Using social media for messaging about healthy eating and active living

I was fortunate to have the opportunity to do a session on “using social media for messaging about healthy eating and active living” with Dr Becky Freeman from the University of Sydney recently. I’ve attached the slides from the session below, which probably won’t adequately capture what was covered but may provide some background if you have any questions. If you do, please email.

Does health impact assessment protect health? Is that the right question?

There’s a thought-provoking piece at ABC Environment on Does environmental impact assessment protect the environment? The piece quotes several well-known Australian EIA academics about how well EIA in Australia is performing in terms of environmental protection.

There’s no consensus in the piece about whether EIA is successfully protecting the environment or not, though some different ways of thinking about it are discussed. I think that’s because the article dances around the core issue: what is the purpose of EIA? This may seem axiomatic and uncontested but I wonder if it’s an under-examined difference between the goals and purpose of impact assessments.

In a sense we’re lucky in the HIA field. The yoke of regulatory requirement and government mandate hasn’t weighed us down too much… yet. Practice is still evolving and hasn’t been circumscribed by regulations and legal challenge to the same extent as EIA. Because of this, my impression is that there’s more acceptance that an HIA will probably have a limited impacts on health outcomes in itself. The stated goals of HIA are to protect health, promote health and to reduce health inequalities (and possibly to improve governance and public decision-making, as well as learning). HIA seeks to influence decision-making and implementation in order to influence a range of determinants of health, which in turn will impact on health outcomes, as shown below:

Diagram - HIAs Influence

This is an idealised representation of an HIA’s influence. Other assessment processes, organisational considerations and even broader social conditions will play much larger roles. In fact the process depicted is never linear either. Health outcomes and determinants are constantly changing, and decisions are constantly revisited. The delay between an activity and eventual health outcomes can sometimes stretch to decades. At each step there are a multitude of other factors that exert influence, apart from the HIA.

Though HIA’s goal is to protect health, like EIA’s is to protect the environment, the practical purpose of an HIA is to change decisions and implementation – the first step in the process depicted above. We should think about the purpose of EIA the same way. It’s not an environmental intervention, it’s a decision-making intervention/ Burdening it with expectations of environmental protection isn’t realistic.

If we do acknowledge that it will be difficult if not impossible for an HIA to demonstrate its role in changing health outcomes, we should redouble our efforts to prove its effectiveness in influencing decisions and implementation. I made a related argument in a recent article:

In some ways the issue of effectiveness may have less currency in relation to other forms of IA [than HIA]. Impact assessment, in particular environmental impact assessment, is used in some form in almost every country. Its use is common, accepted, well understood and not usually actively compared to other interventions or activities. This is not necessarily true for health impact assessment though because of the resource constraints and associated health disciplinary and epistemological concerns… if HIA’s use is to continue to be supported in increasingly resource-constrained health systems that demand evidence of the comparative effectiveness of interventions.

The right question is not whether HIA changes health outcomes. Instead it’s does HIA change decisions, implementation and ways of working?

Health Impact Assessment: A triumph over common sense?

I’m giving a plenary talk at the 4th Asia Pacific Health Impact Assessment Conference in Seoul this week. I’ve attached the slides, a detailed paper and abstract below.

Download the detailed paper of the talk (21 pages PDF)


Evaluations of health impact assessments (HIAs) have highlighted its potential impacts on decision-making, implementation and broader factors such as intersectoral collaboration (Harris-Roxas et al. 2011, Harris-Roxas et al. 2012b, Wismar et al. 2007). Tensions often arise between stakeholders about the outcomes of HIAs however. Studies that have looked at this have found that there are:

  • Often disagreements between stakeholders about the perceived purpose of the HIA and what form it should take (Harris-Roxas et al. 2012a, Harris-Roxas & Harris 2011); and
  • The perception that an HIA’s recommendations could have been identified through normal planning and implementation processes and that the HIA didn’t necessarily have to be conducted (Harris-Roxas et al. 2011). In other words, that an HIA’s recommendations are “common sense”.

These two issues, about the perceived purpose of HIA and the “common sense” nature of HIAs’ recommendations, lie at the heart of any discussion of the HIA effectiveness. These issues have also been under-explored in the literature to date.
This plenary will present initial findings from a study that looked at two decision-support equity-focused HIAs of similar health sector proposals (local health service obesity prevention and treatment service plans) longitudinally. This involved conducting 23 semi-structured interviews with key stakeholders before, during and after the HIAs, and document reviews. One of the HIAs was completed while the other one was screened and determined to be unnecessary. This study is unique in relation to HIA to the authors’ knowledge, because it looks at expectations and perceptions of effectiveness before and after the HIAs were completed. It also compares two similar planning situations, one in which an HIA was conducted and one in which the HIA was screened out.

The study’s findings highlight that while many of the recommendations and distal impacts of an HIA (Harris-Roxas & Harris 2012) could notionally be anticipated through common sense analysis, in practice they are rarely foreseen. A similar phenomenon has been demonstrated in other fields such as organisational psychology and management (Orrell 2007, Watts 2011). This study also highlights the critical role that learning plays in impact assessment practice (Morgan 2012, Bond & Pope 2012). This learning takes three forms: technical, conceptual and participatory (Harris & Harris-Roxas 2010, Glasbergen 1999). Learning may also take place at individual, organisational and social levels.

This suggests that “common sense” is anything but common in the real world of planning and decision-making, and for good reasons. What seems obvious in hindsight is rarely apparent in advance. HIA, as a structured process for looking at under-considered impacts, has an important role to play in moving beyond common sense towards broader learning and more nuanced analyses of alternatives.

Bond A, Pope J (2012)
The State of the Art of Impact Assessment in 2012, Impact Assessment and Project Appraisal, 30(1):1-4. doi:10.1080/14615517.2012.669140

Glasbergen P (1999)
Learning to Manage the Environment in Democracy and the Environment: Problems and Prospects (Eds Lafferty W and Meadowcroft J), Edward Elgar: Cheltenham, p 175-193.

Harris-Roxas B, Harris E (2011)
Differing Forms, Differing Purposes: A Typology of Health Impact Assessment, Environmental Impact Assessment Review, 31(4):396-403. doi:10.1016/j.eiar.2010.03.003

Harris-Roxas B, Harris E (2012)
The Impact and Effectiveness of Health Impact Assessment: A conceptual framework, Environmental Impact Assessment Review:accepted, in press. doi:10.1016/j.eiar.2012.09.003

Harris-Roxas B, Harris P, Harris E, Kemp L (2011)
A Rapid Equity Focused Health Impact Assessment of a Policy Implementation Plan: An Australian case study and impact evaluation, International Journal for Equity in Health, 10(6), doi:10.1186/1475-9276-10-6.

Harris-Roxas B, Harris P, Wise M, Haigh F, Ng Chok H, Harris E (2012a)
Health Impact Assessment in Australia: Where we’ve been and where we’re going in Past Achievement, Current Understanding and Future Progress in Health Impact Assessment (Ed Kemm J), Oxford University Press: Oxford, accepted – in press.

Harris-Roxas B, Viliani F, Bond A, Cave B, Divall M, Furu P, et al. (2012b)
Health Impact Assessment: The state of the art, Impact Assessment and Project Appraisal, 30(1):43-52. doi:10.1080/14615517.2012.666035

Harris E, Harris-Roxas B (2010)
Health in All Policies: A pathway for thinking about our broader societal goals, Public Health Bulletin South Australia, 7(2):43-46.

Morgan RK (2012)
Environmental impact assessment: the state of the art, Impact Assessment and Project Appraisal, 30(1):5-14. doi:10.1080/14615517.2012.661557

Orrell D (2007)
The Future of Everything: The science of prediction. Basic Books: New York.

Watts D (2011)
Everything Is Obvious (Once you know the answer). Crown Publishing: New York.

Wismar M, Blau J, Ernst K, Figueras J (Eds.) (2007)
The Effectiveness of Health Impact Assessment: Scope and limitations of supporting decision-making in Europe, European Observatory on Health Systems and Policies, World Health Organization: Copenhagen. International Standard Book Number 978 92 890 7295 3.


Improving public health messaging

I wrote this post for Croakey and Reporting on Health a little while ago. The ideas are relevant to a lot of health-related communication.

If you follow health reporting on TV or in newspapers you could be forgiven for thinking that the only things that happen are scandals in clinical services or trials of new drugs.

But journalists and PR people aren’t necessarily all to blame. As health professionals we often do a pretty bad job at explaining what we’re doing.

I’ve been thinking about how we can do a better job of explaining the slightly more complex interventions that are required for a lot of the population health problems we face. New drugs and clinical stuff-ups fit into well understood tropes. We don’t have to explain everything, the audience can take shortcuts because they understand what type of story it is.

When it comes to population health issues it’s often not as easy because the issues are interdependent, and many of the interventions are unfamiliar to a mainstream audience.

A lot of my work is on health impact assessment, which involves developing evidence-informed recommendations to inform decision-making and implementation.

When it’s explained like that, it’s no wonder journalists aren’t interested. It sounds like a technocratic snooze-fest.

Instead, let’s think about the demand for new housing in most Australian cities and the pressures to release new land on the fringe. Also think about how disastrous the design of some new suburbs has been for population health in the past by promoting car dependence, limiting walkability and increasing social isolation. The design of our suburbs matters.

Health impact assessment has been a practical way to get people to think about the health consequences of the way suburbs are designed and here’s a few examples…

Contrast that story with the bland description of health impact assessment in the earlier paragraph. It sounds a lot more engaging.

We often fail to describe this broader story in population health, not just when pitching stories but also when we communicate with other sectors (or even within the health sector).

Here are four ways I think we could get better at messaging.

1. Don’t explain the solution, explain the problem

Or better yet, explain the causes of the problem. This piece from the Atlantic Cities is a good example. It describes the phenomenon of “ghost estates” in Ireland, which came about when 2,800 housing developments were abandoned as a result of the GFC. A community group has started planting trees on these sites to reintroduce some aspects of nature into these abandoned building sites. The piece works because rather than leaping into a description of the NAMA to Nature group, it first describes the problem as well as its causes. Too often we forget the broader context when describing what we’re doing in population health.

 2. Don’t rely on the usual suspects

There’s evidence that people are more willing to listen to arguments when they come from unexpected sources, at argued in this Ramp Up post. A good example recently is the conservative economist Judith Sloane’s calls for an increase in the NewStart allowance. She could hardly be described as a usual suspect when discussing the rights of the unemployed. Different people paid attention to her comments as a result.

3. Avoid jargon and language that alienates people

The importance of this is emphasised in the Robert Wood Johnson Foundation report A New Way to Talk About the Social Determinants of Health. People switch off when things are described in stereotypical or politicised terms. As health professionals we often tend to fixate on the solutions and the jargon that surround them, partly because it’s what occupies most of our time but also because we are already convinced about the importance of the problem.

4. Describe the human impact

This is often the hardest part for population health stories. Individual stories can illustrate broader population issues but they can also be misleading and seem glib. We often understandably resist this because we have an obligation to respect the dignity and privacy of the people we work with and we can’t control how their experiences will be reported. Without the human dimension though it’s difficult for not only journalists but also the audience to connect with the story. Human-scale narratives still matter, even with the most abstract ideas.

A good example of a media piece that embraces history, messiness, complexity and a population approach is Melissa Sweet’s description of Miller for Inside Story. It’s a story about the problems faced by a suburb in South West Sydney.

It’s an almost impossible story to convey in usual journalistic form because it has a lot of history and people involved and doesn’t have a neat narrative arc or resolution. Despite this, the piece manages to convey a lot of the complexity to the reader and provides a number of insights. The point is that it is still possible to tell even the most complicated stories in engaging ways.

We’re confronting big social and population health challenges but we have some ideas about the solutions. We just need to make sure we don’t bury the lede.

Talking Twitter on Radio National Drive, 1 June 2012

I was on Radio National Drive with Julian Morrow, discussing interesting stuff from Twitter. Here some of the Twitter accounts and links I mentioned:

Digital sabbaticals

Political ads from 60 years ago

The new computer game baddies: Drones

Alain de Botton’s “Better Porn”

Links from the RN Drive Twitterati segment

I was on RN Drive talking about Twitter. Here are some of the links and accounts I mentioned:

All Titanic, all the time


The “tribal” textile prints craze that’s sort of Dutch – and a bit Indonesian

Pirates in space!

Recipes in 140 characters

Account to follow: @RandomTEDtalks
@ RandomTEDtalks

Health Impact Assessment: The state of the art


Several International Association for Impact Assessment Health Section members and I have written a paper in the latest issue of Impact Assessment and Project Appraisal on Health Impact Assessment: The state of the art. It’s part of a special issue on the state of the art in impact assessment that was edited by Alan Bond and Jenny Pope. Most of the papers are excellent reading for anyone interested in impact assessment.

Harris-Roxas B, Viliani F, Bond A, Cave B, Divall M, Furu P, Harris P, Soeberg M, Wernham A, Winkler M.  Health Impact Assessment: The state of the art, Impact Assessment and Project Appraisal, eFirst.

The paper is available for free to IAIA members, just log into the IAIA website and follow the IAPA link. If you have difficulty accessing the paper please contact me.

A curator is not a digital dilettante

There’s been a lot of discussion about online curation recently in the wake of the Curator’s Code and the video below from Percolate. Most of it hasn’t sat well with me. I’m a compulsive consumer and sharer of online media. I think people mostly follow me for the links I share. I probably fit more into the “online curator” category than any other. Why, then, do I consider so much of the discussion about online curation to be self-indulgent silliness?

Marco Arment, the developer of Instapaper, posted a salient critique of the Curator’s Code. Most of the critiques to date have focused on the silliness of promoting squiggly lines for attribution but the fundamental problem runs much deeper. It’s the nonsense notion that finding and sharing information on the “whimsical rabbit hole of discovery” (urgh) is a creative act that warrants attribution.

Marco’s right about this fundamental point. My personal critique of the online curation movement is based on two central concerns and thinking about this has also prompted me to think about whether things should or could be done differently.

My first concern is that being obsessed with “ideas” and “interesting things” encourages superficial engagement with topics. It encourages us to focus on stuff that’s fun, exciting, and almost immediately gone from our minds. Very rarely does it challenge us or encourage deeper engagement with topics. As any actual expert will tell you, the more you know about a subject, the more you realise how nuanced, conditional and dependent on other factors much knowledge is. We also collectively face an increasingly complex set of wicked problems. Exposing people to often overly simplistic and superficial descriptions of topics is not curation; it’s entertainment. That’s a legitimate activity but don’t pretend it’s something that it’s not.

My second concern is that curation is more than just presenting a grab-bag of links based on your personal taste or what you think will attract clicks. Curating tells a story. It involves bringing together several works in a way that may lead to greater appreciation, understanding and insight. Instead of worrying about via or ht (hat-tip) attribution for links we should be worrying about the story that’s told by the links we share, as a gestalt. What do they say about us and what we care about? What do they give to the people who take the trouble to read or watch what we link to?

So what is the story we should be telling through online curation? (though that term still doesn’t sit well with me) I’m not sure. Thinking about this prompted me to consider what broader messages I’ve been trying to convey through the links I share. I think I’ve been trying to say three things:

  • Many issues are related and interconnected;
  • We face huge problems that we have a responsibility to tackle; and
  • The best thing about humans is our capacity to have fun!
  • I’m fairly sure I haven’t succeeded in conveying these ideas to my audience, which I wouldn’t like to pretend is overly large. Even thinking about it has helped me though, because it’s also forced me to consider what I’m not trying to suggest when I link to stuff online.

    Attribution, via squiggly unicode characters or otherwise, should be the least of our concerns. Such egoistic behaviour is beneath us.

    Referring to this sort of activity as curation also dishonours the hard work of actual curators going back centuries. When was the last time you went into a museum and found a pile of unrelated stuff that someone thought was “interesting”? That’s not a curated collection, it’s a garage sale.

    Be honest about what you’re doing – sharing links and having some fun.