This week there are two feature articles, both by masters of public health students at the Dalla Lana School of Public Health at the University of Toronto: Systems Thinking: A Paradigm for Health Innovation by Anne Rucchetto and Using Science as a tool for Public Health Innovation by Akanksha Ganguly
Using Science as a tool for Public Health Innovation
II Community Engagement
III Supporting Education, Empowerment and Development through Science (S.E.E.D.S.)
-- Submitted by Akanksha Ganguly
As health promotion students, most of the work that we do revolves around improving the health of marginalized communities through work focused on the social determinants of health (SDOH). Creating lasting and sustainable impact for these populations often involves a cornerstone of public health: community engagement, which is sometimes difficult to achieve. Through my work as the co-founder and CEO of a not-for-profit organization, Supporting Education, Empowerment and Development through Science (S.E.E.D.S.), I have been able to develop and test an innovative method for community engagement: delivery of a science-based program which allows participants to employ a scientific lens to address public health problems in their communities.
This article will focus on three key lessons of this approach:
- Science education creates a foundation with which participants are able to understand and analyze their lifestyles and behaviours.
- Participants who better understand the impact that their choices have on their own health are more likely to adopt healthier behaviours.
- Empowering participants to make behaviour change individually develops a foundation where change on a community level is more likely.
This article will also discuss how such a model can be used to further other public health messages.
“Go to the people. Live with them. Learn from them. Love them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say 'We have done this ourselves’.”
- Lao Tzu
II Community Engagement
Community engagement is known as a “blend of science and art that is based on multiple scientific disciplines and organizing concepts.”  It is also the process of working “with and through groups of people so that they become involved in decisions that affect them.”  These decisions can involve anything from planning, developing and implementing a service on a community level to implementing policy changes on a municipal or provincial level. Key principles of successful community engagement in public health include early involvement, transparency and accountability and a foundation of mutual trust and respect between the public health practitioner and the community itself. 
However, in spite of incorporating these principles, sustainable and long-term community engagement is often difficult to achieve. Community engagement amongst youth is especially difficult, as it often incorporates an added barrier of power inequity due to age differences between the public health practitioner and the community of youth.
III Supporting Education, Empowerment and Development through Science (S.E.E.D.S.)
S.E.E.D.S. is health promotion at its very core. It is a forum for youth to identify, discuss and debate factors behind lifestyle choices: stress, poverty, cultural norms, as well as media and peer influences. While some activities focus on understanding the psychosocial impact of the media in influencing food consumption and physical activity, others delve into nutrition and its impact on oral health and self-esteem. Others still focus on smoking as a lifestyle choice, and the inability for consumers to quit despite knowing the repercussions. S.E.E.D.S. believes that youth who are better informed about the scientific and socio-economic factors behind their lifestyle choices are more likely to make better ones.
Since its inception in 2012, S.E.E.D.S. has overcome many challenges related to youth engagement in the communities that it serves. Some of these challenges include lack of interest in public health issues, academic, and extracurricular activities, and in their communities as a whole. Through the development of an innovative science-based afterschool program that targets key public health issues within high needs neighbourhoods in the GTA, S.E.E.D.S. has been able to tackle these challenges and successfully engage youth. This success is attributed to the utilization of the following approach:
- Understanding the community.
- Building a mutual foundation of trust and understanding.
- Empowering youth to make a change.
This approach can be better understood using the example of a pressing public health issue that S.E.E.D.S. has tackled: tobacco consumption among youth in high needs areas. The first step in addressing this issue was to understand the community itself. While demographics and data related to the numbers of youth that were smoking within the community were easily accessible, understanding why the initiation and prevalence of smoking was so high within this community in particular was important in developing a solution.
To do this, multiple key stakeholders within the community were consulted including principals and teachers of community schools, community youth advocates and pre-existing organizations already working with youth within the community. This level and type of community engagement allowed for the underlying factors behind high rates of youth tobacco use to be brought to light. Through this process it was determined that the two key factors that led most to tobacco use within this community were lack of activities to keep them occupied afterschool; and lack of understanding about the impact of continued tobacco use.
To tackle these underlying factors, it was important to build a mutual foundation of trust and understanding which was only possible when the same language was used to communicate. In this case, the language was science. Through science, youth were able to better understand why tobacco use was injurious to their health through conducting their own experiments and discussions. An activity titled “Graphing the consequences of smoking” was developed by the S.E.E.D.S. team, where time elapsed and impact on the body were two axes of the chart. Students were then asked to determine what some of the effects that tobacco use could have on their body, such as: yellow teeth, bad breath, trouble breathing, COPD, lung cancer, and eventually death, and graph them according to the duration of tobacco use. The end product was a visual representation of the impact of continued smoking on health, an image that many students said really helped them understand how smoking even a few cigarettes daily for a long period of time could put them at higher risk of developing serious and life-threatening diseases later on in life. It helps them become aware of the traps new smokers often fall into when first making the decision to try smoking; underestimating the long term effects.
Additionally, an activity titled the “Model Lung” that explores the biological changes that take place within the body due to smoking was also created to further illustrate the direct and long-term impact of tobacco use on health. Participants were asked to create model lungs using bottles and balloons, and were then asked to modify parts of the model lung to illustrate the impact of smoking on changes within the lung itself. In discussions that took place after this activity, youth participants mentioned that they were more likely to remember the visual representation and scientific lesson of the impact of smoking on a biological level and were less likely to smoke in the long-term. Thus, through the use of a common language, science, to educate youth about the impact of personal decisions that they were making allowed them to explore their environment and change their perceptions at a convenient time.
While some personal perceptions about smoking changed as a result of these afterschool science-based programs, the true impact of the S.E.E.D.S. program was a result of various tools, skills and resources used to empower youth to make change within their communities. These tools and skills included helping youth participants identify areas in their community where tobacco use was prevalent, and helping them develop an initiative to help inform and educate their friends, family and other members of their communities about the impact of tobacco use on health and well-being. To ensure the sustainability of these initiatives, these youth were also connected to resources within their communities, such as public health nurses, and advocates within youth-run organizations to help support their goal of making their communities smoke free.
Thus, through the approach of understanding the community, building a mutual foundation of trust and understanding, and empowering youth to make a change, S.E.E.D.S. has been able to successfully promote community engagement, especially among youth participants in high needs areas. This innovative approach built on the foundation of a common language, science, is a new way to engage communities about today’s pressing Public Health issues.
1. Peel Region. 2012. “Community Engagement as a Public Health Approach”. Retrieved online from: https://www.peelregion.ca/health/library/pdf/Community_Engagement.pdf
2. City of Guelph. 2014. “Guiding principles for community engagement”. Retrieved online from: http://guelph.ca/city-hall/communicate/community-engagement/
For more information about S.E.E.D.S., please visit our website: http://www.scienceforlife.org, follow us on twitter: @SEEDSscience and like us on Facebook: https://www.facebook.com/seedsscience. All activities are licensed and copyrighted under S.E.E.D.S. Inc. 2015 and may not be duplicated or used without the permission of the organization.
Systems Thinking: A Paradigm for Health Innovation
--Submitted by Anne Rucchetto
To best address the health needs of Ontario’s diverse population, a scaling back from a focus on individuals is required, as well as a critical investigation of larger societal structures and contextual factors.
Systems thinking, an increasingly discussed approach to healthcare, operates with the understanding that health status is a reflection of the larger “whole” of our lives, and is one component of a set of interdependent, complex parts. This means that the conceptions and treatment of health require reflexively considering the intersection of our social, political, geographical, and ecologic environments (Norman, 2015). Growing research reflects that health outcomes are symptoms of governing systems which largely determine the habits, “choices”, and behaviors that have been traditionally associated with individualism. The importance of systems thinking is based in its ability to integrate precipitating factors into our understanding of health: a primary indicator of individual—and societal—well-being. This requires acknowledging that the causes of health problems cannot always be stated conclusively or definitely. In some cases, these adverse outcomes are expression of persistent, deeply embedded patterns that underlie deceptively simple pathways to certain outcomes, such as obesity. If policymakers, educators, academics, and practitioners can work together for a common goal of improved health with the motivation to address distal influences on health outcomes, there is an opportunity for sustained innovation.
Health promotion, a field which is influenced by diverse disciplines including biomedical empiricism, epidemiology, psychology, and sociology, is uniquely positioned to communicate the benefits of systems thinking. Drawing from a spectrum of knowledge is a core component of both health promotion and systems thinking. Public health is concerned with equity and advocacy. Health promoters can link theory and practice to the array of stakeholders that preside over healthcare, using knowledge translation and accessible information to work towards a paradigm shift that embraces systems thinking. Looking at individuals as products of their environment is advantageous because it allows for new developments in healthcare.
Spending on healthcare continues to increase, but whether or not benefits have been accumulating is debatable (Canadian Institute for Health Information, 2014). One issue of major discussion and debate is the current obesity epidemic in Ontario—and across Canada. This healthcare issue will only become more “expensive”, in terms of dollars spent and in the cost to people’s well-being and quality of life. Systematic reviews of interventions that target obesity at the individual level are important, but mostly serve to illustrate that they cannot begin to “solve” this societal problem, beyond a band-aid approach. Tackling obesity presents an opportunity to engage systems thinking.
Obesity is a health issue that often results in chronic disease and death, when “untreated” (Health Canada, 2006; Statistics Canada, 2013.) But what does the growing incidence of obesity really show us? Growing research has shown that people’s sociodemographic characteristics—the social determinants of health—illustrate systemic patterns in the distribution of disease, with obesity serving as one of the most prominent examples of this. People who experience marginalization, which can occur (and compound) in terms of race, socioeconomic status, education, and neighborhood of residence, are at much higher risk for obesity than wealthy, well-educated, white people living in neighborhoods with high walkability and accessible grocery stores.
Therefore some people are experiencing increased “exposure” to the outcome of obesity, based on the context they operate within. Eating “healthy” through reducing caloric intake and exercising are two recommended solutions for people struggling with their weight. But they often face many barriers to be able to make these changes in behaviour including lack of time, cultural differences, diverse body types, and deficit of access to services. Furthermore, the moralization of obesity has positioned those who are obese, or noticeably “overweight” as targets for a multi-billion dollar diet industry, mockery in popular media, and even, in some cases, condemnation at the hands of the healthcare industry.
When we contemplate the environment within which inequalities manifest, obesity can be re-framed as an issue of inequality rather than lack of self-control or some other presumed capacity deficit. Rather than direct resources into interventions that might provide individuals with a dietitian, a meal plan, or a personal trainer, health promoters and other key stakeholders might instead expand the presence of bike lanes, or increase community resources such as grocery stores and community centers. However, urban planning strategies to target obesity are one approach to consider, in conjunction with the expertise of other sectors. Interventions at the interpersonal, community, and population level are required to challenge a “system” with many unintended outcomes contributing to obesity and poor health generally. It is in the most deprived geographic areas where health inequalities are the most striking. This is why broadening our vision of health beyond the narrow focus on the individual to include the broader social determinants of health is vital as we go forward, trying to promote and sustain a healthier population. Rather than focus solely on individual lifestyles, a collaboration of industries and experts is needed to consider the intense influence of the systems we operate in. Health is one piece of a large, complex puzzle, but without considering the parts that comprise it, we are left with a very incomplete picture indeed.
Canadian Institute for Health Information. (2014). National Health Expenditure Trends 1975-2014. Retrieved from: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/nhex_2014_report_en
Health Canada. (2006). Obesity: It’s your Health. Retrieved from: http://www.hc-sc.gc.ca/hl-vs/alt_formats/pacrb-dgapcr/pdf/iyh-vsv/life-v...
Norman, Cameron. “Systems Thinking.” University of Toronto. Dalla Lana School of Public Health, Toronto, ON. (4 February 2015). Lecture.
Statistics Canada. (2015). Obesity. Data File. Retrieved from: http://www.statcan.gc.ca/eng/help/bb/info/obesity