Goodbye Canada - Hello USA!

So, I’ve left lovely Canada after 6 great weeks spent visiting 5 different cities from East to West. I met some great people and learnt lots - and certainly have had plenty to reflect on during my time out in Jasper and Vancouver (in-between spotting bears, elks, orcas, sea lions and so many bald eagles I confess I became a bit blase…).

So, I’m now in the USA and spending the final leg of my journey in Seattle. I have a busy few days ahead with visits to a range of people and projects including…

The Auburn Food Bank 

The Chinese Information Service Center - to learn more about and observe what Community Advocates in Seattle do.

The International Community Health Services Center  where I hope to observe a diabetes education class and meet the Health Services Director and Health Advocacy Manager.

The Seattle Department of Neighbourhoods - including visits to a Neighborhood Payment and Information Service center (NPIS) and Neighborhood District Coordinators Program  I’ll also get  chance to learn more about the Neighborhood Matching Fund Project & PPatch gardens in the city.

The Public Health Department of King County Council to learn more about their ‘Communities Count’ project and equity and social justice work.

I’ll end the week with a visit to the High Point neighborhood who are holding a Health Fair for community members on Friday evening. High Point is one of Seattle’s most diverse neighbourhoods and the High Point Neighborhood Association’s mission is to foster "the development of a vibrant and caring community committed to service, inclusiveness, lifelong learning, and well-being." Sounds just my kinda thing....

So - a busy old week but I am really looking forward to it…watch this space for updates!

What makes a community healthy? Why not ask them…?

Who’s to say what makes us and our communities healthy? Concepts of what we need to make and keep us healthy may vary amongst individuals and from community to community. Having said that, we know there are some recognised determinants of health such as:

·         where we live and our physical environment

·         our income level and socio-economic status

·         our education levels and whether we have a job (and what kind of job it is)

·         the services we have access to

·         our ability to cope and manage our lives

·         our social networks and social support

·         our gender and culture.

Colleen Cameron and Susan Eaton of the Coady International Institute have been heavily involved in development and implementation of the People Assessing Their Health (PATH) project in Canada and overseas. PATH is a community driven health impact assessment process, and both Susan and Colleen were keen to stress that, “Community engagement, empowerment and capacity building are central to the PATH approach.”

Sounded right up my street…. I was keen to learn more.

The PATH process provides a way for communities to identify what a healthy community means to them. The first stage of the PATH process involves the community identifying what impacts on their health – with a focus on the wider social determinants of health (those things listed above). They are tasked with answering the question: “What does it take to make and keep our community healthy?” and asked to devise a vision of a healthy community. Community members are invited to use the following prompts to help them come up with their responses:

“A healthy community is….” Or “In a healthy community…”

Some examples have been:

·         A healthy community is a dynamic community.

·         A healthy community is a changing community.

·         In a healthy community, assets are valued.

·         In a healthy community, diversity is valued.

·         In a healthy community, people work together.

·         In a healthy community, the goal is the overall health of the community.

         

[An example from the Antigonish Town & County Community Health Board is below to give an idea of what these might look like.]

Colleen explained that most groups identify the same kind of issues that affect health – with some cultural differences in terms of language and focus (e.g. for aboriginal peoples).

The next stage in the PATH process is for the community to design and test a Community Health Impact Assessment Tool (CHIAT) which can be used to assess the potential impact of any policy or intervention, actual or proposed. The CHIAT asks, “Will [name of intervention/policy] have an impact on…[dimension of a healthy community]” . The impact can be a positive or negative  – and sometimes is both (some things can be both good and bad – depending on which way you look at it – right?).For example, a new factory may create more jobs and may also increase air pollution.

As Susan said, PATH isn’t about saying what is ‘right or wrong’ or ‘good or bad’ but that there was, ”great value in hearing different voices and viewpoints…it promotes dialogue.” Susan went on to explain that, “PATH is about a conversation, about social learning…it’s a way for communities to create new knowledge and that’s just so empowering”.

The final stage in the PATH process is for the group to make a plan to use the CHIAT to assess the impact of a proposed or actual policy or action. An example of a policy assessed using the CHIAT was that of proposed school closures. In one community the closure would have led to negative impacts and loss of services (as the building was used for many things) in another community, the process enabled the community to identify of how the school could be used for other community activity.

I asked about what changes had occurred as a result of the PATH process, but as Susan and Colleen explained – identifying what makes a healthy community is one thing – influencing policy change as a result is a different matter, “The central idea is that communities use the tool to assess the impact of policies or interventions on the health of the community…but the PATH process needs to be supported in some way. People need resources to keep going and to take actions.”

So - where does PATH fit into the ideas about asset based approaches and building social capital….?

Well, in identifying what makes the community healthy the PATH process helps people to identify the assets they have that make (or keep) them and their communities healthy. These might be individual assets such as having a job or having family nearby, or community assets such as a local market providing access to cheap fresh fruit & veg, a community garden or a good public transport so people can get around and are less isolated.

It also seems that PATH is an incredibly empowering process for community members. It helps participants develop analytical skills and articulate what makes and keeps them healthy. The PATH process facilitates the development of a unique health impact assessment tool that a community can use when considering the effect projects or policies will have on community well-being and is recognition that, when it comes to health, the community voice is a valuable voice.

The PATH process could also be a way of helping to develop health public policy in helping to identify that any impact on the wider social determinants of health are taken into account when implementing or considering changes in policy, practice or service provision.

The Antigonish Town & County Community Health Board (ATCCHB) is a community-based health planning board.

Mission:

To develop a community health plan through broad community participation and consultation that includes strategies that promote and improve the health of our community.

A healthy community is a dynamic community, which includes:

·         Participation

·         Community leadership (from women and men)

·         People having control over decision-making that affects their lives

·         Institutional support

A healthy community is a changing community, which means:

·         It is evolving, not stagnant

·         It is open to embracing new ideas, people and approaches

·         It is prepared for change

·         It encourages intergenerational activities

In a healthy community, assets are valued, which means:

·         People’s various talents and skills are fully utilized

·         People feel that they are listened to and that their opinions are respected

·         Special attention is given to those not normally heard

In a healthy community, diversity is valued, which means:

·         Valuing the things that different groups can bring to the community, not just focusing on what can be “done” for them

·         Acknowledging that policies and programs can affect different groups in different ways

·         Consciously integrating different groups and cultures into our work

In a healthy community, people work together, which means:

·         There is collaboration (between churches, organizations, municipal governments, etc.)

·         Efforts are made to foster cooperation and overcome community “turf” protection

·         Leadership and participation skills are supported

·         Communication uses clear language

In a healthy community, the goal is the overall health of the community, which means:

·         Health includes all aspects of people’s lives (economic, social, spiritual and cultural, as well as physical)

·         The health of people and the community is influenced by a broad range of factors generally called the “determinants of health”

·         Primary health care (including health education, health promotion, disease prevention, rehabilitation, and the support and treatment of illness and injury including palliative care) is alive and well and available to all with no gaps.

More information on the PATH process as used by Antigonish Women's Centre can be found here.

The Power of Peers

As anyone living with, or involved in the care of someone with, a chronic condition will know - self-management is critical. We also know that knowledge, skills and confidence are core prerequisites for effective self-care management.

 

Peer support can help with the daily management of living with a chronic condition and help build the necessary knowledge, skills and confidence.  Peer supporters may have a role in helping with range of things including:

• Identifying local resources e.g. where to buy healthy foods, good locations for exercise
• Helping people cope with social or emotional barriers
• Helping to keep people motivated to reach their health goals.
• Identifying when it is necessary to seek medical assistance.

 Sounds a bit like the role of a Community Health Champion – right? (we are actually  piloting some work involving GPs, Health Trainers and Health Champions in supporting diabetes management in two areas of the Yorkshire region at the moment).

In Canada, there are a number of Community Health Centre’s delivering self-management programmes. Many of these use the Stanford Programme  as a model of delivery – and a number of them focus on diabetes management.

 Here are just a couple of examples for starters….

 

North Hamilton Community Health Centre runs the Stanford programme of peer support - a chronic disease self-management programme run by volunteers. The training is delivered over 6 weeks with a 2 ½ hour session each week with a focus is on diet, exercise, goal setting, and leadership training and takes a ‘train the trainers’ approach. There are around 15 people in each class and recruitment is usually from community groups. Expenses are paid.

 

The programme co-ordinator, Peter, explained that, as lay leaders, the volunteers are asked to ‘guide from the side’ and told there is no ‘sage on the stage’. This helps to put responsibility on client and to encourage small changes and develop confidence.

Evaluation uses the self-efficacy measures as set by the Stanford Programme (including confidence to perform self-management behaviors, confidence to manage condition in general, confidence to achieve outcomes). Participants are also asked to write a letter to Stanford at the end of the programme to say what they have learnt. Peter told me that these letters were often very powerful and told of the benefits people had gained in terms of taking control over their health and improving their ability to self-manage - and also the benefits of meeting others with the same issues and having increased social networks. More evidence of social capital building!

 

Black Creek CHC Diabetes Program: Live, Learn and Share

In Toronto, I had lunch with Michelle (Diabetes Manager), Spencer (Community Development Worker) and Sandra (Peer Educator), who are involved in a self-management programme around diabetes care in Black Creek.



Spencer, Michelle and Sandra from
Black Creek CHC



The programme is called. “Live, Learn and Share” and their materials on peer support sum up the value of peer support pretty well;

 “Peer relationships promotes respect, trust, warmth and helps empower the individual to make changes and decisions that enhance their lives”

Michelle explained how the programme was developed to meet an identified need. She told me how local people with diabetes, ”wanted to meet others with diabetes, to share experience, break isolation, learn about management strategies and form connections.” – so, as well as improving self management, it’s also about building social capital and connecting people. Community members have been heavily involved in the development of the programme and the training materials, so the training guide is based on, and informed by, individual lived experience and expertise.

Sandra, who has had diabetes for 6 years but only felt able to speak openly about her condition a year ago (as result of her involvement in the peer support programme) – now runs a peer support group for others. She told me how the Peer support programme and training she received gave her, “the knowledge to help other people…and I feel good about that.”

Spencer (who trains the trainers and supports the support groups) explained how the programme uses a strength based approach, “focusing on the wisdom, capacities and expertise of community members.” So - about identifying assets in communities to improve outcomes. Sounding familiar…?

Training for Peer Educators, delivered over 3 x 2.5 hour sessions, focuses on self-management, healthy eating and physical activity – very much like some of the training for Health Champions being delivered by some Altogether Better Projects.

The training for people wanting to set up peer support groups is delivered over 7 x 2 hour workshops and focuses on the role of peer support and the practical skills needed to set up, deliver and evaluate a peer support group.

Spencer shared how the effectiveness of peer support in improving self-management had been shown through research. An RCT (Heisler et al 2010) looked at the efficacy of two alternative approaches helping patients with diabetes develop self-care management efficacy:

• one-on-one telephone conversations between two patients (of similar age )with diabetes
• telephonic nurse care management

The findings show that a simple weekly phone call with a peer facing the same self-management challenges, helped diabetes patients manage their condition and improve their blood sugar levels better than those who used traditional nurse care management services alone. The study also showed that women with uncontrolled diabetes reduced their A1c levels after 6 months in the program.

It seems there is clear role (and financial incentive from a service point of view) for the use of Peer Support in terms of improving self-management and thereby empowering people to take more control of their condition (and their lives) and reducing demand on health services.

In the UK, Community Health Champions and Health Trainers are playing a partial role in some areas – but this is by no means any sort of universal provision and many people with chronic conditions continue to struggle with self management issues.  So – why aren’t peer support systems a more integral part of the wider health care system? Seems a no-brainer to me…

Sources:

The Black Creek Diabetes Programme Training Manual can be found here.  

The ‘Self-help Provincial Network’ has many materials for individuals interested in self-help / peer support www.selfhelp.on.ca

References:

Heisler, et al.  Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management – A Randomized Trial. Annals of Internal Medicine. 2010;153:507-515.

Dale, J. et al.  Peer support telephone calls for improving health. The Cochrane Library. 2009, Issue 3.

The journey so far...

I am meeting so many people (the business cards below represent a large number but there have been many more!). And those people introduce me to other people or organisations who have an interest or experience in the subject of my fellowship. It is a true snowballing effect! I just wish there were more hours in the day and more energy in my bones to be able to take full advantage....

So - I am coming to the end of week three of the fellowship and have spent time in Toronto, Ottawa and Montreal so far. All great cities for different reasons (and am not sure I'm allowed to have a favourite anyway...).

I have attended 4 different conferences, visited 11 organisations and spent time in communities where services are targeted. I have also had countless conversations with people about Community Health Champions, the Altogether Better programme and  our work in the UK. Some conversations - as you might expect - were at conferences and events but others were more random - like whilst eating a Beaver Tail in Ottawa, over Moules Mariniere and at the Bixi Bike stand in Montreal! Seems Canadians like to chat...which is great!

There's too much to report the details but to give you a flavour - here are a couple of highlights from my time in Toronto...

My visit to Health Nexus in Toronto provoked some interesting thoughts about the social determinants, of health and health equity. Health Nexus 'view health broadly' (as their strapline says) and have been enabling communities to promote health for the past 25 years. They assist organizations and individuals  to develop and implement prevention and health promotion strategies that aim to enhance well-being and reduce demand on the health care and social service systems. Community Health Champions could be one such strategy and I was able to share our evidence reviews and resources. Thanks to Peg, Barb, Subha and Suzanne for the stimulating discussion (and tasty lunch!). 

Visit to Health Nexus, Toronto

The Wellesley Institute  is a non-profit research and policy institute with  a focus on developing research and community-based policy solutions to the problems of urban health and health disparities. We spent a useful  afternoon sharing information about our respective areas of work.  Of particular interest was their work around Peer Health Ambassadors - (more on that later) and a participatory action research project on how neighbourhoods affect well-being in one densely populated area of Toronto (St James Town). You can read more about the St James Town  initiative here. 

Tomorrow I leave for Nova Scotia, a weekend in Halifax and then onto the Coady Institute in Antigionish (which I have now learnt how to pronounce correctly... or so I am informed when I pull a quizzical face). After Nova Scotia I head west to Vancouver (via the Rockies...very excited) for some much needed R 'n' R before heading south to Seattle to complete this part of the journey.

Phew.

Better get packing....

Community Health Centres: An empowering and holistic approach to well-being

Whilst in Toronto, I attended the Ontario Association of Health Centre’s Conference – along with a few hundred others from across Canada and further afield. I was also fortunate enough to get the opportunity to visit a couple of Centres to see what goes on there.

Community Health Centres (CHCs) seek to provide services to those whose circumstances mean they may be vulnerable to poor health or face obstacles accessing the care they need  - they also aim to give people a voice and a choice about how their health care is delivered. An empowering idea of an approach if ever I heard one…but what’s the reality?

There are 1,500 Community Health Centres (CHCs) across North America but only 300 in Canada (most are in the States). Only 4% of the population of Ontario have access to a CHC and it is estimated that around 18% need access, so provision is lacking for many communities.

CHC’s provide primary care (and other services) to those with limited financial resources and focus on meeting the basic health care needs of their individual communities. They provide services to a range of groups living in poverty with who may otherwise face barriers to services e.g. homeless, residents of public housing, migrant workers, refugees, Aboriginal peoples. Centre's have an open-door policy, providing treatment regardless of an individual’s income or insurance cover.  They provide comprehensive care, including physical, mental and dental care.

As the opening speaker at the conference stated, CHCs;

“were born out of the struggle to create more equitable health and have a crucial role to play as catalysts of change”.

CHCs;

 “take a bottom up approach to serving communities….and recognise there is a circle of care that extends beyond clinical health.” 

 The Canadian model of CHCs has been heavily informed by the USA model where, it is claimed, the provision of CHCs has resulted in between 25 – 35% costs saved to the health care system (according to the National Association of CHCs - Centres save the US national health care system between $9.9 billion and $17.6 billion a year by helping patients avoid emergency rooms and making better use of preventive services).

The Community Health Centre model of care focuses on five service areas:

·         Primary care

·         Illness prevention

·         Health promotion

·         Community capacity building

·         Service integration

So - what are these Centres like....? I popped along to a couple to investigate...

North Hamilton Community Health Centre

I visited the North Hamilton Community Health Centre (NHCHC) about an hour from Toronto. Earlier this year, the centre moved to an environmentally friendly and very smart new building. The Centre is described as the “anchor” in the heart of the community it serves and is a place for community members, partners and staff to share together and work towards health and well-being - for present and future generations.

North Hamilton Community Health Centre

NHCHC uses a holistic approach to improving health of individuals and families and communities.  Elizabeth Beader,  Executive Director, shared with me their vision of, “No obstacles to health” and mission, “to enable health through healing, hope and wellness.”. So it’s not just about providing GP services (although primary care provision is based here too)…

NHCHC has around 180 visits per day and provides a wide range of services and facilities including:

1.       Community room

2.       Community kitchen

3.       Primary care services

4.       Children’s programs

5.       Pathways to education programme – encourages and incentivizes Grade 8 students at risk of ‘dropping out’ to stay in school by working with pupils and parents.

6.       Health Wellness Gymnasium – a smart new facility which is free to access. Helping address financial barriers to accessing private gym facilities for some community members.

7.       Health promotion

8.       Foot care

9.       Diabetes programs – including an outreach programme visiting shelters and  helping homeless people to manage their diabetes. Delivered using a partnership approach with Shelter Health Network and community centres.

10.   ‘Drop in day’ for seniors – to learn about services available, enjoy a healthy lunch and socialize with other older adults in the community

11.   Dietitians service

12.   Occupational Therapy

13.   Physiotherapy

14.   Client support services / counselling / social care

NHCHC also helps facilitate community outreach events with over 30 programs offered. Seen as essential for promoting the CHC programs and services available, these include:

·         Volunteer appreciation dinner – an annual event to thank the 200+ volunteers who lend skills and time to assist clients.

·         Community Health Day – which included an open house focused around healthy food (with a healthy lunch) and a discussion on the social determinants of health where the community were invited to share their thoughts on what could be done to create positive change around each determinant.

They also run a volunteer led Peer Support programme for people with chronic illness, which had some similarities with our Community Health Champion approach. The approach is based on the Stanford Programme and I’ve discovered this programme (or adaptations of it) are run by a number of CHCs…so will write a separate post on this later.

Access Alliance - Toronto

I also visited Access Alliance - a Community Health Centre based to the east of Toronto in an area with an extremely diverse community including many new immigrants and refugees. Their Vision statement reflects this – “Toronto’s diverse communities achieve health with dignity.” They seek to, “improve health outcomes for the most vulnerable immigrants, refugees, and their communities by facilitating access to services and addressing systemic inequities”.

The centre is based on a series of beliefs which inform their approach and strongly reflect the community driven, empowering approach to reducing health inequities:

·         All people should have access to the resources and supports they need.

·         Anti-oppression principles strengthen our work.

·         The strength and resilience of immigrants and refugees enriches our City.

·         Innovation thrives in a diverse environment.

·         Diverse sources of knowledge inform our practice.

·         Collaboration broadens our impact.

·         We are accountable for the provision of high quality services and programs.

Access Alliance CHC, Toronto

As we walked around the centre, in addition to the well equipped and pristine clinical and examination  rooms  - we were also shown the roof top community garden, the basement 'den' for young people to connect with each other in a safe environment, the Internet 'cafe' area where community members can access information and meet with each other and the range of art work on the walls which had been produced by community members and gave a real sense of ownership. All in all a great facility reaching and providing services to some of those in greatest need.

Some of the art work produced by local young people
 at Access Alliance.

The Access Alliance model of care can be found here.