A fish, an elephant, and an iceberg: Orienting community towards root causes and systems

When a community is trying to address a public health problem, the immediate causes are often the most apparent.

Too many youth aren't physically active. Why? They don't understand the value of physical activity or the consequences of not being active. What should we do? An education and mass communication campaign to help them understand this value and these consequences, so that they are motivated to be more active.

Not only are immediate causes often the most apparent, the solutions required to address them are often (relatively) non-controversial and don't require the upheaval of established systems.

But to truly transform health in communities, we need to move beyond the immediate. We need to 1) drill down to root causes and 2) fly up for a systems wide view.

On the first point -

WHY are too many youth not physically active? Do they have safe spaces to run and play in their neighborhood, and do their schedules allow them to do so? Are the costs of joining recreational sports leagues prohibitive? Are the apps on their phones designed to be addictive, so they have less time for everything else?

To get community members thinking about root causes, one exercise I have found quite helpful is a fishbone diagram (where you start with the problem, which is the "head" of the fish, and then brainstorm multiple causes, as well as causes of causes). This diagramming is often paired with the "5 whys" facilitation strategy (where you keep asking "why" five times to drill down to deeper root causes). The idea here is that this process can help identify countermeasures (things that prevent root causes) instead of merely solutions (things that might just put a bandaid on the problem by treating a symptom instead of a root cause).

On the second point -

HOW might systems be transformed to encourage more physical activity among youth?

First, we need to be able to take a step back and see the system as a whole. I find the elephant analogy an incredibly helpful way to remind ourselves and our communities to do this. It’s an ancient parable you may have heard before about blind/blindfolded individuals encountering an elephant for the first time. Each person feels only one part of the elephant and comes to a conclusion about what they are encountering based on that. It leads to a lot of misconceptions and no single person who has the full and accurate picture.

To take community thinking a step further, from recognizing there is a broader system to understanding how we can improve that system, I love using the iceberg model of systems thinking. It's a great way to reminder ourselves that what we can see of a problem is usually only the tip of the iceberg. "We know that an iceberg has only 10 percent of its total mass above the water while 90 percent is underwater. But that 90 percent is what the ocean currents act on, and what creates the iceberg’s behavior at its tip." Most public health issues are like this as well! I especially appreciate the way this model helps community members walk through the process of identifying trends, underlying structures, and ultimately mental models.

I've often had clients point to a fairly surface-level approach or solution and say, "This is what our community said they want to see." This may be true, and I'm 100% on board with community-driven approaches. However, we also need to ask ourselves if we've walked ourselves and our communities through the kind of tools above to make sure that the solutions we're brainstorming are oriented towards root causes and systems.

Have you had success with setting the stage to approach problems in a way that is focused on root causes or systems? Or have you tried using any of the tools mentioned above? Please share your experience with me!

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Too many partners, too little time, one nifty tool

Public health problems live at the intersection of many different sectors and issues.

You can’t help kids in schools do and feel better without also making sure their teachers are well, that school policies don’t kick them out of class, that their communities are safe, and so on.

So any community health improvement effort worth its salt is going to involve multiple components led by multiple partners.

But it can be really hard for those involved in a joint effort to truly understand the work of other partners. Heck, as anyone who has worked at a large corporation or agency can attest to, it's really hard to understand the work of different departments and teams within the same organization, let alone partner organizations!

Yes, we have logic models and summary descriptions and annual reports, but we often don't have the time to read those things and even when we do, they often fail to give us a true understanding of how the work looks, sounds, and feels on the ground where it's happening.
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We were grappling with just this problem as part of a multi-partner effort to help kids in DC schools thrive. We were bringing various partners together for an in-person convening and many of them had expressed a desire to know more about the activities others were leading. How could we create the space for this without taking up the entire day and while keeping things engaging and interesting?
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One of my colleagues on the project suggested using the Ignite Talks format - “20 slides, 15 seconds a slide, 5 minutes on stage, just you and the audience”. The emphasis in this format is on highly visual slides with interesting imagery. It’s similar to the PechaKucha format, which originated in Japan, and involves 20 slides, each for 20 seconds.

We were a little worried about asking our partners to put together a new presentation just for this convening, but decided it was worth the risk.

And it definitely was! We used these talks to open our convening and it was lively, engaging, interesting, and everyone learned a lot about the different elements of this joint effort we were engaging in.

• By emphasizing visuals, we got to see what the work looked like in action.

• By forcing everyone into a new presentation format, we escaped the boilerplate slides and explanations we otherwise would have gotten.

• Perhaps most surprisingly, by providing a tiny bit of extra structure (“20 slides, 15 seconds each” - instead of just saying “no more than 5 minutes, please”), we actually had everyone stay within the time limit - every single person. (Who else has tried the “no more than X minutes, please” route before, only to find that no one listened to you? Turns out, a little extra structure is the answer!)

All in all, it was a wonderful experience, and one I’ll be looking for opportunities to replicate in other settings and with other groups! I think it’s a great tool for community coalitions and collaboratives to have in their pocket - if you use it, please share how it goes, and if you have questions about how we used it, please reach out.

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