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Reducing Health Disparities Experienced by Refugees Resettled in Urban Areas: A Community-Based Transdisciplinary Intervention Model


Abstract and Figures

There is a growing recognition that social inequities in education, housing, employment, health care, safety, resources, money, and power contribute significantly to increasing health disparities globally, within countries, and even within specific urban environments. Thus, to promote health and well-being for all people, the World Health Organization recommends improving daily living conditions, measuring and understanding problems of health inequity, assessing the impact of action to address these problems, and ensuring equitable distribution of money, power, and resources (CSDH, 2008). Among the diverse populations that bear the burden of social inequities and health disparities are the increasing numbers of refugees and immigrants settling in urban areas.
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Converging Disciplines
Maritt Kirst ·Nicole Schaefer-McDaniel ·
Stephen Hwang ·Patricia O’Campo
Converging Disciplines
A Transdisciplinary Research Approach
to Urban Health Problems
Foreword by Patricia Rosenfield and Frank Kessel
Maritt Kirst
Ontario Tobacco Research Unit
Dalla Lana School of Public Health
155 College St., 5th Floor
M5T 3M7 Toronto, Ontario
Nicole Schaefer-McDaniel
Centre for Research on Inner City Health
St. Michael’s Hospital
30 Bond Street
M5B 1W8 Toronto, Ontario
Stephen Hwang
Centre for Research on Inner City Health
St. Michael’s Hospital
30 Bond Street
M5B 1W8 Toronto, Ontario
Patricia O’Campo
Centre for Research on Inner City Health
St. Michael’s Hospital
30 Bond Street
M5B 1W8 Toronto, Ontario
ISBN 978-1-4419-6329-1 e-ISBN 978-1-4419-6330-7
DOI 10.1007/978-1-4419-6330-7
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2010936516
© Springer Science+Business Media, LLC 2011
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Springer is part of Springer Science+Business Media (
The year 2007 was a turning point in human history as it saw half of humanity already
living in towns and cities. By 2030, three-quarters of the world’s population is projected to
be urban.
Anna Tibaijuka, Under-Secretary-General of the United
Nations and Executive Director of UN-Habitat, 2009.
Knowledge seeps through institutions and structures like water through the pores of the
membrane. Knowledge seeps in both directions, from science to society and from society
to science. It seeps through institutions and from academia to and from the outside world.
Transdisciplinarity is therefore about transgressing boundaries.
Helga Nowotny,2004.
The helter-skelter nature of urbanization, characterized by unpredictable inflows
of migrants from rural and suburban areas as well as war zones, the patchwork
quilt of services and systems with most not reaching low-income, marginal pop-
ulations and often inefficient governance mechanisms ... all these concatenating
factors make urban planning a vitally important area for research and action (Ash,
Jasny, Roberts, Stone, & Sugden, 2008). As a positive corollary, urbanization should
also serve as a space for innovative researchers, policy makers, practitioners, and
communities to collaborate in creating workable and livable cities. While many neg-
ative dimensions of urban life – especially, crime, unemployment, poor education
– are grist for the popular media mill and urban despair, the dimension of life that
arguably detracts most from a viable urban fabric is human health. In the past, the
black plague and outbreaks of cholera made cities high-risk environments. Today, as
amply detailed in this comprehensive collection, a challenging range of direct and
indirect health problems permeates urban life.
The distinctive nature of this book is that the chapters are woven together by
the theme of transdisciplinary (TD) research as applied to the problems of urban
public health. The authors of all the chapters analyze how to initiate and conduct
TD research and apply results utilizing this new frame. The TD research approach,
carefully defined in the first part of the volume, places issues of urban health at
the center of its focus and brings an appropriately wide range of perspectives and
expertise to bear on the goal of understanding the underlying causes, consequences,
vi Foreword
and solutions to key problems. In essence, on the assumption that complex health
and social problems demand integrated analyses and solutions, TD research is an
approach that draws together concepts and methods from a wide range of fields.
As the editors state in Chapter 1, “It is necessary for researchers to work with
experts of other disciplines in other areas of knowledge, and together, move beyond
disciplinary perspectives, methodologies, theories, boundaries, and limitations to
understand these complex urban health problems more fully and attempt to resolve
A related, now widespread conclusion and concern is that, while supporting and
drawing on largely separate disciplines is more manageable (i.e., outcomes are more
readily defined, measured, and evaluated), such a linear approach has often led to
ineffectively implemented and poorly sustained solutions (Rosenfield, 1992). Hence
the importance of the studies in this volume that demonstrate, through a variety of
illustrations and applications, how a TD approach “is advantageous for increased
understanding of complex health problems emergent in urban settings” (O’Campo
et al., Chapter 1). Such applications build on the recognition that integrated input
from many different disciplines, including those with an understanding of health
systems, community preferences, politics, and economics, is needed to achieve
results that are both used and useful, as Chesney and Coates (2008), for exam-
ple, have found by designing and systematically applying multi-level, integrated
analyses to the problem of HIV/AIDS in San Francisco.1
As Nowotny, a pre-eminent European social scientist who has written extensively
on this topic, declared in 2004, “Transdisciplinarity is a theme which resurfaces time
and again.” And yet, while such a research paradigm is the focus of much recent
discussion, it is still not fully accepted as a viable approach for complex social
problem-solving ... neither by practitioners, policy-makers, or funders, or even by
many researchers. Under such circumstances, and particularly through its presenta-
tion of a wide range of carefully analyzed case studies, this collection is a welcome
and vibrant contribution to the process of illuminating the use and the value of TD
research. In addition, the chapters in Part IV not only assess the opportunities and
challenges of such an approach but also provide practical recommendations on how
to extend the use of TD research in addressing apparently intractable urban health
Converging Disciplines: A Transdisciplinary Research Approach to Urban
Health Problems thus augments the emerging, albeit still limited, literature on
the application of TD research. Through detailed assessment of the value of TD
approaches applied to issues ranging from intimate partner violence, child injury,
substance abuse, and harm reduction to homeless adults and refugees, the authors
demonstrate the feasibility and value of multilayered studies in complex settings.
As important, such studies are developed by teams drawn not only from relevant
1Although Chesney et al. refer to the work of the Center for AIDS Prevention Studies (CAPS) as
“multidisciplinary,” we have suggested (Kessel & Rosenfield, 2008b, p. S230) that the potential for
it to become truly and importantly transdisciplinary is embedded in all of its projects and successes,
which now extend well beyond San Francisco (see the postscript in Chesney & Coates, 2008).
Foreword vii
disciplines, but also from practitioners and community members themselves. This
volume thus contributes in a fine-grained manner to furthering our understanding of
both the application of TD research and the related development of team science.
In so doing, this book significantly extends the findings and recommendations of
three directly related publications. As noted in Chapter 1, the collection amplifies
conclusions drawn from a series of case studies, presented in Kessel, Rosenfield, and
Anderson (2008), that describe and analyze the creative work of interdisciplinary
teams encompassing a range of health and social sciences.2A second publication on
“The Science of Team Science: Assessing the Value of Transdisciplinary Research,”
edited by Stokols, Hall, Taylor, Moser, and Syme (2008), addresses basic concepts,
methods, assessment, and training, as well as specific instances of team science in
the study of tobacco-harm reduction and cancer. Finally, building on the burgeon-
ing European movement in transdisciplinarity, the Handbook of Transdisciplinary
Research edited by Hadorn et al. was also published in 2008. Like the innovative
material presented here and in the other two collections, the Handbook presents
a series of studies, ranging from river basins to nanotechnology, as the basis for
critiquing and developing a TD research approach.
So the question arises: Given the increasing volume of research adopting a TD
framework, why has it been a challenge for it to achieve recognition as an accepted
approach to examine and address complex problems? Based on various analyses
of case studies of interdisciplinary and TD research, we believe that, beyond those
inherent in establishing collaboration that crosses discipline and departmental lines,
key constraints revolve around the challenges in training and concomitant university
support, the difficulty of achieving success in sustained funding, and the limited
availability of publication opportunities (Kessel & Rosenfield, 2005, 2008b; Stokols
et al., 2008). Such challenges are also noted in many of the case studies presented
in this volume. And the fourth part provides detailed analyses of advances in such
research, the need for sustained funding, and the appropriate training programs,
along with the need for innovative approaches in assessing TD research’s value and,
as a corollary, its value added.
Considering this book’s thoughtful presentations of the challenges and results
of TD research, we suggest that two major features could significantly enhance the
acceptability and applicability of such an approach, particularly around the cluster
of urban health problems that are increasingly prevalent in the twenty-first century.
The first such feature, and significant value added, is demonstrated by the multiple
ways in which Kirst and her colleagues have incorporated practitioners and users
into their research teams. Analogous to the development of translational research in
biomedical research fields, where practitioners are brought into the process or, as a
minimum, the possible application of the intervention is actively considered from
the outset, this expansion of teams should greatly enhance the acceptability and use
of research results by health and other service providers, as well as decision makers
2The original edition, published in 2003, was titled, Expanding the Boundaries of Health and
Social Science: Case Studies in Interdisciplinary Innovation.
viii Foreword
(Andrews et al., 2009; Contopoulos-Ionnaidis, Alexiou, Gouvias, Ioannidis, 2008;
Kaiser, 2009).
That said, given the appropriate involvement of a multiplicity of disciplines and
methods, the language for communicating research results and, indeed, the nature
of the research process itself to both the public and the decision makers requires
reflective, self-critical attention. An especially intriguing discussion of this pro-
cess of knowledge translation (KT) is presented in this volume by Murphy, Wolfus,
and Lofters (Chapter 9). Using the framework of a Socratic dialogue, they discuss
the problems that emerge when “transdisciplinarity is presented as a collaborative
research strategy that essentially ends when KT begins”. What can be missed here is
that the TD research approach and TD teams also open up important opportunities
for promoting “praxis”; or, the integration of inquiry and action to advance social
change (see Chapter 9). Murphy et al. discuss how the KT framework can extend
the process of interdisciplinary research and bring about greater collaboration of
the researchers with communities, practitioners, and policy makers. In this context,
it is worth noting how several authors have recently underscored an ever-present
risk of communicating research in too simple a fashion so that the complexity of a
proposed solution is unclear, perhaps even misleading. More positively put, given
the increasing emphasis on building bridges between researchers, policy makers,
and practitioners, as well as with community members who have a central stake
in obtaining solutions to problems, it is likely that such risks will be minimized
(Alberts, 2008; Downs, 2000; Klein, 2004).
The second feature that we believe could significantly enhance the acceptability
and applicability of a TD research approach relates to the institutional structure
of the research framework itself. As elaborated by Kirst and her colleagues in
Chapter 12, TD research can seem unwieldy, complicated, and costly in terms of
time and money. It also involves a considerable commitment to the collaborative
process itself, sometimes only indirectly related to the substantive form and focus
of the research. In addition, echoing other analyses, Kirst et al. highlight the invest-
ment required in learning other disciplines’ languages and the related need to listen
to a wide range of voices and perspectives.
With those challenges in mind and seeking to facilitate the conduct of TD
research – notably on the complex, multi-faceted problems of urban public health
– so that the enterprise becomes at once less daunting and more manageable and
more systematic, we would like to mention three innovative analytical approaches.
First, there is the ecologically oriented work of Stokols and his colleagues, both in
this volume (Chapters 8 and 10) and elsewhere, aimed at articulating and instan-
tiating “the science of transdisciplinary action research” (Stokols, 2006). Second,
there are the efforts of Cacioppo, Davidson, Seeman, and others that represent
significant strides toward a theoretically sophisticated and empirically grounded
framework that bridges and, indeed, blends the neuro-biological, psychological, and
socio-cultural dimensions of health (Berntson & Cacioppo, 2008; Davidson, 2008;
Seeman, 2008).
Finally, stimulated by Berntson and Cacioppo and others, in our own writings we
have been exploring the concept of heterarchy. Originally developed in computer
Foreword ix
and cognitive science and now extended in a number of fields (e.g., Crumley, 2005),
this concept provides a framework for understanding the kinds of reciprocal, multi-
level, and non-linear phenomena that are a central focus of TD research approaches.
In our view, heterarchy is a heuristically rich way to organize the complexity
required for analyzing and addressing deep-seated social problems. Moreover, and
as we have noted elsewhere (Kessel & Rosenfield, 2008a, 2008b), heterarchy has
great potential not only as an analytical lens but also as a way of conceptualizing
the non-hierarchical organization of TD teams and related institutional structures.
We therefore suggest that the next phase for the expansion of TD research on urban
health problems be organized, in part, around a heterarchical framework.
Whatever specific next steps are taken in the development of TD research on
urban health problems, the penetrating analyses in this publication will serve as a
firm foundation for future efforts. If only, but not only, because of the wide range
of urban public health problems addressed, these chapters provide the basis for
practitioners, community members, and researchers to collaborate creatively to help
ensure that the two-thirds of humanity who will be urban citizens in the twenty-first
century will lead healthier and hence more fulfilling lives.
Patricia Rosenfield
Frank Kessel
Alberts, B. (2008, April 11). Hybrid vigor in science. Editorial. Science, 320, 155.
Andrews, N., Burris, J. E., Cech, T. R., Coller, B. S., Crowley, W. F., Gallin, E. K., et al. (2009,
May 15). Translational Careers. Editorial. Science,324, 855.
Ash, C., Jasny, B. R., Roberts, L., Stone, R., & Sugden, A. M. (Eds.) (2008, February 8). Cities:
Special section. Science,319, 739–775.
Berntson, G. G., & Cacioppo, J. T. (2008). A contemporary perspective on multi-level analyses and
social neuroscience. In F. Kessel, P. L. Rosenfield, & N. A. Anderson (Eds.), Interdisciplinary
research: Case studies from health and social sciences (pp. 21–43). New York: Oxford
University Press.
Chesney, M. A., & Coates, T. J. (2008). The Evolution of HIV prevention in San Francisco: A mul-
tidisciplinary model. In F. Kessel, P. L. Rosenfield, & N. B. Anderson (Eds.). Interdisciplinary
research: Case studies from health and social sciences (pp. 393–428).New York: Oxford
University Press.
Contopoulos-Ionnaidis, D. G., Alexiou, G. A., Gouvias, T. C., Ioannidis, J. P. A. (2008,
September 5). Life cycle of translational research for Medical Interventions. Science.321,
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Davidson, R. J. (2008). Affective neuroscience: A case for interdisciplinary research. In F. Kessel,
P. L. Rosenfield, & N. A. Anderson (Eds.), Interdisciplinary research: Case studies from health
and social sciences (pp. 111–134). New York: Oxford University Press.
Downs, M. (2000, August 18). Researchers reach out to ‘stakeholders’ in studies: Partnerships
with affected citizens can improve the science, but it’s not easy to build consensus on the best
approach. The Chronicle of Higher Education, 46, A17–A18.
Hadorn, G. H., Hoffman-Riem, H. biber-Klemm, S., Grossenbacher-Mansuy, W., Joye, D., Pohl,
C., Wiesmann, U. & Zemp. E. (Eds.). (2008). Handbook of transdisciplinary research. Zurich,
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Kessel, F., & Rosenfield, P. L. (2005). Closing commentary. In F. Kessel, P. L. Rosenfield, & N.
A. Anderson (Eds.), Expanding the boundaries of health and social sciences: Case studies in
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Part I An Introduction to Transdisciplinary Research
1 Introducing a Transdisciplinary Approach to Applied
Urban Health Research ........................ 3
Patricia O’Campo, Maritt Kirst, Nicole Schaefer-McDaniel,
and Stephen Hwang
2 Benefits and Challenges of Transdisciplinary Research
for Urban Health Researchers ..................... 13
Nicole Schaefer-McDaniel and Allison N. Scott
3 In Search of Empowering Health Research
for Marginalized Populations in Urban Settings:
The Value of a Transdisciplinary Approach ............. 23
Maritt Kirst, Jason Altenberg, and Raffi Balian
Part II Examples of Transdisciplinary Research
4 Reducing Health Disparities Experienced
by Refugees Resettled in Urban Areas:
A Community-Based Transdisciplinary Intervention Model .... 41
Jessica R. Goodkind, Ann Githinji, and Brian Isakson
5 The Street Health Report 2007: Community-Based
Research for Social Change ...................... 57
Erika Khandor and Kate Mason
6 Safety as a Social Value: Revisiting a Participatory Case
Study in Scotland ............................ 69
Helen Roberts, Susan J. Smith, Betty Campbell, and Cathy Rice
Part III The Process of Transdisciplinary Research
7 Methodological Notes on Conducting Transdisciplinary
Research ................................. 83
Patricia G. Erickson and Jennifer E. Butters
xii Contents
8 Collaborative Processes in Transdisciplinary Research ....... 97
Shalini Misra, Kara Hall, Annie Feng, Brooke Stipelman,
and Daniel Stokols
9 From Complex Problems to Complex Problem-Solving:
Transdisciplinary Practice as Knowledge Translation ........ 111
Kelly Murphy, Beverly Wolfus, and Aisha Lofters
Part IV Moving Forward
10 Transdisciplinary Training in Health Research: Distinctive
Features and Future Directions .................... 133
Shalini Misra, Daniel Stokols, Kara Hall, and Annie Feng
11 Funding Agencies and Transdisciplinary Research ......... 149
Joy L. Johnson and Sharon Hrynkow
12 Moving Forward: The Future of Transdisciplinary Health
Research ................................. 161
Maritt Kirst, Nicole Schaefer-McDaniel, Stephen Hwang,
and Patricia O’Campo
Subject Index ................................. 169
Jason Altenberg South Riverdale Community Health Center, Toronto, ON,
Raffi Balian South Riverdale Community Health Center, Toronto, ON, Canada
Jennifer Butters Centre for Addiction and Mental Health, Toronto, ON, Canada
Betty Campbell Community Member, Corkerhill, Glasgow, Scotland, UK
Patricia G. Erickson Centre for Addiction and Mental Health, Toronto, ON,
Annie Feng School of Social Ecology, University of California, Irvine, CA, USA
Ann Githinji Division of Prevention and Population Sciences, Department of
Pediatrics, University of New Mexico, Albuquerque, NM, USA
Jessica R. Goodkind Division of Prevention and Population Sciences, Department
of Pediatrics, University of New Mexico, Albuquerque, NM, USA
Kara Hall School of Social Ecology, University of California, Irvine, CA, USA
Sharon Hrynkow National Institute of Environmental Health Sciences, National
Institutes of Health, USA
Stephen Hwang Centre for Research on Inner City Health, St. Michael’s Hospital,
Toronto, ON, Canada
Brian Isakson Division of Prevention and Population Sciences, Department of
Pediatrics, University of New Mexico, Albuquerque, NM, USA
Joy L. Johnson Institute of Gender and Health, Canadian Institutes of Health
Research and School of Nursing, University of British Columbia, Vancouver, BC,
Erika Khandor Metrics and Planning, Planning and Policy, Toronto Public
Health, Toronto, ON, Canada
xiv Contributors
Maritt Kirst Ontario Tobacco Research Unit, Dalla Lana School of Public Health,
University of Toronto, Toronto, ON, Canada
Aisha Lofters Centre for Research on Inner City Health, St. Michael’s Hospital,
Toronto, ON, Canada
Kate Mason Centre for Research on Inner City Health, St. Michael’s Hospital,
Toronto, ON, Canada
Shalini Misra School of Social Ecology, University of California, Irvine, CA,
Kelly Murphy Centre for Research on Inner City Health, St. Michael’s Hospital,
Toronto, ON, Canada
Patricia O’Campo Centre for Research on Inner City Health, St. Michael’s
Hospital, Toronto, ON, Canada
Cathy Rice Health Improvement Lead, Adults and Older People SW CHCP,
Cardonald, Glasgow, UK
Helen Roberts UCL Institute of Child Health, University of London, London, UK
Nicole Schaefer-McDaniel Centre for Research on Inner City Health,
St. Michael’s Hospital, Toronto, ON, Canada
Allison N. Scott Centre for Research on Inner City Health, St. Michael’s Hospital,
Toronto, ON, Canada
Susan J. Smith Girton College, University of Cambridge, Cambridge, UK
Brooke Stipelman School of Social Ecology, University of California, Irvine, CA,
Daniel Stokols School of Social Ecology, University of California, Irvine, CA,
Beverly Wolfus Ministry of Community and Social Services, Toronto, ON,
About the Authors
Jason Altenberg is the urban health manager at South Riverdale Community Health
Centre. His work focuses on the integration of health, social, and community pro-
grams for drug users and others who experience barriers to health care, social
services, and social inclusion. He has developed programs and clinical care mod-
els for people with co-occurring substance use and mental health issues, integrated
mental health “recovery”/harm reduction programs, and Hepatitis C treatment.
Raffi Balian has been a harm reduction outreach coordinator for over 10 years. He
developed and currently coordinates the COUNTERfit harm reduction program at
the South Riverdale Community Health Centre in Toronto. Mr. Balian has had work
on harm reduction programming and research published in several local, national,
and international journals, magazines and periodicals, and his identity as an active
injection drug user has been instrumental in the development of programs that
respond to the needs of illicit drug users in Toronto and elsewhere.
Jennifer Butters is an affiliate scientist with the Centre for Addiction and Mental
Health. Her primary research interests focus on the intersection of drug use, vio-
lence, and mental health among youths. She has served as a co-investigator on
several research projects and participates in the graduate collaborative program in
addiction studies [CoPAS] at the University of Toronto.
Betty Campbell has lived in Corkerhill since 1974 and played a pivotal part in the
work described in Chapter 6. She was active in the Corkerhill Community Council,
campaigning for improved housing, safer roads, and play parks. She set up and ran
a “Danger Watch” group which turned the safety problem on its head with children
identifying and reporting dangers rather than being told how to keep themselves
Patricia G. Erickson has been a senior scientist with the Centre for Addiction
and Mental Health, and before that the Addiction Research Foundation, for over
30 years. She is also adjunct professor of sociology and criminology and a for-
mer director of the graduate collaborative program in addiction studies [CoPAS]
at the University of Toronto. Her long-standing interests include illicit drug use,
harm reduction, and drug policy. Recent research projects have examined drug use,
mental health, and violence in groups of high-risk youth and marginalized women.
xvi About the Authors
An innovative dissemination project, “Toronto Youth Street Stories,” combines
research on street-involved youths with their own writing about their experiences
in a web-based format at
Annie Xuemei Feng is a behavioral scientist, a SAIC Frederick contractor, sup-
porting to the behavioral research program of the Division of Cancer Control and
Population Sciences at the National Cancer Institute (NCI). She is a member of
the NCI evaluation team of large initiatives, engaging in the evaluation of trans-
disciplinary initiatives and the study of team science. Her research interests include
examining the talent development trajectory of scientists, team science, and transdis-
ciplinary training. She received her B.A. and M.A. in English language and literature
in China and her doctorate in education from St. John’s University in New York.
Ann Githinji has a master’s degree in biology from New Mexico State University.
She is currently a doctoral student in medical anthropology at the University of
Virginia. Ms. Githinji is from Kenya and is involved in socio-cultural anthropo-
logical health research with African refugees and immigrants resettled in North
America. She is multilingual and is fluent in Kiswahili, Kikuyu, and English.
Jessica Goodkind is an assistant professor in the Department of Pediatrics,
Division of Prevention and Population Sciences, University of New Mexico. She
received her Ph.D. in ecological/community psychology from Michigan State
University, and her primary interests are community-based participatory research to
promote the mental health and well-being of marginalized populations and engaging
students in service learning opportunities that work toward social justice.
Kara L. Hall is a health scientist in the office of the associate director of the
behavioral research program in the Division of Cancer Control and Population
Sciences at the National Cancer Institute (NCI). During her career, Dr. Hall has
participated in a variety of interdisciplinary clinical and research endeavors. Since
arriving at NCI, Dr. Hall has focused on advancing dissemination and implementa-
tion research and the science of team science as well as promoting the use, testing,
and development of health behavior theory in cancer control research.
Sharon Hrynkow has spent over 15 years working with the US National Institutes
of Health (NIH) and the Department of State, leading major efforts in programs and
policies addressing HIV/AIDS, emerging infectious disease, the health impacts of
climate change, global health research and training, and partnership development.
She holds a Ph.D. in neuroscience from the University of Connecticut and conducted
post-doctoral studies at the University of Oslo.
Brian Isakson is a clinical psychology post-doctoral fellow at the University of
New Mexico Center for Rural and Community Behavioral Health. He earned his
Ph.D. from Georgia State University in 2008. Dr. Isakson has conducted research
and clinical work with refugees and torture survivors for 9 years with a specific
focus on community-based interventions.
Joy Johnson is a professor in the School of Nursing at the University of British
Columbia and the scientific director of the Institute of Gender and Health of the
Canadian Institutes of Health Research. In this latter role she leads the development
and implementation of a strategic plan for funding health research related to gender
and health in Canada.
About the Authors xvii
Frank Kessel is a professor in the Department of Individual, Family and
Community Education and a senior fellow in the Robert Wood Johnson Foundation
Center for Health Policy at the University of New Mexico. Prior to joining UNM,
he served for 12 years as program director for the culture, health and human
development program at the Social Science Research Council. A fellow of both
the American Psychological Association and the Association for Psychological
Science, Kessel received his Ph.D. from the University of Minnesota and his M.A.
at the University of Cape Town and has held academic positions at the University of
Houston, the University of Alberta, and the University of Cape Town.
Erika Khandor holds a master of health sciences (MHSc) degree in public health
(health promotion) from the University of Toronto. Her research interests focus on
community-based research and the social determinants of health including housing,
income security, employment, and immigration status. Ms. Khandor spent 4 years
working as the research and evaluation coordinator at Street Health, a community-
based organization providing health and social services to homeless people in
Toronto, where she conducted program evaluation and community-based research
on homelessness and related issues. The research project described in this book was
conducted during Ms. Khandor’s tenure at Street Health, as was the writing of the
chapter itself. Ms. Khandor currently works as an epidemiologist at Toronto Public
Aisha Lofters is a family physician and global health scholar with the Department
of Family & Community Medicine, St. Michael’s Hospital, research scholar with the
Department of Family & Community Medicine, University of Toronto, and CIHR
strategic training fellow with the Centre for Research on Inner City Health in the Li
Ka Shing Knowledge Institute of St. Michael’s Hospital.
Kate Mason holds a master of health sciences (MHSc) degree in public health
(health promotion) from the University of Toronto. Ms. Mason spent 3 years work-
ing as a research coordinator at Street Health, a community-based organization
providing health and social services to homeless people in Toronto. Ms. Mason has
led and implemented several community-based evaluations and research projects on
homelessness issues. The research project described, and the writing of the chapter,
in this book was conducted during Ms. Mason’s time at Street Health. Ms. Mason
currently works as a research coordinator at the Centre for Research on Inner City
Health at St. Michael’s Hospital.
Shalini Misra is a Ph.D. candidate in planning, policy, and design in the School
of Social Ecology at the University of California, Irvine. Her interdisciplinary
research interests include the health, interpersonal, and community level impacts
of the Internet and other digital communication technologies. She is also inter-
ested in understanding the factors that influence the success of transdisciplinary
collaboration, training, and action research initiatives.
Kelly Murphy is a director of knowledge translation and partnerships and a
staff scientist at the Centre for Research on Inner City Health in the Li Ka Shing
Knowledge Institute of St. Michael’s Hospital. Over the past 10 years, she has
designed and evaluated numerous transdisciplinary training initiatives to build
health research transfer capacity in Ontario.
xviii About the Authors
Cathy Rice was chair of the Community Council in Corkerhill and a local res-
ident at the time of the research reported in Chapter 6. She still lives in Glasgow
and works for the NHS in the South West Community Health and Care Partnership
Health Improvement Team as lead officer for adults and older people.
Helen Roberts works in the General Adolescent and Paediatrics unit at University
College London Institute of Child Health. Professor Roberts’ main intellectual inter-
ests are evidence based child public health, how we deal with the gap between what
we know and what we do, and reducing inequalities in child health. Until 2001,
she was Head of R&D with Barnardo’s, the UK’s largest children’s NGO. She is
a non executive director of NICE (the National Institute for Health and Clinical
Patricia L. Rosenfield is a program director, Carnegie scholars program, at
Carnegie Corporation of New York. She previously led the corporation’s program
on strengthening human resources in developing countries and the program on
International Development. In the 1980s, Dr. Rosenfield developed and managed the
social and economic research component of the UNDP/World Bank/World Health
Organization special program for research and training in tropical diseases and
was the program economist. Dr. Rosenfield holds an A.B., cum laude from Bryn
Mawr College and a Ph.D. from Johns Hopkins University. In 1998, she received an
honorary doctorate in social science from Mahidol University in Bangkok, Thailand.
Allison Scott is a Ph.D. candidate in the Department of Epidemiology and
Biostatistics at McGill University in Montreal and a research fellow in the Centre
for Research on Inner City Health at St. Michael’s Hospital in Toronto, Canada. She
took part in the Canadian Institutes of Health Research (CIHR) training program
on the transdisciplinary approach to the health of marginalized populations between
2006 and 2008 and is currently conducting a qualitative community-based research
project on pregnancy among homeless young women.
Susan J. Smith is Mistress of Girton College Cambridge. She was a profes-
sor of geography at Durham University from 2004 to 2009 and prior to that held
the Ogilvie Chair of Geography at the University of Edinburgh. Her research on
housing-related topics spans more than 20 years, addressing themes as diverse as
residential segregation, housing for health, fear of crime, and – most recently – the
origins and effects of credit, price, and liquidity risks in housing markets.
Brooke Stipelman is a postdoctoral fellow in the behavioral research program
of the Division of Cancer Control and Population Sciences at the National Cancer
Institute (NCI). Dr. Stipelman holds a doctoral degree in clinical psychology
from the University of Maryland. As a fellow within the NCI evaluation team
Dr. Stipelman assists in the evaluation of several large-scale transdisciplinary
research initiatives funded by NCI. She also is involved in conducting research on
the science of team science.
Daniel Stokols is a chancellor’s professor of planning, policy, and design, psy-
chology and social behavior, and dean emeritus of the School of Social Ecology
at the University of California, Irvine. He is also a professor of public health and
epidemiology in the College of Health Sciences at UCI.
About the Authors xix
Beverly Wolfus has worked for the Province of Ontario for over 20 years in
a variety of capacities. Most of this time, she worked in a research and program
evaluation capacity in the Ministry of Community and Social Services. Dr. Wolfus
is a psychologist by training.
About the Editors
Maritt Kirst is a research associate at the Ontario Tobacco Research Unit in the Dalla
Lana School of Public Health at the University of Toronto, Canada. At the time the
book was developed, she was a research associate at the Centre for Research on
Inner City Health at St. Michael’s Hospital. She received her Ph.D. in sociology
and addiction studies from the University of Toronto. Her research interests pertain
to social capital, the health of marginalized populations, tobacco control, substance
use and misuse, health equity measurement, evaluation of complex health interven-
tions, and mixed research methods. Dr. Kirst’s current work examines the influence
of network- and neighborhood-level social capital on health, and the evaluation of
programs and focused on the prevention of tobacco use.
Nicole Schaefer-McDaniel completed her Ph.D. in environmental psychology at
the Graduate Center of the City University of New York. She is currently a research
associate at the Centre for Research on Inner City Health at St. Michael’s Hospital,
Toronto, Canada where she explores the relationship between neighborhood con-
text and residents’ health, health equity issues among low-income and marginalized
individuals and methodological advancements in urban health research.
Stephen Hwang is a research scientist at the Centre for Research on Inner
City Health, St. Michael’s Hospital, an associate professor in the Departments of
Medicine, Public Health Sciences, and Health Policy at the University of Toronto
and a director of the Division of General Internal Medicine at the University of
Toronto, Canada. His research focuses on deepening our understanding of the rela-
tionship between homelessness, housing, and health through epidemiologic studies,
health services research, and longitudinal cohort studies. Dr. Hwang’s current
research projects include a study of predictors of health-care utilization in a rep-
resentative sample of 1,200 homeless men, women, and families in Toronto, a study
of the barriers to the management of chronic pain among homeless people, and an
evaluation of the effects of a supportive housing program on health and health-care
utilization among homeless and hard-to-house individuals.
Patricia O’Campo is Alma and Baxter Ricard Chair in Inner City Health and
Director of the Centre for Research on Inner City Health at St. Michael’s Hospital
in Toronto, Canada. She is also a professor of public health sciences at the University
of Toronto and adjunct professor at the Johns Hopkins Bloomberg School of Public
xxii About the Editors
Health. She has conducted research on the social determinants of health and well-
being among women and children for over 17 years. As a social epidemiologist, her
research has a focus on social determinants of well-being and on effective policies
and programs that reduce health inequalities among women and children across
North America.
Part I
An Introduction to Transdisciplinary
Chapter 1
Introducing a Transdisciplinary Approach
to Applied Urban Health Research
Patricia O’Campo, Maritt Kirst, Nicole Schaefer-McDaniel,
and Stephen Hwang
In the context of increased urbanization in the last century, public health research
has evolved to explore the impact of urban environments on health (Galea & Vlahov,
2005). This relatively new body of research is referred to as urban health research
and it seeks to explore determinants and outcomes of health as well as the interrela-
tionships between them (Harpham, 2008). City living can affect health in multiple
ways. Specifically, health in the urban context can be affected by such factors as the
physical environment, the social environment, and access to health and social ser-
vices (Galea & Vlahov, 2005). In the past, health research has primarily examined
the influence of individual characteristics on health. However, given the effects of
multiple factors on health in the urban context, an understanding of the complex-
ity of health problems in the urban environment is beyond the boundaries of any
one discipline, thus the involvement of multiple disciplines and sectors and vari-
ous research methods is required (Galea & Vlahov, 2005; Harpham, 2008). As a
result, urban health research has evolved to encompass a variety of methods and
perspectives to study these complex health problems.
As we and our contributors will be discussing throughout this book, it is nec-
essary for researchers to work with experts of other disciplines and areas of
knowledge, and together move beyond disciplinary perspectives, methodologies,
theories, boundaries, and limitations to understand these complex urban health
problems more fully and attempt to resolve them.
Current State of Urban Health Research
Urban health is not a mature field, but is constantly evolving. For example, urban
health studies can include the examination of the urbanization process, of health sta-
tus and behaviours among populations in the developing world, of slum and inner-
city populations and issues, and/or of the health of socio-economically marginalized
P. OC a m p o ( B)
Centre for Research on Inner City Health, St. Michael’s Hospital, 30 Bond Street, M5B 1W8
Toronto, Ontario, Canada
M.Kirstetal.(eds.),Converging Disciplines, DOI 10.1007/978-1-4419-6330-7_1,
Springer Science+Business Media, LLC 2011
4 P. O’Campo et al.
and disadvantaged populations. A common thread among these agendas is a focus
on the study of how poverty as well as attributes of the social and physical environ-
ment and access to services (e.g. health, social) affect complex social/health issues.
Moreover, all of these undertakings emphasize the need to link research to action.
For example, The World Health Organization Knowledge Network on Urban Health
Settings (WHO KNUS) has recently made a call for research concerning a number
of pressing urban health issues, including strategies to improve deprived urban liv-
ing conditions, create healthy urban governance, and reduce powerlessness of those
experiencing urban poverty (WHO KNUS, 2008).
Recent developments in the establishment of urban health research include
the founding of an international society (International Society for Urban Health, that hosts an annual international conference as well as a journal
dedicated to the topic (the Journal of Urban Health, published by Springer) and
recent books and reports on population health in urban settings by Galea and Vlahov
(2005), Freudenberg, Galea, and Vlahov (2006), and WHO KNUS (2008).
Unidisciplinary, Multidisciplinary, and Interdisciplinary
Research Studying Urban Health Phenomena
In the early development stages of urban health research, the field was challenged
because various disciplines studying the same urban health issue used different
definitions and language regarding the health effects of urbanization and rarely
collaborated despite common fields of study (Vlahov & Galea, 2003). Urban
health research was undertaken using mostly unidisciplinary and multidisciplinary
approaches, with fewer interdisciplinary studies being generated. Yet, very different
kinds of knowledge are generated depending on what approach is taken, as described
by Rosenfield (1992). Unidisciplinary approaches are studies that are initiated and
carried out by those within a single discipline. According to Rosenfield (1992),
multidisciplinary research occurs when researchers work sequentially or in paral-
lel to each other on a topic, but do so from their own discipline. Interdisciplinary
research occurs when researchers from different disciplines collaborate jointly on
projects concerning the same topic, but still draw from and remain true to their
own disciplinary training. The next level of integration of the disciplines occurs
with transdisciplinary (TD) research. This approach involves “researchers working
jointly using shared conceptual frameworks drawing together disciplinary theo-
ries, concepts, and approaches to address a common problem” (Rosenfield, 1992,
p. 1351). These frameworks therefore combine and extend “discipline-based con-
cepts, theories, and methods to address a common research topic” (Stokols, 2006,
p. 67).
While we agree with this definition, we expand it to include other collabora-
tors such as community or policy partners. That is, our own experience with TD
research involves teams composed of individuals with academic and non-academic
backgrounds who are all concerned with solving the same health problem. We next
1 Transdisciplinary Approach to Applied Urban Health Research 5
use the example of intimate partner violence to illustrate a more in-depth exploration
of the differences between uni-, multi-, inter-, and transdisciplinary approaches.
Intimate partner violence (IPV) is a significant public health problem with life-
time prevalence reaching as high as 40% in some North American studies (Krug,
Dahlberg, Mercy, Zwi, & Lozano, 2002). The health and social consequences of
being a victim of partner violence include mental health problems such as depres-
sion, substance use, and post-traumatic stress disorder (PTSD); physical injuries
from physical or sexual violence; reproductive and sexual health problems such
as unwanted pregnancy from sexual abuse; loss of wages and work days; hous-
ing instability and even homelessness (Campbell et al., 2002; Kaminer, Grimsrud,
Myer, Stein, & Williams, 2008; Messing, 2008; O’Campo et al., 2006; O’Campo,
Ahmad, & Cyriac, 2008; Pallitto, Campbell, & OCampo, 2005; Roschelle, 2008;
Swanberg & Logan, 2007). Furthermore, while most of the research in this area has
been with households residing in urban areas, there are differences in prevalence,
resources available, resources accessed by victims of abuse, environmental influ-
ences, and even coping styles in urban versus non-urban areas (Burke, O’Campo, &
Peak, 2006; Shannon, Logan, & Cole, 2006).
An example of unidisciplinary research on partner violence comes from the field
of psychology concerning perpetrators of IPV. Such research is critical as only a
relatively small proportion of the overall research on IPV is concerned with perpe-
trator issues. From the perspective of psychologists, Carrud, Jaffe, and Sillitti-Dokic
(2008) studied attachment styles of perpetrators of violence in an attempt to link
attachment to emotional aggressiveness and controlling behaviours. While this fac-
tor may be important in understanding perpetration, the authors did not consider
other relationship characteristics (e.g. marital or cohabitation status, length of rela-
tionship, and status inconsistency where one partner has a higher socio-economic
position than the other) or potentially important variables such as social class, which
limit the application of the findings to a broad set of contexts or situations.
A separate study on perpetrators of IPV from the field of criminology, conducted
around the same time as the study by Carrud et al., focused on the role of police
data in the prediction of the continuation and escalation of IPV episodes and crim-
inal persecution for IPV. Several variables contained in police data were found to
be useful in determining these outcomes such as the use of a weapon, use of threats
to injure/kill the victim, perpetrators’ involvement with the criminal justice sys-
tem, and cohabitation/separation status, to name a few. These factors are commonly
studied in criminology but are often not of primary interest in psychology, pub-
lic health, or clinical health studies on IPV. Thus, while these two unidisciplinary
studies are both concerned with identifying perpetrator factors associated with IPV,
taken together they also illustrate a multidisciplinary approach to the study of per-
petration of IPV (i.e. parallel investigations of the topic from different disciplinary
perspectives). The strengths and limitations to this approach will be briefly outlined.
First, the variables identified in each of these studies are valid factors that are
supported by disciplinary-specific theories and a history of previous research on
those particular topics. Second, taken together, these studies identify a broad range
of perpetrator factors that are associated with IPV. In fact, if the issue of IPV
6 P. O’Campo et al.
perpetration was studied within a single discipline, this full set of factors would
not have been identified. Yet, on the other hand, it is unlikely that continuation of
a multidisciplinary approach, through the parallel study of IPV perpetration with
continued segregation of the disciplines, will lead to an integrated framework or
understanding of perpetrator factors important for IPV.
This brings us to the next level in the study of IPV, an interdisciplinary approach.
Our example here focuses on IPV in the workplace. While much IPV occurs in the
home, emerging research is starting to explore the ways in which IPV spills over
into non-home environments such as the workplace (e.g. stalking at work, harassing
co-workers about the victim, or even barring women from attending job training).
An example of an interdisciplinary approach is a collection of papers put together
in a special issue of the Journal of Interpersonal Violence on IPV in the workplace
(Swanberg & Logan, 2007). The chapters in this collection are from authors from a
wide variety of disciplines such as social work, management, human resource man-
agement, sociology, psychology, and anthropology. The topics are also very broad
and include stalking in the workplace, support or stigma that results from disclo-
sure to other co-workers, an examination using a gender role theory of women in
higher status and higher paid jobs (an area that is rarely studied especially in rela-
tion to IPV), organizational costs of IPV to workplaces, and the interrelationships of
social support, stable or unstable employment, and IPV. While this is an emerging
area of investigation, these papers advance our understanding of the myriad ways
in which IPV impacts the workplace and point to areas in which workplaces can
provide support to women who are victims. There is a richness to the information
generated given that the papers drew from multiple disciplines and involved authors
from more than one discipline.
We finally give a brief look into how IPV research can be approached using
a TD perspective. The example concerns the assessment and implementation of
an IPV community response system (Ritchie & Eby, 2007). An existing commu-
nity coalition invited academics from a local university to their meetings in which
research activities had been ongoing. The research project sought to identify avail-
able community-based services to individuals and families experiencing IPV as
well as any barriers to effective service delivery. The seven-member research team
comprised academics from the fields of social work, community psychology, and
women’s studies as well as two community members who had expertise in com-
munity development and front-line social work. The team sought to ensure that
all disciplinary and community perspectives were represented in all aspects of the
project, and many of the activities prioritized the needs of the community-based
stakeholders affiliated with the research and project team. The whole process was
not without struggle and constant adjustments as noted by the authors, in part stem-
ming from the different perspectives and priorities around the research table. The
research findings generated were viewed by the community as not only being rig-
orous but also being familiar as they mirrored what the community had already
identified through anecdotes. The voice of the community was also recognizable
during public presentations of the findings.
The characteristics of this project described by the authors are very consis-
tent with what Rosenfield has described as TD. Yet, it should be noted that the
1 Transdisciplinary Approach to Applied Urban Health Research 7
authors refer to their work as “interdisciplinary”. The conflation of multi-, inter-,
and transdisciplinary approaches to research is not uncommon and is discussed later
in this book. While the authors refer to their work as interdisciplinary, we felt that
it was also a clear example of a TD approach and treat it as such here. In fact, anec-
dotes from this project nicely summarize the experiences and sentiment of many
TD projects. The authors note that their approach to their research, while yielding
many benefits, also requires time, community building, and a long-term commit-
ment. They further note while promoting their TD approach that the problem of
community response to IPV does not stand in isolation but “must be understood
in context, as embedded in a network of multidirectional causation and manifesta-
tions involving a variety of systems (e.g. social, psychological, biological, spiritual,
economical, and political). Disciplinary blinders can limit the vision necessary to
adequately address such issues and problems” (Ritchie & Eby, 2007, p. 141). These
struggles are, as we will see in the next section and throughout this book, part
and parcel to a TD research approach and necessary for holistic problem solving
required to address complex health issues. Yet, in our opinion and in the opinion
of many who undertake TD research, the benefits outweigh the negative impact of
these struggles.
TD Research for Urban Health
As the examples of research on IPV showed, urban health issues are socially com-
plex and multi-dimensional that are affected and constrained by the environmental
and political contexts in which they occur. As shown above, an understanding of
the complexity and uniqueness of health problems that arise in urban environments
is beyond the scope of any one discipline. In contrast to interdisciplinary research,
TD research is carried out not just by academics but also by the community, policy
makers, practitioners, and other stakeholders who work together as a team and draw
upon their expertise and experience to jointly develop a “shared conceptual frame-
work drawing together disciplinary-specific theories, concepts, and approaches to
address a common problem” (Rosenfield, 1992, p. 1351).
Hence, transdisciplinarity distinguishes itself from other cross-disciplinary
approaches such as interdisciplinarity and multidisciplinarity in that a “fusion”
of different disciplines and perspectives into a common conceptual framework is
involved (Wickson, Carew, & Russell, 2006) and that researchers are expected to
leave the comfort zones of their disciplines (Lawrence & Depres, 2004; Rosenfield,
1992). As discussed, this fusion of disciplines and experts can include non-academic
or non-scientific stakeholders such as community organizations or the population of
study (Ramadier, 2004; Smith, 2007). However, all types of expertise are consid-
ered equally important; not one academic discipline or area of expertise is privileged
throughout the research process.
One of the benefits of a TD research approach is that it allows researchers to
“go beyond a linear application of a static methodology and aim for an evolving,
dynamic, or responsive methodology that is iterative and an ongoing part of the
research process” (Wickson et al., 2006, p. 1051). TD work provides the research
8 P. O’Campo et al.
team an opportunity to examine various dimensions of a problem through a num-
ber of methods, which in turn facilitates moving research into practice. Further,
TD research is problem focused and concerned with problem solving rather than
hypothesis testing (as is the emphasis in much disciplinary research). TD work is
therefore action oriented and aims to achieve social change by connecting knowl-
edge to real-world solutions (Kessel & Rosenfield, 2008; Lawrence & Despres,
2004), for example, by informing public policies or developing and informing
programs and interventions. The actionable nature of TD research is facilitated
by ongoing knowledge exchange processes that are weaved throughout the entire
research process to inform all stages of the investigation so that there is a “constant
flow between knowledge and practical application” (Smith, 2007, p. 161).
In summary, the TD research approach is problem oriented, dynamic, contex-
tual to the application and research focus, creates knowledge for impact, and is
socially accountable. Since TD teams comprise experts from different backgrounds,
this type of research will almost certainly require a mixing of methods, creation
of new methods, and/or a willingness to consider alternative epistemological mod-
els. A TD approach therefore lends itself well to urban health research as it seeks to
solve problems that are complex and multi-dimensional (Wickson et al., 2006). That
is not to say that the TD approach is the end-all solution for applied researchers as
it may not be ideal for every type of undertaking. In particular, TD researchers may
confront challenges such as learning to speak the same language when building a
shared understanding of a topic (see Chapter 2). However, we believe that applied
problems that are complex and unique, such as those related to urban health issues,
are ideal candidates for TD inquiry.
Aims and Organization of the Book
This book will introduce TD research as it relates to urban health issues and will
discuss the contributions it can make to the field of urban health. The aims of the
book are to
(1) introduce a wide audience of researchers, policy makers, community organiza-
tions, and funding agencies to the concept of transdisciplinarity and its promise
for urban health research;
(2) provide readers with information on theoretical backgrounds, methodological
approaches, and case examples of TD urban health research;
(3) provide information for researchers to utilize and apply this approach in their
own work and to develop skills in the knowledge transfer of TD findings; and
(4) foster a dialogue between researchers, policy makers, funders, community-
based organizations, and academia on the promising contributions of TD urban
health research.
The book is divided into four parts. The first part introduces the TD research
approach and discusses its potential for exploring complex health problems.
In Chapter 2, Nicole Schaefer-McDaniel and Allison Scott draw on their own
1 Transdisciplinary Approach to Applied Urban Health Research 9
participation in a TD research project on best practices in community-based treat-
ment for homeless adults experiencing concurrent mental health and substance use
disorders to highlight the strengths and challenges this type of collaboration has
for researchers. Particularly, they suggest that TD collaboration has the potential to
foster a deeper understanding of the phenomenon of inquiry but it is also associ-
ated with difficulties and challenges around group dynamics and communication. In
Chapter 3, Maritt Kirst, Jason Altenberg, and Raffi Balian illustrate the many bene-
fits that TD work can have for community members involved in the research process.
The chapter discusses how a TD research approach can build community-level
capacity for health improvement and provides examples of community members’
experiences of working towards and within a TD approach in the area of substance
use and harm reduction research.
The second part of the book presents various case studies in which TD research
methods were used to explore important topics related to North American and inter-
national health issues. In Chapter 4, Jessica Goodkind, Ann Githinji, and Brian
Isakson present the Refugee Well-Being Project (RWP), an innovative mental health
intervention that brings together refugee families and undergraduate students to
engage in mutual learning and the mobilization of community resources to reduce
health disparities experienced by refugee children and their families in urban areas
in the United States. The case study involves a mixed-method longitudinal design,
with program results indicating significant increases in English proficiency, access
to resources, quality of life, and significant decreases in psychological distress
among participants.
In Chapter 5, Erika Khandor and Kate Mason discuss a study on the health
of homeless adults in Toronto, Canada which applies principles of community-
based participatory research within the context of TD collaboration. Their chapter
highlights the importance of collaborating with diverse stakeholders including the
community of study and demonstrates how wide advocacy and dissemination efforts
are successfully integrated into a TD framework. Chapter 6, the final case study
by Helen Roberts, Susan Smith, Betty Campbell, and Cathy Rice, takes readers to
Corkerhill, Scotland, in the early 1990s. The authors reflect on their experiences
and involvement in a community-based participatory study on child injury, one of
the first projects to combine multiple methods within that research topic.
The third part encompasses chapters that discuss methodological and practi-
cal issues related to TD urban health research. In Chapter 7, Patricia Erickson
and Jennifer Butters present a case study of two research projects that were both
focused on substance misuse and dependence among at-risk youth. One project was
a unidisciplinary effort rooted in quantitative criminology; the other brought diverse
perspectives to bear in an evolving TD undertaking. The authors suggest that the lat-
ter approach was more inclusive, flexible, and adaptive to circumstances in the field
and may have greater potential for practical impact. In Chapter 8, Shalini Misra,
Kara Hall, Annie Feng, Brooke Stipelman, and Daniel Stokols discuss the nature of
collaborative processes necessary to facilitate and conduct TD research. They also
propose strategies for improving the effectiveness of TD collaborations and suggest
directions for future research.
10 P. O’Campo et al.
A TD research approach is characterized by a unique knowledge translation pro-
cess, in which dissemination of findings to stakeholders is ongoing throughout all
stages of the research in order to ensure that results are relevant and actionable for
policy development. In Chapter 9, Kelly Murphy, Bev Wolfus, and Aisha Lofters
consider how the TD approach facilitates more adequate understanding of com-
plex problem-solving contexts and processes and discuss how TD research practices
open up new pathways for mobilizing research evidence in healthy public policy.
In light of increased recognition of transdisciplinarity as an important research
approach in the urban health field, mechanisms regarding the management of TD
team collaboration, funding sustainability, and academic/intellectual support of this
approach continue to evolve (Kessel & Rosenfield, 2008). The fourth part of the
book thus considers current trends in structural advancements in TD health research
and the need for further evolution. While TD health research is still relatively
new, US federal agencies have funded numerous training programs, and in Canada,
the Canadian Institutes for Health Research has funded over 80 five-year training
programs nationwide. Thus, given that training is an important aspect of the emer-
gence of TD research, the fourth part includes a chapter concerning the training
of future TD health researchers by Misra and colleagues. This chapter systemati-
cally discusses distinguishing features of TD training programs for both doctoral
and postdoctoral trainees, methods and metrics that are suitable for evaluating TD
training, and some of the challenges encountered by these programs.
Increasing recognition in North America of the transdisciplinary approach as a
viable method for understanding complex health issues has led to increased dedi-
cated funding opportunities supporting its use. In Chapter 11, Joy Johnson, from the
Canadian Institutes of Health Research, and Sharon Hrynkow, from the National
Institutes of Health Research in the United States, comment on the current state of
funding for TD health research and speculate about the future. Finally, Chapter 12
summarizes the strengths and challenges of conducting TD urban health research
and makes recommendations for the advancement of this approach.
TD research has numerous benefits to offer the field of urban health with perhaps
an equal number of challenges. In the chapters that follow, we seek to document
myriad examples and perspectives on TD research to ensure that challenges can be
minimized and that the field continues to successfully evolve.
Burke, J., O’Campo, P., & Peak, G. (2006). Neighborhood influences and intimate partner violence:
does demographic setting matter. Journal of Urban Health, 83(2), 182–194.
Campbell, J., Jones, A. S., Dienemann, J., Kub, J., Schollenberger, J., O’Campo, P., et al. (2002).
Intimate partner violence and physical health consequences. Archives of Internal Medicine,
162(10), 1157–1163.
Carrud, L., Jaffe, P. D., & Sillitti-Dokic, F. (2008). Romantic attachment, emotional and instru-
mental aggressiveness in batterers. Practiques Psychologiques, 14, 481–490.
Freudenberg, N., Galea, S., & Vlahov, D. (Eds.). (2006). Cities and the health of the public.
Nashville: Vanderbilt University Press.
1 Transdisciplinary Approach to Applied Urban Health Research 11
Galea, S., & Vlahov, D. (2005). Handbook of urban health: Populations, methods, and practice.
New York: Springer.
Harpham, T. (2008). Urban health in developing communities: What do we know and where do we
go? Health and Place, 15, 107–116.
Kaminer, D., Grimsrud, A., Myer, L., Stein, D., & Williams, D. (2008). Risk for post-traumatic
stress disorder associated with different forms of interpersonal violence in South Africa. Social
Science and Medicine, 67, 1589–1595.
Kessel, F., & Rosenfield, P. L. (2008). Toward transdisciplinary research: Historical and contem-
porary perspectives. American Journal of Preventive Medicine, 35(2S), S225–S234.
Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (2002). Violence – A global
public health approach. World report on violence and health (pp. 3–21). Geneva: World Health
Lawrence, R. J., & Despres, C. (2004). Futures of transdisciplinarity. Futures, 36, 367–405.
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Ritchie, D., & Eby, K. (2007). Transcending boundaries: An international, interdisciplinary com-
munity partnership to address domestic violence. Journal of Community Practice, 15(1–2),
Roschelle, A. (2008). Welfare indignities: Homeless women, domestic violence, and welfare
reform in San Francisco. Gender Issues, 25, 193–209.
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Chapter 2
Benefits and Challenges of Transdisciplinary
Research for Urban Health Researchers
Nicole Schaefer-McDaniel and Allison N. Scott
The previous chapter outlined how transdisciplinary (TD) research, namely research
that integrates divergent perspectives, frameworks, epistemologies, methods, and
theories, enables urban health researchers to gather a more comprehensive under-
standing of social phenomena. In this chapter, we highlight the strengths TD
research provides for urban health researchers as well as some of the challenges
they can face. To illustrate our discussion, we will draw upon the following TD
case study.
Realist Review of Community-Based Services for Homeless
Adults with Concurrent Mental Health and Substance Use
An example of TD research is a recent study from the Centre for Research on Inner
City Health (CRICH) at St. Michael’s Hospital in Toronto, Canada. This project was
part of a Canadian Institutes of Health Research (CIHR)-funded training program–
Strategic Training Initiative in Health Research (STIHR) (see Chapter 11 for more
information on this type of funding) focused on training young researchers across
various disciplines at the pre- and post-doctoral level in the health of marginalized
populations. The goal of this particular study was to conduct a systematic review
of academic and non-academic literature on existing community-based treatment
services for homeless adults with concurrent mental health and substance use disor-
ders. Unlike traditional systematic reviews that focus on whether or not a particular
intervention works, the aim of this study was to understand not only which pro-
grams are successful but also what it is about these programs that worked and why
(O’Campo, Kirst, Schaefer-McDaniel et al., 2009).
N. Schaefer-McDaniel (B)
Centre for Research on Inner City Health, St. Michael’s Hospital, 30 Bond Street, M5B 1W8
Toronto, Ontario, Canada
M.Kirstetal.(eds.),Converging Disciplines, DOI 10.1007/978-1-4419-6330-7_2,
Springer Science+Business Media, LLC 2011
14 N. Schaefer-McDaniel and A.N. Scott
The topic rose out of a stakeholder scan CRICH conducted with community-
based health organizations in downtown Toronto to identify pressing service and
policy needs. Lack of knowledge about services geared specifically for marginalized
people experiencing concurrent mental health and substance use problems emerged
as a recurring theme. When academic researchers met with community agencies to
discuss these findings, it was the community that asked researchers for evidence to
help meet their specific service needs. Thus, similar to other TD projects that are
discussed throughout this book (e.g., see Chapter 3 and Chapter 6), it was the com-
munity that initiated this project and set the course of much of the research. For
example, from the beginning, this project was concerned with an applied research
question that sought to create knowledge that could be directly translated into action.
While we originally focused on the issue of treatment programs for adults expe-
riencing concurrent mental health and substance use problems more broadly, we
narrowed our scope to the homeless population over the course of the project since
this represented a population that was served by most of the community partners
involved in the study.
In order to examine best practices in service provision, a TD research team was
assembled consisting of representatives from five community agencies that provided
frontline services for marginalized people in Toronto, graduate students, pre- and
post-doctoral research fellows, and academic faculty with a wide range of expertise
including social epidemiology, psychology, biostatistics, sociology, ethics, knowl-
edge translation, community medicine, public health, and social work. Together, the
team integrated the represented expertise and experiences and conducted a synthesis
of academic publications, non-scholarly literature, and key informant interviews, as
well as an appraisal of the quality of each piece of evidence. The transdisciplinar-
ity of this project was further evidenced by the iterative and dynamic methodology
that guided the research process, namely a realist review (Pawson, 2006; Pawson,
Greenhalgh, Harvey, & Walshe, 2005) and narrative synthesis. In line with the
action-oriented nature of TD research, academic team members worked together
with community partners to translate findings into knowledge translation products
useful for community agencies’ advocacy and planning activities in the second stage
of the project.
[Multiple] Heads are Better than One: Strengths and Benefits
for TD Researchers
One of the most important benefits of taking a TD research approach is that it allows
investigators to examine the issue of inquiry from many different perspectives
and points of view. Such in-depth, day-to-day collaboration between individuals
with different expertise allows for frequent collisions between disciplines, expos-
ing assumptions, paradoxes, congruencies, and conflicts among them. While these
confrontations can be frustrating and may slow the pace of research, they are also
extremely beneficial to the research process and topic of inquiry as they often raise
2 Transdisciplinary Research for Urban Health Researchers 15
important issues that would otherwise have been missed. Specifically, by exploring
these paradoxes and conflicts as well as examining how information from diverse
disciplines intersects, new understandings of the phenomenon can arise and new
research directions can emerge (Ramadier, 2004).
Our case example, the ‘Realist Review’ of community-based services for home-
less adults experiencing concurrent mental health and substance use problems, is
a good example of the benefits of exploring paradoxes at the intersection of dis-
ciplines. The literature search yielded a group of 10 heterogeneous community
treatment programs for homeless persons experiencing concurrent disorders. Each
program contained many different treatment components in many different contexts
with variable success on mental health symptoms and substance use behaviours. A
recent quantitative systematic review of similar programs for people with concurrent
disorders found conflicting results between studies suggesting that the “resulting
heterogeneity limits comparability of studies, the potential for meta-analysis, and
the strength of inferential validity” (Drake, O’Neal, & Wallach, 2008, pp. 133–
134). While this particular review concluded that there was some evidence that three
service approaches were “probably” effective (namely group counselling, long-
term residential treatment, and contingency management), Drake and his colleagues
(2008) were unable to state why some of these programs were effective and some
were not.
In contrast, the TD Realist Review examining services for homeless adults expe-
riencing concurrent disorders was able to make sense of such conflicting information
by drawing on (a) epidemiological principles to appraise quantitative evidence,
(b) realist review principles to highlight the importance of context, (c) experien-
tial knowledge of service providers to ground the literature, and (d) a narrative
synthesis approach to closely analyze the content and effectiveness of the pro-
grams. This TD study by O’Campo et al. (2009) found that six program components
(e.g., the provision of housing, building quality relationships between provider and
client) appear to contribute to success in reducing mental health symptoms among
homeless persons with concurrent disorders.
Another benefit of TD research is that research teams have wider access to theory,
research literature, data collection methods, and analysis techniques thus equipping
them with more tools to study a particular phenomenon. This can assist team mem-
bers in asking clearer and more appropriate research questions and utilizing more
appropriate (and more creative) data collection and analysis techniques for the prob-
lem at hand. That is not to say that “more is always better” since the inclusion of
more literature, theory, methods, and other research tools can also be conflicting
and confusing. The challenge in TD research lies in finding the correct balance
and determining when information (e.g., as it relates to the conceptual framework
or topic of a study) has been satiated, a process that in our opinion can only suc-
cessfully take place through (multiple) discussions with team members representing
diverse areas of expertise.
In the Realist Review example, representation from different disciplines assisted
greatly in building a comprehensive list of search terms for the literature search,
identifying appropriate sources of non-academic literature, and in designing a
16 N. Schaefer-McDaniel and A.N. Scott
research question that was practical, viable, rigorous, and fulfilled a need of the
community. We also utilized epidemiology’s rigorous approach to quality appraisal
to evaluate the quality of the quantitative studies and capitalized on the strengths of
qualitative narrative synthesis to infer how and why certain programs worked.
Close collaboration among individuals with different areas of expertise can also
act as an inherent “quality control” mechanism and provide a support system
for team members. This is especially true when community members or service
providers are included in the research team. For example, community partners in the
Realist Review example were the first to point out to the academic team members
that one of the reviewed service approaches as it was described in the US literature
had little in comparison with how the same service program was being carried out in
Toronto, Canada. This information shaped how that service approach was described
in research bulletins and publications designed for Toronto policy makers to ensure
there were no misunderstandings.
A TD research team may also be better equipped to point out design flaws, threats
to feasibility or validity, and whether the work replicates a research agenda or find-
ing from another field of inquiry. Furthermore, the multitude of expertise involved in
TD collaboration helps team members anticipate practical, moral, and ethical prob-
lems that might arise in the course of the research and develop an appropriate course
of action. This is particularly important for work with marginalized or vulnerable
TD research also has the potential to increase resources for team members. For
example, academic partners can access funding options outside their disciplines by
partnering with experts from other areas. Similarly, partnering with academic mem-
bers can increase community partners’ resources by providing access to academic
libraries, academic publications, and research expertise. In the Realist Review case
study, the community partners were able to use results of the project and the exper-
tise of the academic partners in various ways to meet their organizational needs.
The team not only produced a community report that could be used for advocacy
and to seek program funding but also developed two policy bulletins and a protocol
for an internal evaluation for two of the community partner organizations to assess
the effectiveness of their concurrent disorder programs.
Another substantial benefit of TD research that includes community members is
that the community can influence the direction of the research project such that it
fulfils their needs. This can ensure that the research that is produced is of practical
use to the community and policy makers and thus has impact outside the academic
community. The inclusion of policy makers, community members, and researchers
with varying areas of expertise on the research team provides a natural vehicle for
dissemination of the findings and can enhance the credibility of the research in the
eyes of fellow policy makers and community members. Community members and
policy makers have the expertise and the connections to produce knowledge trans-
lation events that can impact news media. In the Realist Review project, community
members shaped the research question and gave continuous feedback as to the kind
of information that would be useful for them. Furthermore, because of the partner-
ship generated by the project, two community partners collaborated independently,
2 Transdisciplinary Research for Urban Health Researchers 17
outside the joint Realist Review project, to launch a policy bulletin on “Women and
Homelessness” (Street Health, 2008). They also organized a “speak-out” evening
where homeless women could speak with provincial officials about their concerns
and how poverty affects them. This event was videotaped and given to key pub-
lic officials along with copies of the bulletin, and the campaign made an impact
on news media (Monsebraaten, 2008). The ease with which the community orga-
nizations organized such a successful advocacy campaign impressed the partnering
academic members and was another demonstration of how academics can benefit
from community expertise.
Many Hands [Do Not] Make for Light Work: Challenges
for TD Researchers
Despite the many benefits associated with TD research, it is also a very labour-
intensive undertaking since it involves a great deal of negotiation and discussion in
order to bring together team members, their disciplines, and areas of knowledge.
This negotiation, if not handled carefully in an open and accepting environment,
can result in tension and possibly conflict. As Stokols (2006) suggests, TD research
“requires an ethic of resolute openness, tolerance, and respect toward perspectives
different from one’s own and a commitment to mutual learning and mediational
processes in which contrasting values and conflicts of interest are negotiated and
accepted, if not entirely resolved” (p. 68).
In this section, we discuss challenges associated with TD research in terms
of team composition and group dynamics as well as in relation to academic
Process Challenges
One of the first challenges associated with TD research deals with team composition
and structure. At the onset of TD collaboration, investigators might find themselves
pondering the following questions: How should team members come together? Who
should be invited to join the collaborative team? Which areas of expertise and expe-
rience need to be represented? Clearly, there is no absolute answer to any of these
questions as they are dependent upon a number of issues such as the topic of inquiry,
the financial support for the project, the physical location of team members, and
members’ interests and availability.
Once a team has been assembled, additional challenges well known to team
collaborations can quickly arise such as determining how decisions will be made,
agreeing on a research and action plan, as well as deciding how the project will
be managed and led. Bringing a diverse group of people together to work on the
same research problem automatically raises concerns related to group and power
dynamics. For example, team members might have varying priorities for research-
ing the particular issue and consequently advocate for diverging starting points and
18 N. Schaefer-McDaniel and A.N. Scott
directions of inquiry. Power struggles can also emerge if team members do not rec-
ognize other types of knowledge as valid or do not respect others’ worldviews and
epistemological paradigms (see Gray, 2008; O’Cathain, Murphy, & Nicholl, 2008).
Wallerstein (1999) recommends that in order to develop productive relationships in
team research, it is crucial for team members to reflect on their own positions of
power, privilege, background, and experience as these “characteristics inform our
ability to speak and interpret the world” (p. 49). Furthermore, Wallerstein and Duran
(2006) encourage team members to examine their own motivations for participation
as levels of participation often vary by degree of project ownership. O’Cathain et al.
(2008) and Wallerstein (1999) recommend discussing issues surrounding group and
power dynamics from the beginning as well as throughout the entire course of a
team project as group dynamics need to be carefully negotiated and time is required
to build trust and strong working relationships among team members.
We find that leadership is very important in mitigating, negotiating, and avoiding
the above-mentioned pitfalls in TD work. While each team will need to decide on
its own leadership and organizational structure and discuss what type of coordina-
tion would be most beneficial, in our experience, a good TD team leader is one who
is committed to the project and to the principles of equity and democratic decision
making; keeps the group on track, organized, and moving forward; and is comfort-
able mediating disagreements. Further, we find that good TD leaders view their role
as facilitating and supporting the will of the team, ‘leading from behind,’ rather than
authoritatively determining the direction of the team.
TD researchers need to be mindful of group dynamic issues and, at the onset
of a project, set an appropriate amount of time aside to ensure that careful plan-
ning and preparation can take place. A “Terms of Reference” agreement is a useful
tool that can help group collaborations overcome some of these challenges. Such
a document generally outlines project goals and objectives, guiding principles that
members agree to abide by (see Israel, Eng, Schulz, & Parker, 2005), team mem-
bers’ roles and responsibilities, and procedures for how decisions will be made. In
the Realist Review example, it took 2 months to develop and negotiate our Terms of
Reference. The group felt that taking the time to discuss this agreement was help-
ful in setting the tone for democratic group collaboration and served as a helpful
guide that could be referred to throughout the course of our research. Taking time at
the beginning of a joint collaboration ensures that team members understand each
others’ goals, expectations, and values regarding team work and collaboration and
prevents future misunderstanding and conflict. It is also noteworthy to keep in mind
that a “Terms of Reference” agreement does not need to be finalized at the onset of
a project. Rather, it can evolve over time as the team encounters new challenges or
Another challenge commonly associated with team research such as TD collab-
oration has to do with communication. For example, the use of academic language
(i.e., jargon) to dominate a conversation can exclude some members (e.g., commu-
nity team members, academics from different disciplines). This difficulty can also
arise when power is equally shared among team members: discipline-specific lan-
guage that might be natural and easily understood for some team members can be
2 Transdisciplinary Research for Urban Health Researchers 19
unintelligible to others. More dangerous, however, are words that have common
usage but very specific connotations within a particular discipline such as “bias” in
epidemiology, “political” in the qualitative traditions, or “theory.” In the Realist
Review project there were several heated discussions that were finally resolved
when we realized that team members were talking about the same issue but were
using different language to express themselves or were using the same language but
referring to different issues. Team members must be prepared to spend time learning
new vocabulary and concepts or relearning old ones so that all investigators share
the same understanding and meaning of the topic and issues at hand. Team mem-
bers should thus be on the alert for communication difficulties, pause and spend
the time to explore the meanings behind the words that are used, and ensure that
everyone understands each other. Building a new shared vocabulary can be a very
time-consuming and frustrating experience, and as Peter Smith (2007) reminds us,
“there are no benchmarks to indicate when a researcher has achieved sufficiently
familiarity with the other disciplines in a research team” (p. 163).
A similar challenge that can arise in TD collaboration relates to arriving at the
same understanding of what counts as evidence. Often, disciplines place empha-
sis on different concepts or aspects of (even shared) methodology. Team members
need to be sensitive to these concerns and should discuss openly which specific
methodologies, procedures, and findings will be considered valid, important, and
necessary for rigorous research. While this challenge can complicate the research
since not all team members may initially agree, it is essential that the team as a
whole comes to a joint decision in order to advance the process of research. For
example, in the Realist Review project, the epidemiologists were adamant about
reporting confidence intervals, power calculations, and detailed information regard-
ing study design and analysis, while the social scientists were less concerned with
power calculations and more concerned with the context of the research and the
interpretation of the findings. As a compromise, the team decided to place equal
emphasis on contextual and statistical information.
Academic Support Challenges
Aside from challenges related to group dynamics and team composition, academic
TD researchers may also struggle with academic realities as structural issues of
academia, publishing, and granting agencies make it more difficult for these types of
researchers to engage in TD collaboration. Specifically, universities and university-
based research institutions provide “extremely strong incentives to work within
an established discipline, using its established methodologies on problems that
are deemed important in the field” (Hildebrand-Zanki et al., 1998). Firstly, there
are often limited funds available for cross-disciplinary and TD collaboration, as
compared to the plethora of funding streams for unidisciplinary research. While
TD collaboration allows the team access to a greater number of funding agen-
cies, unidisciplinary-specific funding streams may not look kindly on the additional
20 N. Schaefer-McDaniel and A.N. Scott
time and costs of TD research teams (for instance, expenses to accommodate group
meetings and knowledge translation costs, see Chapter 8).
Secondly, in the current “publish or perish” academic climate, promotion and
tenure greatly depend on the candidate’s academic, peer-reviewed publication
record. However, TD work is very time consuming and often requires additional
projects that are not counted in the rubric for funding or tenure, such as writing
bulletins for policy makers, giving community presentations, or other knowledge-
translation activities. It is therefore not realistic for TD academic researchers to
produce as many academic publications as disciplinary-based researchers, yet many
academic departments and funding agencies do not have a mechanism to take these
additional activities into consideration.
Authorship is a prime example of this. Because TD research teams can be quite
large, the list of authors can be very long. In many academic traditions, the number
of authors and the order of authorship are used to judge the amount of involvement
and the amount of “ownership” an author had in a particular paper. Single-author
papers in the social sciences and the first or last author role in the medical sciences
are generally weighted more positively. However, academic researchers involved
in TD research can find themselves contributing more time and effort to these
types of publications compared to disciplinary publications without receiving sim-
ilar acknowledgement in the order and configuration of authorship. This can be
a disadvantage when funding agencies or university promotion bodies consider a
researcher’s publication record for career development. In order to legitimize such
cross-disciplinary collaborations in the eyes of academic institutions, we encourage
initiatives like those currently underway by the Community–Campus Partnership for
Health (CCPH) which seeks to transform academic–community collaborations in
the USA by addressing some of the challenges commonly faced by faculty engaged
in community-based research including issues related to faculty development, ade-
quate research dissemination, tenure, and promotion ( For
example, they recommend taking non-traditional publications such as technical and
non-peer-reviewed reports to community organizations as well as the overall devel-
opment of researchers themselves in terms of innovation and quality work into
consideration when reviewing tenure applications (see Jordan, 2006).
Finally, finding an appropriate venue to publish a TD research project can also
be a concern for researchers since many conventional, high-impact journals have a
strong disciplinary focus that may not welcome other types of research endeavours
including TD work (Smith, 2007). Furthermore, many of these conventional journals
have strict word limits that are often not sufficient for TD researchers to adequately
describe methods, process, and results of their TD projects making it thus chal-
lenging to reach the most appropriate audience. While a few specific TD academic
journals currently do exist (e.g., The International Journal of Transdisciplinary
Research,Journal of Transdisciplinary Environmental Studies), they tend to be very
topic specific, covering issues related to economics or environmental studies, for
example. With the increasing popularity of online journal subscriptions and the pos-
sibility of additional content available online, journals have the ability to allow for
more in-depth discussion of research issues, so we encourage journal editors as well
2 Transdisciplinary Research for Urban Health Researchers 21
as publishers to consider these suggestions to make TD research more accessible to
target audiences.
In this chapter, we drew upon our experiences as team members in a Realist Review
project to illustrate how combining and integrating various disciplines and per-
spectives in TD research can be a powerful tool for urban health researchers in
understanding complex problems. The Realist Review project (O’Campo et al.,
2009) benefited tremendously from the multitude of collaborators’ expertise in
defining the research question, selecting the appropriate review method, choosing
search terms for the literature search, and disseminating the research findings to a
broad audience.
By bringing various stakeholders together to work jointly on the same research
question, TD researchers have access to greater resources and research tools and
are more likely to develop a more complete understanding of the issue at hand.
As with all types of team collaborations, this approach can also pose challenges
including longer time investments, publication concerns, and issues related to group
and power dynamics. However, given the complex nature of many urban health
issues, we believe that finding successful solutions to these problems is beyond the
scope of any one discipline. TD research with its focus on social change and action
can thus be an appropriate approach for the study of urban health problems.
Drake, R. E., O’Neal, E. L., & Wallach, M. A. (2008). A systematic review of psychoso-
cial research on psychosocial interventions for people with co-occurring severe mental and
substance use disorders. Journal of Substance Abuse Treatment, 34, 123–138.
Gray, B. (2008). Enhancing transdisciplinary research through collaborative leadership. American
Journal of Preventive Medicine, 35(2S),S124–S132.
Hildebrand-Zanki, S., Cohen, L., Perkins, K., Prager, D., Stokols, D., & Turkkan, J. (1998). Report
from the working groups of the youth tobacco prevention initiative. Washington, DC: Center
for Advancement of Health.
Israel, B. A., Eng, E., Schulz, A. J., & Parker, E. A. (2005). Introduction to methods in community-
based participatory research for health. In B. A. Israel, E. Eng, A. J. Schulz, & E. A.
Parker (Eds.), Methods in community-based participatory research for health (pp. 3–26). San
Francisco, CA: Jossey-Bass.
Jordan, C. (2006). Developing criteria for review of community-engaged scholars for promo-
tion or tenure. Report of the Community-Engaged Scholarship for Health Collaborative for
the Community–Campus Partnership for Health (CCPH). Retrieved February, 27 2009, from
Monsebraaten, L. (2008, June 23). Homeless women in peril; groundbreaking Toronto survey finds
they endure more sex assaults and mental illnesses than men. Toronto Star,p.A1.
O’Campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. (2009).
Community-based services for homeless adults experiencing concurrent mental health and sub-
stance use disorders: A realist approach to synthesizing evidence. Journal of Urban Health,
86(6), 965–989.
22 N. Schaefer-McDaniel and A.N. Scott
O’Cathain, A., Murphy, E., & Nicholl, J. (2008). Multidisciplinary, interdisciplinary, or dys-
functional? Team working in mixed-methods research. Qualitative Health Research, 18(11),
Pawson, R. (2006). Evidence-based policy: A realist perspective. London, UK: Sage Publications.
Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005). Realist review: A new method
of systematic review designed for complex policy interventions. Journal of Health Services
Research and Policy, 10(S1), 21–34.
Ramadier, T. (2004). Transdisciplinarity and its challenges: The case of urban studies. Futures, 36,
Smith, P. M. (2007). A transdisciplinary approach to research on work and health: What is it, what
could it contribute, and what are the challenges? Critical Public Health, 17(2), 159–169.
Stokols, D. (2006). Towards a science of transdisciplinary action research. American Journal of
Community Psychology,38, 63–77.
Street Health. (2008, June). The Street Health report 2007, Research bulletin #2: Women &
homelessness. Retrieved October 17, 2008, from Street Health, Toronto, ON Web site:
Wallerstein, N. (1999). Power between evaluator and community: Research relationships within
New Mexico’s healthier communities. Social Science and Medicine, 49, 39–53.
Wallerstein, N. B., & Duran, B. D. (2006). Using community-based participatory research to
address health disparities. Health Promotion Practice, 7(3), 312–323.
Chapter 3
In Search of Empowering Health Research
for Marginalized Populations in Urban Settings:
The Value of a Transdisciplinary Approach
Maritt Kirst, Jason Altenberg, and Raffi Balian
The urban environment has become an important determinant of health in the
context of increased urbanization over the last century (Freudenberg, Galea, &
Vlahov, 2006; Galea & Vlahov, 2005). Along with a growth in urbanization has
come increased socio-economic disparities and marginalization among populations
living in many urban centres (O’Campo & Yonas, 2005). Social, political and eco-
nomic processes have led to the unequal development of urban areas and health
inequities in these environments. Such health inequities place socio-economically
disadvantaged and marginalized populations (i.e. individuals experiencing stigma,
social exclusion, a lack of economic resources) at greater risk of morbidity and
mortality, and lower quality of life (Geronimus, 2000; World Health Organization
Knowledge Network on Urban Settings (WHO KNUS), 2008). The social and eco-
nomic conditions that lead to the poor health of these populations contribute to
feelings of powerlessness and an inability to gain control over life circumstances,
making powerlessness an important social determinant of health (Wallerstein, 2002;
WHO KNUS, 2008).
The empowerment of the individual and the development of a sense of control
over his/her health have thus been identified as crucial steps in addressing health
inequities (Marmot, 2006; Pridmore, Thomas, Havemann, Sapag, & Wood, 2007).
However, there is also a need for social interventions that seek to reduce health
inequities in urban settings through the building of skills and experiences with
which to assist marginalized populations in gaining greater control over their lives
(Harpham, 2009; Wallerstein, 1999; WHO KNUS, 2008).
A growing body of research is focusing on the social and environmental factors
that contribute to the poor health of socio-economically marginalized popula-
tions (Geronimus, 2000; Harpham, 2009; WHO KNUS, 2008). Health research
approaches that involve the participation of marginalized populations in various
aspects of the research process can facilitate access to knowledge, empowerment
and capacity-building to affect social change with which to improve health in their
M. Kirst (B)
Ontario Tobacco Research Unit, Dalla Lana School of Public Health, 155 College St., 5th Floor,
M5T 3M7 Toronto, Ontario, Canada
M.Kirstetal.(eds.),Converging Disciplines, DOI 10.1007/978-1-4419-6330-7_3,
Springer Science+Business Media, LLC 2011
24 M.Kirstetal.
communities (Wallerstein, 1999). In this chapter, we will discuss how collaborative,
transdisciplinary (TD) research methods, with careful attention to building equi-
table research partnerships, present an important opportunity to build capacity
to empower the broader community through the production of actionable health
research. In our discussion, we draw on examples from research projects exploring
health behaviours of marginalized drug users and related harm reduction program-
ming. The examples represent the journey towards TD research taken by a working
group engaged in advocacy and research on health risks and harm reduction prac-
tices among illicit drug users in Toronto, Canada, in which some of the authors
of this chapter are actively involved (Balian and Altenberg). These examples illus-
trate important features of TD health research well suited to working with and for
marginalized populations.
Considering “Transdisciplinarity”
In recent years, it has been recognized that determinants of urban health must
be studied in a multisectoral and multi-level way in order to effectively examine
their complexity and subsequently problem solve (Harpham, 2009). Furthermore,
translating research into practice is an ongoing challenge for research addressing
health inequities in urban settings (Harpham, 2009; Roche, 2008; Schulz, Krieger,
& Galea, 2002; WHO KNUS, 2008). Research of this nature tends to produce evi-
dence that is accessible primarily to the academic sector and is not easily translatable
into social action at community and/or policy levels (Roche, 2008). A TD approach
satisfies the growing need for multi-level and multisectoral urban health research as
it brings together various disciplines, sectors, perspectives, and resources, and thus
facilitates the examination of the problem and the ongoing translation of findings
into community- and policy-relevant steps for action.
Nevertheless, while the principles of TD research embrace the involvement of
various stakeholders (e.g. academics, service providers, service consumers, policy-
makers) and the types of knowledge they may provide (e.g. academic knowledge,
lived experience, policy expertise), the term “trans-disciplinary” implies a primary
focus on the contributions of academic disciplines to the research. This is somewhat
counterintuitive to its goal of the equitable integration of various types of knowl-
edge into research and to not privilege one discipline or type of knowledge above
others. Such an emphasis on contributions of academic disciplines could possibly
undermine research of this nature and imply a “credentialist” approach in which
individuals who do not have academic training in a discipline, such as community
members with lived experience of a particular phenomenon under investigation, are
not welcome or their contributions will not be as valued or respected in the research
process as someone with academic training (Travers et al., 2008). Perhaps the term
“trans-disciplinary” should be revised to foster and guarantee more inclusivity in
order to live up to its mandate to bring together various perspectives surrounding
complex problems and move beyond traditional research methods and approaches
with which to study and solve such problems.
3 The Value of a Transdisciplinary Approach 25
Key Components of the TD Approach and Their Contribution
to Research on the Health of Marginalized Populations
Despite such terminological limitations, there are several components of a TD
research approach that can facilitate empowerment of marginalized populations with
respect to health. In this section, we illustrate this argument through a broader, the-
oretical discussion of key components of the TD research approach, specifically
drawing on qualities of community-based research (CBR) methods. Then, the dis-
cussion shifts to the first-hand experiences of co-authors Raffi Balian and Jason
Altenberg in conducting community-based research on drug use-related risks and
harm reduction programming needs in Toronto, Canada. Their experiences illustrate
the importance of these components to the production of actionable health research
and also present practical challenges in this process.
Collaborative, Participatory Methods in the Production
of Cross-Sectoral Knowledge
A key component of TD research is that it involves collaboration not only across
academic disciplines but with non-academic community stakeholders and policy-
makers as well (Balsiger, 2004; Stokols, 2006; Wickson, Carew, & Russell, 2006).
This type of intersectoral collaboration facilitates the action-oriented nature of TD
research, whereby the emphasis of academic collaborations on research and the
emphasis of community groups on community action are linked. Such a linkage
facilitates the building of mastery and empowerment of stakeholders and partic-
ipants through raised awareness of the problem, knowledge sharing, and skills
development and, subsequently, the more effective, direct translation of research
findings into public policies (Stokols, 2006).
Empowerment through the collaborative dimension of the TD approach is con-
sistent and aligned with the principles and methods of CBR. The compatibility of
the TD approach and CBR methods is evident in CBR’s definition as “system-
atic inquiry, with the participation of those affected by the issue being studied, for
the purposes of education and taking action or affecting social change” (Green &
Mercer cited in Leung, Yen, & Minkler, 2004, p. 504). CBR methods can empower
marginalized populations through the involvement of community partners and those
affected by the issue of study in all aspects of the research process, including
conceptualization, data collection, analysis, interpretation, and ongoing knowledge
translation. In theory, this involvement creates power-sharing between academics
and community members, thus shifting authority over the research process away
from experts and allowing for equal ownership of the research and subsequent find-
ings. Collaboration between academics and community participants in CBR assists
in identifying the social factors that affect the health of these communities and
promotes building on community member/participant strengths and knowledge to
effectively address these factors (Schulz et al., 2002). This results in findings that
26 M.Kirstetal.
are more responsive, “accessible, understandable, and relevant” to the interests and
needs of participants and thus are more translatable into community-level social
change (Leung, Yen, & Minkler, 2004). Furthermore, involvement of community
members in all aspects of the research process validates their lived experience,
which can be further motivation to affect social change.
However, the process of academic and community collaborations in the con-
text of TD and CBR research can be challenging. A debate has emerged as to
whether there is a disjuncture between CBR theory and practice in the sense that,
in reality, the extent of community involvement in all stages of the research process
may be less than desired. A recent analysis of CBR experiences in Canada showed
that involvement of academic researchers and service providers was high in almost
all stages of the research, whereas community members were the least engaged
(Flicker, Savan, Mildenberger, & Kolenda, 2008). A low level of involvement of
community members in CBR may relate to power imbalances and differing research
agendas between collaborators. For instance, academic researchers and community
members often have different agendas in that researchers seek to gain knowledge to
problem solve on a broad level whereas community members typically seek to gain
skills in order to problem solve within their local communities. In the process of
partnering, academic researchers, equipped with research skills and funding, may
take on the leadership role and may only consult community members at the begin-
ning and/or end of the project, and/or may not present results to community mem-
bers in an accessible way that is useful for the local community (Wallerstein, 1999).
In order for a TD approach that incorporates CBR methods to be empower-
ing, it is extremely important that partnerships between the various sectors be
equitable and negotiable in order to ensure that community partners who repre-
sent marginalized populations have a voice to advance the research endeavour
(Benoit, Jansson, Millar, & Phillips, 2005). Without such equitable partnerships,
the research collaboration can suffer from mistrust between partners and/or per-
ceptions of “credentialism” and/or “tokenism”, making the research findings less
relevant and credible within the community setting. The consequences may in turn
lead to lowered capacity within the community to address the complex health issue
of study and create mistrust towards future research (Roche, 2008; Travers et al.,
2008; Wallerstein, 1999).
Integration of Quantitative and Qualitative Methods
A TD approach nurtures the integration of various research methods derived from
different disciplines (Wickson et al., 2006). The integration of quantitative and
qualitative methods is particularly important for empowerment in research with
marginalized populations. The inclusion of quantitative data can provide informa-
tion on the extent to which social factors influence the health and health behaviours
of marginalized groups. The inclusion of qualitative data can complement the quan-
titative findings and also fill gaps in explanations left by the quantitative data
through the elucidation of rich, contextual information. The inclusion of both types
3 The Value of a Transdisciplinary Approach 27
of methods and subsequent data, thus, allows for a more complete interpretation
and explanation of study findings (Tolomiczenko & Goering, 2000). The elicita-
tion of the lived experience of community members is an important inclusion in
research on health inequities as it assists public health and epidemiological research
in moving beyond its positivistic focus. It does so by situating individuals in the
social contexts in which health inequities arise and by elucidating the meanings
that individuals “attach to their experience of places and how this shapes social
action...” (Popay, Williams, Thomas, & Gatrell, 1998, p. 636). The incorporation
of qualitative methods and data thus provide greater explanatory power regarding
the causes of health inequities and can facilitate greater understanding of the rela-
tionships between human agency and social structures that produce these inequities
(Popay et al., 1998).
Furthermore, the inclusion of qualitative methods and data provides marginalized
populations with a voice to express their stories and to capture their lived experience
in meaningful detail. Being provided the opportunity to tell their stories can be an
empowering experience for disadvantaged groups who have experienced adversity
in life and are likely underserved and unheard with respect to health issues. The rich,
detailed data elicited from qualitative, open-ended questions may also resonate with
service providers, who may need and appreciate this information in more effectively
meeting client health needs (Tolomiczenko & Goering, 2000).
In order to allow for the empowerment of marginalized populations within the con-
text of the TD research experience, reflexivity, a process in which the researcher
reflects and questions the personal experiences that influence his/her interpretations
of the data, is an important, yet challenging, component. Given the diverse skills and
experiences comprised in the TD research team, issues with power dynamics will
likely arise. In order to facilitate collaboration in light of such dynamics, it is recom-
mended in TD work that the researchers become engaged and embedded with the
research problem in order to gain an in-depth understanding. To achieve such a level
of integration, it is important for the researcher to examine how his/her own posi-
tion, beliefs, and experiences influence the research process (Wickson et al., 2006).
Access to lay knowledge through collaboration with practitioners and marginalized
groups in the community can facilitate such embeddedness. For researchers who are
‘outsiders’ to the groups of study, it is through this reflexivity that they can achieve a
greater understanding of the lived experiences of these groups. Such a reflexive pro-
cess may also facilitate a paradigm shift away from a predominant focus on risk and
illness in social epidemiological research with marginalized populations towards an
applied research approach focused on resiliency that can promote and build capacity
for improvements in health among these groups (Harpham, 2009).
Academic and community members not only enter into the research collabora-
tion with different experiences, but, as mentioned earlier, they enter with different
research agendas with respect to purpose and outcomes. It is therefore extremely
28 M.Kirstetal.
important for the integrity of the research process that partners acknowledge and
understand these differentials by reflecting on the meaning of participation (i.e.
‘who’ is participating, and why?) and how differing social positions or power
dynamics may affect the process of participation (Wallerstein, 1999).
The Road to TD Research: Examples of the Evolution of Harm
Reduction Research in Southeast Toronto
Injection drug and crack cocaine users are at risk of several health problems includ-
ing substance abuse or dependence, HIV, hepatitis B and C, and other infectious
diseases; endocarditis, skin abscess, mental health problems; and fatal and non-fatal
overdoses (Fischer, Pouris, Cruz et al. 2008; Des Jarlais, Diaz, Perlis et al., 2003;
Wong, 2001). Substance use and abuse are complex health issues, highly influenced
by social, political, epidemiological, psychological, geographic and economic pro-
cesses and determinants (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005).
Harm reduction refers to a set of public health policies and programs that seek
to reduce the risks and harms associated with injection drug and other types of
substance use by providing drug users with new drug use equipment, condoms,
information, and support with which to use drugs more safely, without requiring
cessation of use (Ritter & Cameron, 2006).
The journey towards TD research on drug use for co-authors Jason Altenberg
and Raffi Balian began in the mid-1990s in their work as harm reduction ser-
vice providers and advocates in Southeast Toronto, Canada. Here, we present
this journey through a discussion of their involvement and experiences with three
research projects – one unidisciplinary, one interdisciplinary and one TD – on drug
use-related risks and harm reduction.
Experiences with Unidisciplinary Harm Reduction Research
In the fall of 1994, concerned with the number of crack cocaine users in his
constituency, a Toronto city councillor asked the public health department to do
something about the increasing crack cocaine-use problem. The request went to the
needle exchange program at the public health department, and its executive director
called a group of workers together, including Balian, to see if there was anything
they could do to address the growing problem. The initial meeting at the public
health department took place just as crack cocaine was taking hold of Toronto’s most
marginalized drug users. At the conclusion of the meeting, the attendees agreed to
form a committee to look into a variety of ways to tackle the issue in downtown
Their first task was to examine the severity of the problem. For this, a question-
naire was devised to be distributed by harm-reduction agencies and organizations
that worked with crack cocaine users. Crack users all over the city of Toronto
responded to the questionnaires and when the responses were eventually examined,1
3 The Value of a Transdisciplinary Approach 29
a disturbing image of the issue began to develop. Almost half of the respondents
admitted to having injected crack at least once. Another worrisome factor was the
extent of lip burns and mouth sores experienced among crack smokers combined
with the liberal sharing of smoking equipment among the community, posing a risk
for the spread of infectious diseases. During that period, harm reduction strategies
for crack use were not available, and thus, the crack-using community was vulnera-
ble to harms associated with drug-use equipment sharing. Finally, almost one-third
of female respondents reported that they had been sexually assaulted after having
used crack.
Next, the committee explored the potential of crack pipe distribution as a harm
reduction intervention for crack cocaine users in order to reduce the risk of contract-
ing infectious diseases through crack pipe sharing. The working group developed a
plan to collect used pipes from crack users and test them for possible HIV, hepatitis,
or tuberculosis contamination. Unfortunately, the project could not secure funding
due to scepticism regarding the correlation between HIV and crack pipe sharing and
the ability of community members to produce credible research; the project was
eventually laid to rest. Balian and his partner at the time spearheaded the formation
of an advocacy group comprising drug users, called the Illicit Drug Users’ Union of
Toronto (iDUUT), in response to the lack of accountability towards illicit drug users
in general and towards crack users in particular, who, hitherto, had been voiceless.
Despite a lack of research evidence and support due to opinions that the dis-
tribution of crack pipes was illegal, the advocacy group developed “safer crack
stem kits”, consisting of a clean, glass crack stem/tube and other tools to use crack
safely, and began distributing them to crack users. Because of the paucity of infor-
mation regarding crack use and crack users in Toronto, the group also decided to
gather as much information as possible during the safer crack stem kit distribution
project and began further survey data collection on crack-use patterns and related
risk behaviours among crack users. The results of the surveys conducted by iDUUT
identified the increased use of crack by marginalized populations in Toronto and
frequent crack pipe sharing and other health risk behaviour among these groups.
The results were presented at a press conference and were shared with community
agencies, the public health department and members of the research/academic com-
munity. The results were regarded by many, including epidemiologists, as some of
the first and best data obtained from street level crack users at the time.
Due to iDUUT’s persistence in approaching the academic research community
for support, an academic research team eventually began to take interest and pro-
posed a study to examine used crack stems as a potential vector for infectious disease
transmission. Despite mobilization and the collection of valuable research data on
the problem by community advocates for years, academic credentials emerged as
an important issue for policy change, as it was only once academic researchers
were engaged in investigating the problem and had released their findings that the
safer crack stem kit distribution program became sustainable through the receipt of
municipal and provincial funding. The safer crack kit distribution program gained
official support from the city in 2005, more than 10 years after a local politician
30 M.Kirstetal.
raised concern over the problem and community advocates mobilized and began
their harm reduction work.
Without this first piece of community action/research, harm reduction pro-
grams could not have begun to develop pragmatic strategies (i.e. safer consumption
devices) to engage crack cocaine users. A recent evaluation study of a safer crack
pipe distribution program in Ottawa has shown that this type of program can reduce
the risk of transmission of HIV, hepatitis C and other infectious diseases among
drug users (Leonard et al., 2008). This example illustrates that, despite numerous
attempts of community members to bring about change through collaborated efforts,
ultimately the lack of partnership among community, policy-makers and researchers
led to a delay in implementation and benefits of an important public health initiative
for marginalized populations. User/activist knowledge and empowerment to mobi-
lize, exemplified in iDUUT’s efforts to collect data and initiate safer crack stem
distribution, were an important precursor for harm reduction programs and aca-
demic researchers to access and further mobilize that community surrounding this
issue. Since that time, a relationship among the crack-user community, health ser-
vices and the research community in Toronto has been built thus demonstrating the
need for these key stakeholders to be sitting at the research table at the same time
and throughout all stages of the research process.
Experiences with Interdisciplinary Harm Reduction Research
In 2003, equipped with lessons learned from the previous crack cocaine risks
and harm reduction research initiative, Balian, then the program coordinator of
COUNTERfit, a harm reduction service program in the South Riverdale Community
Health Centre (SRCHC) located in Southeast Toronto, and Altenberg, director at
Alternatives East End Counselling Services at the time, partnered with two sociolo-
gists at the University of Toronto3to conduct community-based, participatory action
research (PAR) to explore the integration of harm reduction and mental health ser-
vices. The question of integrating harm reduction and mental health services arose
from an active partnership between COUNTERfit and Alternatives and as a result
of successful collaboration in service delivery. The mental health service system
in the province of Ontario was being reviewed at the time. The need to integrate
mental health and substance use programs was an established “good practice” from
a policy perspective, given increasing awareness of the challenges experienced by
individuals with concurrent mental health and substance use disorders in navigat-
ing separate mental health and substance use treatment systems (Altenberg, Balian,
Lunansky, Magee, & Welsh, 2004). The details of service integration were still being
developed in a variety of settings.
Balian and Altenberg were concerned that the needs of many individuals expe-
riencing concurrent disorders would only be addressed successfully via integrated
strategies and programs that also included an integration of harm reduction prin-
ciples and practices. They wanted to use their experience to impact practice at
both the local and provincial levels. Balian and Altenberg approached the academic
3 The Value of a Transdisciplinary Approach 31
researchers for guidance on how to conduct research with this purpose in mind.
The PAR qualitative study sought to explore, through a series of focus groups with
service providers and service users, how integrated mental health and substance
use services might help reduce mental and physical health issues and social prob-
lems among drug users in Southeast Toronto (Altenberg et al., 2004). Based on
themes generated from the focus groups, the study yielded a number of recom-
mendations for mental health and substance use services, including: the integration
of harm reduction and mental health services to reduce stigma towards drug users
and increased access to treatment; the inclusion of service components such as
community-based outreach and flexible hours; the encouragement of staff qualities
such as non-judgemental attitudes and lived experience; the development of harm
reduction-based counselling for service users; capacity development for other com-
munity programs to incorporate a harm reduction perspective into service provision
(Altenberg et al., 2004).
Upon reflection, members of the research team saw many advantages to the part-
nership. Service users were an integral part of the research process, building research
skills by informing research materials and facilitating focus groups. The experi-
ence also required the negotiation by partners of differing experiences and agendas
affecting the research process. Altenberg notes:
The process of conducting research, collecting and analysing data forced us to come to
terms with the difference between our beliefs and experiences and those of service users and
other providers who had experiences with mental health, substance use, and harm reduction
services. Our academic partners, while sharing our goal to improve services for people
with mental health and harm reduction needs, did not have the conviction derived from
experience and approached the data with a different lens than ours as service providers
and program managers. What we came to the research with as assumptions of truth, our
partners questioned. In some way it felt as if our priority was particular outcomes and theirs
was the integrity of the process. In holding us to that need for “validity,” we came to more
nuanced understandings of the needs of the community we served and forced us to accept,
what seemed to us at the time and still seem to be, contradictions in what service users
and providers found most useful in addressing mental health and substance use issues (i.e.,
using a harm reduction perspective in one service but not always in the other).
Since the completion of this study, an Urban Health Team at SRCHC was cre-
ated that addresses the specific needs of drug users and those with mental health
issues. This program was informed by the recommendations that emerged from
the project in the sense that unique integrated mental health and harm reduction
services have been created, incorporating staff positions for individuals with lived
experience. The process of PAR and interdisciplinary research has had an impact on
the Team’s vision for the services they provide. It has impacted how they approach
interdisciplinary work in that they acknowledge and expect the research team to see
things from diverse perspectives, to challenge each other, and in so doing to improve
the breadth and depth of how health problems and issues are approached.
32 M.Kirstetal.
Experiences with TD Harm Reduction Research
A TD research approach can contribute to the evolution and advancement of theory
that has the potential, when set into policy, to build capacity within marginalized
communities to improve health. As discussed earlier, injection drug use is a complex
health issue that is affected by social, political, epidemiological, psychological, geo-
graphic and economic processes (Rhodes et al., 2005). Such complex issues demand
a research approach that considers the impact of all of these factors on the health
behaviours and outcomes of drug users. Interest in the use of a TD approach is
growing in the addiction research field (Abrams, 2006; Sussman, Stacy, Johnson,
Pentz, & Robertson, 2004), as the approach facilitates the merging of methods and
multiple, relevant perspectives in the exploration of the various intersecting factors
that affect substance use and abuse.
Informed by the benefits and challenges of previous unidisciplinary and inter-
disciplinary research collaborations, Balian and Altenberg became involved as
partners in a national, multi-site surveillance project regarding the risk behaviours
of injection drug users in Canada. The project sought to increase under-
standing of the HIV epidemic among injection drug user populations through
improved surveillance using epidemiological, socio-behavioural, ethnographic and
community-based research (Public Health Agency of Canada, 2006). The project
established a national surveillance system to monitor injection drug use (IDU)-
related risk behaviours to inform provincial and municipal program planning and
The project involved a multi-site team of epidemiologists, physicians, social
epidemiologists, public health researchers, community harm reduction program
staff, drug users and policy-makers. Each of the seven sites had a lead researcher,
and each site was encouraged to create local research questions specific to their
particular region. In Toronto, the principal investigator worked with local stake-
holders, including service providers, drug users and policy-makers, to formulate
research questions relevant to drug-use trends and complex service needs within the
Toronto context. Interviewers included individuals with lived experience of injec-
tion drug use and were trained on all aspects of the study protocol (Public Health
Agency of Canada, 2006). Knowledge translation occurred on an ongoing basis as
reports were developed for data specific to each city and each participating site.
These results were shared with the sites in aggregate form to provide information
on national trends in addition to site specific reports. The efforts of the research
team to provide both national and local data on various factors that contribute to
IDU-related risk behaviour was a reflection of both a respectful TD process and
an understanding of the diverse needs of the research participants. The project
honoured the pragmatic needs of the participating community harm reduction pro-
grams and recognized that “integrated knowledge translation”, a key component of
a TD approach involving the ongoing sharing of study findings with stakeholders
(see Chapter 9 for more information), could have a direct impact on program-
ming. The project was truly TD as the process involved respectful partnerships
3 The Value of a Transdisciplinary Approach 33
involving input and involvement of all stakeholders throughout the life of the
project, and wide dissemination of findings.
Furthermore, the project facilitated significant capacity-building at the commu-
nity level necessary to improve harm reduction programming provision and uptake.
The SRCHC used the project’s site-specific data to inform a wide range of organiza-
tional and programming decisions. The site-specific data confirmed suspicions that
HIV was exceptionally low in prevalence among drug users in the community served
by SRCHC and COUNTERfit. Service providers at the SRCHC were encouraged by
these findings and felt that they suggested that their harm reduction program model
was effective in maintaining low HIV rates. Hepatitis C virus (HCV) rates, however,
were substantially higher among IDUs from all programs and all sites. The project
reports stimulated mobilization and development which has led to the creation of a
program that offers a unique access point to HCV education, support and treatment
for illicit drug users in a community setting. This programming has filled a service
gap for the drug-using population in Toronto, who have previously received limited
access to HCV treatment, related education or support under the assumption that
the chaotic lifestyles of drug users would contribute to low adherence to the difficult
HCV treatment regimen (Edlin et al., 2001; Grebeley et al., 2007).
Data from the project also confirmed that the proportion of women accessing
harm reduction programs was substantially lower than men. This informed another
research project examining the specific harm reduction programming experiences
of women and men with the intent to develop a specific harm reduction program for
women. This project in turn led to the development of a permanent women’s harm
reduction program at SRCHC. Drug users continue to be involved in all aspects of
the women’s harm reduction program development, implementation, and evaluation.
This involvement can facilitate empowerment at both individual and community
levels. At the individual level, the experiences of drug users are valued and acted
upon. This in turn can empower the larger community of drug users with respect to
adoption of harm reduction practices through the validation of lived experience and
the provision of services that are tailored to their needs.
TD research in an ideal sense should be research that is taken up and applied
in policy due to the diverse partners involved in the research enterprise. It should
also be equally focused on the needs of all partners. This project is illustra-
tive of the ability of a TD team of academics, service providers, service users
and policy-makers to effectively move research into practice through the quick
uptake of findings into community program planning for a complex health problem.
The project exemplifies the necessity of equitable participation by all stakehold-
ers in research design, in posing relevant research questions, capacity-building
within the affected community, and ongoing access to relevant data with which
to make TD health research most actionable. It also demonstrates the importance
of a willingness on the part of academic partners to support the needs of com-
munities and programs and a reciprocal responsibility on the part of community
partners to support meaningful access to community resources, knowledge and
34 M.Kirstetal.
Recommendations for the Implementation of Empowering
and Actionable TD Research for Marginalized Populations
Based on our theoretical and practical discussions, the TD research approach has
many benefits and can potentially empower marginalized populations in various
ways. The merging of multiple perspectives and methods in order to explore and
address complicated health conditions with multiple antecedents and consequences
can contribute to increased explanatory power of findings and inform the develop-
ment of appropriate interventions. Based on the authors’ experiences working in
harm reduction service provision and/or research, we take this opportunity to make
some recommendations for the production of empowering and actionable TD health
research for marginalized populations:
(1) Community member knowledge is a necessary component in all stages of the
TD health research process. In order to begin to effectively research and under-
stand the complex health problems that affect marginalized populations, the
harnessing of local knowledge from experts with lived experience is impera-
tive (Roche, 2008). Furthermore, researchers need access to local populations
in order to identify appropriate research questions and methods. Research part-
nerships must be equitable in order to facilitate working relationships between
academic researchers and community members in light of power imbalances,
differing agendas and potential mistrust. Furthermore, without inclusiveness,
equitable community-level involvement and support for the project, it may
be difficult to recruit members of the marginalized community affected, who
are often difficult to reach, as research participants. In order for TD health
research to problem solve for marginalized populations, capacity within the
affected community must be built to use findings to raise awareness of the
health problem and develop interventions to address the problem (Benoit et al.,
2005). Essentially, involvement of community at all of these stages serves
to increase explanatory power and the capacity for action from the research
(2) As our examples have illustrated, there should be willingness to collaborate
and trust among all research partners in order to facilitate the balancing of
power and arrival at equitable involvement of community in all research stages.
Partners should take the time to first consult with all prospective team members
in order to ensure that they will be a good fit, thus contributing to the fruit-
fulness of the collaboration. They must also focus on building trust in order to
avoid commonly reported problems in CBR of perceptions of “credentialism”
and feelings of “tokenistic” involvement by community partners on the research
team (Roche, 2008; Travers et al., 2008). If community partners do not feel that
their experiences are valued and are only included in selected aspects of the
research, this will erode the empowerment and capacity-building component
of the research and diminish the research team’s ability to produce actionable
findings with which to improve the health of marginalized groups. Tools such as
“Terms of Reference” that outline roles, responsibilities and terms of conduct
3 The Value of a Transdisciplinary Approach 35
for all members of the research team can be useful to help build trust and ensure
a respectful research partnership.
(3) An important part of trust building is reflexivity with respect to each partner’s
social position and the understanding that academic and community partners
may have differing agendas with respect to the purpose and outcomes of the
research (Benoit et al., 2005; Wallerstein, 1999). As exemplified in the PAR
project on concurrent disorders, the research team recognized that they had
differing research agendas but were open to learning from the different per-
spectives and knowledge each brought to the project with respect to goals and
outcomes. Only if partners are aware of and willing to negotiate these differing
agendas, will harm to the research and capacity-building processes be avoided.
(4) Finally, there needs to be greater clarity regarding the empowerment and
capacity-building goals of TD research projects. Such clarity regarding how
marginalized populations want to and will be involved in all stages of the
research (e.g. will peer researchers be trained and employed to collect data,
will individuals with lived experience be involved in an advisory panel inform-
ing all stages, will participatory methods be used whereby research participants
generate and analyze the data and disseminate findings, or all of the above?)
and how empowerment and capacity-building at the broader community level
will be sustained once the research project ends, can guide the realization of
empowerment goals through TD research.
The key to the production of empowering and actionable TD health research
for marginalized populations lies in the level of inclusiveness of the research pro-
cess. Representatives of the affected community should participate in all aspects of
the research process: conceptualization, data collection, analysis, interpretation and
ongoing knowledge translation. However, throughout this process the research team
must be cognizant of power dynamics and the needs of all partners (Roche, 2008).
Particular focus should be placed on the needs of community partners in order to
ensure the relevance of the data collected with which to understand the complex
health problems in their local communities. This focus will also serve to promote
engagement in future research and program planning that will generate capac-
ity building to develop solutions to the complex health problems of marginalized
populations in urban settings.
Acknowledgements The authors would like to thank Dr. Peggy Millson, Dr. Sandy Welsh, Dr.
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Part II
Examples of Transdisciplinary Research
Chapter 4
Reducing Health Disparities Experienced
by Refugees Resettled in Urban Areas:
A Community-Based Transdisciplinary
Intervention Model
Jessica R. Goodkind, Ann Githinji, and Brian Isakson
“Social justice is a matter of life and death. It affects the way
people live, their consequent chance of illness, and their risk of
premature death.”
– WHO Commission on Social Determinants of Health, 2008
There is a growing recognition that social inequities in education, housing, employ-
ment, health care, safety, resources, money, and power contribute significantly to
increasing health disparities globally, within countries, and even within specific
urban environments. Thus, to promote health and well-being for all people, the
World Health Organization recommends improving daily living conditions, measur-
ing and understanding problems of health inequity, assessing the impact of action
to address these problems, and ensuring equitable distribution of money, power, and
resources (CSDH, 2008). Among the diverse populations that bear the burden of
social inequities and health disparities are the increasing numbers of refugees and
immigrants settling in urban areas. These newcomers often have higher rates of dis-
tress, limited material resources, lingering physical ailments, and loss of meaningful
social roles and support, all of which are often compounded by racism, xenophobia,
other forms of discrimination, and marginalization of their cultural practices.
This chapter presents a case study of the Refugee Well-being Project, a transdis-
ciplinary (TD) research effort that has the specific goal of promoting social justice
and reducing health disparities experienced by refugee families in urban areas in
the USA. The project involves the development, implementation, and evaluation of
an innovative mental health intervention that brings together refugees and under-
graduate students to engage in mutual learning and the mobilization of community
resources. After describing the project, we discuss the ways in which it repre-
sents a TD research approach, our research team and design, and challenges and
implications for future research.
J.R. Goodkind (B)
Division of Prevention and Population Sciences, Department of Pediatrics, University of New
Mexico, Albuquerque, NM 87131, USA
M.Kirstetal.(eds.),Converging Disciplines, DOI 10.1007/978-1-4419-6330-7_4,
Springer Science+Business Media, LLC 2011
42 J.R. Goodkind et al.
There were an estimated 14 million refugees and asylum seekers at the end of 2008
(US Committee for Refugees and Immigrants, 2009,2008). A majority of refugees
remain in their country of first asylum (usually in the “developing” world) or are
repatriated to the country from which they fled. Voluntary repatriation to a secure
country of origin is preferred because refugees are able to reintegrate into their
homeland and a culture they understand, and it simultaneously relieves the tempo-
rary host country of economic and cultural stress, thus leading to long-term stability
inaregion(UNHCR,1996). Less than 1% of refugees are resettled into a third
country in the “developed” world. The United States, Canada, and Australia accept
the majority of refugees from this group, and thus North America fulfills an impor-
tant role in resettling refugees who are unable to return home or remain in their
country of asylum. The USA remains by far the largest acceptor of refugees, for
example, resettling 79,900 refugees in 2009. (United Nations High Commissioner
for Refugees, 2010).
Because refugees are usually survivors of numerous traumas and face many
resettlement challenges, they frequently have multiple health needs that require indi-
vidual attention. However, without a focus on larger social and system changes, in
terms of both the living conditions and health care for refugees in their countries
of resettlement and the dynamics that create ever-increasing numbers of refugees
and internally displaced persons worldwide, the root causes of suffering will remain
unaddressed. The result is an apparent tension in regard to the level of intervention
on which to focus. For instance, psychologists might typically focus on eliminating
refugees’ distress through the reduction of individual barriers and problems while
sociologists might seek to understand the structure of the health-care system in a
particular area and how it impacts refugees’ access to health care. Political scien-
tists might work to change global policies and processes that are contributing to
the creation of large numbers of displaced persons in the world, while community
members might direct their efforts toward organizing and mobilizing for change
around a specific local policy that impacts refugees. A TD approach recognizes the
importance of all of these efforts and furthermore reveals that they are not mutually
exclusive but can be addressed simultaneously within one project.
Refugee Mental Health and Well-being
Mental health cannot be understood outside of a cultural context. What is consid-
ered “normal” behavior within one culture may be indicative of mental illness in
another. In addition, people from different cultures react differently to distress. For
instance, somatization (psychological distress manifested as physical symptoms)
is common among many non-Western cultures (Jenkins, 1996; Kirmayer, 1996).
Although Western medicine attempts to separate physical and mental health, many
cultures consider them inseparable and interrelated and thus take a holistic approach
to health (Vontress, 2001). Additionally, Western psychology generally focuses
4 Reducing Health Disparities Experienced by Refugees Resettled in Urban Areas 43
on the individual and locates causes of distress within the individual (Marsella
& Pedersen, 2004; Summerfield, 1999). However, cultures have widely varying
beliefs about causes (and therefore cures) of mental illness (Fuertes, 2004). Thus,
Western individual psychotherapy cannot be assumed