Thursday, March 24, 2011

Concept Mapping: Quelling the Anxiety of Complex Problems

Some public health problems are pretty straightforward. Implementing a vaccination program in an area of high incidence of polio, for example, might be fraught with political or infrastructure obstacles, but we know if we administer the vaccine to the population, polio will decrease and lives will be saved. This is a “tame problem.” On the other hand, there are large, abstract issues whose boundaries are unclear, which are aptly called “wicked problems” (Rittel and Webber, 1973).

One such wicked problem is insidious, spanning all levels of society, from the cell to the population, and it has kept me up for more nights than I care to admit. This is the social determinants of health, the complex web of socioeconomic conditions that affect the health of individuals as well as communities (Raphael, 2004).

A video on the social determinants of health by Lemongrass Media commissioned by Vancouver Coastal Health clearly demonstrates the predicament. It features a married couple representing people of high socioeconomic status (SES) and two unmarried individuals representing people of low SES. This cinematic juxtaposition of high and low SES brings home the message that social factors and money affect the quality of one’s life and health. That stark contrast also brought up many emotions for me when witnessing how people of lower SES struggle with being able to access the services needed to raise a child or even pay for necessary medications (2010).

One of the obstacles endemic to addressing wicked problems is how overwhelming they can be, setting in a kind of stress-induced paralysis (Finegood, 2011). A common stress management tool is to break down a large problem into smaller problems and tackle them one by one. This is where the process of concept mapping can be extremely useful.

Another way of looking at concept mapping is creating a “thinking tool,” which can help access one’s tacit beliefs regarding an intractable problem. The authors of Sketching at Work describe their book as a guide to visual problem solving, stating that concept mapping “invites the drawer to explore a change in perspective” (Eppler and Pfister, 2010, p. 7).

In my own process of concept mapping of the social determinants of health, I realized that I previously thought researching causation and helping people were the same thing. But making a concept map helped me realize that this wicked problem is so complex that if we took the time to fully determine causation before acting, more and more people would be lost.

When I sketched out the pathways that led to poor health I saw how one’s level of education is clearly connected to the kinds of jobs one can attain and how that leads directly to the amount of income one can make. Those pathways are interconnected with healthcare access, food choices, autonomy, security, and awareness of risk and disease. All of these factors are interrelated and extremely complex. Real people are dying every day, and there comes a time when scientists have to put the search for causation on hold and apply their powers to ameliorating the problem. I finally understood why Kreiger and Zierler call for epidemiologic theory to go beyond the narrow focus of “modeling causation and explaining error” (1996) and instead espouse that whatever the means of causation, be it direct or indirect, intervening in social determinants such as education and early childhood development is a high priority.

Because drawing a concept map helped me get to a deeper understanding of this wicked problem, others on the causation bandwagon might be served by making their own map. Fixating on causation in part perpetuates the problem by creating a delay in action. Changing perspective is important in helping science become more aware of the complexity of the problem and move towards figuring out solutions without understanding exact casual mechanisms.


Eppler, M.J., Pfister, R. (2010). Sketching at Work. Switzerland:University of St. Gallen.

Finegood, D.T. (2011).The complex systems science of obesity In J. Cawley, (Ed.), Handbook of the social science of obesity. (p 1-48). USA: Oxford University Press.

Krieger, N., Zierler, S. (1996). What explains the public’s health?: A call for epidemiologic theory. Epidemiology, 7(1):107-109.

Lemongrass Media (2010). Videos: Social Determinants of Health. Retrieved on January 26, 2011 from

Raphael, D.(2004) editor. Social Determinants of Health:Canadian Perspective: Canadian Scholars’ Press Inc. Toronto

Rittle H.W.J., Webber, M.M., (1973). Dilemmas in a general theory of planning. Policy Sciences, 4: 155-169.

Tuesday, March 15, 2011

Justifying Simplicity in the Face of Complexity

Anyone contemplating the problem of chronic disease plaguing countries in the second or third stages of the epidemiologic transition has to be awed by its overwhelming complexity. Of course, many of these diseases are heavily influenced by modern dietary patterns interwoven with many biological and social factors (Popkin 2001; Glass and McAtee, 2006). Here in Canada the problem is no less significant, and Health Canada is working hard on this problem. One area that I will focus on is the food guide, which was developed as one small tool in this battle.

When looking at the latest iteration of Health Canada’s food guide the first graphical element I see is a dizzying array of information simultaneously competing for attention. Further compounding the problem is a cacophony of nutritional messages that come in every shape and form of media, from TV to magazines to Twitter. The overall picture can totally bewilder anyone trying to make healthy lifestyle changes. It is no surprise that public health’s efforts to change behavior are equally as complex as the problems they are trying to change, but does the messaging have to be complex, too?

One important theory from social psychology says no. The limited resource view, developed by Roy Baumeister, states that the brain has only so much glucose to devote to given tasks, and when glucose levels become depleted people will give up more challenging problems (Baumeister et al, 2003;Baumeister and Vohs, 2007). One such challenging problem is changing one’s behavior. People of low socioeconomic status (SES) tend to be taxed by social exclusion, prejudice, and higher levels of work stress (Marmot, 2005). Thus, when faced with challenges like losing weight, exercising, or changing dietary habits, many people simply throw in the towel and quit (Baumeister et al, 2003). I think Health Canada’s food guide can take some advice from this theory and simplify its message.

Here are my three recommendations to Health Canada’s Food Guide Advisory Committee. One is to make a commitment to simpler, more meaningful messages that an average person can understand and follow. Forget about the recommended daily allowances of dairy, grains, proteins, and oils and fats plus leave off the last page with 8 other recommendations. It’s too much information. Focus on the part with the biggest bang for the buck: fruits and vegetables.

If there is one thing you can suggest about increasing health through dietary change it is increasing consumption of fruit and vegetables. Increased fruit and vegetable consumption is associated with eating less processed foods and reducing mortality from coronary heart disease (CHD) and many types of cancer (Crowe et al, 2011:Dauchet et al., 2006). Those two diseases claim the most lives of Canadians (WHO, 2005).

My second recommendation to Health Canada would be that instead of spending so much money and effort on a printed food guide that is widely distributed, I would use the budget differently. I would scale down the food guide and make it web-only, targeted to health educators, institutions who specifically need it, and motivated individuals. Then I would hire a marketing/PR firm to develop a really simple, punchy logo/image and ad campaign to focus on the essential message, one that becomes engrained in the public psyche.

Finally, my third approach would be to work like gangbusters to convince partners in the battle against chronic disease, such as the Heart and Stroke Foundation, BC Cancer Agency and others, to support Health Canada’s message for increasing fruit and vegetable consumption.

Creating a movement of social change needs a consistent, simple message. The average person is being bombarded by all kinds of information; they are stressed and they don’t have the cognitive resources to make the kinds of changes that the current food guide recommends. They just need a simple message to follow.


Baumeister, R., Vohs, K.D. (2007). Self-regulation, ego depletion, and motivation. Social and Personality Psychology Compass , 1(1):115-128 DOI:10.111/j.1751-90042007.0001.x

Crowe FL, Roddam AW, Key TJ, et al European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart Study Collaborators. (2011). Fruit and vegetable intake and mortality from ischaemic heart disease: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study. Eur Heart J 2011; DOI:10.1093/eurheartj/ehq465.

Dauchet, L., Amouyel, P., Hercberg, S., Dallongerville, J. (2006). Fruit and vegetable consumption and risk of coronary heart disease: a metanalysis of cohort studies. Journal of Nutrition, 136(10):2588-2593.

Glass, T.A., McAtee, M.J. (2006). Behavioural science at the cross roads in public health: extending horizons, envisioning the future. Social Science and Medicine 62:1657-1671.

Marmot, M.(2005). Social determinants of health inequalities. Lancet, 365:1099-104.