“Iteration” is the practice of regularly reflecting on our knowledge of a particular issue or population and adjusting our thinking and processes to address gaps, inconsistencies and oversights as well as to accommodate new knowledge or insights. In other words, iteration involves regularly asking what the issue is, who framed it, who is at risk or in need, and what evidence is available to shed light on the topic.
Iteration is essential in every aspect of SGBA, but it is perhaps most important during the development of implications because it has the potential to shift our perspectives: it can prompt us to think about an issue in a new way; to include other or additional populations; to search for different types or sources of evidence. Think back to our jigsaw puzzle. As we start to put the pieces together, it may become clear that there is something we don’t know yet – some pieces of the puzzle are missing. Or we may realize that we have to look at an issue or population differently – the pieces of the puzzle fit together in ways we had not expected. Practicing iteration means being willing to step back, to reflect on the evidence, situation or context and to ask questions that had not come to mind before. In the process, the puzzle may change shape and so will the picture we are working to create.
To understand the practice of iteration, and its effect on the development of implications, let’s turn again to the example of wait times for hip and knee replacement surgery. As mentioned earlier, the researchers began with what seemed like a relatively straightforward question: do women and men wait the same length of time for surgery. As they delved further into the research, they realized that before they could answer this question, they needed a definition of “wait time”. As it turns out, there are many ways of defining and measuring wait times, and policy makers, health care providers, and patients do not always share a common definition of wait time.
At the same time, the researchers began to ask if women and men had the same underlying need for hip and knee replacements. They found that while women and men did have a similar need for surgery, their joints were damaged in different ways. People’s need for joint replacement was influenced by both sex and gender – the biology of joint damage and the way that women and men use their bodies for work and play. Men, for example, were more likely to have engaged in weight-bearing sports that injured their joints, while women had higher rates of arthritis. At the same time, the researchers discovered that x-rays, one of the standard tests for hip and knee replacement, was a poor predictor of the level of pain and disability associated with joint damage, especially for women.
In stepping back and returning to the research question time and again – practicing iteration – the researchers began to think differently about the issue, populations and evidence. Their initial question was replaced by a number of sub-questions. Rather than asking simply if women and men were waiting the same length of time for surgery, they began to wonder if women and men were receiving surgery at all, and if both women and men were being treated according to their level of need