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.

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