Preventive Veterinary Medicine 112 (2013) 222–229
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Transdisciplinary research for complex One Health issues: A scoping review of key concepts B. Min a , L.K. Allen-Scott b , B. Buntain c,∗ a b c
Bachelor of Health Sciences Program, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada Veterinary Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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Article history: Received 8 March 2013 Received in revised form 14 June 2013 Accepted 14 September 2013 Keywords: Transdisciplinary One Health Ecohealth Global Health Scoping review
a b s t r a c t In order to address the complexity inherent in researching One Health (OH) issues, we support the concept that researchers must transcend individual disciplinary and nondisciplinary boundaries, and move into the realm of transdisciplinary (TD) research approaches. For the purposes of this paper we use the term OH and the concept that OH research is conducted to solve complex health challenges at the animal-human–human–ecosystem interface. TD goes beyond interdisciplinary research to engages disciplines and communities through a unified conceptual framework. In this scoping review we investigated key concepts, definitions and themes in OH and TD based on the peer reviewed literature. We identified nine emerging themes in TD research: (1) education, (2) conflict amongst disciplines, (3) effective communication, (4) shared conceptual framework, (5) leadership, (6) perceived power differentials, (7) community-based methodologies, (8) support for TD research and (9) time and effort. This review provides a synthesized knowledge base that describes the nature, extent of evidence and challenges of engaging in TD initiatives. This knowledge base further provides a foundation for those interested in developing improved strategies for TD collaborative and cross-sectoral research in OH. © 2013 Published by Elsevier B.V.
1. Introduction Modern veterinary and human preventive medicine recognizes that global health is facing challenges from a multitude of interconnected infectious and non-infectious diseases. These health issues are occurring in human and animal populations that are inextricably linked to the interconnections of social and ecosystem determinants of health and to our interactions with animals worldwide (Rock et al., 2009; Zinsstag et al., 2011). Current discussions on this topic have been framed as One Medicine, One Health, Ecosystem Health, Global Health, and Health in SocialEcological Systems (HSES). For the purposes of this paper we use the term One Health (OH) and the concept that OH
∗ Corresponding author. Tel.: +1 403 220 6436. E-mail address: [email protected] (B. Buntain). 0167-5877/$ – see front matter © 2013 Published by Elsevier B.V. http://dx.doi.org/10.1016/j.prevetmed.2013.09.010
research is conducted to solve complex health challenges at the animal–human–ecosystem interface. The concept of OH has emerged internationally primarily as an approach to address animal–human interactions resulting in emerging and reemerging zoonotic diseases. Further, ecosystem health or ecohealth has gained prominence in addressing the sustainable health of people, animals and ecosystems by applying transdisciplinary (TD) sciences (Mazet et al., 2009; Zinsstag et al., 2012). Both of these approaches call for integrative, systemic health research methods that will facilitate the deconstruction of academic, institutional, disciplinary, stakeholder, and government silos. Interdisciplinary research has gained prominence as more funding organizations recognize the importance of teams comprised of multiple disciplines addressing complex issues; however, TD research may be critical to solving complex health issues in a more holistic manner
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(Rosenfield, 1992; Stokols, 2006). TD research goes beyond interdisciplinarity to include multiple levels of stakeholders, including the community, academia and government. It extends discipline-based concepts, theories and methods that enable researchers to focus on a health issue through a unified conceptual lens (Rosenfield, 1992; Wiesmann et al., 2012). Here we aim to provide the reader with an in-depth review of the current body of peer reviewed literature on TD approaches to investigating health challenges resulting from the interactions of ecosystems, humans and animals. Although we focus on TD literature for this review, the emerging themes and challenges also apply to interdisciplinary research collaboration.
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students (Institute of Medicine of the National Academies, 2013). The Swiss Academies of Arts and Sciences expertly described how to enhance TD research through fifteen propositions that addressed the stumbling blocks and cornerstones of TD research, from process to outcomes (Herweg et al., 2012). It was proposed that the TD approach should be integrated at specific stages throughout the research program from the beginning through the translation of knowledge (Wiesmann et al., 2012). Integrating TD approaches at various stages of the research timeline may hold the key to successfully addressing complex OH challenges and facilitating translation of knowledge into action. 3. One Health/Ecohealth convergence
2. The evolution of TD research Health research approaches have evolved from multidisciplinary to interdisciplinary and most recently to TD. Interdisciplinary research essentially involves collaboration among different disciplines in order to transfer methods or concepts from one discipline to another (Herweg et al., 2012). The extent of collaboration and types of disciplines involved can vary with context. For example, an interdisciplinary approach aiming to study an emerging infectious disease may include collaboration among medicine, veterinary medicine and environmental sciences (Anholt et al., 2012). However members of interdisciplinary teams approach an overarching problem with their individual disciplinary conceptual frameworks, methods and definitions resulting in different types of answers (Herweg et al., 2012). In contrast to interdisciplinarity, TD research focuses on interactions between, across and beyond disciplines with a shared conceptual framework. The surge of recent interest in TD research reflects the recognition that tackling complex health issues requires a new model of collaboration (Stokols et al., 2005; Abrams, 2006). Collaborative research must transcend individual disciplinary boundaries and perspectives to achieve the level of progress needed to improve human health (Rosenfield, 1992). TD offers a holistic approach to health research where researchers from multiple disciplines work together with community and government stakeholders to create a shared conceptual framework that will be used to address a common problem (Rosenfield, 1992). Conceptual frameworks provide an outline or visual representation of possible courses of action to solve a research question. They are essential, especially in large and diverse TD teams, as they facilitate a coherent approach to inquiry. Without a shared conceptual framework, members of the TD team may be on “different paths” to addressing the research aim, which would ultimately result in disjointed outcomes and extended research-toaction timelines. For example, the Global Health conceptual framework proposes a TD perspective of health where various domains (biomedical, behavioral, psychological, social and spiritual) influence health outcomes in a holistic manner (Picard et al., 2011). The concept of establishing “TD professionalism” has been actively discussed in the human healthcare field as a means to act collaboratively and transfer skills to
Currently there is a conceptual “convergence of Ecohealth and One Health” that supports a TD field of collaboration (Zinsstag, 2012; Zinsstag, 2013). One Health research has focused primarily on zoonotic diseases and health services research, but is evolving in the literature to consider systemic approaches of the impact of societies, communities, and ecosystems on health (HSES) (Zinsstag et al., 2011). We see an integration of animal, social and ecosystem determinants of health with sustainability through the application of TD approaches to ecosystem health research. TD is heavily rooted in ecosystems approaches to health that brings together disciplines and stakeholders in an environment where community representatives are co-researchers who provide informed knowledge based on their experiences. A TD approach applied at appropriate times in the research process facilitates understanding the complexities of improving health at the animal–social–ecological interfaces (Marmot, 2005; Charron, 2012; Wiesmann et al., 2012). To date there is a paucity of peer-reviewed OH articles that evaluate the implementation and resulting added value of TD approaches at the human–animal–ecosystem interface. Moreover, a systematic and broad synthesis of the existing knowledge of TD approaches for OH is required to highlight the challenges and successes of the TD approach. Here we present a synthesized knowledge base from the peer-reviewed literature that describes key emergent themes or elements of TD OH research. This evidence base provides researchers a foundation for building capacity to address complex OH challenges. 4. Methods 4.1. Scoping review A scoping peer reviewed literature review was conducted to identify key themes in the current body of knowledge on TD and OH research. This type of review was chosen to gather evidence in a broad topic area and inform further research. The review was exploratory, and therefore did not specify concepts before interpreting the results. Rather, our open and broad research question was refined by the search results and the concepts of conducting TD research were emergent in the analysis (Levac et al., 2010). Our aim was to map the key concepts and sources
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that underpin the area of TD research in OH in order to build the evidence-base required for successful TD research projects. 4.2. Identifying relevant studies Relevant peer-reviewed articles published from 1990 until August of 2012 were sought using the electronic databases of Global Health, Health Star and Web of Knowledge. Our multi-disciplinary team (B.M., L.K.A. and B.B.) developed a search strategy using the following key terms: One Health, EcoHealth and one medicine. These terms were searched as subject headings and combined using the Boolean operator “and” with the terms: transdisciplinary AND model OR framework OR tool OR structure OR approach. Titles, abstracts and full-text were reviewed using specific inclusion criteria. Hand searches were conducted on the references of included articles. This was an iterative process that involved constant revisiting of the literature as we uncovered key concepts in TD OH research. 4.3. Study selection Inclusion criteria: (1) peer-reviewed articles that described TD approaches to OH issues, (2) peer-reviewed articles that discussed a TD method to investigate a complex health issue, (3) peer-reviewed articles that described TD research approaches and (4) peer-reviewed articles in English. Our definitions of OH and TD were based on an iterative knowledge of the literature. The definitions below represent our starting conceptualizations, which were iteratively reviewed and updated as our knowledge of the topic area expanded. All three authors contributed to consensual decision-making on inclusion or exclusion (B.M., L.K.A. and B.B.). One Health: “the collaborative efforts of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and our environment” (American Veterinary Medical Association, 2008). TD: “Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address common problem” (Rosenfield, 1992). During the review process the TD definition was expanded to the more current description of TD that moves beyond disciplines and includes the community as key stakeholders in the research process (Schelling et al., 2007). Complex issues were defined as problems requiring the integration of multiple perspectives and theories. 4.4. Charting the data B.M., L.K.A. and B.B. developed a data charting form to extract key information from the included studies. Both a narrative review and a descriptive analytical method were used to extract contextual and process data on the TD research methods used to investigate OH issues (Levac et al., 2010).
4.5. Analytic framework The breadth of the literature was described analytically to provide an overview of the field. A brief quantitative analysis was conducted to describe the characteristics of the included studies. The definitions of TD and OH provided within the included studies were also analyzed for consistency. A thematic analysis of the included studies was then completed in order to uncover emerging themes in the process of conducting TD OH research (Burnard, 1991). 5. Results 5.1. Overview of the literature Out of the 404 originally identified articles, 16 met the inclusion criteria for this review (Fig. 1). Table 1 outlines the characteristics of these included studies. The included studies represent a variety of research published in the USA, Canada, Switzerland and Brazil, six of which focused on a review of TD research. Five articles were seminal TD articles that sought to define, evaluate or describe TD research. The remaining five articles were studies that utilized TD approaches to address complex health issues. The majority of these articles addressed health issues in developing countries, including Tanzania and Chad. One of the two Canadian articles addressed the impact of climate change in a community in Nunatsiavut, Canada (Harper et al., 2012). The other assessed the strengths and weaknesses of TD approaches in Community Health Research Unit members in Ontario, Canada (Maclean et al., 2000). 5.2. Working definitions The definition of TD utilized by the majority of the seminal articles on TD research was based on Rosenfield (1992). There was an overall agreement that TD was a type of research approach that involved multiple disciplines or professions, and most of the articles mentioned that TD involved moving beyond disciplinary boundaries (Table 2). However, two articles, both published in Switzerland, emphasized the role of community involvement in describing TD approaches (Schelling et al., 2007; Zinsstag et al., 2011). Their methods underscored community-based, participatory approaches to solving health concerns of animal and human populations. One TD article published in Canada integrated ecosystem approaches and TD, stating that, “ecosystem approaches, as developed and applied in ecology, human ecology, environmental planning, anthropology, psychology, and other disciplines, may provide a more TD route to successful integration of environment and development” (Slocombe, 1993). This implied that ecosystem approaches to sustainable systems were inherently TD. Another author, Mazet et al. (2009) echoed this idea by stating that ‘One Health approaches’ were TD by nature. Generally, the definition of OH was not explicitly stated or different terminology was used, such as ‘EcoHealth’ or ‘ecosystem approaches’. Conrad et al. (2009) and 2
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Fig. 1. Flow diagram of literature search and selection of articles. *Inclusion criteria: describe TD approcahes to One Health issue in English; if the study does not address an explicity One Health issue, it uses a TD approach to investigated a complex issue; the study provides an interesting definition of TD.
other articles described OH as involving an interconnection between human, animal and environmental health (Conrad et al., 2009) (Table 2). Most articles described issues such as health disparities and emerging infectious diseases, which, although not explicitly stated as being OH,
can be considered complex problems involving the integration of multiple health perspectives. A consensus was that TD approaches were necessary to solve complex health problems at the human–animal–environmental interface and more broadly any complex health issue (Table 2).
Table 1 Characteristics of included studies. Article descriptions
Country of publication
Articles
TD review articles
Brazil (n = 1, 0.17) Canada (n = 1, 0.17) Switzerland (n = 1, 0.17) USA (n = 3, 0.50)
Boischio et al. (2009) Parkes et al. (2005) Zinsstag et al. (2009) Abrams (2006), Conrad et al. (2009), Gehlert et al. (2010)
Seminal TD articles
Canada (n = 1, 0.20) USA (n = 4, 0.80)
Slocombe (1993) Rosenfield (1992), Stokols et al. (2003, 2005), Stokols (2006)
Addressed complex health issues in developing countries
Canada (n = 2, 0.40) Switzerland (n = 1, 0.20) USA (n = 2, 0.40)
Harper et al. (2012), Maclean et al. (2000) Schelling et al. (2007) Clifford (2008), Mazet et al. (2009)
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Table 2 Working definitions and terminology of transdisciplinary and One Health. Terminology
Description
Examples
Transdisciplinary
“A research approach that cuts across disciplines through the use of a common conceptual framework to address a common problem, blending together commonly accepted theories and concepts. Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address common problem” Community-based; participatory approaches
Slocombe (1993), Stokols et al. (2003), Parkes et al., 2005, Stokols et al. (2005), Stokols (2006), Abrams (2006), Schelling et al. (2007), Boischio et al. (2009), Conrad et al. (2009), Mazet et al. (2009), Zinsstag et al. (2009), Gehlert et al. (2010), Maclean et al. (2000), Harper et al. (2012) Schelling et al. (2007), Zinsstag et al. (2009)
One Health
An interconnection between human, animal and environmental health “By its very nature, the One Health approach is transdisciplinary” Complex issues involving the integration of multiple disciplines
Zinsstag et al. (2009), Mazet et al. (2009), Conrad et al. (2009) Mazet et al., 2009 Rosenfield (1992), Stokols et al. (2003), Parkes et al. (2005), Abrams (2006), Schelling et al. (2007), Boischio et al. (2009), Conrad et al. (2009), Mazet et al. (2009), Zinsstag et al. (2009), Gehlert et al. (2010), Harper et al. (2012)
5.3. Thematic analysis
6.2. Conflict amongst disciplines
Analysis of included articles revealed 9 key emergent themes or elements of TD OH research: (1) education, (2) conflict amongst disciplines, (3) effective communication, (4) shared conceptual framework, (5) leadership, (6) perceived power differentials, (7) community based methodologies, (8) support for TD research and (9) time and effort.
TD training programs that emphasize effective communication can reduce conflict among disciplines and enhance social competencies required for successful TD teamwork. University curricula were seen as lacking in this area by Schelling et al. (2007), and about half of the articles described the challenges of overcoming disciplinary mindsets when working in a TD team. The issues ranged from tensions and conflicts among TD participants, disciplinary disrespect, and challenges in working with differing terminology (Maclean et al., 2000; Stokols et al., 2003; Parkes et al. 2005; Stokols, 2006). Certain aspects of TD research, including deciding upon shared conceptual frameworks, research designs and methods of analysis, were seen as potential areas for conflict (Gehlert et al., 2010). Overcoming these challenges requires strategic training and field experience paired with encouraging certain interpersonal characteristics. Patience, respect and prioritization of problem solving over territory-defending were some characteristics that were seen as solutions to potential conflict within TD teams (Parkes et al., 2005). TD research was further perceived as requiring participants with personality and interpersonal qualities conducive to fostering cooperation (Abrams, 2006) and an ethic of openness, tolerance and respect (Stokols, 2006).
6. Discussion In the sections below we discuss the emergent key elements of OH and TD research with regard to the successes and challenges that have been identified by research teams trying to address complex OH issues. 6.1. Education Institutional support for TD research affects the education of future TD scientists and scholars. One possible solution for the academic and professional challenge of attempting TD research was for professional societies to sponsor sessions that include TD education (Gehlert et al., 2010). A growing consensus was that promoting education on TD research methods was critical to furthering TD research initiatives (Rosenfield, 1992; Stokols et al., 2005; Abrams, 2006; Stokols, 2006). These studies focused on extending the professional education of investigators, researchers and students. In contrast, one article mentioned that the existing evidence base, together with the experience and knowledge of psychologists with regard to in-group processes is sufficient to build successful TD teams (Maclean et al., 2000). The majority of articles that utilized TD approaches emphasized health promotion in the community (Clifford, 2008; Mazet et al., 2009; Harper et al., 2012). Some also noted the need for specific training programs of TD methodology in research institutions that are paired with an intensive field experience (Schelling et al., 2007; Mazet et al., 2009).
6.3. Effective communication TD research can be viewed as an iterative process with continual dialog among all of its initiatives (Gehlert et al., 2010). This involves shared language and terminology among disciplines. Rosenfield (1992) emphasized that team members must become familiar with the concepts and approaches of their colleagues to facilitate the crossing of disciplinary boundaries. Some strategies for effective communication included daily communication by email, frequent visits to one another’s laboratories and offices (Gehlert et al., 2010), brainstorming sessions and off-campus retreats (Stokols et al., 2005). These aspects
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were generally not discussed in the primary research articles that applied TD methods to their investigations. 6.4. Shared conceptual frameworks Effective communication is also critical for the development of shared conceptual frameworks, community-based methodologies and the overall outcomes of research. Theoretical discussions of TD research underscored the salience of the development of shared conceptual frameworks (Rosenfield, 1992; Stokols et al., 2003, 2005). However, development and implementation of conceptual frameworks were only explicitly described in a few studies where researchers coordinated and integrated among disciplines (Schelling et al., 2007; Harper et al., 2012). The development or identification of a shared conceptual framework needs to be explicit and negotiated at the beginning of the TD OH partnership in order to guide the entire research process and knowledge to action continuum. 6.5. Leadership Several seminal TD research articles highlighted the importance of leadership skills or the role of individual leaders. Researchers may be leaders in their respective fields but the need to establish a central leader to maintain the team’s focus on the bigger picture must be addressed when applying TD approaches (Gehlert et al., 2010). Moreover, the institutions and organizations involved in TD research influence the role of leadership. Two of the studies incorporated leadership from a wide variety of institutions, from veterinary research centers to universities (Schelling et al., 2007; Mazet et al., 2009) that led to complex leadership roles and responsibilities within these diverse teams. The process of developing leadership roles within TD teams was determined as an important gap in the literature. If leadership roles are not overtly defined and developed, perceived power differentials within the team may result. 6.6. Perceived power differentials Although the majority of TD review articles did not address perceived power differentials, Stokols (2006) stated that deemphasizing differences in status and power between university and community members would increase the chances of achieving successful outcomes to TD research. Boischio et al. (2009) further argued that participatory approaches enforce a more empowering, democratic and equitable approach to TD research. Three studies that applied TD perspectives utilized participatory methods and focused on community-based strategies for their investigations (Schelling et al., 2007; Zinsstag et al., 2011; Harper et al., 2012). In particular, Schelling et al. (2007) described that through their research program, a foundation of trust was established between communities and researchers. Harper et al. (2012) involved the community in all aspects of their research, from identifying the issue of interest in the community, to the research method, to the type of data collection and sharing of the investigatory results.
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6.7. Community-based methodologies The utilization of community-based methodologies varied amongst TD studies. Harper et al. (2012) and Schelling et al. (2007) emphasized community involvement that engaged local citizens from project design to data analysis. Mazet et al. (2009) and Clifford (2008) mentioned involving community members through stakeholder meetings, informal interviews and education. Mazet et al. (2009) and Harper et al. (2012) included authors from their respective communities of interest, Tanzania and Nunatsiavut, respectively. Community participation at some levels of investigation was described in most articles, but not to the depth and extent of Harper et al. (2012) and Schelling et al. (2007). Ultimately, successful TD approaches to solving community problems involves greater continuity of collaboration among researchers, practitioners and stakeholders (Stokols, 2006). Studies that encouraged community participation during most stages of research emphasized the creation of results that could inform culturally appropriate health polices. These studies ultimately focused on building sustainable community practices to facilitate health promotion. 6.8. Support for TD research Various factors at the academic and funding level are involved in establishing and maintaining successful TD teams. In particular, the lack of academic structure encouraging TD research was determined as a key influencer in the development of TD projects. Two articles described issues in tenure and merit review procedures that discouraged TD research, such as an emphasis on individual academic achievement as opposed to team-focused achievement (Rosenfield, 1992; Stokols et al., 2003). Some TD review articles echoed this sentiment; however, primary TD research rarely addressed this issue. One study conducted by Harper et al. (2012) described a unique funding approach where community-based institutions, including Health Canada’s First Nations and Inuit Health Branch, provided the funds necessary to complete the research project. Although resources and funds from outside the community were also required, the unique funding structure enabled community members to control the project finances. The issues surrounding funding and academic structures were seen as a major barrier to initiating TD projects. 6.9. Time and effort required for maintaining and establishing TD research teams TD research calls for close and continued collaboration within and between multiple disciplines and the non-academic community. It is this requirement for the constant exchange of ideas and networking that makes TD research time-consuming. Yet the reported lack of knowledge about the time and effort required to establish successful TD teams can foster conflict and tension (Stokols, 2006). The understanding that TD approaches require extra effort and time was outlined in articles that discussed TD from a more theoretical perspective
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(Rosenfield, 1992; Stokols et al., 2003; Abrams, 2006; Stokols, 2006). This was reflected in most TD primary research articles. For instance, Harper et al. (2012) identified the central issue of interest in a community through an exploratory survey in 2009, but published the research findings in 2012. Other studies emphasized that more time was required to conduct the research than in non-TD investigations (Maclean et al., 2000; Mazet et al., 2009). We propose that more research is needed on the added value of extended timeframes to the success TD OH research collaborations from inception to implementation and action.
The Faculty of Veterinary Medicine at the University of Calgary provided funding for this work. Lisa K. Allen is a funded for her PhD work by Vanier Canada Graduate Scholarships. A University of Calgary International Project Grant funded the OH and TD workshop.
7. Recommendations
Acknowledgments
Based on this scoping review we propose key recommendations to move the OH TD research agenda forward: (1) tailored training and field experience programs held at the academic, government and community levels on OH and TD in order to foster the development of TD “transmitters” who have the required social and research competencies, (2) explicit and early establishment of a conceptual framework through effective communication among stakeholders, (3) development of a TD roadmap that will help teams delineate leadership roles and responsibilities, (4) increased utilization of participatory methods and community-based strategies to reduce perceived power differentials and facilitate knowledge to action, (5) development of unique collaborative funding opportunities and reward structures for academics, and (6) systematic evaluation of the timeframes and unique outcomes and added value of successful TD OH research.
We would like the thank Dr. Jakob Zinsstag for his wisdom and guidance into the field of OH and TD. A workshop held at the University of Calgary, attended by: Vic Neufeld, Chris Thomas, Jennifer Hatfield, Andrea Meisser, Susan Kutz, Frank van der Meer, Karin Orsel, Susan Cork and David Hall was an important step in the development of this scoping review.
8. Conclusion The application of TD principles to OH research holds great promise. This scoping review has highlighted key concepts that must be considered when developing and implementing OH research projects using TD approaches. We have shown here that there remains a gap between theory and practice and ultimately the challenge of integrating the conceptual and empirical knowledge into primary OH research. This scoping review furthers the discussion on the key characteristics of applying TD tools to assist researchers in an integrative, holistic approach to complex problem solving. We call for scholars to test and refine these concepts. There is also a need to create evaluation criteria and to document the added value of conducting TD research irrespective of the conceptual framework used (HSES, ecosystem health and/or OH). Institutes of higher learning have an important role and ethical responsibility to train the best health research disciplinarians with the added skills of knowing when and how to utilize TD methods to bring their research to action. Authors contributions B.M., L.K.A. and B.B. were involved in the development of the research question and methodology. B.M. conducted the search in collaboration with L.K.A. and B.B. All authors
checked all themes and outcomes. B.M. wrote the majority of the manuscript with L.K.A. and B.B. providing edits and guidance. All authors have approved the final version of the manuscript. Role of the funding source
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Contents lists available at ScienceDirect
Preventive Veterinary Medicine journal homepage: www.elsevier.com/locate/prevetmed
Transdisciplinary research for complex One Health issues: A scoping review of key concepts B. Min a , L.K. Allen-Scott b , B. Buntain c,∗ a b c
Bachelor of Health Sciences Program, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada Veterinary Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
a r t i c l e
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Article history: Received 8 March 2013 Received in revised form 14 June 2013 Accepted 14 September 2013 Keywords: Transdisciplinary One Health Ecohealth Global Health Scoping review
a b s t r a c t In order to address the complexity inherent in researching One Health (OH) issues, we support the concept that researchers must transcend individual disciplinary and nondisciplinary boundaries, and move into the realm of transdisciplinary (TD) research approaches. For the purposes of this paper we use the term OH and the concept that OH research is conducted to solve complex health challenges at the animal-human–human–ecosystem interface. TD goes beyond interdisciplinary research to engages disciplines and communities through a unified conceptual framework. In this scoping review we investigated key concepts, definitions and themes in OH and TD based on the peer reviewed literature. We identified nine emerging themes in TD research: (1) education, (2) conflict amongst disciplines, (3) effective communication, (4) shared conceptual framework, (5) leadership, (6) perceived power differentials, (7) community-based methodologies, (8) support for TD research and (9) time and effort. This review provides a synthesized knowledge base that describes the nature, extent of evidence and challenges of engaging in TD initiatives. This knowledge base further provides a foundation for those interested in developing improved strategies for TD collaborative and cross-sectoral research in OH. © 2013 Published by Elsevier B.V.
1. Introduction Modern veterinary and human preventive medicine recognizes that global health is facing challenges from a multitude of interconnected infectious and non-infectious diseases. These health issues are occurring in human and animal populations that are inextricably linked to the interconnections of social and ecosystem determinants of health and to our interactions with animals worldwide (Rock et al., 2009; Zinsstag et al., 2011). Current discussions on this topic have been framed as One Medicine, One Health, Ecosystem Health, Global Health, and Health in SocialEcological Systems (HSES). For the purposes of this paper we use the term One Health (OH) and the concept that OH
∗ Corresponding author. Tel.: +1 403 220 6436. E-mail address: [email protected] (B. Buntain). 0167-5877/$ – see front matter © 2013 Published by Elsevier B.V. http://dx.doi.org/10.1016/j.prevetmed.2013.09.010
research is conducted to solve complex health challenges at the animal–human–ecosystem interface. The concept of OH has emerged internationally primarily as an approach to address animal–human interactions resulting in emerging and reemerging zoonotic diseases. Further, ecosystem health or ecohealth has gained prominence in addressing the sustainable health of people, animals and ecosystems by applying transdisciplinary (TD) sciences (Mazet et al., 2009; Zinsstag et al., 2012). Both of these approaches call for integrative, systemic health research methods that will facilitate the deconstruction of academic, institutional, disciplinary, stakeholder, and government silos. Interdisciplinary research has gained prominence as more funding organizations recognize the importance of teams comprised of multiple disciplines addressing complex issues; however, TD research may be critical to solving complex health issues in a more holistic manner
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(Rosenfield, 1992; Stokols, 2006). TD research goes beyond interdisciplinarity to include multiple levels of stakeholders, including the community, academia and government. It extends discipline-based concepts, theories and methods that enable researchers to focus on a health issue through a unified conceptual lens (Rosenfield, 1992; Wiesmann et al., 2012). Here we aim to provide the reader with an in-depth review of the current body of peer reviewed literature on TD approaches to investigating health challenges resulting from the interactions of ecosystems, humans and animals. Although we focus on TD literature for this review, the emerging themes and challenges also apply to interdisciplinary research collaboration.
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students (Institute of Medicine of the National Academies, 2013). The Swiss Academies of Arts and Sciences expertly described how to enhance TD research through fifteen propositions that addressed the stumbling blocks and cornerstones of TD research, from process to outcomes (Herweg et al., 2012). It was proposed that the TD approach should be integrated at specific stages throughout the research program from the beginning through the translation of knowledge (Wiesmann et al., 2012). Integrating TD approaches at various stages of the research timeline may hold the key to successfully addressing complex OH challenges and facilitating translation of knowledge into action. 3. One Health/Ecohealth convergence
2. The evolution of TD research Health research approaches have evolved from multidisciplinary to interdisciplinary and most recently to TD. Interdisciplinary research essentially involves collaboration among different disciplines in order to transfer methods or concepts from one discipline to another (Herweg et al., 2012). The extent of collaboration and types of disciplines involved can vary with context. For example, an interdisciplinary approach aiming to study an emerging infectious disease may include collaboration among medicine, veterinary medicine and environmental sciences (Anholt et al., 2012). However members of interdisciplinary teams approach an overarching problem with their individual disciplinary conceptual frameworks, methods and definitions resulting in different types of answers (Herweg et al., 2012). In contrast to interdisciplinarity, TD research focuses on interactions between, across and beyond disciplines with a shared conceptual framework. The surge of recent interest in TD research reflects the recognition that tackling complex health issues requires a new model of collaboration (Stokols et al., 2005; Abrams, 2006). Collaborative research must transcend individual disciplinary boundaries and perspectives to achieve the level of progress needed to improve human health (Rosenfield, 1992). TD offers a holistic approach to health research where researchers from multiple disciplines work together with community and government stakeholders to create a shared conceptual framework that will be used to address a common problem (Rosenfield, 1992). Conceptual frameworks provide an outline or visual representation of possible courses of action to solve a research question. They are essential, especially in large and diverse TD teams, as they facilitate a coherent approach to inquiry. Without a shared conceptual framework, members of the TD team may be on “different paths” to addressing the research aim, which would ultimately result in disjointed outcomes and extended research-toaction timelines. For example, the Global Health conceptual framework proposes a TD perspective of health where various domains (biomedical, behavioral, psychological, social and spiritual) influence health outcomes in a holistic manner (Picard et al., 2011). The concept of establishing “TD professionalism” has been actively discussed in the human healthcare field as a means to act collaboratively and transfer skills to
Currently there is a conceptual “convergence of Ecohealth and One Health” that supports a TD field of collaboration (Zinsstag, 2012; Zinsstag, 2013). One Health research has focused primarily on zoonotic diseases and health services research, but is evolving in the literature to consider systemic approaches of the impact of societies, communities, and ecosystems on health (HSES) (Zinsstag et al., 2011). We see an integration of animal, social and ecosystem determinants of health with sustainability through the application of TD approaches to ecosystem health research. TD is heavily rooted in ecosystems approaches to health that brings together disciplines and stakeholders in an environment where community representatives are co-researchers who provide informed knowledge based on their experiences. A TD approach applied at appropriate times in the research process facilitates understanding the complexities of improving health at the animal–social–ecological interfaces (Marmot, 2005; Charron, 2012; Wiesmann et al., 2012). To date there is a paucity of peer-reviewed OH articles that evaluate the implementation and resulting added value of TD approaches at the human–animal–ecosystem interface. Moreover, a systematic and broad synthesis of the existing knowledge of TD approaches for OH is required to highlight the challenges and successes of the TD approach. Here we present a synthesized knowledge base from the peer-reviewed literature that describes key emergent themes or elements of TD OH research. This evidence base provides researchers a foundation for building capacity to address complex OH challenges. 4. Methods 4.1. Scoping review A scoping peer reviewed literature review was conducted to identify key themes in the current body of knowledge on TD and OH research. This type of review was chosen to gather evidence in a broad topic area and inform further research. The review was exploratory, and therefore did not specify concepts before interpreting the results. Rather, our open and broad research question was refined by the search results and the concepts of conducting TD research were emergent in the analysis (Levac et al., 2010). Our aim was to map the key concepts and sources
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that underpin the area of TD research in OH in order to build the evidence-base required for successful TD research projects. 4.2. Identifying relevant studies Relevant peer-reviewed articles published from 1990 until August of 2012 were sought using the electronic databases of Global Health, Health Star and Web of Knowledge. Our multi-disciplinary team (B.M., L.K.A. and B.B.) developed a search strategy using the following key terms: One Health, EcoHealth and one medicine. These terms were searched as subject headings and combined using the Boolean operator “and” with the terms: transdisciplinary AND model OR framework OR tool OR structure OR approach. Titles, abstracts and full-text were reviewed using specific inclusion criteria. Hand searches were conducted on the references of included articles. This was an iterative process that involved constant revisiting of the literature as we uncovered key concepts in TD OH research. 4.3. Study selection Inclusion criteria: (1) peer-reviewed articles that described TD approaches to OH issues, (2) peer-reviewed articles that discussed a TD method to investigate a complex health issue, (3) peer-reviewed articles that described TD research approaches and (4) peer-reviewed articles in English. Our definitions of OH and TD were based on an iterative knowledge of the literature. The definitions below represent our starting conceptualizations, which were iteratively reviewed and updated as our knowledge of the topic area expanded. All three authors contributed to consensual decision-making on inclusion or exclusion (B.M., L.K.A. and B.B.). One Health: “the collaborative efforts of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and our environment” (American Veterinary Medical Association, 2008). TD: “Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address common problem” (Rosenfield, 1992). During the review process the TD definition was expanded to the more current description of TD that moves beyond disciplines and includes the community as key stakeholders in the research process (Schelling et al., 2007). Complex issues were defined as problems requiring the integration of multiple perspectives and theories. 4.4. Charting the data B.M., L.K.A. and B.B. developed a data charting form to extract key information from the included studies. Both a narrative review and a descriptive analytical method were used to extract contextual and process data on the TD research methods used to investigate OH issues (Levac et al., 2010).
4.5. Analytic framework The breadth of the literature was described analytically to provide an overview of the field. A brief quantitative analysis was conducted to describe the characteristics of the included studies. The definitions of TD and OH provided within the included studies were also analyzed for consistency. A thematic analysis of the included studies was then completed in order to uncover emerging themes in the process of conducting TD OH research (Burnard, 1991). 5. Results 5.1. Overview of the literature Out of the 404 originally identified articles, 16 met the inclusion criteria for this review (Fig. 1). Table 1 outlines the characteristics of these included studies. The included studies represent a variety of research published in the USA, Canada, Switzerland and Brazil, six of which focused on a review of TD research. Five articles were seminal TD articles that sought to define, evaluate or describe TD research. The remaining five articles were studies that utilized TD approaches to address complex health issues. The majority of these articles addressed health issues in developing countries, including Tanzania and Chad. One of the two Canadian articles addressed the impact of climate change in a community in Nunatsiavut, Canada (Harper et al., 2012). The other assessed the strengths and weaknesses of TD approaches in Community Health Research Unit members in Ontario, Canada (Maclean et al., 2000). 5.2. Working definitions The definition of TD utilized by the majority of the seminal articles on TD research was based on Rosenfield (1992). There was an overall agreement that TD was a type of research approach that involved multiple disciplines or professions, and most of the articles mentioned that TD involved moving beyond disciplinary boundaries (Table 2). However, two articles, both published in Switzerland, emphasized the role of community involvement in describing TD approaches (Schelling et al., 2007; Zinsstag et al., 2011). Their methods underscored community-based, participatory approaches to solving health concerns of animal and human populations. One TD article published in Canada integrated ecosystem approaches and TD, stating that, “ecosystem approaches, as developed and applied in ecology, human ecology, environmental planning, anthropology, psychology, and other disciplines, may provide a more TD route to successful integration of environment and development” (Slocombe, 1993). This implied that ecosystem approaches to sustainable systems were inherently TD. Another author, Mazet et al. (2009) echoed this idea by stating that ‘One Health approaches’ were TD by nature. Generally, the definition of OH was not explicitly stated or different terminology was used, such as ‘EcoHealth’ or ‘ecosystem approaches’. Conrad et al. (2009) and 2
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Fig. 1. Flow diagram of literature search and selection of articles. *Inclusion criteria: describe TD approcahes to One Health issue in English; if the study does not address an explicity One Health issue, it uses a TD approach to investigated a complex issue; the study provides an interesting definition of TD.
other articles described OH as involving an interconnection between human, animal and environmental health (Conrad et al., 2009) (Table 2). Most articles described issues such as health disparities and emerging infectious diseases, which, although not explicitly stated as being OH,
can be considered complex problems involving the integration of multiple health perspectives. A consensus was that TD approaches were necessary to solve complex health problems at the human–animal–environmental interface and more broadly any complex health issue (Table 2).
Table 1 Characteristics of included studies. Article descriptions
Country of publication
Articles
TD review articles
Brazil (n = 1, 0.17) Canada (n = 1, 0.17) Switzerland (n = 1, 0.17) USA (n = 3, 0.50)
Boischio et al. (2009) Parkes et al. (2005) Zinsstag et al. (2009) Abrams (2006), Conrad et al. (2009), Gehlert et al. (2010)
Seminal TD articles
Canada (n = 1, 0.20) USA (n = 4, 0.80)
Slocombe (1993) Rosenfield (1992), Stokols et al. (2003, 2005), Stokols (2006)
Addressed complex health issues in developing countries
Canada (n = 2, 0.40) Switzerland (n = 1, 0.20) USA (n = 2, 0.40)
Harper et al. (2012), Maclean et al. (2000) Schelling et al. (2007) Clifford (2008), Mazet et al. (2009)
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Table 2 Working definitions and terminology of transdisciplinary and One Health. Terminology
Description
Examples
Transdisciplinary
“A research approach that cuts across disciplines through the use of a common conceptual framework to address a common problem, blending together commonly accepted theories and concepts. Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address common problem” Community-based; participatory approaches
Slocombe (1993), Stokols et al. (2003), Parkes et al., 2005, Stokols et al. (2005), Stokols (2006), Abrams (2006), Schelling et al. (2007), Boischio et al. (2009), Conrad et al. (2009), Mazet et al. (2009), Zinsstag et al. (2009), Gehlert et al. (2010), Maclean et al. (2000), Harper et al. (2012) Schelling et al. (2007), Zinsstag et al. (2009)
One Health
An interconnection between human, animal and environmental health “By its very nature, the One Health approach is transdisciplinary” Complex issues involving the integration of multiple disciplines
Zinsstag et al. (2009), Mazet et al. (2009), Conrad et al. (2009) Mazet et al., 2009 Rosenfield (1992), Stokols et al. (2003), Parkes et al. (2005), Abrams (2006), Schelling et al. (2007), Boischio et al. (2009), Conrad et al. (2009), Mazet et al. (2009), Zinsstag et al. (2009), Gehlert et al. (2010), Harper et al. (2012)
5.3. Thematic analysis
6.2. Conflict amongst disciplines
Analysis of included articles revealed 9 key emergent themes or elements of TD OH research: (1) education, (2) conflict amongst disciplines, (3) effective communication, (4) shared conceptual framework, (5) leadership, (6) perceived power differentials, (7) community based methodologies, (8) support for TD research and (9) time and effort.
TD training programs that emphasize effective communication can reduce conflict among disciplines and enhance social competencies required for successful TD teamwork. University curricula were seen as lacking in this area by Schelling et al. (2007), and about half of the articles described the challenges of overcoming disciplinary mindsets when working in a TD team. The issues ranged from tensions and conflicts among TD participants, disciplinary disrespect, and challenges in working with differing terminology (Maclean et al., 2000; Stokols et al., 2003; Parkes et al. 2005; Stokols, 2006). Certain aspects of TD research, including deciding upon shared conceptual frameworks, research designs and methods of analysis, were seen as potential areas for conflict (Gehlert et al., 2010). Overcoming these challenges requires strategic training and field experience paired with encouraging certain interpersonal characteristics. Patience, respect and prioritization of problem solving over territory-defending were some characteristics that were seen as solutions to potential conflict within TD teams (Parkes et al., 2005). TD research was further perceived as requiring participants with personality and interpersonal qualities conducive to fostering cooperation (Abrams, 2006) and an ethic of openness, tolerance and respect (Stokols, 2006).
6. Discussion In the sections below we discuss the emergent key elements of OH and TD research with regard to the successes and challenges that have been identified by research teams trying to address complex OH issues. 6.1. Education Institutional support for TD research affects the education of future TD scientists and scholars. One possible solution for the academic and professional challenge of attempting TD research was for professional societies to sponsor sessions that include TD education (Gehlert et al., 2010). A growing consensus was that promoting education on TD research methods was critical to furthering TD research initiatives (Rosenfield, 1992; Stokols et al., 2005; Abrams, 2006; Stokols, 2006). These studies focused on extending the professional education of investigators, researchers and students. In contrast, one article mentioned that the existing evidence base, together with the experience and knowledge of psychologists with regard to in-group processes is sufficient to build successful TD teams (Maclean et al., 2000). The majority of articles that utilized TD approaches emphasized health promotion in the community (Clifford, 2008; Mazet et al., 2009; Harper et al., 2012). Some also noted the need for specific training programs of TD methodology in research institutions that are paired with an intensive field experience (Schelling et al., 2007; Mazet et al., 2009).
6.3. Effective communication TD research can be viewed as an iterative process with continual dialog among all of its initiatives (Gehlert et al., 2010). This involves shared language and terminology among disciplines. Rosenfield (1992) emphasized that team members must become familiar with the concepts and approaches of their colleagues to facilitate the crossing of disciplinary boundaries. Some strategies for effective communication included daily communication by email, frequent visits to one another’s laboratories and offices (Gehlert et al., 2010), brainstorming sessions and off-campus retreats (Stokols et al., 2005). These aspects
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were generally not discussed in the primary research articles that applied TD methods to their investigations. 6.4. Shared conceptual frameworks Effective communication is also critical for the development of shared conceptual frameworks, community-based methodologies and the overall outcomes of research. Theoretical discussions of TD research underscored the salience of the development of shared conceptual frameworks (Rosenfield, 1992; Stokols et al., 2003, 2005). However, development and implementation of conceptual frameworks were only explicitly described in a few studies where researchers coordinated and integrated among disciplines (Schelling et al., 2007; Harper et al., 2012). The development or identification of a shared conceptual framework needs to be explicit and negotiated at the beginning of the TD OH partnership in order to guide the entire research process and knowledge to action continuum. 6.5. Leadership Several seminal TD research articles highlighted the importance of leadership skills or the role of individual leaders. Researchers may be leaders in their respective fields but the need to establish a central leader to maintain the team’s focus on the bigger picture must be addressed when applying TD approaches (Gehlert et al., 2010). Moreover, the institutions and organizations involved in TD research influence the role of leadership. Two of the studies incorporated leadership from a wide variety of institutions, from veterinary research centers to universities (Schelling et al., 2007; Mazet et al., 2009) that led to complex leadership roles and responsibilities within these diverse teams. The process of developing leadership roles within TD teams was determined as an important gap in the literature. If leadership roles are not overtly defined and developed, perceived power differentials within the team may result. 6.6. Perceived power differentials Although the majority of TD review articles did not address perceived power differentials, Stokols (2006) stated that deemphasizing differences in status and power between university and community members would increase the chances of achieving successful outcomes to TD research. Boischio et al. (2009) further argued that participatory approaches enforce a more empowering, democratic and equitable approach to TD research. Three studies that applied TD perspectives utilized participatory methods and focused on community-based strategies for their investigations (Schelling et al., 2007; Zinsstag et al., 2011; Harper et al., 2012). In particular, Schelling et al. (2007) described that through their research program, a foundation of trust was established between communities and researchers. Harper et al. (2012) involved the community in all aspects of their research, from identifying the issue of interest in the community, to the research method, to the type of data collection and sharing of the investigatory results.
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6.7. Community-based methodologies The utilization of community-based methodologies varied amongst TD studies. Harper et al. (2012) and Schelling et al. (2007) emphasized community involvement that engaged local citizens from project design to data analysis. Mazet et al. (2009) and Clifford (2008) mentioned involving community members through stakeholder meetings, informal interviews and education. Mazet et al. (2009) and Harper et al. (2012) included authors from their respective communities of interest, Tanzania and Nunatsiavut, respectively. Community participation at some levels of investigation was described in most articles, but not to the depth and extent of Harper et al. (2012) and Schelling et al. (2007). Ultimately, successful TD approaches to solving community problems involves greater continuity of collaboration among researchers, practitioners and stakeholders (Stokols, 2006). Studies that encouraged community participation during most stages of research emphasized the creation of results that could inform culturally appropriate health polices. These studies ultimately focused on building sustainable community practices to facilitate health promotion. 6.8. Support for TD research Various factors at the academic and funding level are involved in establishing and maintaining successful TD teams. In particular, the lack of academic structure encouraging TD research was determined as a key influencer in the development of TD projects. Two articles described issues in tenure and merit review procedures that discouraged TD research, such as an emphasis on individual academic achievement as opposed to team-focused achievement (Rosenfield, 1992; Stokols et al., 2003). Some TD review articles echoed this sentiment; however, primary TD research rarely addressed this issue. One study conducted by Harper et al. (2012) described a unique funding approach where community-based institutions, including Health Canada’s First Nations and Inuit Health Branch, provided the funds necessary to complete the research project. Although resources and funds from outside the community were also required, the unique funding structure enabled community members to control the project finances. The issues surrounding funding and academic structures were seen as a major barrier to initiating TD projects. 6.9. Time and effort required for maintaining and establishing TD research teams TD research calls for close and continued collaboration within and between multiple disciplines and the non-academic community. It is this requirement for the constant exchange of ideas and networking that makes TD research time-consuming. Yet the reported lack of knowledge about the time and effort required to establish successful TD teams can foster conflict and tension (Stokols, 2006). The understanding that TD approaches require extra effort and time was outlined in articles that discussed TD from a more theoretical perspective
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(Rosenfield, 1992; Stokols et al., 2003; Abrams, 2006; Stokols, 2006). This was reflected in most TD primary research articles. For instance, Harper et al. (2012) identified the central issue of interest in a community through an exploratory survey in 2009, but published the research findings in 2012. Other studies emphasized that more time was required to conduct the research than in non-TD investigations (Maclean et al., 2000; Mazet et al., 2009). We propose that more research is needed on the added value of extended timeframes to the success TD OH research collaborations from inception to implementation and action.
The Faculty of Veterinary Medicine at the University of Calgary provided funding for this work. Lisa K. Allen is a funded for her PhD work by Vanier Canada Graduate Scholarships. A University of Calgary International Project Grant funded the OH and TD workshop.
7. Recommendations
Acknowledgments
Based on this scoping review we propose key recommendations to move the OH TD research agenda forward: (1) tailored training and field experience programs held at the academic, government and community levels on OH and TD in order to foster the development of TD “transmitters” who have the required social and research competencies, (2) explicit and early establishment of a conceptual framework through effective communication among stakeholders, (3) development of a TD roadmap that will help teams delineate leadership roles and responsibilities, (4) increased utilization of participatory methods and community-based strategies to reduce perceived power differentials and facilitate knowledge to action, (5) development of unique collaborative funding opportunities and reward structures for academics, and (6) systematic evaluation of the timeframes and unique outcomes and added value of successful TD OH research.
We would like the thank Dr. Jakob Zinsstag for his wisdom and guidance into the field of OH and TD. A workshop held at the University of Calgary, attended by: Vic Neufeld, Chris Thomas, Jennifer Hatfield, Andrea Meisser, Susan Kutz, Frank van der Meer, Karin Orsel, Susan Cork and David Hall was an important step in the development of this scoping review.
8. Conclusion The application of TD principles to OH research holds great promise. This scoping review has highlighted key concepts that must be considered when developing and implementing OH research projects using TD approaches. We have shown here that there remains a gap between theory and practice and ultimately the challenge of integrating the conceptual and empirical knowledge into primary OH research. This scoping review furthers the discussion on the key characteristics of applying TD tools to assist researchers in an integrative, holistic approach to complex problem solving. We call for scholars to test and refine these concepts. There is also a need to create evaluation criteria and to document the added value of conducting TD research irrespective of the conceptual framework used (HSES, ecosystem health and/or OH). Institutes of higher learning have an important role and ethical responsibility to train the best health research disciplinarians with the added skills of knowing when and how to utilize TD methods to bring their research to action. Authors contributions B.M., L.K.A. and B.B. were involved in the development of the research question and methodology. B.M. conducted the search in collaboration with L.K.A. and B.B. All authors
checked all themes and outcomes. B.M. wrote the majority of the manuscript with L.K.A. and B.B. providing edits and guidance. All authors have approved the final version of the manuscript. Role of the funding source
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