Going Global!

I spent the last 2 days discussing community health workers and community empowerment with a group of people from all over the world. I joined delegates from India, Iran, Bangladesh, Pakistan, Brazil, Ecuador, Kenya, South Africa, the Congo, Canada*, Australia* and New Zealand* - and was also lucky enough to meet with some of the people I will meet in South Africa in October for part 2 of my fellowship.

Just some of our International grouping!

The focus of the two day event was on Comprehensive Primary Health Care (CPHC) and it marked the end of a 4 year international study co-ordinated by Ron Labonte at the University of Ottawa and David Sanders at the University of the Western Cape in South Africa. The project - ‘Revitalising Health Care for All’ - involved 20 projects in 20 different countries and more than 60 researchers.

The projects had identified a number of key themes - many of which were of interest and relevance to my fellowship including: 

1.  Community Health Workers  (CHWs)
2. Community Empowerment
3.  Inter-sectoral working

We know that models and roles of Community Health Workers (CHWs) across the world vary. As just two of many examples, in northern India the ASHA (Accredited Social Health Activists) are volunteers whose role is focused around child and maternal health whilst in Iran the 'Behvarz' are paid, permanent employees of the health system who receive 2 years training to prepare them for their role which is focused on helping to build community capacity and mobilising community members. 

Despite these differences - learning from the experience of other countries where health needs, resources and policies may be very  different to the UK, was extremely helpful in terms of offering an alternative perspective - though it seems many issues are the same the world over.

We were reminded that the original rationale for CHWs in the developing world was to address the fact that poor families were less likely attend or access state health care facilities, and that CHWs could have a role in increasing access to services.   The findings from the project also demonstrated a number of other potential roles undertaken by CHWs:

1.      Health care provider

2.      Advocate for community

3.      Agent of social change

4.      Facilitating inter sectoral / partnership work

Some research gaps in relation to CHWs were identified which reflect some of the outstanding questions have about Community Health Champions in the UK:

1.      What are the communities views on CHWs?

2.      What factors constrain or facilitate CHWs in operating as agents of change?

3.      What factors and polices could improve recruitment and retention of CHWs?

4.      Which roles should CHWs undertake?

5.      What are the possible negative effects of CHW programmes?

6.      What payment and support systems are needed?

There was also much discussion about the wider social determinants of health (e.g. housing, education, poverty) and the role of community health workers in helping to address these. This quote clearly illustrates the need to not just tackle ‘health’ as an issue – but also those factors that impact on health:

“what good will it do to treat people’s illnesses…and then send them back to the conditions that make them sick?”

Community participation and empowerment processes were also recognised as effective in improving population health and increasing levels of social capital.  We talked about mobilising communities as part of the wider CPHC agenda - and how CHWs may have a role in identifying and mobilising community assets.

There were questions raised around the somewhat sticky issue of how we define and measure community empowerment - and how we demonstrate empowerment in a way that speaks to funders and policy makers, so that they take it seriously. Seems this isn't an issue unique to the UK...but just how do you convince funders to pay for empowerment activities when they are so often hooked on tangible, measurable health outcomes such as smoking cessation or reduced hospital admissions? Whilst we have developed some ideas around this linked to our work on demonstrating social capital and our Altogether Better Evidence Reviews on empowerment and well-being (both of which I was able to 'plug'!) it remains a challenge.

Ron Labonte (Project Grantholder) and Sara (Iran),
Sara (Canada) and Sarah (UK)!

There was lots of interest in our work in the UK and  - all in all - it was a great forum with a great bunch of people -  all passionate about improving health equity and health outcomes for all and I was very glad to be part of it.

The ’Revitalising Health for All’ project has database of articles on CPHC from each of the participating countries.



* most delegates were working in low to middle income countries. Those people from Australia, New Zealand and Canada were representing Indigenous communities within those countries who still face many barriers to health care and are considered low/middle income countries within wealthier nations.

Health as a ‘hook’ for engagement

Today I went to Pembroke (Ontario) to meet with some of the volunteers who have been involved in the CHAP programme in Ontario. CHAP (the Cardiovascular Health Awareness Program) is a community-based program that brings together GPs, pharmacists, other health professionals, volunteers, and health and social service organizations to work together to promote and actively participate in the prevention and management of heart disease and stroke. Volunteers are trained to take blood pressure checks from those aged over 65 in pharmacies and other community settings (including Walmart stores). A volunteer ‘greeter’ would meet people on arrival and explain the process – another volunteer would take the BP check and collect other lifestyle information.

The programme was developed in partnership with McMaster University and has been piloted in 20 communities with impressive results – a 9% reduction in hospital admissions for cardiovascular disease for those aged over 65. (Read the full study in the BMJ).

Whilst this reduction in hospital admissions is an impressive result and will be sure to make health care commissioners take interest  – I also learnt today about some of the other ‘softer’ outcomes of the programme and how it had a potential role in increasing social capital for participants.



CHAP volunteers Gary and Laura
and Co-ordinator Holly.



Volunteers Gary, Laura and Delores told me how the main problem for most of the people who came for BP checks was not physical, “they are people who face barriers to getting out and socialising…who want to talk and tell their story”.

They went on to explain how they would see the same people at each session and how the BP check and the sessions themselves, “became a ‘hook’ to get people involved, provided a place to meet and a way to connect people”. In some cases the volunteers developed a ‘peer mentor’ role, offering advice on issues such as portion size and telling people about other services they could access - all activities which further enable people to feel more empowered to make decisions about their own health and well-being and,  potentially, increase social capital.

Read more about the CHAP programme here.

Sport: More than just a hockey game...

Another day – another interesting connection made.

I spent of couple of enjoyable hours today with Christina Parsons of the True Sport Foundation  - learning about their efforts to work with asset based approaches in four communities across Canada.

True Sport is not just about sport. It is a national social movement and enabler for sport AND for community. Its core mission is;

“to be a catalyst to help sport live up to its full potential as a public asset for Canada and Canadian society – making a significant contribution to the development of youth, the well-being of individuals, and quality of life in our communities.”

As Christina says, "sport is an asset  where people come together to integrate, to communicate and to make new connections", and sport can also be, "a tool to help build more resilient communities".

So – it’s not just about playing hockey (though I understand - for many Canadians - that’s very important too….).

As their information leaflet states; at the heart of True Sport is the simple idea that “good sport can make a great difference.” True Sport believe that sport embodies a range of principles which are applicable way beyond the playing field - and  are neatly summed up in this short film.

·         Go for it – Always rise to the challenge.

·         Play fair – Play honestly and obey the rules.

·         Respect others - respect teammates, competitors and officials both on and off the field

·         Keep it fun – Have a good time.

·         Stay healthy – respect your body, stay in shape.

·         Give back – do something that helps your community

Through working with communities via Community Foundations in the four pilot areas, True Sport has funded a range of activities aimed at increasing accessibility and inclusivity in ‘sport’ – in its broadest sense (from increased recreation and use of parks and green spaces to more structured, traditional  ‘sporting activities’).

The criteria for funding applications states that all projects should involve sport (obviously) but should also:

• Enhance a sense of belonging to the community
• Allow neighborhood residents to give back to the community (e.g. through volunteering)
• Build skills, knowledge and ability to continue to strengthen the community in the future

So the programmes are not just about sport – they are about identifying and mobilizing community assets, about embedding and promoting the principles of good community engagement – and about building social capital.

Read more about True Sport and ABCD approaches here

'Face' based not 'place' based

"It's about faces - not places" - these are words that will stick with me from my time on Monday spent in the company of David Derbyshire - a community development worker in Hamilton, Ontario. David is a truly remarkable and inspirational (and incredibly modest) individual who clearly cares deeply about people and  about communities - 'faces not places'.

Core to David's approach is the connections and relationships he skillfully builds with and between people in the communities he works in. David sees himself as a 'conduit' for action and for building capacity in individuals and communities to enable them to identify and mobilize the assets they have. He takes a truly asset based approach and seeks to "empower people to do what they want to do".



David in the McQuesten Community Centre -
just two of the communities many 'assets'

I was lucky enough to spend an afternoon and evening with  David  where we visited some of the communities he works in and met some of the people he has worked alongside and inspired. First stop was the McQuesten neighbourhood, a public housing area inhabited by, what David described as, 'the working poor' (people living close to the poverty line).

Hamilton is a place with large inequalities in life expectancy. There is a 21 year gap in life expectancy between the lowest and highest rates.  There is also high unemployment in sections of the city due to industrial decline. McQuesten is not untypical of other parts of the city in having a diverse community made up of people from many different countries and cultures. Racism has been problem in the past and David told me that there was a time when people across the street from one other would not talk to each other. Now things are very different.

 As we walked around the community - David seemed to know everyone by name and issued a warm, "Hi - how are you?",  to everyone we met - he was always greeted with a positive response - and sometimes a question or a request for information.

We visited several people in their homes who were universally full of praise for David and the support he gives to them and to the community. Rose - who recently won the David Derbyshire 'Citizen of the Year' award (an award the community established in recognition of David's valued input) said she wouldn't do any of the activities she's involved in if it wasn't for David.

We visited Pat who chairs the neighbourhood Planning Team. Pat told me how she loved living in the area - and really valued the opportunity to make so many new friends and connections with people from different backgrounds.



Sign in McQuesten Community Centre



 We bumbed into Michael - a young man, who having grown up in the community,  has encouraged other young people to get involved in music as a diversion for other, less positive, activities.



David in the McQuesten Community Garden.



With David's facilitation, the McQuesten community has identified and mobilized a huge has a range of  'assets' including: 

• A community garden where residents can grow their own fruit and veg (many people urged me to go and see the garden and are justly proud and pleased that it exists).
• Block parties and community BBQ's where neighbours get together for a social gathering, sharing the work of planning, organising and providing the food
• Several colourful and well maintained playgounds
• Lots of green space
• A community centre -  which is valued and well used and provides a whole range of activities and services. As we walked around the center, I met the leader of a club for young girls which sought to address issues of low self esteem and low confidence through providing activities aimed at improving physical, mental and emotional health





One of McQuesten's Playgrounds



Later that same day, we attended the Planning Team meeting for another neighbourhood - South Sherman. We sat outside the meeting venue (a local church) on the grass in the sunshine and waited as people arrived and sat down to join us.

Community Planning Teams meet once a month and are made up of service providers, education,  local businesses and local residents. A range of issues were discussed including the approval a small grant for $300 for a community BBQ and how to deal with concerns about pollution from a local factory without jeopardising the employment opportunities the company provided. As David put it - as well as presenting a potential issue - the factory was also an asset and they needed to invite the asset to 'play nice'.

This comment from Celeste, who runs 'Property Angels', a service which seeks to provide  help with property repairs and needs - sums up the value of taking an asset based approach and of communities working together, and highlights the social capital that can result;

"what I love about it is that people who didn't know each other -

now know each other  - and help each other..."

You see- David was right - it's about faces - not just places.

Read more about the Community Development work in McQuesten here.

First day done...

Well, today was the first day of my fellowship - and what an inspiring, thought provoking and engaging day it was. It was also quite a long day (up at 6, out at 7 and back home at 10pm!) so will  report back tomorrow - but for now - here's a pic (from my packed but valuable day in Hamilton) which highlights some of what I'm here to learn about...

Poster in North Hamilton Community Health Center

 

Arrival in Toronto

Well – I’ve successfully crossed the Atlantic and I’m here! I left Manchester at 11.15am - after checking in my average sized but VERY heavy suitcase - and following a brief (but slightly fraught) change in Philadelphia, arrived in Toronto at 6pm (11pm UK time) so am struggling to keep my eyes open a little…!

View from my room!

A dodgy in flight ‘entertainment system’ (I saw the first 10 minutes of 3 different movies before the system crashed…again!) – meant that I managed to read Jim Dier’s excellent book
‘Neighbor Power: Building Community the Seattle Way’ which provided much food for thought and generated a greater sense of excitement about my visit to Seattle (though I won’t be there until mid-July – I have Canada to ‘do’ first!). Jim has been a great help in connecting me to people and projects in the Seattle area so it was good to read more about the history of the work he has been involved in. Jim was the first Director of the Dept of Neighborhoods in Seattle whose mission is focused on:

“preserving and enhancing Seattle’s diverse neighborhoods, empowering people to make positive contributions in their communities, and bring Government closer to all people, ensuring it is responsive” (Diers, p 30)

Jim's book assures me that there's lots to learn from the Seattle experience.

So...I have a Toronto room with a view (CN tower one way, Lake Ontario the other) and my first week is all set. After a weekend of jetlag recovery and  Toronto orientation, on Monday I head out to Hamilton (about an hour by bus) to visit the North Hamilton Community Health Center, Hamilton Roundtable for Poverty Reduction and Hamilton Community Foundation to learn more about their work snd will be sure to report back. Am looking forward to a busy old week Canadian style!

Now - to bed!



The journey begins...

So. I am all packed and awaiting the train to the airport. I fly to Toronto tomorrow morning and arrive in time for tea. Watch this space for updates from the other side!