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Tag: global health

  • What is norms-shifting in immunization and global health?

    What is norms-shifting in immunization and global health?

    The concept of “norms shifting perspective”, in the field of immunization and global health focuses on strategies that aim to alter norms and attitudes towards vaccination to promote uptake and acceptance.

    This perspective acknowledges the influence that social norms have on individuals decisions regarding vaccination. Aims to utilize this insight to enhance acceptance through well crafted policies, messaging and interventions. The goal is to make vaccination the expected and socially endorsed choice across communities

    Here are a few aspects of this perspective.

    Recognizing the influence of social norms on vaccination behavior:

    • People’s vaccination decisions are significantly influenced by their perceptions of what others in their community think and do regarding vaccines.
    • Misperceptions about how many others accept vaccines can lead to lower uptake.

    Using accurate information about norms to increase acceptance:

    • Providing factual information about high levels of vaccine acceptance in a community can increase individuals’ intentions to vaccinate.
    • This works by correcting underestimations of vaccine acceptance and leveraging social conformity.

    Shaping norms through public policy:

    • Government policies and messaging around vaccines can shape social norms and expectations.
    • Mandates, passports, and other policies signal what is considered normal or expected behavior.

    Designing targeted interventions:

    • Campaigns that feature relatable community members getting vaccinated can help establish vaccination as a social norm.
    • Messaging that emphasizes the social benefits and widespread acceptance of vaccines can be effective.

    Considering unintended consequences:

    • Heavy-handed approaches like strict mandates may backfire by creating resistance and polarization.
    • Care must be taken to avoid stigmatizing unvaccinated individuals.

    Adapting to local contexts:

    • Effective norm-shifting interventions need to be tailored to specific communities and cultures.
    • What works to shift norms in one setting may not work in another.

    Taking a long-term view:

    • Changing deeply held social norms around health behaviors takes time and sustained effort.
    • The goal is to create lasting shifts in how vaccination is perceived and valued in communities.

    Where to learn more about norms-shifting in immunization?

    Bardosh, K., De Figueiredo, A., Gur-Arie, R., Jamrozik, E., Doidge, J., Lemmens, T., Keshavjee, S., Graham, J.E., Baral, S., 2022. The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good. BMJ Glob Health 7, e008684. https://doi.org/10.1136/bmjgh-2022-008684

    Fayaz-Farkhad, B., Jung, H., Calabrese, C., Albarracin, D., 2023. State policies increase vaccination by shaping social norms. Sci Rep 13, 21227. https://doi.org/10.1038/s41598-023-48604-5

    Moehring, A., Collis, A., Garimella, K., Rahimian, M.A., Aral, S., Eckles, D., 2023. Providing normative information increases intentions to accept a COVID-19 vaccine. Nat Commun 14, 126. https://doi.org/10.1038/s41467-022-35052-4

    Reñosa, M.D.C., Landicho, J., Wachinger, J., Dalglish, S.L., Bärnighausen, K., Bärnighausen, T., McMahon, S.A., 2021. Nudging toward vaccination: a systematic review. BMJ Glob Health 6, e006237. https://doi.org/10.1136/bmjgh-2021-006237

    Vriens, E., Tummolini, L., Andrighetto, G., 2023. Vaccine-hesitant people misperceive the social norm of vaccination. PNAS Nexus 2, pgad132. https://doi.org/10.1093/pnasnexus/pgad132

    Image: The Geneva Learning Foundation Collection © 2024

  • Integrating community-based monitoring (CBM) into a comprehensive learning-to-action model

    Integrating community-based monitoring (CBM) into a comprehensive learning-to-action model

    According to Gavi, “community-based monitoring” or “CBM” is a process where service users collect data on various aspects of health service provision to monitor program implementation, identify gaps, and collaboratively develop solutions with providers.

    • Community-based monitoring (CBM) has emerged as a promising strategy for enhancing immunization program performance and equity.
    • CBM interventions have been implemented across different settings and populations, including remote rural areas, urban poor, fragile/conflict-affected regions, and marginalized groups such as indigenous populations and people living with HIV.

    By engaging service users, CBM aims to foster greater accountability and responsiveness to local needs.

    • However, realizing CBM’s potential in practice has proven challenging.
    • Without a coherent approach, CBM risks becoming just another disconnected tool.

    The Geneva Learning Foundation’s innovative learning-to-action model offers a compelling framework within which CBM could be applied to immunization challenges.

    The model’s comprehensive design creates an enabling environment for effectively integrating diverse monitoring data sources – and this could include community perspectives.

    Health workers as trusted community advisers… and members of the community

    A distinctive feature of TGLF’s model is its emphasis on health workers’ role as trusted advisors to the communities they serve.

    The model recognizes that local health staff are not merely service providers, but often deeply embedded community members with intimate knowledge of local realities.

    For example, in TGLF’s immunization learning initiatives, participating health workers frequently share insights into the social, cultural, and economic factors shaping vaccine hesitancy and uptake in their communities.

    • They discuss the everyday barriers families face, from misinformation to transportation challenges, and strategize context-specific outreach approaches.
    • This grounding in community realities positions health workers as vital bridges for facilitating community engagement in monitoring.

    When local staff are empowered as active agents of learning and change, they can more effectively champion community participation, translating insights into tangible improvements.

    Could CBM fit into a more comprehensive system from local monitoring to action?

    TGLF’s model supports health workers in this bridging role by providing a comprehensive framework for local monitoring and action.

    Through peer learning networks and problem-solving cycles, the model equips health staff to collect, interpret, and act on unconventional monitoring data from their communities.

    For instance, in TGLF’s 2022 “Full Learning Cycle” initiative, 6,185 local health workers from 99 countries examined key immunization indicators to inform their analyses of root causes and then map out corrective actions.

    • Participants began monitoring their own local health indicators, such as vaccination coverage rates.
    • For many, this was the first time they had been prompted to use this data for problem-solving a real-world challenge they face, rather than just reporting up the next level of the health system.

    They discussed many factors critical for tailoring immunization strategies.

    This transition – from being passive data collectors to active data users – has proven transformative.

    It positions health workers not as cogs in a reporting machine, but as empowered analysts and strategists.

    By discussing real metrics with peers, participants make data actionable and contextually meaningful.

    Guided by expert-designed rubrics and facilitated discussions, health workers translated this localized monitoring data into practical improvement plans.

    For an epidemiologist, this represents a significant shift from traditional top-down monitoring paradigms.

    By valuing and actioning local knowledge, TGLF’s model demonstrates how community insights can be systematically integrated into immunization decision-making.

    However, until now, its actors have been health workers, many of them members of the communities they serve, not service users themselves.

    CBM’s focus on monitoring is important – but leaves out key issues around community participation, decision-making autonomy, and strategy.

    How could we integrate CBM into a transformative approach?

    TGLF’s experiences suggest that CBM could be embedded within comprehensive learning-to-action systems focused on locally-led change.

    TGLF’s model is more than a monitoring intervention.

    • It combines structured learning, rapid solution sharing, root cause analysis, action planning, and peer accountability to drive measurable improvements.
    • These mutually reinforcing components create an enabling environment for health workers to translate insights into impact.

    In this framing, community monitoring becomes one critical input within a continuous, collaborative process of problem-solving and adaptation.

    Several features of TGLF’s model illustrate how this integration could work in practice:

    1. Peer accountability structures, where health workers regularly convene to review progress, share challenges, and iterate solutions, create natural entry points for discussing and actioning community feedback.
    2. Rapid dissemination channels, like TGLF’s “Ideas Engine” for spreading promising practices across contexts, enable local innovations in response to community-identified gaps to be efficiently scaled.
    3. Emphasis on root cause analysis and systemic thinking equips health workers to interpret community insights within a broader ecosystem lens, connecting localized issues to upstream determinants.
    4. Cultivation of connected leadership empowers local actors to champion community priorities and navigate complex change processes.

    TGLF’s extensive digital network connects health workers across system levels and contexts, enabling them to learn from each other’s experiences with no upper limit to the number of participants.

    By contrast, CBM seems to assume that a community is limited to a physical area, which fails to recognize that problem-solving complex challenges requires expanding the range of inputs used.

    Within a networked approach that connects both community members and health workers across boundaries of geography, health system level, and roles, CBM could become an integral component of a transformative approach to health system improvement – one that recognizes communities and local health workers as capable architects of context-responsive solutions.

    Fundamentally, the TGLF model invites a shift in mindset about whose expertise counts in monitoring and driving system change.

    CBM could provide the ‘connective tissue’ for health workers to revise how they listen and learn with the communities they serve.

    For immunization programs grappling with persistent inequities, this shift from passive compliance to proactive local problem-solving is critical.

    As the COVID-19 crisis has underscored, rapidly evolving public health challenges demand localized action that harnesses the full range of community expertise.

    TGLF’s model offers a tested framework for actualizing this vision at scale.

    By investing in local health workers’ capacity to learn, adapt, and lead change in partnership with the communities they serve, the model illuminates a promising pathway for integrating CBM into immunization monitoring and beyond.

    For epidemiologists and global health practitioners, TGLF’s approach invites a reframing of how we conceptualize and operationalize community engagement in health system monitoring.

    It challenges us to move beyond tokenistic participation towards genuine co-design and co-ownership of monitoring processes with local actors.

    Realizing this vision will require significant shifts in mindsets, power dynamics, and resource flows.

    But as TGLF’s initiatives demonstrate, when we invest in the leadership of those closest to the challenges we seek to solve, transformative possibilities emerge.

    Further rigorous research comparing the impacts of different CBM integration models could help accelerate this paradigm shift, surfacing critical lessons for the immunization field and global health more broadly.

    TGLF’s model not only offers compelling lessons for reimagining monitoring and improvement in immunization programs, it also provides a pathway for integrating CBM into a system that supports actual change.

    CBM practitioners are likely to struggle with how to incorporate it into existing practices.

    By investing in frontline health workers as change agents, and surrounding them with an empowering learning ecosystem, the model offers a path to then bring in community monitoring.

    Without such leadership from health workers, it is unlikely that communities are able to participate.

    The journey to authentic community engagement in health system monitoring is undoubtedly complex.

    But if we are to deliver on the promise of equitable immunization for all, it is a journey we must undertake.

    TGLF’s model lights one promising path forward – one that positions communities and local health workers as the beating heart of a learning health system.

    While Gavi’s evidence brief affirms the promise of CBM for immunization, TGLF’s experience with its own model suggests the full potential of CBM may be realized by embedding it within more comprehensive, digitally-enabled learning systems that activate health workers as agents of change – and do so with both physical and digital communities implementing new forms of peer and community accountability that complement conventional kinds (supervision, administration, donor, etc.).

  • Why asking learners what they want is a recipe for confusion

    Why asking learners what they want is a recipe for confusion

    A survey of learners on a large, authoritative global health learning platform has me pondering once again the perils of relying too heavily on learner preferences when designing educational experiences.

    One survey question intended to ask learners for their preferred learning method.

    The list of options provided includes a range of items.

    (Some would make the point that the list conflates learning resources and learning methods, but let us leave that aside for now.)

    Respondents’ top choices (source) were videos, slides, and downloadable documents.

    At first glance, this seems perfectly reasonable.

    After all, should we not give learners what they want?

    As it happens, the main resources offered by this platform are videos, slides, and other downloadable documents.

    (If we asked learners who participate in our peer learning programmes for their preference, they would likely say that they prefer… peer learning.)

    Beyond this availability bias, there is a more significant problem with this approach: learner preferences often have little correlation with actual learning outcomes.

    And learners are especially bad at self-evaluating what learning methods and resources are most conducive to effective learning.

    The scientific literature is quite clear on this point.

    Bjork’s 2013 article on self-regulated learning emphatically states that: “learners are often prone to illusions of competence during learning, and these illusions can be remarkably compelling.”

    The study by Deslauriers et al. (2019) provides a compelling demonstration that while students express a strong preference for traditional lectures over active learning methods, they actually learn significantly more from the active approaches they claim to dislike.

    This disconnect between preference and efficacy is not surprising when we consider how learning actually works.

    Effective learning requires effort, struggle, and sometimes discomfort as we grapple with new ideas and challenge our existing mental models.

    It is not always an enjoyable process in the moment, even if the long-term results are deeply rewarding.

    Furthermore, learners (like all of us) are subject to various cognitive biases that can lead them astray when evaluating their own learning.

    The illusion of explanatory depth, for example, can cause us to overestimate how well we understand a topic after passively consuming information about it.

    None of this is to say we should ignore learner perspectives entirely.

    Motivation and engagement do matter for learning.

    But we need to be thoughtful about how we solicit and interpret learner feedback.

    Asking about preferences for specific content formats (videos, slides, etc.) tells us very little about the actual learning activities and cognitive processes involved.

    A more productive approach might be to focus on understanding learners’ goals, challenges, and contexts.

    What are they trying to achieve?

    What obstacles do they face?

    What constraints shape their learning environment?

    With this information, we can design evidence-based learning experiences that truly meet their needs – even if they don’t always match their stated preferences.

    As learning professionals, our job is not to give learners what they think they want.

    It is to create the conditions for transformative learning experiences that expand their capabilities and perspectives.

    This often means pushing learners out of their comfort zones and challenging their assumptions about how learning should look and feel.

    References

    Bjork, R. A., Dunlosky, J., & Kornell, N. (2013). Self-regulated learning: Beliefs, techniques, and illusions. Annual Review of Psychology, 64, 417-444. https://doi.org/10.1146/annurev-psych-113011-143823

    Deslauriers, L., McCarty, L.S., Miller, K., Callaghan, K., Kestin, G., 2019. Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proceedings of the National Academy of Sciences 201821936. https://doi.org/10.1073/pnas.1821936116

  • Klepac and colleagues‘ scoping review of climate change, malaria and neglected tropical diseases: what about the epistemic significance of health worker knowledge?

    Klepac and colleagues‘ scoping review of climate change, malaria and neglected tropical diseases: what about the epistemic significance of health worker knowledge?

    By Luchuo E. Bain and Reda Sadki

    The scoping review by Klepac et al. provides a comprehensive overview of codified academic knowledge about the complex interplay between climate change and a wide range of infectious diseases, including malaria and 20 neglected tropical diseases (NTDs).

    The review synthesized findings from 511 papers published between 2010 and 2023, revealing that the vast majority of studies focused on malaria, dengue, chikungunya, and leishmaniasis, while other NTDs were relatively understudied.

    The geographical distribution of studies also varied, with malaria studies concentrated in Africa, Brazil, China, and India, and dengue and chikungunya studies more prevalent in Australia, China, India, Europe, and the USA.

    One of the most striking findings of the review is the potential for climate change to have profound and varied effects on the distribution and transmission of malaria and NTDs, with impacts likely to vary by disease, location, and time.

    However, the authors also highlight the uncertainty surrounding the overall global impact due to the complexity of the interactions and the limitations of current predictive models.

    This underscores the need for more comprehensive, collaborative, and standardized modeling efforts to better understand the direct and indirect effects of climate change on these diseases.

    Another significant insight from the review is the relative lack of attention given to climate change mitigation and adaptation strategies in the existing literature.

    Only 34% of the included papers considered mitigation strategies, and a mere 5% addressed adaptation strategies.

    Could we imagine future mapping to recognize the value of new mechanisms for and actors of knowledge production that do not meet the conventional criteria for what currently counts as valid knowledge?

    What might be the return on going at least one step further beyond questioning our own underlying assumptions about ‘how science is done’ to actually supporting and investing in innovative indigenous- and community-led, co-created initiatives?

    This gap highlights the urgent need for more research on how to effectively reduce the impact of climate change on malaria and NTDs, particularly in areas with the highest disease burdens and the populations most vulnerable to the impacts of climate change.

    While the review emphasizes the need for more research to fill these evidence gaps, this begs the question of the resources and time required to fill them.

    This is where there is likely to be value in the experiential data from health workers on the frontlines to provide insights into the mechanisms of climate change impacts on health and effective response strategies.

    The upcoming Teach to Reach 10 event (background | registration) , a massive open peer learning platform that brings together health professionals from around the world to network and learn from each other’s experiences, offers a unique opportunity to engage thousands of health workers in a dialogue that can deepen our understanding of how climate change is affecting the health of local communities.

    Experiential data has been, historically, dismissed as ‘anecdotal’ evidence at best.

    The value and significance of what you know because you are there every day, serving the health of your community, has been ignored.

    The expertise and knowledge of frontline health workers are often overlooked or undervalued in global health decision-making processes, despite their critical role in delivering health services and their deep understanding of local contexts and challenges.

    Yes, the importance of incorporating the insights and experiences of health workers in the global health discourse cannot be overstated.

    As Abimbola and Pai (2020) argue, the decolonization of global health requires a shift towards valuing and amplifying the voices of those who have been historically marginalized and excluded from the dominant narratives.

    This concept, known as epistemic justice, recognizes that knowledge is not solely the domain of academic experts but is also held by those with lived experiences and practical expertise (Fricker, 2007).

    Epistemic injustice, as defined by Fricker (2007), occurs when an individual is wronged in their capacity as a knower, either through testimonial injustice (when a speaker’s credibility is undervalued due to prejudice) or hermeneutical injustice (when there is a gap in collective understanding that disadvantages certain groups).

    In the context of global health, epistemic injustice often manifests in the marginalization of knowledge held by communities and health workers in low- and middle-income countries, as well as the dominance of Western biomedical paradigms over local ways of knowing (Bhakuni & Abimbola, 2021).

    By engaging health workers from around the world in peer learning and knowledge sharing, Teach to Reach can help to challenge the epistemic injustice that has long plagued global health research and practice.

    By providing a platform for health workers to share their experiences and insights, Teach to Reach – alongside many other initiatives focused on listening to and learning from communities – can contribute to ensuring that the fight against malaria and NTDs in the face of climate change is informed not only by rigorous scientific evidence but also by the practical wisdom of those on the ground.

    That is only if global partners are willing to challenge their own assumptions, and take the time to listen and learn.

    Moreover, the decolonization of global health requires a shift towards more equitable and inclusive forms of knowledge production and dissemination.

    This involves challenging the historical legacies of colonialism and racism that have shaped the global health field, as well as the power imbalances that continue to privilege certain forms of knowledge over others (Büyüm et al., 2020).

    By fostering a dialogue between health workers and global partners, Teach to Reach can help to bridge the gap between research and practice, ensuring that the latest scientific findings are effectively translated into actionable strategies that are grounded in local realities and responsive to the needs of those most affected by climate change and infectious diseases.

    The value of experiential data from health workers in filling evidence gaps and informing effective response strategies cannot be understated.

    As the Klepac review highlights, there is a paucity of research on the impacts of climate change on many NTDs and the effectiveness of mitigation and adaptation strategies.

    While more rigorous scientific studies are undoubtedly needed, waiting years or decades for this evidence to accumulate before taking action is not a viable option given the urgency of the climate crisis and its devastating impacts on health.

    Health workers’ firsthand observations and experiences can provide valuable insights into the complex mechanisms through which climate change is affecting the distribution and transmission of malaria and NTDs, as well as the effectiveness of different intervention strategies in real-world settings.

    This type of contextual knowledge is essential for developing locally tailored solutions that account for the unique social, cultural, and environmental factors that shape disease dynamics in different communities.

    Furthermore, engaging health workers as active partners in research and decision-making processes can help to ensure that the solutions developed are not only scientifically sound but also feasible, acceptable, and sustainable in practice.

    The involvement of frontline health workers in the co-creation of knowledge and interventions can lead to more effective, equitable, and context-specific solutions that are responsive to the needs and priorities of local communities.

    References

    Abimbola, S., & Pai, M. (2020). Will global health survive its decolonisation? The Lancet, 396(10263), 1627-1628. https://doi.org/10.1016/S0140-6736(20)32417-X

    Bhakuni, H., & Abimbola, S. (2021). Epistemic injustice in academic global health. The Lancet Global Health, 9(10), e1465-e1470. https://doi.org/10.1016/S2214-109X(21)00301-6

    Büyüm, A. M., Kenney, C., Koris, A., Mkumba, L., & Raveendran, Y. (2020). Decolonising global health: If not now, when? BMJ Global Health, 5(8), e003394. https://doi.org/10.1136/bmjgh-2020-003394

    Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. Oxford University Press.

    Klepac, P., et al., 2024. Climate change, malaria and neglected tropical diseases: a scoping review. Transactions of The Royal Society of Tropical Medicine and Hygiene. https://doi.org/10.1093/trstmh/trae026

  • Climate change and health: perspectives from developing countries

    Climate change and health: perspectives from developing countries

    Today, the Geneva Learning Foundation’s Charlotte Mbuh delivered a scientific presentation titled “On the frontline of climate change and health: A health worker eyewitness report” at the University of Hamburg’s Online Expert Seminar on Climate Change and Health: Perspectives from Developing Countries.

    Mbuh shared insights from a report based on observations from frontline health workers on the impact of climate change on health in their communities.

    Investing in the health workforce is vital to tackle climate change: A new report shares insights from over 1,200 on the frontline

    Climate change is a threat to the health of the communities we serve: health workers speak out at COP28

    The Geneva Learning Foundation, a Swiss non-profit, facilitated a special event “From community to planet: Health professionals on the frontlines of climate change” on 28 July 2023, engaging 4,700 health practitioners from 68 countries who shared 1,260 observations.

    “93% of respondents believed that there was a link between climate change and health, and they reported a direct local experience of a wide range of climatic and environmental impacts,” Mbuh stated.

    The most commonly reported impacts were on farming and farmland, the distribution of disease-carrying insects, and urban areas becoming hotter.

    Health impacts linked to these climatic and environmental changes included increased malnutrition and/or undernutrition, increased waterborne diseases, and changes to the incidence and distribution of vector-borne diseases.

    Mbuh emphasized that these impacts were particularly prevalent in smaller communities or mid-sized towns.

    Mbuh highlighted the unique role of frontline health workers as trusted advisors to their communities: “Frontline health workers are trusted advisors of the communities that they serve, and they have unique insights to local realities and are strategically positioned to bring about change,” she said.

    The Geneva Learning Foundation aims to leverage its digitally-enabled peer learning network of health workers to drive change across different levels of the health system and geographical boundaries.

    Mbuh concluded : “These experiences demonstrate the importance of community engagement, sustainable practices, and support from relevant stakeholders in addressing the climate health nexus and building resilience in the face of a changing climate.”

    The presentation underscored the urgent need to invest in frontline health workers at the local level to build resilience against the impacts of climate change on health, particularly in vulnerable communities in developing countries.

    The event was organized by the International Expert Centre of Climate Change and Health (IECCCH) at the Research and Transfer Centre Sustainable Development and Climate Change Management, Hamburg University of Applied Sciences, in collaboration with the European School of Sustainability Science and Research (ESSSR), the UK Consortium on Sustainability Research (UK-CSR), and the Inter-University Sustainable Development Research Programme (IUSDRP).

    Photo: The Geneva Learning Foundation Collection © 2024

  • Making the invisible visible: storytelling the health impacts of climate change

    Making the invisible visible: storytelling the health impacts of climate change

    On March 18, 2024, the Geneva Learning Foundation (TGLF) hosted a workshop bringing together 553 health workers from 55 countries with TGLF’s First Fellow of Photography and award-winning photographer Chris de Bode. Watch the workshop in English and in French. Poor connectivity? Get the audio-only podcast.

    The dialogue focused on exploring the power of health workers who are there every day to communicate the impacts of climate change on the health of those they serve. Learn more…

    The Geneva Learning Foundation’s exploration of visual storytelling began, two years ago, with a simple yet powerful call to action for World Immunization Week: “Would you like to share a photo of your daily work, the work that you do every day?” Over 1,000 photos were shared within two weeks. “We repeated this in 2023, to show that it is people who make #VaccinesWork”, explains Charlotte Mbuh, the Foundation’s deputy director. Watch the 2022 and 2023 events, as well as the inauguration of the First International Photography Exhibition of the Movement for Immunization Agenda 2030 (IA2030).

    In July 2023, over 4,700 health professionals – primarily government workers from 68 low and middle-income countries – responded to the call to share their firsthand observations of the impacts of climate change on health. Watch the special event “From community to planet: Health professionals on the frontlines of climate change“… Get the insights report…

    That is when Chris de Bode, who has spent decades documenting global health stories, expressed his excitement to flip the script:

    “Over the last two years, we received so many pictures about your daily work. By asking you a new question, a different angle on what you work on, we can go a little bit deeper in what you actually do. Since you are on the front line everywhere in the world, it’s super interesting to create a collection of images to show the world and also show each other within the community.”

    What would Taphurother Mutange, a community health worker from Kenya, want to show in the photos she will take?

    “What I want to show to people is the floods. In my community where I work, the floods were too much. Water went into a house where there was a 12-year-old girl sleeping. The water carried the girl out, and up to date, as I’m talking, she has never been seen.”

    She linked this devastation directly to health, adding, “So climate change goes together with health, because after the rains, the children, pregnant mothers, and even older people get sick, and you might see there’s not enough drugs in the facility. So we might even go on losing some lives.”

    Brigitte Meugang, a health professional from Yaoundé, Cameroon, captured the essence of why visual storytelling matters:

    “I’m attending this event because I believe that with a picture, you can say a thousand words.

    And with a beautiful picture, you can learn a lot.

    You can understand a lot.

    And you can understand really the story just by looking at a picture, usually.”

    Chris guided participants on the psychology and ethics of photography, the power of light, and how to create compelling visual narratives.

    He challenged the idea that photos must be candid to be authentic.

    “A picture is always subjective.

    It’s your position as a photographer who decides which picture you take and what you want to tell with the image.

    When I take portraits of people, I stage, and I always stage.”

    Participants grappled with this in the context of their health work.

    Emmanuel Musa, from Nigeria, highlighted the tension:

    “Professionally, we’ve been asked to take pictures, action pictures, but not to have a kind of arranged, organized setting…

    Because normally we look at pictures that are actionable, that probably funders can see, probably supervisors can see what’s happening in the field, instead of organizing a group picture, you set as if we’re in a studio.”

    Aimée N’genda, a health worker from the Democratic Republic of Congo (DRC), also emphasized the importance of consent and the risk of exploitation, especially in urban settings.

    “Based on our experience, you need to ask for a written consent that you should keep, because you’ve got some people that will take advantage of it and think that when you take pictures of their children, they think you make money out of this, without paying them any fees.”

    Despite the challenges, Chris affirmed the unique power health workers have as visual storytellers.

    “You guys and ladies, you are there on the spot.

    You’re there every day.

    You have a large, large advantage on us, professional photographers who have to go there.”

    Participants left energized to apply what they learned.

    François Desiré, for example, declared, “I’m going to share pictures of mobile clinics that integrate immunization and nutrition.”

    The dialogue equipped health workers to harness visual storytelling to communicate vital stories of how climate change impacts health in their communities, sparking change through the power of a single image.

    The Geneva Learning Foundation (TGLF) is actively seeking a donor or sponsor to support visual storytelling by health professionals.

    Version française: Raconter la santé en image: un atelier photo avec Chris de Bode pour Teach to Reach 10

    This story was written by generative AI, based on a word-for-word transcript of the workshop.

    Image: Screen shot of the chat during the workshop “Visual storytelling for health” on 18 March 2024.

  • Five examples of double-loop learning in global health

    Five examples of double-loop learning in global health

    Read this first: What is double-loop learning in global health?

    Example 1: Addressing low uptake of a vaccine program

    Single–Loop Learning: Improve logistics and supply chain management to ensure consistent vaccine availability at clinics.

    Double–Loop Learning: Engage with community leaders to understand cultural beliefs and concerns around vaccination, and co-design a more localized and trustworthy immunization strategy.

    What is the difference? Double-loop learning questions the assumption that the primary goal should be to increase uptake at all costs. It considers whether the program design respects community autonomy and addresses their real concerns. It may surface competing values of public health impact vs. community self-determination.

    Example 2: Responding to an infectious disease outbreak

    Single–Loop Learning: Rapidly mobilize health workers and supplies to affected areas to contain the outbreak following established emergency protocols.

    Double–Loop Learning: Critically examine why the health system was vulnerable to this outbreak, and work with communities to redesign surveillance, preparedness and response systems to be more resilient.

    What is the difference? Double-loop learning interrogates whether the existing outbreak response system is built on the value of health equity. It asks if the system privileges the needs of some populations over others and perpetuates historical power imbalances. It strives to create a more inclusive, participatory approach to defining outbreak preparedness and response priorities.

    Example 3: Implementing a maternal health intervention that shows low adherence

    Single–Loop Learning: Retrain health providers to improve their counseling skills and provide better patient education on the intervention.

    Double–Loop Learning: Conduct participatory research with women and families to understand their needs, preferences and barriers to care-seeking, and collaborate with them to iteratively adapt the intervention design.

    What is the difference? Double-loop learning challenges the implicit assumption that the intervention design is inherently correct and that non-adherence is a ‘user error’. It examines whether the intervention embodies values of respect, humility and co-creation with communities. It seeks to align the intervention with women’s self-articulated reproductive health values and preferences.

    Example 4: Evaluating an underperforming community health worker (CHW) program

    Single–Loop Learning: Strengthen CHW supervision, increase performance incentives, and optimize the ratio of CHWs to households.

    Double–Loop Learning: Facilitate a joint reflection process with CHWs and community representatives to examine program strengths, challenges and equity gaps, and co-create a revised strategy that better aligns with community priorities and integrates CHWs’ insights.

    What is the difference? Double-loop learning questions whether the CHW program is driven by the value of empowering communities as agents of their own health vs. treating CHWs as an instrument of technocratic public health aims. It re-centers the program on the value of CHW leadership and community-driven problem definition.

    Example 5: Reforming a health financing policy to improve population coverage

    Single–Loop Learning: Adjust the premium amounts, enrollment processes and benefit package based on initial uptake data.

    Double–Loop Learning: Convene citizen panels and key stakeholders to deliberate on the fundamental goals and values underlying the financing reforms, and recommend redesigning the policy to better advance equity and financial protection.

    What is the difference? Double-loop learning interrogates whether the true intent of the policy is to advance equity and financial protection for marginalized groups or simply to expand coverage as an end unto itself. It opens up debate on the core values and theory of change underlying the reforms. It aims to re-anchor the policy in a wholistic vision of equitable universal health coverage.

  • Learning culture: the missing link in global health between learning and performance

    Learning culture: the missing link in global health between learning and performance

    Learning culture is a critical concept missing from health systems research.

    It provides a practical and actionable framework to operationalize the notion of ‘learning health systems’ and drive transformative change.

    Read this first: What is double-loop learning in global health?

    Watkins and Marsick describe learning culture as the capacity for change. They identify seven key action imperatives or “essential building blocks” that strengthen it: continuous learning opportunities, inquiry and dialogue, collaboration and team learning, systems to capture and share learning, people empowerment, connection to the environment, and strategic leadership for learning (Watkins & O’Neil, 2013).

    Crucially, the instrument developed by Watkins and Marsick assesses learning culture by examining perceptions of norms and practices, not just individual behaviors (Watkins & O’Neil, 2013).

    This aligns with Seye Abimbola’s assertion that learning in health systems should be “people-centred” and occurs at multiple interconnected levels.

    Furthermore, this research demonstrates that certain dimensions of learning culture, like strategic leadership and systems to capture and share knowledge, are key mediators and drivers of performance outcomes (Yang et al., 2004).

    This provides compelling evidence that investments in learning can yield tangible improvements in health delivery and population health.

    Learn more: Jones, I., Watkins, K. E., Sadki, R., Brooks, A., Gasse, F., Yagnik, A., Mbuh, C., Zha, M., Steed, I., Sequeira, J., Churchill, S., & Kovanovic, V. (2022). IA2030 Case Study 7. Motivation, learning culture and programme performance (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7004304

    As Watkins and Marsick (1996) argue, to develop a strong learning culture, we need to “embed a learning infrastructure”, “cultivate a learning habit in people and the culture”, and “regularly audit the knowledge capital” in our organization or across a network of partners.

    While investments in learning can be a challenging sell in resource-constrained global health settings, this evidence establishes that learning culture is in fact an indispensable driver of health system effectiveness, not just a “nice to have” attribute.

    Subsequent studies have also linked learning culture to key performance indicators like care quality, patient satisfaction, and innovation.

    Why lack of continuous learning is the Achilles heel of immunization

    To advance learning health systems, it is important to translate this research in terms that resonate with the worldview of global health practitioners like epidemiologists and to produce further empirical studies that speak to their evidentiary standards.

    Ultimately, this will require expanding mental models about what constitutes legitimate and actionable knowledge for health improvement.

    The learning culture framework offers an evidence-based approach to guide this transformation.

    References

    Abimbola, S. The uses of knowledge in global health. BMJ Glob Health 6, e005802 (2021).

    Watkins, K. E. & O’Neil, J. The Dimensions of the Learning Organization Questionnaire (the DLOQ): A Nontechnical Manual. Advances in Developing Human Resources 15, 133–147 (2013).

    Watkins, K., & Marsick, V. (1996). (Eds.). In action: Creating the learning organization (Vol. 1). Alexandria, VA: ASTD Press.

    Yang, B., Watkins, K. E. & Marsick, V. J. The construct of the learning organization: Dimensions, measurement, and validation. Human Resource Development Quarterly 15, 31–55 (2004).

  • What is double-loop learning in global health?

    What is double-loop learning in global health?

    Argyris (1976) defines double-loop learning as occurring “when errors are corrected by changing the governing values and then the actions.” He contrasts this with single-loop learning, where “errors are corrected without altering the underlying governing values.”

    • Double-loop learning involves questioning “not only the objective facts but also the reasons and motives behind those facts”.
    • It requires becoming aware of one’s own “theories-in-use” – the often tacit beliefs and norms that shape behavior – and subjecting them to critical reflection and change. 

    This is challenging because it can threaten one’s sense of competence and self-image.

    Checking for double-loop learning: ‘Are we doing things right?’ vs. ‘Are we doing the right things?’

    In global health, double-loop learning means not just asking “Are we doing things right?” but also “Are we doing the right things?” It means being willing to challenge long-held assumptions about what works, for whom, and under what conditions.

    Epistemological assumptions (“we already know the best way”), methodological orthodoxies (“this is not how we do things”), and apolitical stance (“I do health, not politics”) of epidemiology can predispose practitioners to be dismissive of a concept like double-loop learning. 

    Learn more: Five examples of double-loop learning in global health

    Seye Abimbola is part of a growing community of researchers who argue that double-loop learning is critical for advancing equity and self-reliance in global health systems, because global health tends to overlook its own assumptions.

    Is it reasonable to posit that some global health interventions have been driven by unchecked assumptions – assumptions about what communities need, what they value, and what will work in their context? How often have we relied on a one-size-fits-all approach, implementing ‘best practices’ from afar without fully understanding local realities? How do we know to what extent programs have thereby failed to meet their goals, wasted precious resources, and may have even caused unintended harm?

    As Abimbola (2021) notes, “double-loop learning goes further to question and influence frameworks, models and assumptions around problems and their solutions, and can drive deeper shifts in objectives and policies.”

    For example, affected communities hold vital expertise to mitigate health risks.

    However, fully leveraging this potential requires global health professionals to fundamentally rethink their roles and assumptions.

    • For research to serve the needs of affected communities, it is likely to be useful to reframe these roles and assumptions to see themselves as “subsidiary” partners in service of “primary” community actors (Abimbola, 2021).
    • Institutionalizing double-loop learning requires enabling critical reflection and co-production between health workers, managers and citizens (Sheikh & Abimbola, 2021).
    • It also depends on developing the learning capacities of communities and health workers in areas like participatory governance, team-based learning and innovation management.

    The next logical question is ‘how’ to implement double-loop learning.

    Learning culture is a critical concept missing from health systems research.

    It provides a practical and actionable framework to operationalize the double-loop learning notion of ‘learning health systems’ and drive transformative change.

    Learn more: Learning culture: the missing link in global health between learning and performance

    Further reading

    Learning-based complex work: how to reframe learning and development

    What learning science underpins peer learning for Global Health?

    How do we reframe health performance management within complex adaptive systems?

    References

    Abimbola, S. The uses of knowledge in global health. BMJ Glob Health 6, e005802 (2021). https://doi.org/10.1136/bmjgh-2021-005802

    Argyris, C. Single-loop and double-loop models in research on decision making. Administrative science quarterly 363–375 (1976). https://doi.org/10.2307/2391848

    Argyris, C. Double-loop learning, teaching, and research. Academy of Management Learning & Education 1, 206–218 (2002). https://www.jstor.org/stable/40214154

    Kabir Sheikh & Seye Abimbola. Learning Health Systems: Pathways to Progress. (Alliance for Health Policy and Systems Research, 2021).

    Image: The Geneva Learning Foundation Collection © 2024

  • Metaphors of global health: jazz improvisation ensemble or classical orchestra?

    Metaphors of global health: jazz improvisation ensemble or classical orchestra?

    In the realm of classical music, the orchestra stands as a formidable emblem of aesthetic grandeur and refinement. However, beneath the veneer of sophistication lies a deeply entrenched system that stymies the potential for creative exploration and spontaneity. As in a straitjacket, the rigidity of this system threatens to reduce the rich tapestry of human experience into a sterile hierarchy, devoid of the serendipity that breathes life into artistic expression.

    The classical orchestra is governed by a hierarchy that places the conductor at the apex, wielding an almost tyrannical authority over the musicians. It is a system that perpetuates a culture of conformity, where musicians are coerced into subsuming their individuality in the service of an imposed order. This stifling environment leaves little room for the musicians to contribute their own interpretations or creative impulses, and instead demands that they adhere strictly to the conductor’s vision, which is often based on a prescriptive reading of the composer’s intent.

    The result is a musical experience that is reductive in nature, an experience that is stripped of the chaos and unpredictability that are essential to the vitality of artistic expression. In its quest for order, the classical orchestra neglects the potential for serendipity, which can arise from the unscripted interplay of individual talents and the embrace of the unexpected. By eschewing the possibility of chance encounters and emergent beauty, the orchestra constricts the wellspring of creative potential, relegating the musicians to mere cogs in a mechanistic apparatus.

    Furthermore, the insistence on a strict adherence to the conductor’s interpretation perpetuates an illusion of coherence and stability that belies the complexities of the human experience. The orchestral structure does not allow for the acknowledgement of discord and dissonance that are inherent in life. Rather, it seeks to impose a singular vision of order, relegating the multitudes of voices and perspectives to the margins of the performance.

    In the end, the classical orchestra emerges as an antiquated institution that, in its blind pursuit of order, risks smothering the creative spirit that animates the very essence of artistic expression. It is a system that demands submission and conformity at the expense of individuality and exploration. By refusing to acknowledge the serendipity and complexity that lie at the heart of human experience, the classical orchestra risks becoming a hollow shell, a lifeless relic of a bygone era that has yet to fully grasp the true potential of the human spirit.

    Is global health more like a classical orchestra or jazz improvisation?

    In a dimly lit club, a hazy smoke fills the air, while the soft murmur of conversation weaves its way through the room. Then, the jazz ensemble erupts in a mesmerizing explosion of sound – an intoxicating mix of chaos and order, each musician adding their own unique twist to the shared melody. As their improvisation unfolds, the music becomes a living, breathing entity, transcending the boundaries of the individual instruments.

    This vibrant expression of creativity and spontaneity form the improvisational spirit. Could embracing the fluidity and adaptability inherent in jazz as a metaphor help us rise to meet the myriad challenges that crop up in our quest to improve the health of people across the globe?

    The notion of orchestrating global health initiatives like a classical ensemble, with a conductor dictating every note and movement, might be appealing at first glance. But the diverse and interdependent nature of global health demands that we adopt a more inclusive approach that values flexibility, adaptability, and collaboration. Just as a jazz ensemble thrives on its ability to respond to the unexpected, global health initiatives must be nimble enough to adjust to the constantly shifting realities on the ground.

    It’s a world where the unexpected reigns supreme, where musicians effortlessly dance between moments of chaos and harmony. In this realm of improvisation, there’s a certain magic that takes hold – a power that transcends the limits of scripted notes and carefully crafted melodies.

    The power of improvisation lies in its ability to tap into the uncharted territories of human creativity. It’s a process that relies on a deep sense of trust and vulnerability between the musicians, who must be willing to venture into the unknown, guided by nothing more than their intuition and their shared connection to the music. As they navigate this uncertain terrain, the musicians become explorers of a musical landscape that is constantly shifting and evolving, and in doing so, they discover new possibilities and pathways that would have otherwise remained hidden.

    Improvisation also fosters a unique form of communication, one that transcends the boundaries of language and culture. In the midst of a jazz jam session, the musicians engage in a conversation that is at once wordless and profound, speaking to one another through the language of their instruments. As each musician adds their own voice to the collective melody, they create a tapestry of sound that tells a story – a story that is rich in emotion and nuance, and that speaks to the universal human experience.

    Moreover, improvisation has the power to challenge and transform our understanding of what is possible. By breaking free from the constraints of traditional structures and forms, improvisation invites us to question the status quo and to reimagine the world in new and exciting ways. It teaches us to embrace uncertainty and change, and to see the beauty in the unexpected. In this sense, improvisation serves as a potent reminder of the boundless potential that lies within each of us, waiting to be unleashed.

    As the haunting strains of a saxophone solo rise and fall, and the pulse of the bass line echoes through the dimly lit club, the power of improvisation is laid bare for all to see. It’s a force that defies categorization, and yet it holds within it the capacity to move and inspire, to challenge and transform. In the ever-changing world of jazz, the power of improvisation is the lifeblood that courses through the music, and it’s a force that, if harnessed, can open up new worlds of possibility and wonder.

    In this context, the jazz ensemble emerges as the more fitting metaphor. By incorporating the principles of complexity and change found within the jazz improvisation, we can more effectively navigate the challenges that come with addressing global health issues. It is through this adaptable and collaborative approach that we can truly accelerate progress and create lasting, meaningful change.

    So, as the last notes of the saxophone linger in the air and the final beats of the drums echo through the club, we’re reminded of the power and potential of improvisation. It’s a lesson that, if taken to heart, might help transform our efforts to improve global health and the lives of those we seek to help.

    Is global health more like a classical orchestra or a jazz improvisation ensemble? Which should it be in the future?

    Reference

    Jacobson, J., Brooks, A., 2022. Reflections on “Orchestrating for Impact”: Harmonizing across Stakeholders to Accelerate Global Health Gains. The American Journal of Tropical Medicine and Hygiene. https://doi.org/10.4269/ajtmh.21-1101