3
The IUHPE Blueprint
for Direct and Sustained Dialogue in Partnership Initiatives
CATHERINEM. JONES ANDMAURICEB. MITTELMARK
The International Union of Health Promotion and Education (IUHPE) depends heavily on dialogue to build bridges of mutual understanding and direction with its partners. The “IUHPE Blueprint” for dialogue is based upon the premise that we must provide well-structured opportunities for experts and decision-makers to come together to better comprehend and integrate each others’ needs and priori- ties. The aim of this chapter is to provide an overview of dialogue methodology and to illustrate its usefulness in IUHPE knowledge-based advocacy, in particu- lar in the realm of health promotion effectiveness. Particular attention is given to the IUHPE’s use of dialogue methodology in the original European Effectiveness Project from which the Global Programme on Health Promotion Effectiveness (GPHPE) emanated (IUHPE, 2007).
Defining Dialogue: Fundamental Distinctions
Dialogue is a distinct communication technique, a specialized form of conversa- tion that forges a path to collective intelligence. As defined by the Co-Intelligence Institute (2007), dialogue is shared exploration towards greater understanding, connection or possibility. Dialogue should not, and must not, be confused with debate, discussion or training; many forms of communication do not qualify as dialogue. Unfortunately, dialogue is most frequently misused and confused with debate, when in fact these two communication forms are indeed diametrically opposed (Table 3.1).
Victory is the driver of debate, the inherent purpose of debate being to con- vince the other side, to win them over to agree with one’s argument and claims.
Dialogue, on the other hand, seeks camaraderie through finding common ground. Through a merging of ideas, dialogue aims to create an atmosphere of understanding. Dialogue can be visualized as a solvent, a powerful agent capa- ble of dissolving barriers and unwrapping new avenues for cross-fertilization of concepts and ideas through mutual, open exploration. In the words of Edgar Shein (1998), “Dialogue makes it possible not only to create a climate for more interpersonal learning, but also may be the only way to resolve
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interpersonal conflict when such conflict derives from differing tacit assump- tions and different semantic definitions.”
Thus, dialogue has tremendous value for the field of health promotion, as a field of research and practice in which productive partnerships and collaborations are fundamental. The usefulness of dialogue techniques has been demonstrated in diverse fields, including education, negotiation and mediation, psychology, envi- ronmental and development studies, inter-faith and inter-cultural work, commu- nity development, social work, policy development and futures technology (Sliska, Karelova & Mitrofanova, 2003; Brown & Bennett, 1995; Schatz, Furman, & Jenkins, 2003; VanWynsberghe, Moore, Tansey, &Carmichael 2003;
de Haas, Algera, van Tuijl & Meulman, 2000; Ratner, 2004; Steinberg & Bar-On, 2002; Innes & Booher, 2000). In health promotion, the dialogue method is partic- ularly suited to the many situations where collaboration involves practitioners, organizations and community members. It generates common understanding that bridges the special points of view that all actors bring to a collaborative endeav- our, enhancing the “balance between the knowledge and power of institutions and professionals, and the knowledge and power of communities” (Labonte, Feather
& Hills, 1999).
Dialogue can take many forms, but here we take up just one of those forms, collaborative policy dialogue. Innes and Booher (2000) have outlined a theory, informed by their vision of the world as a complex system, to help understand how and why collaborative policy dialogues work in practice and how they differ from traditional policy making. In our increasingly globalizing world, power is ever more fragmented, and there is an increasingly rapid flow of information across the globe, made possible in a matter of seconds, which dominates our com- munication processes. Although we are evermore intertwined with our fellow cit- izens in this global community, we cannot count on shared objectives and values as a basis to conduct business. Therefore, we must start from scratch in order to better understand each other and what is going on in our societies. Collaborative thinking and dialogue methods are capable of producing qualitatively different solutions and alternatives to those produced by traditional methods of policy making.
TABLE3.1. Dialogue versus debate
Dialogue Debate
Collaborative Oppositional
Common ground Winning
Enlarges perspectives Affirms perspectives Searches for agreement Searches for differences Causes introspection Causes critique Looks for strengths Looks for weaknesses Re-evaluates assumptions Defends assumptions Listening for meaning Listening for countering Remains open-ended Implies a conclusion
Source: Adapted from the Co-Intelligence Institute
The IUHPE Blueprint: Dialogue among Researchers, Practitioners and Policy and Decision-Makers
Although not referred to as such in the early days, the IUHPE has been imple- menting various forms of dialogue methodology since the renowned European Effectiveness Project,*which produced a set of documents that have become an essential staple on many health promoters’ bookshelves. This project was built upon an innovative process created to use evidence to initiate dialogue as a stim- ulus to lead to further understanding, rather than the search for evidence as an end product in and of itself. The GPHPE received important impetus from IUHPE work in Europe in the mid- to late 1990’s, in the project and resulting publications entitled The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe, managed on behalf of a broad-based partnership by the IUHPE (IUHPE, 1999). The project had two aims: summarize twenty years of evidence on health promotion’s effectiveness, and communicate the information directly to policy-makers in Europe. The starting point of the project was the acknowledge- ment of the following points:
• Health promotion has developed a growing range of low-cost, highly effective technologies for improving public health, but has had limited success in influ- encing key decision-makers to modify health policies and funding accordingly;
• Health promotion researchers and practitioners have been using professional language and arguments to try to influence political processes; this is the wrong language, leading to unpersuasive arguments;
• The root of the problem is therefore communications failure, not lack of suffi- cient evidence.
Addressing this problem, the IUHPE developed a communications strategy with these elements:
• Provide opportunities for experts and decision makers to come together to bridge gaps of understanding of each group’s needs and priorities through collaborative dialogue. Early in the project, health promotion experts and European experts on policy-making and policy processes were brought together to decide the dimen- sions and the strategy of the project. Not surprisingly, there was discord. The subject-area experts used academic jargon and arguments to make their points, and often concluded that “more research was needed!” The politically savvy par- ticipants highlighted the self-defeating nature of this approach. They urged that the project summarize not just health impacts, but also social, economic, and political impacts of effective health promotion – and remain focused on what works. The vital component to this was the engagement of a communication expert who was hired to assist in facilitating the dialogue and transforming the outcome into a particularly readable and convincing document. In fact, this mix
*The “Impact and Effectiveness of Health Promotion Project” was funded by the European Commission [Project Number SOC 97 202247 05F03 (97CVVF3-443)].
of political, health promotion and communications expertise to me was key in the success of the project.*
• Value the priorities of decision-makers as legitimate concerns throughout this process conducted by the experts, leading them to recognize that their input may need re-directing to be understood. Initial drafts of evidence prepared by the subject-area experts were dismantled by the policy experts in face-to-face debates, and the experts gave way, re-drafting the evidence summaries in ways that communicated with the intended audience.
• Reject rigid guidelines about what counts as evidence and what does not. It was agreed from the outset that medical models of evidence generation – clinical tri- als to test new therapies for example – are rarely if ever suitable to generate evi- dence in community settings such as schools and workplaces, or to test policy interventions. What was needed was triangulation, agreement from evidence collected by various methods leading to prudent decisions about what works under real life conditions.
• Produce usable summaries for decision-makers and in-depth analyses to back them up. This led to the development of two books of evidence. A core docu- ment of only 28 pages crystallized the evidence and made concrete recommen- dations for action by decision-makers. A detailed report of 164 pages backed the core document, providing information about what works in workplace and school health promotion, what infrastructure is needed to mount effective health promotion at national and regional levels, health promotion for the aging population, oral health promotion, and mental health promotion.
• Engage decision-makers in face-to-face dialogue about health promotion policy, using the published evidence reviews as the stimulus – not the end product. An exhibition booth was set up at the European Parliament in Strasbourg from January 17–20, 2000. The booth consisted of two parts, highlighting both the IUHPE and the European Commission’s activities in the area of health promotion; however, the overall emphasis was placed on the effectiveness documents described above. On January 18, a cocktail reception was held at the booth with the goal of introducing members of Parliament (MEPs) to the potential that health promotion can bring to addressing health and well-being. The reception gathered 20 members of the project team and approximately 60 MEPs. The reception provided MEPs with the chance to discuss European health issues and concerns with health promotion professionals. The reception was followed by a dinner at the Parliament for the MEPs and health promotion specialists. Dining tables were arranged to mix MEPs and members of the Effectiveness Project, pro- viding for lively exchange. Commissioner David Byrne opened the evening with introductory remarks. The IUHPE Vice-President for Scientific and
*As the Project’s Editor and communication expert, David Boddy, a leading European health lobbyist, served as an instrumental part of the bridge-building process between the political and health promotion communities.
Technical Development, Maurice Mittelmark at the time, introduced the pertinence of health promotion, concluded his remarks as follows:
I’ll end by posing a question that we do not yet have a clear answer to, but desperately need:
why is this proven health promotion technology under-utilised in Europe? Is it because the word ‘health’ in health promotion automatically takes us down the wrong path, by making us think immediately of other health technology, such as hospitals, doctors and curative med- icine? Is it because the word ‘promotion’ has connotations that distract one’s attention from the solid basis on which the technology is built? Is it because people think of health ‘police’
when they hear health promotion, misunderstanding our technology and approach? Is it because evidence on health promotion effectiveness is not presently in the right way, to the right people, at the right time? Is it all of these, or none of these? We hope that your discus- sions before and during dinner have included a focus on this issue, and we look forward to a lively dialogue this evening.
This was followed by several hours of discussion. Both the exhibit and the dinner-dialogue were sponsored by MEP John Bowis, who also participated in the entire length of the project. Following the dinner, one participant stated:
. . .at my table, where we had two MEPs from Italy, we talked a lot about health issues.
They had some knowledge, of course, but they seemed to appreciate the evening. . . . Probably an evening of this kind is more useful than a traditional meeting to which MEPs would hardly come if they were invited. The reception before the dinner also attracted MEPs who normally might not attend a meeting about health. So, “non-traditional” ways should be tried and used a lot more.
Thus, the IUHPE communications approach followed a plan leading to direct and sustained dialogue with key decision-makers, using the evidence of health promotion effectiveness as the foundation for discussion. The participants judged the strategy as a success, so much so that the same strategy has been used by the IUHPE since to structure communications about mapping national capac- ity for health promotion in Europe, and about public-private partnerships for bet- ter health care in Europe and in India. For example, the IUHPE’s HP-Source.net* is a discovery tool where health promotion capacity is mapped through an on- going voluntary dialogue amongst researchers, policy makers and practitioners who share the goal of maximizing the efficiency and effectiveness of health pro- motion policies, infrastructures and practice. In another example, in the IUHPE- managed Indo/European Union dialogue† on public/private partnerships for sustainable health care systems, dialogue stimulated a two-way learning process that led to substantial consensus despite vast differences in European and Indian contexts.
Most recently, the IUHPE has employed a refined method of dialogue to engage the international Project Advisory Group of a project (in collaboration with the Canadian Consortium on Health Promotion Research) to renew commitment to the
*http://www.hp-source.net/
†This project was funded by the European Commission (IND SPF/191002/965/96-447).
Ottawa Charter, through the development of recommendations on the policy and system conditions necessary for sustainable and effective health promotion.*
The Effectiveness of Dialogue
A United Nations (UN) survey of good practice in public-private sector dialogue for a UN Conference on trade and development provides evidence about the validity of dialogue as a research tool, and provides a set of principles and effective mechanisms for promoting dialogue (United Nations, 2001). The results show that dialogue methodology can influence policy makers’ and researcher’s mindsets, helping them move from an orientation focused on data extraction to a participative orientation. Products from this UN work include indicators for maturity of dialogue, a paradigm for the management of dialogue, and a taxon- omy for assisting dialogue. However, instead of presenting these in detail, it is more constructive in light of this chapter’s aim to consider why dialogue is effec- tive rather than merely focus on the principles of effective dialogue.
Schatz and colleagues (2003) at the Department of Social Work at Colorado State have published an interesting analysis of the effectiveness of dialogue in social work interventions and involving multi-cultural learning. They conclude that dialogue is effective because it satifies people’s need for human connection and belonging; it leaves no room for a passive participant; it is a synergistic expe- rience; it promotes the values and uniqueness of each member; it develops trust and intimacy; it promotes both individual and group reflections on values and vulnerabilities; and it cultivates interpersonal relationships.
While there is not adequate space available here to provide details, a number of organizations have developed practical tools and guidelines which are valuable resources for the practice of dialogue.†
Concluding Remarks
The IUHPE is committed to further developing dialogue as a central methodology in its knowledge-based advocacy for health, through an in-depth and on-going review of the relevant literature, and then through applied research on the use of dialogue methods in future IUHPE projects. This brief treatment of dialogue
*This project has received funding from the Public Health Agency of Canada.
† Some of the most practical ones include the National Coalition for Dialogue and Deliberation (http://thataway.org/), PublicPrivateDialogue.org
(http://www.publicprivatedialogue.org/), The Co-Intelligence Institute (http://www.co-intelligence.org/P-dialogue.html), Viewpoint Learning Inc.
(http://www.viewpointlearning.com/), The World Café (http://theworldcafe.com/), and the United Nations University Framework for Action for a Dialogue of Civilizations (http://www.unu.edu/dialogue/FrameworkForAction.pdf).
methodology is presented with the intention to stimulate discussions in the health promotion community about how increased use of dialogue can help improve the effectiveness of advocacy and policy development activities. The IUHPE’s posi- tive experiences with dialogue methodology give weight to the idea that health promotion training programmes should consider adding it to the list of core com- petencies of graduates. The ethical use of dialogue methodology requires careful attention and skill, especially to curb any tendency to slip “back” into ways of thinking and working that resemble debate more than dialogue. We are optimistic that the proper use of dialogue in the health promotion policy development and advocacy arenas will serve to dissolve the barriers that separate some of the exist- ing disciplinary ghettos. When more health promoters and advocates will have been formally trained to use dialogue methodology appropriately, the likelihood of its misuse will be diminished.
Acknowledgements. The authors would like to extend their sincere thanks to Anne Bunde-Birouste and Spencer Hagard for their support, encouragement and useful comments in the development of this chapter. Anne Bunde-Birouste, as the designer and coordinator of the original European project, has made substantial contributions to the creativity and enthusiasm which drove the original project to successful fruition in partnership with many experts from around the world. Her management and supervision of this original process was a source of inspiration to the development and launching of the GPHPE. Spencer Hagard has been a steadfast and persistent leader in this field, providing guidance and direction as a participant in many of the IUHPE collaborative projects which have been con- structed upon dialogue in some shape or form.
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