8

Crafting a Research Agenda to Facilitate Knowledge Generation That Informs Action

Session moderator Aaron Bernstein, from Harvard T.H. Chan School of Public Health and Boston Children’s Hospital, introduced the session with the story of rapamycin, a drug that prevents transplanted organ rejection and plays an essential role in the use of cardiac stents (Halford, 2016; Kahan, 2003). This drug was originally discovered as part of a global search for novel compounds that might have useful biological activity. Isolated from a soil sample taken on Easter Island, rapamycin showed promise as an antifungal drug. Suren Sehgal, a microbiologist who worked on the rapamycin project, was convinced this compound had medicinal value.

___________________

¹ This list is the rapporteurs’ summary of the main points made by individual speakers (noted in parentheses), and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

His persistence eventually led the U.S. Food and Drug Administration (FDA) to approve rapamycin to treat several types of cancer, prevent organ rejection, and coat cardiac stents. “This is a great example among many of the potential of very good science never being put into action,” said Bernstein, who added that he told this story to underscore how important it is not just to do science but to make sure that science gets used.

RESEARCH TO INFORM PRACTICE: THE NATURE AND HEALTH INITIATIVE

Presented by Josh Lawler, University of Washington

Lawler described a study in which patients recovering from gall bladder surgery were put in two types of recovery rooms: one with a window with a view of nature, and the other with a window looking out on a brick wall (Ulrich, 1984). Patients in the room with the view of nature recovered more quickly from their surgery, needed fewer pain medications, and had fewer negative notes from doctors and nurses in their charts. He noted that other studies have found at least some evidence that exposure to nature improves sleep, heart health, and maternal outcomes and reduces depression, anxiety, and stress (Frumkin et al., 2017). He also pointed out that the benefits of time spent in nature are not distributed equitably.

To explore the connection between nature and health, Lawler created an initiative at the University of Washington called Nature and Health (Frumkin et al., 2017). This collaboration among practitioners, researchers, and policy makers had two goals: to better understand how interactions with humans can improve human health, and how to take that knowledge and use it to build better programs and policies that produce healthier people and protect the environment.

One project to come out of this initiative—a collaboration among Seattle Children’s Hospital, the University of Washington, and the Trust for Public Land—focused on greening school yards in Tacoma, Washington.² Lawler explained that this project involves bringing a community together to design a green school yard and examining how the design works, how well it works, and how well it serves the community. In addition, the study is looking at whether that greening affects the academic performance of the students and the mental and physical health of the people in the surrounding neighborhood.

Another project, Greening Research in Tacoma,³ is studying how greening a neighborhood with more pavement and less tree canopy than the city average can reduce heat island effects and how planting trees affects the mental health of the neighborhood’s residents. This project is a collaboration among the Nature Conservancy, Puget Sound Partnership, City of Tacoma, Tacoma Tree Foundation, and the University of Washington. Lawler also mentioned a project that is examining how set of outdoor activities designed for Girl Scouts to do independently affected the girls’ mental health and physical activity levels. For this project, a member of the Girl Scouts who is not a researcher was at the table co-designing and implementing the program.

Building a community of practice involves engaging researchers and practitioners on a continual basis to identify problems and co-produce research to address them, Lawler pointed out. Together, these studies illustrate the co-designed and co-produced research that the Nature and Health initiative is trying to build, he said. He emphasized that none of these projects would have been possible without the community of researchers and practitioners the Nature and Health initiative assembled.

___________________

² Additional information is available at https://irleaders.org/team/team-tacoma-wa/ (accessed November 24, 2022).

³ Additional information is available at https://tacomatreefoundation.org/grit (accessed November 24, 2022).

NATURE AS MEDICINE

Presented by Mahtab Jafari, University of California, Irvine

Jafari described the results of a survey she and her colleagues conducted in 2020 in which 87 percent of the college students surveyed reported that the COVID-19 pandemic had negatively affected their mental health (Frumkin et al., 2017). Moreover, in 2021 academic success had fallen 22 percent because of depression and 38 percent because of stress. She noted that the typical solutions universities offer to address mental health issues are counseling, workshops, medications, and hospitalizations when suicide is a risk; she asked, “How about using nature as a non-pharmacological intervention?”

Four universities in 2019 founded the Campus Nature Rx Network, a coalition that has since expanded to include nearly 50 colleges and universities.⁴ The coalition has published studies suggesting that as little as 10 minutes of nature therapy improved student mental health (Kang and Shin, 2020; Meredith et al., 2019; Roberts et al., 2021). At her institution, Jafari and her colleagues developed a course called Life101–Mental and Physical Self-Care that is now taught on all 10 University of California campuses and is available through Coursera.⁵ The course includes a nature therapy module that teaches the students about the science and practice of nature therapy. Pre- and post-course surveys that Jafari conducted over the past 10 years found that almost 90 percent of the students did not know about nature therapy; once they learned, there was a 107 percent increase in the weekly practice of nature therapy.

Jafari commented that the way to translate research and knowledge into action is to broaden the research agenda to include large prospective studies involving different and diverse populations to examine the effect of nature therapy on the mental health of those populations. These studies, she said, could provide an excellent opportunity to engage local communities and partner with them to co-develop and co-design the research.

Jafari had several suggestions for turning the knowledge that nature therapy improves mental health into action. These included increasing green spaces on college campuses and in communities; offering more courses on nature therapy in elementary schools, high schools, and colleges; having a research database shared among scientists who study nature therapy and creating a platform for them to collaborate; and increasing research funding. She also produced two additional ideas while listening to the workshop’s discussions. She asked, “How about if we place nature therapy stations in our green spaces and in our parks, encourage our community to engage in nature therapy, and explain very briefly on the science what nature therapy really is? What if we put a QR code next to these signs and ask them to share their experiences after practicing nature therapy?”

Before discussing the role that botanicals can play in improving human health, Jafari quoted Richard Louv, who said, “The skeptic will say the nature prescription is problematic, given our quickening destruction of nature, and the skeptic will be right. The natural world’s benefits to our cognition and health will be irrelevant if we continue to destroy the nature around us” (Louv, 2008). Nature, after all, is a source of medicinal plants. Many FDA-approved drugs come from plants, botanicals are sold to the public as dietary supplements, and botanicals in their raw form have uses in traditional medical practices. FDA does not have the authority to review dietary supplement products for safety and effectiveness before they are marketed, and by the time FDA gets involved, a botanical supplement may have harmed people (Jafari, 2021).

___________________

⁴ See https://www.campusnature.com/ (accessed November 24, 2022).

⁵ This course was developed in 2013 and expanded in 2021. See https://www.coursera.org/learn/life101 (accessed November 24, 2022).

With botanical research, said Jafari, higher-quality preclinical research does not translate into positive clinical trial outcomes, pointing to the importance of high-quality research at all levels and training for future scientists in botanical research (Sorkin et al., 2020). As an example of high-quality botanical research, Jafari cited work she and her team conducted over the past 18 years on Rhodiola rosea, a plant native to arctic and dry regions used in traditional medical practices for thousands of years.

An important aspect of high-quality botanical research, explained Jafari, is ensuring that the preparations are standardized and of good quality, and conducting experiments with the right animal. Her research group found that feeding standardized preparations of this plant to fruit flies increased their lifespan and improved their health span (Jafari et al., 2007; Schriner et al., 2013). She and her collaborators have also shown that the plant improves biomarkers of diabetes and inflammation and modulates the microbiome (Jafari et al., 2022). Jafari noted that because the preclinical data have been replicated, she feels confident enough to develop a clinical study in type 2 diabetes.

As part of this project, Jafari has worked with farmers in Alaska to ensure that the quality of their harvests meets the standards she developed in her laboratory. One concern of hers is that climate change will affect Rhodiola rosea farming given that arctic ecosystems are experiencing some of the most rapid changes resulting from a warming planet.

Jafari reiterated the need for rigorous research on botanical extracts. She also emphasized the importance of interacting with local communities and partnering with them to co-design these studies and to learn about possible next steps. She underscored that community education should inspire the public to call for high-quality research on botanicals, and she pointed out that FDA regulation would also increase the quality of research. As a final thought, she said she wants to see the research community develop a repository of botanical extract studies to increase collaboration and data sharing.

Q&A DISCUSSION

Steve Luby, from Stanford University, asked Jafari if she engaged with agricultural extension agents in Alaska to increase awareness and perhaps increase the breadth of participants in her research project. Jafari appreciated that suggestion. What prompted the current collaboration, she explained, was a presentation she gave at the University of Alaska in Anchorage, where she had the opportunity to meet with the many farmers cultivating Rhodiola rosea. The farmers, she added, have a co-op that allows them to communicate with and help one another.

Katie Arkema, from the Pacific Northwest National Laboratory, asked Lawler if he could talk about potential outcomes from the projects he is running on greening school yards in Tacoma and with the Girl Scouts. Lawler replied that both of these projects are well poised to scale. For the Girl Scout project, the funder had a goal and already has a mechanism in place to scale it. For the school yard greening project, the Trust for Public Lands was already greening school yards in many places and wanted the Tacoma collaboration to provide more information about how that effort was working and what elements might be the most effective for improving health. The Trust is now incorporating that knowledge into its existing program for greening school yards.

Arkema then commented that both Lawler’s and Jafari’s examples highlight how local communities are searching for scientists who can help them answer some of their questions. In both cases, she said, the community partners knew what they wanted to do.

Teresa Horton, from Northwestern University, asked the speakers if they knew of examples where silos had been broken and if they would discuss how to make it easier to break down silos. Jafari replied that she designed the Life101 course in collaboration with students, which she considered a small

example of silo busting. Lawler said he had no examples of silo busting at the government scale, but he witnessed a time it almost happened when the Department of the Interior convened a meeting of agency heads to talk about climate change. Though it seemed as though they would form an interagency climate change task force, it never happened.

Jonathan Sleeman, who is with the U.S. Geological Survey National Wildlife Health Center, responded to Lawler’s comment by noting that some progress resulted from that meeting, including the formation of national and regional Climate Adaptation Science Centers⁶ that are embedded in universities. These centers bring together scientists from government and universities, along with wildlife managers and the local communities, to conduct research and translate the findings into adaptation strategies for wildlife.

Benis Egoh, from the University of California, Irvine, recounted a program she was involved with in South Africa called Working for Water,⁷ in which the government worked with her team to create jobs for people to remove invasive species from the country’s waterways. The project was so successful at removing invasive alien species and benefiting the nation’s water supply that South Africa now has seven other “Working for” programs addressing fire, land, and other natural systems. In addition, it led to a collaboration among the Department of Water Affairs and Forestry and the Departments of Environmental Affairs, Tourism, Agriculture, and Trade, as well as industry, research foundations, and provincial departments of agriculture, conservation, and environment.

Bernstein said that after 20 years of lobbying, the National Institutes of Health (NIH) has created an NIH-wide initiative on climate change. This points to the fact that breaking down silos requires long-term efforts. “It requires almost generational change, and we do not have that kind of time,” said Bernstein. “That is our problem.”

Reflections on the Presentations

Presented by Craig Stephen, University of British Columbia; Neil Vora, Conservation International; and Louise Willemen, University of Twente

Stephen first commented that there has been progress in breaking down silos and significant change in how researchers work together and what types of discussions they have. The main deficit he identified is that academia has not trained, encouraged, and supported those people who are boundary crossers.

Reflecting on the question of how to generate a research agenda that facilitates knowledge generation to inform action, Stephen said inaction does not mean apathy. Having heard during the workshop that it is difficult to get public health practitioners to care, he referred to a project he is conducting that asks frontline public health practitioners about integrating concern across the environment, animals, and One Health. “It is very clear that public health [practitioners do] care,” he said, noting that the role of public health is to create healthy working and living spaces for everyone. The challenge, said Stephen, is that the issues of health and environment as discussed at this workshop may not be prioritized in the daily work of public health practitioners. “I do not mean […] that they do not care,” he clarified. “I mean that they are overwhelmed with COVID recovery. They have a

___________________

⁶ Additional information is available at https://www.usgs.gov/programs/climate-adaptation-science-centers (accessed November 24, 2022).

⁷ Additional information is available at https://www.dffe.gov.za/projectsprogrammes/wfw (accessed November 24, 2022).

workforce crisis. They have concurrent epidemics of overdose crises, mental health problems, wildfires, and floods, and there are no personnel to branch out right now.”

A second issue he encountered in this study is that public health is struggling with a value proposition. Public health officials with the legislative responsibility to develop and deliver public health programs are concerned that caring for nature is a “luxury” of those who have dealt with all other problems or that it is somebody else’s job. He also noted that the science in this area in general is more focused on defining problems than solutions.

Stephen said there has been an imbalance in funding, with large investments around the social determinants of health at the expense of addressing the environmental determinants of health. The environmental determinants of health can be seen solely as a source of public harm rather than an asset for well-being. One reason for this is the lack of a cohort in public health with the training that puts social and environmental determinants on equal footing. An additional problem rests in the substantial evaluation gap. There are many passionate arguments, said Stephen, but only a small subset of practitioners who have shown that they create public health–relevant outcomes that can be brought to their agencies. Thinking about approaches to help advance an actionable research agenda, Stephen drew on prior experience with the harm reduction techniques used with drug and alcohol addiction. This approach recognizes, for example, that getting rid of fentanyl or heroin will not happen; the focus could be shifted to reducing harms such as needle-borne diseases by setting up safe injection sites, needle exchange programs, and addiction recovery programs. In his view, lessons from harm reduction could help advance an action agenda.

He suggested that this community can help take the pressure off frontline public health workers. “I think we have to recognize that people are facing many pressures and many problems, and continuing to add to that without helping them deal with what they are already dealing with is not going to be a successful strategy for action,” said Stephen. As an example, Stephen shared that while protecting wildlife is a public health asset, one does not need to engage public health to do that. Finally, he pointed out that the scientific community needs to identify the target for knowledge mobilization and action for public health to achieve the desired change.

Based on his experience translating evidence into actionable policy solutions, Vora had six suggestions for translating research into action that can be applied across the range of human health benefits from nature. First, more transdisciplinary research is the only way to comprehensively understand existential threats such as climate change and pandemics, which are too large for any one individual, discipline, or institution to fully address (Vora et al., 2022). “Many of the solutions to today’s existential threats such as pandemics have not worked because the approach to the problem has historically been too narrow,” he said.

Second, more diversity and inclusion in the research workforce would likely be beneficial. Too many voices have been excluded, said Vora, and even today this is a major reason the current crises exist.⁸ Solutions, he said, could harness different historically marginalized perspectives and knowledge systems.

Third, more examples of interventions that have made some progress against these existential threats could be helpful (Vora et al., 2023). “While we have to be careful about anecdotes, they do serve a useful purpose in that they help to translate abstract ideas into tangible concepts that show that success is possible,” said Vora. Many people in the public health and medical fields do not have a deep familiarity with ecology, conservation, and related disciplines. Simply saying to people in public health or to policy makers that protecting rainforests is important for preventing pandemics is too nebulous and

___________________

⁸ The speaker made a reference to the “many ways of knowing” from the author and scientist Robin Wall Kimmerer (see Marchese, 2023).

seems unattainable. Giving specific examples of how to decrease deforestation can show concretely that the proposed solutions are achievable.

The fourth suggestion is effective communication, which means avoiding jargon when speaking to a general audience or when writing research papers. “If research cannot be communicated to others, it means that it will end up as just another research paper that serves little purpose other than to enhance one’s résumé,” said Vora. This means that at a minimum, the abstract, introduction, and discussion sections of scientific papers should be written in language that is easy to understand so that the paper is broadly interpretable.

Fifth, it is important to recognize the big picture, which means highlighting research results that can help solve society’s problems. Regular engagement among researchers, policy makers, and civil society is helpful for accomplishing this by ensuring that research will address the fundamental gaps in knowledge needed to develop and implement policy.

The sixth suggestion is to prioritize equity. Historically, and even to this day, health policies have had inequitable benefits, said Vora. “This is wrong and will preclude long-term success of any policy,” he said. In his view, research could therefore focus on equity so that when translated into policy, the resulting policies maintain that focus on equity.

The first point Willemen made was that a research agenda does not influence policy or practice—people do. She said that acquiring actionable information involves continual co-creation, which begins with getting the relevant policy makers and scientists together to set and agree on the agenda for what needs to be assessed and to agree on expectations for a project. As scientists do their work, it would be beneficial to keep policy makers involved by allowing them to review the work and comment regularly, for example. The final step is that both sides could take ownership of the project.

Willemen offered three suggestions. First, acknowledge that a project is relevant for both scientists and policy makers. Second, both policy makers and scientists could dedicate the time and skills to co-design and co-create with a clear goal in mind. This means that the academic system would give researchers the space to work with policy makers and celebrate or reward that work. Third, to make that happen, policy makers, practitioners, and funders could regularly remind academic institutions that they could fully value research that makes a societal impact.

Discussion with the Plenary Speakers and Panelists

Bernstein asked the panelists to talk about the features of a research agenda, other than the human element, that may influence policy makers, conservation practices, or other relevant outcomes. Vora suggested that it is important to put people at the center of any research agenda, which means the design process should be intentionally inclusive from the outset. Doing that will enable different voices to be included at the beginning so the outcomes at the end of the day are likely to be more representative and accepted. By putting people at the center, the benefits to nature should follow.

Stephen remarked that changes to protect the natural environment need not rely on changes in government policy. Government policy is important, but corporate policies, household policies, and individual policies make a difference, too. Many proposals have a heavy focus on methods and not enough attention is paid to formulating the right question that needs to be answered. One problem, Stephen suggested, is that there is tremendous value for the researcher to become immersed in the population or community in order to identify and refine their research question, but funding agencies do not explicitly incentivize researchers to do this work of engaging with different stakeholders and formulating the “right” or actionable research questions.

Willemen agreed that co-creation and setting the research agenda are key because actionable information will not do much good if it is answering the wrong question. She noted that co-creation does not stop when setting the agenda; keeping the community involved can help ensure that a project stays on track and gets to an answer in the most efficient way. Jafari added that academia may need to change paradigms regarding promotion and tenure to reflect a new definition of high-impact research that extends beyond publication and includes research that impacts the lives of many people.

Stephen agreed that universities need to have a better understanding of what high-impact research is, but academics can still take some risks given the importance of actionable research. He suggested that everyone who supervises a student could ask that one chapter in the thesis or dissertation discusses the policy relevance of the findings. In his view, the biggest impediment to action is the lack of an inspired cohort of scientists and trainees to take risks.

Vora raised the problem that many public health experts receive their training in a narrowly focused discipline and may not understand or appreciate ecology and other disciplines relevant to the natural environment. “If you do not know what you do not know, you are not fully aware of the solutions and context that you might be missing,” he said. “That is a dangerous recipe because then we implement incomplete solutions to these existential threats.” He also commented on the short timelines and funding cycles that ignore the fact that results from implementing a solution will be borne out over a longer period.

Willemen suggested that funding agencies could help fill in missing areas of expertise by making connections among researchers or by expecting a research proposal to include certain disciplines as collaborators. For example, the Dutch Science Foundation requires that a proposal include collaborators throughout the knowledge chain, including active practitioners.

Sarah Olson, from the Wildlife Conservation Society, commented that this field is using a theory of change that proposes research on a diverse and increasingly rich list of how nature affects health and how that information can subsequently inform policy makers to effect change. This approach could make change happen and get people to care. However, she noted her skepticism, given that many of the workshop topics have been around for 20 years and failed to produce the desired change. Her alternative approach to change would acknowledge that the public health challenges discussed at the workshop are rooted in society’s colonizing values⁹ and the predominant profit-driven worldview. Changing that worldview will likely have to start with an educational approach that nurtures and moves society toward a more sustainable worldview. New tools may be needed to measure ecocentric thinking in different societal actors, including children, chief executive officers, public health and government officials, and Indigenous populations.

Olson noted that critics have called out environmental, social, and government funds for focusing their investments on companies that take on more financial risk rather than on companies that act responsibly with regard to the environmental, social, and human health sectors. An alternative framework, the planetary boundaries framework, lays out a safe operating space for humanity based on the planetary systems that regulate Earth’s stability (Steffen et al., 2015). So far, Olson shared, about 3,700 businesses have signed onto this framework, with 1,400 committed to achieving net zero carbon emissions and 1,800 using science-based targets. She aims to understand why those companies are signing on to this approach and others are not. She also noted that future discussions could include experts from the education policy and business sectors.

Vora remarked that he is inspired by medical students who are developing a planetary health report card to improve accountability for what medical schools are teaching. In terms of incorporating

___________________

⁹ In this instance, the colonizing values refer to a preference for the values associated with capitalism.

Indigenous ways of knowing into education, he raised the importance of acknowledging the source of that information instead of appropriating that knowledge.

Stephen added that selecting who delivers educational programs may be more important than changing curricular structures. He envisioned a scholarship of success that focuses on identifying the factors that created change effectively and the conditions that allowed change to occur.

Sleeman raised the idea that there may be a risk of seeming biased if research focuses too much on advocacy. “You may no longer be seen as independent in the production of that information,” said Sleeman, which creates a problem when there is already a mistrust of science. He then asked the panelists for their thoughts about alternative approaches for delivering information, perhaps by building more partnerships and interacting with community leaders to have them help translate the science. Lawler replied that graduate students are receiving more training in science communication, and boundary-spanning and communication-focused organizations such as COMPASS¹⁰ will be key in any communication effort because they have the time and communication skills that the research community may not possess.

Stephen commented that it is important to define what advocacy means. In public health, for example, advocacy is a core competency. “Advocacy means being able to take what you know and get it to the people who need to know in a way that is understandable and fair and objective,” said Stephen. “It does not mean locking yourself to a tree and calling for a change without sound evidence or sound reason.” He believes the field needs a stronger advocacy agenda and people trained to be advocates. Advocating need not mean being biased, but it can mean speaking about the available information within the context of the decision-making environment. Willemen said she sees science as an enabler and researchers should ensure that they are transparent in what they do, how they do it, and how they present their results. Albert Ko, from Yale School of Public Health, suggested training practitioners and researchers to have a common language.

Egoh said the White House has announced plans for a national nature assessment,¹¹ and she asked the panelists for their thoughts on how to design the assessment process to break down silos and support local communities and practitioners. Willemen noted that the ongoing Nexus assessment, organized by the Intergovernmental Science–Policy Platform on Biodiversity and Ecosystem Services, is looking at the interlinkages among biodiversity, water, food, and health on an international basis. She wondered if institutional barriers prevent people from joining a worldwide initiative such as this. For her, the main point to address in such initiatives is to ensure that people know they can contribute to them. “There are so many experts investigating health and nature relationships,” said Willemen. “I do not buy the argument that the knowledge is not there. It is simply that it is not conferred.”

Jafari asked if it would be a good idea to teach advocacy in schools. Shanondora Billiot, from Arizona State University, replied that she teaches a graduate-level course on advocacy, and it would make her job easier if graduate students had already learned about advocacy. Ko noted that there is a difference between activism and advocacy; academics and research organizations can promote advocacy.

Willemen acknowledged that the system is difficult to change and that there are many barriers, but there are also many opportunities, no matter how small they are, to effect change. For example, when mentoring students, one idea is to help them think about making an impact with their research.

___________________

¹⁰ See https://www.compassscicomm.org/ (accessed November 24, 2022).

¹¹ See https://www.globalchange.gov/nna (accessed March 20, 2023).

This page intentionally left blank.