The 'P' word: Poverty (and other determinants of health)

I noticed a much more explicit focus on poverty in my discussions about health and well-being  in North America. Perhaps it’s just the circles I’m moving in but it feels there’s much more  reference to the links between ‘health equity’ and the wider social determinants of health.

Liz Weaver (from the Tamarack Institute) uses this powerful quote from David Shipler to highlight the case in point:

“Every problem magnifies the impact of the others, and all are so tightly interlocked that one reversal can produce a chain reaction with results far distant from the original causes. A rundown apartment can exacerbate a child’s asthma, which leads to a call for an ambulance, which generates a medical bill that cannot be paid, which ruins a credit record, which hikes the interest rate on an auto loan, which forces the purchase of an unreliable used car, which jeopardizes a mother’s punctuality at work, which limits her promotions and earning capacity, which confines her to poor housing.”

David Shipler, The Working Poor:  Invisible In America (2004)

I also found this simple yet illuminating story on the Canadian Public Health Agency website which highlights the complex set of factors or conditions that determine the level of health we have;

"Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to supervise them.
But why does he live in that neighbourhood?
Because his parents can't afford a nicer place to live.
But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?"

This story highlights some of the key determinants of health which are:

·         Income and Social Status

·         Social Support Networks

·         Education and Literacy

·         Employment/Working Conditions

·         Social Environments

·         Physical Environments

·         Personal Health Practices and Coping Skills

·         Healthy Child Development

·         Biology and Genetic Endowment

·         Health Services

·         Gender

·         Culture

Community Health Champions (CHCs), and those in similar roles, can help address some of these determinants. Whilst the Altogether Better programme was funded to deliver health outcomes around healthy eating, physical activity and mental health, we have an increasing amount of evidence that CHCs can help to improve social networks and  provide social support creating better social environments. They can help with health practices, self management and coping skills and help improve health literacy by improving knowledge and understanding of issues affecting health in its broadest sense. Some CHCs report feeling having a renewed sense of purpose and increased self esteem  and confidence since becoming involved in our projects. Many have developed new knowledge and skills and an increasing number have gone on to complete further training, education and even obtain paid jobs. All factors which contribute to (and I would argue are essential to) improved well-being

There was also much talk in my discussions  with people about the need for health improvement initiatives to be as much about addressing the material circumstances in which people live – as about addressing community health needs. Where we live and work and raise our children has a huge impact on health. If people are living in circumstances where they are worried about paying the bills, being able to feed their children, having a roof over their head - then any talk of behaviour change related to eating more fruit and taking a little more exercise - are likely to have little impact until these broader, more basic, needs are addressed.

 Increased empowerment and giving people a 'voice' and a say in their communities and neighbourhoods can  be mechanisms for addressing the material and environmental circustances in which people live. The Be Active Together Project, Seattle's Neighborhood Matching Fund and Vibrant Communities in Canada are partly about trying to address these needs - based on the notion that improved environments / communities = improved well-being. They are also about identifying and mobilising community assets (e.g. people, skills, organisations)  to improve communties and the places people call home.

This short film from Sudbury & District Health Unit makes valuable viewing for anyone interested in learning more...

 Let's start a conversation about health...and not mention health care at all.

 The Unnatural Causes series is also essential viewing for anyone interested in the social determinants of health and the impact of place and where we live on health and well-being.

A bumper crop: Seattle's P-Patch Gardens

Gardening has the potential to hit on a range of health and well-being outcomes including:

• Healthy eating – through growing and eating fresh fruit and veg.
• Physical Activity – gardening can be hard work and requires physical exertion!
• Mental Health – gardening can bring people together to work together and share skills and knowledge - increasing confidence, skills and self esteem and reducing social isolation.
• Improved social networks - Gardens can be a social space for people to meet up and connect with new people through a shared interest.

In order to increase gardening opportunities and encourage the development of these related outcomes - Seattle has over 75 ‘P-Patch’ gardens across the city, serving around 4,500 gardeners. Overseen by the the P-Patch community garden team at the Dept of Neighborhoods and the P-Patch Trust, the gardens are managed by the communities they serve. The P-Patch scheme is similar to the allotment system in the UK -  although people usually rent out  a smaller ‘patch'.

I visited quite a few P-Patches during my time in Seattle – all slightly different both in terms of size, locations, who uses them and what is grown there – but all had a burgeoning array of fruit, vegetables and flowers blooming. I was mightily impressed (and made hungry!) by what I saw.

I visited the Interbay P-Patch which is on the site of an old dump. It sits by the side of a highway but provides an oasis of calm with its glorious colourful flowers and abundant vegetable crop. 

Some of the gardens have kitchens so people can cook together, others have playgrounds so that kids can play while parents garden. The Coleman garden also has a children section to the garden so that children can learn about plants and growing stuff from an early age.

Gardeners at High Point preparing produce for the Market Garden

The people who use the gardens tend to reflect the community where the garden in based and this in turn influences what is grown there. In one area in South Seattle, there is a large Somali population and they grow the kinds of things they might grow at home - so – it’s not always the more traditional veggies you might expect to see…
Julie Bryan of the P-Patch Community Gardening Programme told me how she has had tried to learn the names of plants in a multitude of languages so she can help the gardeners in different communities. Julie has a role in supporting people to make best use of the gardens – providing advice where needed on growing and harvesting but also dealing with the management of the gardens when needed.

Many of the PPatches have an area that is dedicated to providing produce to local Food Banks. So, the gardeners are helping out their neighbours who may not have access to fresh produce easily.

Some of the gardens also have ‘bumping spaces’ (in the form of a shared seating area, a meeting room, a gazebo) - areas where the gardeners can get together maybe over lunch or for a meeting about garden planning or just for a chat. So they are also a potential breeding ground for  improved social capital!

It's easy to see how the P-Patch scheme is helping communities to help themselves in a whole range of ways.

For the past 37 years, P-Patch community gardeners have been:

• Growing community
• Nurturing civic engagement
• Practicing organic gardening techniques
• Fostering an environmental ethic and connecting nature to peoples’ lives
• Improving access to local, organic, and culturally appropriate food
• Transforming the appearance and revitalizing the spirit of their neighborhoods
• Developing self-reliance and improving nutrition through education and hands-on experience
• Feeding the hungry
• Preserving heirloom flowers, herbs, and vegetables
• Budding understanding between generations and cultures through gardening and cooking

Children's Play Park at Coleman P-Patch

You can read more about P-Patch Gardens here.

Community gardeners preparing vegetables for sale at the Farm Stand.

The Value and Role of Community Health Workers

Whilst in Montreal (back in June…seems an age ago!), I attended the Public Health Association of Canada’s Annual Conference which was a 4 day event attended by around 700 academics, service providers and policy people from across the country.

Talking about Health Champions in Montreal!

On the first day of the conference, I contributed to a half day session on “Exploring intersectoral partnerships in working with Community Health Workers (CHW)/Lay Health Workers in Canada and internationally”. I was invited to do short input about Community Health Champions (as a form of Lay Health Worker) and the Altogether Better programme. The session was hosted by Population Health Improvement Research Network (PHIRN) at the University of Ottawa.

 

During the session, we also heard from Terry Mason (an Independent Public Health Policy Consultant from Boston, Massachusetts) who spoke on ‘The Importance of Community Health Worker Leadership in Developing the Field’ and the need for recognition of the CHW role. Ronald Labonté  from the University of Ottawa gave us an international perspective and Sara Johnson, from the Ontario Federation of Indian Friendship Centers talked about Improving Urban Aboriginal Health Outcomes. Ivy Bourgeault (University of Ottawa), talked about the increasing global interest in CHWs and Sara Torres (University of Ottawa) talked about her PhD on Models of collaboration between immigrant community-based organizations and public health units.

Me, Ivy Bourgeault, Terry Mason, Sara Torres, Sarah Johnson

The group discussion that followed was lively and generated a number of interesting issues and questions around Community Health Workers (CHWs). I’ve attempted to summarise some of the key points below:

CHWs: Volunteers or Paid Roles?

• Different models of CHWs exist - from volunteer to paid para-professional role. Does using volunteers give the state the opportunity to step back / take less responsibility and reduce service provision?
• Both paid CHWs and volunteers co-exist in some places. Would paying CHWs act as a disincentive? The keenest people maybe those who do the work for the love of it – this may be lost if CHWs were to be paid. Need to consider what motivates CHWs and the different motives for different people (e.g. retired skilled people wanting to volunteer ‘v’ people seeing volunteer role as a step on a pathway to personal development and employment).
• What is the role of empowerment? Not just for the communities /’end user’ but also the impact of skills development for the CHWs.
•  What rewards / benefits should CHWs get? e.g. education, training, professional advancement, financial reward?

The key roles of the CHW

• CHWs are critical linkers /bridges to services. In Dakar there are 2000 new immigrants arriving every day and the role of CHWs is to link these people to services
• How can CHWs be used to help improve social cohesion – especially amongst Aboriginal communities?
• Could CHWs be involved in other roles aimed at increasing health equity? E.g. use CHWs to help identify child labour victims. How much can CHWs realistically take on? Need to consider what CHWs role should be (e.g. to refer well and develop relationships).
•  Community Health Representatives (CHR) are paid CHWs in 9 communities in Quebec working with 1^st nation people. Focus is on prevention and management of diabetes. Use a train the trainers approach. CHRs are recruited from communities and are respected by the community. In some rural communities, CHR are particularly valuable as they may be the only public health presence.
• Legitimation of CHWs role is linked to the internal policies of the organisations to which CHWs are linked. An internal policy statement should state what the role of CHWs is and what support they will receive – this will allow CHWs to make claims for support. For CHWs to do a good job – they need to be supported well and have access to resources and to professionals. These should be stated as the ‘rights’ of CHWs.

Professionalisation and Recognition ‘v’ Community Credibility?

• How can we make CHWs more recognised – to ensure they are at the centre (or at least ‘at the ‘table’ not ‘on the menu’). Should CHWs be more formally part of the health system? Need to consider what health systems are about. Should CHWs be part of how health services are revised and changed?
•  The ‘Professionalism’ debate creates tension between the need to generate more credibility and recognition for CHWs and the need to maintain their valuable ‘grass roots’ connections and community links. If CHWs become more highly ‘professionlised’ they may lose some credibility with the community with whom they work.
• In some places, people (CHWs) without statutory authority (i.e. not part of the state) were seen as more ‘fair’ and the most trusted source of information regarding health issues. This means they could be a good mechanism for accessing target communities. This may be lost if they became paid state employees.
•  Need to build up intersectoral health councils / partnership working methods to look at community problems together and explore how these can be addressed. Is there a role for asset based community development approaches to address the wider determinants of health?
• Should CHWs be organised /unionised (as in some parts of the US?)? In Massachusetts, the ‘certification’ of CHWs resulted from having powerful CHW leaders who organised for recognition. The Association of CHWs has set standards and requirements for CHWs (Terry Mason, Boston). The mobilisation / organisation of CHWs can allow them to look at what they need to do to work more effectively.

What does anyone think….? Feel free to post any comments or further questions.