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Closing the gap

Region works with community groups to alleviate health inequities

Stephane Gray, Program Manager, Bell Hotel (from left), Lisa Goss, Executive Director, Main Street Project, and Sharon Kuropatwa, Director - Housing, Supports and Service Integration and Community Area Director for Downtown-Point Douglas
Stephane Gray, Program Manager, Bell Hotel (from left), Lisa Goss, Executive Director, Main Street Project, and Sharon Kuropatwa, Director - Housing, Supports and Service Integration and Community Area Director for Downtown-Point Douglas.
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Gaps in health

Health equity in action

2014 Community Health Assessment report

What is health equity?

BY BOB ARMSTRONG
Winnipeg Health Region
Wave, January / February 2016

Sharon Kuropatwa tells a small story that helps illustrate a much larger one.

In 2011, she was working on a project to convert the Bell Hotel into a residence for individuals with a history of homelessness. At the time, a number of the residents living in the newly renovated facility signed up for home care.

Typically, clients are required to keep track of their home-care appointments. When a client is not at home for their scheduled appointment, the Home Care program still covers the cost of sending staff and uses staff time without actually making a connection for service. If this happens repeatedly, the client's service may be at risk.  

But there was just one problem, says Kuropatwa, who serves as the Winnipeg Health Region's Director of Housing, Supports and Service Integration and Community Area Director for Downtown-Point Douglas.

As she explains, many of the formerly homeless residents of the Bell hadn't lived the kind of life in which set schedules and appointments were a regular feature. As a result, clients were often not home for their scheduled visits, meaning that they did not get their needed service and home-care workers were not making the best use of their time.

After reviewing the problem, the Home Care program came up with a solution. The on-site support workers were able to build relationships with the tenants, get to know them and their schedules, and build up a system of reminders. In addition, staff visits for the building were scheduled in block appointments, so that if the home-care worker arrived and one client wasn't available, another client could be seen instead.

The result, says Kuropatwa, was that the program was able to provide better health care to the residents of the building by adapting to their needs.
In its own way, the story about the Bell and its residents is symbolic of a much larger shift in thinking taking place within the Region, one that is being driven by a desire not just to make health care available, but to make sure it is received by those who need it most.

This approach is embodied in a concept known as "health equity," a term used to describe efforts to ensure everyone in the community has the chance to reach their full potential for health.

The concept was first endorsed by the Region's board in a position statement approved in Dec. 2012. Last year, the board took another step to emphasize the importance of health equity by embedding it in the Region's strategic plan for 2016-2021.

As the position statement notes, "Health equity asserts that all people have the opportunity to reach their full health potential and should not be disadvantaged from attaining it because of social and economic status, social class, racism, ethnicity, religion, age, disability, gender, gender identity, sexual orientation or other socially determined circumstance."

In practical terms, this commitment means the Region will continue to work towards ensuring all the services it provides - either on its own or through partnerships with community-based groups - will be in line with the values and goals of health equity.

The Region's evolving role in housing is a case in point. In the past, the Region's emphasis in housing was on connecting seniors with the appropriate kind of assisted living or personal care homes. More recently, however, the Region has started working with government and community organizations to develop housing options for the city's homeless population, many of whom suffer from a variety of chronic mental or physical illnesses.

In the case of the Bell, for example, the hotel was converted into an apartment building for the homeless based on the "housing first" model. Under this approach, individuals with a history of addictions, mental illness and chronic homelessness are provided housing without having to undergo treatment or receive other services as a condition.

The project was undertaken through a partnership that included the Region, Centre Venture, Main Street Project, and the three levels of government. The building is currently managed by Main Street Project, with the Region providing health services, such as home care.

As Kuropatwa explains, the reasoning behind this approach is fairly straightforward: "In order for people to have stabilized health, they need to have stabilized housing."

Of course, the application of health equity is not limited to housing. Indeed, the Region believes that this approach will prove useful in helping to address a wide range of health issues, particularly the large gap in health status between people living in the inner city and those living in the suburbs. 

This gap was outlined last year in the Region's Community Health Assessment. The 500-page report, released every five years, compares health outcomes across Winnipeg's income quintiles and in 12 community areas, which are also broken down into 25 smaller neighbourhood clusters. A quick look at the report reveals that on most indicators of health, Winnipeg is on average a little healthier than the province as a whole and a little less healthy than the Canadian average.

For example, the average life expectancy in Winnipeg is 80.1 years, which compares to 79.5 years for Manitoba and 81.1 years for Canada. For premature mortality, the rate within the city is 2.9 per 1,000, compared to 3.1 for Manitoba and 2.6 for Canada. Self-perceived health follows the same pattern: 59.5 per cent of people within Winnipeg consider themselves in very good or excellent health, compared to 57.6 per cent for Manitoba and 59.9 per cent for Canada.

But a closer look at the numbers reveals much sharper differences in the health status of people living within the city itself, particularly between those living in higher-income and lower-income neighbourhoods. 

Simply put, lower-income neighbourhoods, which are concentrated in the inner city, particularly in the North End, tend to have higher rates of child mortality, premature death and suicide. People living in these neighbourhoods are also more likely to have diabetes, heart issues, cancer, dementia and hypertension.

Region public health officials say the gap in health status is caused in large measure by factors known as the social determinants of health - issues such as education, housing and employment. Indeed, a 2008 report to the Canadian Senate stated that as much as 50 per cent of health outcomes could be attributed to these factors. 

A report produced by the Region entitled Health For All: Building Winnipeg's Health Equity Action Plan sums it up this way: "Income, education, where you live, the opportunities you had or did not have in childhood, especially early childhood, are among the key factors that shape your chances of good health throughout life."

The gap in health status across the income gradient has the most impact on people in lower-income neighbourhoods. But it also has an effect on the health-care system as a whole, as revealed by a number of measures in the health assessment.

One startling statistic is that the rate of hospitalization for ambulatory-care sensitive conditions (people hospitalized for conditions that can be treated in the community) is 9.1 times higher in the lowest-income community than in the highest. These conditions include asthma, angina, gastroenteritis and congestive heart failure, which, with good primary care, can be treated and managed without the patient being admitted to a hospital.

"Health inequities have significant financial costs - they aren't just unfair and unjust, which by itself should drive us to action," says Horst Backé, Interim Director of Public Health with the Region.

Dr. Sande Harlos, a medical officer of health with the Region, agrees. She says that a report from the Public Health Agency of Canada estimated in 2004 that 20 per cent of Canada's health spending (then $200 billion) could be attributed to socio-economic disparities.

As a result, improving outcomes for the least healthy members of the population could have a positive effect on health care for everybody, according to Hannah Moffatt, Population Health Equity Initiatives Leader for the Region.

"If people are sicker and come to the hospital more often, then you have more people in hospital and longer waits for everybody," says Moffatt.

Of course, tackling these health issues is much more complicated than it might seem.

For example, health issues such as diabetes or cancer are often linked to various risk factors. And, as one might expect, lower-income neighbourhoods also have higher risk factors than higher-income communities. For example, the smoking rate among people 12 years of age and older in Point Douglas is 39 per cent, compared to the city-wide average of 19 per cent (as low as 10 per cent in Assiniboine South). The obesity rate is higher and the immunization rate is lower in Point Douglas. Fruit and vegetable consumption is also lower in Point Douglas, as is travel and leisure-related physical activity. 

Conventional wisdom would suggest that if you can address these risk factors, you can improve health outcomes. But while there is obviously some truth in that, it's not the whole story.

As Harlos points out, the difference in the rates of activity level, fruit and vegetable consumption and other lifestyle factors is much smaller than the difference in overall health.

As a result, she says, it's important to look at "the cause of the causes." In other words, if people in lower-income areas are more likely to smoke or less likely to eat fruits and vegetables, it's important to look at the underlying reasons and search for potential solutions.

This is where health equity comes into play. 

"To close the large health gap shown in the Community Health Assessment, there is no single answer," explains Harlos. "No simple health-care fix like a new drug or technology can close decades of difference in life expectancy," she says.

"But the accumulation of many simple solutions, some as simple as kindness, can. Simple actions across many sectors and at many levels, like better child care, education, job training, income, transportation, health-care services in proportion to need, all add up to better and equitable health for all."

In the current thinking on the health effects of poverty, it's now thought the issue is not only the lack of money for healthy food, recreation or other health needs. Part of the problem, says Harlos, is that growing up in poverty - with uncertain housing and family or other stresses - creates "a toxic soup of stress hormones" that have future impacts on health.

"The health effects of chronic stress should not be underestimated," she says.

Moffatt says that in order to address health inequities, one must first understand the kinds of barriers that organizations put up to those trying to access services.

Fixed appointments (remember the lesson learned at the Bell Hotel) can be a challenge for people whose lives are stressful or who have multiple barriers, like child care or transportation costs, that prevent them from meeting schedules, says Moffatt. Holding programs at locations that are hard to reach by transit prevents those without cars from attending.

Overcoming mistrust can be a challenge when working with people whose past experience has led them to dread encounters with programs and to avoid accessing services.

"What we see is that with poverty and health, there is a system of barriers," says Moffatt. "Sometimes I've sat down and asked, 'Who is accessing this program and who isn't accessing this program, and why?'"

To illustrate her point, Moffatt points to a pre-natal care pilot project as an example of how a health equity approach to care can lead to service improvements for those who need it most.

A recently published assessment of a program called Partners in Integrated Inner-City Prenatal Care (PIIPC) - which specifically focuses on mothers-to-be with the highest needs - found that the program doubled the percentage of women starting prenatal care in the first trimester. And women participating in the program had a 10 per cent lower rate of preterm birth than women with similar backgrounds who didn't participate.

Moffatt says programs with a health-equity focus, like PIIPC, acknowledge that it's necessary to build relationships to remove barriers to health care. "It's about us intensifying our efforts to engage with families facing disadvantage."

Concentrating resources on those who need them most isn't always the most popular approach, in part because it flies in the face of many people's perception of equality. But equity isn't the same as equality. "Sometimes the most inequitable thing you can do is treat people living in unequal circumstances equally," says Moffatt.

While the Region has made health equity a priority, it also recognizes that it can't solve the problem of health inequities alone, says Réal Cloutier, Vice President and Chief Operating Officer for the Region. As he explains, the interconnected nature of health, housing, education, employment and other factors, underscores the need for co-operation among a broad range of government departments and community groups.

Cloutier points to a concept called "collective impact" as a way to bring partners together to address complex problems like health inequity. It's been used by several communities in the United States to address issues as diverse as student achievement, river pollution and childhood obesity. The approach involves bringing together a variety of organizations that can work with a common agenda, a shared system of measuring results, mutually reinforcing activities, continuous communication and a support organization that can act as the backbone to hold the project together.

The Winnipeg Poverty Reduction Council, on which the Region has representation, uses a collective impact approach in its current plan for action and its 10-year plan to end homelessness.

So does the Block by Block Community Safety and Well-being Initiative, which was created to improve community safety and social outcomes for families by unlocking agency, community, and family capacity.

Essentially, the question posed by Block by Block is: "How can the system work with them (families) and remove systemic barriers that may have blocked them from receiving help?" says Cloutier.

The province-wide initiative involves a number of community organizations, plus the Region, Winnipeg Police Service, Winnipeg School Division, and a number of provincial government departments, including Justice, Family Services and Housing, Education, Children, Youth and Opportunities, and Jobs and the Economy.

Staff Sgt. Bonnie Emerson, who was seconded from the Winnipeg Police Service to work on Block by Block and is currently serving as its Acting Executive Director, says a good example of the initiative's work is a project called Thunderwing, which was launched to help families in the North End work to resolve issues that prevent them from achieving their goals towards safety and well-being.

To illustrate Thunderwing's work, Emerson offers an example of an elderly woman who, for various reasons, was evicted from her seniors' residence. As she explains, the woman had a variety of physical and mental health problems as well as some mobility issues. "It was a perfect storm," says Emerson. "She was a wanderer. She also had some mobility issues, so there were concerns for her well-being. None of the shelters and safe temporary locations would admit her because they couldn't accommodate her for a number of reasons, including her many complex issues."

The woman's file was referred to Thunderwing, which also has representatives from the various government and non-government agencies connected to Block by Block. "We identified who was involved with this woman and who could be, based on her wishes and goals," says Emerson. "We got everybody in a room together, including her home-care supervisors, got her panelled (the process for placement in a personal care home) and got her in a (personal care) home. Her medical problems were addressed and stabilized and the safety component was addressed," says Emerson.

"There is no doubt in my mind that if she had been placed in a temporary shelter, she would have wandered," says Emerson. She would have been hurt or dead." That's not because people working in the system weren't trying, she says. It's just that there aren't a lot of mechanisms for people working within the system to share information about people who could otherwise slip through the cracks.

Cloutier says cases like the one involving the elderly woman show the value of having organizations work together to achieve health-equity goals. "We (the health sector) don't own health equity," he says. "Many of our community partners already understand that it's about building the relationships that will allow us all to work together better. To turn this around is going to take a long time, but you've got to start somewhere."

Bob Armstrong is a Winnipeg writer.

Wave: November / December 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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