James Broesch: Surveying Caregivers to Investigate the Role of Culture in Attitudes toward Childhood Obesity

Trained in Anthropology, James Broesch is Knowledge Exchange Leader for Vancouver Coastal Health, one of five publicly funded healthcare regions in British Columbia. As a Health & Society scholar at UW-Madison, he worked on a knowledge exchange project investigating whether culture plays a role in racial and ethnic disparities in child obesity.

How was your knowledge exchange project structured?

The project was about the measurement of culture and basically trying to understand it—operationalizing culture in a different way than tends to be done in health research. Actually being explicit about what it is. What do we mean by culture? What are the cultural models we think matter in this domain?

It was a supplemental component to a project that Alex Adams (Director of the Collaborative Center for Health Equity at UW-Madison) was doing to promote physical activity in childcare settings, especially for low-income kids. We used a survey approach to ask their primary caregivers questions about their attitudes about diet, physical activity, and obesity stigma and to measure the degree to which it was similar between potential grouping variables or different.

What did you find?

A lot of times we’re advocating these education campaigns, targeting these groups that people hypothesize have different attitudes, but probably we’re wasting a lot of resources. Instead of putting resources into education campaigns, we should be looking at the structural factors that are more important.

There was much more agreement between whatever groups you pick than there were differences. Out of 80 questions, the only one that was really meaningful was this one about if kids are overweight they’ll grow out of it, with nonwhite parents mostly agreeing with that statement and white parents mostly disagreeing with it. My sample was not as big as I would have liked, so I had limited power to look at more fine-grained group differences. But that was the gist of it.

If you had had longer to work on the project, what would you have liked to do?

The next step would have been to take that into a policy realm. A lot of times we’re advocating these education campaigns, targeting these groups that people hypothesize have different attitudes, but probably we’re wasting a lot of resources. Instead of putting resources into education campaigns, we should be looking at the structural factors that are more important.

How did you get this project started?

When I heard I was selected for interviews at Wisconsin, I started researching all of the faculty. Working with Alex was really logical. She was a pediatrician. She really cared about what the research results were going to mean to either health policy or her practice.

What were some of the things that you learned during the project?

You have to make clear, concise statements and be OK with uncertainty.

We’re used to communicating to primarily academic audiences. This is different. You have to be able to speak confidently and not hedge your statements with “Well, it’s not statistically significant in this case…” You have to make clear, concise statements and be OK with uncertainty.

Also, when I started I was still thinking that in researching an applied topic, you’re publishing primarily in journals: this model where if you publish great work, people will read it, and if they need to know about it, they’ll find out about it, which isn’t true.

How did you end up with a career in knowledge exchange?

I fell in love with the idea of doing applied work. I was at this moment where I had to decide what I was going to do: keep looking for placeholder positions in academia or try to take what I was doing in the academic context into a public sector position. This was a position that fit with the skills that I have and my interest in helping to inform practical decisions about healthcare policy and health policy in general.

The projects that I have worked on since I took this public sector position have been looking at structure for mental health and addiction programming for Aboriginal populations in urban settings. So, for example, what are some examples of program models that work? What is the evidence that the incorporation of culture into the programming actually has positive impacts for the patients?

Can you talk about a project that uses knowledge exchange in your new job?

It’s important to recognize that some people aren’t going to be convinced by moral arguments about how this is going to have a positive impact on people’s lives, but they might be convinced by seeing “Here’s how much money we’ll save.”

A couple weeks ago, we brought in speakers to talk about Housing First as an approach to addressing homelessness at two events in different municipalities. Most of the people who are working in this area buy into this model because they think we have a moral obligation, but a lot of people who hold the purse strings for making those investments don’t buy the moral obligation. It’s important to recognize that some people aren’t going to be convinced by moral arguments about how this is going to have a positive impact on people’s lives, but they might be convinced by seeing “Here’s how much money we’ll save,” especially for people who are “frequent flyers” in the healthcare system.

So we brought in the mayor from Medicine Hat, Alberta. He isn’t an academic. He’s someone who was conservative and opposed the Housing First model initially. It took his municipal councillors showing him the economic case for it before he was finally convinced that, yes, this is something they should support. They did it in their city and now they have “ended homelessness.” Within 10 days of [a homeless person] coming to them, they have them in a permanent house with wraparound services. It’s so great. It has such a positive impact. So we had him speak on that and what brought him to that realization.

We also had someone that was involved in a large-scale study of this speak to the scientific evidence with a little bit more methodological rigor.

But the most important speaker was someone with lived experience of homelessness. At one of the events, the speaker was able to say “I was in foster care since I was really young and was exposed to all kinds of horrible things while I was in foster care, and then I went into the penal system and it was costing $50,000 a year for me to be in the penal system. And I was in and out, in and out. And then I got in this Housing First program. I have a house. I am still struggling with my mental health issues, but for the first time I wouldn’t even consider resorting back to crime because of how much I would lose.” And he didn’t feel that before. That story makes it real for people.

Don’t just use quantitative data. You have to have a story, so people can bring it home and make it real.

It ties back into knowledge exchange. The people we really need to convince on this, we’re not going to be able to use the same evidence that we feel comfortable with and that we see the majority of the work being done in. That was something I got from the program: Don’t just use quantitative data. You have to have a story, so people can bring it home and make it real. Having the economics argument, the people who aren’t the typical speakers, and then also having some methodological rigor behind it. We got good media coverage, they were well-attended events. It was great.

Did the knowledge exchange exposure you got at UW-Madison help you in your position?

The way that they structured our knowledge exchange seminars made me a lot more comfortable with working on topics that I hadn’t researched previously, things like transportation policy, getting up to speed in a particular area quickly, and being able to say “OK, well here’s what the literature is suggesting in X, Y, and Z area.” Knowledge exchange seminars also helped with being able to explain things to people that aren’t in your field in a way that they are going to understand and find interesting and meaningful, and actionable a lot of the time, too.

The way that the site directors and the faculty talked about things was a new perspective. And a lot of it was economic thinking.

The way that the site directors and the faculty talked about things was a new perspective. A lot of it was economic thinking. I had an opportunity to think differently and spend time looking at questions that I would have not gotten to look at otherwise. Just the idea of opportunity costs—that’s what a lot of it boils down to in making cases for specific policies.

I definitely learned some of the skills there. But I still thought people read more than they actually do. A lot of people who are actually making policy decisions don’t have time to read everything that’s going to come across their desk.

What is the most important thing you’ve learned about communicating with nonacademics?

Two page briefs.

I see how it actually happens at my current job. A lot of times we get reports that are 60, 70 pages long with a 10-page executive summary, and I can tell you the senior executives are not always reading the executive summary. They’re reading the first page or two. A lot of the time they don’t read the whole thing unless it’s really in their area. You have to get the key points down to something that first sets the stage for the policy context, and then the evidence base for it, and then clear recommendations at the end, two or three points. “This is what we’re advocating for, this is what supports it.” I’ve seen that be a lot more effective.

it’s important to take opportunities where there’s media attention, or specific news stories, timely anniversaries of things. Those kinds of opportunities can help a lot in getting policymakers’ attention.

Also, we learned from the media training in HSS that it’s important to take opportunities where there’s media attention, or specific news stories, timely anniversaries of things. Those kinds of opportunities can help a lot in getting policymakers’ attention.

My last year in the program, we had a lunch session about communicating to policymakers, and one of the speaker’s big points was to establish relationships with people, so that it’s not just a cold email. So early on in the research process, probably before even submitting a grant, approaching what we call knowledge users, the people that you’re actually trying to influence, to make sure that you understand their perspectives, understand the evidence that they’re going to value. You can have great qualitative work that supports your position fantastically and all these interviews and great stories of change, but some people are not going to buy it unless they see monetary arguments or strong quantitative methods, and the opposite is also true. So it’s important to engage early on in the research process and not at the end of your study when you have the results.

What are some of the high points and low points of your knowledge exchange work?

The low points would be that sometimes decisions are already made. People already know what they are going to do. That’s frustrating.

Sometimes it can be frustrating, too, when you think that the evidence is there to support something, but the will or the financial resources aren’t going to happen. Also, in the areas we work with, the social determinants of health, it’s a lot harder to measure impact. Sometimes that’s going to discourage people from acting, even if there is strong evidence, because they won’t necessarily be able to measure and demonstrate the impact that they’re having. Will they be able to measure it easily? That’s what a lot of knowledge users, especially in the municipal realm, care about—in the next election campaign being able to say, “We did this, and this is the positive impact we’re having on people’s lives.” And with the social determinants of health, those things aren’t going to happen in 2- or 5- or 10-year cycles.

The high points are knowing that the work I’m putting into something is going to potentially have a tangible impact.

The high points are knowing that the work I’m putting into something is going to potentially have a tangible impact. Maybe it won’t, but if it potentially will, that’s great.

What kinds of scholars do you think should push themselves to engage in knowledge exchange activities?

Anybody who is trying to do something applied. If you want the research that you’re doing to have an impact and be used by people, I think that’s whom it’s most suited to.

Even for a lot of basic research, there’s a reason why you’re doing it and there’s probably an audience for it. If you’re looking at a particular signaling pathway, there are not a lot of knowledge users that are going to make policy decisions based on that. But at the same time, making a case for the social environment impacting biology—there is an audience for that.

Do you have any parting advice for people engaging in knowledge exchange projects?

Recognize the importance of the economic side, the backside of it, the opportunity costs. When you say that you want to see investments in X, Y, or Z area, realize that that money has to come from somewhere else. Don’t just expect people to find where it’s going to come from because you have strong evidence. You’re going to have to be able to say, “This is where it should come from.”

Also, depending on who people are working with, tying recommendations back to broader initiatives that are going on, priority areas, mission and vision statements for organizations is very important. That is really important for academics that want to have impacts in those realms to understand. Sometimes the statements I put into policy briefs sound really corny. “This aligns with our vision, our organizational goals of people first, promoting wellness through research…” But these mission statements, people put a lot of value in that.

Don’t assume people are going to read your work just because it’s great and in a high-impact journal. You need to be proactive about it.

Don’t assume people are going to read your work just because it’s great and in a high-impact journal. You need to be proactive about it. You probably need to take your academic publication and summarize it in simple language that people can understand quickly and easily and eliminate some of the qualifying phrases you put around your results. What I’ve taken to doing is putting the qualifying statements in footnotes, but you have to have the clear statement. You need to push. Decisions are going to get made regardless, so even if you’re uncertain whether you have strong evidence to support a decision, some evidence is better than no evidence.