Innovation in Research & Knowledge Exchange

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

2. Paradigm Shifts in Knowledge, Methods, Analysis … starts with various or diverse notions of what is known… what causes the known

3. “… we must depart from habits of mind that have characterized our usual (knowledge and) thinking.” - Clyde Hertzman

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

5. Philosophies:

6. Knowledge:

7. Governance:

8. Community Organizations:

9. Paradigm Shifts in Knowledge, Methods and Analysis… starts with various? notions of causation Disruptive Linear 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” • 721-1980’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) Disruptive Linear 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. Principles of causation in Social Epidemics “Tipping Point”The “boiling” point of massive modern change”by Malcolm Gladwell “Biographies of Mysterious change 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. Examples: 1987 1 Million fax machines 1989 2 Million fax machines OR 1990 Cellular phone 1998 Everyone has one

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

14. Different Ways of Tipping 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. How can we create positive social epidemics?

17. Epidemiology: 721 in 1980’sCriteria for Causation 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. Reality Is Complex

19. Figure 1: Bioecological Model of the Reciprocal Influences Between Environments on Child Development LEGISLATIVE REGULATORY POLICIES ENVIRONMENTS • School • ESL • Grade 3, 6, 10 • Passing Test • CHILD • Well-being • Achievement • - Birth Weight (HBHC) • EDI/KPS • EQAO • Emergency Visits • (10-24 yr. olds) • Special Needs • Parents • Neighbourhood • Family Constellation • Community • Population Health and Human Service Utilization • Family • Med. Income • CAS • Gov’t transfer

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. Figure 2 Latent LEGISLATIVE REGULATORY POLICIES ENVIRONMENTS • School • ESL • Grade 3, 6, 10 • Passing Test • CHILD • Well-being • Achievement • - Birth Weight (HBHC) • EDI/KPS • EQAO • Emergency Visits • (10-24 yr. olds) • Special Needs • Parents • Neighbourhood • Family Constellation • Community • Population Health and Human Service Utilization • Family • Med. Income • CAS • Gov’t transfer Cumulative Pathways Life Course • 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.

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

24. Figure 3 Racial Discrimination Poverty Youth Sexual Discrimination Physical Illness Mental Illness Latent Intersections of Vulnerability Cumulative Adult Pathway School Age Sensitive Periods Early • Causation is non specific: e.g., exposure to a disadvantaged environment causes multiple outcomes: "multifinality".

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. Changing What We Know

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31. Calculating Sample Size: estimating For main effects For interaction effects Changing

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