From northern Saskatchewan to India

It was not a problem of awareness—the research team knew people were well aware smoking is bad for their health and simply telling them to stop does not work.

So they did not use that approach.

Instead, they started with community values: what are the things most important to the people? For the people of Sturgeon Lake First Nation northwest of Prince Albert, the answer was the health of their children and their elders.

"If I say to you, ‘stop smoking,' what do you think you're going to do with that?" asked Vivian Ramsden, an applied public health researcher in the College of Medicine.

"Well, you've told me a million times before and nothing's happened. If I say, ‘can you step outside and smoke and protect the children and elders or older adults living in the home?' That's made a huge difference."

This strategy is the core of the Green Light Program, developed with the community as active and even leading partners.

Ramsden explained that in 2008, the research team— composed of university and community partners—wanted to better understand the social determinants of public health within Sturgeon Lake First Nation. They worked together to design and implement a commu­nity-based survey that garnered a participation rate of 96 per cent.

The survey provided the foundational knowledge for a public health framework document called Primary Health Care: Chronic Disease Prevention and Management Resulting in Pathways for Wellness. It identi­fied the most common risk factor for chronic disease was tobacco misuse, that is, non-traditional use of tobacco.

The Green Light Program message resonated with the community, with more than two thirds of households partic­ipating and proudly sharing this status with the community with green light bulbs by their doors supplied through the program. Ramsden credits the success to her community partners.

"It's all about them. The methodology is about them; we are coming in to answer their questions in ways that are meaningful," she said. "What's important is the community. They own it."

This success is exportable: Ramsden said there are now 106 communities involved with the Green Light Program, up from 14 communities when it started. This "participatory research" approach is now also being used to tackle issues such as chronic health conditions like diabetes and cardiovascular diseases as well as infectious diseases such as HIV and hepatitis C.

The participatory research approach has won Ramsden the trust of communities from India to northern Saskatchewan. Her efforts were recognized this year when the College of Family Physicians of Canada named her one of the Top 20 Pioneers in Family Medicine Research.

Ramsden's broad geographic reach reflects her position as research director and professor in the Department of Academic Family Medicine. From her office at the West Winds Primary Health Centre on Saskatoon's west side, she teaches research to residents, graduate students and health-care professionals across the province. This includes a research methods survey course developed about eight years ago which has since become standard.

"There was no systematic approach to a research project but every resident in the Depart­ment of Academic Family Medicine has to systematically answer a question and present it at the Annual Resident Research Day," she said. "So I started developing core modules and collaborated with other people for others."

The course—which is updated every year—walks residents through the research process. It has evolved to reflect the Triple C Curriculum, the program that governs the training of family physicians in Canada administered by the College of Family Physi­cians of Canada as well as the newly updated CanMEDS, the program that governs specialist training for physicians adminis­tered through the Royal College of Physicians and Surgeons of Canada.

"CanMEDS 2015 are more competency-based, so the whole course has changed to be competency-based skills," Ramsden said. What this means for the course is participants are taught how to identify a research question from clinical practice and reading the literature, learn the skills needed for peer reviewing quantitative and qual­itative articles, and learn how to put together a research poster so that they are able share what they have learned with others.

A testament to the research methods course value is that faculty from other Canadian universities have taken it as part of their continuing professional development. Some elements of the course are also used with her partners in India.

"It's considered a core course in the Health Sciences Program in the College of Medicine as well as a number of residency training programs," Ramsden said.

Ramsden's initial training was as a nurse and she still strongly identifies with the profession, keeping her RN designation current. Its hands-on nature colours her approach to research.

"I like being a health-care provider first. I'm not going there to change anything or do anything; I'm there to actually help them to help themselves."

The philosophy also applies to Ramsden's work in India. Twenty years ago, she was invited to Omayal Achi College of Nursing to help set up an intensive care unit in a community hospital and teach cardiopulmonary resuscitation techniques to nursing students.

Over the years, this rela­tionship has grown. When she first arrived, there was no graduate training for nurses; today, there are more than 250 masters-prepared and nearly 20 PhD-prepared students. Ramsden would like to see at least some of these students come to Saskatchewan.

"The best thing they can do is come and spend six weeks here learning their trade," she said. "There are lots of things at Sturgeon Lake that we took to India, and lots of things from India that actually apply to Sturgeon Lake First Nation."

For Ramsden, the bottom line for any health intervention is, "does it work?" Sometimes, this means broadening one's perspective, something she said she learned in India where allo­pathic (i.e. Western medicine) and ayurvedic (i.e. "alternative" medicine) are used side by side.

Back in Canada, this means considering and including Aboriginal knowledge and practice.

"They have a healing process, a traditional medicine practice," she said. "So maybe we need to be thinking about outcomes. If blood pressure readings are fine, then however they're treating their blood pressure is working. If their A1Cs (a standard blood glucose test) are normal, however they're treating diabetes is working. Maybe we need to think about asking questions or taking a history in a new way."
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