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Closing the Knowledge to Action Gap: Is Health Promotion and Health Education on the Verge of a Breakthrough?

I International Union for Health Promotion and Education Conference 2007: The View from Outside

This week, several thousand people from around the world are meeting in Vancouver at the 19th IUHPE World Conference on Health Promotion & Health Education. I am one of them. It is day three. This is my first conference of this type. As a relative newcomer to looking at issues in society from a population health perspective, I am intrigued, excited, and concerned about what I am hearing, seeing, and feeling.

I am a graduate student in the Ph.D. program at the Institute of Population Health at the University of Ottawa. However, I have spent 25 years working, volunteering, promoting, and thinking about knowledge mobilization, value creation, and exchange processes and putting what is known into action. I have not always used these terms, but the meanings have been similar. I have done this as a student on projects for Africa and in Canada--yet the same problems that troubled me as an enthusiastic teenager remain now as I approach middle age. The basic techniques of social marketing that I used for profit in business seem to be ignored in these health fields where the efforts are of greater importance and greater potential impact for our most vulnerable populations. One area of government develops programs and infrastructure such as the Community-University Research Alliance program at the Social Services Health Research Council and demonstrates their success through evaluation. But these successes go almost unnoticed in departments with more resources and arguably with greater potential impact, such as Health Canada.

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II  Dynamic Tensions

On the one hand, IUHPE has gathered together bright minds and good hearts--people concerned about their communities, societies, humanity and the environments that we all live in--seeking better ways of coping with the problems faced by people and their families. Some are even reporting that they are finding solutions to ending contagious and chronic diseases and conditions.

On the other hand, the conference has assembled those in positions of influence and authority, armed with the knowledge to end many of the world's great health problems. Yet it is rare to meet those in authority with their sleeves rolled up, with dirt under their nails, pushing hard to implement and utilize this knowledge in the places where the impact is most needed.

This tension is perhaps a dynamic one, an indicator that a change or breakthrough is on the horizon. A graduate student at the plenary session, "Knowledge Translation: Linking Research and Policy" took her stand at the microphone and clearly asked: "Where are the community members? Where's the citizen engagement?" She was applauded. Four others with an opportunity to stand at a microphone referred to her question. The panelists, all senior members of the academy, government, and the health establishment, had little to say in response. It is not that they didn't have anything to say. It seemed that the entire audience knew what they could not say: despite all the knowledge that has been generated in universities, governments, communities, foundations, and multiple other places of our society, we seem unable--if not unwilling--to put the same effort into using what we know.

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III  Health Promotion and Knowledge Mobilization

Health promotion, health education, knowledge transfer, knowledge exchange, knowledge mobilization--are all topics for discussion but if they remain only as discussion, their true meaning is lost. The tension I have felt these past three days speaks to the need of those engaged in health promotion to close the gap between what we know and what we do to improve the health of our society, between the time it takes to do things and the urgency of the things that need to be done.

Health is complex. As such it is emergent--we are or we become healthy because of the interplay of many factors. We know this. As a society, we have known this for a long time, yet many of us are less healthy than we should be. As a father of teenagers, I cringe when I hear that the life expectancy of my children and their peers may be less than my own. But cringing will not fix the problem. Rolling up my sleeves, pushing hard, sweating to implement better health strategies may turn the tide.

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IV  New Forms of Leadership

Much of my work is on leadership and the conditions that support the development of leaders, specifically in marginalized communities or in areas that have been inadequately supported such as child and youth mental health. The message that I am taking from this conference, through this lens, is that those who are most active in the field are creating new forms of leadership. This new leadership may overtake or simply abandon some of the more established institutions of our society.

The presentation on knowledge translation in Aboriginal public health and promotion from the National Aboriginal Health Organization (NAPO) made it clear that they are not waiting for others to come to them to tell them what they need to do. They have waited much too long. They have developed clear guiding principles of empowerment, self-determination, meaningful relationships, and relevance when it comes to research. They have created strong statements about ownership, control, access, and possession or stewardship of information about individuals and the communities they live in. They've created toolkits and workshops on using the tools of research to carve the data and information that they need to make decisions. Among the publications available from the Ajunnginiq Centre is one elegantly titled: "What Sculpture is to Soapstone, Education is to the Soul: building the capacity of Inuit in the health field." Having the stone or information is one thing; carving a thing of beauty whether in stone or in a mind is another. They cannot and must not be confused.

Models of leadership are emerging from communities who have waited too long for help. If you want to see innovative leadership, look to our First Nations communities, look to New Canadian communities, look at what our youth are doing online and among their peers. The old hierarchies are not dead, but they are wounded and they are seen as less effective.

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V  Building Infrastructure

The Ottawa Charter, established over two decades ago in 1986, laid the fundamental guiding principles and values for health promotion. It describes five strategic areas: building healthy public policy, creating supportive environments for health, strengthening community action, developing personal skills, and reorienting in health systems. The feeling in Vancouver is that it is long past the time to put those principles and values into action. It is time to mobilize, partner, collaborate, and build the infrastructure needed for a healthier Canada, and given the international context of this conference, for a healthier world.

But building infrastructure to support action requires resources. These resources are said to be scarce. Yet we see millions upon millions of dollars going into massive projects which do not create health--rather, they destroy it. Resources follow will and power. Those with power, and sometimes those with compassion, control where the resources are applied. They make the decisions. They are the decisionmakers, the policymakers, referred to so often by those seeking to transfer what they know. Yet there is not an individual, a community, or a society, that does not engage in decision making daily, hourly, or minute by minute.

Canada requires innovative structures to support knowledge mobilization processes in health.  This may require new leadership, new organizations, but it will absolutely require more resources and these resources will have to be fought for by strong leaders. One suggestion was for the health promotion and health education community to create the equivalent of a Network Centre of Excellence. Comments overheard in the hallway felt this was a good step but did not go far enough. Either way, organizational innovation is needed.

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VI  Feedback Loops

Complex systems require feedback loops. Not feedback loops that create noise to be ignored, but loops that provide vital information about what is working, what needs adapting, and what needs abandoning. What sorts of feedback loops provide the best data and information to improve the effectiveness of health promotion and health education? Given that few of us have the answers, the US National Institutes of Health are promoting knowledge implementation grants, open internationally, to better understand issues such as this.

Not all decisions are made quickly. One commentator from the Netherlands spoke of fast knowledge and slow knowledge. I like this. We need to think about both efficiency and effectiveness. Indeed, we need to be able to act in timely ways when needed. We also need to have time and space to think, plan, dream, and test our knowledge before we act. And then we need to act. A conference is a good place to do this but a better place is where we live and work. How do we support the energy and enthusiasm found at an international conference when we return home?

One answer to supporting this energy and enthusiasm is found in that graduate student's comment: community. Whether in a "community of practice" or in our traditional concepts of communities of interest or place, the interaction between people in community tends to provide the energy needed to build the bridges between what we know and what we do.

Tomorrow is about strengthening community action and developing personal skills. Whether or not a "breakthrough"--in the big groundbreaking sense of the world--will happen is unclear at this point. However there are small breakthroughs happening with each coffee break, in the hallway discussions, with each question asked at the microphone, over the assorted dinner tables and during the sidewalk conversations back to the hotels.  There is an excitement in the air as well as some caution about where health promotion and education is going.  I am hopeful that it will lead to more courageous action with both the will and the resources needed to make our communities healthier and more aware of our collective needs.  Maybe this awareness is the breakthrough?