, I say "go back and look at it again. How can you make it better?"

    Even children in kindergarten can self evaluate - what they have mastered, what do they still need to learn, do they treat others in a generous spirit. The ones who can't are often dealing with stress which interferes with willingness to self evaluate. In the past, when I had more time to work with children on self evaluation, I found they were experts at ages four and five. Self evaluation has to be facilitated - it takes a long time of asking kids "what did we do today," "how did you feel about that," "how many of you remember what you heard in the talking circle this morning." After working with them they could self evaluate on about 22 items - in the social domain, special content domains, skill domains, physical things. In our one to one child-teacher conferences we covered a lot of areas.

    In recent years our days are more fragmented. We have several hours a week less time in the classroom than in the past and the demands for much standardized evaluation per student is up. Therefore, time to facilitate learning is down. Time to reflect with children about how they are doing is down.

    It's interesting that when I started I was one of the first, certainly in kindergarten, to do this and now it seems we should do it across all grades. But the amount of time isn't there to do it meaningfully and well. The theory is good but the structure of the days and weeks doesn't allow time to do it well. It's too bad. Giving children the self understanding to self evaluate in a school setting is very important.

    This reflection is based on an interview with website editor Barbara Kahan.



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    March 2012 Reflection by Molly Moss: Supporting Health in School

    Molly Moss teaches French Immersion kindergarten at Ecole Connaught Community School, an elementary school, in Regina, Canada.

    The health curriculum has changed over the last 15 years. It used to be "brush your teeth and eat your vegetables and get enough sleep." There's less of that now. Now it's about social skills - lessons about how you behave in the classroom, looking at how children feel about themselves and others, how do you solve problems, how do you manage anger.

    We have kids in the school who are not well nourished either because they're not eating enough or not eating nutritiously. The school used to make a bunch of sandwiches every day and give them to these children but now children have to go to the nutrition room at recess and make their own sandwiches. Often they don't - maybe they'd rather go out and play or they're embarrassed. We're not addressing this issue well right now; although some people are thinking about it, nothing's happening.

    Some teachers are very interested in aerobic function and have body breaks and fitness breaks several times a day. There is wide recognition that it's not natural for children to sit still. We make adaptations to seating, they can have fidgets in their hands.

    There is a large number of children in the school under emotional stress with anti-social destructive behaviour. We try to deal with this in different ways. We have an alternative recess for kids who can't handle regular recess - the noise and activity level is too much for them. The teaching assistants, who originally were supposed to bring First Nations content to the school, are now assigned to high need kids; you often see the assistants walking in the halls with kids. We have a cool down room where children flail and yell, where they go to be angry.

    Some of these children totally disrupt their classrooms and the impact on teachers is profound. These teachers are doing the best they can - they love teaching and they are excellent teachers but they can be deflated because it's impossible to do the kind of teaching they used to do due to high needs children disrupting the class every five minutes. These children are not being pushed aside or rejected but it's costing on a personal level and in terms of the academic achievement of the class as a whole.

    It's a difficult issue. It makes you wonder what a school can do, what is a school about, in terms of health. What's best for these children - is the school the best place for them? Right now there are very few options - there are some high needs programs around the city but most have been closed.

    As a teacher I've noticed in 15 years that children are coming in quite different. So many children have low problem solving skills, poor communication to express themselves clearly, language deficits. Children don't have the range of play skills that they used to have. Their play is limited to a lot of violence, they don't know the old playground games, how to play baseball, they're not as good at climbing and balancing.

    Listening skill is a big area affecting academic outcomes - now, many listen to you like you're a television. They think they can do something else while you're talking, there's no focused listening. It's speculation but children may not have as much one to one talking time as they did in the past. Without that, children don't develop thoughtfulness, reflection, vocabulary levels.

    This reflection is based on an interview with website editor Barbara Kahan.



    April-May 2012 Reflection by Molly Moss: Best Practices from a Teacher's Perspective

    Molly Moss teaches French Immersion kindergarten at Ecole Connaught Community School, an elementary school, in Regina, Canada.

    For teachers, best practices start with knowing who your students are - about their families, where they live, their skills and strengths and interests. That's where it always starts for me. Then you have to have several conversations to get to know each child as they're doing art work or playing in the play house.

    Conversations like this make children feel valued and respected. Once they feel that, facilitate that they show respect and caring for others. Unless children feel good about themselves and buy in that others matter we won't have a good learning environment. However, it's not always within a teacher's power to provide a good learning environment if children are too deeply disturbed.

    The second part is to inspire children to learn, and understand how to learn. You do that by immersing them in environments that are interesting and multifaceted and offer children a lot of different ways to approach learning. In that environment you have to accommodate different learning styles - some children are tactile, others are audial. Bugs is a topic which works for almost everyone - there are so many different ways children can find to be interested in bugs, whether the creepy crawly aspect or beautiful colors. Some go for butterflies, others for carnivores.

    If the environment is stimulating you can take off from that. You have to raise the sensory experiences to a verbal level which translates into a cognitive level - focused listening is a part of learning. When the turtle is crawling on the floor I might say, "Goodness gracious, you're interested - I bet you heard everything I said." I might add, "I bet you didn't know it was that slimy - you're slimy too when you're wet." You have to develop an awareness and consciousness among children - best practices encourage children to have a significant voice in their own learning.

    Best practices also means having excellent communication between home and school. Another part of best practices is being aware of the other players in education, for example the school board. It feels like only a little bit of what we're struggling with gets out from our school to the school board and even less to the government - who is listening? As a teacher, your job is how you teach - but also to have a notion of the structure that you work in - and to know whether you can actually deliver within that structure.

    For best practices you have to know kids, provide a stimulating environment, make sure they understand and verbalize what it is they do - and beyond the teaching part, you have the responsibility as an educator to influence the structure that you work in.

    In order for teachers to use best practices, a few changes are required. Streamline getting intensive support for children, provide relevant training to the people working with children who have problems, give support for the teacher to meet the needs of kids. Reduce the fragmentation of the school day and add regularity over the week, so young minds can flow in an orderly way - students have to deal with huge transitions during the day. Increase teacher-student interaction time, for example by reducing paperwork - administrative tasks take away teaching time. Time is the biggest thing that prevents good practices from being implemented.

    Preserve what is good in current practice - for example reading to the class hasn't been done in years; we used to write every day, we don't do that anymore. When they bring in new stuff, the old stuff is gone. We need to re-evaluate learning expectations. Kindergarteners now are expected to be able to count forwards and backwards starting at any number 1 to 10, to instantly recognize sets to 5 and so much more. Less was asked of children before but they did better at university than children do now. Perhaps they learned more thoroughly?

    Recognize that some of our problems with education are not the result of poor practice but rather of social conditions, family stress, or disabilities requiring extensive support. Address these issues perhaps using the school as a hub for services.

    This reflection is based on an interview with website editor Barbara Kahan.



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    June/July 2012 Reflection by Anne Goodman: Understanding Peace and Health

    Anne Goodman is a professor in Adult Education and Community Development at the Ontario Institute for Studies in Education (OISE) at the University of Toronto. She lives in Toronto, Canada.

    Peace and health are very broad terms and hard to distinguish from each other. They have become separated because we work in a specialized world. In more holistic cultures we wouldn't see the same distinction, since both are really about having a state of well being. Definitely the social determinants of health are the same as the social determinants of peace. Also, the base words for health and peace both mean "wholeness."

    There are many links between peace and health promotion. Both are about community and supporting each other. We have found that people doing work in communities with a lot of violence need a lot of healing. War has one of the worst effects on health. The move to ban landmines started as a health initiative.

    A colleague from Eritrea worked in a community-based health centre where many of the people came from the Horn of Africa - Somalia, Djibouti, Eritrea and Ethiopia. In their homelands, these people would see each other as enemies. Yet in this neighbourhood in Toronto where they are now living they are dealing with similar health issues. My colleague sees this as an opportunity for peacebuilding through facing common health issues together. Peace and health are very interrelated.

    This reflection is based on an interview with website editor Barbara Kahan.


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    August 2012 Reflection by Anthea Darychuk: Exploring best practices

    Anthea Darychuk is a University of Toronto graduate student in the public health, health promotion and global stream.

    A lot of the talk about best practices alienates people and makes them feel that if they can't achieve a best practice then what they've done isn't enough. Instead, best practices, I think, come from lived experience and from pragmatic understandings of life.

    A best practice is one that tries to include different levels of people's experiences and different areas of people's lives - people's family structure, economic circumstances, political attitudes, mental and physical health. I have a very holistic, broad understanding of health - and that health ties to the social environment.

    There is a values piece - you need to base best practices on values as well as evidence. At the same time there has to be a liberal understanding of people's lives, an inclusion of more qualitative broad experiences. It's also good to have peer review. RCTs [randomized controlled trials] are not always appropriate.

    The best evidence mixes qualitative and quantitative. A lot of quantitative data frightens and obscures what's going on. To use a metaphor - quantitative data is like a plant. It doesn't make sense unless it has a context, a foundation, something to grow in. Qualitative data helps us understand what we look at. Without really contextualizing data we don't have an answer that people can identify with. Evidence to me is something that accepts and understands and entails a variety of perspectives - understands that something that works in one situation doesn't necessarily work in another. We need disclaimers that there are other readings of the data.

    I would include my own experience, in consultation with other people, when making decisions. Scepticism and judgement, intuition, all play a role.

    Consulting with an intervention's participants requires presenting concrete ideas of what could happen and then having the debate. Otherwise, people get overwhelmed and confused. One good process is to have a steering committee with leaders who are regular participants in the community - have them draft a number of proposals, and then organize people to come together and discuss what is proposed. What is proposed can then change during the discussion. It is good to have clear ideas of what you're talking about rather than ideals.

    Best practices would involve people from the target population talking about how they experience their health issues, what is less important to them to include in an intervention. Because evaluation is important to best practices, the participants would answer questions about how to measure success, what would life be like if it were better. These conversations should take place at the beginning of the intervention, to provide concrete measures and markers.

    I have a hard time with a lot of theories in health promotion and public health because I feel they haven't taken into account female perspectives in a lot of communities they're working in and trying to improve. I don't connect to these theories immediately - the product of living in communities with a high proportion of women in leadership positions. I roll my eyes a lot because the theories sound good but we don't know if there's a lot of substance to them - are they improving the ability of people to access resources?

    I think a lot about humility. Unless we become more intentional about consulting people involved in our efforts we will do more damage than good. It's hard because you want to act and you think you have the answer - but history tells us that we don't.

    This reflection is based on an interview with website editor Barbara Kahan.



    September 2012 Reflection by Anthea Darychuk:the importance of relationship

    Anthea Darychuk is a University of Toronto graduate student in the public health, health promotion and global stream.

    When working with community, it's not about being efficient per se and it's not about producing something. It's about the interpersonal relationship, which is not quantifiable perhaps - it's simply about being there and promoting discussion and a safe space. That is something we talk about in Canada but don't do. I did see a lot of that in Honduras, Guatemala, Mexico.

    It's not exactly about nurturing. It's about appreciation for just being with someone, the down time and the up time, and figuring out where people are at - not being as goal oriented, not having a linear projection of an idea of success or progress. It's different kinds of relationships contingent on different things. I can be one way in one space and different in another space and that's okay.

    Partly it's about an appreciation of different abilities. Women are really good at bringing that out, because historically women have been called upon to interact with people from different generations - grandmothers, children - and different places in life. It's about an appreciation for lived experience. I'm not saying men don't talk about those kinds of things but I find it's more likely that I will have conversations about day to day life with women.

    Trust, reciprocity, the idea of being responsible for another person - these were really big in the other countries I spent time in. The sense of community was really huge - people knew each other really well, they blended the personal and the professional on an hourly basis.

    That can be a good and a bad thing - if animosity is exacerbated, it can lead to more extreme social isolation, which is an individual and collective problem. But in general, people had a bigger stake in the community than here in Canada, they cared more, participated more. There the community was larger, everything was all in the same public sphere, overlapping. Here it's fragmented and segmented - because of incomes, transportation. There, there was a better understanding of protecting the environment because everyone was using it, you couldn't avoid it. Here, if you're in an upper income bracket, you can avoid certain aspects of the environment, you just drive down a different street.

    This reflection is based on an interview with website editor Barbara Kahan.



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    October 2012 Reflection by Cathy Ellis: Best practices for global maternal-infant health

    Cathy Ellis is a a tenured senior instructor with UBC Midwifery (Department of Family Practice, Midwifery Program) at the University of British Columbia in Vancouver, Canada.

    In Nepal we have specifically tried to work in areas that have a great need. We want resources, money, time, to go to good use to improve equity for those rural health practitioners so they have a chance to get continuing training and know what the best practices are.

    Our best practices are theoretically guided by WHO [World Health Organization] and the ICM [International Confederation of Midwives]. It's important that we teach and model the best practices these organizations promote, such as skin to skin contact which is not done, breastfeeding, as well the use of the partograph. The partograph monitors labour and reduces maternal and newborn death and morbidity by early identification of problems, for example poor progress of labour, high blood pressure, fever, abnormal fetal heart rate. It teaches staff when to use an intervention or when to transfer the woman in labour to another level of facility. Prevention and treatment of hemorrhage is possibly the most important best practice to model, along with other emergency care.

    We are very lucky because we can teach most midwifery subjects in an understandable and culturally appropriate way to the nurses and midwives of the countries where we work. We are successful because we keep going back, we don't just pop in and out of places. We work with the same people, expand outward, none of it is a one-time thing - that's another best practice. We work with internationally accepted guidelines. We plan to go back for follow-up, which is a very important best practice.

    How do you make delivery acceptable and affirming - that's also part of best practices. There is a balance between responding to emergencies and making physiological birth normal and pleasant. It would be fair to say that many women do not have that experience in institutions, while at home they don't have skilled birth attendants.

    The partnership model is one way of doing best practices in a country. The UBC [University of British Columbia] project, which is called Students for Global Citizenship, uses the partnership model. We have brought a Ugandan midwife to UBC - she underwent extensive training in neonatal resuscitation, and now she is an international trainer in Uganda. She works with us on train the trainer projects. She and a head nurse of a hospital went with the team to an ICM conference last year in Durban where we co-presented papers. We travelled together and provided the funding; otherwise they wouldn't have been able to go. It's bilateral learning - we respond to what they want us to present on and we tell them what we and our students want to learn. We don't tell people what to do but as part of the partnership figure out ways each one can be of service to the other.

    You cannot expect to do a lot in a short time - you have to persevere and try to accomplish what you think are the most important goals in collaboration with the people you are working with. Sometimes though they might not want to do those goals even though the ministry wants them to. For example, private practice is a necessity in many countries because they're not paid enough but it interferes with their public sector work.

    A lot of things are not apparent immediately. For example, some countries paid a certain amount for caesareans and a lower amount for vaginal deliveries, so the rate of caesarians conducted was considerably higher than one would think reasonable. It's necessary to look into the demographics of a country, look at their public health and institutional statistics to see what the situation is and try to move or nudge it towards a more equitable maternal-infant system and better outcomes. You might have to go for several years working on the same couple of points before you see change. Follow-up is really important. When people have been doing things for 50 years, like shaking and hanging newborn babies upside down - very dangerous - it's not easy to get them to change their practice.

    Another thing is, when working with nurses and midwives, you have to have "buy in" from the head nurses and physicians who supervise them all the way up to the policy makers. That is very important.

    The best practices approach emerges from the work you're doing in each cultural community. What works in one won't necessarily work in another. In my work I'm not going by any manual - I go by what seems to work at the time. We try to evaluate every year, improve year by year. It's a cycle.

    This reflection is based on an interview with website editor Barbara Kahan.



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    November 2012 Reflection by Anne Goodman: Understanding Peace and Violence

    Anne Goodman is a professor in Adult Education and Community Development at the Ontario Institute for Studies in Education (OISE) at the University of Toronto. She lives in Toronto, Canada.

    There is a nice article by biologist, Mary Clark, that I use in my peacebuilding class - it says that what makes a culture work is relationships and the search for meaning. In the West that's not the way we've done it - we've created pathological institutions which are not peaceful and are not conducive to health.

    Violence is not just direct. It is also structural, in ways that are not always visible. We understand that shooting a gun is a violent act. But people dying needlessly from diseases - isn't that also a form of violence? Even giving students grades - it's arbitrary, and there's a certain violence attached to that. We also talk of cultural violence; the underlying ideas that legitimize violent structures and actions.

    The way I understand peace is that it is about being as human as possible and creating a world where everyone can reach their potential. Violence is anything that prevents people from achieving their potential. Most of us do not live in societies which help us to discover who we are and who we could be. Instead we are always out into positions of comparing ourselves to others and looking at how we are deficient. Advertising is terrible for encouraging that.

    In peace studies we talk about negative and positive peace. Negative peace is the absence of direct violence, for example the absence of war. Negative peace, the cessation of a violent conflict, is essential, but once the war or conflict is over, do we actually have peace? No, because we need reconstruction, we need relationship healing. Positive peace includes working towards something - for justice, to change violent structures. Positive peace is the presence of something, not the absence.

    Peace is not something just to gain knowledge about; we have to apply that knowledge. It's not this abstract thing that may or may not matter.

    I don't talk about pessimism or optimism when I think about peace; I talk about hope. I have no control over whether the world will change - but I can do things that make me feel hopeful as I'm doing them, without thinking about outcomes. It's more about process.

    In the West, our guiding question is "What's wrong?" Other cultures, for example Aboriginal cultures in North America, ask instead, "What's working?" and then build on that. It's a strengths-based approach; a different way of looking at the world. Enhancing, supporting what's there - that's more compatible with a peace approach.

    When we were developing the Vision of InterChange, we suggested using the term, "creating peace". One of our members in Rwanda said, "You can't create peace. It's already there - you have to nurture it," and we incorporated this understanding into our Vision statement.

    This reflection is based on an interview with website editor Barbara Kahan.



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