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Innovation in Research & Knowledge Exchange Dr. Gina Browne CASN Conference Toronto, Ontario May 8, 2012.

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Presentation on theme: "Innovation in Research & Knowledge Exchange Dr. Gina Browne CASN Conference Toronto, Ontario May 8, 2012."— Presentation transcript:

1 Innovation in Research & Knowledge Exchange Dr. Gina Browne CASN Conference Toronto, Ontario May 8, 2012

2 … starts with various or diverse notions of what is known… what causes the known

3 - Clyde Hertzman

4 Alternative Philosophical, Knowledge, Governance and Organizational Structural Assumptions in Health Care Affecting our Thinking

5 AssumptionsLinear & Literal Integrated Thinking Health …within the individual or within the environment …a state …an end …an interaction between the individual and environment …capacity to respond (Antonovsky) …means to well-being …an indicator Environment …single or separate environments …social, natural or socio- economic …the interaction between the individual and three environments Community Support …health care …single solutions …specialized services …health promotion …network of human assets and resources …holistic services

6 AssumptionsLinear & Literal Integrated Thinking Determinants of Health …germ theory …host resistance …single causes …inequities of social assets …multi-factor …multi-level Research …process evaluation …what the masses say …limited dissemination …outcome measured …evidence-based …shared success stories

7 AssumptionsLinear & Literal Integrated Thinking Policy Directions …built in stages, based on crisis …independent silos …exclusive planning and policy development …hold information …single service provision …red tape, long time planning …always look “inside the box” for “return on investment” …integrated governance …integrated planning …stakeholder model …knowledge transfer via improved computer technology …integrated service provision …innovative, learn from failures, risk taking …find new partnerships and promote “outside the box” thinking and new unused resources Funding …independent silos …shared or lost funding if partnered …return unspent money …integrated funding …new funding for integration activities …savings held for future activities Leadership …directing …regulate and control …government planning …standards (“one size fits all”) …building trust …guide, hands-off, shared control …self-organization …innovation

8 AssumptionsLinear & LiteralIntegrated Thinking Structure …single, segregated services …isolation, competition …standard …conflicting ideologies within mandates …multiple, integrated services …inclusion, cooperation, partnerships …diversity …allow organizations to develop to meet the need of local community Location …regional or provincial…municipal or neighbourhood Stakeholders …publicly financed for deficiencies …narrowly defined groups …limited to current health system …feelings of hopelessness …lack of control over work and environment …community health, social, recreation assets that include resources to reduce inequities …increase in community resources …build the current health system and weave with other systems Strategy …primary care …provincial solutions …limited local community capacity …evaluate and criticize …regulation …focus on failures …community health …local community solutions …build local community capacity …support and encourage innovation …entrepreneurship …focus on successes …recognize that health is not an end to itself, but is the result of improved policy in all other areas (work, environment, education)

9 Paradigm Shifts in Knowledge, Methods and Analysis … starts with various? notions of causation DisruptiveLinear Interactions or Curvilinear “The Tipping Point” Malcolm Gladwell… sudden effects caused by a few in certain context Examples: 911 The Arab Spring Occupy 99% vs. 1% SARS “Epidemiology” ’s Dose/Response Examples: Smoking & Lung Cancer Host Resistance Antibiotic resistant bacteria “Human Development” - Clyde Hertzman Latent effects, risks interacting with protective factors Examples: Adverse child events and chronic disease 40 years later

10 Paradigm Shifts in Knowledge, Methods and Analysis … starts with various? notions of causation (Continued) DisruptiveLinear Interactions or Curvilinear Criteria: Stimulus by a few occurring suddenly in specific context Criteria: Consistent Strong Specific Coherent Temporal Criteria: Interactions Non-linear Self amplifying Multiple outcomes Depends on meaning given events

11 1. Contagious Behaviour or ideas: … unexpected properties of things … “sticks”, makes an impact … because of reading, hearing, seeing, thinking e.g… virus, fashion, crime, technologies 2. Law of the few: … little causes having big effects … geometric progression and out-of-proportion, not … proportional or gradual 3. Both contagion and the few happens in a hurry! Dramatic change “The power of context”

12 Million fax machines Million fax machines OR 1990 Cellular phone 1998 Everyone has one

13 1995 increase in S. Rates 1. Crack Cocaine: brings in outside people who take their behaviour home 2. Reduced STD clinic staff by ½, decrease patient visits, decrease outreach 3. Disruptive decrease in public housing: Index people moved

14  Growth of drug (stimulus)  Growth (transformation) of disease: from acute to chronic  Transport of index people and behaviours to a new neighbourhood

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

16  Arab Spring? →  Contagious message of social justice sticks  Occupy: Tax the 1%?  Suddenly “man set himself on fire”  “… Youth raising the village”  Youth rebels  Arab Spread

17 Consistency: different study methods provide similar results Strength of Association Specificity: the precision with which one component of an associated pair can predict the occurrence of the other Coherence: the association is consistent with other known facts about the natural history and biology of the disease Temporal relationship among associated variables: one precedes the other

18

19 ENVIRONMENTS CHILD Well-being Achievement - Birth Weight (HBHC) - EDI/KPS - EQAO - Emergency Visits (10-24 yr. olds) - Special Needs Parents -Neighbourhood -Family Constellation Family - Med. Income - CAS - Gov’t transfer School - ESL - Grade 3, 6, 10 - Passing Test Community -Population Health and Human Service Utilization LEGISLATIVE REGULATORY POLICIES

20  Causation is a result of the interaction between accumulating proximal and distal risk and protective factors. Therefore, the probability of an outcome is uncertain and unpredictable.  Causation (host resistance) results from a multitude of forces (genetic, biological, psycho, social): “equifinality”

21 Latent Pathways Exposure causes outcomes that are: latent (years later); cumulative (add up such as chronic poverty); pathways (one leads to another): poor readiness to learn leads to poor school performance; latent, cumulative, pathway outcomes are coexistent. Life Course ENVIRONMENTS CHILD Well-being Achievement - Birth Weight (HBHC) - EDI/KPS - EQAO - Emergency Visits (10-24 yr. olds) - Special Needs Parents -Neighbourho od -Family Constellation Family - Med. Income - CAS - Gov’t transfer School - ESL - Grade 3, 6, 10 - Passing Test Community -Population Health and Human Service Utilization LEGISLATIVE REGULATORY POLICIES Cumulative

22  Causation is non linear… is curvilinear (too much/too little).  Causation is iterative and recursive results from interactive, between repeated, self amplifying exposures to risk (stress) or protective (social support factors) over time: “cumulative” wear and tear, e.g., measured by allostatic load.

23 Figure 1 Intersection of Diversities can create Vulnerability Source: Delore & Hubert, 2000 Poverty Youth Racial Discrimination Sexual Discrimination Mental Illness Physical Illness

24 Latent Intersections of Vulnerability Cumulative Pathway Early School Age Adult Sensitive Periods  Causation is non specific: e.g., exposure to a disadvantaged environment causes multiple outcomes: "multifinality". Poverty Youth Racial Discrimination Sexual Discrimination Mental Illness Physical Illness

25  Causation can depend on sensitive periods in growth and development; e.g., bonding and attachment.  Causation results from the meaning of the event and the appraisal/ability to manage in the face of the event; e.g., people endorsing experiences of racism and oppression associated with shortening of chromosomal telomeres - a novel measure of aging.

26 All the sources and mechanisms of causation happen simultaneously i. Interaction of multiple and distal factors ii. In humans with genetic, biological psychosocial levels of host resistance iii. Undergoing latent, cumulative and pathways of causation iv. Non linear v. Repeated self amplifying risks rates vi. Results in multiple outcomes vii. Depending on sensitive periods viii. The meaning given events

27 Changing Assumptions about what is known about causation Has led to changes in what we know, measure, methods of inquiry and analysis:  Multi-level Interventions  Enhanced Study Designs  Multiple Levels of Measurement  Multi-level Modeling Analysis

28 FROM:TO NEW FRONTIERS: KNOWING …?Learning? Thinking? Creating? Applying? What and Where?How? Why? When? About?With? Patterns/regularities?Exceptions/outliers? Single causes?Multiple causes? Order and linear steps of change?Disruptive? Psychiatric diagnosis?Sites and mechanisms of dysregulation? Truths?Harms and goods? Changing What We Know

29 About METHODS…? Follow-ups?Timing of measure? Administering measures?Co-creating meaning? Eliminating co-interventions and cofounders? Embracing complexity? Clinical trials?Longitudinal life course research? Changing

30 INTERVENTIONS…? Standardization and fidelity to treatment? Customization tailoring/choice? Cramming new technology into existing structures (patient portals)? Customized and choices in technology and therapy? Single interventions?Multi-level/model interventions? Changing

31  Calculating Sample Size: estimating › For main effects › For interaction effects Changing

32 ANALYSIS…? Categorical or linear analysis?Multi-level or hierarchical regression analysis? Avoiding multi co-linearity?To indexes that combine phenomena (e.g., anxiety and depression)? Rules of statistics shaping knowledge? To knowledge shaping statistical methods? Changing

33 OUTCOME MEASURES…? Achievements?Well-being? Happiness? Gratitude? Absence of disease? Costs? Quality of life? Capacity to respond to adversity? Return on investment? Changing


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