B20 Health Advocacy

Farah M Shroff, PhD School of Population and Public Health and Department of Family Practice, UBC Faculty of Medicine and Shroff Consulting e: farah.shroff@ubc.ca April 2013

Acknowledgement of Indigenous Stewardship  Iroquois and Missasaga Nations  Unceded Territory

What is Health Advocacy?  Definition(s)  Introductions: Who here has engaged in it?

What does it take to make and keep our community healthy?  Tell a story about your life experience, reflecting on the

many factors that have influenced your health, including (but not limited to) health services.

Delve deeper into the story and identify the factors that affect health and well-being and the ways in which these things are inter-related:  What do you see happening in this story? (Description)  So what does this mean / tell us about the factors that affect health

(Description)  Why do you think it happened? (Explanation)  Now what do we do about it? (Action) OR Images of Health and Factors related to it

The ‘Great’ Equation

Health =Medicine

Social Determinants of Health  Income  Social status  

 

-ethno-racial, sex, class etc Housing Education Social support more

Social Determinants of Health  Employment/Working Conditions  Social Environments

 Physical Environments  Personal Health Practices and Coping Skills  Healthy Child Development

 Biology and Genetic Endowment  Health Services

 Gender  Culture

SDOH According to the WHO, “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”

Health For All  Large Scale Changes

Cuba Kerala  Roots of Health: salutogenesis  But Why? story  Needs more than advocacy  Advocacy: terminology

Farah Shroff 2010

Successful Canadian Campaigns ♦tobacco control ♦seat-belts ♦D & D incorporated legislative changes, social norm changes etc carrot and stick role of physicians and surgeons

Farah Shroff 2010

Health Advocacy Spectrum  Health promotion  Disease prevention

 Treatment  Rehab  Palliation

Farah Shroff 2012

Inspiring HA Within the HA spectrum, where is the best place for you as future physicians to work?

Farah Shroff 2012

Successful HFA  Political will  People’s participation

 Intra-sectoral cooperation  Intersectoral cooperation  Appropriate technology

Farah Shroff 2010

How much richer are the richest 20% than the poorest 20%?

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Health and Social Problems are Worse in More Unequal Countries

Index of: • Life expectancy • Math & Literacy • Infant mortality • Homicides • Imprisonment • Teenage births • Trust • Obesity • Mental illness – incl. drug & alcohol addiction • Social mobility

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Child Well-being is Better in More Equal Rich Countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Levels of Trust are Higher in More Equal Rich Countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

The Prevalence of Mental Illness is Higher in More Unequal Rich Countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Rates of Imprisonment are Higher in More Unequal Countries

Source: Wilkinson & Pickett, The Spirit Level (2009)

www.equalitytrust.org.uk

Head & Heart

HA Approaches Encourage  a focus on the root causes of a problem, with evidence to support solutions

 efforts to prevent the problem  improving aggregate health status of the whole society,

while considering the special needs and vulnerabilities of sub-populations

HA Approaches Encourage  a focus on partnerships and inter-sectoral cooperation  finding flexible and multidimensional solutions for

complex problems  public involvement and community participation

Exercise ď‚— If you could focus on working with an equity seeking

group, which would it be?

-Indigenous communities, racialized communities, teen parents, people in prison, lesbians/bisexual/trans/gays/queer folks, working class people or others ď‚— Discuss your approach to successfully serving this group in your future practice

Working Upstream  Health Promotion

Determinants of Health income social status inequities: ethno-racial, gender, sexual identity, age, location etc

 Changing unequal social structures  Sustainability

environment economy society

Farah Shroff 2010

HA Approaches Encourage  a focus on partnerships and intersectoral cooperation  finding flexible and multidimensional solutions for

complex problems  public involvement and community participation

Disease Prevention  Screening  Testing

 Education  Lifestyle modifications etc

Farah Shroff 2010

Treatment  Ever expanding clinical territory  Hospitals, clinics etc: medical system generally works

well  HA helps: families, clinicians and others

Farah Shroff 2010

Palliation  Assisting people to die with dignity  Dying at home

 Finding peace at the end of life

Farah Shroff 2010

Changing Systems  Hard work  Conflict

 Other professions: lawyers, engineers, teachers

Farah Shroff 2010

Courage my Friends! ‘Tis not too late to build a better world.

-Tommy Douglas

DIALOGUE What does HA mean for you as medical students?

How can you best respond more effectively to health disparities, the broader determinants of health, and the related healthcare needs of vulnerable populations?

Inspiring health advocacy in family medicine: a qualitative study.  Context: The physician’s role as health advocate is identified as a key competency by the Royal College of Physicians and Surgeons of Canada (RCPSC). HA relates to the physician’s responsibility to identify and respond appropriately to the social determinants of health and the healthcare needs of vulnerable and marginalized populations. However, HA is regarded as one of the more difficult CanMEDS roles

to integrate into residency training.  Question: What inspires family medicine residents, educators and physicians to engage in health advocacy and how to meaningfully incorporate HA into medical

training.  Methods: In-depth, semi-structured interviews conducted with a purposive sample of residents, physicians and educators who self-identified or were

identified by peers as health advocates. 9 interviews in total.

Findings  Inspiration came mainly from outside of medicine  Family: parents

 Other role models  Travels: SW  Other exposure to inequities

Farah Shroff 2010

Findings 2 Pivotal moments within medicine …there was a program that we were encouraged to apply for that had us volunteering in this inner city health clinic… [it] gave us the opportunity to live in a northern First Nations community.… [Another] experience was living for a summer in rural Mozambique… I was excited about that program and in that found another sort of community of people who were interested in working in marginalized communities but also working on changing health status and improving health in those communities. And that became a very formative part of my medical education so far.

Farah Shroff 2010

HA in Residency  Mixed feelings  Clinical skills

[R]esidency is a time when the focus is on developing competency at clinical practice…Learning [about advocacy] may therefore not be optimal or even as good as it is in medical school when students are less stressed with the day-to-day aspects of providing care.

HA in Residency 2  Opportunities

♦ research project ♦ could negotiate Lots of verbal support but not much time, funding or other support  Less valued: para-clinical nature

Integrating HA into the Curriculum  time and flexibility  health advocacy-oriented research

 specific advocacy electives  longitudinal residency structures which give residents

control over their own schedules  part-time residencies

Community of Practice and Mentorship  Peers very important to research participants

Whatever one gets involved and passionate about, if there’s people to share that with that becomes very very important, …you realize how important those friendships, connections are, and I realized that a group of people that I worked with, I protested with, or you know tried to change things with, often came up against big roadblocks with, those are hugely bonding experiences and that’s really become my community and that sustains me a lot… if we spent more time thinking about that idea of community around activism or… around health advocacy that we could find some ways to encourage and create that a little bit more, at least facilitate the process.

ď‚— For decades, physicians and medical institutions have been called upon to take a more active role in addressing inequities in health, health promotion and disease prevention. ď‚— While most physicians recognize the importance of working on population

health issues, many are not undertaking activities in this arena. ď‚— Residency education provides an opportunity for HA efforts Brill, J.R., S. Ohly, and M.A. Stearns, Training community-responsive physicians. Academic Medicine. 2002;77(7):747.

Gruen, R.L., S.D. Pearson, and T.A. Brennan, Physician-citizens--public roles and professional obligations. Journal of the American Medical Association. 2004;291(1):94-8.

Furler, J., et al., Health inequalities, physician citizens and professional medical associations: an Australian case study. BMC Medicine. 2007;5:23.

Oandasan, I., et al., Being community-responsive physicians. Doing the right thing. Can Fam Physician, 2004. 50: p. 1004-1010.

Parboosigh, J., Medical schools' social contract: more than just education and research. Can Med Assoc J, 2003. 168(7): p. 852-853.

Rubenstein, H.L., E.D. Franklin, and V.J. Zarro, Opportunities and challenges in educating community-responsive physicians. Am J Prev Med, 1997. 13(2): p. 104-108.

Verma, S., Honouring the social contract: medical schools take social responsibility seriously, in University of Toronto Bulletin. 2005.

Merci! !Gracias! Shukriar! Thanks!