I’ve just submitted my PhD! Cue a giant sigh of relief.
I’ve been with The Cynefin Co, on the Health Programme team, since April 2021. Alongside this, I have been on a four-year journey of a cotutelle PhD in Exercise, Nutrition, and Health Sciences between the University of Bristol and the University of Cape Town, titled:
“The role of social network analysis in scaling-up and sustaining community-based health programmes in low- and middle-income countries.”
In (very) brief, I conducted a five study exploration of how to use social network analysis, the measurement and visualisation of relationships between actors in a network, to strengthen community-based health promotion programmes using a South African case study (abstract at the end). All the relevant reports and publications will follow after my viva but for now I’d like to reflect on how The Cynefin Co influenced where my research started to where it ended up.
For the first two years, the aim of this PhD was to explore “what works”. My plan was to determine exactly what social network structures of health programmes lead to their scale-up and sustainability – I’m sorry, I was young and naïve then! It became very clear that not only would it be difficult to measure the social networks of a complex, widely spread community programme which had no way of objectively and simply being labelled a success, but applying any findings to another context would likely not be very valuable.
It was around this time that I joined The Cynefin Co. It was working here that I really learnt about complex adaptive systems and the value of mapping what is currently happening in order to make small decisions that move to an improved future. The work of The Cynefin Co and Dave Snowden validated my feelings that the PhD trajectory I was on, that of trying to create acontextual end-goals of community programme networks, was not worth the time and energy I would have expended on it. It was too late down the line to include The Cynefin Co tools like SenseMaker®, and Estuarine Mapping didn’t exist in the public domain then, but I knew I could use these ways of thinking about, and valuing, complexity in my PhD work.
The Cynefin Co alone didn’t change my PhD focus (that of now taking a step back and exploring the feasibility of SNA in community programme settings). The participants of my research themselves reflected a need for capturing the complexity of their network, being open to unexpected and expected changes, and using real-time data to make small actions towards strengthened relationships (very Vector Theory of Change). I did not use the tools offered but The Cynefin Co helped to give language to what was already being expressed by those on the ground. In the end, I came out with a PhD that provides more questions than answers to community health programmes – and I’m far happier for it.
I suppose my take-away message would be for those who are interested but you/your company are not ready to engage in SenseMaker, Estuarine Mapping, entangled trios etc. Know that you don’t have to use these tools to engage in complexity thinking. The Cynefin Co. is not a gatekeeper to sense-making, it’s a supporter. Challenge yourself and those around you to think about narratives and vector theory of change. Start opening conversations and thought experiments about how it might apply to the work you are doing. Normalise complexity thinking, because the world is so often complex and powerful ideas can come out of it if we listen to it.
….of course, if you would like to engage in our support and tools, let us know!
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PhD abstract:
Background: Non-communicable diseases [NCDs] are an ever-increasing burden globally with low- and middle-income countries [LMICs] disproportionately affected. Community-based programmes [CBPs], which aim to improve the wellbeing of specified populations in a contextually relevant way, have been identified by the World Health Organization as a cost-effective prevention and management strategy of NCDs. However, evidence for scaling-up and sustaining CBPs remains limited. A potential tool to scale-up CBPs could be social network analysis [SNA] which considers real-world complexity by quantifying and visualising relationships between stakeholders. Objective: To explore the role of SNA in scaling-up and sustaining CBPs in LMICs. Methods: Mixed-methods, five sequential studies: 1) Scoping review of SNA in scaling-up and sustaining CBPs in LMICs; 2) Feasibility study of SNA within the case study programme, WoW!, 3) Full SNA of WoW!, 4) Interviews with WoW! stakeholders exploring context and mechanism factors that might be present in the scale-up and sustainability of WoW!, and 5) Interviews exploring the perceptions of WoW! stakeholders of the process and value of SNA. Results: Study 1 identified only three studies that conducted SNA, supporting this research. Study 2 identified practical challenges of collecting SNA data within complex settings, informing approaches for Study 3 which revealed a centralised network, unclear role differentiation, and low rural representation. Study 4 interviewees provided contextual understanding of the SNA findings, with Study 5 participants indicating that while some aspects of SNA were useful, i.e., visual outputs, most analyses did not provide actionable information. They proposed the use of a “live mapping” tool providing the visual benefits of SNA while taking into account the data collection capabilities and information needed to measure and act in complex community networks. Conclusion: This research contributes to the development of a pragmatic and feasible SNA tool in improving the scale-up and sustainability of complex CBPs, particularly in LMICs.
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Banner image from Unsplash
Today is World Health Day! The 7th of April 2023 marks the 75th anniversary of the World Health Organisation since its founding in 1948.
The theme for 2023 is “Health for All”
It is a chance for the Cynefin Centre Health and Care Programme team to reflect on what health means to us and how we hope to shape the world going forward. This blog post explores the boundary of Health and Care – from healthcare professional and patient settings all the way to the effects of inequality, global debts, and climate change. The evidence is too hard to ignore: investment in health not only improves our day to day wellbeing but has knock on effects on labour, economic, and educational productivity (Jamison et al., 2013). Similarly, investment in economic productivity, equality, and climate change has a positive effect on health (Tinson, Major & Finch, 2022). Never before has there been a greater need to expand the boundary of health and care, and invest in all its spheres, to truly ensure health for all.
Some populations are young and growing, others are older or shrinking, technology use in healthcare is expanding, and comorbidities are increasing (World Economic Forum, 2019). The milieu for health professionals and clinical settings is under pressure to adapt to our changing populations. Not to mention the COVID-19 pandemic that exposed and exacerbated pressure on health workers, hospitals, and care facilities all over the world (Kaye et al., 2021). Chronic healthcare professional understaffing, poor retention, insufficient funding, and long patient waiting times are just some of the situations we have found ourselves in today that affect our ability to provide healthcare to all (British Medical Association, 2022)
It is useful to also reflect on how health affects and is affected by, factors beyond clinical healthcare settings. For example, greater income inequality in a society is significantly correlated with a host of other mental and physical health problems. In England, men in the most deprived areas are expected to live almost 10 years less, and women almost 8 years less, than those in the wealthiest areas – with those in the most deprived areas living 19 fewer years in good health (Gregory, 2022). Prof Richard Wilkinson, a British social epidemiologist, outlined how societies with greater inequality also often have weakened social cohesion which affects how people protect and uplift others – with worsening health effects for all (Wilkinson, 2002).
“Increased inequality imposes a psychological burden which reduces the wellbeing of the whole society.” (Wilkinson, 2002)
Debt Justice, a UK based company campaigning to restructure and end global debt, argues that the negative health effects of inequality are not just within countries, but also between countries. For example, despite the Ukraine government experiencing excessive pressure to provide food and medicine to its citizens, it is still having to pay upwards of $7 billion of its national budget to lenders (Phelps, 2022). Due to high interest rates, it was estimated that in 2021, one in five low- and middle-income countries were paying more money to debt repayments than health, education, and social protection sectors combined (International Development Alliance, 2022).
The Health Foundation, an independent health charity in the UK, similarly outlined the link between inequality, reduced economic activity, and health – with increasing ill-health leading to decreased labour and decreased economic growth (Tinson, Major & Finch, 2022). In addition, they are sounding the alarm about the links between health and climate change – both requiring a long-term, prevention approach that spans across government departments and society groups on a global scale.
“The complex systems of determinants and impacts of health and climate change are interconnected, and climate change is adversely harming human health, through both direct and indirect impacts.” (Marshall & Allen, 2023)
Health and care encompasses almost all systems and processes around us, and only with this in mind, can we truly work towards health for all.
Happy #WorldHealthDay, everyone.
P.S. We need evidence to make informed decisions. Gapminder is an independent foundation that aims to help us gather global statistics and present them in an understandable way. I’d highly recommend taking their misconceptions quiz and watch their video on how the world is faring in the Sustainable Development Goals. Spoiler alert, these goals are highly connected and require collaborative approaches.
And for evidence when it comes to complexity? There is of course always Cynefin Co!
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Banner image my own, a chance to show off my home town, Cape Town. In-text image courtesy of WHO campaign page.
Be a part of the expanding Health and Care Programme at Cynefin! We are exploring theory, stories, methods, ethnography, insight into action, and more in all that is the complexity of health and care.
Whether you’re still questioning, have just started, or have a wealth of experience, there’s a space for you.
Virtual QuickStart
For those new to Cynefin or who want to dip their toes in the experience, we are offering a health specific Virtual QuickStart in October 2022.
The VQS is an 8-week learn-as-you-do journey, where we work with you to deliver your own, real pilot engagement, step-by-step. The best way to learn about SenseMaker® is to apply it in context on a real engagement. Quickstart offers you an opportunity to benefit from a blended learning approach which includes access to our online learning platform, live tutorials, case studies, and consultation sessions with expert SenseMaker® practitioners. This means you will receive expert guidance and support from others in the health setting in designing and safely running your project.
Our next cohort starts in October and will run roughly every other week, for 8 weeks. If you would like to join, indicate your interest here and check out the brochure. This is also an ideal space if you’ve been around but have colleagues new to SenseMaker or if you need a structured space to run your project.
Community of Practice
The idea of the Health and Care Community of Practice came about during the height of the pandemic when it became very clear the importance of community and connecting to others. To honour that at Cynefin we want to help provide the space to share, learn, vent, and belong to all those that use SenseMaker® and related methods in health and care. Particularly, we want to create this space together with you!
We had a fantastic first round of Health and Care Meetups to kick us off. A massive thanks to everyone who was able to attend, and to those who couldn’t make this round, we missed you!
We based these first sessions fairly informally around anecdote circles wherein people could share their stories. The conversation prompt was “Take a moment to reflect on your experience of working in health and/ or care, and think of one story/ anecdote/ memory, that in some way helps to explain why you are here today…” Related themes and opportunities were then discussed.
This launched us into a host of interesting conversations around health worker wellbeing, buy-in, complexity, organisation bureaucracy, Cynefin methods (outside of SenseMaker), SenseMaker practicalities, and working in the “real world”. It also prompted several networking moments and sparked topics for future meetups.
The idea is that we will host a meetup every quarter for those involved in the Cynefin Centre and health. Keep an eye out for our next meetup in November led by Paul Ader where we’ll be using Emergent Design to envision the future of the Community of Practice.
If you are part of Cynefin but not yet on our CoP mailer or OurHaunt page, let Ellie or Nina know!
Pulses
Our first Health Programme Pulses are here! These are pre-designed SenseMaker® designs that are ready to go. If you’re new to SenseMaker or looking for something to trial before conducting your own bespoke project or taking out a membership, Pulses are a great way to start.
Our first Pulse is themed around Healthcare workforce wellbeing. With the outbreak of COVID-19, the pressures on healthcare services across the globe have surged to unprecedented levels. This has substantial impacts on the physical, mental, social, and moral wellbeing of healthcare professionals. The healthcare workforce is made up of a myriad of different positions and people and that the possible interactions they can have with patients and the health system are endless. This diversity moves away from the thinking that successful healthcare work is only about control, following protocol, and reducing failures to rather promoting adaptability and autonomy in the face of emergent experiences. It also recognises the emotional and physical load on health workers to create success and be resilient in this complex system.
The second Pulse on offer is on Organisational wellbeing. The psychosocial work environment is concerned with dimensions such as communication styles, workload, support, and motivation which are all relevant to aspects of work organisation, design and management, and interpersonal relationships. Generally we recognise that the psychological and social components of work go a long way in our personal and collective wellbeing: it is often the everyday things which have the power to really make a difference in our working lives. This approach allows us to understand wellbeing as beyond the individual, and related to social context within which they exist and work.
By exploring multi-perspective narratives we can get a much richer picture of how people and groups think, feel, and experience their worlds as integral to understanding complex adaptive system of healthcare, working practices and culture.
Links to the Pulses will be launched on the website soon! But contact us if you would like to know more.
Come join us in the Health and Care Programme! We can’t wait to explore and create together.
Catholic Relief Services [CRS] started piloting SenseMaker® in 2015, and has a wealth of knowledge, experience, and implementation advice that they will be sharing with us. They have travelled the world and worked with people most in need. The journey has not always been easy, but, in the words of Dr Maria Veronica Gottret, Senior Technical Advisor for Agriculture and Agriculture Livelihoods Research/Monitoring, Evaluation, Accountability, and Learning [MEAL] at CRS:
When we first piloted SenseMaker® in Nicaragua, suddenly we could map the pathways, and then we started digging into the experiences of why some farming families in the same country, the same region, under the same policies, with the same projects, were able to progress, while others didn’t. The stories were so rich, and its self-signification provided additional layers of information that enabled us to respond to this question and more, that is when I fell in love with SenseMaker.”
CRS is a non-profit that uses a holistic approach called integral human development – a long-term, dynamic process that facilitates collaboration across civil society and the public and private sectors through programmes around emergency response and recovery, health, agriculture, water security, education, microfinance, justice and peacebuilding, and partnership and capacity strengthening. They support hundreds of projects in more than a hundred countries around the world, using tailored, context-dependent approaches. Headquartered in the United States, CRS also has multiple offices in Africa, Asia, Europe, the Middle East, Latin America, and the Caribbean.
Maria Veronica has a background in agriculture, food and resource economics, and development and has over 30 years of experience in the field. I had the privilege of connecting with her and learning more about the work of CRS and their vast experience of using SenseMaker.
Why complexity?
“Development has to be human centred.”
Within the work of CRS, everything is complex. Even the more straightforward interventions such as seed distribution or cash transfers may result in different outcomes as they depend on a range of factors such as supply chains, farming systems, gender, location, and climate, among others. CRS recognises the importance of honouring that complexity in their implementation and monitoring work. They place people at the centre of systems and structures, noting that food production, technology, economics, and public policy can’t get anywhere without the people involved.
Projects and experience
“There’s so much research and knowledge in research centres and universities, but there’s very little that really gets into development and makes a difference.”
CRS works all over the world. Maria Veronica told me about projects across Central America, Africa, and Asia. In 2015 they started using SenseMaker as part of their MEAL strategy. Some early experience includes using SenseMaker to map pathways to prosperity in Nicaragua and linking to markets in Colombia, to hear the stories of people’s resilience to multiple shocks and stressors in Central America, East Africa, DRC, and Southeast Asia, and evaluating the experiences of Colombian refugees and Venezuelan migrants that had gone to Ecuador.
“The capacity to reflect through the narratives, making sense of them.”
Other experiences include formative research to refine the gender equity and equality promotion strategy for a large food security project in Niger. The assessment of the performance of a community conversations approach implemented in Ethiopia to promote behaviour change. Assessing and monitoring extension agents, field agents and farmers’ competencies for the adaptive management of capacity building activities in Malawi, Central America, and Ethiopia. Formative research on nutrition-sensitive agriculture in Guatemala. And many others.
Check out this fantastic video of ethnographic research and SenseMaker® in action:
The why and how of SenseMaker®
“The other thing is that people enjoy it. We worked with Rita Muckenhirn, an expert in adult education and facilitation, and with her, we innovated in the way that the interviews are conducted. Since a key feature of SenseMaker are the visualization tools, we didn’t just use the tablet, we actually drew these visuals on the ground using ropes, so people physically moved through the signifiers. They had to move their bodies. We started to create protocols where people who are illiterate or with low levels of formal education are able to answer it…And we were getting super accurate data…and we found that while people are standing and selecting their responses, they are adding more to their stories. This has helped with literacy barriers and also allows people to quite literally become the centre of their own story.”
I asked Maria Veronica why CRS uses SenseMaker. In her experience she finds that SenseMaker and sense-making gives people a voice. Rather than asking closed questions or filling out a long survey, people are able to share their experiences. And for many people Veronica has worked with, it’s the first time they have been able to express themselves in a way that is important to them. SenseMaker has the potential to raise awareness and empower respondents. Many have even learnt more about themselves and felt empowered while selecting, sharing, and making sense of their experiences.
“In the final evaluation of the program in Ecuador we asked respondents exit questions after the interviews, which made us realize that respondents appreciated and enjoyed the process of responding. It helped them, they said, to reflect on their lived experience in a different way. Some of them even cried. And they said ‘this is the first time in my life I’m talking about what happened to me in this way. I never had an opportunity to talk about it. Even talking in this way that is not extractive, its sharing my experience’. This shows us that the evaluation method matters.”
Standard monitoring, evaluation, and learning tools haven’t been able to generate the types of conversations that SenseMaker and story-telling has.
“For implementers, even though they are constantly in the field conducting the different project activities, while reading narratives they were like ‘wow, we didn’t know those things about the people we serve’.”
Advice for others
“My mantra became, probe, make sense, adapt.”
Veronica advises that those interested in SenseMaker start by reading the guidance on offer and reports from case studies. Then, importantly, to talk to other practitioners about their experiences as on-the-ground implementation can be very different to the theory.
She highlights that you should not shy away from using active exercises that help people understand complexity theory in an easy way and that it’s important to adapt sense-making to the audience. She also advises that you prepare well. Sense-making is not something that follows a typical work plan (design, field test, do it) but rather requires taking the time to learn, get buy-in, adapt, and innovate.
Learning from CRS
CRS has a webpage with a wealth of resources, case studies, reports, videos, and podcasts about their experiences of implementing SenseMaker around the world. Follow this link to check it out.
We also celebrate the release of the much anticipated book: ‘The Learning Power of Listening: A Practical Guide for Using SenseMaker®’ released by Oxfam and Catholic Relief Services (available here), to help development centre workers and agencies apply much-needed, complexity-informed approaches to their work.
If you would like to contact Maria Veronica directly, please find her on LinkedIn or email her at maria.gottret@crs.org
Contact us at Cynefin Co if you would like to access SenseMaker® or would like to hear about other training and consultation deals on offer.
Banner image by Vonecia Carswell on Unsplash.com. Top image by Practical Action Publishing
Communicating and interacting with others is a funny thing. Even when we speak the same language, communicating is a hot bed for confusion and misunderstanding. What I write down here will likely be interpreted in slightly, and maybe in some cases majorly, different ways to my original intentions. However, communicating and understanding one another is fundamentally important to our personal, social, and economic lives.
This blog was partly inspired by the podcast Why Conversations Go Wrong (which I highly recommend). In it, Deborah Tannen, a Professor of Linguistics, discusses some of the reasons why we get so confused. Tannen explains that we each have a learnt, automatic conversational style which affects conversation on a ‘meta’ level. For example, different people have different expectations about how long a pause between each conversation point should be. This could change one’s experience of talking to someone who is perceived to be constantly interrupting them versus not engaging enough. It also influences preferences for speaking more directly or indirectly – where meaning often gets lost. And don’t get me started on how often we talk in metaphors and idioms (by which I mean, do get me started, it’s a very interesting topic).
Other processes might be at play too. Signal amplification bias, for example, refers to when people incorrectly assume that what they have communicated has been fully understood by the other person (Vorauer & Sakamoto, 2006). This especially happens in new situations, where novelty causes someone to experience heightened self-awareness and so is more likely to perceive that the person they are talking to is similarly aware of these feelings. This can lead to hindered relationships wherein the correct message is not communicated, and so expected feedback is not given.
Many many factors influence how we might interpret and understand events: such as age, gender, culture, mood, stereotypes, personal experiences, cognitive abilities, and physical characteristics (a small child is going to experience a large supermarket much differently to a tall adult). Even if we agree on a dictionary definition, our perceptions around what words mean in practice can be very different. For example, one person’s perception of what is considered an expensive meal will be very different to another. A teenager’s perception of what constitutes a clean room may be very different to their caregiver’s. The additional reliance on technology has made it even more tricky to communicate, without visual cues and voice tones we’re left guessing whether an exclamation mark means someone is excited, surprised, angry, or friendly! (Ferrazzi, 2013). My personal favourite emoji is 😬 – what people actually think of me when I send it, maybe I’d rather not know.
Different perceptions and interpretations can not only be confusing, but it can also be dangerous. For example, it can lead to inappropriate or incorrect medical care when patient and health professional do not understand each other (Iezzoni et al., 2004). Even in the highly standardised industry of aviation, accidents are still often attributed to miscommunication (Molesworth & Estival, 2015). It is therefore important to be humble and responsible with the way we communicate and listen.
We at the Cynefin Co are particularly aware of the efforts it takes in communicating. We are a multi-cultural, multi-disciplinary team, working with an even wider range of clients and collaborators, on multiple virtual and in-person platforms. A standard team meeting consists of finding out what is happening in Cape Town, Greece, Denmark, Wales, Netherlands, Singapore…The complexity of language, accents, and understandings is never far from our minds.
The SenseMaker® tool helps to bring alive these differences, to help us not make assumptions about how people are feeling and experiencing their environment but for everyone to express and explain themselves in their own (written or recorded) words and then to further self-identity how their stories fit into themes. However, it is no magic bullet. So, take care when creating significations and analysing patterns, there’s always room for more perspectives.
Some thoughts on collaborating on design and analysis
Ask us about future Narrative Basecamps for a deeper dive into language and complexity.
Banner image by cdd20 on Unsplash.com. Top image by Mark König on Unsplash.com
I joined the Cynefin Centre seven months ago, and with a background in health systems felt well versed to take on what complexity thinking had to throw at me. However, joining the world of anthro-complexity, sense-making, and complex adaptive systems has opened up a universe of possibilities and explorations that I had not thought were possible before. This is a very exciting thing, but I recognise that for myself and others it can be incredibly overwhelming too.
So, my first piece of advice is, don’t worry. If you are feeling like there is ‘too much’ and you don’t know where to look, this is completely normal. We can take a deep breath and dive in together (it’s worth it).
Being overwhelmed is normal. There is a lot that complexity thinking and Cynefin Company has to offer but we hope that you are feeling excited too. Please tell us what you need, ask the community questions, disagree, and build together. We are all a part of this process.
A bit about me specifically, I’m from Cape Town, South Africa. I was in the UK in 2021 as part of my PhD in Exercise, Nutrition, and Health Sciences and happily found an opportunity to join the Cynefin Centre’s Health Programme. My current research is in using social networks to strengthen physical activity and diet community-based programmes (and reconciling on the ways why this may not be that useful!). My background is in Public Health and Psychology, but I generally have an interest in all things to do with healthy living (be it personal or structural). I most look forward to helping new members through their first SenseMaking journeys. If any of this resonates with you, please do get in touch!
Banner image by Thomas Park on Unsplash.com
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