Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please could you give a brief introduction to injury prevention research?
I am an Emergency Physician who became concerned at the frequency and severity of injury presenting to Mackay Base Hospital where I work as a Staff Specialist.
Every twenty seconds someone somewhere in Australia presents to an Emergency Department seeking treatment for an injury. Every minute someone is admitted to hospital. Every hour someone dies. This litany of human suffering is all the more tragic because every single one of these injuries is potentially preventable.
I was a founding member of a community-based network formed to empower the Mackay Community to address the high rates of injury observed in our community. Our ED has been a valuable source of surveillance data used to inform and focus the networks injury prevention activities.
I undertook a Masters in Public Health and Tropical Medicine and subsequently a Doctorate in Public Health. Given the Mackay Safe Communities was using a social process to coordinate and promote local injury prevention activities, my doctorate used Social Network Analysis, a quantitative sociological tool, to describe, analyse and evaluate how the coalition worked.
Would you say there is a gap between injury prevention research and community safety promotion practice?
Unless research is implemented at scale in the real world it will not save lives or prevent harm.
We could make a huge difference if we just paused briefly to apply what we already know.
It would help even more if the research community was better engaged with practitioners, policy makers and indeed the community itself to design research and report it in a way that is capable of practical application in the real world.
The time for action is now. Our lifestyle is killing us. Whether it be the adverse consequences or our bad choices (eg alcohol or injury), the adverse consequences of our lethargy (obesity, diabetes, heart attack and stroke), or the adverse consequences our indifference to future generations (eg global warming), humans are killing themselves and each other in unprecedented numbers.
What do you think are the reasons for this gap?
Health is a complex phenomenon that has many components. Being healthy is not the same as the absence of disease. Of course it is important to maintain a healthy body and mind, but it is equally to ensure a healthy environment and society.
We see it all in the Emergency Department. It is all too easy to focus on the poor behavioural choices people make. The temptation is to just tell people to “smarten up’. The problem is, people already know that inactivity, excess weight, smoking, excess alcohol and drink driving is bad for them. Unfortunately, the day-to-day hustle and bustle of life has such relentless momentum that they don’t know how to change. Until we learn how to make the healthy choice the easy choice, we are unlikely to make progress.
Humans are social beings. It follows that the way we behave is socially determined. Nicholas Christakis has done a compelling social network analysis of the Framingham data set, demonstrating that health is socially determined. If your friend gains weight, you are more likely to gain weight. If your friend stops smoking, you are more likely to stop smoking. If your friend is happy you, are more likely to be happy. The closer the social association, the stronger the effect. Choose your friends carefully! When it comes to health, the social context in which we live matters.
Health is complex. But complex, is not a synonym for complicated. Health is scientifically complex. Complex systems have unique scientific properties. Determinants are inter-related rather than independent. They have non-linear dynamics, tipping points and emergent phenomenon. Worst of all, they are unpredictable, sometimes well-intended interventions have unexpected adverse consequences.
I identify three gaps between research and practice
The efficacy to effectiveness gap (a scientific problem)
The research to practice gap (a process problem)
The disease prevention to health promotion gap (a political problem)
There is a scientific problem. The transition from researching what works (i.e., efficacy and effectiveness research) to how to make it work (i.e., implementation research) is a critical step, but is not straightforward. Success at a population level, or effectiveness, is not solely determined by the efficacy of the intervention; it is also influenced by multiple interrelated contextual factors within the target community.
There is an implementation problem. While researchers report the efficacy of an intervention at an individual level, they rarely report on the process of implementation, adoption, sustainability, and population impact an intervention. Without this information, how can policy makers or practitioners decide whether the proposed intervention would work in their context?
There is a political problem. The dissemination and widespread adoption of an intervention is a social objective that can only be realized in the context of a community and the organizational and political processes that shape it. Evidence that is compelling for researchers may not be automatically accepted by those with the power to implement an intervention. Public policy is set by those who can build enough consensus to intervene, not necessarily by proponents of “best evidence”.
Do you think there is a need to close this gap?
Communities are under increasing pressure to adopt evidence-based approaches but in the pressure cooker of the real world they often find it difficult to adopt and sustain interventions that apparently worked in a research setting under ideal scientific conditions.
As long as research, practice and policy remain disconnected our efforts will remain largely futile. It is not about any of these professional groups “winning”. Until we have applicable research and researchable application, we are all losers. We can only win, if we win together.
In the intense discourse between researchers and practitioners it is easy to forget a third group of stakeholders—the community. Health is, after all, their problem! The community’s perspective is not only important, it is enlightening. They can provide valuable advice regarding best fit; what is feasible, affordable and sustainable in their community.
How do you propose that this gap is closed?
This problem is often framed as a need for better translation of research evidence into practice. However, there is also a need for better translation of evidence from practice into research.
Perhaps the real barrier is not a lack of understanding, but failure to listen! Good communication, good translation and good research, is necessarily a dialogue, a multidirectional conversation in which everyone’s contribution is valued.
Three complementary types of experts are necessary to design efficacious and effective interventions that can be realised in a real world environment:
researchers (content experts)
clinicians, practitioners and policy makers (process experts)
members of the target community, sports bodies (context experts)
Each brings unique skill and knowledge critical for successful implementation of evidence-based practice at a population level.
Please could you give a brief introduction to social network analysis?
Contemporary literature on societal governance and public health argues that the complex nature of social problems, such as health, has profound implications for how they should be addressed.
Networks have been proposed as an effective response to the complex problems that plague modern society. Health practitioners, researches and administrators have enthusiastically embraced the network metaphor. By networking, sharing knowledge, expertise and resources, it is argued that communities can be empowered to comprehensively and effectively promote their own health and safety. If this is indeed the case, it is important to move beyond the network metaphor to develop methodologies able to describe and analyse how this social process works.
Social Network Analysis (SNA) is a suite of quantitative sociological research tools, which analyse how individuals interact to create the structure and function within social systems, and just as importantly, how the contextual social characteristics of a social system determine the behaviour of individuals.
How have you used social network analysis in your research?
The Mackay Safe Communities (MSC) was established in February 2000 in response to high rates of injury observed in the region. A key objective was to consolidate and better coordinate a network of community groups already working in community safety promotion.
Given that MSC was seeking to use a social process (“networking”) as a vehicle to empower the community to address high rates of injury observed in the community, I used SNA to describe the growth and structure of MSC, the mobilisation of human and other resources utilised by the network, and offer insight into how the coalition functioned.
SNA proved a powerful tool for describing and analysing relationships within the Mackay Safe Communities (MSC). It provided diagrammatic representation of the social structure and quantified important changes in the structure and function of MSC Since the network was established it doubled the number of relationships (500 to 1002), decreased the relational distance separating network members (average distance reduced from 3.9 to 2.7) and as a result increased the cohesiveness of the network (density increased from 0.022 to 0.036). There was an increased tendency for group formation (clustering coefficient increased from 0.30 to 0.50) and a more centralised structure (centralisation index increased from 18% to 43%). MWSC had clearly succeeded in developing cohesive social capital – the ability to collaborate for mutual benefit.
However, the SNA also provided overwhelming evidence that a small number of well-connected facilitator leaders played a prominent role in network activities. Whether measured in terms of direct social influence (degree centrality), efficiency of communication (closeness centrality) or brokering potential (betweenness centrality), six actors, all members of the central coordinating committee, were disproportionately influential. These network members linked the central coordinating committee to action groups, the action groups to each other and the MSC to its external Support Network. They were an important conduit for the exchange of information and resources. While accounting for 44% of network relationships, they accounted for 52% of relationships that shared in-kind resources, 54% of relationships that shared human resources and 66% of relationships that shared financial resources. Their role as brokers of knowledge, expertise and resources appeared critical to the function of MWSC.
Many authors emphasize the voluntary horizontal nature of collaborative network relationships. For network members to remain engaged they must be motivated by the network objectives and find their involvement rewarding. Collaborative partnerships therefore require leaders that provide a synergistic social space in which network members can work together to meet their common goals and organizational objectives.
How did your interest into injury prevention research and practice originate and develop?
I am an Emergency Physician who became concerned at the frequency and severity of injury presenting to my hospital. Surely there has to be a better way to address injury than the “Humpty Dumpty” approach. Sometimes “all the king horses and all the kings can’t put Humpty together again.”
What plans do you have for further research into this area?
I see the major challenge is to get stakeholders to agree what the problem is!
I am interested in promoting productive conversations between researchers, practitioners and the target community and thereby assist in the development of comprehensive, relevant, evidence based community safety interventions.
Would you like to make any further comments?
We have talked about better collaboration between researchers and practitioners for years. It is time to stop talking about talking about it and actually do it.
Where can readers find more information?
Hanson D, Finch CF, Allegrante JP, Sleet DA, Research Alone is not sufficient to prevent sports injury, British Journal of Sports Medicine, 2012 45 (16), p 1253
Hanson D.W., Hanson J.L., Vardon P., McFarlane K., Lloyd J., Muller R., Durrheim D., The injury iceberg: an ecological approach to planning sustainable community safety interventions, Health Promotion Journal of Australia, 2005, 15, p 1-5.
Hanson D., Doctoral Thesis: Community Safety Promotion Networks: From metaphor to Methodology, James Cook University, 2006, http://eprints.jcu.edu.au/1751/
About Dr Dale Hanson
Dr Dale Hanson graduated from Flinders University of South Australia in 1982 with a degree in Medicine. He initially pursued a career in General Practice attaining his fellowship of the Royal Australian College of General Practitioners in 1989 and worked for a number of years a GP in Adelaide. He subsequently returned to hospital-based medicine and commenced training in Emergency Medicine, attaining his Fellowship of the Australasian College for Emergency Medicine in 1996.
Since 1996 he has worked as Staff Emergency Physician at Mackay Base Hospital in regional Queensland. He is heavily involved in teaching undergraduate, postgraduate, prevocational and vocational Medical Practitioners maintaining academic appointments as a Senior Lecturer with the School of Medicine and Dentistry and the School of Public Health Tropical Medicine and Rehabilitation Science at James Cook University and with Queensland Health the Director of Clinical Training at Mackay Base Hospital and Director of Rural Generalist Training for North Queensland. He is a faculty member of Advanced Paediatric Life Support Australia.
Concerned at the high rate of injury he observed during his clinical practice in Mackay he developed an interest in Injury Research and Safety Promotion, completing his Masters Degree in Public Health and Tropical Medicine through James Cook University in 2000 and his Doctorate in Public Health in 2007.
Dr Hanson is a foundation member of the Mackay Safe Communities and the Australian Safe Communities Foundation. Dr Hanson is a member of the Queensland Injury Prevention Council
In 2003 Dr Hanson’s work in Safety Promotion was acknowledged when he received the biennial Australian Injury Prevention Network Award for Meritorious Practice in Injury Prevention at the 6th Australian Injury Prevention Conference held in Perth. His paper describing the development of Social Capital in Mackay Whitsunday Safe Communities was judged the best oral presentation delivered at the 8th International Injury Prevention and Safety Promotion Conference held in Durban South Africa, in April 2006. He was awarded a university medial for his doctoral dissertation by James Cook University in 2007.