Communicating health in the knowledge landscapes
Health-related knowledge is a complicated mixture of levels and dimensions including
molecular research, clinical research, well established practices, new technologies
and treatments, specialized and individualized life-style recommendations, and quality
of life factors. As it concerns everything from microbiology to social well-being,
this complex landscape of knowledge is difficult to grasp even by medical professionals.
Despite its complexity, the relevance of this knowledge is obvious for the individuals,
their families, their professional environment, and the society as a whole. Understanding
health-related knowledge is a prerequisite for patient-centered medicine, and being
acquainted with the newest developments can imply better health, higher quality of
life, and better medical treatment (1,2).
Making healthy decisions is quite a challenge, due to sophisticated and constantly
changing status of medical knowledge. For example, regarding dietary requirements,
foods that are considered healthy today might be defined as not so healthy tomorrow
(as with the Acrylamide debate a few years back), and the prevention activity supported
now, could not be recommended tomorrow (as with running being good or hazardous to
back bone problems) (3,4). Sometimes it borders on the trivial, eg, whether you should
choose an electric tooth brush or not, whether to spend more money on the organic
grown food or not (5). But the decisions about health are not trivial; they can substantially
influence our lives, and in some cases even they can make a difference between life
and death. Therefore, the public interest in health-related knowledge is high and
growing, and the question of how to find relevant health-related information gets
increasingly important, not only to the acutely or terminally ill persons.
In order to achieve efficient knowledge communication between different stakeholders,
we have recently suggested knowledge landscapes as a concept that embraces the present
society as a digital and global society, and we have suggested navigation through
the landscapes as a concept that embraces the individuals in search of knowledge (6,7).
It conceptualizes both successful communication of relevant health advice, as well
as impasses and misunderstandings leading to inappropriate health decisions. Instead
of using a one-way model to describe communication from experts toward users, and
instead of a dialogue model between these two sides, we have suggested a multilateral
communication model of different stakeholders. Due to new software (interactive/Web
2.0 programs) and personalized services (algorithms), the formerly separated knowledge
traditions meet in the digitalized internet-based frame of the present society.
Digital society drags us all into a constant negotiating of meaning, not the least
regarding questions like “What is health?”, “What does a particular diagnosis mean?”,
or “What is the best treatment?”. From the perspective of communicating health and
medicine in the digital environment, there is a renewed need to clarify the subjects
of interest from different angles and perspectives. These angles and perspectives
concern both the knowledge and an additional important parameter – the context (values,
culture, etc). So does knowledge communication, which needs the context to reveal
the meaning. As such, knowledge communication and understanding is context dependent,
and we argue that considering the importance of the context is a prerequisite for
successful navigation through knowledge landscapes. In this paper we wanted to extend
our views of health-related knowledge landscapes by presenting their geography and
discussing their dynamics.
The geography of knowledge landscapes in the digital realm
Multilateral communication that includes multiple participants can occur in both off-line
and online settings. Multilateral online interactions are increasingly important as
a location where one can get access to information, knowledge, and social surroundings,
making the digital realm a major contemporary tool for knowledge dissemination.
The technological advances in the digital realm have provided the necessary platforms
that allow knowledge landscapes to form. Those technological advances excel particularly
in multilateral communication, and they include social networks (eg, Facebook), blogs
and miniblogs (eg, Twitter), forums, virtual networks, and video sharing platforms
(eg, YouTube). The internet also provides the tools for classic one-way communication,
where contents are collected and systematized in the form of web pages, repositories,
and archives, or for a dialogue, enabled through e-mails, instant messaging, or chat
services (6).
Specifically in the medical field, the majority of books, scientific journals, and
teaching materials have their digital versions. The Open Access approach for scientific
information allows every user regardless of education level or affiliation to access
original research publications (8). Together with the repositories of books and online
courses, large quantities of relevant knowledge, including medical knowledge, can
be accessed in the digital world. But the mere presence of this content does not mean
that it will be accessed, and if accessed, that it will be understood. Moreover, how
the accessed knowledge affects the user depends highly on the context of the knowledge
source, as well on the context of the user. Subsequently, the digital knowledge landscapes
geography is defined not only as a series of internet locations, but as a complex
combination of information, its presentations, user-technology interactions, and the
surrounding context.
Academic and research based knowledge is scattered in the digital realm within a variety
of virtual domains and frequently hidden. To find it, the users rely on search engines
and help each other to find what they judge useful. Unless one searches directly in
academic databases (like PubMed, pointing to the research articles, which are in many
instances “pay per view”), the results from general online searches using Google or
Bing will combine quite different sources, which do not need to be directly related
to relevant or evidence-based knowledge. The search results also differ between two
users searching exactly the same, because they are formed by the algorithms of a particular
search engine that organize and present the information, and by the individual search
history as a preference (9).
The flexibility of knowledge landscapes
The geography of knowledge landscapes is neither flat nor stable. Knowledge is not
an absolute, but a tentative entity, therefore its relevance is constantly changing
and it is constantly re-evaluated. The temporal dynamic and context dependency is
an inherent feature of all traditions claiming its content to be knowledge. The tentativeness
of knowledge could be elaborated as its timeliness, dependence on language and culture,
or as a carrier of politics (10-12). Both new points of view and innovations are needed
to facilitate re-evaluation and developments that anew can make knowledge relevant
for particular and tentative contexts. Thus to make knowledge absorbed by society,
we need it to be communicated to the users in order to be effectuated, discussed,
and publicly inquired.
The flexibility of the knowledge landscapes to incorporate an incoming new knowledge
and to adapt to the changes is an asset, and it is enabled by its digital nature.
This provides potentially important benefits for the users, which expect to find on
the internet the latest version of medical knowledge, or hope to be the first to catch
the game changing information of their interest. It is also important for the innovators
and the professionals to have a forum to spread and exchange their ideas and to facilitate
implementation, eg, of new approaches for the better health care. This dynamic also
works the other way around and represents a significant risk of knowledge landscapes
distortion by undermining reflexive processes that ensure context sensibility, and
by avoiding the use of precautionary principles and implementation of ethics (13).
Up and down the knowledge landscapes
Digital technology allows for time-dependent changes, by constantly adding new and
modifying old contents. But as the landscape constantly changes, it makes navigation
through the knowledge landscapes more complicated. The landscape contains layers of
old and new, valid and obsolete, just discovered or forgotten. The journey through
knowledge landscapes is therefore also a journey in time, and not only an exercise
of multilateral communication.
Together with time, as a fourth dimension, the knowledge landscapes’ three-dimensional
geometry implies that the view is frequently obstructed, eg, by the mountains and
slopes of the digital landscapes. If the landscape was a two-dimensional flat surface,
the visibility of the landscape elements would be theoretically without limits and
it would be easy to point out directions so that the users could reach what they searched
for. But finding online knowledge, understanding it, and using or refusing it is a
context-dependent process. Contexts of relevance here are those contexts that work
as a carrier of meaning and are inseparable from the users' understanding of a search
result. Examples might be a text (eg, a health recommendation already know to the
user), a phenomenon (as a disease, an epidemic in past or present time), or a health
strategy (for example regarding what is understood as proper hygiene). Thus all contexts
are not important in all situations, and to understand how online search results are
interpreted, one needs to figure out which contexts are relevant for concrete problems
and communicative situations.
What we are saying is that context is fundamental to the interpretation of the communicative
situation and it needs to be approached as a key element in the communication process.
The myriad of formative contexts includes economy, geography, language, gender, class,
sub-cultural belonging, faith and values, as well as political events, experiences
from the past, actual recourses at hand, social organization as well as organizational
structure and infrastructure, local knowledge traditions (like traditional medicine
and healers), media coverage as well as rumors and propaganda. In addition, technology,
in particular digital technology, needs to be included as a formative context for
communication in a digitalized society. Regarding communication of health and medicine
a key challenge is to identify which context is important for dissemination and communication
to create transparency and avoid misunderstandings and misconduct.
The context is an integrated part of health-related decision-making, moreover it is
also very personal due to the intimate nature of health and disease. For example,
the overwhelming majority of people would agree that smoking causes lung cancer, and
sex without protection might end in an unwanted pregnancy. Still, the decision whether
to smoke or not, whether to use a condom or not, is not only evidence-based, but based
on a variety of factors influencing the individual behavior. The results of any health
intervention (eg, anti-smoking or contraceptive campaign, preventing infections, or
vaccinating children) do not depend only on the evidence-based data, but on understanding
and adapting to the particular contexts (14). Present digitalized society is just
as context dependent as the society was in earlier times. The new aspect of the global
range of digital communication is its immediacy/high speed, as it was recently shown
during the latest Ebola outbreak (15).
The shaping forces of knowledge landscapes geography
The knowledge landscapes geography primarily integrates these two key elements: knowledge
and context. The ups and downs in the landscapes (z-dimension in the coordinate system)
are shaped by contexts integrated into the digital realm: a) technology, the device
and software in use, b) the user and the user’s context, c) the frames and results
that are produced through the interaction between technology and user (Table 1). The
gravity forces of contexts are thus 3-fold: technological, social-cultural, and the
result of the interaction between the first two. The contexts influence the position
of the knowledge in the landscapes, and appear as a gravity force shaping the landscape
geography. Thus, the knowledge could be hidden, eg, behind a mountain reef representing
a language barrier, or due to an algorithm that constantly gives priority to certain
results, or due to the way the algorithm reflects past history of the users' search
pattern. In consequence, the users (eg, crawling through the narrow canyon of the
knowledge landscape) might lose the possibility to see the bigger picture and its
framing structure. This visual interpretation of knowledge landscape geographies aims
to help us understand the user’s behavior. Moreover, it opens up possibilities for
us to get a vocabulary so that we can in a new way discuss how to position the knowledge
to be approachable by the users.
Table 1
Elements of the knowledge landscapes geography
Knowledge landscapes coordinates
As the knowledge landscapes depict a 3-dimensional space, with time as the 4th dimension,
the x-, y-, and z-coordinates apply. Determining what influences the coordinate values
is still open for discussion, but we suggest that up and down (z-value) is context
dependent, providing a visualization of the knowledge-context interactions. Contexts
of relevance are: a) the technology, b) the social, cultural, economic, political,
etc, context that contributes meaning to the user’s interpretation of search results,
c) the constant production of results from the interaction between technology and
user.
Gravity forces
The context is a gravity force that shapes the landscapes, which again host the knowledge
(by assigning the z-value to the 3D-space, the context creates mountains, valleys,
and other possible geographies).
Centers of gravity
These are coherent and concentrated contexts supported by matching knowledge. They
dominate by their gravitational forces in the landscape. They could represent, eg,
a university creating a geographical basin around rivers of knowledge, or a conspiracy
theory creating a black hole.
Isolated landscapes
They are geographies distorting the knowledge. Isolation results in knowledge being
determined and self-confirmatory, lacking tentativeness and re-evaluation.
Black hole
The extreme form of landscape’s geography, which self-perpetuates the distortions
and engulfs the surroundings by the force of the gravity center. Represents a social
disease.
The Open Access notion, which makes all knowledge digital, available, and free is
important as it provides the content to be present on the internet. When we combine
knowledge and context, as in the knowledge landscapes, providing content on the internet
is just a first step toward sharing knowledge and making it useful. The output of
the knowledge communication is context dependent, and the context dimension of the
knowledge landscapes will influence what is disseminated and how it is interpreted.
Therefore, our understanding of the knowledge landscapes is a tool that helps us understand
the complexity of contexts in digital society, as well as helps us to shape the digital
technology and assist the users in their navigation toward knowledge and the solutions
they search for.
Black holes as a specific geography of knowledge distortion
Besides being the places of the efficient presentation of academic and research based
knowledge, the knowledge landscapes are also the places where knowledge is distorted
and where incorrect and misleading information is distributed. The freedom to post
diverse contents on the internet, and the egalitarian nature of the internet, where
experts are in the same positions as all other content providers, does not allow users
to discriminate not relevant from relevant and unreliable from reliable information.
Moreover, contents with commercial motivation are frequently scattered among other
contents, without clear borders. Therefore, navigation in the digital realm is filled
with challenges. There is no objectivity – in the sense of a common organization of
the subjects available online. When accessing the internet, the search engines provide
us with a personalized adjusted approach, trying to guess what we are searching for
(16). Being surrounded by our personal contexts, and guided (or misguided) through
internet by search algorithms can bring us to different knowledge landscapes as well
as to different positions in relation to knowledge. To facilitate healthy decisions,
the ideal landscape’s geography is characterized by openness and flexibility, and
allows confronting contents. This enables the user to create her/his own standpoints
(both open and flexible) and is a prerequisite for the person-centered medicine.
Knowledge distortions can occur when contrary to open and flexible landscapes, users
are isolated in the digital environment (eg, being in a valley surrounded by mountains).
The isolation might happen just by accident, reflecting personal search history, interests,
and knowledge. It can also be a choice reflecting a conviction or social identity
that represents a particular and outspoken stance regarding eg, vaccination, blood
transfer, or dietary patterns.
What might at first be an obstacle, or a steep downhill in the knowledge landscapes,
can, if repeatedly being visited by the user, work as an undermining and altering
force. The location’s relation to other parts of the web, and the algorithms' way
of using a preferred site, can affect future search results. In the vocabulary of
Michel Foucault, one might say that search choices are transformed by algorithm preferences
to search results that create a particular “webs of meanings” (17). The interaction
between users and software will transport the users into already established discourses,
and it will also create new online “webs of meaning,” which are adjusted to the individual
users’ preferences, webs that are wrapping itself around the users and shaping their
life and identity. As they may represent counter academic and counter science information,
they attain power and potency that can harm the user. The user’s search for knowledge
becomes distorted, and what is being presented as search results can be described
as a counter discourse. Although Michel Foucault’s vocabulary is powerful (and seductive)
in describing the dialectical discourse-counter-discourse movement, this only explains
some aspects of how communication is conducted and meaning is constructed online (18).
Distorted evidence mostly work as a force on its own terms, ie, not as a dialectical
process, and through the repetitive selection of the one-sided contents they act as
a gravity force distorting the digital landscape.
Though misconception and distortion might start out as a counter discourse, they may
end up as a self-confirmatory process that create a self-perpetuating context, which
serves as a new center of gravity, distorting the knowledge landscapes. The information,
which confirms the claims of the gravity center appears as stronger than that coming
from the outside. Subsequently, the segregation of the content sources occurs and
the self-confirmatory content gets assigned a higher value of reliability and trust,
which creates the isolated form of knowledge landscapes (Table 1). For example, people
in fear of well-established vaccination for children’s diseases like measles are located
in a particular isolated landscape, belonging to a group that shares and discusses
various internet contents, which are then discussed among them. The gravitational
forces shape in a self-confirmatory way the isolated landscape as a valley with the
slippery slopes where individual could slip toward twisted understandings and harmful
decisions. Still the isolation per se does not determine what is wrong or right, and
the isolated groups bound together by gravity forces of the isolated knowledge landscapes
could be completely right. Therefore, the topics (ie, centers of gravity) that lead
to isolated landscapes are controversial and difficult to handle. It is important
to notice that regardless of whether it is wrong or right, the knowledge in the isolated
landscape is indeed distorted, as it loses its tentative attribute, to be challenged
and re-confirmed. If the communication routes out of the isolated knowledge landscapes
remain open, then these could be used to break the isolation and to regain the necessary
multilateralism of the knowledge communication.
If the isolation deepens, and the gravity center relying on the isolation gets stronger,
the extreme form of knowledge landscapes is forming, which we refer to as a black
hole. The gravity forces of the contexts, strengthened by the technology-user interaction,
segregate the information sources completely and only those contexts shared within
the black hole would be considered relevant. The self-confirmatory and repetitive
nature of the information flow isolates the group of individuals in the black hole,
within their own dynamic, which is not any more influenced by the outer world. The
outside information is per se considered unreliable and even malicious, and attacks
and attempts to pull and incorporate additional landscapes into the black hole can
be expected. Examples of black holes in knowledge landscapes are regrettably numerous,
for example in the medical field it could be avoiding child disease vaccination due
to fear of autism, or avoiding chemotherapy due to conspiracy theories. Their characteristics
are not too different from other conspiracy theories on the internet, eg, on chemtrails
or on water fluoridation. Black holes of the digital realm represent a new form of
a social disease, analogous to medical diseases, and it is important to understand
them and to find ways to counter them in the future.
Presenting the black holes as a product of an extreme form of isolated knowledge landscapes
could hopefully improve the approaches on how to deal with the corresponding topics
and social groups. As knowledge landscapes uplift the relation between knowledge and
context, they provide geographies that potentially might tackle these social challenges
and also strategically approach the isolated landscapes. The openness and flexibility
of the digital realm facilitates individual decision and patient autonomy, hence if
we could discuss the dynamics behind, processes involved, and bring the contents distributed
in isolated landscapes and the black holes to the open, this could profoundly change
key premises of the situation.
Isolated landscapes are the products of a process where technological, sociological,
and cultural factors merge. Visualizing them creates awareness on how processes, imbedded
in digitalized society, are formative for individual health decision makers, affecting
the health communicators’ ability to establish communication with users/target groups.
This is an urgent matter in a situation where digitalization of health information
and communication have become key strategies for governing bodies as well as health
institutions and health related non-governmental organizations. In this vein, we indicate
that the knowledge landscape concept supports the patient autonomy and person-centered
approach in medicine. The importance of context is an argument for the fundamental
importance of an interdisciplinary approach in health interventions that aim toward
better health.