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Reflections, Implications, and Next Steps Print E-mail

The final undertaking of the Symposium saw the participants contribute to a discussion of “Take Home Messages.” Important messages included:

  • The importance of placed-based evaluation and integration.
  • Evaluation possibilities (vertical and horizontal, feed-back systems and protocols).
  • Possibilities from public out-cry.
  • The need to explore mandates.
  • Integration is very political, not just rational.
  • The need for a plan to determine how to influence decision makers at all different levels.
  • The disconnect between policy and public understanding.
  • The organic nature of the integration process.
  • The need for more theory on how MIP integration fits together.
  • The need for tools to help explain MIP integration to community partners.

The use of metaphors was also raised, including:

  • A patchwork quilt of ideas, for example, the possibility of public out-cry.
  • The complexity of combining vertical and horizontal integration; they are represented as two dimensions, while images presented during the symposium such as rippling water and complex flow charts suggest the need to capture other dimensions.
  • The role of public out-cry suggests reframing questions; perhaps getting close to fire with forethought, aim, ready (thanks to Bernard Lamontagne).
  • Researchers working outside their usual comfort zones in areas important to interventions.

Symposium Reflections

Speaker: Susan Duncan

Susan Duncan generously provided her reflections to sum up the Symposium deliberations. Her verbatim comments are provided next, with thanks.

It is a privilege to reflect on the insights achieved over the past day and a half – to experience what is possible when committed people with great minds and experiences in community health research come together.

I would like to offer my remarks according how discussions over the past two days inform the state of our body of knowledge for Multiple Intervention Programs and in particular how they inform structural, process, and equity issues in Multiple Intervention Programs. Ultimately we are developing our understanding of what has to happen to create real momentum for maximum health impact by framing our problematic, engaging diverse communities, and evolving research methods and theories.

My first reflection is that we are talking about re-framing the research process, to one that is organic and focuses on engagement as well as intervention; and on the interaction of context, process, and content. To do this, we require new methods to approach the complexity of this interaction as well as new theoretical perspectives on inquiry that are critical and bring the equity lens to our work. The question of how we bring an equity lens to our work is one that we must commit to; I worry that it could become a checklist rather than commitment to values-based inquiry. Stephen Birch reminded us this morning of the importance of social objectives in equity-based decision-making and choices.

Themes emanating from all presentations pertaining to structure, process, and equity as well as reflect on the insights from our cutting edge researchers in MIPs:


  • Nancy began the day yesterday with key questions of process: how do we understand and work with the levers of change in other sectors? And of structure: what structures are needed to achieve horizontal and vertical integration? She shared the image of the flat bridge in Jamaica as a metaphor of safety for front line workers sharing their vision.
  • There is an awareness of the need for new structures for engaging people; diversity and confronting power differentials, such as the Community Health Centre Model which Jack described as a natural integration structure.


  • The term organic was used by a couple of presenters to describe how we must work in research and policy; meaning that integration may be too linear and we are instead looking at processes that are evolving and may not be nailed down in ways required by funders and accountability frames.
  • There was a discussion of how to engage power and decision makers – the momentum of a call to action at all levels – what is this process and the role of the health sector? These are the critical questions of verticality.
  • Barb gave us the insight of using systems as the lens for viewing situations.
  • Leadership for change is a key process that must be engaged and researched within MIPs – passion, action and politics and fun (Jack McCarthy) – and Jack indicated the role of a leader in asking critical questions about equity issues, for instance: who was affected by the transit strike? It was a powerful example of how equity issues become invisible in complex systems (e.g., the impact of the Ottawa transit strike on the poor).


  • There is a call for critical research processes and research agendas in MIPs; an ethical framework for policy research. The presentations by our 3 researchers yesterday and Colleen Varcoe today were vibrant illustrations of how engaging the right voices can stimulate needed change.

Insights from cutting edge researchers – Erica, Elizabeth and Christine:

  • Integration is non-linear and organic. These were excellent examples from Kenya and maternal child programs for families living in poverty in Canada; I think that Christine asked a key question that is pivotal to our discussions here: Is it part of a MIP to shift ideology that limits the human rights of mothers and children? And if so, how do we do that and how do we ensure that it is integral to our research and policy processes?
  • Our cutting edge researchers all related the theme of voice of those most affected by health issues within vertical decision-making structures.

I conclude with a few other questions that I have heard in our discussions and I think will form significant aspects of our inquiry as we move forward:

  • My first question is underpinned by a note of caution and that is: How do we avoid oversimplifying or decontexualizing the concept of integration? I suggest that in all of our discussions and initiatives we must be very clear on the purpose and context of integration – and we must be aware of the potential to diffuse important programs such as public health under the guise of integration (as Marjorie MacDonald has pointed out – this is a problematic for further inquiry in her research program).

Further Questions:

  • How can we engage our communities, our jurisdictions, and our sectors in deeper awareness and action on the patterns or determinants of our most pressing equity issues in health?
  • What are the exemplars? The country based equity case studies reviewed for this MIP Symposium point to some of the way forward; but how can we build on these with methods including but not limited to case study approaches?
  • How do we engage our communities, jurisdictions and sectors in seeing the whole and adopting “a pattern language – a way to visualize and talk about deeper patterns?” (Senge et al., 2008, p.47)

Relating to the proceedings of the previous symposia and the discussions over the past day and half, I see tremendous gains in our understanding of multiple intervention programs and their relationships to context, process, and structure; and likely the next step is to grapple with the interaction of these three elements as they relate to research and change processes in health. I have no doubt that these methods and theoretical perspectives will evolve and make a difference to equity and social justice, and engage communities in multiple intervention programs, making a difference to the health outcomes that matter most.

Thank you for this opportunity to participate in what has been my first multiple intervention program symposium – perhaps a future symposium could engage people from diverse sectors, communities and jurisdictions around a defined issue to further illuminate issues of process, context, structure, equity, and their interaction.

Closing Remarks

Nancy Edwards closed the Symposium with thanks to presenters and participants, commenting on the fruitful and meaningful insights gained over the day and a half of deliberations. She looked forward to all taking away new perspectives on MIPS and integration and finding ways to incorporate this knowledge and understanding into their work in public health research, policy, and practice. She concluded with an invitation to provide additional input and comments as participants thought about integration and multiple intervention programs in relation to their own research or work.

Last Updated on Sunday, 11 October 2009 22:29