BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT by Eastern Health

BELL ISLAND HEALTH AND WELL - BEING NEEDS ASSESSMENT PHASE ONE P R E PAR E D F O R T H E

B E LL I S LAN D H E ALTH AN D WE LLN E S S C O M M I TTE E B E LL I S LAN D, N EWF O U N D LAN D AN D LAB R AD O R

VE R LÉ HAR R O P, P h D

Cover photo: Reginald Durdle (Bell Island ‘new’ lighthouse) Cover design and report layout: Rodrigue Savoie Bell Island Health and Well-Being Needs Assessment: Phase One June 2006

ISBN 0-9780873-0-5

Prepared for the Bell Island Health and Wellness Committee, Bell Island, Newfoundland and Labrador. The Bell Island Health and Wellness Committee can be contacted by emailing: bellislandhwc@gmail.com

BELL ISLAND HEALTH AND WELL - BEING NEEDS ASSESSMENT PHASE ONE 2006

prepared for the

Bell Island Health and Wellness Committee Bell Island, Newfoundland and Labrador bellislandhwc@gmail.com

Dr. Verlé Harrop P.O. Box 1402 Bell Island A0A 2V0 vharrop@alum.mit.edu

ACK NOWLEDGEMENTS AND R ESEARCH CONTR IBUTIONS The people of Bell Island, especially those who took part in the telephone survey, focus groups and interviews.

Research contributions Verlé Harrop PRINCIPAL INVESTIGATOR

The Bell Island Health and Wellness Committee, Bell Island, Newfoundland and Labrador; and Eastern Health, St. John’s, Newfoundland and Labrador. The staff of the Dr. Walter Templeman Health Centre, for their input, provision of an on-site office and ongoing administrative assistance. The Office of Primary Health Care, St. John’s, Newfoundland and Labrador for their assistance with data collection. The Atlantic Health Sciences Corporation, Saint John, New Brunswick and the Grand Manan Hospital, Grand Manan, New Brunswick for their collaboration on the comparison of health determinants data between Bell Island, Newfoundland and Labrador, and Grand Manan, New Brunswick. Memorial University’s Health Research Unit, Newfoundland and Labrador for the Bell Island Needs Assessment 2004 Telephone Survey based on survey questions from the 1999 Community Needs Assessment for Grenfell Regional Health Services with additional questions provided by the National Research Council Institute for Information Technology e-Health (NRC – IIT e-Health). The NRC – IIT e-Health Group, Saint John, New Brunswick for their generous support during the early stages of this project, and the National Research Council Institute for Ocean Technologies, St. John’s, Newfoundland and Labrador for use of an office during the early stages of this project.

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Andrea Pike DATA ANALYST

Marcelle Saint-Pierre RESEARCHER AND PROJEC T COORDINATOR

Guy-André Gélinas EDITOR AND BUSINESS DEVELOPMENT OFFICER

Rodrigue Savoie EDITOR AND REPORT L AYOUT

Valerie Ryan COMMUNIT Y LIAISON OFFICER

Cheryl Etchegary STATISTICIAN

Art Morgan SITE SUPPORT, BELL ISL AND

Cynthia Sweeny ADMINISTR ATIVE SUPPORT, BELL ISL AND

Colette Bujold ADMINISTR ATIVE SUPPORT, NRC

René Richard TECHNIC AL SUPPORT, NRC

Pat Craig, Teresita McCarthy, Lori Hann, Wayne Miller, Dr. Alexa Laurie, and Dr. David Allison BELL ISL AND HEALTH AND WELLNESS COMMIT TEE DOCUMENT REVIEW SUB- COMMIT TEE

VERLÉ HARROP | VHARROP@ALUM.MIT.EDU

MESSAGE FROM THE BELL ISLAND HEALTH AND WELLNESS COMMITTEE Bell Islanders have a long and distinguished history of pursuing the best possible acute and primary care for their community. This report is but a carefully placed stepping stone in maintaining that tradition. Spring 2003, the Health Care Corporation of St. John’s, on behalf of the Bell Island Health and Wellness Committee, jointly undertook with Dr. Verlé Harrop, Group Leader, National Research Council, Institute for Information Technology, e-Health Group, to carry out Phase One of a Bell Island Health and Well-being Needs Assessment. The primary goal of this multipartite, two-phase initiative, was the development of Foundational Statements and Strategic Directions enabling the partners to apply the Provincial Strategic Health Plan’s vision, “For all Newfoundlanders and Labradorians to enjoy the best possible health and well-being” and mission, “To provide quality health and community services to improve the health and well-being of individuals, families and communities” to Bell Island. This groundbreaking report marks the transition from thinking of health care as the sole responsibility of the health care system to recognizing that individuals, the community and the traditional health care delivery system have equally important roles to play in the health and well-being of Bell Island’s citizenry. It is with pleasure and with confidence in our ability to jointly recognize and create new opportunities for optimal health and wellness for the citizens of Bell Island that the Bell Island Health and Wellness Committee offers the Bell Island Health and Wellbeing Needs Assessment: Phase One, 2006.

Mr. Patrick Craig BELL ISL AND RESIDENT, CHAIR, BELL ISL AND CONCERNED CITIZENS GROUP, CO - CHAIR, BELL ISL AND HEALTH AND WELLNESS COMMIT TEE

Mr. Wayne Miller SENIOR DIREC TOR, CORPOR ATE STR ATEGY AND RESEARCH, EASTERN HEALTH, ST. JOHN’S

Sincerely,

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

CO - CHAIR, BELL ISL AND HEALTH AND WELLNESS COMMIT TEE

VERLÉ HARROP | VHARROP@ALUM.MIT.EDU

EXECUTIVE SUMM ARY Introduction Bell Island, located in Conception Bay, Newfoundland, is a stunningly beautiful island historically populated by warm, ingenious, hard working Bell Islanders who have deep ties to their families and to the island. Prior to the opening of the iron ore mines in the late 1800s, Bell Island was a thriving farming and fishing community. However, the closing of the mines in the late 1960’s resulted in mass emigration. According to Census Canada, by 2001, the population of Bell Island had been reduced from peak numbers of around 13,000 to 3,078 persons living in 1,215 households. The remaining Bell Islanders are well known for their tenacity. Moreover, their commissioning of this report attests to their willingness to meet difficult challenges head on and to their stalwart commitment to getting the very best for their community. Following is the first step in achieving that goal, the Bell Island Health and Well-being Needs Assessment: Phase One, 2006.

Importance This report is important for five reasons. First, it establishes that this Needs Assessment has been community driven. Second, the report provides a comprehensive baseline, for a discrete population, against which the effectiveness of any future intervention can be measured. Third, the report precipitates a paradigm shift. Bell Islanders can continue to expect programs and services to be provided by the health care system. However, there are equally important policies and infrastructure that the community can put in place and healthy behaviours which individuals can endorse. Fourth, in using Health Canada’s Twelve Determinants

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of Health as the framework for this report, individuals, the community and the health system are well placed to identify meaningful health indicators during Phase Two of the Needs Assessment. Finally, the report highlights opportunities for cost effective but innovative uses of information and communication technologies supporting rural and remote diagnosis, treatment, support and self-care. Without question, the dedicated and progressive Bell Island Health and Wellness Committee that commissioned this report has positioned Bell Island to become a living / learning laboratory with the potential to lead community-based research in Canada.

History Spring 2003, the Bell Island Health and Wellness Committee (BIHWC), whose members represent the Bell Island Community, Eastern Health, and the Department of Human Resources, Labour and Employment, contracted Dr. Verlé Harrop of the National Research Council’s Institute for Information Technology (NRC – IIT, e-Health Research Group), Saint John, New Brunswick, to carry out Phase One of a two phase needs assessment. However, at the end of NRC’s five year funding envelope in March 2005, and subsequent closure of the Saint John office, NRC terminated its involvement in the project. Later, NRC released the Bell Island data back to Dr. Harrop who completed the project.

Existing health services In 2004, the island had two fee-for-service physicians, and a pharmacy. Presently, one physician is retiring and a Nurse Practitioner has recently been hired by the Dr. Walter Templeman Health Centre. The Health Centre,

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which has a complement of 42 employees (41.5 FTE), provides in-patient long-term care, acute, palliative and respite care as well as outpatient and emergency services. Health and Community Services, has 7 employees (6.8 FTE) who provide community living and supportive services, mental health and addictions counseling, health promotion, continuing care, child care services and child, youth and family services. From downtown St. John’s, it’s a 20-minute drive to the ferry terminal at Portugal Cove, then a 20-minute ferry ride across the tickle to Bell Island. The 20 bed Dr. Walter Templeman Health Centre on Bell Island and the tertiary care facility in St. John’s are approximately an hour apart. The island is served by two ferries year round.

Needs assessment According to the 2002 New Brunswick Community Health Needs Assessment framework, a community needs assessment “is a process in which each community decides its own issues and develops its own responses.” Phase One of this needs assessment focused on gathering and interpreting health services and community data for the year 2004. Specific objectives included: collecting data from multiple sources in accordance with the Canadian Institute for Health Information Health Indicator Framework; a community profile; conducting an internal analysis of extant health programs and services; collecting data from other agencies or institutions involved in the broader definition of health care delivery; performing a base-line comparative analysis of Bell Island with the Island of Grand Manan, New Brunswick; and, presenting the findings in a report. All six objectives of Phase One were met. Phase Two will focus on helping the community understand the findings in this report and subsequently set priorities and determine indicators and strategic directions.

Methodology The Needs Assessment used a combined qualitative / quantitative methodology which included: a telephone survey of 401 (40%) of the island’s households garnering an 83% response rate; key informant interviews; focus groups; and, a review of relevant historical documents, including provincial / federal agency reports and websites. Additional data sources included: the 2001 Census; Bell Island Community Accounts; and, deidentified data from the Health Centre on Bell Island; the province’s Medical Care Plan; the Newfoundland and Labrador Provincial Drug Plan; and finally, the St. John’s Health Care Corporation and Health and Community Services (now amalgamated under Eastern Health). Because of the small population, data were

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often aggregated and therefore offer an indication rather than representing an absolute value.

Study limitations This study had a number of limitations particularly around the telephone survey. People on social assistance were under represented. Although 44% (Community Accounts, 2005) of the Bell Island population was receiving social assistance in 2001, only 3% of the telephone survey respondents acknowledged receiving government support. There is also an age bias. The survey tool did not canvas the health and well-being needs of children under 19 years of age, babies or preschoolers. Finally, even though the Department of Social Services devolved into two departments back in 1998, namely, Health and Community Services and Human Resources and Employment, the Health Research Unit uses the term Social Services throughout in the telephone survey. More care should have been taken in the survey design and around the timing of the deployment of the survey. For a number of reasons, including the requirements of the ethics committees, the survey was done in advance of key informant interviews. These were the causalities of working from a distance during the early stages. Finally, we were challenged to elicit reliable quantitative data from provincial governments, federal agencies and the health system generally. Although parties, without exception, made every effort to help with data acquisition, in many cases the data had not been captured, data were not consistent across sources, or data had been captured in a way that wasn’t compatible with our purposes.

Structure of the report The Needs Assessment was structured around Health Canada’s Twelve Determinants of Health, namely: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Income and social status; Social support networks; Education and literacy; Employment and working conditions; Social environments; Physical environments; Personal health and coping skills; Healthy child development; Biology and endowment; Health services; Gender; and, Culture.

The report starts by looking at how the determinants play out across the Bell Island community as a whole. In subsequent chapters, we looked at how health and well-being issues raised at the community level, for example, social status, literacy, recreation, family struc-

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ture, and so on, directly impact the health and well-being of infants and preschoolers, children, youth, adults and seniors. Following these chapters is the chapter on Health Services. It was written from the perspective of those working within the health system. Each chapter begins with background data supporting the espoused issues. Each chapter ends with a summary of the challenges identified in the chapter and a preliminary list of suggestions for consideration. Based on the findings presented in each chapter, a customized list of indicators is proposed and opportunities for further research cited. The next to last chapter presents a comparative analysis of Bell Island and the Island of Grand Manan in New Brunswick. This chapter is structured as a discussion document. The report concludes with a chapter summarizing the meta-thematic challenges, overarching suggestions for consideration and preparatory steps for Phase Two.

Select findings As Health Canada points out, “Our health is closely tied to the social and physical environments around us – where we live, work and play. These factors, the quality of parenting, nutrition, exercise, substance abuse, unemployment, poverty and the experience at work are as important to our health and well-being as adequate access to primary care.” Following are summaries of those very factors for the Bell Island community as a whole, the five age groups and health services.

Challenges facing the community x x x x x x x x

x x x x x x x

issues around income and social class; limited employment opportunities; need to maintain adequate ferry service; ongoing emigration; adequate financial services; adequate and clean water; going green(er): reduce, reuse, recycle; recreational facilities that meet the needs of all age groups particularly, infants and preschoolers, youth and seniors; need for community leaders; gender equality at home and at work; devolving family structures; a community strategy to address domestic violence, abuse and neglect; the financial and psychological burden of Wabana’s legacy infrastructure; cultural themes of loss, isolation and disempowerment; transparent protocols and public awareness campaign around priority ferry access for patients

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who are required to travel to St. John’s for medical treatment; x support and overnight accommodation for staff detained on Bell Island due to unfavorable weather and ferry conditions; and, x ubiquitous broadband supporting education and e-health.

Challenges facing infants and preschoolers x ongoing stigmatization and isolation of mothers and babies on social assistance; x number of families with infants and preschoolers living below the Low Income Cut Off (LICO); x increasing number of Intakes and Protective Interventions; x poor dental hygiene; x exposure of infants and preschoolers to secondhand smoke; x universal and adequate access to prenatal classes; x limited engagement on the part of male lone-parent families and dads; x under-utilization of Brighter Futures; x lack of adequate and age appropriate recreational facilities x under-utilization of social workers offering support for parenting and care giving; and x better internal understanding and coordination of Eastern Health services and programs for infants and preschoolers.

Challenges facing children x x x x x

families with children living in poverty; inadequate year round access to nutrition; poor dental hygiene; prevalence of overweight and obese children; adults’ addictive behaviours perceived to impact their ability to provide and care for their children; x enhanced parenting skills and positive parenting role modeling; and, x absence of formal organizations and / or absence of parental involvement in organizations focused on strengthening parents’ relationships with their children and the community.

Challenges facing youth x age appropriate social and recreational activities and facilities; x a place for teens to go and hang out, surf the net, play pool, listen to music and talk; x less than 100% of youth graduating from high school; x limited employment opportunities; x poor dental hygiene; x ready access to family planning and birth control;

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x ready access to crisis management and support; and, x self-reported ready access to and use of tobacco, alcohol, prescription and street drugs.

x concerns regarding the community's and health system's ability to meet the long-term care needs of an increasing number of ageing baby-boomers.

Challenges faced by health services Challenges facing adults x perceived lack of accountability on the part of the system and recipients around social assistance; x low adult literacy rates; x programs to support citizens who want to upgrade their formal education or job readiness skills; x health education around chronic disease management, prevention, healthy behaviours and self-care; x identification, diagnosis and treatment of adults struggling with at-risk behaviours such as obesity and inactivity, drinking, gambling, smoking, prescription and street drugs; x absence of traditional support groups like Alcoholics Anonymous, Gamblers Anonymous, Weight Watchers; x improved usage rates for pap and breast exams; x formal assessments and programs for adults with special needs; x a better understanding of the etiology, prevalence and treatments around mental health; x need to determine the base-line number of diagnosed diabetics; and, x regular access to allied health professionals (physical therapists, occupational therapists, dietitians, chiropodists, massage therapists, dental hygienists, chiropractors, recreational therapists, and so on).

Challenges facing seniors x x x x x x

x x x

x x x x x

poverty; social isolation; low literacy levels; up to date personal medication lists; access to education and coaching around chronic disease management and self care; education for the community and care givers around the health, wellness and prevention, care and enablement of seniors; appropriate and timely use of available homecare services; perceived incidence of senior abuse; education for families, professionals and the general public focused on identifying and eliminating senior abuse; a dedicated social worker for seniors; access to allied health professionals; age and ability appropriate recreational facilities; access to adequate banking services; education for seniors and families regarding available services and financial resources; and,

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x services and programs that encompass the entire health care delivery continuum, to include acute interventions, chronic disease management, primary care, prevention, health and wellness; x strategies for reaching out and meeting the health and well-being needs of Bell Islandâ&#x20AC;&#x2122;s citizenry living below the Low Income Cut Off (LICO); x systematic identification, diagnosis and treatment of persons at risk due to gambling, alcoholism, smoking, obesity, inactivity and street or prescription drugs; x an overarching and integrated plan to address domestic abuse and family violence; x allocation of staff time and resources to address education needs around prevention, health and wellness, and chronic disease management; x the need for specialized staff for example: nurse practitioners, adult and senior social workers, mental health addictions personnel, health education and prevention specialists and so on; x allied health professionals to complement and leverage the health and well-being efforts of the existing primary health care team; x the vision, philosophy, use and layout of the Health Centre and Bennett Street sites; x need for management in St. John's to better understand the context and inherent challenges of working on Bell Island; x securing backfill staffing for physicians, lab and x-ray technicians, community health nurses, child social workers, mental health / addictions counselor, and so on; x a technology infrastructure to support next generation telemedicine, information and communication technologies; x ubiquitous access to broadband supporting Picture Archiving and Communication System (PACS), telehealth and community-based television; x standardized data acquisition and access resulting in valid and relevant analysis of health data; x meaningful indicators for new and extant health services and programs; x lab and x-ray services; x detailed protocols to address challenges faced by support staff and patients when arranging for and following up on medical treatment and appointments in St. Johnâ&#x20AC;&#x2122;s and surrounding environs; x relationships with postsecondary educational institutions, industry and provincial and federal institutes; and,

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x communication between the Health Care Corporation and Health and Community Services, and between these institutions and the community.

Overarching challenges The following high level challenges are germane to the community, individuals and the health system. Note that according to the Bell Island Health and Well-being 2004 Telephone Survey, only 40% of respondents rated their health as excellent or very good. The following data may shed some light on why this number is so low. 1. The stigmatization and marginalization of persons on social assistance x Percentage of the population on social assistance in 2001: 44.4% (Community Accounts, 2005)

and that a true picture will emerge when the cost of these at risk behaviours is trended over time. 3. The need for improved literacy levels, formal education and training x Graduation rate 2003 – 2004: 74% (Indicators 2005: A Report on Schools) x Percentage of adults aged 20 and older without a high school certificate: 50% (2001 Census) 4. The need for a robust information and communication infrastructure x Dial up and limited high speed serviced solely by Aliant (Wabana Town Council; Aliant, 2006) 5. The need for allied health professionals x Presently, a dentist visits Bell Island once a week

x Percentage of the population living below the LICO: 51% (2001 Census)

High level considerations

x Median household income: $17,500 (2001 Census)

Recognizing that success will require an interdisciplinary approach, and that progress will be incremental:

2. The pervasiveness of at-risk behaviours (obesity, inactivity, gambling, alcohol and tobacco consumption, and use of illegal and prescription drugs) x Proportion of Adults with a self-reported overweight / obese BMI: 64% (Telephone Survey, 2004) x Community spending on Atlantic Lottery Corporation sponsored gambling activities: $1,980,761 (Atlantic Lottery Corporation, 2004) x Community (on island) spending on alcohol: $1,624,965 (NL Liquor Corporation, 2004) x Community spending on cigarettes: ~ $1,714,606 (Telephone Survey, 2004; Tobacco Fast Facts, 2004) x Combined total spending on Senior Citizen’s Drug Subsidy Program and the Provincial Income Support Drug Program in 2004: $1,269,555.99; 25 prescriptions / per eligible beneficiary, annually (Newfoundland and Labrador Prescription Drug Program, 2004) Monies spent on at risk behaviours on Bell Island are noteworthy especially in light of the small adult population (2,235 20 years of age and older, 2001 Census) and low median household income ($17,500, 2001 Census). If monies spent on at risk behaviours were averaged across Bell Island’s adult population, each Bell Island adult 20 years and older would have spent roughly $2,380 on tobacco, alcohol and gambling in 2004. This amount translates into $45.77 weekly or $198.33 monthly in 2004 or 14% of the annual median household income in 2001. Be advised that these numbers are just a starting point

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1. Social Status: ensure proportional representation of persons on social assistance in Phase Two. Also make sure that persons on social assistance are members of the Bell Island Health and Wellness Committee. Their involvement in setting priorities is key to the community moving forward in any meaningful way. 2. At-Risk Behaviours: enable citizens, the community and the health system to work together to successfully tackle the community infrastructures and cultural norms presently supporting at-risk behaviours, namely: obesity, inactivity, gambling, alcohol and tobacco consumption, and use of illegal and prescription drugs. 3. Education: use incentives to promote improvements in health, academic achievement levels, literacy training, and job training. 4. Information and Communication Infrastructure: provide ubiquitous broadband information and communication infrastructure that will support data collection and management as well as distance and online: diagnosis, treatment, education, support and self-care. 5. Allied Health Professionals: provide access (real and virtual) to combined public / private services of allied health professionals to signal a shift in focus from acute events to a focus on prevention, wellness and chronic disease management. Services would include, but not be limited to: physiotherapy, podiatry, dietary consults, occupational therapy, massage therapy, optometry, dental hygiene and chiropractic services.

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Opportunities for further research

More specifically:

Following are four suggestions for further research that would have immediate benefit for the three primary stakeholders, namely, the community, individuals and the health care system.

x study the community's extant cultural norms and taboos around gambling (VLT's, tear-aways, Bingo, online gambling and other gambling-based activities);

1. Pilot the research and development of a grass-root, Bell Island Health and Wellness TV channel (Bell Island Community Channel – BIC-TV). The concept is for Bell Island to have a communityowned and operated television channel. Content for the channel would be produced by Bell Islanders for Bell Islanders. Content could include: children’s ads promoting dental hygiene; the broadcasting of: exercise sessions at the Wabana Complex; school council meetings at the elementary and high school; a weekly SuperNanny or Nanny 911 parenting club; a Nurse Practitioner and Community Health Nurse providing instruction on how to care for the elderly at home; youth discussing ‘at risk’ behaviours or upcoming employment opportunities; community postings of ‘Boil Water Orders’, and so on. According to findings from the Bell Island Needs Assessment 2004 Telephone Survey, after health professionals, television is the most common source for health information. Production values for the cable channel would be similar to CBC’s highly popular programs, ‘Here and Now’ or ‘Cooking with Carl’. This suggestion, of a community TV channel, is in direct response to the increasing number of aging adults with low literacy rates and the dire need for education and positive role modeling around healthy lifestyle choices, such as activity and diet, chronic disease management (diabetes, depression), dental care (hygiene), families (caring for the elderly, modeling healthy family behaviours), alternative health and wellness options (homeopathic medicines, massage) and so on. In addition to being available in citizen’s homes, BIC-TV could ride the television airwaves on the ferry, in the Health Center’s waiting room, the post office and in school hallways. 2. Research the impact of emerging family structures on health and well-being outcomes. Using a Participatory Action Research (PAR) methodology and PHOTOVOICE, investigate the drivers, socio-economic impact, health and well-being outcomes of: adult children living with their parents (225: 2001 Census); single parent families (29% of all families: 2001 Census); and, single seniors living alone (79%: 2001 Census). 3. Commission an in-depth case study to fully investigate and understand the impact of gambling in this rural and remote community.

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x determine the impact of gambling on the health and welfare of children and families in the community; x investigate the relationship between gambling, street and prescription drugs, and alcohol consumption on the island and the impact on health and wellness outcomes; x examine the impact of gambling on community organizations and their ability to raise monies and reinvest those monies in the community; x determine the impact of VLT gambling on the community's economy and the impact were VLT gambling to be curtailed or removed; x from the perspective of the individual, the community and the health care delivery system, investigate how to address the challenges that gambling presents; x compare findings with the provincial 2005 report, Newfoundland and Labrador Gambling Prevalence Study, November 2005. Identify the differences and determine how the findings, specific to a small rural and remote community, can inform policy for the community, the health care system and government; and, x formalize the process and results of doing all of the above, so that best practices may be replicated in other rural and remote communities in Newfoundland. 4. Research and develop innovative uses of new and old information and communication technologies supporting primary health care in rural and remote communities. Many small isolated communities in Newfoundland share the challenges that Bell Island currently faces: gambling and alcohol addictions, care of the elderly, restricted access to allied health professionals, to name but a few. Nancy Milroy-Swainson, Director of Health Canada’s Primary and Continuing Health Care Division has said that, “Primary Health Care is about being responsive to changing circumstances and health needs of Canadians.” Ten years ago, who would have predicted gambling of this magnitude on Bell Island? Moving forward, we need to investigate and realize the potential and financial advantages of web and telephone technologies to support diagnoses, treatment, education, support and self-care. For example, 1–800 numbers could be used to host virtual meetings of Alcoholics Anonymous or Gambling Anonymous. Online desktop

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computers and 1–800 numbers or Skype could be used to connect virtual communities of patients and caregivers with specific needs. Leverage the lessons learned, around hosting virtual support groups, from experienced providers like Massachusetts General Hospital in Boston, arguably one of the world leaders in virtual patient / caregiver support groups.

Potential partners The Faculty of Medicine at Memorial University is an obvious partner because it has: the Centre for Collaborative Health Professional Education; the Office of e-Health; the Primary Care Institute; and the Canada Research Chair in Health Promotion and Community Development within the Division of the History of Medicine and Community Health. Bell Island could be an ideal living / learning laboratory for the Centre for Collaborative Health Professional Education. Other university departments that could potentially collaborate on health and well-being R&D include, but are not limited to: the Computer Science Department; the Business School; the Department of Physical Education; the Nursing School; the School of Social Work; the Sociology Department; and the Psychology Department. Other potential local partners include: Eastern Health, the Office of Primary Health Care; the Centre for Applied Health Research; and the Newfoundland and Labrador Centre for Health Information. Potential stakeholders are not limited to Newfoundland and Labrador. Other universities, institutes and federal agencies with a special interest in communities, health and wellness and the determinants of health may be interested in partnering with the Bell Island Health and Wellness Committee. In particular, universities with programs in urban / rural planning, occupational therapy, dentistry, pharmacy, health economics and policy. Institutes focused on rural and remote community economic development, on seniors and on community involvement in health and wellness are also potential partners. Industry is another option. Potential partners could include: Google, the Royal Bank, the Microsoft Foundation and so on. Finally, one would anticipate federal agencies such as: Health Canada; the Canadian Institute for Health Information; the Canadian Institute for Health Research; Canada Health Infoway; and the Canadian Population Health Initiative would be interested in the opportunities for research and development that a living / learning laboratory on Bell Island affords.

Who will be interested in this report? Bell Island is a rural and remote community, with a discrete population, literally on Memorial University’s

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doorstep. Moreover, it has a highly functioning interdisciplinary committee coming to the table with clearly articulated needs and a baseline. Bell Island’s potential to function as a living / learning laboratory supporting community-based collaborative health and wellness presents invaluable research and development opportunities. This report will be of interest to politicians, administrators, researchers, students, institutes and industry.

Business opportunities An island as a living / learning laboratory also presents a number of business opportunities. More specifically, health and wellness on Bell Island, under the auspices of the Bell Island Health and Wellness Committee, has the potential to become an economic tool for wealth development. There are commercial opportunities around innovative uses of information and communication technologies required to support health and wellness in rural and remote communities. A 1–800 virtual support service, with the potential to go nationally, would be one example. There are also commercial opportunities around the population’s participation in health and wellness research and development. The island already has a history of successful co-operatives. However, the best business and citizen participation models will have to be determined. Finally, the processes, lessons learned and grass roots content around BIC-TV could be packaged and marketed as a valueadded service, by Bell Islanders, to other rural and remote communities in Newfoundland and Labrador and beyond.

Next steps 1.

Complete Phase Two of the Health Needs Assessment. Hold a series of study sessions, between the Bell Island Health and Wellness Committee and the research team, focused on fully understanding the findings in this report. The next step is to form seven special interest groups around the community, health services and the five specific age groups. These special interest groups will be instrumental in establishing priorities, and identifying indicators and strategic directions.

Optimize the membership of the Bell Island Health and Well-being Committee so it has the collective skill-set needed to broker community outreach, research, funding, and commercial opportunities.

Under the auspices of the Committee, position Bell Island as a living / learning laboratory for community-based, collaborative primary health care research and development. This would

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involve formalizing the membership and status of the committee, exploring appropriate citizen participation models and appointing a scientific director. 4.

The Twelve Determinants of Health Framework requires a holistic, integrated approach in order for a community to achieve optimal health and wellness. In other words, addressing the challenges would require government departments responsible for health care, economic development, education, infrastructure and so on to work together. To achieve this end, ask Premier Danny Williams to strike an inter-departmental committee tasked to support health and wellness in communities. Offer Bell Island as the pilot site for this undertaking.

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Conclusion The Health and Wellness Committee and Eastern Health are to be commended for their commitment to the people of Bell Island and for their persistence and vision in moving forward. There is no question of their success. With this report in hand, the Bell Island Health and Wellness Committee and Eastern Health have what they need to lead the reshaping of Primary Health Care in Canada and, in the process of doing so, ensure optimal health and well-being for the citizens of Bell Island.

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TABLE OF CONTENTS (ABR IDGED) 1 2 3 4 5 6

Introduction: the story behind the research

Methodology: what’s in a needs assessment?

Bell Island: who we are and where we live

Introduction to the chapters What role does the community play in our health?

Our espoused health and well-being needs

6.1

7 8 9

6.2 6.3 6.4 6.5

appendix

Infants and preschoolers

Children

Youth

Adults

Seniors

Health Services: provision and utilization

Dare to compare: Bell Island and Grand Manan

103

Towards Phase Two

123

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Bell Island Community Profile

appendix

Overview of the three most common reasons for Bell Islanders from ages zero through seventy-nine to be admitted to hospital from 2001 – 2004

appendix

135

NL and NB Provincial Drug Plan Comparisons

appendix

129

137

List of abbreviations and definitions

139

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1 INTRODUCTION THE STORY BEHIND THE R ESEARCH

It is important to put this report in a context. As Following a round of correspondence and several noted in the introductory letter from the committee, meetings, the Bell Island Health and Wellness Commithistorically, Bell Islanders have taken an active role in tee (BIHWC) was formed, with representation from the ensuring health services on the island. In March 2002, Bell Island Joint Committee on Health Care, the Health the Hay Group Report, which was commissioned by Care Corporation of St. John’s, Health and Community the Health Care Corporation of St. John’s, made a Services – St. John’s Region, the Department of Human number of recommendations which directly affected Resources and Employment and the community of Bell the Dr. Walter Templeman Health Centre. The primary Island. The Bell Island community identified Dr. Verlé recommendation was to convert the Health Centre to Harrop as a resource to develop a study of the health an urgent care centre with reduced hours. In response care needs of Bell Island. In recognition of the progress to the Hay Report, a group of concerned citizens met made by both committees the Minister of Health and with the Minister of Health and Community SerCommunity Services issued a cheque in support of the vices, Mr. Gerald Smith. Following this Needs Assessment. Subsequently, in Spring 2003, meeting, citizens decided to form the Health Care Corporation of St. John’s an action group that was reprenever undertook with Dr. Verlé Harrop and the sentative of the community. This National Research Council (NRC) to carry doubt that a small action group was comprised of out the Bell Island Health and Well-begroup of thoughtful persons from health care, the ing Needs Assessment. town council, Boys’ and Girls’ citizens can change the The NRC e-Health Group, which had a Club, education, the RCMP, national mandate, welcomed the opseniors and the general public. world. Indeed, it’s the only portunity to do the needs assessment The aim of the action group thing that ever has for two reasons. First, the e-Health was to be proactive in protectGroup wanted to better understand, MARGARET ing and enhancing the health care first hand, the information and communiMEAD of Bell Island. After several meetings cation technologies required to support rural and much discussion the group decided and remote health care delivery. Second, the to develop a survey that would help to deterNRC e-Health Group was committed to researching mine the health care needs of the island. A letter was and developing e-tools and infrastructure that would sent to the Minister of Health and Community Services enable citizens and communities to become more to determine if any financial assistance was available proactively engaged in chronic disease management, to develop such a survey. The Minister responded that prevention and wellness. Unfortunately, subsequent some financial help could be available. He further sugto the end of NRC – IIT’s five year funding envelope gested that the committee should work in conjunction to March 31, 2005, the NRC was not able to continue with the Health Care Corporation and Health and Comwith the needs assessment. However, NRC enabled Dr. munity Services – St. John’s Region. Harrop to continue with the project independently.

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BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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1 | INTRODUCTION

In this introduction we will look at the history of health care services on Bell Island leading up to the Needs Assessment. Then we’ll look at changes in the provincial and broader Canadian health care delivery landscape that are making us rethink how to best meet Bell Island’s needs. Finally, we’ll introduce the framework and lenses needed to understand and make use of the findings in this report.

Where have we come from? Over the last 40 years there have been significant changes in the structure of health care delivery on Bell Island. In 2006 we find ourselves at another juncture. In order to fully understand the role Bell Islanders play in relation to health services, it is important to appreciate the community’s investment in days past and their political influence moving forward. The Dr. Walter Templeman Hospital on Bell Island was built, in large part, as a result of public campaigning and the fund raising efforts of Local 421, United Steel Workers of America. The hospital, named after the island’s longest serving doctor, opened in 1965. The following year, Bell Island residents received a double blow with the death of Dr. Templeman and the closing of the iron ore mines. For the first twenty years, the Dr. Walter Templeman Hospital was operated by the Cottage Hospital Division of the Provincial Department of Health. Over that time period, the forty-bed inpatient facility added 24-hour emergency services and two ambulances. The community also had the services of a visiting dentist, Public Health nurses and a five-bed licensed boarding home. In 1985, operation of the hospital transferred to St. Clare’s Mercy Hospital in nearby St. John’s. Shortly after this, an advisory committee was formed in 1987 to report to the Board of Governors of St. Clare’s. The Advisory Committee, after surveying the residents of Bell Island, determined that health services should be delivered both in the hospital and in the community. The Committee highlighted the need for “illness prevention, health promotion, public health services, a community health physician and home care for people recently discharged from hospital.” The nursing unit at that time also proposed that long-term and acute care patients no longer share the same unit. Finally, the Advisory Committee recommended that the hospital’s mandate be changed from that of an acute care hospital to that of a community health centre. It further recommended the closure of ten hospital beds to facilitate office space for the administration of Community Health Services. The Board of Governors of St. Clare’s Mercy Hospital approved the recommendations and presented them to the Government.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Following another health care needs assessment conducted in 1993, operation of the Dr. Walter Templeman Health Centre was transferred to the Health Care Corporation of St. John’s in 1995. The Advisory Committee reported that, following a reduction of another ten beds, the centre now had twelve longterm, six acute care and two respite / palliative care beds. In addition, the centre provided emergency and ambulatory care, laboratory and x-ray services as well as ambulance services. A new Advisory Committee, the Bell Island Health Advisory Group was formed in 1996. This group included one trustee each from the Department of Health and Community Services and the Health Care Corporation of St. John’s, four staff members and six community members. Their purpose was to advise both government branches and the Bell Island community. The possibility of further change to the Dr. Walter Templeman Health Centre surfaced again in 2002. With the Health Care Corporation of St. John’s facing an $8.6 million dollar deficit, the Minister of Health and Community Services commissioned the Hay Group to conduct an operational review. With regard to the Bell Island operation, the Hay Group offered its opinion that “It is highly improbable that the Centre will ever be capable of providing the kind of care that is expected of hospitals today and in the future” (Hay Report). The 47th of the Group’s 119 recommendations suggests converting the Dr. Walter Templeman Health Centre into an outpatient primary care health centre. The Hay Group estimated that such a conversion would result in a 25% – 30% reduction in operational costs at the facility while still providing “effective, high quality medical care services to Bell Island’s residents.” Implementing recommendation #47 would include: x eliminating inpatient services; x converting the emergency service into an Urgent Care Centre operating at reduced hours; x using Acute Care Nurse Practitioners as a ‘low cost option’; x creating a primary care home visiting service for the elderly; and, x having x-ray and laboratory testing done in St. John’s instead of on Bell Island. In the response to the Hay Group Report, the Health Care Corporation of St. John’s, 2002, noted that 87 of the 119 recommendations had been implemented or were in the process of being implemented. Recommendation #47 was not one of them. Converting the Dr. Walter Templeman Health Centre into an outpatient

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1 | INTRODUCTION

centre was, the corporation said, one of the recommendations under ongoing assessment. Residents of Bell Island have always had to leave the island to seek specialized care and testing in St. John’s or elsewhere. However, they have been able to depend on primary inpatient care at their community hospital / health centre since 1965. For many reasons Bell Island now finds itself at a crossroads. Advances in medical knowledge and accompanying technologies between 1965 and 2005 are legendary, as are developments in the way we now think about Primary Care, Primary Health Care and Public Health. With these conceptual and technological advancements come changes in roles and foci, opportunities and challenges.

In accordance with Newfoundland and Labrador’s Provincial Strategic Health Plan, the foundational principles guiding this Needs Assessment are: peoplecentered, accessibility, accountability, affordability, equity, evidence-based, quality and sustainability. Taking a minute to elaborate on these principles, as laid out in the Terms of Reference for this study, will help us better understand how they have shaped the data collection, analysis and presentation of the findings in this report. 1.

People-centered: The interests of individuals, families and communities are paramount. All decisions or recommendations for action shall be based on an objective assessment of client needs.

Partnership and collaboration: The capacity of our community and our organizations will be enhanced through developing partnerships and collaborative approaches to addressing priorities for regional planning. This may include working with other stakeholder groups such as the Strategic Social Plan committees, other communitybased organizations, and building on opportunities to develop new and innovative partnerships. Existing organizational structures and mandates should contribute to meeting the needs of the people.

Priorities, innovation and results: The focus shall be on strengthening linkages and finding and implementing new solutions for our regional strategic priorities. This work will be undertaken with openness to new ideas, and the desire to target resources to the high priority needs that eliminate barriers encountered by consumers. This will result in the creation of a more seamless, affordable, accessible and comprehensive health and community services system in the St. John’s region.

Quality and the use of evidence: The quality of service is enhanced when the outcomes of treatment and interventions are built upon a foundation of research and evidence. To ensure the quality of our decision-making we will build our plans on a foundation of research evidence and a coordinated approach to service delivery.

Where are we going? Until recently, health care delivery focused primarily on the provision of medical services in acute (hospital) and primary care settings. In recent years, the circle has widened to include citizens and communities and to embrace prevention, health and wellness. There are several reasons for this shift. As Health Canada points out, in developed countries worldwide, we are now beginning to understand that “Our health is closely tied to the social and physical environments around us – where we live, work and play. These factors, the quality of parenting, nutrition, exercise, substance abuse, unemployment, poverty and the experience at work are as important to our health and well-being as adequate access to primary care” (Determinants, p. 1). The World Health Organization (WHO), in its 2003 report called Social Determinants of Health: The Solid Facts, 2nd Edition, notes that “As social beings we not only need good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work. Without these we become more prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health” (p. 9). Our growing understanding of these social and physical factors in relation to existing knowledge of health status and system performance has been formalized by the Canadian Institute for Health Information (CIHI) in a Health Indicator Framework. In recent years, the CIHI Framework has had a profound impact on health policy in Canada. Moreover, the CIHI Framework has informed the province’s strategic health plan and directly impacted the principles guiding this Bell Island Health and Well-being Needs Assessment.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

How are we going to get there? To summarize: collaboration between the health care system, communities, individuals and their families, in new and innovative ways, is key to 21st century health care in Newfoundland and Labrador. This report marks a shift in roles and focus from illness and institutions to health and well-being, individuals and the community.

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2 METHODOLOGY:

WHAT ’ S IN A NEEDS ASSESSMENT?

The 2002 New Brunswick Community Health Needs Assessment framework document describes a Community Health Needs Assessment as an attempt to measure the health priorities of individuals and their community. To elaborate, a Needs Assessment involves “gathering information about health (facts and opinions); gathering information about health resources available in the community (assets); determining what issues are most important for the community (priorities); building commitment and support to work on addressing community health (partnership).” As the New Brunswick document goes on to say, a Community Health Needs Assessment “is a process in which each community decides its own issues and develops its own responses.” By way of contrast, an operational review, such as the Hay Group Report, focuses on the internal operations of an organization in order to determine how they can operate more economically, efficiently and effectively. The value of the Needs Assessment is that it establishes a baseline – an inventory of existing health care services and how they are used. As importantly, the Needs Assessment provides an accompanying snapshot-in-time of the community’s espoused health and well-being needs. The value of the snapshot and baseline cannot be overstated. These baselines are the benchmarks against which the success, failure or potential usefulness of any future health and well-being intervention is measured.

Structure of the needs assessment A true community-based Needs Assessment can take, on average, three years to complete and require a significant investment of time and money. The Bell Island

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Health and Well-Being Needs Assessment was no exception. The Bell Island Needs Assessment consists of two Phases. Only Phase One is covered in this report. Broadly stated, during Phase One of the Needs Assessment, a critical, comparative analysis and interpretation of health and community information was conducted in order to determine the relative importance and priority of multiple health issues facing the residents of Bell Island. During Phase Two of the project, it is hoped that the Bell Island Health and Wellness Committee will be able to develop a set of Foundational Statements (vision, mission, values and guiding principles) for the delivery of health and community services for Bell Island. The intent of Phase Two is to design a bridge between the current status and the desired future state of health and well-being on the island.

Phase One objectives The specific objectives of the Community Health Needs Assessment for Phase One were as follows: Objective 1: Collect Data from multiple sources in accordance with the Canadian Institute for Health Information (CIHI) Health Indicator Framework. Data sources may include the Newfoundland Centre for Health Information, (NLCHI), Community Accounts and CIHI whose primary function is to identify and analyze specific indicators. Objective 2: Conduct an analysis of the external environment of Bell Island (development of a community profile of Bell Island).

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2 | METHODOLOGY: WHAT’S IN A NEEDS ASSESSMENT?

Objective 3: Conduct an internal analysis of current health programs and services provided on Bell Island. Objective 4: Collect feedback from other agencies and institutions that are involved in or are impacted by the delivery of health and community service programming education, human resources and employment, and municipal affairs. Objective 5: Identify a comparable community, on an island with a ferry service, and present a comparative analysis of key indicators. Objective 6: Present information in a written report to the Bell Island Health and Wellness Committee. Of particular interest is objective number five, ‘a comparison of key indicators with a comparable community’. The Bell Island Health and Wellness Committee chose to be compared with the Island of Grand Manan, located in the Bay of Fundy, New Brunswick. Grand Manan and Bell Island have approximately the same size population. However, key indicator data tell very different stories about each island’s health and wellbeing infrastructure and the people who live there. The purpose of the comparison between Bell Island and Grand Manan is twofold. First, it helps put the data presented in previous chapters in a context. In other words, what we think of as the norm for our community might not be the norm for another community. Second, the comparison provides us with a window on what we might want to change and the possible impact that those changes could have on our community. However, before embarking on any of the above, the research team submitted its research proposal and survey tool and received formal approval from the Memorial University Human Investigations Committee and the National Research Council’s Ottawa Research Ethics Board. The role of these university and regulatory committees is to ensure that the research complies with ethical standards and that the privacy of Bell Islanders isn’t compromised.

Methodologies During Phase One, researchers used a combined qualitative and quantitative methodology. Key data sources included the most recent 2001 Statistics Canada Census data and an extensive telephone survey of 400 households on Bell Island carried out by the Health Research Unit at Memorial University in St. John’s. The survey instrument was based on the Community Needs Assessment for Grenfell Regional Health Services 1999 survey instrument developed by the Memorial Univer-

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

sity of Newfoundland’s Health Research Unit. NRC eHealth added additional questions relating to respondents’ use of technology and understanding of personal health data. The telephone survey on Bell Island was very well accepted with a response rate of 83%. A total of 401 out of 481 eligible residents (representing 40% of all households on the island) provided their consent and completed the telephone survey. The comprehensive coverage of households on the island combined with the high response rate mean that results gathered from the survey can be interpreted as representative of the general population of the island. Additional data sources included: key informant interviews with Bell Islanders and persons working within the health care delivery system; focus groups; a review of documents relating to the history of health services on Bell Island; a review of provincial and federal reports and position papers; related websites, particularly Bell Island Community Accounts; and finally, de-identified in-patient and out-patient hospital data. Because of the small population (3,078 in 2001) some Census data and inpatient and out-patient data are aggregated or modified so individuals can’t be identified. In other words, the numbers in this report offer an indication rather than representing an absolute value. There are good reasons for using a combined quantitative and qualitative methodology. Numbers, although important, do not tell the whole story. The numerical or quantitative data gathered during the Bell Island Needs Assessment 2004 Telephone Survey, gave researchers a heads up on what Bell Islanders perceived to be major issues in their community. By way of contrast, the qualitative data, namely respondents’, insights and opinions, gathered during the telephone survey, interviews and focus groups, helped researchers to better understand the impact these issues may have on the health and well-being of individuals, families and the community as a whole. When possible, additional quantitative data from credible sources such as Federal and Provincial agencies were used to corroborate qualitative evidence.

The study’s limitations This study had a number of limitations particularly around the telephone survey. People on social assistance were under represented. Although 44% (Community Accounts, 2005) of the Bell Island population was receiving social assistance in 2001, only 3% of the telephone survey respondents acknowledged receiving government support. There is also an age bias. The survey tool did not canvas the health and well-being needs of children under 19 years of age, babies or preschoolers. Finally, even though the Department of Social Services devolved into two departments back in

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2 | METHODOLOGY: WHAT’S IN A NEEDS ASSESSMENT?

1998, namely, Health and Community Services and Human Resources and Employment, the Health Research Unit uses the term Social Services throughout in the telephone survey. More care should have been taken in the survey design and around the timing of the deployment of the survey. For a number of reasons, including the requirements of the ethics committees, the survey was done in advance of key informant interviews. These were the causalities of working from a distance during the early stages. Finally, we were challenged to elicit reliable quantitative data from provincial governments, federal agencies and the health system generally. Although parties, without exception, made every effort to help with data acquisition, in many cases the data had not been captured, data were not consistent across sources, or data had been captured in a way that wasn’t compatible with our purposes.

Framework The research team collected a large amount of data. The challenge was to evolve a way of analyzing and presenting the data to the parties who commissioned the needs assessment in a way that would position the community and health system to identify and prioritize strategies on how to move forward. Achieving this end required a framework with three complementary components: determinants; indicators; and, the three lenses (the individual, the community and the health system).

Determinants and indicators Health Canada on its Population Health Approach website, states that, “Health is determined by many factors, including the social and physical environments where we live. These factors are referred to as Determinants of Health. How these factors combine in our lives can determine whether we will be healthy or not.” Health Canada’s Twelve Determinants of Health forming the background structure for this report are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Income and social status Social support networks Education and literacy Employment and working conditions Social environments Physical environments Personal health and coping skills Healthy child development Biology and endowment Health services Gender Culture

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

For each Determinant of Health there are established Health Indicators. These Health Indicators are in effect the measuring sticks for these categories. Or, as set out by Health Canada, “An indicator is a measurement that reflects the status of a system (e.g. social, economic or environmental) over time.” For example, the first of the twelve determinants is Income and Social Status. Two of many possible indicators would be ‘median yearly income’ and the ‘percentage of the population on social assistance’. Without question, the Twelve Determinants of Health framework facilitates comparisons across regions and the established indicators (measuring sticks) generate data that are easily rolled up at the provincial and national levels. These rolled up determinant data are ideally suited for use by health professionals, policy makers or researchers working in governmental agencies or the health care delivery system. However, although the Determinants of Health provide a necessary overarching framework, it is well recognized in Canadian research circles that the standardized indicators are challenged to be truly useful at the community or neighbourhood level. As we will see, a significant effort has been made in this report to identify potentially relevant indicators for individuals, the community and health services.

The three lenses: the individual, the community and the health care system From the onset, it was apparent that the needs assessment had to be seen from three unique but complementary perspectives corresponding to the parties collaborating on this report: that of the individual citizen, the community and those working within the traditional health care delivery system. These three perspectives, or lenses, influenced every stage of the process from designing the data gathering tools, gathering the data, analyzing the data, and ultimately, writing the report. This three-pronged, grass roots, collaborative approach is a departure from historical decision making processes around the provision of health care services in Newfoundland and Labrador. As such it requires a redistribution of power and decision making on the part of the three players. The traditional health care system is only one player – albeit a critical one. The other equally significant players are Bell Island’s citizens and their community. This paradigm shift requires that the health care system and its administrators foster true collaboration and relinquish control. Simultaneously, the community and individuals must commit to action and assume shared responsibility. In other words, Bell Islanders can continue to expect programs and services to be provided by the health care system; however,

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2 | METHODOLOGY: WHAT’S IN A NEEDS ASSESSMENT?

there are policies and practices that the community can put into effect, and behaviours that individuals can endorse – all of which together will have a positive impact on the health and well-being of Bell Islanders. In summary, there are three complementary components to the framework: the overarching Twelve Determinants of Health, attendant indicators, and the three lenses. The first two provide an enduring and accredited infrastructure for presenting the findings. The latter is, in essence, the lenses or trifocals we need to look through in order to make sense of those findings and realize the solutions.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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3 BELL ISLAND WHO WE AR E AND WHER E WE LIVE

Bell Island is located in Conception Bay, Newfoundland. The island measures approximately two miles wide and nine miles long. From downtown St. John’s, it’s a 20-minute drive to the ferry terminal at Portugal Cove, then a 20-minute ferry ride to Bell Island. The Health Centre on Bell Island and the tertiary care facility in St. John’s are approximately an hour apart. The island is served by two ferries year round.

plant and Works, Services and Transportation which is responsible for the ferry service. For health services the island has two physicians and the Walter Templeman Health Centre which offers emergency medical services and long term care. The island also has two schools: St. Augustine’s Elementary School for grades kindergarten through grade six; and, St. Michael’s High School which offers grades seven through twelve. For recreational facilities Bell Island has a hockey rink and Bell Island was initially settled by farmers in the 1700s. multiple softball fields. The island also has four grocery The discovery of iron ore in the late 1800s resulted in stores, one pharmacy, five churches, three restaurants Bell Island becoming and eight bars. It a thriving mining has two seasonal community with museums: the light the third largest house museum, population in the and the mining province. However, museum. It has the since the mines Wabana Complex, closed in 1966 the a Legion, the Boys’ population has been and Girls’ Club, in a steady decline. Cadets, the Church In 1961 Bell Island Lads Brigade and had a population a volunteer fire in excess of 12,000. department. It also APPROACHING BELL ISL AND. PHOTO COURTESY OF HT TP:// W W W.BITSTOP.C A . The 1996 Census has a co-op bakery, placed it at under hardware store, clothing store and too many small in4,000. According to the 2001 Census data there are dependent businesses to mention individually but they 3,078 Bell Islanders inhabiting 1,215 dwellings. In the are captured in the Community Profile appended at the late 1960s many Bell Islanders relocated to Cambridge back of this report. Ontario where unskilled labour was in demand. Today, Finally, and most importantly, in addition to the breathmost Bell Islanders live in the town of Wabana (population: 2,679, 2001) located on the north east side of the taking beauty and clean air, the stunning murals depicting the community’s mining history and the best island. The remaining population is spread out across Lance Cove and Freshwater (population: 399, 2001). berry picking in Newfoundland, the island is populated by Bell Islanders whose warm hospitality is surpassed With the closure of the mines, the largest employers on only by their determination to survive as a community. the island are the hospital, the school board, the fish

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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4 INTRODUCTION TO THE CHAPTERS

In the first chapter, we will look at how the Twelve Phase Two. For example, if someone has a special interDeterminants of Health play out across the Bell Island est in youth or seniors, the relevant data are gathered community as a whole. In subsequent chapters we look under that chapter. Moreover, there is enough detail at how health and well-being issues raised at the comto provide multiple and graded points of entry for munity level directly impact, in turn, the health and everyone from a teen mom to a seasoned researcher. well-being of infants and preschoolers, children, youth, Finally, there is a list of suggested opportunities for furadults and seniors. Each chapter ends with a summary ther research at the end of each chapter. The intent of of the challenges identified in the chapter and a very putting these topics forward is to encourage students preliminary list of suggestions for consideration on to integrate research based on the application of the how those challenges might be addressed. These sugTwelve Determinants of Health into their studies, and gestions are ofin the process of fered merely as doing so, estabstarting points lish Bell Island as for discussion. a living / learning Based on the lab under the findings presentauspices of the ed in each chapBell Island Health ter, opportunand Wellness ities for further Committee. research are also In addition to cited, as are a list the chapters outof proposed indilined above and cators. Finally, the subsequent every reader is section on the encouraged to health care delivmake use of the ery system from BELL ISL AND LIGHTHOUSE. PHOTO FROM HT TP://EN.WIKIPEDIA .ORG / WIKI/BELL _ISL AND. Personal Notes the perspective pages at the end of those working of this report for capturing their thoughts as they work within the system, there is a chapter that compares through the report. Your first impressions and insights Bell Island with a sister island in New Brunswick called will constitute a solid starting point which the Bell Grand Manan. From time to time data from this chapIsland Health and Wellness Committee can build on ter are referenced for comparison purposes. The report when it reconvenes for Phase Two. concludes with a chapter summarizing meta-thematic The chapters are very detailed. This was done to enable challenges, overarching suggestions for consideration citizens or special interest groups to move forward in and preparatory steps for Phase Two.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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5 WHAT ROLE DOES THE COMMUNIT Y PLAY IN OUR HEALTH ?

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In this chapter we will use the Twelve Determinants of Health to look at how the community of Bell Island impacts the health and well being of its citizens. Each determinant is defined and the Bell Island data pertaining to that determinant presented and discussed. Definitions for the determinants were derived from Health Canada and the Canadian Health Network. Data sources for this chapter include: the Bell Island Needs Assessment 2004 Telephone Survey Report; the Community Accounts website; the 2001 Census; At every stage of life, and, de-identified data from Health and Comhealth is determined by munity Services and the complex interactions Health Care Corporation of St. John’s, now known between social and as Eastern Health. In the economic factors, the process of collecting and analyzing the data from physical environment the Telephone Survey, the and individual behaviour. Memorial University Health Research Unit identified a These factors are referred number of challenges and to as determinants of recommendations relating to the community which health. They do not exist are referenced throughout in isolation from each this chapter. This chapter also draws on the communother. It is the combined ity profile, which has been influence of the deterincluded as an appendix to this report. Please note that, minants of health that de- for the reader’s conventermines health status ience, the data presented in this chapter are repeated in HEALTH CANADA, subsequent chapters where WHAT DETERMINES HEALTH and when appropriate.

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BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

For most of us, it’s hard to imagine how a dry concept like ‘Determinants of Health’ translates into everyday life. To help us with that translation, Health Canada offers the following story and analysis from Towards a Healthy Future: Second Report on the Health of Canadians, which can be found on the Canadian Health Network website.

“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 … ?”

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

“As Jason’s story suggests, health depends on a variety of factors. These factors interact with one another and affect individuals, communities and even our nation’s health. Health is closely tied to the environment around us – where we live, work and play. The Determinants of Health is the name given to factors which influence our health and well-being.” In the Bell Island Needs Assessment 2004 Telephone Survey, Bell Islanders themselves identified the major challenges to optimizing their community’s health and wellness. As in the case of Jason, social status, unemployment, lack of education, poverty, and limited recreational facilities emerge as familiar themes. We will now look at the community and these emergent themes. In subsequent chapters, we will examine how these same themes play out across the different age groups from infants and preschoolers up through seniors.

In what ways is Bell Island a healthy community? When Bell Islanders were asked what they liked about their community, invariably they talked about the “peace and quiet” and Bell Island being “a great place to raise a family.” They also commented on the relaxed pace of life, “secluded from the hustle and bustle of city life” and low crime rates, “It’s pretty safe here on Bell Island. There isn’t much vandalism. We can leave our doors unlocked.” Bell Islanders were also quick to point out that the island has the requisite infrastructure. “It is a nice little community

to live in. It has all the amenities” … “I find Doctors very accessible here” … “There is a good hospital system and good educational system.” Bell Islanders also cited cheap housing, a Department of Highways and the “post office which acts as a communication centre”, as positive community attributes. Finally, one can’t talk about Bell Island without mentioning the island’s spectacular beauty and environs. “It’s a great place for outdoor activities such as walking and gardening” … “It’s very beautiful when you drive around” … “In the summertime it is fantastic for swimming, hiking and biking.”

In what ways is the community challenged? When Bell Islanders were asked, in the Bell Island Needs Assessment 2004 Telephone Survey, “What is the single most important problem in your community?”, the top three responses were ‘Unemployment’, ‘Banking’ and ‘Gambling’. Also included in the top ten responses to this question, in order, were: ‘water / sewer’, ‘lack of recreation’, ‘addictions (drugs, alcohol)’, ‘ferry services’, ‘lack of support for elderly’, ‘social services (abuse of system, confidentiality)’ and ‘poverty’. The specifics of Bell Islanders’ responses are captured and presented in Table 1. Interestingly, each of the community problems cited relate in one way or another to the Twelve Determinants of Health. In fact, with the exception of banking and ferry services, every challenge on the list points to a community that has significant issues around the first determinant, namely, Income and Social Status.

Table 1: Top ten community problems identified by Bell Island respondents (2004 Telephone Survey)

Survey Question

“What is the single most important problem in your community?” #

COMMUNIT Y PROBLEM

NUMBER OF RESPONSES

% OF RESPONSES*

Unemployment

104

26.5%

Banking

18.9%

Gambling

14.5%

Water / sewer

6.9%

Lack of recreation

5.4%

Addictions (drugs, alcohol)

5.1%

Ferry service

5.1%

Lack of support for elderly

2.6%

Social services (abuse of system, confidentiality)

2.3%

Poverty

1.8%

* Calculation based on number of responses divided by the total number of responses (n = 392)

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

First Determinant

Income and Social Status According to Health Canada, there is a direct relationship between health, income and social status. As seen in Jason’s case, more family income might have led to better housing and a safer environment for him to play in. More income might also have meant being able to afford healthier food choices or perhaps job training for his parents. According to Health Canada, “Health Status improves with each step up the income and social hierarchy.” Income and social status are important at the individual and family level, but they are just as important at the community level. Communities where there is a real disparity between ‘those who have’ and ‘those who have not’ are not as healthy as those communities where families are more or less equally well off. According to Health Canada, “The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth.” So how does this apply to Bell Island? Data x Average yearly income: $24,307 (2001 Census) x Median household income $17,500: (2001 Census) x Percentage of the population on social assistance in 2001: 44.4% (Community Accounts, 2005) x Percentage of the population living below the Low Income Cut Off (LICO): 51.4% (2001 Census) x Proportion of 2003 community income generated from government transfers: 44.1% (Community Accounts, 2005) x Total government transfers to Bell Island in 2001: $15,739,000 or $4,800 per capita (Community Accounts, 2005) These data suggest that the Bell Island community faces significant challenges when it comes to income and social status. The average yearly income is significantly lower than the provincial average of $46,290 (2001 Census). Moreover, the median (or middle) household income is well below the LICO. Indeed, 51% of Bell Island’s population is living below the LICO. This means that just over half the population on Bell Island lives in poverty. Many of those living in poverty depend on social assistance as their primary source of income. In 2001, 44% of the Bell Island population was on social assistance compared with 13.6% provincially. The community is dependent on government monies: in 2001, 44 cents of every dollar circulating on Bell Island originated from government transfers compared with 23 cents provincially. Put another way, according to Community Accounts, in 2001, government transfers to Bell Island amounted to $4,800 per capita compared with $4,100 per capita provincially.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

The question presents itself, “How did we get here?” With the closing of the mines in the late 1960s, many families who had been dependant on the mining industry moved to Ontario and points west. Those families, who were well established prior to the mines, primarily farmers around Freshwater and Lance Cove and those professionals or families who had successful businesses along ‘The Front’, survived the closure of the mines and have continued to flourish. Unfortunately, many of the mining families who remained on Bell Island, primarily in the town of Wabana, have not fared as well. This history of mine closure, mass emigration and subsequent intergenerational poverty links to the Second Determinant of Health: Social Support Networks. Second Determinant

Social Support Networks

The Ontario Healthy Communities Coalition lists the following as attributes of a healthy community

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x clean and safe physical environment x peace, equity and social justice x adequate access to food, water, shelter, income, safety, work and recreation for all x adequate access to health care services x opportunities for learning and skill development x strong, mutually supportive relationships and networks x workplaces that are supportive of individual and family well-being x wide participation of residents in decision-making x strong local cultural and spiritual heritage x diverse and vital economy x protection of the natural environment x responsible use of resources to ensure long term sustainability

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Social Support Networks refers to one’s intimate circle of family members, HTTP://WWW.HEALTHYCOMMUNITIES.ON.CA/ABOUT_US/ friends and community HEALTHY_COMMUNITY.HTM institutions (for example, the church), to whom persons often turn in times of need. According to Health Canada, “It seems that there is a link between social support and the ability to respond to and cope with stress effectively. Having support from family, friends and co-workers can help people to solve problems and deal better with hardship. It can also help them develop a better sense of control over their life circumstances” (http://www.canadian-health-network.ca). Bell Islanders are renowned for their family ties. Witness the en mass migration back home to Bell Island that takes place every summer and the financial support for Bell

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

Island’s community groups in the intervening months. However, the traditional family structures and social networks that characterized Bell Island forty years ago are evolving. Data x Number of single parent families: 250 or 29% of all families (2001 Census) x Number of single parent families with three or more children: 70 or 28% of all single parent families (Community Accounts, 2005) x Percentage of single seniors living alone: 79% (2001 Census) x Number of children 25 years and older living with parents: 225 (2001 Census) As the data suggest, three changes to traditional family structures and social support networks are emerging. First, the Bell Island community now has a significant population of single parents. Indeed, nearly one third of the families on Bell Island in 2001 were headed by a single parent. Second, a large number of adult children continue to live at home. This trend is now common in urban centres across Canada but much less so in rural communities. Third, the vast majority of single seniors (79%) are living alone. The data give rise to the question, are the changes we’re seeing in the community’s social support networks related in some way to trends we observed in the first determinant, Income and Social Status?

Social support networks for seniors is of particular concern Mass emigration after the closure of the mines invariably meant leaving some family members behind. Many of those same family memFamily bers are now seniors. characteristics play Given Bell Islanders’ a part in whether an instrong family ties, we can understand dividual will become ill and why ‘care for also in how he or she will do seniors’ was cited as one of the top through an illness. Family beliefs, ten problems structures and styles have a bearfacing the community. As we’ll ing on compliance with medical see in the chapregimes, frequency of hospitalizater on seniors, the community tions, use of health care facilities is very concerned and post-illness recovery about seniors who are socially isoCHILD AND FAMILY CANADA, lated or unable to get HEALTH PROMOTION – A around. They are also

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concerned for those seniors who lack family members to take them to doctors’ appointments, follow up on medical tests and procedures, or take care of them when they return home following hospitalization. With many family members now living outside the province, we can see that the community’s Social Support Networks for seniors are key to the health and well being of the community as a whole. Interestingly, for younger persons, Income and Social Status is the number one determinant of health. For seniors, this is not the case. For seniors, the most important predictor of good health is now thought to be literacy and education which brings us to the Third Determinant of Health. Third Determinant

Education and Literacy We tend to associate literacy with the ability to read. However, the definition for literacy is usually much broader. Literacy includes reading, writing and arithmetic as well as the ability to find and evaluate information. As implied in Jason’s story, if you are literate and have an education, you are more likely to live longer, have a job, earn more money and live in a safe neighbourhood. Bell Island has had spectacular success with graduates from the Trade School, particularly from families living in Freshwater or Lance Cove. In fact, the proportion of adults age 20 and over with a trades school education on Bell Island is higher than that of the province: 23% and 18% respectively. Although the Trade School on Bell Island closed in 1996, families with trade school graduates, most notably those from Lance Cove and Freshwater, have children who are continuing the family tradition of attending trade school. However, as evidenced by the data below, there remains a significant proportion of the Bell Island community that remains education and literacy challenged. Data x Number of trades school graduates aged 20 and older: 520 or 23% (2001 Census) x Percentage of population age 20+ with trade school certificate: 21% Wabana; 40% Freshwater and Lance Cove (2001 Census) x High school attrition: in 2005, 45 of the 68 students, who entered grade nine in 2001, successfully graduated from St. Michael’s Regional High School (Department of Education, Newfoundland and Labrador / St. Michael’s Regional High School) x Graduation rate 2003 – 2004: 74% (Indicators 2005: A Report on Schools, 2005) x Percentage of adults aged 20 and older without a high school certificate: 50% (2001 Census)

FAMILY AFFAIR BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

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One Canadian study found that people who are unemployed have more mental health problems including distress, anxiety and depression. Their everyday activity is more likely to be limited, and they are more likely to be inactive due to disability. They are also more likely to visit the doctor and go into hospital than people who are employed

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PUBLIC HEALTH AGENCY OF CANADA, HOW IS WORKING RELATED TO HEALTH?

Bell Islanders have insight into why seniors on the island may have low literacy levels. “We are probably into our fourth generation of people being illiterate. People worked in the mines. A lot of these people went to work when they were 13 years old.” What is less understood is why these low literacy and education levels persist in a community with free schooling from kindergarten through grade twelve. One has to ask, what are the barriers in our community to youth graduating from high school and continuing on to trade school, college or university? All paths, as we saw in Jason’s story, that lead to higher incomes and better health outcomes. We can see why literacy and education are important for our youth, but being able to read, write, find and understand information is just as important for the health outcomes of Bell Island adults and seniors. Being literate and numerate means that you can read the instructions on your pill bottles, directions on how to prepare for a medical procedure or educational material on how to manage your diabetes.

Literacy and education also have direct bearing on employment opportunities for the community as a whole. “It affects bringing in industry. Who wants a population that cannot follow instructions?” The community’s business development arm, Island Advisory Services, has tried, unsuccessfully in the past, to elicit government support to address adult literacy issues. In light of our new understanding of the importance of literacy and education on health and wellness, perhaps potential funding agencies will now be more inclined to support adult literacy, education and training programs. This link between literacy, education and work brings us to the Fourth Determinant: Employment and Working Conditions. Fourth Determinant

Employment and Working Conditions Employment for Bell Islanders covers every scenario from doing shift work at the fish plant to running a

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

business out of their own home. Research shows that not having a job, having a job where your skills and talents aren’t optimized, or having a job that is really stressful, can all have a negative impact on health. In fact, a stressful job or stressful circumstances around your job can shorten your lifespan. Ferry crossings cancelled because of the weather or mechanical failure or even worse, potential cancellations because of bad weather or ferry breakdown, would most probably qualify as stressors. Data x Employment rate: 21% or 529 individuals age 15+ (Community Accounts, 2001) x Number of full time, full year employees: 260 or 31% of all persons with earnings (2001 Census) x Number of persons employed on Bell Island: 300 (2001 Census) x Number of persons who leave the island to work: 185 – 235 (2001 Census) x Number of persons who commute to Bell Island to work: 60 (Ferry Users Committee 2005 Commuter’s List) When survey respondents were asked to identify the number one challenge in the community, employment topped the list, whereas poverty was at the bottom. In Bell Islanders’ own words, they want to work. “There aren’t any jobs for people who want to work. Unemployment is killing people’s spirit” … “They used to have work programs, making quilts and stuff like that and giving them over to social services. I would love working with seniors or anything like that.” Unfortunately, employment opportunities and the pay scale on the island are limited. “At six dollars an hour, ten for taxi and x for ferry, there’s not much incentive to work” … “You’d be better off on welfare than working for six twenty-five or seven dollars an hour.” According to the 2001 Census, 529 individuals age 15 and older were currently employed. Three hundred of these individuals reported employment on Bell Island. Presently, the major employers on Bell Island are the fish plant, the health care system, the schools and the ferry services. There are also many small family owned businesses like barber shops, video stores, corner stores and so on. The 2001 Census also estimated that during this time approximately 185 – 235 of employed persons commuted daily to jobs off the island. The Census could not provide an estimate of the number of individuals who commuted to the island for work. However, according to the Commuter List, provided on the Ferry Users Committee web page (http://www. bellisland.net/ferry_users/index.htm), in 2005, 60 individuals commuted to the island for work.

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

For those persons who want to work but for whom commuting is not an option, Bell Islanders had suggestions for how to solve the unemployment challenge. “We need government funding to start up small businesses” … “I see Bell Island being a tourist mecca with lots of potential there, the mine tour is in the top 10 most visited places in NL. There are 16,000 paying customers per year. How can we build on this?” And finally, “The fish plant can expand, it can process higher value fish.” Clearly, employers like the fish plant, Island Advisory Services, the community, and their voice the town council, are key players in advocating healthy working conditions and realizing employment opportunities related to tourism or fish processing. The role that key groups play in a community’s health, brings us to the Fifth Determinant: Social Environments. Fifth Determinant

Social Environments The determinant, Social Environments, refers to things like community conviviality, governance, community participation, civic engagement and community leadership and pride. All of these things, according to Health Canada define a cohesive community. Research suggests that cohesive communities tend to provide their citizens with a level of support that reduces or avoids many potential risks to good health. Conversely, communities where emotional support is not readily available and where social participation is low, have a negative impact on individuals. When Bell Islanders were asked what they liked about their community, invariably they talked about the people. “Bell Island has very strong people” … “People care for each other and provide lots of support. We trust our neighbours” … “Everyone knows everyone” … “People watch out for one another” … “There is a lot of community ownership.” Evidence of a strong social environment is everywhere from active service groups like the There are rounds Kiwanis Club, Knights of Colof different things umbus, the Masons, the Legion, and different church groups, to that are needed the volunteer fire department, badly on Bell the parents who help with the elementary school’s hot lunch Island. It starts program and those who volunteer with the comat the Walter Templeman Health Centre, to mention but a few.

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munity caring

ANONYMOUS BELL ISLANDER, 2004

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In addition to its volunteers, Bell Island has a strong local culture and spiritual heritage, as evi-

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

denced on http://www.bellisland.net and by the mine and lighthouse tours. Bell Islanders take pride in who they are and what they have accomplished. Data x Population change: 14.5% decrease since 1996 (2001 Census) x Voter turnout municipal elections: 51% for 2005 Municipal Election (Wabana Town Council, 2006) x Voter turnout provincial elections: 70% for 2003 Provincial Election (http://www.elections.gov.nl.ca) x Voter turnout federal elections: 48% for 2004 Federal Election (http://www.elections.ca) x Average monthly number of families using the food bank: 200 (Bell Island Community Profile, 2004) The challenge that Bell Islanders consistently identified as a critical challenge was the shortage of community leaders. “We’re lacking leadership, we’re lacking role models.” There were comments about the responsiveness of the community generally. “If you are in a big city nobody knows your name, your needs, you don’t care about the needs, but in a small community we have been grown up to say community is everybody. We are trying to foster that but you can’t get cooperation, you can’t get anybody to come on board, whether it is the health board or the community itself or anybody in between.” Bell Islanders also cited the need for leaders for special interest groups. “They did have a diabetes association here on the island, but they couldn’t find anyone to be the head of it.” In small rural and remote communities it is often the school teachers, health professionals and clergy who step into these leadership positions. Unfortunately, for Bell Island, most of these professionals commute back and forth to work from St. John’s and aren’t available to participate in evening meetings or weekend community events. In another words, these professionals earn their living on Bell Island, but are not fully integrated into the community. The ability of these professionals to commute back and forth to work on Bell Island brings us to one of the most important determinants of health for a community, namely, Physical and Natural Environments. Sixth Determinant

Physical and Natural Environments This determinant refers to everything from a citizen’s access to natural beauty, clean air and clean water, to a citizen’s ability to own his or her home. It also refers to a community’s infrastructure, for example: transportation, recreational facilities and programs, public spaces,

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footpaths, bike trails, recycling, and all the requisite businesses that support community life. It also includes protection of the natural environment and responsible use of resources to ensure long term sustainability. Physical and Natural Environments is an important determinant for Bell Island, particularly because it is an island. The community is wholly responsible for its Physical and Natural Environments and the infrastructure required to sustain and protect both. This is a very tall order for a very small community. Data x Ferry Service: 20 round trips daily (Bell Island – Portugal Cove Ferry Service) x On Island Transportation: No public transit available. At least four taxi services in operation (Bell Island Community Profile, 2004) x Proportion of homes privately owned: 73% (71% in Wabana; 91% in Freshwater / Lance Cove) (2001 Census) x Average value of dwellings: $35,104 in Wabana; and $48,331 in Freshwater / Lance Cove (2001 Census) x Waste system: Municipal septic system and individual septic tanks (Bell Island Community Profile, 2004) x Internet Access: Dialup and limited high speed connections, serviced solely by Aliant (Bell Island Town Council, 2004; Aliant, 2005)

Ferry Services from two very different perspectives Transportation, more specifically the ferry service, is a complex issue for the community of Bell Island. As reported in the telephone survey, only five percent of the telephone survey respondents (20 / 392) thought that the ferry service was the single most important community problem and only 27% of 398 respondents listed it as a major problem. The Ferry’s importance as a community issue tied unemployment for sixth place behind banking, gambling, water and sewer, lack of recreational facilities and addictions (drugs and alcohol). The ordering of these concerns would appear to indicate that, meeting citizens’ day-to-day basic needs is a more immediate priority, for a significant proportion of the community, than improving the island’s transportation infrastructure. This perspective is supported by Maslow’s theory on a human being’s hierarchy of needs. However, for the commuting Bell Island citizens who are wholly dependent on the ferry to get them to and from work, the ferry has a very different presence in their day-to-day lives. Unquestionably, commuters face a number of ongoing challenges. “The old ferries are

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

always breaking down. There are days when you can’t move at all. You are lined up for three or four hours trying to get home or trying to get over. That’s a big problem.” The consensus amongst those who depend on the ferries is that ”They must have a reliable ferry service which would mean a two boat ferry service with a decent schedule and no increase in rates.” The argument for reliable ferry services from folks in the commuter camp is straightforward, “To put 400 – 500 people to work means we have to have a way to get them to work.”

Commuting is not for the faint of heart

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… health promotion and the creation of healthier cities and communities require the empowerment of individuals and communities to exert more control over all of the factors that contribute to their health and well-being. This means that people, as individuals and as members of the community and neighbourhood organizations have to be centrally involved in the process of creating a healthier community

For some commuters, the unpredictability of the ferry services due to weather conditions and ferry breakdowns is an ongoing stressor. Others, after years of commuting, are more prosaic. “Commuting to work is extremely challenHANCOCK, 1993, P.9 ging in the winter time with rough seas. When the boat is running, you are expected to be on it, although there are a lot of scary moments. There are challenges, but they become part of your everyday and eventually you don’t even think of it. The first year I thought about the boat crossing, but now its just part of my everyday.” For some, the mechanics of commuting represent significant hardship. “It is amazing what people will put up with. Guys are over there working for $10 an hour painting houses, leaving home at 5:30 am, to catch the 6:50 am boat and not getting back home until the 7:30 pm boat and they only get paid for eight hours a day. That is a hard thing to deal with.”

The ferry also impacts the kind of jobs that people can take on Persons with low education and literacy levels can sometimes find shift work. Commuting to work by ferry presents an additional challenge for shift workers. “Five nights a week the last boat is at 10:30 pm. People will not take the night watchman job because there is no guarantee that you will get back and forth” … “The ferry schedule impacts oppor-

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

tunities for shift work, largely jobs that the unskilled population is suited for.” The bottom line is that “The service has to be good enough, accessible enough and affordable for someone to make a decision to live on Bell Island and work in town.”

Increased tourist traffic during the summer months also impacts health services With the bike (motocross) track, mine tours and refurbished light house, Bell Island is a growing tourism destination. “You need triple the health care services and triple everything in the summer months. The population doubles or triples. In terms of traffic on the ferry, you get 3,000 people a day on peak days as opposed to 700 – 800 this time of year (Oct, 2004).”

Access to health services is inextricably tied to ferry services In the eyes of those providing services on the island, there is a direct correlation between the isolation and the basic health services needed on the island. “Until there are four boats running back and forth 24 hours a day to St. John’s, then the health care system here is always going to remain important. Until the liquid road is improved, Bell Island has to have those basic services, nothing can be cut. If the road became a four ferry system or a bridge or whatever, then you could close this hospital because you are 25 minutes away from the biggest hospital in North America probably, or one of the nicest ones anyway, the Health Sciences. We are no better off here than in Nain. Nain and Bell Island are similar.” It is easy to understand why discussions around maintaining or improving the ferry service predominate: the commuters’ and the ferry workers’ livelihoods depend on it. When the stakes are so high, it is difficult to step back and look at the island’s transportation infrastructure within the broader context of the health and well being needs of the entire community. Is it possible that the high profile around the ferry service has overshadowed or usurped the government’s investment in other facets of the island’s physical and natural environment? For example, investment in a recreational facility, which may not be a high priority for commuters, but it may be a high priority for the community’s seniors, young families and youth.

Some of the community’s recreational needs go unmet Like many small communities in Newfoundland and Labrador with a diminishing population and tax base, the town of Wabana is challenged to be all things to all people. According to the telephone survey find-

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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ings, almost half (49%) A 1999 initiative found of the respondents that children living in thought that the lack of recreation facilities and neighbourhoods with activities was a major plentiful community community problem. The “lack of health and resources such as parks, recreational facilities recreational areas, librareven outdoors” for infants and preschoolies, preschool programs ers, youth and seniors and parenting classes was duly noted. “There is nothing here to acscored higher on five cess, to be able to say, important areas of delet’s take our children and do some stuff. The velopment: their physical money is there but the health and well-being, means of doing it is not. That would also social knowledge and apply to seniors.” The competence, emotional same opinions were expressed regarding those maturity, language richwith special needs. ness, and general know“There is nothing on the island, especially if ledge and cognitive you have someone in a skills. They demonstrated wheelchair.” Moreover, the maintenance and behaviours much more continuation of existing consistent with being recreational facilities is often perceived to ready for school than did be at risk. “The one children from neighbourrecreational facility for the whole community, hoods with scarce comthe Bell Island Arena, munity resources threatened to close last year because of PUBLIC HEALTH AGENCY OF lack of funding.” As we CANADA, BACKGROUNDER: will see in subsequent THE PROGRESS OF CANchapters, recreation ADA’S CHILDREN, 2002 or healthy activities (and preferably lots of them) are fundamental to a healthy community. The threatened closure of the arena underscores another sometimes overwhelming infrastructure challenge that the community faces day to day.

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Bell Island has some of the assets (and all the responsibilities) of a much larger community Bell Islanders have a good understanding of why they are experiencing an infrastructure crisis. “We went from an infrastructure of a town that can host 15,000 down to 3,000. So as a town, we have to try to maintain that and it is not easy.” Legacy buildings and infrastructure requirements appear to put tremen-

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

dous strain on Wabana’s limited resources. Moreover, the burden appears to hold the community back from establishing a plan for a recognizable, consolidated town centre that could become a touchstone for the community.

there is not enough water.” Presently, the town council has a water purification system installed for the town of Wabana and expects to have it operational before the end of 2005. There are no plans for fluoridation.

Lack of a banking branch constitutes a major problem for the community

Reduce, reuse, and recycle

According to findings from the telephone survey, the lack of banking facilities on the island is a major concern. More people (376, 94%) rated the lack of banking facilities on the island as a major problem than any of the other community issues with which they were presented. The absence of a bank branch on the island is hard on businesses and hard on the people. Citizens zero in on the salient issues. “Once the bank closed, you can’t go down the street to the next bank because it is an island” … “I have to make a trip to town to cash cheques” … “You can take money out but you can’t put money in” … “A lot of times there is no money in the ATM machines.” And of importance to the community, “The current banking system doesn’t help people save monies, if it is at home they will spend it.” As we will see, the lack of banking services is of special concern to seniors.

Unlike in the cities, public transit is not an option Another indicator of community health is a robust and responsive public transit system. As is the case in many small rural communities, Bell Island does not have a public transportation system with affordable bus passes and discounts for seniors and students. “We can’t use a bus; we have to depend on taxis!” This constitutes a financial burden for some, notably seniors, who not only need rides to get around town, but they also require transportation to get them to medical appointments in St. John’s and back.

Our environment: the air we breathe, the water we drink Clean air and drinkable water are also key indicators of a healthy community. Bell Island excels when it comes to the former, but struggles when it comes to the latter. According to the telephone survey, over half (52%) of respondents indicated that water and sewer in their community were a major problem. Citizens identified three parts to the problem: first, “The water smells and has a gross taste”; second, the water is perceived to be not safe to drink, “We have a boil order on our water. It has been in place for years. I don’t drink our water. We have lovely water on the end of the island where I live. But, because there is a boil order in place I buy or boil the water”; and third, “Often

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Another recognized indicator of a healthy community is the presence of a robust recycling program. Across Canada many communities are going green. Presently, on Bell Island, recycling is not mandatory. However, there is a green depot on the island that recycles bottles and cans. Garbage, in Wabana, is collected once a week by a private contractor hired by the Wabana Town Council. Residents of Freshwater and Lance Cove also have their garbage collected by a private contractor, but each household pays the contractor on an individual basis. The garbage collected from Freshwater and Lance Cove is trucked to St. John’s. Garbage collected from Wabana is moved to Wabana’s landfill site operated by the Wabana Town Council. The garbage is bulldozed daily.

Crime is perceived to be low, yet drugs are considered a major problem Types and the prevalence of crimes are also indicators of a community’s health. Interestingly, only 11% of telephone survey respondents thought crime was a major problem in the community. “The crime rate is low but that is a sign of good policing and police presence” … “Crime prevention and community policing are very strong.” In chapter eight, ‘Dare to Compare’, many of the indicators in this chapter are compared with the same indicators on the island of Grand Manan, New Brunswick. Two of the most startling findings relate to crime. For example, there are approximately four and a half times as many level one assaults and five and a half times the incidence of property damage on Bell Island as there are on Grand Manan. We’re all familiar with the altercations that take place outside bars on a Friday night, but what proportion of these incidents take place at home?

Domestic assault is a crime Findings from the telephone survey indicate that 20% of respondents identified marital difficulties and / or family violence as a major problem in the community. Other professionals on the island, including the RCMP, concur. “I see family violence as a very significant issue that needs to be addressed for sure” … “I think it used to be a lot worse years ago than it is right now, but it is still an issue on the island and that once again would relate back to the gambling.” Many health professionals commented on the dearth

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About 30% of Canadians live in rural and remote areas of the country. While they share many areas of health concern with Canadians in urban areas, they also have additional realities. Among them: a potentially harsher climate, transportation ability and distance considerations, sparser population and different demographics. As a result, in more isolated communities, for example, seniors, at risk infants and people with physical or mental disabilities may find it harder to access the services they need

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CANADIAN HEALTH NETWORK WHY PUBLIC HEALTH MATTERS

of resources for those experiencing domestic or family violence. “The only service that would be available in this community would be the local Mental Health Counselor. We refer to a number of professional agencies, to professional counselors within St. John’s, but if we we’re talking locally it is a challenge. To access these services they would have to go to St. John’s.” Citizens commented that, “Those with higher incomes can go to town and deal with issues. They have the money to get there. Low income, where are they going to go for help? There’s no guidance and they’re in a hole financially.” This shift in focus to circumstances relating to the individual brings us to the Seventh Determinant of Health: Personal Health Practices and Coping Skills. Seventh Determinant

Personal Health Practices and Coping Skills

Personal health practices include: healthy behaviours, such as eating well, and getting plenty of exercise. It also includes preventative practices such as flu shots, and screening activities, for example, annual PAP tests and mammograms for women and PSA tests for men. This determinant also includes ‘at risk’ or addictive behaviours like smoking, gambling, alcohol and drug abuse. The good news stories around Personal Health Practices and Coping Skills are reported in subsequent chapters. In this section, we will look at the prevalence of ‘at risk’ behaviors on the island. Although the Personal Health Practices and Coping Skills determinant is the domain of the individual, it takes two to tango. As we will see, the community’s resources, policies and cultural norms around social status have a huge influence on personal health practices and coping skills of persons living on Bell Island.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Data x Community spending on Atlantic Lottery Corporation sponsored gambling activities: $1,980,761 (Atlantic Lottery Corporation, 2004) x Community (on island) spending on alcohol: $1,624,965 (Newfoundland and Labrador Liquor Corporation, 2004) x Community spending on cigarettes: ~ $1,714,606 (Telephone Survey, 2004; Tobacco Fast Facts, 2004) x Proportion of adults with an overweight or obese BMI: 64% (Telephone Survey, 2004) x Proportion of adults engaging in physical activity two to three times per week: 59% (Telephone Survey, 2004) x Proportion of adults who believe they are eating a healthy diet: 77% (Telephone Survey, 2004)

Gambling: an addiction to hope Seventy-two percent of the telephone survey respondents cited gambling as a major problem in their community. Furthermore, Bell Islanders ranked gambling third in the top 10 problems faced by their community. However, when telephone survey respondents were asked about their personal gambling habits, only 46% of respondents reported that at least one person in the household gambled at least once a week. In addition, many of those respondents commented to the telephone survey interviewers, that their participation in gambling activities was limited to the purchase of lottery tickets. However, the data from Atlantic Lotto tell a different story. In 2004, Bell Islanders spent $1,157,937 on VLTs and $822,824 on lottery tickets. To put that in perspective, if we were to average it out across every adult on Bell Island age 20 and over, each individual would have spent $886 on gambling in 2004. By comparison, in 2002 – 2003, the average Canadian 18 and older contributed $481 to government operated gambling revenues. These numbers for gambling on Bell Island are by no means absolute because, for example, there is no way of estimating the volume of online gambling.

Ample opportunity to gamble may be part of the problem On Bell Island there are eight establishments with a total of 35 VLTs. In other words, for every 280 individuals 20 years of age and older, there is an establishment with a VLT. Moreover, there is a VLT for every 64 individuals. By way of contrast, in Newfoundland and Labrador in 2004, there were 887 individuals aged 20 years and older for every establishment with a VLT and there were 194 individuals aged 20 years and older for every VLT. It should also be noted that while there are

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

more opportunities to gamble on Bell Island than in the province as a whole, commissions for bar owners on Bell Island are not as great ($33,480) as they are across the province ($50,443) as a whole.

Many lives are touched by gambling The pervasiveness of gambling on Bell Island means that almost everyone has an opinion on how it is affecting the community. “It ruins families. It certainly causes many, many children to go hungry, many, many children and it is a shame” … “Family members or spouses are arguing and it does lead to significant complex stress. It doesn’t always have to be physical. It is the emotional burden that families are going through with the VLTs. Families are breaking up because of the stress and the difficulties. Children are subject to this.” Although we now have a sense of the global amount spent on gambling in the Bell Island community, we don’t know how many persons have an actual gambling addiction.

Gambling is eating away at the community’s infrastructure

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Church run card games and bingo have always been a mainstay on Bell Island and, although they are a form of gambling, their impact on community life is very different than that of the VLTs and break open tickets. “When I came here there were only bingo and card games. Bingo costs a person five, ten or fifteen dollars. Okay, maybe some people would say that is a lot but in comparison it is not. The money There is growing recognition is made for the that personal life ‘choices’ church organization, the Boys and Girls are greatly influenced by the club and so on. It is socioeconomic environments all going back into the community. That in which people live, learn, is no big deal. But work and play. Through the VLTs are taking the money. There research in areas such as are now only one or health disease and disadvantwo bingo’s because people would rather taged childhood, there is put their money into more evidence that powerful VLTs.” Similarly, “The VLTs came out, along pathways link the individual with the break open socioeconomic experience to tickets and the 6/49 draws. Families vascular conditions and other started putting off adverse health events a certain amount of their income towards PUBLIC HEALTH AGENCY OF CANthat gambling. The ADA, WHAT DETERMINES HEALTH? income that they put

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BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

into that gambling was the money that they used to use to support the Lions, Kinsmen, Kiwanis and the Legions. So the Legions and all those organizations that existed, at one point in time, are now closing because they don’t have the income coming in from the people that used to spend it there.” Other members of the community think the exact opposite, “If you got rid of those VLTs, you would be getting rid of the Lions Club, the Legions all across NL and Labrador.” More research is required to fully understand these issues around gambling and how they impact the community’s infrastructure.

Not all Bell Islanders would be happy to see the VLTs go Gambling is big business for the government and for bar owners. In 2004, owners of Bell Island establishments with VLTs made, on average, $33,480 in VLT commissions per site. Given the revenue generating capacity of VLT’s, bar owners may not want to see things change. “Bars wouldn’t be in existence if it weren’t for those machines. Nobody is going to just sit down in the bar and have a chat. They come to play the machines” … “If you got rid of the VLTs you would shut down every bar in town. The curling club would close, everything would close. The Legion would be dead. You would be shutting down all drinking establishments on the island. That is what keeps the places open. The only thing that pays the heat bills is the machines.” Some felt there would be players who would be just as committed to keeping the VLTs in place as the bar owners. “I think the majority would be for keeping them and most of the majority (of Bell Islanders) are for playing them.”

What is the community going to do? There is a continuum of opinions on how to move forward. On one side you have citizens who want their outright removal. “VLTs, get them the hell out of here!” Then there are others who want a little help moving in that direction. “They need to get rid of the gambling machines and the break-open tickets. The government should step in and ban VLTs.” There are others who propose a more moderate approach. “VLTs are addictive. If we were going to wean ourselves from them, we are going to have to do it by saying that the bars will only be allowed four and next year only allowed three.” Some recognize that whatever they do, it is going to be a complex process. “To take away the machines and to keep everything else running, you would have to educate the people by saying, that the money you used to waste on the machines, we now want you to spend it in the same facility and we want you to feel good about

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it.” Education appears to be a key part of the strategy for moving forward. “We need education sessions in the schools on gambling. We definitely need to get that education out there and the earlier the better.” The town council recognizes that there is a problem and is investigating if they have the jurisdiction to make changes. They are also following closely how other communities are dealing with this problem. “Mr. X is the Member for the House of Assembly for Lab City or Lab Area. He wants to put a question on a referendum to ban VLT machines in the province. We have the most VLT machines in the country. It is a problem here on Bell Island, a big problem. A lot of people lose.”

What help is there for those who are addicted? Until this report, the extent of gambling in the community had not been quantified. That being said, Bell Island’s health professionals are challenged to determine who in the community may need or want help. “The gambling piece is very small right here in terms of my caseload, but potentially could be very large. I know from talking to people and to various community members that gambling is a very, very big problem … VLTs are a major problem.” At present, outreach is Eastern Health’s first line strategy. “We are not sure if people realize that help is available so we would like to make it known, very clearly, that help is available for anyone addicted to gambling.”

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Bell Island is really known for its diabetes. I think it’s the lifestyle, they drink more, they party more, they eat more and the low income people eat more carbs and drinks that are cheaper and fast foods. They are more obese today because they are not as active. It is the lifestyle

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ANONYMOUS BELL ISLANDER, 2004

Street drugs and prescription drugs are a problem When respondents were asked to identify the single most important problem in the community, addiction to drugs and alcohol was listed in the top ten and in fact, tied with ferry services. In the telephone survey, 38% of the respondents rated illegal drugs as ‘a major problem’. Moreover, 23% of telephone survey respondents rated prescription drugs as ‘a major problem’. This perspective differs from that of the law enforcement officers. “Drugs are between a small and medium problem at this point.” Health professionals have yet another perspective on the seriousness of the problem. “If I look in terms of case load, alcohol

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

would probably be a major factor. Not only alcohol but street drugs and prescription drugs as well. Prescription drugs are a medium problem.” There are two data points that might support the community’s concern regarding the prevalence of prescription drugs First, Newfoundland and Labrador’s Provincial Income Support Drug Program spends approximately three and a half times more, per capita on Bell Islanders, than New Brunswick’s comparison per capita spending in Grand Manan, $768.31 versus $223.04 respectively. Second, there are over four times as many per capita claims for Bell Islander’s who use the Provincial Income Support Program than their counterparts in Grand Manan (26 and six claims respectively). This phenomenon warrants further investigation.

There is a significant amount of alcohol consumption on the island In 2004, total alcohol sales on the island were $1,624,965. If this amount was averaged out across Bell Islanders 20 years and older, that would amount to $727 per adult. Note that this total doesn’t take into account alcohol that is made on the Island or bought elsewhere. As in the case of gambling, ready access may be contributing to the problem. Citizens also expressed concern about teen’s perceived ready access to alcohol. “Early access to alcohol is a problem and should be taken more seriously. Cops stop and chat with students on weekends and must smell booze on their breaths, but nothing is ever done.”

Smoking It was difficult to determine community spending on tobacco use. However, we were able to generate a rough approximation for monies spent on cigarette smoking. Telephone survey findings concluded that 32% of household members age 20 and older were reported to smoke on a daily basis. Even though tobacco is a controlled substance, hard data on the volume of cigarettes sold on the island were not available. However, extrapolating from provincial estimates, if the 32% of smoking adults smoked the provincial daily average number of cigarettes (14.6 / day), it would represent a cost of approximately $2,398.00 per smoker annually. Again, this is a rough approximation.

Obesity rates exceed provincial and national percentages Obesity has long been associated with increased risk of cardiovascular disease, diabetes, stroke and cancer. The Bell Island Needs Assessment 2004 Telephone Survey Report notes that 39% of the 388 respondents, who self-reported height and weight information, had a BMI in the overweight category and 24% were in the

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obese category. These rates are higher than Canadian percentages in 2003, namely, 34% for overweight and 15% for obese. When respondents were asked what they could do to improve their health, 138 (34%) said lose weight and 14 (3%) said eat a healthier diet. Access to healthy food choices on the island was cited as a challenge. “You have one drugstore, you have one grocery store. So basically you don’t have the competition that you have in St. John’s. You don’t have the assortment of fruits and vegetables. The cost here certainly appears to be a lot higher than in St. John’s. People (those who can afford to) are going to St. John’s to do their banking and their shopping.”

healthy nutrition; and, the need for age-appropriate recreational facilities and outdoor spaces. The community, and in particular the Town Council, can identify how it can contribute to the health and well being of the community’s infants and preschoolers by working with the members representing this special interest group during Phase Two of the Needs Assessment.

Eighth Determinant

Ninth Determinant

Healthy Child Development

Biology and Endowment

For Bell Island, this determinant holds tremendous promise. As you will see in the next chapter on Infants and Preschoolers, exciting progress is being made when it comes to giving Bell Island babies the best possible healthy start to life. Rather than preempt the upcoming chapter on Infants and Preschoolers, this section will briefly reference Healthy Child Development issues that are of particular importance at the community level. Data x Number of lone-parent families: 250 or 29% (2001 Census) x Median income of lone-parent families: $17,000 (Community Accounts, 2005) x Median income of two parent families: $27,100 (Community Accounts, 2005) x Percentage of families on social assistance: 52% (Community Accounts, 2005) x Number of families living below the LICO: 485 or 57% (2001 Census)

The community has an important role to play in supporting healthy child development Bell Island has many community assets that benefit its infants and preschoolers. There is Brighter Futures, the Head Start preschool and a cadre of dedicated education and health professionals running programs and offering services. However, there remain a number of challenges to achieving optimal health and well being for this age group. Poverty remains an obvious challenge but there are also issues around: social class; family structure; father’s involvement in childrearing; access to good parenting role models; infants and preschoolers’ exposure to second-hand smoke; the prevalence of dental caries; access to adequate and

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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Getting at the root of the problem of obesity and poor diets requires examining the determinants of health and their impact on these risk factors. For example, when people live in poverty, they have fewer opportunities to choose healthy food and less time and money for recreational physical activity

According to Health Canada, “Although socio-economic MCMASTER UNIVERSITY, INTERand environmental factors HEART STUDY, 2004 are important determinants of overall health, in some circumstances genetic endowment appears to predispose certain individuals to particular diseases or health problems.” Determining if Bell Islanders have a genetic predisposition to certain diseases and conditions was beyond the scope of this research. However, we know that the most common cause of death, on Bell Island in 2004, was due to cardiovascular disease. Until very recently, cardiovascular disease was thought to have a strong genetic component. However, in 2004, findings from the INTERHEART study out of McMaster University in Hamilton, Ontario determined that nine risk factors accounted for 90% of the world’s cardiovascular disease. In other words, independent of where you live in the world the same factors predict your likelihood of developing cardiovascular disease. Those factors are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Smoking Bad cholesterol (abnormal lipids) High blood pressure (hypertension) Diabetes Size of your waistline (abdominal obesity) Psychosocial factors (e.g. depression and stress) Lack of fruits and vegetables Lack of physical exercise Level of alcohol consumption

According to the INTERHEART study, changing one’s behaviours around these nine risk factors will impact health outcomes. However, as we’ve seen earlier in this chapter, a person’s ability to make behavioural changes, for example, eat more fruit and vegetables or get more

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

exercise is tied to their income and social status. In other words, those who can afford to will be able to eat more fruit and vegetables and get a membership at the gym in St. John’s. But for those who can’t, and that would be approximately 50% of the population on Bell Island, citizens and the community will have to come up with alternative strategies to support the desired behavioural changes. Tenth Determinant

Health Services There are many dimensions to health services: primary care, prevention, screening, acute interventions and chronic disease management, to name but a few. As noted earlier, this report is not in any way an operational review of how effective or efficient the health system is on Bell Island. Rather, the focus is on the community identifying its health and well being needs and then looking at how health services can be better molded to meet those needs. After the chapters on the different age groups, there is an entire chapter on Health Services, consequently, this section is restricted to a brief discussion of the community’s unique ability to participate in the primary health care reform taking place across Canada.

Bell Island is well positioned to participate in the next generation of Primary Health Care

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The four pillars of Primary Health Care are: ‘Teams’, ‘Information’, ‘Access’ and ‘Healthy Living’. Woven through these four pillars is the intent to: “ensure individuals have access to appropriate health professionals; ensure that clients / patients are part of the team and empowered to make decisions about their own health”; and, to embrace “healthy living, a holistic approach to wellness that encompasses chronic disease management and encourages support for self-care.” Moreover, just as we have done in this report, primary health care “acknowledges that factors outside of the health system can influence individual and community health.” As the Bell Island Health and Wellness Committee has maintained from the very beginning, “Health care is about keeping us well rather than just treating us after we’ve become sick.” Now that Bell Island Nothing will happen has a health programs and services baseline and automatically. Change a clear understanding of depends on what you the community’s needs, it is well positioned to be and I do everyday a true partner in primary health care. Opportunities GLORIA STEINEM and challenges, around

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BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

next generation Primary Health Care for the Bell Island community, are detailed in the chapter on Heath Services. Eleventh Determinant

Gender According to the Public Health Agency of Canada, “Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis.” Many of the gender differences, identified on Bell Island, reflect the broader cultural norms in the community. For example, women are more likely to be single parents, have lower incomes, be subjected to sexual or physical violence and so on. As the following data demonstrates, these are familiar themes within the Bell Island community. Data x Number of single parent female households: 245 (2001 Census) x Number of single parent male households: 25 (2001 Census) x Number of women reporting unpaid, informal care-giving to seniors: 275 (2001 Census) x Number of men reporting unpaid, informal caregiving to seniors: 125 (2001 Census) x Number of women reporting unpaid, informal care-giving to children: 515 (2001 Census) x Number of men reporting unpaid, informal caregiving to children: 305 (2001 Census) x Number of self-employed men: 65 (2001 Census) x Number of self-employed women: 20 (2001 Census) On Bell Island, there are significant gender differences when it comes to self employment, care-giving for seniors, raising children and being head of a single parent family. Across each of these dimensions, women on Bell Island do not fare as well as men. Research has demonstrated that changing attitudes around gender differences starts with involving male partners in prenatal care, delivery and raising children. This is in part the rationale behind offering prenatal classes for couples, having husbands in the delivery room and supporting paternity leave. All of these activities are designed to involve both parents in raising young families. Ninety-six percent of Bell Island’s single parents are women which, according to Health Canada, puts them at risk for poorer health outcomes. Attributes around gender are intimately entwined with culture and that brings us to the twelfth and final determinant.

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Twelfth Determinant

it is a connected community, so there are a lot of positives too, but resources are an issue.”

Culture The final and twelfth determinant is Culture. Both Health Canada and Visions Centre of Innovation, suggest that a community’s cultural values can have a huge impact on the community’s social and economic environment. Following are three themes widely espoused by the Bell Island community. As Health Canada suggests, these themes of loss, disempowerment and isolation may have some bearing on the way the community perceives and receives its heath care programs, supports and services, as well as the economics around those services and programs. These cultural themes began to emerge with the closure of the iron ore mines. Interestingly, by 2001, approximately 36% of the population on Bell Island was born after the mine closed in 1968. The Bell Island community frequently references their culture of loss and disempowerment. “When people see the kinds of blows to the community that we have had, you kind of get a sense that everything is being lost. We lost the vocational school several years back and then, we lost the bank and then, we lost another one of the schools. There is an obvious sense of loss for the community which doesn’t lead to a stronger sense of community. It leads to a sense of grief and loss. It is hard on the sense of community and the longing that you have, because things are lost. It is very disempowering, I think.”

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When compared to mothers with partners, single mothers are at increased health risk due to a range of social factors: the great majority are low-income (81% vs 15% of partnered mothers); more than half experience food insecurity (54% vs 10%); and 40% experience violence compared to 7% of partnered mothers

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HEALTH CANADA GENDER-BASED ANALYSIS, 2003

Isolation is another frequent theme. “Bell Island is isolated by geography, isolated by weather, isolated by social systems from the bigger social systems in St John’s” … “I think just the feeling of isolation, the feeling of not having access to resources is very disempowering. You see that a lot here. The population is very disempowered at times. Sometimes they feel that they are at a disadvantage being here on Bell Island, not having access to all the resources, for example, like in St. John’s. They also see strength being on Bell Island because it is a small community,

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

This Needs Assessment, commissioned by the Bell Island Health and Wellness Committee, is the first step in changing the culture around community health and wellness and health care delivery on Bell Island. The Committee, with the assistance of Eastern Health, has, in the words of Dr. Leonard Syme, decided “to learn: how to make things work for their benefit; how to select a problem and succeed in solving it; how to develop strategies for getting done what they want to get done; and how to take control of their destiny!”

Summary of challenges Following is a list of community challenges identified by Bell Islanders. In subsequent chapters, we will look at how those same challenges play out across the different age groups. x issues around income and social class

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Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language & culture and lack of access to culturally appropriate health care and service

x proactive engagement of individuals and families receiving government assistance in Phase Two of the needs assessment

VISIONS, CULTURE

x evolving family structures namely, significant numbers of single parent families, adult children living with their parents, and seniors living alone x persistent low literacy rates x less than 100% of youth graduating from high school x limited employment opportunities on Bell Island x dearth of community leaders x need for the town council and employers to collaborate on optimal working conditions for all Bell Islanders x need for formal adult education and training x need for formal adult literacy programs x mitigate the impact of emigration on seniors x maintain adequate ferry service x financial services, namely a bank branch or credit union

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x alleviate financial and psychological burden of Wabana’s legacy infrastructure x affordable transportation x adequate and clean water x go green(er): reduce, reuse, recycle x address the pervasiveness of ‘at risk’ conditions and behaviours to include: gambling, alcohol, tobacco, obesity, inactivity and use and availability of illegal and prescription drugs x community strategy to address domestic violence, abuse and neglect x recreational facilities that meet the needs of all age groups, especially infants and preschoolers, youth and seniors x ready access to services provided on Bell Island by allied health professionals to include, but not be limited to: physiotherapists, occupational therapists, dietitians, massage therapists, opticians, recreational therapists, chiropodists, and chiropractors x gender equality at home and at work x redress cultural themes of loss, isolation and disempowerment

Suggestions for consideration Income and Social Status: It is hard to talk about social status especially in a small community. However, 44.4% of Bell Island’s population receives some form of government assistance. Moving forward, this sector needs to be fully represented and a visible partner in Phase Two if the Needs Assessment process is to be successful. As Dr. S. Leonard Syme recounted, not engaging these members of the community will result in a failure to make and / or sustain change. An opening strategy might be for each committee member to partner with a person receiving government support for the duration of Phase Two of the Needs Assessment. Employment: Employment has a direct bearing on health. To create employment, Bell Island will require the assistance of and collaboration between the government departments responsible for fishing, tourism and farming. Does Bell Island have an economic development plan? Have business opportunities around the tourism industry on Bell Island been fully explored? Does Bell Island have comprehensive data on its tourism industry, including numbers of visitors and dollars contributed to the island’s economy? Does Bell Island have a formal tourism plan covering: what services the community has to offer; what the community needs to develop; what existing attractions (the lighthouse, mining and scuba diving tours) can be leveraged and how?

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Is the fish processing plant operating at full capacity? What are the barriers to doing so? Are there outstanding issues, for example, such as access to a reliable workforce or challenging working conditions? If the working relationship between the fish plant and community needs to be improved, who in the community is going to step forward and work with the fish plant towards realizing that end? At the turn of the century, Lance Cove was an enormously successful producer of food. Is there an opportunity on Bell Island for an organic gardening co-operative? Health Education and Communication: The need for improved and more effective communication, as well as health and wellness education, will be one of this report’s most enduring themes. Bell Island may benefit from a Bell Island Health and Well Being Community television channel. Television programming would address: low literacy rates most notably in a burgeoning senior population; the growing need for education around ‘at risk’ behaviours (gambling, alcohol, tobacco use, illegal and prescription drugs, and obesity); the need for education around parenting and healthy families; the need for education on the part of patients and care-givers around chronic disease management like diabetes and Alzheimer’s; and finally, population health initiatives like dental hygiene. The idea is that the channel would be run by Bell Islanders, for Bell Islanders. Content would be generated by the community, for the community. For example, children could create and record their own ads about dental hygiene; seniors could host and record a guest speaker talking about grief; community health nurses could do a series on ‘at risk’ behaviours, and so on. Education: The community, in collaboration with the appropriate government agencies, needs to develop a comprehensive plan to provide adult literacy programs and adult education and training. The Trade School had a positive and long lasting impact on Bell Island. Are individuals on income support aware of programs designed to advance their educational skills and employment opportunities? Are literacy, education and training programs coupled with financial incentives? Broadband: Full broadband connectivity for Bell Island would be ideal. The advantage of broadband is that it supports the sending and receiving of large amounts of data, video or voice information. Also, Cable TV can use broadband transmission. Broadband could be used to support distance education, online support groups, medical diagnosis and treatments as well as communication between the community and universities.

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Urban Planning: Wabana is saddled with what is referred to in town planning circles as ‘legacy infrastructure’. This would include all the buildings and their required services (water, sewer, electrical and so on) that, were the town to be built from scratch tomorrow, would not be built nor built in the same place. This legacy infrastructure places a huge financial and psychological burden on the citizens and even more so, on the town council. Re-visioning the physical buildings, basic services and their physical placement in the community is central to meeting Bell Islanders’ health and well being needs. The re-visioning process and end product, namely, community consensus on a widely held plan, will be an important step in enabling the community to move from a culture of loss, isolation and disempowerment, to one of hope and potential. One suggested strategy for assistance with this process is to offer Bell Island as a research site to a university’s School of Rural / Urban Planning. Planning students could do the re-visioning with the community as part of their Masters and or PhD program. It might also be to Bell Island’s advantage to involve business students as part of the re-visioning process. The entire re-visioning process would be ideal ‘Reality TV’ material for a series on the Bell Island Health and Well Being Community Channel. Water: Clean, odourless water and an adequate supply of it are a top priority both in and outside the town of Wabana. Perhaps there is need for a public education program on how to treat and maintain wells so that the iron eating bacteria, which gives Bell Island’s water that distinctive rotten eggs smell, is eradicated. There also needs to be a more reliable way to let citizens know when the water is drinkable, as well as, when and where there is a boil water order. Again, this important public bulletin could be posted on the community TV channel. Finally, the high rate of dental caries in children suggests that the town should explore fluoridation of Wabana’s water supply. Leadership: Investigate the feasibility and advantages of including ‘residency clauses’ in the contracts of teachers, health professionals and so on. Having these professionals in the community is important not only because of their skill-sets but also because of their connections that can directly or indirectly benefit a community. To fully appreciate the advantages of doing so, look at the impact that members of the RCMP force and the catholic priest have had as residents of Bell Island. Are isolation pay or special tax incentives an option for employees committed to living on Bell Island? Financial Services: Is there a business opportunity here? According to the findings of the telephone survey, over 80% of persons interviewed use debit and ATMs, 37% use telephone banking and 11% use

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

online banking. Moreover, an ageing population with low literacy rates may be of special interest to financial institutions. Larger financial institutions have research and development divisions that could be approached. Maybe there is a value added service that a bank could be offering that would justify their reinvestment in Bell Island. Perhaps servicing rural and remote communities like Bell Island could be a niche market for certain financial services companies. Note how Banks have set up single employee commercial fronts in grocery stores. This community challenge would be an ideal project for business school students. This issue warrants further investigation. Allied Health Professionals: More will be said about allied health professionals in the chapter on Health Services. However, one of the ongoing concerns of health professionals commuting to and from the island to work is the prospect of not being able to get home. Is it possible for the community to put an emergency action plan in place? Are there families who would volunteer to house overnight a commuting professional, in the event, that they were detained due to inclement weather or ferry mechanical breakdown? Having a clearly articulated backup plan, complete with brochure, to hand out to allied health professionals when they came over to hold their clinics would be a selling point. Bell Island as a Living / Learning Laboratory: Bell Island has the potential to become a living / learning laboratory. Completing Phase Two of the Needs Assessment is the next step for the community in achieving that end. The community, in collaboration with the Bell Island Health and Wellness Committee, has the opportunity and potential to turn health and wellness into a growth industry on Bell Island.

Suggested indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point for discussion. The wording of these indicators would be formalized in Phase Two of the Needs Assessment. The end goal is to identify indicators at the community level that are truly meaningful for the Bell Island community. 1.

Percentage of persons on government assistance involved with Phase Two of the Needs Assessment

Percentage of professionals (teachers, Eastern Health staff, clergy and so on) residing on Bell Island

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

Presence of and enrollment in a formal adult literacy program

Presence of and enrollment in adult education classes face-to-face and or online

Presence of enhanced and or alternative financial / banking services

Percentage of island households with adequate and safe drinking water

Total annual dollar value of all recyclables

Number of ‘green’ community initiatives

Existence of a community strategy for addressing domestic violence, abuse and neglect

10. Recreational facilities meeting the needs of all age groups 11. Re-visioning plan for Wabana’s physical layout and infrastructure 12. Number of health professionals who availed themselves of the meals and accommodations provided by the community 13. Percentage of the island households serviced by broadband 14. Presence of a community television channel and number of hours of health and wellness related programming 15. Monitoring of the community’s feelings of loss, disempowerment and isolation 16. Number and types of students (urban planning, business school, telecommunications, and so on) involved in community re-visioning, term or ongoing research / class projects

Topics for further research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to come forward and integrate research on Bell Island into their studies. Doing so, will help establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Wellness Committee. 1.

How have other rural and remote communities, particularly those that have lost their main industry, dealt with legacy buildings and infrastructure resulting from emigration? What lessons can the Bell Island community learn from these experiences? Are there successful programs that combine government support with education? What are these

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programs and are there ways that they could be successfully integrated into the Bell Island community? 3.

Do a business case on a fixed link connecting Bell Island to the Avalon Peninsula.

References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. A Community-University Research Alliance. Rural communities impacting policy. [online]. (April 2006). http://www.ruralnovascotia.ca Annis, Robert. (1999 – 2005). Final report: determinants of health of rural populations and communities research project. [online]. (April 2006). http://www.brandonu.ca/rdi/Publications/SSHRC%20 Final%20Report%20-%20Public%20Report.pdf Atlantic Health Sciences Corporation. (2002). The New Brunswick community health needs assessment. [online]. (April 2006). http://www.gnb.ca/0601/pdf/ CHCNBNeedsAssessmentEngNov201.pdf Bell Island Website. [online]. (April 2006). http://www. bellisland.net/ Boeree, George. Personality Theories: Abraham Maslow. [online]. (April 2006). http://www.ship. edu/~cgboeree/maslow.html Calgary Health Region. Community prevention of childhood obesity. [online]. (April 2006). http://www. calgaryhealthregion.ca/childobesity/ Campaign 2000. 2003 Report card on child poverty in Canada. [online]. (April 2006). http://www. campaign2000.ca/rc/ Canadian Association of Food Banks. Hunger count. [online]. (April 2006). http://www.cafb-acba.ca/ english/ Canadian Public Health Association. (1999). Building a healthy future. [online]. (April 2006). http://www. phac-aspc.gc.ca/ph-sp/phdd/report/toward/ Canadian Rural Revitalization Foundation. [online]. (April 2006). http://www.crrf.ca/about/index.shtml GoogleEarth Bell Island. [online]. (April 2006). http:// GoogleEarth.com Government of Canada CIHI. [online]. (April 2006). http://secure.cihi.ca/cihiweb/splash.html Government of Canada. CIHI CPHI. (2004). Improving the health of Canadians. [online]. (April 2006). http://www.cihi.ca/cihiweb/dispPage.jsp?cw_ page=media_25feb2004_e

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5 | WHAT ROLE DOES THE COMMUNITY PLAY IN OUR HEALTH?

Hancock.T. (1993). Presentation: Healthy cities and communities: past, present and future. [online]. (April 2006). http://www.scahec.net/courses/ PH%20Modules/Mod4Hancock.pdf Handcock, Labonte, Edwards. (1999). Indicators that count! Measuring population health at the community level. Can J Public Health. 1:S22-6. Health Canada Canadian Health Network. (2006). Current health events. [online]. (April 2006). http:// www.canadian-health-network.ca/servlet/ContentS erver?cid=1042668267588&pagename=CHN-RCS/ Page/HEHPageTemplate&c=Page&lang=En Health Canada Canadian Health Network. How do relationships with others affect people’s health? [online]. (April 2006). http://www.canadian-healthnetwork.ca/servlet/ContentServer?cid=11270887636 80&pagename=CHN-RCS/CHNResource/CHNResourc ePageTemplate&c=CHNResource Health Canada. (1999). Towards a healthy future: second report on the health of Canadians. [online]. (April 2006). http://www.phac-aspc.gc.ca/ph-sp/ phdd/report/toward/ Health Canada. (2003). Working paper: Social capital as a health determinant: how is it defined? [online]. (April 2006). http://www.hc-sc.gc.ca/sr-sr/alt_ formats/iacb-dgiac/pdf/pubs/hpr-rps/wp-dt/20030207-social-defin/2003-0207-social-defin_e.pdf Health Canada. Health care system, about primary care. [online]. (April 2006). http://www.hc-sc.gc. ca/hcs-sss/prim/about-apropos/index_e.html HEPAC (The Healthy Eating Physical Activity Coalition of New Brunswick). http://www.gnb.ca/0049/ activities-e.asp and http://www.hepac.ca/ INTERHEART study (McMaster University). http://www. cihr-irsc.gc.ca/e/26489.html Legowski, B. (2002). A sampling of community and citizen-driven quality of life / societal indicator projects. [online]. (April 2006). http://www.cprn. com/en/doc.cfm?doc=84 Memorial University of Newfoundland and Labrador Centre for collaborative health professional education. [online]. (May 2006). http://www.mun. ca/regoff/calendar/sectionNo=GENINFO-0615

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Photovoice. [online]. (April 2006). http://www. photovoice.org/ Public Health Agency of Canada Atlantic Region. (2002). An inclusion lens. [online]. (April 2006). http://www.phac-aspc.gc.ca/canada/regions/atlantic/ Publications/Inclusion_lens/index.html Public Health Agency of Canada. Towards a healthier future. [online]. (April 2006). http://www.phac-aspc. gc.ca/ph-sp/phdd/determinants/index.html Public Health Agency of Canada. What determines health? [online]. (April 2006). http://www.phac-aspc. gc.ca/ph-sp/phdd/determinants/ Romanow, R.J. (2002). Building on values: the future of health care in Canada. [online]. (April 2006). http://www.hc-sc.gc.ca/english/care/romanow/index. html Rural Centre: Research and Resource Links. [online]. (April 2006). http://www.theruralcentre.com/links. html Ryan-Nicholls, K. (2004). Rural Canadian community health and quality of life: testing a workbook to determine priorities and move to action. Rural Remote Health April – June; 4(2):278. Statistics Canada. (2002). Canadian community health survey: a first look. [online]. (April 2006). http:// www.statcan.ca/Daily/English/020508/d020508a. htm Syme, S.L. (2004). Presentation. Social determinants of health: the community as an empowered partner. Preventing Chronic Diseases. 1:1-5, 2004. [online]. (April 2006). http://www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=544525 Syme, S.L. Publications [online]. (April 2006). http:// sph.berkeley.edu/faculty/syme.htm University of Alberta Centre for Health Promotion Studies. Canada Links. [online]. (April 2006). http:// www.chps.ualberta.ca/links/canada.htm Visions Center of Innovation. [online]. (April 2006). http://www.visions.ab.ca

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6 OUR ESPOUSED HEALTH AND WELL - BEING NEEDS 6.1 INFANTS AND PR ESCHOOLERS This chapter provides an overview of existing community supports and health services for infants and preschoolers on Bell Island. It also highlights how some of the individual and community behaviours, outlined in the preceding chapter on the community, impact the health and well being of this age group. Data are from the Bell Island Needs Assessment 2004 Telephone Survey, the 2001 Census, the Community Accounts website, and de-identified data from the Health Care Corporation of St. John’s. Due to the small number of infants and preschoolers, some of the data are for years 2001 – 2004 inclusive. The reason for aggregating the data over several years is to protect the identity of the individuals concerned. The layout of this chapter is slightly different from the remaining chapters. Although the material is cross-referenced with the Twelve Determinants of Health, it does not use them as an outline because, like Health Services, Healthy Child Development is one of the determinants.

Poverty has a huge impact on our babies’ health and well being Health researchers the world over, report that income and social status have a significant short and long term impact on the health and well being of children from birth to five years. The following list, generated primarily from 2001 Census data, sets out some of the social and economic conditions that infants and preschoolers are being born into on Bell Island.

HEAD START, WABANA COMPLEX. PHOTO COURTESY OF DESMOND M C C ARTHY.

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Children in low-income families and neighborhoods are at a higher risk than children who grow up in families with higher incomes for infant death and low birth weight. They are more likely to experience developmental delays and injuries, and to be exposed to environmental contaminants that have a negative effect on health

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PUBLIC HEALTH AGENCY OF CANADA, INVESTING IN EARLY CHILDHOOD, 2002

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Data x Number of children between ages 0 – 4: 115 (2001 Census) x Number of households: 1,215 (2001 Census) x Number of two parent families: 600 (2001 Census) x Number of lone parent families: 250 (2001 Census) x Average number of members in two and lone parent families: 3.0 (2001 Census) x LICO for a family of three: $21,268 (Canadian Council on Social Development, 2004) x Median income of two parent families: $27,100 (2001 Census) x Median income of lone parent families: $17,000 (2001 Census) x Median family income Wabana: $18,613 (2001 Census) x Median family income Freshwater and Lance Cove: $30,009 (2001 Census) If we generalize the findings from the Bell Island Needs Assessment 2004 Telephone Survey Report, 50% of Bell Island households are living below the Statistics Canada LICO level. Moreover, approximately 54% of all Bell Island children are living in poverty. Finally, almost one third of the families on Bell Island are lone parent families and approximately 85% of those lone parent families are living in poverty. Note, families living in Lance Cove or Freshwater are better off financially than those living in Wabana. In reviewing these data one begins to understand that the majority of babies born to Bell Islanders are born into low-income families meaning that their health and well being are at risk. However, the good news is that dedicated parents, volunteers, health professionals and the Bell Island community together are working hard to mitigate those risks.

Teen pregnancy rates appear to be dropping Between 2001 and 2004, 73 babies were born to Bell Island mothers. According to the data from the St. John’s Health Care Corporation, all babies born during this time period (April 2001 – March 2004) were born at the General Hospital, Health Sciences Centre in St. John’s. Fifty-seven babies (78%) were delivered vaginally, while sixteen (22%) were delivered by caesarean section. During this time period there was zero infant mortality. Moreover, relatively few of the babies were born to teenage mothers. According to 2001 Statistics Canada Data, Newfoundland has the lowest teen pregnancy rate in Canada. In 2000 the Canadian teen pregnancy rate was 38.2%. In 2000, the teen pregnancy rate for Newfoundland and Labrador was lower

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at 28.5%. Although a precise figure for Bell Island’s teen pregnancy rate is unavailable, hospital admissions data were used to calculate a rough approximation. Between 2001 and 2004, there were 21 recorded cases of hospitalizations due to pregnancy and childbirth for young women between the ages of 15 – 19. Furthermore, there were 140 females aged 15 – 19 living on Bell Island in 2001. Therefore, it is estimated that the teen pregnancy rate on Bell Island was 15% (21 / 140) during this time period and it is observed to be dropping.

Some birth weights are low An important health indicator is the weight of babies at birth. Of the 73 Bell Island newborns between 2001 and 2004, 62 (85%) had healthy birth weights meaning that they were between 2,500 and 4,000 grams or 5.5 – 8.8 lbs. The rate of 85% for healthy birth weights on Bell Island is significantly lower than the provincial and national rates, 94.6% and 94.5% respectively (Statistics Canada, 2001). Factors contributing to low birth weights can include: smoking, stress, abuse and or family violence, lack of social support, living in poverty, poor nutrition, and use of alcohol and Early childhood drugs.

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More Bell Island mothers are breastfeeding Good news on Bell Island is the increasing numbers of new mothers who are breastfeeding their infants. The Community Health Nurses have every reason to be excited. “We have a new baby group that a lot of moms are attending and loving it. I find that my moms are more educated and coming to us more often and the number one thing is that breast feeding has increased. When I first came to Bell Island there was hardly any breast feeding. It was evaporated

experiences have an important impact on health throughout a person’s life. Studies show that successful early childhood development depends on factors such as good nutrition, the good health of mother and child, good parenting and strong social supports. Poor early childhood development can lead to restricted brain development, reduced language capacity and poorer lifelong physical and mental health. Low birth weight has been found to be associated with lower cognitive development CIHI, IMPROVING THE HEALTH OF CANADIANS, 2004

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.1 INFANTS AND PRESCHOOLERS

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milk. Now our breast feeding rate is up, some years as high as 38%.” This rate of breast feeding is cause for celebration. Bell Island mothers are approaching the provincial average to be approximately 55% in 2002 as reported in the provincial government’s report Stepping Into the Future 2003 – 2004. Reasons for breastfeeding, and for doing so as long as possible, are well documented. Furthermore, there is increasing evidence that “The length of time spent in ’exclusive’ breastfeeding, when the baby is nourished only by breast milk, lowers the risk of developing obesity in later childhood.” (CIHI, Improving the Health of Canadians, 2004). In fact, a recent study examining rates of overweight and obesity in Newfoundland’s preschool children estimated that 26% of the Province’s children aged 3.5 – 5.5 fall into these troubling weight categories (Canning, Courage, & Frizzell, 2004). On Bell Island, where the incidence of overweight and obese adults significantly exceeds provincial and national averages, encouraging and supporting new mothers to breastfeed is of particular importance. Although the Community Health Nurses advocate breastfeeding, they recognize that there is much to be gained from providing an open and supportive environment for all new mothers. To this end the ‘drop-in’ breastfeedBirth to age five is a ing group held Tuesday afternoons at Brighter Fucrucial time for brain tures has been opened up development. During to include mothers who bottle feed their babies. this time period chilThis session has proved dren develop the ability very popular. Breast and bottle feeding mothers to communicate using come to socialize and get language, learn, cope their babies weighed by the Community Health with stress, have healthy Nurses.

relationships with others, and feel a sense of self. If children do not have the very best conditions for development during this time, their developing brain will be physically different from that of children who have these condition

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CANADIAN HEALTH NETWORK, 2004

Mothers who bottle feed are challenged to buy formula by the tin Bell Island mothers who bottle feed have also made advances by switching from evaporated tinned milk to formula. “Now it is commercial formula or breast feeding, there is no more evaporated milk.” However, mothers on low incomes who bottle feed their babies face an additional challenge. “You can’t buy

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baby formula by the can (on Bell Island). You can order it through the drug store or at the supermarket at quite a markup. If you don’t have it what are you going to feed your child? If you have $150 for two weeks you can’t buy extra to be sure. You run the risk of running out or you run the risk of not feeding the baby formula.” Mothers in this situation report having family or friends pick up tins of formula for them in St. John’s on an as-needed basis.

Our two Community Health Nurses are hard at work Working from offices located in the Dr. Walter Templeman Health Centre, the Community Health Nurses or Public Health Nurses as they used to be called, offer a comprehensive health promotion program supporting new mothers and their babies. According to data provided by the Walter Templeman Health Centre, programs and services provided by the Community Health Nurses include: x Immunization at the Child Health Clinics for babies two, four, six, 12 and 18 months of age (200 visits annually). According to the Community Health Nurses, they “immunize every single person as a child from birth up through school” x Prenatal education: one-on-one and through the Health Baby Club (six visits weekly) x Postnatal education: through individual home visits, clinic visits and weekly Baby Talk Club (one – 15 client visits weekly) x Breastfeeding support one-on-one and in groups (20 in 2004 – or approximately 38% of new mothers) x Health Check Three Clinics: developmental, hearing, speech and vision assessments of children at three years of age (approximately 25 annually) x Parenting programs: Nobody's Perfect (taught in conjunction with Brighter Futures twice in the past five years) x Healthy Beginnings: one-on-one regular postnatal follow up for six to eight weeks, (approximately 12 – 21 clients, 2004) x Long Term Healthy Beginnings: one-on-one follow up until 18 months (approximately 15 – 21 clients, 2004) In addition to their clinical activities, the Community Health Nurses also act in a liaison capacity for Brighter Futures Family Resource Centre and the Bell Island Head Start Program. They also liaise with Memorial University which, in the past, led to “some students working with us who ran a parenting group which went quite well. We had quite a response so it can happen.” The latter comment refers to Bell Islanders’

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self reported and well recognized reticence to participate in groups with a personal focus.

Some Bell Island mothers are proactive about their babies’ needs

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The purpose of the Health Check Three Clinics is to carry out developmental, height, weight, hearing, vision and speech assessments on all three year olds in preparation for kindergarten. These developmental checks are highly valued by the mothers, so much so that some mothers suggested that their babies would benefit from an additional developmental assessment at 18 months when they get their immunization. The rationale for the current three year and proposed 18 month assessments is to address any developmental delays well in advance of the child starting school. In addition to the services noted above, a number of mothers expressed interest in having a dedicated baby day clinic run by a pediatric nurse three or four times a year. This would give mothers the opportunity to have specific concerns and questions fielded by an expert. The Community Health Nurses themselves have raised the possibility of having specialists come and present topics like ‘Playing with Children’ at the Brighter Futures Tuesday drop-in sessions. This suggestion was of Supportive commungreat interest to the mothers.

ity environments can help prevent behavioural and emotional problems in children. Programs for parents and community development activities such as workshops, improve parenting skills and community connectedness

Brighter Futures Family Resource Centre has the potential to be a jewel in the community’s crown

Brighter Futures recently relocated from the east end of the island near the island’s incinerator to a beautifully renovated house downtown across from the Fire Station. Brighter Futures is staffed by one paid employee and two volunteers. This Health Canada funded program supports families with children ages zero to six years old and CIHI, NEW REPORT: IMis open year round although PROVING THE LIVES OF there is a ‘slow down’ durCANADIANS, 2004 ing the summer months. All programs are run free of charge and transportation and childcare are provided for those in need. Brighter Futures offers a broad spectrum of activities. Most focus on parents and their children doing things together, for example, Cooking with Parents and Tots, Crafts with Parents and Tots, Family Day, Books for Babies, the Celebrity Reading Program and special family outings around St. John’s.

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In fact, parents or a caregiver must attend preschooler and family activities with their child. In addition to Child / Adult activities, Brighter Futures also offers programs and activities just for parents, namely, the Parent Club, Nobody’s Perfect and an Adult Literacy Program. Nobody’s Perfect has been co-taught by the Community Health Nurse and the Brighter Futures Director who are both trained and certified to teach the course. The Child Social Workers also cited the need for parenting classes but the teachers are challenged to attract parents to take the program. Brighter Futures also offers parent training on stress management, time management, health and child safety, and landlord / tenant relations.

Brighter Futures facility and programs are presently underutilized Attendance at Brighter Futures programs has been sparse. Hard data were not available from either the local centre on Bell Island or the central headquarters in St. John’s, but staff estimated that in 2004, 25 – 30 families with 20 – 30 children made use of Brighter Futures. Brighter Futures staff attributed poor attendance to a lack of referrals and the perception out in the community that Brighter Futures is only for families on social assistance. Brighter Futures is working hard to dispel that myth. “We are trying to chuck the stigma that people think that because something is free and is all paid for it must be just for social services or for families that can’t manage their children.” Because Bell Island is a small community, the population is understandably sensitive when it comes to personal privacy. “A lot of the people are hesitant to use these types of resources. Some of them just won’t go into a group where everyone knows you. If it is going to a group and talking about private issues they are quite resistant.” Finally, Brighter Futures staff espouse that Health and Community Services send

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How children grow and develop in their early years is a powerful determinant of health. More and more evidence is being found that prenatal and early childhood experiences have a more powerful and long-lasting effect than researchers had previously understood on health, well-being and competence. Evidence also shows that these three factors are strongly linked with adults’ ability to cope with problems and stress, and their sense of identity CANADIAN HEALTH NETWORK, 2004

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more referrals to the early childhood daycare program, Head Start, operating out of the Wabana Complex. Brighter Futures staff is acutely aware of being underutilized and cite the need for ‘a general education campaign (in the community)’. Workers hope that their new location will result in a higher profile and subsequently increased use of the facility.

Community Health Nurses and Brighter Futures successfully reach out to young families

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By all accounts, the prenatal and postnatal programs jointly offered by the Community Health Nurses and held at Brighter Futures are an enormous success. Working together, the A loving secure attachnurses and Brighter Futures ment between parents, Staff offer a round-robin of services and programs caregivers and babies in focused on optimizing the first 18 months of the health and well being of new parents and their life helps children debabies. As committed velop trust, self-esteem, professionals, the nurses and Brighter Futures staff emotional control and understand that their work the ability to have posiwith these new mothers and their babies can last a tive relationships with lifetime.

others in later life

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Although Brighter Futures has been challenged to INVESTING IN EARLY move their own program CHILDHOOD, 2002 forward, their partnership with the Community Health Nurses, focused on prenatal and postnatal care, has attracted an increasing number of new mothers and their babies to the facility. “Sometimes you have to go out and get them to come. The Public Health nurses do a really good job at that. They are involved with the families one-on-one doing immunizations for example and there is the entry point really. They are meeting with them, talking about the resources, and giving them information – those are good things.”

The Healthy Baby Club Working together, Brighter Futures and the Community Health Nurses offer The Healthy Baby Club. This is the only group prenatal class on Bell Island. This outreach program is designed to reach out to teen pregnancies, high-risk pregnancies, low income families and persons on social assistance. Unfortunately, this group is restricted to a maximum of six clients so there are times when high-risk mothers are put on a waiting list. The

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goal of the Healthy Baby Club is to eliminate low-birth weights associated with lower cognitive development. To that end, in addition to the monthly $45 Mother Baby Nutrition Supplement, each week program participants receive one dozen oranges, one dozen eggs, and seven liters of milk to supplement their diet. The monthly $45 Mother Baby Nutrition Supplement is designed to offset the additional expense of eating healthy food during pregnancy and during the baby’s first year of life – a time when mothers are most likely to be breastfeeding. Mothers do not have to be eligible for income support to qualify for the monthly $45 Mother Baby Nutrition Supplement. Not much is known about the amount or type of nutrition children receive after they graduate from the Mother Baby Nutrition Supplements and before they enter kindergarten.

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Infants and children exposed to second-hand smoke are more likely to suffer chronic respiratory illness, impaired lung function, middle ear infections, food allergies and can even succumb to sudden infant death syndrome. Exposure to second-hand smoke during pregnancy may contribute to birth defects such as cleft palette. Moreover, smoking mothers produce less milk and their babies have a lower birth weight

Once a month, the Health and Community Services Mental Health / Addictions Counselor attends the Healthy Baby Club and does presentations on topics such as self-esteem, healthy relationships or post-partum depression. “This gives new mothers the opportunity to get HEALTH CANADA, SECONDconnected to the mental health HAND SMOKE, FAQ S worker and understand that there might be different phases from time to time as new mothers.” The Healthy Baby Club has a high profile on the island and clients most often self-refer or follow up on their practitioner’s advice to contact the Community Health Nurse and enroll in the program. In fact, from time to time there is a waiting list for the Healthy Baby Club. Even women who don’t meet the criteria expressed interest in attending the Healthy Baby Club understanding that they would not receive the food supplement. Their interest was in the prenatal education and socialization.

The Baby Talk Club and Infants and Tots Group Informal postnatal education is offered in the Baby Talk Club which takes place for an hour each week. As the infants age they can move on to the Infants and Tots Group which is also held at Brighter Futures. The

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.1 INFANTS AND PRESCHOOLERS

Community Health Nurses and Brighter Futures Staff are delighted to see parents who participated in the Healthy Baby Club continue on with the Tuesday breast and bottle feeding group. “Some positive things have happened. We have stuck it out and now people look up to us now and feel more comfortable coming to us with personal problems and issues. It takes a while and we are there now.” It is hoped that, over time, these mothers and their families will migrate to the core programs offered by Brighter Futures.

Second-hand smoke and poor dental hygiene put Bell Island babies at risk In 2003, Health Canada reported that almost 14% of Canadian homes with children under 12 years old were exposed to second-hand smoke from cigarettes, cigars or pipes. Findings from the Bell Island telephone survey indicate that 22% or 14 of the 65 children ages zero to nine years in our sample were living in a home with at least one smoker. Second-hand smoke poses a significant health risk to babies and their mothers during the prenatal and postnatal period. The nurses recognize that the immediate prenatal and postnatal period offer a window of opportunity when mothers are more open to making behavioural changes that will benefit both their babies and themselves. As a result the nurses actively promote smoking cessation and are having some success. “I’m getting some people to quit smoking due to education and just some lifestyle changes. I have seen results in four years.” Good dental hygiene during pregnancy is another strategy for producing a healthy baby. Expectant mothers with dental disease have a seven-fold increased risk of delivering a preterm, low weight baby (Offenbacher, S et al., 1996).

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Offering comprehensive Early Childhood Education and Care (ECEC) services to single mothers and their children pays for itself within one year, due to reduced health and social service costs, and high levels of exits from social assistance

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BROWNE ET AL., 1999

Fathers need to be brought into the circle Respondents also noted that although the prenatal program was open to men, few attended. Personal accounts were given regarding the reluctance on the part of the men to attend pre-natal classes. The most common response by men, to being asked to accompany their partner to class being, “Are there other guys there?” Women underscored the need for videos on how to change a baby or the birthing process that they could take home and watch with their husbands. A clear division of male and

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female roles around the care of babies and small children was frequently expressed. A common refrain being “In Newfoundland the thing is, the moms rear the children.” However, the 2001 census reported 25 male loneparent families on Bell Island.

Grandparents play an important role in childrearing Numerous parents underscored the involvement of their extended family in child rearing, particularly help received from grandparents. “Here in Newfoundland grandparents usually look after the grandchildren. Grandparents are usually more taken up with their grandchildren than they were their own.” One participant suggested engaging experienced grandparents as informal ‘healthy family’ mentors as part of the Brighter Futures / Community Health Services programs.

Bell Island Head Start Child Care Centre Inc. is a key community asset Bell Island has a well established early childhood education and care (ECEC) program called Head Start for children ages two to six. This private daycare program was initiated in 1988. Head Start operates September through June out of the Wabana Town Complex also known as the Vocational School. The program is open to the public at $10 per half day. Health and Community Services covers the fees if a family is on social assistance. Head Start offers two half day sessions, one in the morning and one in the afternoon. The program includes nutritious snacks and has a secure outdoor playground. The two staff members are trained in early childhood education. Approximately 23 – 27 children were enrolled in 2004. Head

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Two recent studies in Ontario provided comprehensive services (including quality child care and recreation, employment retraining and visits from a public health nurse) to lone-parent families on social assistance. Twentyfive percent of families offered the full range of services exited social assistance, compared to 10% of those without the services. Offering recreation services alone resulted in a 10% greater exit from social assistance, compared to parents of children who did not receive this service. It also resulted in improved health for both mothers and children. Recreation paid for itself through reduced use of health and social service BROWNE ET AL., 1999; BROWNE ET AL., 2001

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Start has the capacity to accommodate 32 children. In addition to the cognitive and social reasons for children to attend preschool, research indicates that there are compelling financial reasons.

There is a real need for age-appropriate recreational facilities As expressed by other age groups, namely the youth and seniors, there is a real desire for a recreational facility that accommodates the needs of families with infants and preschoolers. Presently, there are no ‘free’ outings other than to Brighter Futures or the Library. On Bell Island, “You can’t take children to the museum or the park.” However, research has shown that recreation can play a powerful role in increased health and wellness for babes and their mothers as well as the economic well being of the community.

Hospitalization data indicate a prevalence of dental caries (tooth decay) According to the in-patient hospitalization data for years 2001 – 2004, provided by the Health Care Corporation of St. John’s, the primary reason for hospitalization of children ages one to four at the Janeway Hospital in St. John’s was health problems of the mouth and ears. Eleven children (25%) in this age category were admitted as inpatients to the Janeway Hospital in St. John’s and 33 (75%) of the children were admitted for day surgery. More specifically, of the 33 day surgery cases within this age range, 19 or 57.6% of cases were admitted for dental caries, more commonly known as tooth decay. Sixteen tooth restorations, one tooth extraction, one total, and one partial excision were the procedures performed. By way of comparison, dental caries represented 41.7% of the day surgery admissions among children age one to four in Newfoundland and Labrador as a whole – a substantial difference. Dental caries among Bell Island children appears to represent a significant burden on the health care delivery system, yet with good dental hygiene, dental caries is thought to be almost 100% preventable. Furthermore, all dental services for children aged 12 and under are covered by the Newfoundland and Labrador Medical Care Commission (MCP).

Unfortunately, not all families on Bell Island are able to meet their babies’ and preschoolers’ needs As mandated by Health and Community Services, the two social workers responsible for child protection work with families and the community to “prevent, reduce and / or resolve risks to child safety, health and well being.” According to 2004 data, and subsequent analysis provided by Health and Community Services,

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Infants and young children need affectionate touching and an environment rich in stimulating experiences. Their conditions will help them to grow brains that have lots of neural connections (the connections between brain cells). Conversely, children who are exposed to insecure, violent or chaotic environments can end up with an adult brain that secretes excessive stress hormones when faced with stress. This hinders that adult’s ability to cope well with difficult situations, and also makes it harder for their body to physically fight disease CANADIAN HEALTH NETWORK, 2004

there appeared to be an increase in Intakes (approximately 24 – 31 in 2004). Intakes refers to calls to the agency when a child is alleged to be at risk of maltreatment. In these situations, “social workers provide risk assessment and risk reduction planning to ensure the child is safe.” During the same time period there appeared to be an increase in Protective Interventions (approximately 1 – 10 in 2004). Protective Interventions are customized for each family. In some cases it may be working on parenting skills, in other families the focus may be on the child’s behaviours. If the situation requires a child to be removed from the home, that is called being taken into custody. Because of privacy issues arising from the small size of the community, numbers for intakes, interventions and custody cases were not broken down into specific age groups. However, working with a total population of 550 children from ages zero to 14, this means that approximately 4.4 – 5.6% percent of the child population required the assistance of social workers in 2004. During the same period, use of the Family Services Program, Services to Birth Parents and use of the Caregiver Home Administration Program were reported to be nominal. Provincial comparison data for the above are not currently available. A word of caution: The data provided by Health and Community Services is compromised due to lack of standardized recording practices and should be interpreted carefully. For example, if services provided to a client were completed and the client program was not closed before the end of the reporting period, the case will still be counted. This means that the number of clients that appear to be receiving treatment in any given month may actually be inflated. On the other

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hand, the numbers reported each month refer only to cases that are active at the end of the reporting period. New client cases that are opened and closed during the month long reporting period may not be counted. This means that the numbers of intakes may actually be higher than is reported above. These and other data limitations encountered over the course of the current project will be discussed further in the chapter detailing Health Services. Presently, Health and Community Services recognizes that they are challenged to collect meaningful utilization data.

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Infants and children, who are neglected or abused, are denied the stimulation and nurturing they need in the early years. This puts them at higher risk for behavioural, social and learning problems throughout the life cycle

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INVESTING IN EARLY CHILDHOOD, 2002

The two child social workers also offer community outreach The two child social workers, who are broadly engaged in child, youth and family services, play a vital role ensuring that the best interests of the children are paramount while at the same time working to strengthen parenting capacity and community support. Less known are the outreach services that the social workers offer. In addition to general information on any number of topics – custody, behavioural issues and so on, a case worker can be assigned to work with parents who want support in care giving and parenting without opening a formal file on that family.

Summary of challenges x number of families with infants and preschoolers living below the LICO x increasing number of Intakes and Protective Interventions x poor dental hygiene x ongoing stigmatization and isolation of mothers with young families on social assistance x limited engagement on the part of male loneparent families and fathers in the prenatal and postnatal experience and parenting of infants and preschoolers x universal and adequate access to prenatal classes independent of income x under-utilization of Brighter Futures x better internal understanding and coordination of services and programs offered by Brighter Futures, Head Start, the Community Health Nurses, the

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Mental Health and Addictions Counselor and the Child Social Workers x recreational facilities for families with new infants and preschoolers x restricted access to baby formula on a per can basis x access to a pediatric nurse trained in lactation and developmental assessments x availability of topical educational videos on breastfeeding, birthing, child development and so on x under-utilization of social workers who offer support for parenting and care giving x exposure of infants and preschoolers to secondhand smoke

Suggestions for consideration The following suggestions build on the four key areas for action set out by the First Ministers and endorsed by the province. Those key areas are: 1. promote healthy pregnancy, birth and infancy; 2. improve parenting and family supports; 3. strengthen early childhood development, learning and care; and 4. strengthen community supports. The following suggestions may be of interest to individuals, the community and the health care system working together or independently. Build community capacity: Leverage and build on existing successes of the Community Health Nurses and Brighter Futures: optimize programs and activities at Brighter Futures: make Brighter Futures the downtown hub. Healthy baby club: Ensure that there is the capacity to accommodate all comers. Get an early jump on Dental Hygiene: Design and integrate a dental hygiene program into the existing prenatal care program, Health Check Three and the general programming offered at Brighter Futures and Head Start. Tooth Fairy pedigrees: Building on the adage that ‘what gets measured gets done’, have new mothers start a dental record for their baby. The concept of the dental record could be expanded to include immunizations, weight and height, involvement in Brighter Futures and Health Start programs, a history or diary of health events, health activities and so on. Foster internal communication, coordination and collaboration: Strengthen communications and relationships between the personnel from Brighter Futures and Head Start, the Community Health Nurses, the Mental Health and Addictions Counselor and the Child Social Workers. The net result being the creation

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of a mutually supportive community-of-practice (COP) focused on identifying and responding to the needs of infants and preschoolers and as importantly, the child’s parents and their extended families. Educate and publicize available resources: Profile the complementary programs and activities offered by Brighter Futures, Head Start, the Community Health Nurses and the Child Social Workers. Inclusive parenting: Actively reach out to all new or expecting parents, especially low income parents, loneparent fathers and grandparents and draw them into the Brighter Futures extended family. In an effort to increase parenting skills, initiate a SuperNanny or Nanny 911 club that meets every second week to watch and discuss for example, ‘Jo Frost’ videos. Guaranteed supply of formula: Explore the possibility of having a ‘Formula One Co-op’ to address the challenges around securing baby formula by the tin rather than the case. Positive parent role modeling: Produce infants and preschoolers or new mothers ‘reality’ segments for the proposed Bell Island Health and Wellness Community Television Channel. Second-hand smoke: Heighten community awareness around the dangers of second-hand smoke for children using home made TV adds for the proposed Bell Island Health and Wellness Community Channel. Leverage relationships with Memorial University: Establish a distance or online link between Brighter Futures and Memorial University with the intent of involving students studying nursing, early childhood education, social work and so on. Participants benefit from access to students’ skill-sets and role models. Investigate if establishing a remote link between Bell Island and MUN students in the Health Sciences would be of interest to the new Centre for e-Health Innovation starting up at the MUN Medical School. Education, Education, Education: Collaborate with the local librarian to bring in educational videos on breastfeeding, natural childbirth, the Ferber Method, SuperNanny, Nanny 911 and so on, and cycle them through Brighter Futures.

for discussion. The wording of these indicators would be formalized during Phase Two of the Needs Assessment. The goal is to identify indicators that are truly meaningful for Bell Island’s young families with infants and preschoolers. Indicators should also be concordant with the indicators proposed in “Stepping Into the Future, Newfoundland and Labrador’s Early Childhood Development Initiative, 2003 – 2004.” 1.

Percentage of infants and preschoolers with an up-to-date Tooth Fairy Pedigree

Percentage of households where infants and preschoolers are exposed to second-hand smoke

Percentage of expectant mothers and fathers participating in prenatal classes / Healthy Baby Club

Percentage of new mothers who breastfeed

Percentage of teen pregnancies

Percentage of newborns with ideal birth weights

Immunization rates for infants and preschoolers

Percentage of families with infants and or preschoolers participating in at least one activity at Brighter Futures

Percentage of preschoolers attending Early Childhood Education

Opportunities for further research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to integrate research on Bell Island into their studies. Doing so will help establish Bell Island as a living laboratory under the auspices of the Bell Island Health and Wellness Committee. 1.

Execute an in-depth qualitative study to determine the barriers to 100% participation in the Brighter Futures program and how they can be overcome.

Determine a comprehensive and coordinated approach to dental hygiene for expectant mothers, infants and preschoolers and how it can complement the proposed dental hygiene program in the elementary school. Articulate policy implications.

Investigate what infant and preschooler programs and support services are presently being offered in Newfoundland and Labrador. What information and communication technologies and partnerships would Bell Island need in order to tap into a network of support services and

Recreational facilities: Work with the community to identify short, medium and long term solutions to the need for recreational facilities appropriate for infants and preschoolers.

Suggested indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point

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resources? Are there information and communication technology partnerships and funding that Bell Island could access? 4.

Investigate the type, amount, and families’ strategies for providing nutrition for infants and preschoolers between when they finish receiving Mother Baby Nutrition Supplements up until the child enters kindergarten. Over a third of Bell Island’s families are lone parent families and 85% of these families live in poverty. Additional research is required to better understand the health and well being needs of families with infants and preschoolers and how those families can be enabled and empowered to meet those needs. Apply for funding to research, develop and pilot a Tooth Fairy Pedigree for infants and preschoolers. Over time, the Tooth Fairy Pedigree would be one component of a personal health record that could help parents keep track of immunization rates, weight, height, acute events, and so on. Determine the reasons for low birth weights on Bell Island and strategies to bring birth weights in line with the national average.

References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. American Academy of Otolaryngology Health and Neck Surgery. Children and second hand smoke. [online]. (April 2006). http://www.entnet.org/ healthinfo/tobacco/secondhand_smoke.cfm Breastfeeding. [online]. (April 2006). http://www. breastfeeding.com Browne, G. et al. (1999). Benefiting all the beneficiaries of social assistance: the 2-year effects and expense of subsidized versus non-subsidized quality child care and recreation. National Institute for Early Education Research. National Academies of Practice Forum: Issues in Interdisciplinary Care. 1(2):131 – 1710. Browne, G. et al. (2001). When the bough breaks: provider-initiated comprehensive care is more effective and less expensive for sole support parents on social assistance. Social Science and Medicine, 53 (12):1697 – 1710. Canadian Council on Social Development. (2002). The progress of Canada’s children. [online]. (April 2006). http://www.ccsd.ca/pubs/2002/pcc02/index.htm

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Canning, P.M. et al. (2004). Prevalence of overweight and obesity in a provincial population of Canadian preschool children. Canadian Medical Association Journal. 171, 240 – 242. Government of Canada CIHI. (2004). Improving the health of Canadians. [online]. (April 2006). http://dsppsd.pwgsc.gc.ca/Collection/H118-14-2004-1E.pdf Government of Canada Report. (2001 – 2002). Early childhood development activities and expenditures. [online]. (April 2006). http://socialunion.ca/ecd/2002/ reporta.pdf Government of Newfoundland and Labrador Community Accounts Bell Island accounts. [online]. (April 2006). http://www.communityaccounts.ca/ CommunityAccounts/OnlineData/default.htm Government of Newfoundland and Labrador Health and Community Services. [online]. (April 2006). http://www.health.gov.nl.ca/health/ Government of Newfoundland and Labrador. (1996). Health children, healthy society: child and adolescent health indicators for Newfoundland and Labrador. [online]. (April 2006). http://www.gov.nl.ca/publicat/ Government of Newfoundland and Labrador. (2002 – 2003). Stepping into the future, Newfoundland and Labrador’s early childhood development initiative, annual report. [online]. (April 2006). http://www.gov. nl.ca/publicat/ Health Canada Canadian Health Network. Can experiences in early childhood affect a person’s health during adulthood? [online]. (April 2006). http://www.canadian-health-network.ca Health Canada. Second hand smoke: the facts. [online]. (April 2006). http://www.hc-sc.gc.ca/hl-vs/ tobac-tabac/second/index_e.html Health Canada. The facts about tobacco. [online]. (April 2006). http://www.hc-sc.gc.ca/hl-vs/tobactabac/fact-fait/fs-if/index_e.html Health Canada. The facts about tobacco: the health effects of second-hand smoke. [online]. (April 2006). http://www.hc-sc.gc.ca/hl-vs/tobac-tobac/second/ fact-fait/index_e.html Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Human Resources Development Canada and Health Canada. (2003). Well-being of Canada’s young children. [online]. (April 2006). http://www. socialunion.ca/ecd/2002/ecd-report-2002-toc-e.html Masse, L.N. & Barrett, W.S. (2003). A benefit cost analysis of abecedarian early childhood intervention.

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National Institute for Ear Education Research. [online]. (April 2006). http://nieer.org/resources/ research/AbecedarianStudy.pdf Offenbacher, S. (1996). Periodontal infection as a possible risk factor for preterm low birth weight. Journal Periodontal. 67:1103 – 1113. Public Health Agency of Canada. Backgrounder: investing in early childhood. [online]. (April 2006). http://www.phac-aspc.gc.ca/ph-sp/phdd/report/ toward/back/invest.html

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Statistics Canada. (2001). Profile for census subdivision: Wabana, Freshwater and Lance Cove. The Ferber Method. [online]. (April 2006). http://www. babycenter.com Wilkinson and Marmot. (2003). Social determinants of health: the solid facts, 2nd edition. [online]. (April 2006). http://www.who.dk/document/e81384.pdf

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6.2 CHILDR EN K INDERGARTEN TO GR A DE SIX

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Following is a profile of the children ages five through 14 on Bell Island. These ages extend beyond those of children in grades kindergarten to grade six. While most data presented in this chapter correspond to children at these grade levels, it was not possible to obtain Census data in this precise age format. For this reason, data gathered from the 2001 Census refer to children up to and including 14 years of age. Other data sources include: the Community Accounts website; deidentified data from the Health Care Corporation of St. John’s and Health and Community Services; data from interviews and focus groups; and, from the Bell Island Needs Assessment 2004 Telephone Survey.

Children who live in persistent poverty are less likely to be included in aspects of society that are critical to their growth and health development. They are twice as likely to live in a ‘dysfunctional’ family, twice as likely to live with violence, and more than three times as likely to live with a depressed parent. Only half of the children who lived in persistent poverty participated in recreation at least once a week, compared to three-quarters of those children who have never been poor THE PROGRESS OF CANADA’S CHILDREN, THE PROGRESS OF CANADA’S CHILDREN

As part of the telephone survey, respondents were asked what they liked about Bell Island. Many of them cited reasons that had to do with raising their children on Bell Island: “more freedom for the kids than in the city”; “fresh air”; “time to spend with them”; “good schools”; “it’s a safe community.” In addition to highlighting the many advantages of raising children on Bell Island, this chapter investigates some distinct challenges, especially for those children whose parents are poor. Data x Number of children between ages five to 14: 435 (2001 Census) x Percentage of all Bell Island children under the age of 19 living in poverty: 54% (Telephone Survey, 2004)

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x Percentage of lone-parent families living in poverty: 85% (Telephone Survey, 2004) x Number of lone-parent families in 2001: 250 (2001 Census)

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x Number of lone-parent families in 2001 with three or more children: 70 (2001 Census) x Median family income for female lone-parent families in 2001: $13,530 (2001 Census) x Number one reason for day surgery on children ages five to nine years 2001 – 2004: dental caries, more commonly know as tooth decay (41.7%) (Health Care Corporation of St. John’s, 2004) x Number of children in kindergarten to grade six at St. Augustine's School for the 2004 – 2005 academic year: 212 (Newfoundland and Labrador Government – Department of Education, 2005) x Approximate percentage of children participating in St. Augustine's School lunch program in 2004: 96% (elementary school principal) x Percentage of children and youth between ages 10 & 19 exposed to second-hand smoke: 45% (Telephone Survey, 2004)

INCOME AND SOCIAL STATUS On Bell Island, income and social status go hand in hand Although more than half of Bell Island’s children live on a combination of social assistance and the Child Tax Benefit there is a persistent and often expressed bias against these families, and in particular intergenerational families receiving government assistance, “Children are brought up in that situation and instead of being encouraged to go on and do more for themselves, they say, well mother and dad are surviving. They are getting what they need and this is being paid for and that is being paid for. What am I going to bother for? They leave home and go back on the system again. The cycle just completely recycles itself.” But others in the community have a different point of view, “A lot of times when people really do want to go on to better themselves, there are all kinds of obstacles in their way. People that are legitimately on social services, it is because they can’t do anything, they can’t find work or it is physically impossible. You got three or four youngsters and you are by yourself, you’re raising them you can’t afford to be going out to a babysitter and going and working for minimum wage to come home and hand over your cheque to a babysitter. I mean, what are you working for?”

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SOCIAL SUPPORT NETWORKS There are strong feelings around the perceived impact of adults’ ‘at-risk’ behaviours on children

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Some of the backlash expressed by the community against families receiving government assistance arises from the espoused view that monies from Social Assistance and the Child Tax Benefit are feeding adults’ addictive behaviours such as gambling, drinking and smoking, rather than feeding and clothing the children. Moreover, there is a perception that these behaviours are indicative of a larger picture of family and community breakdown: “The alcohol problem is in the families who are receiving social services. As I said they are either gambling it or drinking it. That causes lack of parental care in children or family fighting, family abuse. The main problem is the poverty that the children go through.” Concern around these interrelated problems is widespread. When survey respondents were asked to rate community problems, banking, unemployment, gambling, smoking and alcohol made the top 10 of 30 issues. Moreover, when asked to identify the number one community problem, ‘gambling’ was cited in the top three, and addictions (alcohol and drugs) and poverty in the top 10. Data from the Newfoundland Liquor Corporation and the Atlantic Lottery Corporation suggest that there may be grounds for those concerns. If one were to divide the The greatest proportion total amount spent on alcohol and gambling sales by of children who experithe number of households ence difficulties are found on Bell Island the approxiamount per household in the bottom 20% of the mate would be $2,968 for 2004. socioeconomic scale This figure does not include average tobacco sales per PUBLIC HEALTH AGENCY household. Nor does this OF CANADA, INVESTING IN total include monies spent EARLY CHILDHOOD, 2004 on alcohol, gambling, and tobacco off the island.

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The community has multiple strategies for feeding hungry kids The Bell Island community has a number of strategies in place to ensure that children do not go hungry. There is a breakfast and lunch program at St. Augustine’s Elementary School. Breakfast is provided on an ad hoc basis to those children who come to school and ask for breakfast. A hot lunch is provided five days a week by a group of dedicated volunteers. The lunch program is subsidized by the Kids Eat Smart Foundation of Newfoundland and Labrador and the weekly fee for families is five dollars for each child. The

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program offers children nutritious food choices and in doing so models healthy eating behaviours. Of the 212 students attending St. Augustine’s in 2004, approximately 96% were taking part in the lunch program. The lunch program has a high profile in the community, “People work very hard and put a lot of effort into that program and they are very responsive to the needs of the children.” Many of the food supplies for the lunch program come from the Bell Island Food Bank. The school also offers cartons of milk at a reduced price as part of the School Milk Foundation of Newfoundland and Labrador. The Boys’ and Girls’ Club also offers children after school snacks Education starts on a daily basis. “There are a lot of kids who go there to get at home, if you something to eat. If it wasn’t for are encouraged the Boys’ and Girls’ Club they at home you will wouldn’t have a lunch after school or a good supper. Some take that with you kids go home and they are not even gone long enough to eat ANONYMOUS BELL supper and they are back at the ISLANDER, 2004 club waiting to get in to get another bite to eat.” Of particular note is the Boys’ and Girls’ Club commitment to healthy food habits. No junk food is allowed on the premises. During the summer months there isn’t a formal lunch program in the community although snacks are still available to those who attend activities at the Boys’ and Girls’ Club. It is not known how the absence of a school lunch program through the summer months impacts children. For some parents, food provided by the elementary school and Boys’ and Girls’ club plays an important role in the family budget.

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There are concerns around parenting Within the Bell Island community, the specter of hungry children leads to probing questions and concerns around parenting. There is a sense that in recent generations many of the parenting skills relied on to adequately feed, cloth and launch children into the working world have been lost. “Children hear disrespect at home. There are no role models or decorum, no working with the teachers” … “There is no discipline, you need to give them a work ethic, you have to do things that you don’t like.”

Parents themselves have good ideas on how to improve parenting Having identified what some perceive to be the problem, other parties were thoughtful about possible solutions. “Use the veins of the elementary school to educate parents. Have them attend parenting class

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as part of kid’s schooling” … “Kindergarten, grades one and two, parents will come, that’s where parents can be helped.” Others proposed a more generalized approach to working with parents to improve their skills. “What about a resource centre for women with children? There are folks in the community who could rotate through a resource Low income chilcentre, retired people, teachers, dren are at greater someone that has raised a family.” All advocated “zeroing in risk for poor health. on parenting for the next genRates of poor eration: discipline, diet, exerhealth, hyperactivcise and stay at it!” Respondents were also very positive about the ity and delayed vopotential outcome: “If you are cabulary developencouraged at home, you will want to be ambitious, go out ment have been and take on the responsibilshown to be higher ity yourself and make something of yourself.” Parenting among children in courses are offered in St. John’s low income famat the Janeway Hospital. Health professionals have observed ilies than among that all but the most determined parents are challenged to attend children in middle because of the time, cost, and and high income ferry commute which is subject to bad weather and mechanical families. These breakdowns. All parties stress the poorer outcomes importance of having parenting tend to persist programs provided locally.

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into adulthood CIHI, IMPROVING THE HEALTH OF CANADIANS, 2004

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The local priest speaks out in support of healthier families

The Catholic Church on Bell Island has been particularly vocal and responsive in identifying and responding to the breakdown of the family unit and the social fabric that sustains family life. “The new priest is trying to promote doing family stuff. Several times a year he will have family events that are free and you can come and bring your child and take part. He is promoting bring your child to church and be a family but on a religious basis.”

EDUCATION AND LITER ACY The school is proactive when it comes to children’s health and well being On Bell Island, the number of children has been in a steady decline. Telephone survey data suggest that this trend is continuing. The 2001 Census showed that

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27% of Bell Island’s population was made up of zero to 19 year olds. However, data from the telephone survey indicated that in 2004 only 23% of the sample studied (considered representative of the population) was made up of zero to 19 year olds. As a result of this trend, in 2004, grades five and six became part of St. Augustine’s and grades seven and eight merged with the high school. In 2004, a total of 212 children were enrolled full time at St. Augustine’s. The elementary school is proactive when it comes to behaviours and disabilities that may potentially impact learning or the students’ general health and well being. Through the school board, St. Augustine’s has a behavioral management specialist who comes to the island on an as-needed basis to work with students. Health and Community Services also has a behavioural management specialist who comes over to Bell Island once a week to do in-home work or services with the family around management, In terms of reading / developmental and / or grammar skills, 27% of behavioural issues. The case load of the Health children in poverty for and Community Services two years were doing behavioural management specialists is restricted well as compared with to six clients but at the 44% of children who same time there is rarely a waiting list. The school had never been poor, also tracks and documents and there was a gap children with Attention Deficit Disorder (ADD) between poor children and Attention Deficit (70%) and non-poor and Hyperactivity Disorder (ADHD). The school children (90%) in terms works closely with the of school-readiness island’s physicians to get professional assessments PUBLIC HEALTH AGENCY OF and treatment. However, CANADA, BACKGROUNDER: learning disabilities are reTHE PROGRESS OF CANported to be more difficult ADA’S CHILDREN, 2002 to diagnose and children can wait up to a year to see a specialist. A speech pathologist comes to the school on an as-needed basis. One of the barriers to optimizing a child’s performance at school was the perceived time lag, from when the Community Health Nurses identified a child as needing his or her sight tested, and when parents were able to take their child to St. John’s and have the testing done. In some cases, the delay in getting the child’s sight and hearing needs addressed negatively impacts the child’s academic progress. Understandably, services, for example those of a speech-language pathologist, would not be assigned by the school until the parent confirmed that issues surrounding their child’s hearing or vision had been addressed.

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SOCIAL ENVIRONMENTS The Boys’ and Girls’ Club is very active and held in high regard The Boys’ and Girls’ Club plays a significant role in the lives of children ages five and up, who live in and around Wabana. This program offers a number of key programs focused on social skills, recreation, tutoring, help seeking, anger management and so on. The program is very well received in the community by parents and professionals alike. “I am familiar with the one here and the one in St. John’s. Here they are always supportive. They are always wonderful. I find they are a very close organization and looked upon very well by community members.” The Boys’ and Girls’ Club is funded through a foundation, fundraising and partnerships. On Bell Island, the Boys’ and Girls’ Club draws support from the Town of Wabana and the Kiwanis Club. The club also has an active and generous alumni in Fort McMurray, Alberta and in Cambridge, Ontario.

The RCMP reach out to children in the community The Royal Canadian Mounted Police (RCMP) offers two programs DARE (Drug Abuse Resistance Education) and PALS. (Police At Local Schools). DARE focuses on children in grades five and six. DARE is a comprehensive prevention education program designed to equip school children with the skills to recognize and resist social pressures to experiment with tobacco, alcohol, drugs and violence. The RCMP also runs PALS. This informal program focuses on identifying and eliminating bullying and harassment. The PALS Life Skills 101 aims to reduce conflicts at school and help students complete their studies and become positive role models for their peers.

Parents need to be encouraged to get involved Traditionally, parents become more involved in their children’s lives through parent-teacher associations (PTA) now called School Councils, a Block Parent Association or the Big Brother / Big Sister Association, and so on. As is the case in many small rural communities across Newfoundland and Labrador, these particular organizations do not exist on Bell Island. There is a School Council at St. Augustine’s but presently it isn’t an effective vehicle for involving parents. As parents noted, “You have to take it on your own self to be involved at school” … “I will ask the teachers if they want any help (with the lunch program)” … “I am involved with the school with my kids, but it is up to individual persons to say they will be involved.”

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Again, as seen in many small communities, parents noted that the same persons assumed the same executive positions in extra curricular clubs, year after year, because other parents were not coming forward.

PHYSICAL ENVIRONMENTS Recreational resources are readily available There are numerous organized activities for children in this age group to do on Bell Island: figure skating, hockey, softball and piano lessons in addition to the sports programs offered in the school and at the Boys’ and Girls’ Club. However, as the number of children continues to decline, coaches have had to come up with new strategies for pulling together teams Families have and ensuring that their children everything to do stay active and involved in recreation. “Trying to coach four or with health. Young five kids gets boring, so this year children develop we are affiliated with Conception Bay South.” most of their strat-

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PERSONAL HEALTH AND COPING SKILLS Children need to see their parents modeling healthy behaviours Some parents on Bell Island feel very strongly about the need for parents, generally, to act as better role models for their children when it comes to at-risk behaviours like smoking, obesity, drinking, gambling and exposure to violence. “If we want a smoke free population, we have to start with education and awareness and work our way through that. We have the young kids now knowing that smoking is bad. From Grade one up to Grade five or six we are educating the kids but we are not doing anything to educate their parents. The children learn for six hours a day that smoking is awful and they are going home and watching mother and dad smoke for another six hours and

egies for interacting with their environment within the family. It is also within the family that most adults make important decisions, regarding health-related behaviors, such as dietary habits, or taking time for physical exercise. Family members usually exhibit similar attitudes and behaviour with regard to smoking, physical activity and eating habits POTVIN & EISNER, 1995

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.2 CHILDREN (KINDERGARTEN TO GRADE SIX)

that is okay. They [kids] have this argument or conflict in their head every day of their lives, trying to figure out why it is good at home and bad at school. I think we have to shut off the competing messages. If we can shut off or eliminate the competing messages, then, what we actually do is going to be seen as so strong that it will have more value.” In addition to negative role modeling, exposure to second-hand smoke presents a very real health risk. Findings from the telephone survey confirm that 45% (72 / 161) of the children and youth aged 10 – 19, in our sample, were living in a home with at least one smoker.

There is a real need for ‘healthy parenting’ role models The importance for providing a healthy role model around gambling and children’s exposure to violence was also cited. “Gambling: they teach kids to buy break open tickets – five or six years old. They have the little kids opening up these tickets, teaching them to waste their money on these things. That is not a good thing” … “Every time you turn on the TV, there is some foolish commercial on making people think that everything but education and strong morals and values are important, fighting, killing and maiming is idealistic for kids today … when you say to somebody, well you can’t hit each other, they say, look at this video game here.”

The promotion of health and well being is happening on many fronts

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Teachers at St. Augustine’s and staff at the Boys’ and Girls’ Club are proactive about personal health and coping skills. In addition to their commitment to healthy eating, the school offers self-esteem workshops in grades three to six, and hopes to expand the program to kindergarten through grade two. Dedicated staff at the Children in lowBoys’ and Girls’ Club also offers income families children in this same age group an accredited life skills program.

are almost twice as likely to suffer from high levels of emotional problems as children whose family incomes are $30,000 or greater NATIONAL LONGITUDINAL SURVEY ON CHILDREN AND YOUTH, 1994

The importance of good dental hygiene needs to be front and centre

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As evidenced by the day-patient data presented at the beginning of this chapter, dental hygiene should be a major concern for children in this age group. Dental caries represented 42% of the day surgeries for children from five to nine years of age. Provincial rates for this age group were comparable (41.2%).

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Reasons given for the high incidence of dental caries include a high sugar diet, lack of dental hygiene and social assistance economics, meaning, “Even if a parent wanted to buy real juice instead of Tang, they couldn’t afford it.” Parents and children do not seem aware of the long term effects of poor dental care, such as: increased risk for cardiovascular disease; aggravation of diabetes; pneumonia and other respiratory diseases; stroke; and, adverse pregnancy outcomes. According to Human Resources, Labour and Employment, dental services for all children aged 12 years and under are covered by the Newfoundland and Labrador Medical Care Commission (MCP). Collecting data on rates of childhood obesity on Bell Island was beyond the scope of this study. However, according to findings in the 2005 report, Healthy Eating and Active Living in School Settings: Taking action to assess obesity in children and youth, in Newfoundland and Labrador, one in four preschool children are overweight or obese. This finding is significant because, as the CIHI points out, obese children and adolescents have a greater occurrence of hypertension and high cholesterol levels, two known risk factors for cardiovascular disease. It is not known how many children on Bell Island have Type I and Type II diabetes. Further research is required to better understand the prevalence and contributing factors to overweight and obese children on Bell Island.

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In 1998 – 1999, children age two to 11 in low-income families were 1.5 times as likely to be obese as children in families not in low income. Moreover, children in the Atlantic provinces are at greater risk of being overweight

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CIHI, NEW REPORT: IMPROVING THE HEALTH OF CANADIANS, 2004

HEALTH SERVICES Community Health Nurses and Child Social Workers continue to play an important role The Community Health Nurses play an active role in prevention, health and wellness with this age group. They do all the immunizations, hearing tests and health promotions for the schools. As in the case of infants and preschoolers, the Child Social Workers, responsible for child protection, foster care, adoptions and youth services, continue to play a key role in ensuring the safety, health, and well being of Bell Island’s children. In 2004, there was a reported increase in the number of intakes and protective interventions on Bell Island. However, due to the small population, numbers are not broken down by age. Moreover, the system for collecting data is relatively new to staff. Data collection and analysis are expected to improve with time. Presently,

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the reason for the increased number of intakes and interventions is not known. Referrals to Bell Island’s two Child Social Workers, also referred to as child protection workers, come from individuals in the community, physicians, police, the school, and so on. The Child Social Workers work closely with Human Resources, Labour and Employment’s three client services officers whose office provides financial assistance and referrals to employment programs.

Help-line services for children not well known There isn’t a woman’s shelter on Bell Island for children to turn to in the event of abuse or domestic violence. However, there is an after-hours social worker on call in St. John’s. In the event of an after-hours domestic event involving children, the RCMP and social workers work with the extended family on Bell Island to ensure that children are safe. At present, a child can call the Health and Community Services’ Mental Health and Crisis Centre phone service (1–800–737–4668) for assistance. However, this system requires that a person leave his or her number so that a social worker can return the call. This is not a workable interface for children in crisis. The other potential source for help is the 1–800–668–6868 national help line and website (http://www.kidshelpphone.ca/en/about/default.asp). It is uncertain if children are aware of or have access to these resources.

Summary of challenges x families and children living in poverty x inadequate year round access to nutrition for all children x poor dental hygiene x need for enhanced parenting skills and positive parenting role modeling x adults’ addictive behaviours perceived to impact their ability to provide and care for their children x absence of formal organizations and / or absence of parental involvement in organizations focused on strengthening parents' relationships with their children and the community x anticipated prevalence of overweight and obese children

Suggestions for consideration These suggestions may be of interest to individuals, the community and the health care system working together or independently. Dental Hygiene: Piggyback a dental prevention program on the school’s breakfasts and lunches and

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GET TING READY FOR THE SANTA CL AUS PAR ADE. PHOTO COURTESY OF DESMOND M C C ARTHY.

the Boys’ and Girls’ Club after school snack program. Children would floss and brush after their hot lunch and after snacks at the Boys’ and Girls’ Club. Coordinate with the Community Health Nurse’s proposed dental hygiene program at Brighter Futures for expectant mothers, infants and preschoolers. Elicit the endorsement and support for supplies from a commercial partner. Start the program at the elementary school with kindergarten and grade one and in six years all six grades will be taking part in the program. Involve teams of parents through the School Council to work with the teachers on this project. Keep the project manageable. Incremental progress is better than none at all. Encourage all children and their parents to avail themselves of the dental services provided by the province’s Medical Care Commission. Health Canada created an Office of the Chief Dental Officer in 2004. Investigate if there are monies available from this office to support a dental hygiene initiative on Bell Island. Personal Health Record: Continue with the Tooth Fairy Pedigree and expand it to track height, weight, immunizations, food allergies, physical activity, and so on. It may be that the personal health record for this age group will take the form of a personal scrapbook. Parenting Community: Leverage Brighter Future’s success with babies and preschoolers and provide an extended family continuum which can accommodate parents with school-age children. The extended program would not be allowed under the Brighter Futures program, because it is a federally funded program aimed at parents of children zero to six years old. However, there have been cases where Brighter Futures partners with another organization and does activities for parents with older children. These arrangements are common in smaller communities where resources are scarce.

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Parenting Skills: As suggested in Infants and Preschoolers, actively reach out to all parents, especially low income parents, lone-parent fathers and grandparents and actively engage them in learning how to improve their parenting skills. The School Council could start a Supernanny or Nanny 911 club that meets twice a month to watch ‘Jo Frost’ videos. A discussion of Frost’s parenting techniques and time to compare notes over a cup of coffee would follow. A child education specialist, psychologist or child social worker, for example, could join the group remotely by teleconference. This might also be an opportunity for a university student placement. This interest group could alternate meeting at the elementary school and at Brighter Futures. Leadership Skills: Promote parent memberships in the School Council so parents can become acculturated to taking a proactive role in their child’s health and well being. Webcast these meetings over the proposed Bell Island Health and Well Being Community Channel. Concomitantly, investigate Thrive, the Canadian Centre for Positive Youth Development. Determine if this program would serve Bell Island’s children. Healthy Behaviours: Support St. Augustine’s pupils in the development of content focused on Healthy Behaviours for the proposed Bell Island Health and Well Being Community TV Channel. Children could generate ads focused on their active lifestyles; cavity free smiles, healthy eating, help lines and so on. Go Green: Invest in ‘Home Grown’ community gardens, gardening, and cooking clubs. Focus on children growing, preserving and preparing healthy food. In addition to supplementing school lunches, a field of carrots could become a family focused school fund raiser. Partner with Katimivik and with high school students who are required to volunteer in the community, and have the youth help build a school garden. Healthy Eating Policies: In keeping with the provincial policy on Healthy Eating and Active Living in School Settings, leverage the progress and early success of the Boys’ and Girls’ Club by endorsing healthy eating policies at the elementary school and throughout the wider community. As part of this program, support the hot lunch volunteers with relevant educational material. Engage and educate parents about healthy food choices and dental hygiene through volunteer involvement in the hot lunch program or have each class, in turn, invite their parents to lunch. Emergency Help Lines: Ensure that every child knows the websites: http://www.kidshelp.sympatico.ca or http://www.kidshelpphone.ca/en/about/default.asp and telephone number (1–800–668–6868) to turn to in the event of a crisis.

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Determinants of Health: Integrate the Twelve Determinants of Health into the core school curriculum.

Suggested Indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point for discussion. The wording of these indicators would be formalized during Phase Two of the Needs Assessment. The goal is to identify indicators that are truly meaningful for Bell Island children. 1.

Percentage of cavity free children by age and grade

Number of kilograms of carrots grown annually in elementary school gardens

Percentage of parents involved in the School Council

Percentage of children with an up-to-date personal health record starting with a Tooth Fairy Pedigree

Percentage of children who know the 1–800 helpline number and website address

Percentage of children with a healthy BMI

Number or percentage of juvenile and child Type II diabetics

Number of child asthmatics

Roster of community organizations endorsing provincial Healthy Eating Policies: Boys’ and Girls’ Club; softball club, hockey club; St. Augustine’s, and so on.

10. Number of children with learning disabilities / impaired cognitive functioning 11. Percentage of children exposed to second-hand smoke 12. Percentage of children who have annual dental check ups 13. Record for each grade six student of what they want to be when they grow up

Opportunities for Further Research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to integrate research on Bell Island into their studies. Doing so will help establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Wellness Committee.

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Investigate children’s strategies and success in securing adequate and healthy nutrition during the summer months when the school is closed. Determine if there is a relationship between food scarcity and increased intakes and interventions.

Further research is needed to fully understand the challenges faced by children in this age group and their families living below the LICO.

As in the case of infants and preschoolers, apply for funding to research, develop and pilot a Tooth Fairy Pedigree for children. Over time the Tooth Fairy Pedigree would be one component of a personal health record that helped children keep track of their immunization record, as well as their dental status, weight, height, healthy activities, and so on.

Determine the impact of second-hand smoke on the health and well being of Bell Island’s children. Does exposure to second-hand smoke result in a higher incidence of ear infections, low birth weights, asthma, and so on, on Bell Island.

References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. Berall, G., Balso, K. (2004). Battling the bulge: obesity in kids. Journal of Diagnosis. [online]. (April 2006). http://www.stacommunications.com/journals/ diagnosis/2004/March/pdf/067.pdf Boys and Girls Club of Canada. [online]. (April 2006). http://www.bgccan.com/index.asp Calgary Health Region. Childhood obesity. [online]. (April 2006). http://www.calgaryhealthregion. ca/childobesity/ Campaign 2002 – 2005. Report care on child poverty in Canada. [online]. (April 2006). http://www. campaign2000.ca/rc/rc03/index.html Canadian Association of Food Banks. (2004). Hunger survey. [online]. (April 2006). http://www.cafb-acba. ca/english/843.html Canadian Council on Social Development. (2002). The progress of Canada’s children. [online]. (April 2006). http://www.ccsd.ca/pubs/2002/pcc02/index.htm Federal / Provincial / Territorial Early Childhood Development Agreement. (2003). Well-being of Canada’s young children. [online]. (April 2006). http://www.socialunion.ca/ecd/2003/RH64-202003E.pdf

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Government of Canada CIHI CPHI. (2004). Improving the health of Canadians. [online]. (April 2006). http://www.cihi.ca/cihiweb/dispPage.jsp?cw_ page=media_25feb2004_e Government of Newfoundland and Labrador Community Accounts Bell Island accounts. [online]. (April 2006). http://www.communityaccounts.ca/ CommunityAccounts/OnlineData/default.htm Health Canada. Office of the Chief Dental Officer. [online]. (April 2006). http://www.hc-sc.gc.ca/ahcasc/branch-dirgen/fnihb-dgspni/ocdo-bdc/index_ e.html Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Kids Help Phone. [online]. (April 2006). http://www. kidshelpphone.ca/en/about/default.asp National Child and Youth Health Coalition. (2004). Initiative to establish Canadian infant, child and youth health indicators. [online]. (April 2006). http:// www.caphc.org/documents_partnerships/ncyhc/ workshop_info_package.pdf Newfoundland and Labrador Public Health Association. (2005). Healthy eating and active living in school settings: taking action to address obesity in children and youth. [online]. (April 2006). http://www.nlma.nf.ca/documents/backgrounders/ backgrounder_1.pdf Potvin, L., Eisner, K. (1995). Health promotion – a family affair. [online]. (April 2006). http://www. stacommunications.com/journals/diagnosis/2004/ March/pdf/067.pdf Public Health Agency of Canada Population Health. (2004). What makes Canadians healthy or unhealthy? [online]. (April 2006). http://www.phac-aspc.gc.ca/ dca-dea/publications/pdf/acph_ecd_e.pdf Public Health Agency of Canada. Backgrounder: investing in early childhood. [online]. (April 2006). http://www.phac-aspc.gc.ca/dca-dea/publications/ pdf/acph_ecd_e.pdf Statistics Canada. (1994). National longitudinal survey on children and youth. [online]. (April 2006). http:// www.statcan.ca/Daily/English/021018/d021018b.htm Statistics Canada. (2001). Profile for census subdivision: Wabana, Freshwater and Lance Cove. Thrive Canada. Invest in kids. [online]. (April 2006). http://www.investinkids.ca or http://www. thrivecanada.ca

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6.3 YOUTH GR A DES SEV EN TO T WELV E

Following is a profile of youth ages 15 to 19 on Bell Island. Data sources include: the Bell Island Needs Assessment 2004 Telephone Survey Report; interviews and focus groups; the 2001 Census; de-identified data from Health and Community Services and the Health Care Corporation of St. John’s; and the Community Accounts website. In the process of collecting and analyzing the data from the Telephone Survey, the Memorial University Health Research Unit identified a number of challenges and recommendations relating to youth which are referenced throughout this chapter. The Memorial University Human Investigations Committee and the National Research Council’s Ottawa Research Ethics Board would have requested additional protocols were we to involve individuals under 16 years of age in this research program, therefore we chose to have contact with young persons ages 16 and over. Consequently, the needs and perceptions of younger teenagers may not be adequately represented. Like anywhere else in Canada, Bell Island teenagers like to ‘hang out with friends’, ‘go for a walk’, ‘watch a few movies’, ‘listen to music’, ‘chat on the Internet’, ‘babysit’, ‘play volley-ball’ or ‘basketball’, ‘go to the rink’, ‘do homework’, ‘attend cadets’ or ‘the Church Lads Brigades’, and ‘go to town on the weekend’. Bell Island youth clearly value the lifestyle and sense of community that Bell Island affords. In the words of one teen, “Myself, I wouldn’t change anything. I would add things that aren’t here.” Data x Number of youth between ages 15 – 19: 285 (2001 Census) x Percentage of all children 19 years and younger on Bell Island living in poverty: 54% (Telephone Survey, 2004) x Number of youth enrolled at St. Michael's Regional High: 233 in 2003 – 2004 (Education Statistics, Newfoundland and Labrador Department of Education, 2004) x High school graduation rate 2004: 74% (Indicators 2005: A Report on Schools, 2005) x Number one reason for day surgery on children ages 10 – 14, years 2001 – 2004: dental caries, more commonly known as tooth decay (31.6%) (HCCSJ, 2005) x Approximate teenage pregnancy rate: 15% (HCCSJ, 2005; 2001 Census)

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EDUCATION AND LITER ACY Bell Island teens are challenged to finish high school In 2004 the graduation rate at St. Michael’s Regional High was only 74%. To put Bell Island’s high school graduation rate in perspective, the provincial graduation rate was 87% for the same year. Teens attribute dropping out of school, in part, to a lack of expectations on the part of the community. Parents and youth noted that graduation has become a social rather than an academic event. In the eyes of some teens, this devalues academic accomplishments. Parents are also perceived to influence whether or not a teen finishes high school. “A lot of parents themselves have not completed secondary school and don’t necessarily model the importance of getting an education.”

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Education is often an important factor in determining whether young people obtain jobs that enable them to support themselves and their families. Young people who leave school before high school graduation (22% of young Canadian men and 14% of young Canadian women in 1995) are more likely to dislike school, to have failed a grade in the past, to come from low socioeconomic backgrounds and to be a young parent PUBLIC HEALTH AGENCY OF CANADA, IMPROVING THE HEALTH AND WELL-BEING OF CANADA’S YOUTH, 2002

EMPLOYMENT AND WORKING CONDITIONS Youth are challenged to find jobs on Bell Island Year round there are part-time positions at the Boys’ and Girls’ Club. During the summer months, Island Advisory Services administers a number of programs funded under the Human Resources Development Canada Summer Career Placement program. The latter pro-

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.3 YOUTH (GRADES SEVEN TO TWELVE)

vides about 60 employment opportunities for students who graduate from the high school as well as post secondary students. There is also the Student Work and Services Program (SWASP) which provides $50 a week and a voucher to be used at a post secondary institution. Bell Island teens and the community were impressed with the Katimavik youth whom Bell Island Advisory Services sponsored to work on the island from 1997 to 2001. Katimavik is a well known federal program, whereby nine students rotate through the community every four months on a yearly basis. “They (Katimavik youth) were very, very strict. They’ve got values in life. They worked and had chores to do. When they were on the island they did an awful lot.” Some Bell Islanders wondered about the same kind of summer work program for their youth but had doubts. “But then again, the problem with the youth here is that they are not educated enough.”

GR ADUATION NIGHT. PHOTO COURTESY OF DESMOND M C C ARTHY.

Bottom line, the community would like to see more jobs for their teenagers. “Often, kids who can’t get jobs here go to Cambridge, Ontario.” Bell Islanders are also concerned about the lack of work for teens who are challenged or have special needs. “Years ago we had a program for students who were not of great ability. It was a combined school and work experience program, where they could attend three days at school getting the basic skills, then spend two days in the community getting practical know how. Unfortunately, that program doesn’t exist anymore for those students of that particular ability.”

Human Resources, Labour and Employment (HRLE) provide opportunities for youth A number of programs are administered under this provincial government department to include: Allied Youth, a youth development and leadership program for students in Grades seven to 12; the Youth Exchange Program which has three sub programs for high school students, namely: the Intra Provincial Travel Program,

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the Interchange on Canadian Studies and the Encounters with Canada; the Duke of Edinburgh Award Program for youth ages 14 – 25; the Tutoring for Tuition Program; and finally, the High School Employment Program. No data were available on the number of youth who took part in these programs in 2004.

SOCIAL ENVIRONMENTS Teens age 18 and under report having no place to go and nothing to do By the time youth reach their early teens, some feel that they have outgrown the only free option namely, the Boys’ and Girls’ Club. Various team activities are offered by the school and through community clubs like Cadets. These activities include: softball, basketball, volley-ball, skating, hockey, and so on. However, there are no recreational programs or facilities for the individual. “If they put in a gym here a lot of people would use it. We need a real gym, a workout place not just weights and stuff, but treadmills and everything.” The overall lack of recreational and social facilities (swimming pool, gym, teen centre) was cited as one of the main reasons why, “People here resort to drinking and dope.” To summarize, “There is no community centre for teens, no place to go after school, no place to go on Friday and Saturday night if you don’t want to drink.” Over the years, privately owned teen centres have been opened and closed numerous times. On-going issues around underage use of alcohol were cited as a contributing factor to closure. To meet their recreational and social needs, teens suggested opening ‘an arcade, or Happy Home where kids could hang out, play games, listen to music, play cards or pool and go online’. A place where there is high speed internet access is of particular interest. There is a Community Access Point at the Public Library but it does not constitute a hangout in the eyes of those 19 and under. Teens’ interest in the internet was thought by some youth to have contributed to decreased attendance at the Boys’ and Girls’ Club.

High school students play an important role in the community The high school hosts blood donor clinics and a highly successful bi-annual Health Fair for the Bell Island community. “The Health Fair is a good event. It is for the public but also for the school. They pull together all

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types of resources from here on Bell Island. All the community agencies will be presenting topics for example; suicide, STDs and so on. Health professionals will also be coming from Community Health Services in St. John’s”. Teens help organize and participate in this event. Although teens generally feel positively towards the community, their experience is that sometimes the community does not reciprocate. “This summer, we all drove up to the baseball diamond and we actually had a game of ball. But someone called the police and told them we were drinking. The police came and checked on us. They assumed that we were drinking.”

PHYSICAL ENVIRONMENT Transportation challenges also impact the lives of teens In the winter, everyone including home and visiting sports teams are challenged to get on and off the island. There is always the possibility that players will get stuck on the island and not be able to get home. Regardless of the challenges presented by bad weather and ferry constraints, coaches and volunteers from The Boys’ and Girls’ Club and the Minor Hockey leagues have been assiduous in ensuring that teens, regardless of resources, take part in off-island outings.

Sometimes our youth get into trouble

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The RCMP has a very high profile presence within the school systems and their relationship with the teens is reported to have improved in recent years. “When the RCMP first came to Bell Island, the kids were negative toward the police, but now they have integrated The rate of youth charged themselves. They will go out of their way to speak with violent crimes into them, the kids will, and creased by 7% in 2000. the sense is very positive regarding to the police These rising rates for officers.” To facilitate the violent crimes and lower RCMP’s relationship with youth on the island, the rates for property ofRCMP detachment has an fences among youth, office at the high school and is available to lecture echo the same trend in on crime prevention, crime the adult population apprehension and related topics on an as-needed CANADIAN COUNCIL ON SOCIAL basis.

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DEVELOPMENT, THE PROGRESS OF CANADA’S CHILDREN, 2002

Despite everyone’s best intentions, some of the

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Island’s youth get into trouble. Youth ages 12 – 17 who return to Bell Island on probation report to the Health and Community Services Community Supports and Youth Corrections Officer. If necessary, the Community Supports and Youth Corrections Officer, who is a social worker, will also keep in touch with the school that the youth is attending and make referrals for drug addictions. If the youth is involved in a first-time offense, at the RCMP’s discretion, the individual may be referred to the Extrajudicial Sanctions Program, whereby youth appear before a volunteer community board, acknowledge the error of their ways, and contract with two volunteers to do community work, and so on. The extrajudicial program is designed to keep youth out of the courts. If a youth goes to court, that incident remains on their record for five years. If the youth become part of the extrajudicial program, they have a record for two years.

PERSONAL HEALTH AND COPING SKILLS Bell Island’s teen pregnancy rate appears to be below provincial and national averages Data provided by the Health Care Corporation of St. John’s, between years 2001 and 2004, were used to calculate a rough approximation of the teen pregnancy rate on Bell Island. During this period, there were 21 recorded cases of hospitalizations due to pregnancy and childbirth. Given that there were about 140 females of this age group living on Bell Island at the time, we estimate the teen pregnancy rate to be approximately 15%. This is less than the provincial teen pregnancy rate of 28.5%, in 2000, and the national rate of 38.2%, also for 2000. Teens perceive the central issue to be limited access to birth control, citing for example, no condoms in the grade 9 – 12 school washrooms. Bell Island convenience stores were reported to be too public when making such a personal purchase. “Those stores have a direct line to parents!” Moreover, some teens expressed having limited access to stores in St. John’s where anonymity is assured. Teens themselves cited teen pregnancy as either an accident or a strategy for moving out. “Some students view pregnancy as an option for gaining financial assistance.” Health professionals disagree, “I certainly wouldn’t think people would have children to get the child tax benefit, because you would get an extra $180 – $200 per month per second child, but then they cost so much more than that. So it isn’t logical to really think that. A lot of young Girls’ are having children here, because of the basic issues of just not practicing safe sex and not getting the message, not listening to the message. I think there

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is just disempowerment and I think just the whole package [living on Bell Island]. I think sometimes too, some of them come across as just wanting to be loved or to get out of the situation or whatever. These are the same issues as to why teens get pregnant anywhere.” On Bell Island, babies are seldom put up for adoption and teen mothers rarely return to finish high school. A tendency for the teen’s parents to be very involved in raising the grandchildren was frequently cited.

between students and between staff and students at the high school. The high school Guidance Counselor, the Mental Health-Addictions Counselor and the RCMP collaborate on courses and strategies to address bullying issues in the high school.

How can we help our teens ‘Kick the Nic’?

According to findings from the Bell Island Needs Assessment 2004 Telephone Survey, only five percent or four out of the 80 household members age 15 – 19 were reported to smoke daily. This number is not representative of youth smoking rates on Bell Youth are asking for a reality-based approach Island. Note that the Bell Island Needs Assessment to sex education 2004 Telephone Survey was restricted to respondents Youth: “They don’t want to listen to teachers. They aged 19 and older. According to the Newfoundland want to listen to someone who actually went and Labrador Alliance for the Control of Tobacco through it.” The Human Dynamics course, in (ACT), in 1998, 38% of youth smoked in the grades 11 and 12, where teens take home province. However, findings from the ‘Baby Doll’ [a doll programmed to Canadian Community Health Survey, simulate the demands of a newborn], Parents’ 2003, report that cigarette smoking was reported by teens to provide a attitudes make a has since been reduced to 17% ‘reality check’. A number of youth (HealthScope, 2004). Although difference as to whether also cited the need for parents to the legal age for smoking in the actively discuss with teens the or not children will adopt province is 19, access on Bell ‘life altering consequences’ of Island to cigarettes was not certain behaviours. A child teen pregnancy. In cases where cited as a barrier. this is not possible, “Teens whose parents disapprove need a place to go to discuss Teens report succumbing of smoking is five times birth control and teen pregto peer pressure to smoke nancy.” The Community Health less likely to start smoking Some youth identified peer Nurses have self-identified as than one whose parents pressure as playing a big role being willing to play this role, in starting to smoke. “If you but some teens noted that hisshow no objection are in grade nine and you don’t torically there has been resistance smoke and you watch your big on the part of the high school. An NOLTE ET AL., 1983 alternate strategy for decreasing teen sister even going out there, you’re pregnancy espoused by some community going to think that is cool, so you will members is abstinence. go out there too.” According to youth, Bell Island kids start to smoke because, “In rural areas Bullying is on every school’s radar screen there is nothing else to do.” Some adults on Bell Island agree, “There is nothing else to keep them ocFindings from a 2004 internal high school survey on cupied. There isn’t a pool here and you don’t have bullying, developed by the guidance counselor at recreational facilities. If you have kids that are idle, the elementary school indicated that, of the 98 high they are going to try smoking.” In previous years, the school students surveyed, 80 had witnessed bullying ‘Kick the Nic’ smoking cessation program was offered at school and 42 were victims of bullying. Some of the jointly by teachers and the mental health / addictions older teens reported observations of increased verbal counselor, but not in 2004. No association with Provinand physical bullying amongst Girls’ in grades seven cial Teen Tobacco Team was cited. and eight. Older teens rationalized bullying as a means of attracting the attention of the older kids and as a Why do our teens appear to have such ready part of being cool. The 2004 amalgamation of high access to substances that put them at-risk? schools and integration of grades seven and eight, into St. Michael’s, has understandably resulted in some As in the case of cigarettes, teens reported that getchanges to the student body pecking order. Teens ting access to drugs and alcohol was not an issue. The and teaching staff also commented on a perceived culture around drinking and smoking drugs appears increase in the number of violent confrontations both well established. “Drinking is a weekend thing, dope

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is everyday.” A number of teens also reported easy access to prescription drugs.

Attitudes towards dental hygiene have to change

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nurses or the mental health and addic-

Young tions counselor more involved. women aged 12 – 17 On a related personal health issue in the school, the tampon maare particularly vulnerable chines in the high school were to sexual abuse by a family reported to be often broken or not stocked, requiring teens member or date. Young women to go to the school office aged 18 – 24 are most likely, of for supplies. This was felt by some students to infringe on all age groups, to report being their autonomy and personal assaulted by an intimate partner privacy.

Health professionals report that it is not unusual for youth to have their teeth removed in their late teens or early twenties. Dental care, for all children in Newfoundland and LabPUBLIC HEALTH AGENCY OF CANADA, What happens to our teens rador, is covered until the age IMPROVING THE HEALTH AND when they’re in crisis? of 12, and children ages 13 – 17 WELL-BEING OF CANADA’S Nurses on night duty at the Dr. years old are covered for fillings, YOUTH, 1999 Walter Templeman Health Centre do extractions and dental examinations their best with teens who present themevery two years. It is not known what selves with problems after hours. There are no percentage of those children and youth on Bell data on access to or use of crisis lines by Bell Island Island avail themselves of the weekly dental services on teens. Survey findings reported that some respondents Bell Island. However, it is known that 31.6% of all day felt violence in the home, leading to child abuse, may surgeries among youth ages 10 – 14 from 2001 – 2004 be a hidden issue on the island and that child protecwere the result of dental caries. The provincial rate of tion services could be doing more to prevent violence, dental caries among youth ages 11 – 14 during this abuse and neglect. period were substantially different, representing only 14.3% of day surgeries. However, it must be noted Some youth ages 16 – 18 are eligible for the Youth that provincial rates including 10 year olds were not Services Residential Program. Health and Community available. Services social workers assess the youth’s need for an out-of-home placement. Health and Community Services finances board, lodging and a monthly living alHEALTH SERVICES lowance. In order to participate in this program, clients must have a plan in place meaning, school or volunteer Bell Island youth hold the Community Health activities for so many hours of the day.

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Nurses in very high regard The Community Health Nurses’ immunization and public health services are well received by teens, who noted that their role in the school could even be expanded. Sex education at the high school was identified by some as inadequate because of religious issues. Some noted that topical health issues like Premenstrual Syndrome (PMS) need to be covered. Some youth suggested, that a program for teenage girls around ages 13 – 15 focused on healthy eating, facial care, nails and self-image, would be particularly welcomed and could be offered at school or the Boys’ and Girls’ Club. Mental Health / Addictions and Community Health Nurses are presently working with the high school to incorporate subjects like: ‘healthy relationships’, ‘self-esteem’, ‘assertiveness’, ‘good communication skills’ as well as topics including ‘drugs’, ‘gambling’ and ‘alcohol’, into the formal heath curriculum. There is also a Healthy Living course in high school, which highlights a different health issue each month (bullying, sexual assault, and so on). Teens would like to see community health

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Summary of challenges x age appropriate social and recreational activities and facilities x self-reported substance abuse to include prescription and street drugs, tobacco and alcohol x youth not graduating from high school x limited part time employment opportunities during the winter and full time employment during the summer x ready access to family planning and birth control x place for teens to go and hang out, surf the net, play pool, listen to music and talk x ready access to crisis management and support for teens x self-reported ready access to tobacco, alcohol, prescription and street drugs x dental hygiene

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Suggestions for consideration These suggestions may be of interest to individuals, the community and the health care system working together or independently. Recreation: In the short term, provide access to physical environments that support ad hoc recreational activities for youth during evenings and on weekends. Engage youth in identifying, building and maintaining, in the downtown central square area, an outdoor skateboard park, roller blade course, and a basketball and volleyball court. In the medium term, investigate the possibility of a registered teen centre and available funding to support same. Engage youth in Phase Two of the Needs Assessment so their long term recreational needs are addressed. Role Models: Establish a working relationship with MUN physical education and recreation departments, with the intent of having university students come over to Bell Island to do their practicums. In addition to increased physical activity, youth will benefit from access to positive role models and exposure to career options. Creating Content for the Community TV Channel: Invite the Newfoundland Independent Filmmakers Cooperative (NIFCO) to offer a ‘First Time Film Makers’ class for Bell Island teens. Have the course count as an academic credit. Investigate how they implemented their film makers program at the Community High School on Grand Manan. Provide technical support, using a co-operative model, for students who want to generate material (anti-smoking or pro-recreation and so on) for the proposed Bell Island Health and Wellness Community Television Channel. Investigate further the opportunities for youth to connect with the burgeoning teen film community in St. John’s. Birth Control and Sex Education: Install condom dispensers in upper grade high school washrooms. The School Council could sponsor a four part series on sex education. The Community Health Nurses, teens and parents could meet to watch and discuss Dr. Sue videos. A specialist in sex education or a related area could be invited from Memorial University or another private or public health agency to talk about sexually transmitted diseases, at-risk behaviours and so on. At-risk Behaviours: Establish zero tolerance for alcohol and drugs at school and on school and adjacent properties. In collaboration with the Community Health Nurses and the Mental Health and Addictions Counselor, increase school education programs dealing with alcohol, drugs, tattoos, body piercing, smoking, safe sex, and so on. Get a Bell Island youth appointed to the Provincial Teen Tobacco Team. Determine and eliminate sources for youth’s ready access to tobacco, alcohol, and street and prescription drugs.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Education: In addition to topics relating to personal and public health and wellness, cover household management, and more specifically, single and family financial planning and management in the high school curriculum. Stress the realities of single and two parent family financing with and without a high school education. School Council: Reinstate the School Council. Host a number of career nights for parents and teens. Poll the students to ensure that the speakers (university students and professionals) relate to youth’s personal interests: trades, nursing, teaching, social work and so on. Broadcast these sessions over the Bell Island Health and Well-being TV Channel. High School Graduation: Reinstate graduation as an academic event. Build on intergenerational post secondary school successes. Establish an ‘In Your Father’s / Mother’s Footsteps’ program, the purpose being to identify and encourage students, who come from households where someone attended trade school, to continue the tradition. The same can be done with students whose parents have attended a community college or university. Scholarships could play a role. Single mothers: Provide the support and incentives necessary to enable single teen mothers to return to high school and graduate. Using a 1–800 number or online virtual support group, partner these teens with single mothers who successfully returned to school and graduated. Volunteer Activities: In small but successful communities, everybody pitches in. Volunteering is presently a high school educational requirement. Youth could make a significant contribution to the community, if the volunteer requirement focused on assisting seniors. This option is discussed more fully in the chapter on Seniors. Employment: Leverage the community’s positive experience with Katimavik. Become a Community Partner as set out on the Katimavik website. Have Bell Island’s youth take part in a collaboration focused on leadership and projects, for example, building a hiking trail around Bell Island; building community gardens, or a carrot garden for the elementary school. Crisis Intervention: Provide youth with clear and available information on where they can access safe, appropriate online and telephone crisis and addiction counseling. Tomorrow’s Leaders: Continue to encourage youth to take an active role in civic leadership, for example, positions on the Town Council. Similarly, youth should be encouraged to actively participate in community discussions and strategy sessions around a recrea-

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tional facility, which meets all age groups’ health and well-being needs. Youth should also take an active role in Phase Two of the Health and Well-being Needs Assessment. Dental Hygiene: Encourage youth to persist with optimal dental hygiene and care. Have a celebrity face off celebrating the biggest, brightest, and whitest smiles. Establish a dental hygiene scholarship.

Suggested Indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point for discussion. The wording of these indicators would be formalized in Phase Two of the Needs Assessment. The goal is to identify indicators that are truly meaningful for Bell Island youth. 1.

Percentage of youth who smoke; Percentage of youth living in households where they are exposed to second-hand smoke; Number of teens who participate in Kick the Nic; Number of teens who successfully quit smoking Percentage of youth who graduate from high school

Percentage of youth who volunteer

Percentage of youth who have part-time employment through the academic year

Percentage of youth who have full time employment during the summer months

Percentage of teen pregnancies

Percentage of teen mothers that return and complete high school

Percentage of teens that know the coordinates of the provincial and national crisis helpline

Percentage of youth who self-report use of the crisis helpline 1–800 number or website

10. Number of youth picked up but not charged for underage drinking 11. Number of violent incidents involving youth and requiring the RCMP to intervene but not press charges 12. Number of bullying incidences reported at school 13. Percentage of grade 10 – 12 students who know and can contextualize the Twelve Determinants of Health 14. Percentage of students ages 13 – 17 given a dental ‘clean bill of health’

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

15. Number of youth taking part in each of the youth programs offered by Human Resources, Labour and Employment

Opportunities for further Research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to come forward and integrate research on Bell Island into their studies. Doing so will establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Wellness Committee. 1.

Initiate a Participatory Action Research (PAR) project, with Bell Island’s rural and remote teens, to determine precipitating factors for engaging in at-risk behaviours to include, but not be restricted to drinking, smoking, unprotected sex, prescription and street drugs, and so on.

Further research is required to better understand the number and needs of single mothers and how the community, families and health system can best assist them to go back to school and graduate.

Investigate the impact of ‘a community in decline’ on youths’ attitudes towards schooling.

Much could be learned by asking those young adults who did not pass grade 12 the reasons why they didn’t graduate. In years to come, refer back to the dreams that those same individuals espoused and articulated in grade six. Ask those individuals what barriers interfered with them realizing their dreams.

What are the barriers to Bell Island youth optimizing their participation in the youth programs offered by Human Resources, Labour and Employment? How can these barriers be overcome?

References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. Ado Sante. Youth Health and Wellness Website [online]. (April 2006). http://www.adosante.org Canada Health Portal. Smoking. [online]. (April 2006). http://chp-pcs.gc.ca/CHP/index_e.jsp/pageid/4005/ odp/Top/Health/Addictions/Tobacco_and_Smoking Canadian Council on Social Development. (2002). The progress of Canada’s children. [online]. (April 2006). http://www.ccsd.ca/pubs/2002/pcc02/index.htm

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Canadian Council on Social Development. (2002). The progress of Canada’s children. [online]. (April 2006). http://www.ccsd.ca/pubs/2002/pcc02/hl.pdf Government of Canada Health Canada. Youth. [online]. (April 2006). http://www.hc.sc.gc.ca/jfyspv/youth-jeunes_e.html Government of Newfoundland and Labrador Community Accounts Bell Island accounts. [online]. (April 2006). http://www.communityaccounts.ca/ CommunityAccounts/OnlineData/default.htm Government of Newfoundland and Labrador. (2003 – 2004). Education statistics. [online]. (April 2006). http://www.ed.gov.nl.ca/edu/dept/ er.htm#Publications Government of Newfoundland and Labrador. Department of Education. (2005). Indicators 2005: a report on schools. [online]. (April 2006). http://www. ed.gov.nl.ca/edu/dept/er.htm#Publications Government of Newfoundland and Labrador. Teen Tobacco Team. [online]. (April 2006). http://www. health.gov.nl.ca/health/guide/ttt/pg12.html Health Canada. (1999). Towards a healthy future: second report on the health of Canadians. [online]. (April 2006). http://www.phac-aspc.gc.ca/ph-sp/ phdd/report/toward/ Health Canada. (2003). Canadian tobacco use monitoring survey (CTUMS). [online]. (April 2006). http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/researchrecherche/stat/ctums-esutc/index_e.html Health Canada. (2004). Evaluation of retailers’ behaviour towards certain youth access-to-tobacco restrictions. [online]. (April 2006). http://www. hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/eval-2005/index_ e.html Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Katimavik. [online]. (April 2006). http://katimavik.org Mr. M. Walsh. (2004). Survey tool on bullying for St. Augustine’s School, Bell Island. National Child and Youth Health Coalition. (2004). Initiative to establish Canadian infant, child and youth health indicators. [online]. (April 2006). http:// www.caphc.org/documents_partnerships/ncyhc/ workshop_directions_document.pdf Newfoundland and Labrador Centre for Health Information. (2004). HealthScope: reporting to Newfoundlanders and Labradorians on comparable health and health system indicators. [online]. (April 2006). http://www.health.gov.nl.ca/health/ publications/pdfiles/healthscope_report_2004.pdf BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Newfoundland and Labrador Public Health Association and Partners. (2005). Healthy eating and active living in school settings: taking action to address obesity in children and youth. [online]. (April 2006). http://www.nlma.nf.ca/documents/ backgrounders/backgrounder_1.pdf Nolte, A.F. Smith, B.J., & O’Rourke, T. (1983). The relative importance of parental attitude and behaviour upon youth smoking. Journal of School Health, 53, 356 – 271. [online]. (April 2006). http:// www.cdc.gov/tobacco/parenting/appendixC.htm Poulin, C. (2003). Newfoundland and Labrador (island portion only) student drug use survey. [online]. (April 2006). http://www.health.gov.nl.ca/health/ publications/pdfiles/sdus.pdf Public Health Agency of Canada Canadian Health Network. How does education affect health? [online]. (April 2006). http://www.canadian-healthnetwork.ca/servlet/ContentServer?cid=1005636&pa gename=CHN-RCS%2FCHNResource%2FFAQCHNRe sourceTemplate&c=CHNResource&lang=En Public Health Agency of Canada Population Health. What makes Canadians healthy or unhealthy? [online]. (April 2006). http://www.phac-aspc.gc.ca/ ph-sp/phdd/determinants/index.html Public Health Agency of Canada. Family / Parenting. [online]. (April 2006). http://www.phac-aspc.gc.ca/ dca-dea/family_famille/index_e.html Public Health Agency of Canada. Improving Canada’s youth. [online]. (April 2006). http://www.phac-aspc. gc.ca/canada/regions/atlantic/Publications/The_next_ wave_discussion/app_1_e.html SIECCAN. (2004). Adolescent sexual and reproductive health in Canada: a report card in 2004. The Canadian Journal of Human Sexuality. [online]. (April 2006). http://www.sieccan.org/pdf/mckay.pdf St. Michael’s Regional High School. (2004). School newsletter. Statistics Canada. (1994). National longitudinal survey on children and youth. [online]. (April 2006). http:// www.statcan.ca/cgi-bin/imdb/p2SV.pl?Function=ge tSurvey&SDDS=4450&lang=en&db=IMDB&dbg=f& adm=8&dis=2 Statistics Canada. (2001). Profile for census subdivision: Wabana, Freshwater and Lance Cove. Statistics Canada. Frequency of heavy drinking. [online]. (April 2006). http://www.statcan.ca/english/ freepub/82-221-XIE/2004002/nonmed/behaviours2. htm

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6.4 ADULTS This chapter focuses on Bell Island’s adult population between the ages of 20 and 64. Data sources for the chapter include: the Bell Island Needs Assessment 2004 Telephone Survey Report; interviews and focus groups; data from the Community Accounts website; the 2001 Census; and, de-identified data from Health and Community Services and the Health Care Corporation of St. John’s. In the process of collecting and analyzing the data from the Telephone Survey, the Memorial University Health Research Unit identified a number of challenges and recommendations relating to adults which are quoted extensively throughout this chapter. Results from the 2004 Telephone Survey indicated that 40% of Bell Islanders rated their own heath as excellent or very good. This was significantly lower than both the national and provincial values. According to the Canadian Community Health Survey (2003) 55% percent of Canadians and 64% of Newfoundland and Labradorians rate their health as excellent or very good. Using the Twelve Determinants of Health, this chapter looks at some of the reasons why Bell Islanders selfreport poorer health. Data x Number of persons ages 20 – 64: 1,775 (2001 Census) x Number of persons ages 20 – 39: 645 (2001 Census) x Number of persons ages 40 – 64: 1130 (2001 Census) x Employment rate: 21.2% (2001 Census) x Median Household Income: $17,500 (2001 Census) x Unemployment rate on Bell Island: 41% (2001 Census) x Percentage of adults living below the LICO: 50% (Telephone Survey, 2004) x Percentage of households consisting of adults with children and / or youth living below the LICO: 40% (Telephone Survey, 2004) x Percentage of Bell Island’s population on social assistance in 2001: 44% (Community Accounts, 2005) x Percentage of adults ages 19 – 64 with an overweight BMI: 38% (Telephone Survey, 2004) x Percentage of adults ages 19 – 64 with an obese BMI: 24% (Telephone Survey, 2004).

x Percentage of respondents rating their health as excellent or very good: 40% (Telephone Survey, 2004) x Number of children 25 years or older living at home with their parents: 225 (2001 Census)

INCOME AND SOCIAL STATUS Half the adult population faces significant financial challenges Findings from the Bell Island Needs Assessment 2004 Telephone Survey determined that, of the 363 households that provided any income information, over half (56%) had a household income of less than $20,000 a year. The estimated mean income for the 326 households that provided detailed information was $26,047. This number is significantly higher than the median family income of $17,500 for all census families in 2001. Several factors could account for this marked difference. It may be that several persons with very high incomes were interviewed resulting in a higher average score. It may also be that an appropriate proportion of the 44% on social assistance were not interviewed. Finally, income is a sensitive issue and it is possible that the quoted income levels were not wholly accurate. Researchers have determined that the total household income, is not always reflective of the true economic status of a household. So they use a calculation called the Low Income Cut Off which takes into account household income, number of household members, and the size of the city, town, or community in question. The Memorial University Health Research Unit telephone survey researchers calculated the Low Income Cut Off (LICO) for 346 households. Based on LICO tables for 2003, 173 (50%) of these 346 households were living below the LICO. Moreover, 46% of adult only households were below the LICO as were 40% of the adults with children and or youth.

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There is a strong link between income and health. Low income Canadians are more likely to die sooner and to suffer illness than Canadians with higher incomes. This holds true regardless of a person’s age, gender, cultural background or place of residence. With each step up the income scale, our health improves

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CANADIAN HEALTH NETWORK BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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For some, living on social assistance means subsistence living and being stigmatized According to calculations made by the Community Accounts Unit supported by the Newfoundland and Labrador Centre for Health Information, 44% of Bell Islanders received some form of social assistance in 2001. Many of these persons report that they are just getting by day by day, “I have $228 a month for my phone bill, clothes and food. As far as going in a grocery store and buying a full week’s groceries and a cart load, forget it. You haven’t got the money. I buy day by day when I need it. I got no children but what are the ones with children doing?” Moreover, some respondAs social beings, ents felt that allocation of social assistance money and support we need not only through the Bell Island Human Regood material consources, Labour and Employment was not equitable. Even though ditions but, from 44% of the Bell Island populaearly childhood tion was reported to be on some form of social assistance, there onwards, we need was an often expressed view that to feel valued and those persons on social assistance were not responsible or accountappreciated. We able. “If I’m on social assistance need friends, we and today is payday, I’ll take my cheque and I’m going to buy need more sociable some alcohol. The rest of their societies, we need money has probably gone into the gambling machines hoping to feel useful, and they will make a few dollars. we need to exerWho suffers – the family! Then they go to the food bank.” In cise a significant a small community, these strong degree of control sentiments may constitute an additional challenge for those over meaningadults and their families who are ful work. Without on social assistance but want to these we become move outside their prescribed role.

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more prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health INTERNATIONAL CENTRE FOR HEALTH AND SOCIETY, THE SOLID FACTS, SECOND EDITION, 2003

SOCIAL SUPPORT NETWORKS The social fabric of Bell Island is changing

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During the telephone survey and field research many Bell Islanders reflected on the importance of their close ties with families and friends. Findings from the telephone survey support that claim. Of the 401 persons interviewed for the Telephone Survey, 80%

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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It seems that there is said that they had someone to talk to if stressed: a link between social 73% family, 22% friend, support and the ability 4% professional. As we will see in the Dare to to respond to and cope Compare chapter where with stress effectively. we compare Bell Island with Grand Manan, Bell Having support from Island is evolving very diffamily, friends and coferent family structures. First, many more Bell workers can help people Island adults continue to to solve problems and live at home. For example, according to the Census, deal better with hardship. in 2001 there were 225 It can also help them children 25 years and older living at home, with develop a better sense their parents on Bell of control over their Island, as compared with 55 children 25 years and life circumstances older still living at home on Grand Manan. Second, CANADIAN HEALTH NETWORK there are a large number of single parent families on Bell Island. Again for comparison, in 2001 there were 250 lone parents on Bell Island and only 115 on Grand Manan. Moreover, on Bell Island there were 70 lone parents with three or more children compared with 15 on Grand Manan. More research is required in order to better understand how these trends impact Bell Island’s families, their social support networks, as well as the health and wellbeing of the community as a whole.

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EDUCATION AND LITER ACY The Trade School opened the door to jobs for Bell Islanders The Trade School on Bell Island which was in operation from 1963 to 1996, had a significant impact on its graduates’ ability to gain employment. Note that historically, the area outside the town of Wabana has produced a significantly higher percentage of Trade School graduates than either Wabana or the province. For example in 2000, 40% of Freshwater and Lance Cove’s employed persons reported employment in trades, transport and equipment operations, and related occupations compared to 25% of Wabana’s workforce and 17% of the provincial workforce (2001 Census). A Trade School education may also explain in part why, according to the 2001 census, the median income in Lance Cove and Freshwater was almost twice as high as in Wabana, $23,296 versus $14,542 respectively. According to the 2004 telephone survey, households with an

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.4 ADULTS

individual possessing at least a high school certificate were significantly more likely to report incomes above the LICO than those without a high school graduate in the household (143:30).

Bell Islanders are challenged to access adult education The closure of the Trade School is still described as a blow to the island. “When they closed the Trade School they [Bell Islanders] stopped doing the upgrading … like x said, that is a bad situation – you quit school because that was the thing to do and then, a few years later, they wanted to go back and do something. If only they could do something on the island to get their GED, as opposed to St. John’s where they have to pay for it. They are on Canadians social assistance. They aren’t going to go to St. John’s to do it.” In other with low words, now that the Trade School is literacy skills closed the financial and human costs of commuting to St. John’s pose an are more additional barrier to academic uplikely to be grading. According to the Telephone Survey, in 2004, 37% of Bell Islanders unemployed had internet access. Presently, customand poor, to ized distance education programs for Bell Islanders have not been developed.

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suffer poorer heath and to die earlier than Canadians with high literacy levels

Education, education, education

Health education is a key component of health promotion. The premise is that people who exercise healthier lifestyle choices are aware of the health consequences of their actions. Professionals and adults alike cited the overwhelming need for health educaSECOND REPORT ON tion, particularly for those dealing with THE HEALTH OF chronic conditions. “I have spoken CANADIANS, 1999 to seniors, I have spoken to young people, I have spoken to middle aged people all with different levels of diabetes and they lack education. They lack education, they lack the facilities on Bell Island to get the food and the education they need.” In addition to learning more about their disease process, other respondents also expressed a strong interest in acquiring skills that would enable them to contribute to the care of others, “even education on foot care, education on diabetes, education on breast cancer, education on how to take care of the catheter that is in your loved ones chest.” The above being said, when surveyed, respondents overwhelmingly reported feeling that they had access to necessary health information.

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BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Low literacy levels impact health and wellbeing As we’ll see in the next chapter on Seniors, literacy plays a crucial role in health and well-being. Low literacy impacts everything from being able to read health promotion material to understanding the instructions on your pill bottle. On Bell Island, virtually half (49%) of the adult population has less than a grade 12 education. In fact, the largest proportion of those individuals has less than a grade 9 education (28% of the adult population). Although there are persons on Bell Island who are trained to teach adults to read using the Laubach (http://www.laubach.ca/) method, there is not a demand for these services. It is uncertain if the population is aware of these services.

EMPLOYMENT AND WORKING CONDITIONS Employees who work off the island face a number of challenges According to the Bell Island Ferry Users Committee, approximately 539 Bell Islanders used the ferry to commute to work in 2005 (http://www.bellisland.net). In the chapter, ‘The Role of the Community in our Health’, where issues around the ferry were roundly discussed, the number of commuters based People who are on 2001 Census data is much unemployed have smaller. To reiterate: somemore mental health times weather conditions and ferry breakdowns result problems including in persons being stranded on either side of the tickle distress, anxiety and [water mass between Bell depression. Their Island and Portugal Cove]. For commuters and their families, everyday activity is who are then forced to wait more likely to be in their cars in ferry lineups, this is an ongoing stressor, limited, and they are particularly during the winter more likely to be months. However, other commuters view commuting by inactive due to disferry, and all the unknowns ability. They are also that it brings, as just part of more likely to visit the the job.

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Employers and employees identify issues in the workplace A number of Bell Islanders noted that their wages, compared to their counterparts

doctor and go into hospital than people who are employed

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SECOND REPORT ON THE HEALTH OF CANADIANS, 1999

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in St. John’s, were lower. Moreover, some were of the opinion that their employers were able to maintain low wages and curtail advancement because the competition for jobs on Bell Island was so high. Also, employees were very reticent to comment on working conditions, because of concerns around personal job security and the perceived need to keep major employers in the community. Employers on the other hand cited a generally unreliable workforce, pointing to absenteeism, poor work ethic, resistance to change and so on. Regardless, an important consideration in attracting and retaining businesses on Bell Island is having a viable work force, one that is trained and has a strong work ethic. Bell Islanders have a history of being hard workers, but for employers this reference point is sometimes undermined by the population’s perceived reliance on and preference for social assistance over employment. Presently job readiness training is not available on Bell Island. Strongly held views around working conditions and the perceived general unreliability of the work force are duly noted, but further investigation to better understand the issues raised was beyond the scope of this study.

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The relationship between work and health is believed to have a biological basis, whereby the stress created in ‘bad job’ situations affects the nervous system. This in turn influences the immune system, making it harder for us to fight disease

Another important group on Bell Island is adults with special needs The specific health and well-being needs of adults with special needs is presently poorly understood. In 2004, there were an estimated twenty-six adults with special needs on the community social worker’s case load. There are two programs that these adults can take part in: A Touch of Class, located in downtown Wabana, which offers a sheltered workshop environment structured in part around a privately owned florists’ store; and, a flourishing Christmas Wreath operation. The special needs program at Touch of Class also involves three micro-businesses which are owned by the clients. There is also another program in Wabana for adults with special needs involving a plant nursery. Finally, Crafts and Décor, a small independent business, also graciously accommodates adults with special needs and their respite workers on an informal basis. The formal programs at Touch of Class and the greenhouse do not share clients, programming or resources. Presently these programs are not affiliated with sister organizations in St. John’s such as Mill Lane. The concern of health professionals on the island is that many of the adults with special needs are not involved in any program.

We need to better understand domestic violence on the island

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CANADIAN HEALTH NETWORK, HOW IS WORKING RELATED TO HEALTH, 2004

SOCIAL ENVIRONMENTS In a small community privacy is a big concern One of the paradoxes of a small community is that the closer and more tightly knit the community, the harder it is to get people to come together in a group, especially for something with an intensely personal focus like Alcoholics Anonymous, Narcotics Anonymous or Gamblers Anonymous and so on. “A lot of people want to keep their anonymity. Being in a small community is a challenge because people know people.” Repeatedly, we heard that things had to be done one-on-one. “They won’t come to meetings or clinics. It has to be done one-on-one.” Although there is an AA group on the island, it has been challenged to maintain an active presence on Bell Island.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

As noted in the chapter on ‘The Role of the Community in our Health and Well-being’, adults that experience some form of domestic violence do not have access to the same resources available in a larger urban centre like St. John’s. “If there is an incident in the middle of the night there is no ferry, no intake worker and no shelter.” Kirby House, a safe house in St. John’s which is tasked with outreach to Bell Island, noted that their staff was challenged to get to Bell Island because of the time commitment required to travel there and back and staff shortages. In a population of 3,000, one would expect to see reported incidences of domestic violence equivalent to the national average of 7% annually (Statistics Canada, 2005). The needs of this population warrant further investigation if they are to be fully understood.

PHYSICAL ENVIRONMENTS Getting to and from medical appointments in St. John’s is challenging Traveling to St. John’s for medical treatment can take the whole day and be fraught with frustration. “I get up at five. I have to fast. The taxi will pick me up at my house and take me down to the boat. We will

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wait for the boat to go, about half an hour. I have my letter to get on the boat because the commuters who have to get on the boat normally have priority. So I will get there for my treatment. They usually have my bed waiting as soon as I get there. The treatment is three to four hours, sometimes five according to my blood pressure. Then I am home at maybe two or three o’clock, a bit drowsy. Coming home, if I am really bad and I am sick the hospital in St. John’s will give me a letter so I have priority getting back on the ferry.” Moreover, some patients also find it difficult to get into town for early morning appointments. “For some unknown reason we always get the eight am or nine am appointment and it drives me nuts.” Presently, there is a protocol in place for getting priority on the ferry going over to Portugal Cove, but the protocols for the return trip are not well established or well known. “We get priority going over, if you get there 20 minutes ahead, they will put you on, but you have no priority coming back and there are a lot of people that go for chemo. I have seen people open the car door and throw up” … “If you provide a letter from your specialist, they now will give you priority coming back, but most people don’t even realize it.”

PERSONAL HEALTH AND COPING SKILLS Given that persons 19 years and older took part in the Bell Island Needs Assessment Telephone Survey, a substantial amount of data were collected on adults personal health and coping skills. The Needs Assessment 2004 Telephone Survey, carried out by the Memorial University Health Research Unit as part of the Bell Island Needs Assessment, is quoted extensively in this section.

Obesity is a growing health problem on Bell Island The Telephone Survey researchers collected height and weight for 388 of the 401 respondents. This allowed them to calculate a value for Body Mass Index (BMI). Based on this self-reported data, telephone survey researchers determined that 38% of adult respondents had a BMI in the overweight category compared with 37.3% across the province in 2003. Also, 24% were in the obese category compared with 19.9% provincially in 2003. These percentages are significantly higher than expected values based on provincial and Canadian BMI data. As found across the province, more men in the survey sample were overweight or obese compared to women (75% and 60% respectively). There was no significant difference in BMI category across age groups: 55% age 19 – 34 were overweight

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

or obese as were 65% for persons age 35 – 64 and 64% for persons age 65 and older. When respondents were asked what they could do to improve their health, 34% said lose weight and 3% said eat a healthier diet. Interestingly, persons who are overweight or obese are just as likely to report very good or excellent health as those that fall within the normal category. These data may point to persons feeling well even though they are at-risk for stroke, heart disease, and diabetes.

High stress levels can be associated with sleep deprivation and living with problem drinkers Findings from the telephone survey indicate that stress levels did not relate significantly with income. About half (57%) of those with high or very high stress levels were in households below the LICO and half were not (43%). Stress levels did not relate to gambling, having someone to talk to or one’s ability to cope with family health problems. However, stress levels did relate significantly with having someone in the household who consumed alcohol on a regular basis. Respondents who had high stress levels were also significantly more likely to report lack of sleep.

Alcohol consumption on Bell Island is of concern In the telephone survey, few households reported anyone consuming more than seven drinks a week. However, the total alcohol sales on Bell Island in 2004 exceeded one and a half million dollars ($1,624,964). Put another way, the average Bell Islander, 20 years of age and older, would have spent approximately $727 on alcohol purchased on Bell Island in 2004. Please note that these numbers do not take into account that the legal drinking age on the island is 19 years of age. Unfortunately for our purposes, the Census organizes age categories such that nineteen year olds are included in an age category with 15, 16, and 17 year olds so the total of $727 may be somewhat less. Also note that it is not known how much of this alcohol is purchased by visitors to the island – especially during the summer months when the tourist season is in full swing. Also, alcohol imported and / or made on the island is not factored into the $727 total. (See Table 2 for a rough approximation of the total monies spent by Bell Islanders on alcohol consumption and other at-risk behaviors).

Bell Islanders smoke more than their fellow Newfoundlanders and Canadians generally Telephone survey findings concluded that 32% of household members age 20 and older were reported to smoke on a daily basis. This is slightly higher than Statistics Canada 2001 values for the province and Can-

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ada across all age groups (25% and 22% respectively). When survey respondents were asked what they could do to improve their health, 19% said they wanted to quit smoking. Even though tobacco is a controlled substance, hard data on the volume of cigarettes sold on the island were not available. However, extrapolating from provincial estimates, if the 32% of smoking adults smoked the provincial daily average number of cigarettes (14.6 / day) it would represent a cost of approximately $2,398.00 per smoker annually. This is a rough approximation. (See Table 2 for a rough approximation of the total monies spent by Bell Islanders on cigarette smoking and other at-risk behaviors).

Data confirm a culture of gambling on Bell Island Telephone survey researchers found that even though 45% of household members over age 20 reported gambling at least once a week, many respondents commented that it was only lottery tickets. However, in 2004 the combined ticket and video lottery terminal sales for Bell Island amounted to approximately two million dollars ($1,980, 071). Please note, this number does not take into account online gambling, BINGO or local draws. The total of $1,980,071 amounts to $886 per adult between age 20 and over in 2004. Again, this number may be marginally inflated as we could not include 19 year olds in our calculations. Nonetheless, gambling of this magnitude is a relatively recent phenomenon. How it impacts the health system, community, individuals and their families is poorly understood at present. (See Table 2 for a rough approximation of the total monies spent by Bell Islanders on gambling and other at-risk behaviors). To summarize, monies spent on at-risk behaviours on Bell Island are noteworthy especially in light of the small adult population (2,235 20 years of age and older, 2001 Census) and low median household Table 2: Monies Spent on At-risk Behaviours on Bell Island in 2004

Monies Spent on At-risk Behaviours on Bell Island in 2004 ADDIC TIVE BEHAVIOR

ANNUAL MONIES SPENT ON BELL ISL AND

Drinking

$1,624,964

Cigarette smoking*

$1,702,862

Gambling

$1,980,071

Total

$5,307,897

* rough approximation based on cost of tailored cigarettes

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

income ($17,500, 2001 Census). If monies spent on at-risk behaviours were averaged across Bell Island’s adult population, each Bell Island adult 20 years and older would have spent roughly $2,380.00 on tailored cigarettes , alcohol and gambling in 2004. This amount translates into $45.77 weekly or $198.33 monthly in 2004 or 14% of the annual median household income in 2001. Be advised that these numbers are just a starting point, and that a true picture will emerge when the cost of these at-risk behaviours is trended over time.

Data point to issues around street and prescription drugs Data provided by the RCMP, in the form of the 2004 Mayors Report, records seven reported and actual street drug charges. Moreover, 2004 data from the Newfoundland and Labrador Provincial Drug Plan raises questions, particularly the figures from the Income Support Program, where eligible participants made approximately 26 claims each during the 2003 – 2004 fiscal year. By way of comparison, in Grand Manan, the per capita claim rate for the Income Support Drug Program was six per eligible beneficiary, substantially less than that of Bell Island. It appears Bell Islanders made over four times as many claims as their counterparts in Grand Manan.

Bell Island women are signing up for ‘Buns of Steel’! In addition to the regular recreational offerings, curling, hockey, dances and so on, the recreation craze that has swept the island is the women’s’ exercise classes offered at the Wabana Complex. These evening classes, which focus on low-intensity exercises for middle-aged women and seniors, have become a phenomenon. “The program is successful because it targets specific needs and a specific group.” The classes started in 2003 with eight to ten women meeting two nights a week. Just one year later, 70 – 80 women had signed up for classes (25 – 30 participating regularly). The group continues to meet twice weekly. The Wabana Complex offers the space free of charge and the instructor is a volunteer. Findings from the telephone survey noted that although just over half of all household members were reported to participate in regular physical activity, respondents conceded that they were not getting enough exercise. This is reflected in responses from respondents to the question, “What can you do to improve your health?” Exercise was the most commonly cited factor with 39% stating that they need to increase their level of physical activity with regular exercise.

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Adults are challenged to make healthy food choices The telephone survey researchers found that the vast majority of respondents (77%) believed that their families were eating a healthy diet, although many admitted that breakfast was often skipped and fruits, vegetables and milk products were not regularly consumed in the household. More specifically, only 73% of households eat breakfast, 63% eat fruit and vegetables, and 65% milk and milk products. In addition, households living below the LICO were less likely to report a healthy diet. For those that stated that their family did not eat a healthy diet, 54% said cost was the problem, 40% cited bad eating habits and 6% said availability of quality food was the issue. Several persons we interviewed tied the lack of quality food to restricted incomes on the island. “They [grocery stores] are catering to a population of people who are on social services and they are getting low quality food at cheaper prices.”

Working together, patients and providers are doing a good job when it comes to prevention Regular blood pressure, cholesterol and blood sugar checks are markers of good preventative primary care. Almost all respondents (92%) had had their blood pressure checked within the last two years (Oct 2002 – Oct 2004). This is significantly better than for Canada as a whole (85%). Almost all (97%) of those who had ever had their blood pressure checked knew whether their blood pressure was normal, high or low. However, only 16% said they knew the actual value but of these 59 respondents, 57 (97%) gave blood pressure values which corresponded correctly to their estimate of normal, high or low. A majority of respondents (75%) also had cholesterol and blood sugar tests within the last year and 91% and 84% respectively knew whether their values were normal, high or low. Only 13% said that they knew their actual cholesterol value and 21% knew their blood sugar level. To summarize, Bell Island health practitioners are doing an excellent job monitoring blood pressure, cholesterol and blood sugar. The next step is to effect what is popularly referred to as ‘knowledge transfer’. In addition to the Health Care provider knowing if one’s blood pressure is high or low, citizens need to learn what their blood pressure is and be able to situate it in the low-high blood pressure continuum because there may be improved health outcomes for doing so.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Engagement with personal health data appears to go hand in hand with better selfreported health Respondents who reported normal blood pressure were significantly more likely to rate their health as excellent or very good, compared to those reporting high blood pressure. Respondents who reported normal cholesterol values were significantly more likely to rate their health as excellent or very good, compared to those reporting high cholesterol. Blood sugar levels were not associated with self-reported health. These findings may point to the value of a personal health record that enables individuals to become more proactively engaged in their own data. To date, however, very few of Bell Island’s residents (<15%) keep records of their blood type, weight, or blood pressure. That being said, 37% of households surveyed, reported keeping a medication list as part of their personal health records.

PAP tests and breast exams need to be encouraged but PSA testing exceeds provincial and national values About half of all female respondents had a doctor or nurse perform a breast exam or had a PAP test in the last two years (Oct 2002 – Oct 2004) and 30% had a mammogram. These percentages are notably less than both the national and provincial values for PAP tests and mammograms. Sixty-eight percent of Canadian women and 70% of the women in this province had a PAP test within the last three years. At both the national and provincial levels, 49% of women ages 19 and over had a mammogram within the last three years. Forty-five percent of all male respondents had a PSA test within the last two years. The provincial and national values for the past three years are 37% and 38% respectively.

Some Bell Islanders want to take a more active role in their personal health There are adults on the island who are prepared to step from information to intervention. “I hear of a new medication and I investigate the 1–800 hot lines. I live on the Internet. Can’t I be given a supply of pills and have someone here qualified to maintain me, review my blood work and ask me questions on a survey and push the information on to the main centre. I would kill to be in on some of the clinical trials, but I can’t get in them. Many studies want you there five days a week for blood work or whatever they want to find. Should I be left out just because I don’t live in town, no! I suffer the same disease.” Regina Herzlinger, at Harvard Business School, wrote a book published in 1999 titled

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Market-Driven Healthcare. The premise of this book is that, consumers’ [patients’] needs for convenience, self-mastery and control will become the main drivers in healthcare delivery. The preceding quote suggests that there are Bell Islanders who are already moving in that direction.

We need to learn more about grief and depression on the island Although grief and depression were frequently cited as reasons for referrals to the Health and Community Services mental health and addictions counselor, it was not possible to get hard data on the numbers of referrals. This was due, in part, because of the way these numbers are captured, but also there have been extended periods of time where the position of the half time mental health / addictions counselor has been vacant. Grief and depression on the island are poorly understood and require further research.

BIOLOGY AND ENDOWMENT Diabetes and obesity have a genetic component Findings from the 2003 Canadian Community Health Survey reported that 6.4% of Newfoundlanders and Labradorians, age 12 years and older, said they had been diagnosed with diabetes by a health professional. If the provincial incidence of diabetes holds true for Bell Island, one would expect approximately 197 individuals on the island to have been diagnosed with diabetes. However, the only way to determine the number of diabetics on Bell Island is by carrying out a chart review which unfortunately was beyond the scope of this study.

HEALTH SERVICES Use of inpatient services varied across age groups and institutions An analysis of centralized, de-identified inpatient data from years 2001 – 2004, found that the use of health institutions varied by age group. Understandably, when women are of child bearing age (20 – 39), the majority of inpatient stays take place at the Health Sciences Centre on the maternity ward. Between ages 40 – 50, inpatient days were spread out evenly across Health Sciences, the Walter Templeman and St. Clare’s. However, from age 50 on, use of the Walter Templeman Health Centre increased dramatically. The highest number of inpatient days was attributable to persons ages 60 – 69. Overall, pregnancy was the most com-

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

mon reason for admission in younger age groups with musculoskeletal disease prevalent in ages 40 – 59 and circulatory diseases predominating from age 60 on. Diseases of the digestive system were the second most common reason for admission across these age groups. There was also a peak in mental health admissions in persons ages 40 – 49 and again between ages 60 – 69.

Getting a better fit between adults’ needs and existing health programs and services Respondents had suggestions on how to get a better fit between their health and well-being needs and the current health care delivery system. Gambling was near the top of most lists. Respondents and persons interviewed cited the pressing need for addiction diagnosis and counseling services. They also felt there would be a role “for support groups for unusual conditions or medications. Maybe a centralized service could offer putting people in touch with the appropriate support groups.” Adults also felt that in the case of chronic illness, they were underserved. “Our healthcare facility is a godsend to some people, but it has a very low level of what they can do for someone with a chronic illness.” Respondents also expressed a desire for specialists, for example a rheumatologist to visit Bell Island and hold a clinic once a month. Of particular interest were the monthly or bi-monthly services of allied health professionals to include a dietitian, physiotherapist and massage therapist: “I don’t understand how the health care board cannot deem that as part of their nine to five shift, the health care providers just have to work over on Bell Island that day instead of at the Health Science or St. Clare’s.” Respondents also expressed a need for occupational therapy, “I think when you have any long-term anything, assistance with the simple things, that’s what you appreciate most. Specialists cannot live on Bell Island. Large hospitals cannot be on Bell Island but what about help with the simple things that could assist us with our daily living.” Some Bell Islanders were also willing to pay for services. “I would love to have someone take care of my feet even if I had to pay for it out of my own pocket.”

Accessible and timely medication reviews are important to patients A number of adults were observed to lack successful strategies for having their medications reviewed if they were prescribed by a specialist in town, “You’re given a new bottle of pills and if something goes wrong with what they have given you, you are not getting back in until several months later.” Adults did not appear aware that the practitioners on the island would have been fully apprised of the drugs prescribed by the specialists and moreover, would welcome the oppor-

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tunity to review medications with patients. Medication reviews are an important primary care service. Self-reported ready access to prescription drugs may provide opportunities for self medication and in the absence of physical therapists, acupuncturists, relaxation and massage therapists the primary recourse for pain management reported by some is medication. “For chronic headache and back pain – drugs are the only solution” … ”We have become great self managers for pain management because of the long waits.”

There may be a role for telemedicine and other e-health technologies When asked if Bell Islanders would be open to video teleconferencing with specialists and other health professionals in St. John’s rather than traveling to St. John’s and back the response was very positive, “You know I think the people of Bell Island would graciously accept any help you could give them” … “I would imagine Telemedicine: the first thing they would think is, well, someone is trying to help them. They Someone will try it because it is something the hospital’s now got and they didn’t to discuss have. They would come here thinking it with is at first it was going to be a big help whether or not they decide it was a as good help” … “You are asking them quesas seeing tions when they come into your home. Those questions could easily be done the doctor on a screen. Okay, can you tell me why or better I am throwing up so much, can you tell me why I am constipated? These are ANONYMOUS BELL simple questions. I don’t need to go to ISLANDER, 2004 St. John’s to ask them.”

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Can existing laboratory and x-ray services be optimized? Some respondents asked if laboratory services on the island could be expanded or if coordination of services between the Bell Island and St. John’s laboratories could be improved. “You wait in the department at the Health Science for a urine analysis. Sometimes you can wait eight hours. I’m not allowed to come over here and pee in a cup and then they send it over for them to check. How come they won’t allow them to do it here? I don’t understand that.” Bell Islanders also questioned why they weren’t part of the St. John’s Picture Archiving and Communication System (PACS). “I had x-rays done at St. Clare’s. She took the x-rays and I asked when he would be able to read them. I am thinking 10 days, because that is what we are used to here. She said, he can do them now. All the radiologist has to do is bring them up on the computer. I don’t understand why our link

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

is not upgraded with the rest of the health care system. You know we [the Health Centre] are under the one heading, under one roof [the Health Care Corporation of St. John’s].”

Bell Islanders report ready access to physicians and emergency services Bell Islanders appreciate and are very proud of their ready access to family physicians and emergency services. “I find doctors are very accessible here. You can drop in and be seen in half an hour versus waiting one to two weeks for an appointment.” Many adults did however, comment on extended periods of time spent in the waiting room for their appointments with the doctor. The public may not be aware that the hospital clinic functions both as a clinic and an emergency department, with emergencies and ‘walk-ins’ being fitted in around patients with appointments. In other words, it is a very inefficient clinic but a very efficient emergency department. There appears to be a need for the public to better understand why there might be delays. When asked if office hours needed to be extended the general response was, “Commuters don’t want clinics nights and weekends because they work all week.” The Health Centre makes a special effort to accommodate commuters by giving them the last office appointment of the day.

Eastern Health needs to communicate who they are and what they do Adults underscored the need for the Health Care Corporation of St. John’s (HCCSJ) and Health and Community Services, now Eastern Health, to do a better job of promoting what they are doing and to do so in plain language. “The HCCSJ can do more to let people know what they do for example, particularly when it comes to mental health and addictions.”

Summary of Challenges x social assistance: perceived lack of accountability on the part of the system and the recipients x social assistance: subsistence existence coupled with stigmatization x poorly understood changes in family structure: namely, a significant number of single parent families and mature adults living with their parent(s) x formal assessments, programs and services needed for adults with special needs x programs to support citizens who want to upgrade their formal education or job readiness skills x health education around chronic disease management, prevention, healthy behaviours and self-care

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x low adult literacy rates x traditional support groups like Alcoholics Anonymous or Gamblers Anonymous x infrastructure to support victims of domestic violence x transparent protocols and public awareness campaign around priority ferry access for patients who are required to travel to St. John’s for medical treatment x identification, diagnosis and treatment of adults struggling with at-risk behaviours such as obesity and inactivity, drinking, gambling, smoking, prescription and street drugs x improved usage rates for pap and breast exams x a better understanding of the etiology, prevalence and treatments around mental health x determine the base-line number of diagnosed diabetics x provide regular access to allied health professionals (physiotherapists, occupational therapists, dietitians, chiropodists, chiropractors, massage therapists, and so on) x optimize laboratory and x-ray services x technology infrastructure to support next generation telemedicine, information and communication technologies

Social Assistance: Working together, the community, individuals, the Bell Island Health and Wellness Committee and Eastern Health, are encouraged to use a Participatory Action Research (PAR) methodology to better understand the issues around social assistance on Bell Island and how they can be ameliorated. It will take a significant effort on the part of the community and health care system to engage individuals on social assistance, but their engagement is key during Phase Two of the Needs Assessment. Adults with Special Needs: The two existing programs should be assessed. The occupational therapist in charge of Evergreen Recycling has the requisite expertise. Moreover, she and her staff would be able to help formalize the programs on Bell Island, as well as offer a professional community of support. These Bell Island programs would be ideal field placements for occupational therapy students in the MUN / Dalhousie University program. Also, medication should be made available in blister packs for this population at no additional cost, providing the prescribing fee is covered by the Newfoundland and Labrador Prescription Drug Program. Education: Once again, low literacy levels build the case for a community-based Health and Well-being TV channel. Newfoundland adults are acculturated to Land & Sea which focuses on local topics of interest. A local TV channel, with local content focused on addressing local health and well-being topics, could provide a point of entry into people’s homes. Health education around chronic disease management, prevention, healthy behaviours and self-care are made-for-TV topics. With respect to personal health data, knowledge about one’s personal health is analogous to knowledge about one’s personal finances. Knowing that you are in debt is very different from knowing how much you are in debt. Knowing the actual number and being able to put that number in a context is the first step in proactively engaging in a strategy for addressing one’s debt or high blood pressure.

LEAVING BELL ISL AND. PHOTO COURTESY OF HT TP:// W W W.BITSTOP.C A .

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Addictive behaviours: Although data from Atlantic Lottery Corporation and Liquor Control Board indicate that there is a problem, we lack data confirming what proportion of the population is struggling with addictive behaviours. Regardless of the final number, a half time mental health / addictions counselor will not be able to meet the need for diagnosis and treatment. Virtual means (online and / or telephone) of providing diagnosis, treatment and access to addictions professionals and support groups should be investigated. Findings would have relevance across the province. Potential partners for research and

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development around this topic, in addition to the Bell Island Health and Wellness Committee and Eastern Health include: the Faculty of Medicine’s Primary Care Research Institute and its Canada Research Chair in Health Promotion and Community Development, as well as the Faculty of Medicine’s new Office of e-Health. This area would also be fertile ground for computer science students and faculty with an express interest in medical informatics. This area would also be of interest to psychology and social work students. Mental Health: The province recently released “Working Together for Mental Health: a Provincial Policy Framework for Mental Health and Addiction Services in Newfoundland and Labrador”, October, 2005. Efforts to better understand and meet the needs of those Bell Islanders requiring mental health and addiction counseling should reflect the directions set out in that document. Medication should also be made available in blister packs for this population at no additional cost providing the prescribing fee is covered by the Newfoundland and Labrador Prescription Drug Program. Domestic violence: Determine the level of need and establish ready access to appropriate resources, programs and support services to address domestic violence. Lobby Kirby House to provide the services they are mandated to deliver. Partner with the MUN specialist in the Division of Community Health and History of Medicine, on a research project to address domestic violence issues in rural and remote communities. In terms of education materials, take note of the mini pamphlet produced by the Coalition Against Abuse in Relationships in New Brunswick, as it provides an excellent model. Education upgrades: Income and social status have a significant influence on an individual’s health outcomes. Presently there are limited opportunities for persons to upgrade online or in a traditional classroom setting. Provide job readiness training that gives participants a certificate to indicate to potential employers that the individual is ready to enter the workforce. This is especially important for persons who did not graduate from high school. Investigate opportunities that encourage and support adults achieving their Grade 12. Brighter Futures has access to persons trained to assist adults who want to learn how to read. Are Bell Islanders aware that this opportunity exists? Grand Manan’s ‘Manannet’ is a good adult education model. Ferry usage: Transparent criteria and protocols around priority ferry usage, for patients who are required to travel for treatment, need to be established. Publish these in the monthly policing newsletter and post in the ferry terminals. Moreover, if possible, book patients’ appointments so they are not required to

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travel during peak commuter hours. The bulletin regarding patients traveling for treatment could also be posted on the community TV channel. At-risk behaviours: Because of the scale of the at-risk behaviours, the need for diagnosis, treatment and education around obesity and inactivity, drinking, gambling and smoking calls for a population health approach in addition to extant primary care. By definition, population health focuses on improving the health of the entire population and in doing so focuses on the broad range of factors and conditions that impact the entire community. Population health also looks at the inequalities within a population and how those inequalities influence health outcomes. The Determinants of Health Framework is helping us achieve that end. Dr. Jay Winsten at the Harvard School of Public Health says that in order to sustain behavioural change, you have to have individuals engaged in their personal health data and you have to have community (family, fellow workers, friends, online group) support. Determining at the community level that there is a problem is the first step; bringing it down to the level of the individual follows. Concordantly, individuals need tools to track personal progress, whether it is increasing their activity levels, measuring their waist, giving up smoking, or getting a handle on how much they gamble. A Personal Health and Well-being record may be such a tool. Allied health professionals: Increased access to allied health professionals, more particularly, physiotherapists, occupational therapists, dietitians, chiropodists, chiropractors and massage therapists is of interest to adults and seniors. Presently, the Health Centre accommodates a private dentist and, in the past, has accommodated an optician. This program should be extended. Build on the ‘Networks’ cornerstone of primary health care, and offer space in the Walter Templeman Health Centre as well as administrative infrastructure to allied health professionals who are willing to provide public and / or private services on Bell Island. Information and Communication Technologies (ICT): Lobby the government to ensure that Bell Island has full broadband internet coverage to support next generation telemedicine and e-health initiatives, as well as connecting them to the corporation’s PACS network. An ICT infrastructure that supports affordable community television is key.

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The goal is to identify indicators that are truly meaningful for Bell Island adults. 1.

Percentage of adults employed

Rate of unemployment

Percentage of adults living below the Low Income Cut Off (LICO)

Percentage of adults with children or youth living below the LICO

Number of single parents

Number of adults with three or more children

Percentage of adults 25 years or older living at home

Percentage of adults on social assistance

Percentage of adults with an overweight BMI

10. Percentage of adults with an obese BMI 11. Percentage of adults who, if appropriate, have reduced their waist measurement and by how much 12. Percentage of adults reporting their health as very good or excellent

24. Percentage of adults who are daily smokers 25. Percentage of adults with special needs and / or mental health issues taking medication prescribed in blister packs at no additional out-ofpocket cost to the client 26. Number and classification of prescriptions per adult

Opportunities for further research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to integrate research on Bell Island into their studies. Doing so will help establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Well-being Committee. 1.

Determine the base-line number of diagnosed Type I and II adult diabetics.

Determine why there are so many hospital admissions of adults for diseases of the digestive system.

Use a participatory action research methodology to better understand the issues around social assistance on Bell Island and how they can be ameliorated.

Develop a privacy model for rural and remote communities. Individuals living in small rural and remote communities have very different views on privacy, security and trust (PST) than their counterparts in large urban centers. Attitudes towards PST will have a direct impact on the design of information and communication technologies, and program design around virtual diagnosis, treatment and education.

Gambling on Bell Island requires further study. A detailed research program is outlined in the final chapter of this document.

Changes in family structure, namely single parents and adults living with elderly parents requires further research in order to better understand the impact that these trends have on the health and well-being of the adults, their families and the community as a whole. Moreover, are these same changes taking place elsewhere?

Building on the important work carried out by the Health and Community Services, Community Supports and Youth Corrections Officer, research is needed to better understand the needs of adults with special needs and how to meet their health and well-being needs.

13. Percentage of adults going on to some form of post-secondary education 14. Number of persons upgrading their education online 15. Number of adults engaged in upgrading their literacy skills 16. Number of adults that have completed job readiness training 17. Number of adults with special needs enrolled in formal programs 18. Number of members of the womanâ&#x20AC;&#x2122;s exercise group at the Wabana Complex 19. Percentage of adults who have had their blood pressure, cholesterol and blood sugar checked in the past year, know what it is and if it is within normal range 20. Percentage of women who have had their annual pap test and breast exam 21. Number of confirmed Adult Type I and II diabetics on Bell Island 22. Percentage of adults who are at-risk for problem drinking 23. Percentage of adults who are at-risk for problem gambling

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Investigate the utility of the medications dispensed in blister packs for adults with special needs, mental health clients and seniors.

Investigate the prevalence of prescription drugs for adults covered by the Provincial Income Drug Support Program.

References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. Atlantic Lottery Corporation (2004). Bell Island Health and Well-being Needs Assessment 2004 Telephone Survey. Bell Island. Website. [online]. (April 2006). http:// www.bellisland.net/ Government of Canada Canadian Health Network. [online]. (April 2006). http://www.canadian-healthnetwork.ca Government of Newfoundland and Labrador Community Accounts Bell Island accounts. [online]. (April 2006). http://www.communityaccounts.ca/ CommunityAccounts/OnlineData/default.htm Government of Newfoundland and Labrador. (2005). Working together for mental health: a provincial policy framework for mental health and addiction services in Newfoundland and Labrador. [online]. (April 2006). http://www.gov.nl.ca/publicat/2005/ WorkingTogetherForMental%20Health.pdf Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Herzlinger, R. (1999). Market Driven Healthcare: who wins, who loses in the transformation of America’s Largest Service. Perseus.

http://www.comminit.com/healthecomm/research. php?showdetails=299 Laubach Literacy of Canada. [online]. (April 2006). http://www.laubach.ca Newfoundland and Labrador Centre for Health Information. (2003). Tobacco use fast facts. [online]. (April 2006). http://www.nlchi.nf.ca/pdf/Tobacco_ Use_fastfacts06.pdf Newfoundland and Labrador Centre for Health Information. (2004). HealthScope: reporting to Newfoundlanders and Labradorians on comparable health and health system indicators. [online]. (April 2006). http://www.nlchi.nf.ca/pdf/healthscope_ 2004.pdf Newfoundland and Labrador Provincial Liquor Commission (2004). Public Health Agency of Canada. (1999). Towards a healthy future: second report on the health of Canadians. [online]. (April 2006). http://www.phacaspc.gc.ca/ph-sp/phdd/report/toward/ Public Health Agency of Canada. (2002). Healthy lifestyle: strengthening the effectiveness of lifestyle approaches to improve health. [online]. (April 2006). http://www.phac-aspc.gc.ca/ph-sp/phdd/docs/ healthy/intro.html Real Age. [online]. (April 2006). http://www.realage. com Statistics Canada. (2001). Profile for census subdivision: Wabana, Freshwater and Lance Cove. Statistics Canada. (2003). Canadian community health survey. [online]. (April 2006). http://www.statcan. ca/Daily/English/040615/d040615b.htm Third Age. [online]. (April 2006). http://thirdage.com

International Centre for Health and Society. (2003). The solid facts, Second edition. [online]. (April 2006).

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6.5 SENIORS

N A C O M P L E X ). P H O T O

Following is a profile of the seniors ages 65 and older on Bell Island. Data sources include: the Bell Island Needs Assessment 2004 Telephone Survey Report; interviews and focus groups; the 2001 Census; deidentified data from Health and Community Services and the Health Care Corporation of St. John’s; and, the Community Accounts website. In the process of collecting and analyzing the data from the Telephone Survey, the Memorial University . P.C A S TO Health Research Unit identified BIT . W W a number of challenges and W : // P T recommendations relating to seniors which have been incorporated into this chapter.

x Percentage of adult, senior households living below the LICO: 36% (Telephone Survey, 2004) x Number of combined seniors and adults immunized for influenza by physicians: 485 (Health Centre, 2006) x Life expectancy on Bell Island: 76 (Community Accounts, 2005) x Percentage of seniors who use automated banking machines: 69% (Telephone Survey, 2004) x Per capita cost of the Senior Citizen’s Drug Subsidy Program, 2003 – 2004: $861.96 (NLPDP) x Percentage of households using home care services: 3% (Telephone Survey, 2004)

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On Bell Island, in 2001, the proportion of persons 65 years and older was 15% – higher than that of the province (13%) and the country as a whole (13%). Moreover, the proportion of seniors on Bell Island appears to be increasing. Results of the 2004 Telephone Survey indicate that there were 27% more seniors living on Bell Island in 2004 than recorded in the 2001 Census. In addition, due to the disproportionately large number of adults aged 40 – 64 living on Bell Island, the next 20 years will see a further increase in the proportion of seniors living on the island. Presently life expectancy on Bell Island is 76 – just one and a half years shy of the provincial average (77.2 years). Using the Determinants of Health Framework, this chapter looks at the factors that impact the health and wellness of our seniors.

x Percentage of adult, senior, and child households living below the LICO: 38% (Telephone Survey, 2004)

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Data x Number of persons 65 years and older on Bell Island: 460 (2001 Census) x Percentage of households with at least one senior: 36% (Telephone Survey, 2004) x Percentage of households in which seniors reside living below the LICO: 47% (Telephone Survey, 2004) x Percentage of lone senior households living in poverty: 84% (Telephone Survey, 2004) x Percentage of two senior households living below the LICO: 19% (Telephone Survey, 2004)

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INCOME AND SOCIAL STATUS On Bell Island income, social status and living arrangements are inextricably intertwined Seniors on Bell Island have five housing options. They can live alone, in which case, “If there are two old age pensioners living under one roof, they are nice and comfortable whereas, for one old age pensioner alone it is almost [financially] impossible.” This statement was supported with data from the 2004 telephone survey which showed that a greater proportion of lone senior households reported incomes below the LICO (84%) than did households with two seniors (19%). Surprisingly, over half (53% or 195) of the island’s seniors living in private households were single in 2001. Moreover, 79% of those individuals were living alone. The second housing option for seniors is to live in the privately owned Island Manor Personal Care Home. It has 10 beds and caters to persons of any age requiring level one care. Residents using the home have three payment options: pay privately with no subsidy; pay with their pension supplemented by the government; or payments are made through Human

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Resources, Labour and Employment. The third housing option is Long Term Care at the Walter Templeman Health Centre, where residents receive level three, 24 hour nursing care. The fourth option is an apartment at the Senior’s Complex which has 16 units. To qualify for residency, residents must be receiving a pension. The Senior’s Complex is run by the Bell Island Co-op and subsidized by Newfoundland and Labrador Housing. The fifth option is for seniors to live with their extended family. According to 2001 census data, only 13% of single Bell Island seniors are living with their relatives, compared to the 25% of seniors living with their relatives in the Province. Understandably, concern for the elderly was among the top ten community problems identified by Bell Islanders. Further research is necessary to determine why so many seniors are living alone, in poverty, when other viable options for example, the hospital, the home, or the senior’s complex are readily available.

SOCIAL SUPPORT NETWORKS

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The ageing of the population, combined with the shift away from institutional care for the aged, and changes in health and social services, suggested that abuse of older adults could increase in the future as the demands on family members to care for older relatives increases

Adequate care for the elderly is cited as one of the top 10 challenges facing the community

Data from Statistics Canada suggest that social support declines with age. Decreasing social support networks appear to be exacerbated on Bell Island because of emigration. Many family members moved to Cambridge, Ontario when the mines closed or went further west for work. In some cases, this now means that, “The senior lacks a family member to represent them and speak for them or take them to the physician if they see something wrong.” Newfoundlanders are renowned for their strong family ties and JUSTICE CANADA, ABUSE Bell Island is no exception. When OF OLDER ADULTS: Bell Islanders were asked during A FACT SHEET the Bell Island Needs Assessment 2004 Telephone Survey to rate the importance of a list of community problems, 27% of respondents rated lack of support for the elderly as a major problem. Further, 3% of respondents believe that lack of elderly support is the single most important problem facing the community, placing it in the top ten community problems. Bell Islanders were

”

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concerned about the lack of activities, availability of home care, transportation, housing, banking, cost of drugs, and the loneliness experienced by their senior population.

Use of Long Term Care in the Dr. Walter Templeman Health Centre is declining The trend for seniors to remain outside institutions as they age is seen across the province. According to the 2001 Census, compared with two decades earlier, more elderly adults are living with a spouse, with adult children, or living alone, and fewer are living in health care institutions. The sixty percent occupancy of long term beds at the Walter Templeman Health Center corroborates that trend. However, it is important to recognize that the trend could be reversed at any moment and indeed was between when these data were gathered and the report written. Nevertheless, some community members are concerned that the long term care beds will be closed, and that those seniors requiring level three care will be moved to the Miller Centre in St. John’s. Although this may make fiscal sense, a number of Bell Islanders felt it would have a negative long-term impact on the social fabric of the community. “Families are not going to want to go visit their parents in St. John’s. It is not fair to the families. If they are on social services it is damn expensive. They don’t all have cars. They would have to use taxis.” Some Bell Islanders attribute the decline in use of longterm care at the Dr. Walter Templeman Health Centre to an increase in the number of alternative support services. “When long-term care started there was no home care services, no seniors complex, no seniors nursing home, or supervised living arrangements. People are staying in their homes longer because the services are there to keep them there.” However, another interpretation espoused by some community members is that “seniors are being kept at home longer because they are a source of income” … “In a lot of cases, the parents probably would be willing to go into a home for care, but the children don’t want them to go because they want to keep the money.” Formal workshops or courses designed to help educate care givers and family members on how to enable and care for seniors, presently are not available on Bell Island.

We need to be vigilant when it comes to neglect and abuse of seniors Even though the province has adult protection legislation, Bell Island’s community and health care professionals report being challenged in instances where they suspect abuse or neglect. “I know patients that are

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According to the Canadian Department of Justice, some of the signs that may indicate an older adult is being abused include:

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x Depression, fear, anxiety, passivity x Unexplained physical injuries x Dehydration, malnutrition or lack of food x Poor hygiene, rashes, pressure sores x Over-sedation

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home that actually should be in our level II care.” Bell Island’s health professionals report being challenged to identify incidences of senior abuse and take appropriate action. They are not alone. “Podniek’s 1990 survey of 100 Family Physicians (in the golden horseshoe area of Ontario) found that only about 44% of physicians recognized senior abuse and of the 44%, less than 50% knew what to do.” Navigating these situations, in a small community like Bell Island, is particularly difficult. Statistically, one can expect that senior abuse does exist. A national study by Elizabeth Podnieks, co-founder for the Prevention of Elder Abuse (1990), showed that, “Each year, four percent, or about 100,000, seniors across Canada reA very simple defport some form of physical, psychological and financial inition of abuse and abuse or neglect from famneglect is mistreatment ily members or in-home care givers.” In other words, of older people by based on these statistics, those in a position of annually, one could expect to see approximately 18 trust, power or responcases of senior abuse on Bell sibility for their care Island. Presently, there isn’t a social worker for seniors on SWANSON, 1998 Bell Island.

“

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EDUCATION AND LITER ACY For seniors, literacy is a key predictor of health In younger age groups, socio-economic status is one of the strongest predictors of health. However, for seniors, income is not the best predictor of health. According to recent research cited by Statistics Canada, education levels may be the strongest predictor of health. Research has proven that poor literacy skills can potentially result in errors when it comes to following instructions on how to prepare for medical tests, or how and when to take medications. Health professionals

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on Bell Island corroborate those findings. “If you ask a senior what medication are you taking, they have no idea – ‘all I know is I have a pink one, a green one, and I take it in the morning and the evening’. Again, sometimes they don’t even know if they have taken it.” Literacy levels also impact many activities of daily living, for example, dealing with appointment slips, consent documents and health education materials. Poor literacy skills can also isolate seniors from sources of important public health announcements, for example, a boil water advisory in the Bell Island Community Policing Newsletter or notices of upcoming events organized by the Bell Island Seniors Advisory Group. Low literacy skills can also increase a senior’s dependence on family members or close friends, “He only got grade two. He don’t understand bills. He can write his name, but he can’t read. He never paid a bill in his life. I always did it for him. I pay all his bills, his car payments, his groceries. He won’t go in a store. He can’t read the labels. I give him an allowance.” Low literacy rates were also reported to negatively impact some seniors’ ability to use the ATMs on Bell Island, “Some people here can’t read and if you can’t read you can’t use anything in the machine.”

SOCIAL ENVIRONMENTS Seniors want to have places to go, people to see and things to do Like Bell Island’s youth, seniors are looking for places to go and things to do. Several times a year the Seniors Resource Group meets at the Canadian Legion to hear guest speakers and socialize. Although the subject matter is topical, for example bereavement, the turnout and frequency of sessions are reported to be low. Seniors also expressed the need for a place where they can learn how to use the internet, to communicate with friends and family or get information online. There is an Industry Canada Community Access Point (CAP) site at the library, but it is not well advertised and formal instruction on how to use computers is limited. One respondent noted that, ‘’With the population declining, the people here see fewer and fewer resources. Teens and the elderly are the most affected, because the middle group can get up and go to the city or wherever.”

Seniors face a number of challenges if they want to socialize outside their homes Although some seniors express being lonely and housebound, particularly during the winter months, some are at the same time hesitant to leave their homes. “We offer free transportation, but it’s very difficult to get people to go. You call them and ask,

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‘Would you like to come down tomorrow?’ But if you don’t do that, they won’t get in touch with you.” Some of the seniors who do get out report that the challenges of getting on and off the island impact their ability to coordinate activities on the other side of the tickle (the body of water between Bell Island and Portugal Cove) and to attend special events for seniors in St. John’s. Moreover, The population aged although some seniors 75 and older is estiare comfortable driving mated to grow by 48% around Bell Island they do not drive in town (St. in Newfoundland during John’s). Income is also an important factor when it the next 20 years comes to socializing. The ECONOMICS AND STATISexpense of driving back TICS BRANCH, DEPARTMENT and forth to St. John’s is OF FINANCE, GOVERNan additional constraint MENT OF NEWFOUNDLAND for those living on fixed AND LABRADOR, 2001 incomes.

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PHYSICAL ENVIRONMENTS Not having a bank branch is a major inconvenience and potentially puts seniors at risk The lack of a bank branch on Bell Island presents a number of hardships for seniors – hardships that undermine their autonomy and independence and potentially expose seniors to financial fraud, abuse and theft. There are ATMs on Bell Island, but “All you can do here is withdraw and pay a bill. You can’t deposit and you can’t bring your book up to date.” Seniors who don’t have a car, or someone to drive them to town often give their cheques and pin numbers to friends or family members who do their banking for them. Physically going to St. John’s to do banking constitutes a hardship for some seniors. “To put your cheque in the bank is a five hour job. They probably got to go down to the lineup at nine am, get on the 10 or 11:20 boat, go over and put their cheque in, come back to the line-up and sit in the cold for two or three boats depending on the weather and number of boats running.” Those seniors, who cash their cheques on the island, are frequently charged a percentage by Bell Island businesses or they have to spend a minimum amount in the store. Some seniors are reported to just keep their monies in their house. Tellers who work in banks or other financial institutions are often the first ones to recognize financial abuse. If a community doesn’t have a bank, this safety check against financial abuse is not in place. Canadian studies have found that financial abuse is the

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most commonly reported form of abuse experienced by older people (Manitoba Seniors Directorate, 1991).

Transportation poses a number of challenges for seniors Unlike larger urban centers, there isn’t a public transportation system on Bell Island. Getting around requires hiring a taxi or relying on family members. Having to use a ferry to attend medical or social appointments in town adds an additional layer of complexity as well as expense. “I have a mother who is in her 80s. She is petrified on the water. We make our appointment, we show up. If there is a possibility of getting there, we get there. The woman has herself into frenzy before we even get there, about the boat, and if she misses the appointment, oh, you are not going to get another appointment for another six months to a year. Excuse me, we never just forgot about it. It’s not possible. The woman is over 80, maybe she is just not having a good day. We can’t just get up and run down the street. We have to cross the water.” Trips to St. John’s also constitute a financial burden for some seniors. “A person can be referred to allied health professionals in town but then they need to hire an escort, get someone to taxi them around, pay for the ferry, then wait in the line up to get on the ferry.”

Seniors have unmet recreational needs Many seniors attend the women’s exercise classes held at the Wabana Complex. However, there was an often expressed need for proper walking paths in and around town, as the formal hiking trails on Bell Island are considered too rugged and walking on the side of the road was felt to be too dangerous. “We need some place that seniors can go, a little park or something. You take a nice day like today. It would be nice to go to a place where you could go for a little walk around. There is nothing like that here. There is nothing for seniors to do. They have a seniors club here and all they do is play cards. They do not get outside. We need a nice place with benches and trees where you could take your friends and have a walk around.”

PERSONAL HEALTH AND COPING SKILLS Seniors and their families need information and education Health care professionals are the first to point out that seniors and their families need more information about the home care and financial options available to them.

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“You say, how much are you paying for your medications? Now do you know that there is a program that you can apply to social services (Human Resources Labour and Employment) and that over $300 is the magic number?” There is also a recognized need to teach seniors and their care givers about prevention and self care. “The major health problem here is education. They are not compliant [with medication instructions], usually when they wait, they wait too long. If they have congestive heart failure, we won’t see them for four or five days. They are frightened, they live by themselves. They go for a long time without water and they won’t drink. A lot of them are dehydrated. A lot of them their hygiene is not that good.” Seniors and family members also need education on chronic disease management, how to best manage diabetes, obesity, high blood pressure, and so on.

HEALTH SERVICES Seniors and their families need to better understand and avail themselves of homecare services Lack of support for the elderly (including lack of home care services) was included in the list of the top ten most important community issues facing the island. In addition, results of the 2004 telephone survey indicated that despite the fact that 36% (or 145) of the households surveyed house at least one senior, only 3% (or 14) of those households reported use of homecare services in the year preceding the study. Professionals and citizens alike expressed the need for seniors to be made aware of what home services entail and how they can access home services. “Seniors also need to know that there are alternative care options to their current circumstances and they need to be educated as to what those options are” … “Sometimes you have an 80 year old taking care of an 80 year old person. I think they all have the impression that they can’t go into a home. They are afraid of change.” Seniors also have to come to terms with the fact that, if they have the income, they will have to contribute to the cost of these services. “It is an educational process for seniors to let them understand that we are not here to take every last cent. They have such a fear that everything is going to be taken from them financially.” There are also cultural reasons for not using home care services. “If a senior has to pay for four hours a week, they can’t comprehend why they should have to. They’d rather not do it because four hours to them translates into 40 to 60 dollars. It means that nobody cares about them.” In some cases successful homecare requires a

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few modifications to the home. “Sometimes if there were renovations to their house and hospital beds were provided, they could stay in their home.” Many thought the home assessment services of an occupational therapist would be very helpful in achieving this end.

Staff and services at the Dr. Walter Templeman Health Centre are deeply appreciated According to the findings of the telephone survey, the majority of seniors and their attendant families were very appreciative of the end-of-life services provided by the Dr. Walter Templeman staff. The Health Centre is heavily used by seniors. According to data provided by the Health Care Corporation of St. John’s, by age 60, 50% of in-patient stays take place at the Heath Centre and by age 80, 75% of inpatient stays take place in the Dr. Walter Templeman Health Centre. “The nursing staff is very good with families whose parents are dying in the hospital.” The same is said for palliative care. “The Palliative Care Unit, they should never, never consider leaving. Seniors on this island know that when the time is coming, they can come in here and they will be allowed to have visit with neighbours, family, and loved ones.”

Seniors identify additional health and well being needs Seniors were proactive when it came to identifying their unmet needs. They also recognized that their needs could be met by a combination of private and public services and programs preferably offered at the Dr. Water Templeman Health Centre. x Physical Therapy: “I had to go two times a week for six weeks during the winter. It takes longer to heal if you don’t have Physical Therapy.” x Occupational Therapy (OT): “OT would be very helpful for our seniors who are being looked after by their children. They could be doing things in their house that could help seniors remain independent. Now they have no one to teach them to do these things. That would be very, very important – teaching people how to look after their elderly.” x Podiatrist or Chiropodist: “We need someone who can help take care of feet” … “People here are confined to their homes so this [foot care] is something that is badly needed.” x Education: “We want information around fall prevention and a response system in the event of a fall.” x Grief counseling or a Bereavement Support Program: “Presently a specialist from St. John’s comes once a year but that is not enough.”

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x Chemo therapy at the Walter Templeman Health Centre: “That’s a big thing for us people that are going through it and have to go to St. John’s in the winter. It’s really difficult.” x Meals on Wheels: “That would be super, except that you are not going to get the seniors to pay five dollars a meal. It all comes back to seniors having to give up their money.” x Improved medical equipment: “We need an x-ray table, like the ones in St. John’s, that is easy to get on and off.”

Summary of challenges x access to adequate banking services x social isolation x poverty x perceived incidence of senior abuse x education for families, professionals and the general public focused on identifying and eliminating senior abuse x low literacy levels x age and ability appropriate recreational facilities x access to education and coaching around chronic disease management and self care x a dedicated social worker for seniors x access to allied health professionals x education for the community and care givers around the health, wellness and prevention, care and enablement of seniors x education for seniors and families regarding available services and financial resources x concerns regarding the community's and health system's ability to meet the long-term care needs of an increasing number of ageing baby-boomers x appropriate and timely use of available homecare services x up to date personal medication lists

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Provide a polycom teleconference for these meetings so homebound seniors can listen in to the ‘live session’, ask questions, comment and take part in discussions. This technology builds on this population’s long-time familiarity with phone-in talk shows on the radio. Homecare: In collaboration with seniors, their families and health care professionals, carry out an in-depth homecare services needs assessment. Concordantly, work on establishing what the policies, protocols, criteria and accountability mechanisms are for seniors going into care or receiving homecare services. Through the education of the families and professionals, establish these as community norms. Nutritional Requirements: Provide Meals on Wheels through the hospital in collaboration with a volunteer population. Alternatively, investigate Meals on Wheels as a business venture. If seniors are unwilling or unable to pay for the service, the adult children may be interested in subscribing to the program. Medication Management: Offer medication management support as a value-added service to Wheels on Meals. For example, the volunteer who delivers the meals could say, “I have 15 minutes or so. While I am here lets have a visit and go over your medications. I’m going to restock your pill dispenser for the week, so you know what to take and when.” The volunteer could also review instructions for preparations for medical procedures, dietary restrictions and so on, with the senior. Medication Compliance: An option for seniors with low literacy levels is the custom medication packaging services offered by drugstores. This is a service whereby the individual’s drugs are prepared in blister packages according to when medications are to be taken. Seniors, as a group, might be able to avail themselves of this service locally and if not locally then approach Lawton’s Drugstore, which offers this service in St. John’s. Moreover, if the drugs are covered by the Newfoundland and Labrador Drug Prescription Program, make sure that the prescribing fee covers the dispensing of blister packs. Finally, ensure that every senior on Bell Island has an up-to-date and standardized medication list posted on their fridge. Financial Abuse: Have pension and other government cheques deposited automatically and provide the necessary education to allay seniors’ fears and concerns regarding electronic banking. Developing and packaging education on electronic banking for seniors in rural and remote areas could potentially be a commercial opportunity for the community. Banking: Lobby a bank or coop for ATMs that take deposits. Investigate the ‘no service fees’ options that President’s Choice has to offer seniors. Investigate the

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.5 SENIORS

possibility of Bell Island having a single employee BMO banking outlet like the ones seen in Sobey’s grocery stores in St. John’s. Communication: Use the proposed Bell Island Health and Well Being TV Channel to support public awareness about the different types of senior abuse (physical, psychological or emotional, and financial abuse or exploitation) and the province’s adult protection legislation. Endorse zero tolerance for senior abuse. Moreover, use the proposed Health and Well Being Channel to broadcast educational programs, which would increase the public’s understanding of ageing and how to enable and care for seniors. Use the proposed Health and Well Being Channel to provide content of interest to seniors, for example, bereavement, electronic banking for seniors, response systems in the event of a fall and so on. In support of the need for a Community Health and Well Being Television Channel, Statistics Canada reports that in 1994, seniors with low prose literacy (64%) are more likely than those with high literacy (50%) to watch two or more hours of television on a daily basis. Virtual Support Groups for Seniors: Provide 1–800 teleconference access to seniors, who want to participate in support groups, that connect them with other seniors around the province with the same interests and support needs. As in the case of working with adults who have addictions, over time this service could become Canada wide. Researching, developing and marketing this service could be a commercial opportunity for Bell Island. Virtual Support Groups for Care Givers: Provide the same 1–800 or online access to support groups for care givers and family members caring for seniors with special needs, for example, Alzheimer’s. Alternatively, provide access to a 1–800 teletriage service Community Outreach: Building on the warmth and inclusiveness of Bell Islanders, implement an ‘Extend a Hand’ community-wide program. The intent would be to encourage informal one-on-one relationships with seniors, whereby they are included in family activities and outings, for example, attending a child’s performance at the school, going to the grocery store and so on. A volunteer community-based telephone-network reassurance program would be another variation on community outreach. In other words, volunteers would call seniors on a designated day and time for a chat. Volunteers working with Seniors: Volunteer career placements are part of the high school curriculum. Suggest that the volunteer program focus on seniors in the community. Over time, the high school and its students would develop valuable social capital and expertise in senior support. The program would also

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

ensure that caring for seniors becomes a community norm. Allied Health Professionals: Increase the local availability of outpatient chronic care management and allied health professionals, to include but not be limited to: diabetic clinic, physiotherapy, occupational therapy, message therapy, foot clinic, and so on. Hospital Services: Continue to provide highly valued inpatient, palliative and long-term care on Bell Island. Health and Community Services: Assess and meet seniors’ needs for a dedicated social worker. Recreation: Have a sub-committee of seniors work with the community, an urban / rural planner, recreational therapist and other special interest groups, like youth and babies and preschoolers, to develop a recreational plan that meets these groups’ short, medium and long-term recreation goals. Personal Health Record: Seniors on Bell Island might benefit from an online Personal Health Record that has the capacity to be accessed by distant family members. The up-to-date medication list could be generated from the Personal Health Record.

Suggested Indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point for discussion. The wording of these indicators would be formalized in Phase Two of the Needs Assessment. The goal is to identify indicators that are truly meaningful for Bell Island’s seniors and their caregivers. 1.

Number of seniors living with family

Number of seniors using home care

Reported cases of senior neglect and or abuse

Number of seniors using custom blister packs for their medications

Number of seniors who have an up-to-date and standardized medication list posted on their fridge.

Number of seniors attending sessions hosted by the Seniors’ Resource Group.

Number of seniors using direct deposit for government cheques

Number of seniors who have regular contact with community volunteers

Number of seniors who exercise according to the governments suggested guidelines

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.5 SENIORS

10. Number of seniors using allied health professionals, provided they come to Bell Island 11. Number of seniors using Meals on Wheels, if the service becomes available 12. Number of seniors participating in 1-800 virtual support groups 13. Number of seniors taking part in a volunteer, community-based telephone network reassurance program 14. Number of seniors who have access to a social worker

Opportunities for further research These research topics relate directly to the material in this chapter. The intent of putting these topics forward, is to encourage undergraduate and graduate students to integrate research on Bell Island into their studies. Doing so will help establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Well Being Committee. 1.

Invest in a preliminary report on the potential impact of increasing numbers of seniors on the community and healthcare system over the next 10 – 15 years. In collaboration with families and professionals, carry out an in-depth homecare services needs assessment and establish what the policies, protocols, criteria and accountability mechanisms are for seniors going into care or receiving homecare services.

Investigate and evaluate the transportation needs of Bell Island’s elderly population and assess community interest in establishing a volunteer driver program.

Partner with the local drug store or Lawton’s Drugs, on a research project, to determine if custom pre-packaged medications increases medication compliance in a senior population with low literacy levels. Negotiate lower prescription costs or an alternative financial to-be-determined advantage for those seniors who agree to take part in the research project. Standardize an up-to-date medication list to be posted on the fridge. Design a fridge magnet that features Bell Island Emergency numbers, for example, the Health Centre ambulance and so on. The magnet could also feature the normal range for blood pressure, blood sugar, cholesterol and so on.

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References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. Alberta Center for Active Living. [online]. (April 2006). http://www.centre4activeliving.ca/ Alberta Council on Aging. [online]. (April 2006). http://www.seniorfriendly.ca/sf.htm Berkman, L.F. (1984). Assessing the physical health effects of social networks and social support. Annual Review of Public Health. 5:413 – 432. Berkman, L.F., Breslow, L. (1982). Health and ways of living: the Alameda county study. New York, Oxford University Press. Government of Newfoundland and Labrador Community Accounts Bell Island accounts. [online]. (April 2006). http://www.communityaccounts.ca/ CommunityAccounts/OnlineData/default.htm Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Justice Canada: seniors. [online]. (April 2006). http:// canada.justice.gc.ca/en/ps/fm/adultsfs.html Nova Scotia Department of Community Services. Fact sheet 7 elder abuse. [online]. (April 2006). http:// www.seniors.gov.ab.ca/services_resources/WEAA/ Fact7_WEAAD_E.pdf Podneiks, E. et al. (1990). National survey on abuse of the elderly in Canada: The Ryerson Study. Ontario, Ryerson Polytechnic Institute. Public Health Agency of Canada National Clearing House on Family Violence. Financial abuse of older adults. [online]. (April 2006). http://www.phac-aspc. gc.ca/ncfv-cnivf/familyviolence/html/agenegl_e.html Public Health Agency of Canada. National Clearing House on Family Violence. [online]. (April 2006). http://phac-aspc.gc.ca/ncfv-cnivf/familyviolence/ html/agecommuni_e.html Public Health Agency of Canada. Seniors. [online]. (April 2006). http://phac-aspc.gc.ca/seniors-aines/ pubs/new%20horizons/NH_fact8_e.htm Roberts, P. & Fawcett, G. Centre for International Statistics. At risk: a socio-economic analysis of health and literacy among seniors. [online]. (April 2006). http://www.statcan.ca/english/freepub/89F0104XIE/ high3.htm Seniors Resource Centre of Newfoundland and Labrador. [online]. (April 2006). http://www. seniorsresource.ca/

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6 | OUR ESPOUSED HEALTH AND WELL-BEING NEEDS / 6.5 SENIORS

Statistics Canada. (1999). A portrait of seniors in Canada, third edition. [online]. (April 2006). http:// www.statcan.ca/Daily/English/991001/d991001a. htm Swanson, S. (2001). Abuse and neglect of older adults: community awareness and response. [online].

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(April 2006). http://www.phac-aspc.gc.ca/ncfv-cnivf/ familyviolence/pdfs/agecommuni_e.pdf Third Age. [online]. (April 2006). http://thirdage.com Worrall, G., Knight, J. (2003). Short report: Care for people aged 75 and older. Canadian Family Physician. May, 49:623 – 5

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7 HEALTH SERVICES :

PROVISION AND UTILIZATION

Following is a profile of the health care delivery system on Bell Island. Data sources include: findings from the Bell Island Needs Assessment 2004 Telephone Survey; de-identified data from the St. John’s Health Care Corporation and Health and Community Services; and, data from interviews and focus groups. In the process of collecting and analyzing the 2004 Telephone Survey data, the Memorial University Health Research Unit identified a number of challenges and recommendations for Health Services referenced in this chapter.

final section presents the challenges faced by the staff and health professionals when delivering services and programs. As in preceding chapters, this chapter concludes with a summary of the challenges and suggestions for consideration on how to address those challenges. It also suggests health service indicators and opportunities for further research.

The majority of health care services on Bell Island are provided by: two fee-for-service physicians; a local pharmacy; the This chapter Health Care focuses on those Corporation of persons workSt. John’s (HCCSJ); ing within the and, Health and healthcare system, Community Servinamely providces St. John’s Reers, management gion. Please note and staff. Health that prior to the Services is one of completion of this the Twelve Deterreport, the Health minants of Health Care Corporaso this chapter tion and Health follows a slightly and Community different format Services amalgamfrom the precedated and were ing chapters. The renamed Eastern chapter is divided Health. Programs WABANA L ANDSC APE. PHOTO COURTESY OF DESMOND M C C ARTHY. into three sections. and services under The first section the auspices sets out the services and programs offered by the of HCCSJ operate out of the Dr. Walter Templeman Health Centre and Health and Community Services as Health Centre located in downtown Wabana. Health well as the known costs associated with those health and Community Services has staff offices in the Health services. The second section looks at how Bell Islanders Centre and in another government building on Bennett use those programs and services and the challenges Street, approximately five city blocks away from the around data acquisition and analysis. The third and Health Centre.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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Services provided by the Dr. Walter Templeman Health Centre The Health Centre provides inpatient long-term, acute, palliative and respite care for Bell Island’s residents. It also offers outpatient and emergency services. The Senior Medical Officer, assisted by an outpatient nurse, runs a fee-per-service outpatient clinic out of the Health Centre. The Health Centre is also affiliated with the Memorial University Medical School. As part of that relationship, the Senior Medical Officer preceptors third and fourth year medical students.

test results are available the same day however thyroid and cholesterol results may take a week. Emergency blood tests are done on Saturdays and Sundays. General x-rays are done with an outdated x-ray machine which has a number of limitations. For example, x-rays of the neck can only be done standing up. If the x-ray has to be read by a specialist in St. John’s, the results can take up to three weeks to come back to the Health Centre. Presently the Health Centre is not connected to the Health Science’s new online Picture Archiving and Communication System (PACS).

Information Systems Emergency services The Health Centre provides 24/7 emergency services. Clients are assessed by a triage nurse. The facility contains an examination room which is soon to be replaced by a functional trauma room. This $125,000 upgrade has recently been approved and a section of the Health Centre will be renovated for this purpose. The Centre provides pre-hospital care for emergency calls and transfers to another facility, typically the Health Sciences or St. Clare’s Hospital in St. John’s. A general practitioner is on site or can be called in within a very short period of time. Coverage on weekends and holidays is provided by locums and / or a nurse practitioner. Emergency pharmacy services, EKG and laboratory services are also provided. Three of the Health Centre’s nurses are certified in Advanced Cardiac Life Support.

Long-term, acute, palliative and respite care for inpatients The Health Centre has a total of 20 beds. There are 12 long-term care beds (level III), six acute care beds and one palliative suite. There is also one respite / convalescent bed.

Ambulatory / Outpatient service Ambulatory care or outpatients refers to services that do not require an overnight hospital stay. Available outpatient services on Bell Island include: physician visits; procedures and follow up on procedures with the physician or clinic nurse; rehabilitation; and chemotherapy administered by one of the three nurses who have chemo therapy training. The Health Centre also houses a private dental practice which operates one day a week.

Diagnostic Services Laboratory and X-ray The Dr. Walter Templeman Health Centre has the capacity to perform hematology, chemistry and urinalysis. It does not carry out coagulation or genetic tests. Blood is taken for immunology and histology and sent to the Health Sciences Centre to be processed. Most

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

By and large, data capture, management and storage at the Health Centre is paper based. Outpatient / Ambulatory information is recorded manually when a person registers for a service. Client data, for example, the patient’s name, treatment and MCP number is faxed each day to Health Records in St. John’s where it is entered into an electronic data base by Health Records employees. These data can then be accessed by the Health Centre’s staff through MEDITECH. Inpatient ‘discharge data’ are faxed once a month to St. Clare’s where they are classified according to ICD-10 codes and entered into the Health Care Corporation of St. John’s Health Information System. Laboratory and x-ray data remain paper-based and are stored on site at the Health Centre.

Utilization of Dr. Walter Templeman Health Centre facility for groups and / or programs A number of groups have used the Dr. Walter Templeman Health Centre over the years. Groups include: Weight Watchers; Alcoholics Anonymous; and the Seniors Advisory Group. The Health Centre boardroom also provides a meeting place for the Health Advisory Group and is used as a Teleconferencing Educational Site. Teleconferencing is used by interns, nurses, paramedics and the doctor for educational purposes.

Volunteer Services As in many small communities across Newfoundland and Labrador, the Health Centre has a number of volunteers dedicated to improving the stay of patients in the Health Centre. These volunteers contribute by feeding the patients in long-term care, organizing the Christmas Party and maintaining the gift shop.

Dr. Walter Templeman Health Centre Staffing Profile 2003 – 2004 As indicated in Table 3 (see following page), there are 42 employees (41.5 FTE) at the Dr. Walter Templeman Health Centre.

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Table 3: Dr. Walter Templeman Health Centre Employees, 2003 – 2004

Dr. Walter Templeman Health Centre Employees, 2003 – 2004 T YPE OF ROLE

# OF POSITIONS

Management / Support

3 permanent full-time

Nursing

15 permanent full-time 4 temporary staff

Laboratory / x-ray

2 permanent full-time

Facilities

2 permanent full-time

Housekeeping

4 permanent full-time

Dietary

3 permanent full-time

Dietary / Housekeeping

2 permanent full-time 3 temporary staff

Stores

1 permanent part-time

Ward Clerk

1 permanent part-time

Medical Records Technician

1 permanent full-time

Admitting Clerk

1 permanent full-time

Services provided by Health and Community Services Health and Community Services professionals and staff have offices in the Health Centre and at their Bennett Street premises. To reiterate, the two Community Health Nurses and the half time Mental Health / Addictions Counselor work out of the Health Centre. The remaining Health and Community Services staff work from the second floor of the Bennett Street site. There are two child social workers and a third social worker who is responsible for community supports. These professionals are supported by a clerk typist and point three of a clerical support position. Like the Health Centre, Health and Community Services has a relationship with Memorial University in St. John’s and as a result accepts student placements from the School of Social Work. Health and Community Services works with individuals, families, the schools and the community generally. Clients self-refer or are referred by other healthcare providers. The most frequent users are parents through the public health programs or families already on the Children and Youth Family Services case load.

Human Resources Labour and Employment Health and Community Services works closely with Human Resources, Labour and Employment (HRLE) located on the ground floor of the Bennett Street building. HRLE’s three client services officers are responsible for providing income support and the promotion of programs supporting the employment of youth and adults.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Child Care Services The Community Health Nurses work with Head Start, the local early childhood education and care centre, to ensure that a licensed child care service is accessible and meets government standards for a safe, nurturing and stimulating child care environment. Head Start is located in the Wabana Complex, which the community also refers to as the old Trade School.

Community Living and Supportive Services This Health and Community Services program provides support, financial services and case management for individuals of all ages with physical and / or developmental disabilities. The program also covers those affected by deinstitutionalization under the ‘Right Future Project’. Finally, the program serves those individuals requiring protection under the ‘Neglected Adults Act’. The program’s focus is on supporting individuals, families, caregivers and promoting independence, community inclusion, safety and well-being.

Mental Health and Addictions This program is responsible for the coordination and delivery of mental health and addictions counseling, prevention, and education services on Bell Island. Services provided include advocacy, early intervention, prevention and treatment. The counselor’s tasks vary according to the population’s needs. Counseling is based on any number of mental health issues, such as: parenting, depression, grief counseling and / or relationship issues. Individual, couple or family counseling is also available. The counselor provides prevention and education linkages between services and other community agencies. Bell Island’s half time mental health and addictions counselor works closely with the Community Health Nurses on a number of preventative programs and services focused on youth and new families.

Health Protection The local Mental Health Counselor is also the primary contact for family violence. There isn’t a woman’s shelter on the island. After four in the afternoon the nurses at the Health Centre become the front-line. Kirby House in St. John’s is the closest resource.

Continuing Care The Community Health Nurses provide curative, preventative, rehabilitation, maintenance and palliative services. Services focus on assisting individuals to live independently at home with the intent of preventing, delaying or substituting for long-term care or acute care alternatives. A coordinated approach is used to

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7 | HEALTH SERVICES: PROVISION AND UTILIZATION

x Hearing tests for school age children

help clients and their families access a variety of facility and community based services, including long-term care.

x Travel immunization

The Community Health Nurses provide the following services all of which are based on ongoing client assessment and individual need:

x Distribution of health promotion literature (sexually transmitted diseases, healthy eating, healthy heart and so on)

x B12 shots x Wound management and foot care x Blood pressure and weight monitoring x Diabetes patient counseling x Monitoring medication compliance x Special Assistance x Palliative Care x Discharge Planning x Personal Care Home x Delegation of function, for example dressing changes x Other nursing related care, for example: port-acath flush; blood work; suture or staple removal; and colostomy care The Community Health Nurses also carry out assessments of persons 65 years and older to determine the need for home support and the best long-term placement care options. Choices include long-term care in the Health Centre, a Nursing Home or a Personal Care Home. The Community Health Nurses are responsible for the Personal Care Home on the island which falls under the jurisdiction of Health and Community Services.

Health Promotion This Community Health and Services program is responsible for the development, implementation, and evaluation of a wide range of population health and community development programs, including health promotion and illness prevention initiatives. As noted in previous chapters, the Community Health Nurses are responsible for x Prenatal education x Postnatal care for six weeks (home visits and assessments of the infants) x Child Health Clinics (immunizations for two to 18 months old infants) x Baby Group (support group for breastfeeding and bottle feeding mothers and infants) x Healthy Baby Club (pre-natal group for low socioeconomic income mothers) x Nobody’s Perfect parenting education program x Preschool health

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

x TB skin testing for employment or travel purposes

The Community Health Nurses also provide outreach to the schools and community groups, for example, the Boys’ and Girls’ Club.

Speech Language Specialist and Behavioral Management Specialists The Department of Education provides the schools with a Speech Language Therapist and a Behaviour Management Specialist on an as-needed basis. Health and Community Services also has a Behavioral Management Specialist who comes to Bell Island once a week to work with families in their homes or at the Bennett Street office. The Health and Community Services Behavioral / Child Management Specialist’s caseload is limited to six clients. The specialist works with parents whose children have behavioural issues or with parents whose children are developmentally delayed.

Child Youth and Family Services The Child Social Workers, who also refer to themselves as child protection workers, are focused on meeting the needs of children, youth and families. Child and Family Services promote the safety, well-being and protection of children as well as supporting the capacity of families and communities to provide for the well-being of children. The child social workers are responsible for child protection, foster care, adoption and youth services covering individuals 16 – 18 years old. The comTable 4: Health and Community Services Employees, 2003 – 2004

Health and Community Services Employees, 2003 – 2004 T YPE OF ROLE

# OF POSITIONS

Community Health Nurses

2 permanent full-time

Child Social Workers

2 permanent full-time

Community Support and Youth Corrections Social Worker

1 permanent full-time

Mental Health Addictions Counselor

1 permanent part-time

Cerk Typist III Clerical Support Behaviour Management Specialist

1 permanent full-time 1 permanent part-time once a week

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7 | HEALTH SERVICES: PROVISION AND UTILIZATION

munity supports social worker is responsible for youth corrections which includes extrajudicial sanctions. These Youth and Family Services Programs are in place to ensure that young people have the support they require to make a healthy transition into adulthood.

Health and Community Services Staffing Profile 2003 – 2004 As noted in Table 4, there are 8 employees (6.8 FTE) in Health and Community Services.

Cost of health services on Bell Island 2003 – 2004 The 2004 budget for the Dr. Walter Templeman Health Centre was $2,131,825.00. The 2004 budget for Health and Community Services was $426,389. The combined budget is $2,558,214. In addition, in 2004, there were 32 emergency transfers from the Health Centre requiring the ferry to run after hours. At a cost of $790 per trip this amounts to $25,280. This expense was covered by Works, Services and Transportation. In 2004 there was one night time air transfer. The cost of a night transfer using a Cougar helicopter is approximately $2,700 including ambulance transfer from landing site to hospital. There were no daytime air transfers in 2004 which normally cost approximately $800. Again, this amount includes the cost of transferring the patient by ambulance from the landing site to the hospital. In 2004, emergency air transportation was covered by Government Air services. The total expenditures for Bell Island beneficiaries under the provincial Senior Citizen’s Drug Subsidy Program in the 2003 – 2004 fiscal year was $441,321.36 or ($861.96 / capita). This amount was slightly less than the provincial per capita cost during the same period: $882.44. The total expenditures for Bell Island beneficiaries under the Provincial Income Support Drug Program in the 2003 – 2004 fiscal year was $828,234.63 or ($768.31 / capita). Again, this amount is less than the provincial per capita cost of $848.08 during the 2003 calendar year (comparable figures for the 2003 – 2004 fiscal year were not available). According to the Department of Health and Community Services Medical Care Plan (MCP), a total of 4,473 MCP beneficiaries whose address included one of Bell Island’s three postal codes, made 17,634 visits to feefor-service General Practitioners in 2004 at a cost of $497,299. Because of poor data quality, MCP officials were unable to determine what percentage of these visits took place on Bell Island. These same 4,473 MCP beneficiaries also made 1,996 visits to fee-for service physicians who were not General Practitioners at the cost of $116,499. MCP was not able to calculate the

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

number or the cost of those same beneficiaries’ visits to salaried physicians. Please note that although Bell Island had a population of 3,078 in 2001, MCP noted that there were still 4,473 persons giving their address as Bell Island in 2004. This cohort of 1,395 virtual Bell Islanders increases the difficulty of accurately attributing and forecasting healthcare costs. It also makes it difficult to design the best complement of services and programs. According to the Newfoundland Centre for Health Information (NLCHI), they have assigned every person in the province with a unique patient identifier (UPI). However, the UPI is not always linked with a postal address. It appears that presently, we have systems in place to help determine where practitioners are providing services but we do not have systems in place that can track which citizens are receiving services and where they are receiving services. Finally, no estimate was possible for health related out-of-pocket expenses incurred by Bell Island’s 3,078 citizens.

How Bell Islanders use Health Services We will now look at how Bell Islanders avail themselves of these health services and programs. Data for this section were derived from three sources: 1. inpatient and outpatient data provided by the Health Care Corporation of St. John’s; 2. data provided by the Dr. Walter Templeman Health Centre on Bell Island; and, 3. data derived from the Bell Island Needs Assessment 2004 Telephone Survey. There were challenges collecting and analyzing the data.

Need for valid and timely health data Independent of a health institution’s size or location, data collection and data husbandry are the life blood of any Health Care System. The overriding challenge to building a verifiable picture of how Bell Islanders use the health care system was the lack of clean data. To elaborate, because of the complex and highly variable way data are captured across health institutions, to include the Dr. Walter Templeman Health Centre on Bell Island, the Health Sciences Centre St. John’s, the Janeway Children’s Hospital and St. Clare’s Hospital St. John’s, it was impossible to build a comprehensive and wholly accurate picture. For example, there were issues around recording the number of admissions on Bell Island. In 2004, the Health Centre on Bell Island initially recorded 1,394 admissions on Bell Island (3.82 admissions per day) whereas data from the Health Care Corporation St. John’s, which enters the data faxed to them by the

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7 | HEALTH SERVICES: PROVISION AND UTILIZATION

Table 5: Usage of programs and services at the Dr. Walter Templeman Health Centre in 2003 – 2004

Usage of programs and services at the Dr. Walter Templeman Health Centre in 2003 – 2004 SERVICE

Physician Services

USAGE

Physician Clinic, Monday – Friday Physician / Nurse Practitioner after hours Off site private Physicians Clinic

24-Hour Emergency Services

Technical services

8,200 patient visits 2,100 patient visits 10,000 patient visits 127 ambulance transfers to city hospitals (30 requiring ferry during its off hours) 88 emergency ambulance calls on Bell Island 1 air ambulance

Laboratory Service X-Ray Service EKG Ambulatory care Acute Care Palliative Care Respite Care

5,572 visits 958 visits 512 visits 2,089 treatments 124 admissions 21 7

Long-term Care

12 beds (60% occupancy)

Visiting Dentist

1,250 (approximate visits / year)

Community Health Nurses Continuing Care

200 Child Health Clinic visits / year 6 Healthy / Baby Group visits / week 25 Preschool Health Checks / year 1 – 15 visits / week

Mental Health Addictions Counseling

n/a : transitioning to new software

Social Workers: Child, Youth and Family Services Community Youth Corrections

n/a: transitioning to new software

Health Centre on Bell Island, only reported 207 admissions for 2004, (one admission, approximately every two days). Subsequent requests to the Health Centre brought the number of Health Centre Admissions in at 124 which would be more in keeping with the numbers seen on Grand Manan but it still doesn’t explain the disparity between the Health Centre (124) and HCCSJ (207) accounts. There were also problems around recording reasons for outpatient visits on and off Bell Island. First, a patient’s visit was not always recorded. From 2001 – 2004 there were a total of 40,671 outpatient visits spread among the various HCCSJ sites. Unfortunately, the reason for those visits was recorded for only 7,177 visits, or less than 20% of all cases. Therefore, we caution that the data presented in this section is meant to give an idea of the kinds of reasons that were recorded for outpatients, but should not be taken as a representation of all outpatient visits for the people of Bell Island. Second, even when the reason for a visit was recorded, it was done as free text meaning; whoever entered the

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information did so in a manner that made sense to him or her. The lack of standardized data entry resulted in a single reason for a visit being entered in multiple ways. For example, ‘x-ray’ was recorded 30 different ways, to include ‘ray’, ‘rays’, ‘xray’, ‘x-ray’ and so on. Recording a patient’s age was also a free text entry. The lack of standardized recording practices for recording age meant that it was recorded several different ways. Unfortunately, data analysis software can only complete calculations on an age variable when it is entered consistently. Re-entering such data would have been more time consuming than resources allowed. Consequently, these data were not analyzed and as a result, we have no indication of potential trends in outpatient visits among the different age groups. More will be said about the challenges surrounding data acquisition, management and analysis as we proceed through this chapter. Following are three profiles of how Bell Islanders use health services.

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First Profile: How Bell Islanders used the health services and programs available on Bell Island in 2003 – 2004 These data demonstrate how Bell Islanders use the health services and programs offered on Bell Island. Data for this profile were provided by management at the Dr. Walter Templeman Health Centre. Table 5 sets out the services and programs provided by the Health Care Corporation of St. John’s and Health and Community Services St. John’s at the Bennett Street and Dr. Walter Templeman Health Centre sites. Based on data provided by the Health Centre, each Bell Islander made approximately seven visits to his / her family doctor from 2003 – 2004. According to The Office of Primary Health Care, the provincial per capita rate of visits to his / her family doctor from 2003 – 2004 was three to four visits annually. Roughly 10% of these office visits on Bell Island were made after hours. A number of groups have used the Dr. Walter Templeman Health Centre over the years. As in any small rural community, membership in these groups waxes and wanes. The groups and their aggregate memberships were reported as follows (Table 6).

Table 6: Groups that have used the Dr. Walter Templeman Health Centre

Groups that have used the Dr. Walter Templeman Health Centre GROUP IDENTIFIC ATION

Weight Watchers

# OF USERS / USAGE TIMELINE

10 / 5 yrs

Alcoholics Anonymous

15 / 5 yrs

Seniors Advisory / Resource Group

10 to 15 / N/A yrs

Kick the Nic Program

N/A

Health Advisory Group

10 / 7 yrs

Teleconference Educational Site

100 / 5 yrs

Volunteer Services

20 / 5 yrs

Second Profile: How Bell Islanders use Inpatient and Outpatient Services on and off the island 2001 – 2004 These data illustrate how Bell Islanders use their local Health Centre, the Health Sciences Centre, St. Clare’s Hospital and the Janeway Children’ Hospital. In other words, we look at how Bell Islanders are using inpatient and outpatient services on Bell Island and in St. John’s. These data were provided by the Health Care Corporation of St. John’s.

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Be forewarned that there were a number of challenges around the data. For example, the numbers for outpatient services are not wholly representative. Information on the use of outpatient services was obtained from the HCCSJ which records the number of outpatient visits electronically. However, in 2001 outpatient visits at the Dr. Walter Templeman Health Centre were not faxed to the HCCSJ to be recorded electronically and therefore virtually no visits were listed in the HCCSJ outpatient database covering Bell Island that year. In 2002, the Health Centre was included in the database of outpatient visits within the HCCSJ but it was not possible to get the data for years 2002 – 2004 only. The rationale for the HCCSJ aggregating the data from 2001 – 2004 was to protect the identity of the patients. Recognizing this shortcoming, it is still important to look at a comparative analysis because these tentative findings point to surprising trends. Note that while emergency services fall under the broad category of outpatient services they will be examined on their own as the continued provision of emergency services at the Dr. Walter Templeman Health Centre on Bell Island is of particular interest. For the purposes of this comparison, all visits to treatment sites in the capital city were combined. Data presented in the following table affords a very preliminary look at how Bell Islanders use services available to them on the island and in St. John’s. From 2001 – 2004 the HCCSJ recorded 702 inpatient admissions at the Walter J. Templeman Health Centre. During the same time period 866 additional inpatient stays were recorded for Bell Islanders at various treatment sites within St. John’s where specialty services and the tertiary care facility are located. There were large differences in the number of outpatient treatments received by Bell Islanders on and off Bell Island. From 2001 – 2004 15,356 outpatients

Table 7: Utilization of inpatient and out-patient services on and off Bell Island 2001 – 2004

Utilization of services TREATMENT SITE T YPE OF SERVICE

Inpatient Services

BELL ISL AND (2001 - 2004)

702

ST. JOHN’S (2001 - 2004)

866

Outpatient Services

15,356*

25,314

Emergency Services

1,273*

1,539

* Only outpatient visits from the years 2002 – 2004 were available for the Health Centre on Bell Island.

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visits occurred on Bell Island whereas 25,314 took place in the city. Outpatient visits in St. John’s would have included, for example, specialist visits, dermatologist visits, diabetic teaching programs, dialysis, dental services, physiotherapy services, radiology services, cardiology clinic, stress testing, audiology, and so on. To reiterate, the 15,356 outpatient visits occurring on Bell Island do not take into account the missing data for 2001 but even so the total number of out-patient visits in St. John’s was unexpected. Requiring further investigation is the number of emergency treatments received by Bell Islanders at the Walter J. Templeman Health Centre and in the city. It appears that from 2001 – 2004 there were 1,273 emergency visits recorded on Bell Island and 1,539 emergency visits recorded in St. John’s. This is a very preliminary look at available outpatient data. As mentioned earlier in the chapter, the outpatient data were compromised in several respects. For this reason, an in-depth study would be required to fully understand the story around where Bell Islanders are receiving their emergency services.

Espoused barriers to Health Services Data from the 2004 Telephone Survey indicated several barriers to obtaining health services. Twenty five percent of the residents surveyed felt that long wait times at the hospital clinic presented them with a problem in obtaining necessary health services. In addition, 20% of those surveyed felt that the lack of specialty services, specialists and staff on the island also presented a barrier to effective use of health services. Moreover, 23% of residents also felt that the difficulty and cost of transportation (by ferry) to St. John’s for health services was problematic. Wait times for specialty consultants and services in St. John’s only serve to intensify the barriers to Health Services. The wait times for outpatient consults in St. John’s were reported by Health Centre staff as follows: 10 months for mental health; six months for specialists; eight months for an MRI and four to five months for an ultrasound.

Third Profile: Inpatient diagnosis trends among Bell Islanders ages zero through 79 from 2001 – 2004 In the third profile, we examine the most common diagnoses of Bell Islanders admitted to hospital from 2001 – 2004. This overview of inpatient diagnosis, by the different age groups, across hospital sites, provide us with an indication of the most common health problems faced by Bell Islanders leading to hospitalization. These data were provided by the Health Care Corporation of St. John’s.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

The following analysis points out trends in the most common diagnosis categories among Bell Island inpatients from ages zero through 79 for the years 2001 – 2004. We looked at 16 age groups comprised of five year increments. Only the most notable trends in diagnosis are discussed. For a complete overview of the three most common reasons for inpatient admission please see the table appended to this report. Perhaps the most striking trend in diagnosis is the overwhelming presence of ‘diseases of the digestive system’. This particular diagnosis category, which includes conditions such as cirrhosis of the liver, inflammatory bowel diseases, hepatitis, gastrointestinal cancer, ulcers, gallstones and so on, ranked in the top three most common diagnosis categories for all but one of the 16 age groups examined (70 – 74). Given this striking trend, further research is warranted to help uncover why Bell Islanders are experiencing these types of problems. For example, are diseases of the digestive system a marker for poor nutrition, alcohol consumption, obesity, and / or questionable water quality? ‘Diseases of the genitourinary system’, involving conditions such as renal disease, calculus of the kidney, and urinary tract infections was also among the top three most common diagnosis categories of half of the age groups studied. Specifically, it appeared in the top three diagnoses for those in groups between the ages 30 – 54 and again for those in groups between the ages 65 – 79. ‘Diseases of the circulatory system’, involving conditions such as heart disease, angina, and stroke, was also a relatively common diagnosis category for those receiving inpatient care. This was particularly true for those in age groups between the years 60 – 79. ‘Diseases of the circulatory system’ was the most common diagnosis category for all age groups within this age range. ‘Diseases of the circulatory system’ also ranked as the second most common diagnosis for persons aged 50 – 54. The final, and to be expected diagnostic trend involved the pregnancy, childbirth, and puerperium diagnosis category. This was the most common reason for hospitalization recorded for the four age categories between the ages 15 – 34 years.

Stories from the inside: management, staff and providers identify the challenges To reiterate, this chapter focuses on the healthcare delivery challenges from the perspective of persons working inside the system, namely the practitioners, management and front-line staff.

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Isolation makes the case for maintaining existing health services on Bell Island Even though Bell Island is only a 20 minute ferry ride or 2.8 miles from Portugal Cove, when the wind comes up or the ice moves in, Bell Island’s roughly 3,000 residents can be as isolated as any rural and remote community in Newfoundland. Because of the isolation, healthcare professionals working on the island are unwavering in their support and commitment to the ongoing existence of the Health Community Center. “The hospital is very, very valuable to this island simply because of the fact that we are an island and therefore we are isolated at times particularly in the wintertime. You run into strong winds, tides, the ferry can’t run and you can’t get a patient off of Bell Island and therefore we need the hospital to treat them to the best of our ability. Also you can get ice in the tickle [water mass between Bell Island and Portugal Cove] in the wintertime and the boat can’t load and if it’s dark you would have a job to get a helicopter because you need to get a large helicopter and they usually have to come in from Gander so there it is a long wait. Also an ice breaker takes a long time to get here. That is a big problem so there the hospital is very, very important in this situation.” According to the Bell Island Ferry Users Committee, in 2004 approximately five percent (or 365 trips) of the total number of crossings were cancelled due to weather and / or ferry maintenance.

In rough weather even emergency services are challenged In the event of an emergency sometimes even the backup helicopter service is challenged. “The small helicopters come from St. John’s if they haven’t got fog. They run in the daytime and they would be here between half an hour and an hour by the time they make the arrangements and get over. If we have an emergency here and the ferry is running it is quicker sending them by ferry than by helicopter. But if it is foggy or at night time the small helicopter cannot run because they run by vision only. The larger ones can fly at night time. The larger ones take four to six hours by the time you get it all arranged. The big ones fly in pretty near all conditions. The little ones don’t. If it is windy here in the daytime, enough to stop the ferries, usually the little ones can’t fly.”

sionals who commute to the island for work. In 2004 the strike by the province’s public service employees (which included ferry workers), resulted in additional challenges for staff who commute to work on Bell Island. “There are no accommodations for us when we are stuck!” … “We had to sleep on the office floor for a month during the strike so those things are hard.”

Being rural and remote results in ongoing recruitment and retention issues Across the board there are short- and long-term staffing issues. These shortages result in “a gap in services because there are no monies in the system to replace professionals on leave or between hires.” Moreover, there is “the perception that the high turnover rate results in lack of continuity of care for mental health and addiction and extended periods of time when no services are available.” It was suggested that “The case load is not picked up because Bell Island is an island, not in town – involvement [getting to and from Bell Island] requires an additional layer of effort.” There have been months at a time when Bell Island has been without a mental health counselor. As a result, “Mental health shows up in outpatients and results in additional load for the physician.” The bottom line is, “If staff are off, there is no one to absorb the caseload.”

Staff shortages impact the workload and possibly health outcomes Both the Health Centre and Health and Community services have experienced staff shortages. Some of these shortages impact populations that the community has identified as having unmet needs, “There is supposed to be a social worker for those over 65 years old but there is not – we do all that.” Health professionals recognize that there is a real need for expertise with seniors, “It’s just that there is no one to cover issues like abuse and elder abuse. We come across cases but we do not know exactly what the procedures are.” Sometimes professionals have to backfill for duties that are outside their scope of practice, “We also do long-term care assessments for placements for over 65 year olds here in the hospital. That is not in our job description but we are told to do it.”

Management in St. John’s is a world away Health Services staff face commuter challenges The lack of a 24/7 ferry service, frequent ferry breakdowns and resulting reduced schedule of crossings make it particularly challenging for staff and profes-

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Being in the same health region doesn’t mean that employees experience the same working conditions and case load. The working conditions in an isolated community require a different relationship between workers and their management. Management has

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to have a better understanding of employees’ work environment. “So to keep a Public Health Nurse over here they really have to change how things are done. We need more management support, incentives, a bed to sleep in if we are stuck over here. Mind you, the hospital has been great. They make us feel really welcome.” As feedback from Health and Community Services staff indicated, “Many decisions are made by the Health Care Corporation of St. John’s Region with St. John’s proper in mind only. Rural communities are different in many ways. How can a manager understand how a community works if they never go to that community? In four and a half years a manager has never been here.” Workers also pointed out that it is very easy to get caught up in the issues and priorities of the Health Sciences and Janeway Hospital but that their day-to-day working reality delivering programs and services on Bell Island is very different.

Challenges around recruiting practitioners in the short- and long-term In 2004 the two physicians on Bell Island had an on call schedule of one night in four. Sometimes the Health Centre is challenged to provide relief for its physicians, “Sometimes we’re challenged to get locums to come over, especially during the holidays.” Presently, remuneration is compensation for the inconvenience and isolation. “Fee-for-service docs are more interested in coming over than salaried physicians.” The point has been made that looking ahead, Bell Island may not be able to support two fee-for-service physicians. “There is not going to be enough population to warrant two doctors on fee-for-service. They are going to have to pay them a salary which I doubt the government will. Or they are going to start hiring nurse practitioners which is a good thing.”

Nurse Practitioners are part of the plan moving forward There is a Nurse Practitioner that comes over to Bell Island on the weekends. Ironically, it costs more for the Nurse Practitioner than it does for a physician locum. There are two reasons for this, the first being that “The Nurse Practitioner has to be paid overtime for her work on Bell Island because she is doing overtime when she comes over and covers on the weekends.” Second, that “Nurse Practitioners are covered under the Newfoundland & Labrador Nurses Union therefore payment for Nurse Practitioners comes out of the Community Health Centre’s budget whereas the Department of Health covers the cost of a locum.” The Health Care Corporation of St. John’s did advertise for a full time Nurse Practitioner but “There were no

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

takers.” To address the cost issue, management has recommended that the Nurse Practitioner position become part of the Walter Templeman’s salaried nurses’ budget. Note that subsequent to the field work for this study, a Nurse Practitioner was hired by the Health Centre on Bell Island to focus on health promotion.

Support staff experience front-line challenges A number of front-line challenges are reported by support staff. Those include: ‘keeping track of patients’ information when they see specialists in town’; ‘booking specialist appointments later in the day to avoid conflicting ferry usage with commuters’ and ‘managing the community’s expectations around access’: “When they call the doctor they want to come the same day. The doctor is really booked. There is only so much the doctor can do.” On occasion, there are the long waiting-room times to see the physician at the Health Centre. Patients may not understand that the practitioner is also covering emergencies which, should they arise, result in long waiting-room times. There was also the suggestion that double booking occurred from time to time to offset patients’ canceling their appointments.

Staffing and running the x-ray machine There have been many complaints about the x-ray machine by staff and patients. The original x-ray machine from 1965 died in 1995. The Medical Director then asked for a new machine. Instead, Bell Island received a reconditioned machine as part of a larger Health Sciences order. Staff deemed this second hand machine inferior to the original machine. Presently the x-ray machine is ten years old and presents a host of problems not the least of which are frequent breakdowns. Moreover, “When the single staff person takes holidays, time off or training courses, there is no one to man the machine and patients have to go to town.” Also, there are “limitations as to the kind of x-rays that can be taken: chests have to be done standing up. Sinuses are very difficult and neck injuries not possible because the patient has to stand up.” Although the intent was to cross-train the laboratory technician on the x-ray machine it was determined that the x-ray machine was too old for new staff to train on. Times when there isn’t an x-ray technician available and an individual requires an emergency x-ray, they are sent over to the Health Sciences by ambulance. If the individual is on social assistance the cost is covered. If the patient is not receiving social assistance then the individual is charged $150. Staff pointed out that if that same person lived in St. John’s they wouldn’t have to pay for the ambulance. Some staff feel that this constitutes a two-tiered healthcare system.

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Why isn’t Bell Island plugged into PACS? Earlier in 2005, “The Picture Archiving and Communication System (PACS) was installed throughout the corporation but it was deemed too expensive to be installed on Bell Island. The estimated $100,000 price tag for this web-based system was not budgeted for” but the need for an online service integrated with the imaging departments in St. John’s continues. Under the current system, namely sending patients into St. Clare’s for x-rays, means that “It is difficult to get a verbal report and the written report can take two – three weeks.” Staff have asked that x-ray results be entered into MEDITECH in an attempt to shorten that three week period.

Is there a way of benefiting from what’s going on in town without patients having to go to St. John’s? Workers observe that the challenges and cost of getting on and off the island has a direct impact on how Bell Islanders utilize healthcare services on and off the island. “I think the geographical disconnection would be probably one of the biggest challenges. You hear a lot of people say that they would love to go to this and that but are unable to make it because of the transportation piece. In an ideal world it would be wonderful to have the same resources available to the people that there are in St. John’s.” Health professionals identified resources in St. John’s from which their clients and patients could benefit. “The Health Care Corporation offers a wonderful seminar on grief but it is very difficult for people to get over there because of transportation issues and so on.” Moreover, “Connections with support groups would certainly be a useful.” For example, “The grief session is offered once a month two different times, two different sessions. It could be possible to bring a speaker here. There is a lack of support groups, no Alcohol Anonymous, no Narcotics Anonymous, no Gambling Anonymous. AA has been in and out, it has and hasn’t worked. Those are the essential resources. We try to encourage people to go to them [in St. John’s] but most of them are in the evening and you have to get there [St. John’s] and back.” Staff also noted that the cost of traveling to St. John’s and back was a deterrent for some clients.

Providers are committed to providing addiction services but are challenged to reach their audience The half-time addictions / mental health counselor started the job just a short time before this research took place. Prior to the counselor’s arrival, the position had been vacant for six months. The consensus

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

amongst Bell Island’s health professionals is that “The mental health piece is known but the addictions piece may not be as widely known. Health and Community Services provides mental health counseling on anything from parenting, to depression to mental illness, any type of mental health problem, couples relationship issues, and it goes on and on. Referrals come from the physicians but we get a lot of self-referrals – so the word has gotten out there that the Mental Health Counselor is here.” However, health professionals are challenged to have ready contact with those struggling with addictions. For example gambling, “If we can get some of that ‘gamblers awareness information’ out there and there was a big enough group of people that eventually it came together it could be a good support. There are spaces on Bell Island where you could run a gambling group. Group sessions for drinkers or gamblers are extremely useful. We can leave pamphlets in the room so people can take them home.” However, at the same time, health professionals on the island point out, “Group attendance on Bell Island has been notorious for being very difficult and I think that goes back to the rural community, the privacy.” For example, while gambling and alcohol addictions were listed in the top ten community problems, the findings from the telephone survey also indicate that the addictions specialist was used by less than 1% of the households on the island. There is a consensus about the challenge and the potential solution. “There is a taboo around addiction and mental health. It is important to get that mental health out there. It is about breaking down the barriers in the small communities.”

There is a recognized need for public and private allied health professionals Without exception healthcare workers and providers on Bell Island reiterated the need for a physiotherapist, occupational therapist, dietitian, chiropodist / podiatrist, optometrist, chiropractor and message therapist. In addition to serving the chronic care needs of inpatients, particularly those in long-term care, the presence of these professionals would act as a catalyst for addressing at risk behaviours and encouraging health promotion. Providers and staff cited the Health Centre’s ability to accommodate allied health professionals visiting Bell Island as they do for the dentist, “We have the space to set up some kind of physio room, it is not like we have to build a building.” The Health Centre is recognized as a real asset. “If they close the chronic care facility, I would like to see them keep it open for some other form of usage – somebody on staff for diabetic training, diabetic teaching, someone to do foot care, someone to

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do chemo therapy for cancer” … “Utilize the space for something else. Don’t just close it down.” The need for an optometrist was also cited. “He used to come up to a year ago. Maybe we could advertise for another one and offer a free room.” One often expressed observation by staff was patients’ reluctance to go to St. John’s for treatment. “We need more resources on Bell Island, we have very little resources. If somebody needs physiotherapy or occupational therapy or needs anything additional and they have to go to St Johns, they don’t have the income to go, so they don’t go, they go without.” As one of the staff so aptly put it, “It would be nice to have one Primary Health Care setting and have everyone in the one building.” Staff also observed that these allied health professionals would also be instrumental in keeping seniors independent in their homes and enjoying optimal quality of life. Finally, nothing breeds success like success. One staff member pointed out that if Bell Island were to host the proposed allied health professionals on an ongoing itinerant basis that would make the prospect of both coming here to work and moving to Bell Island that much more attractive, “If we had the facilities here for our physiotherapist and our dietitian and our optician it would sure be an attraction for people to come here.”

Continue to build staff capacity through crosstraining and extending professional skill-sets At the time of the study, Health Centre staff and management were all engaged in upgrading or broadening their skill-sets. For example, the laboratory technician was training to take x-rays, one nurse had just started training as a nurse practitioner, the Health Centre administrator was hard at work on his Masters, and other nurses were training in Advanced Cardiac Life Support. Nurses also expressed strong interest in cross-training with allied health professions. “They could set up a physio program in the community Health Centre. The physio could work with the nurses, do assessments and treatments plans and the nurses could do the treatment under the direction of the physio. There are limits to what the nurses are trained to do but even walkers would make a difference.”

Extant professionals are too strapped for time to take on Health Promotion Providers are quick to point out that the need for health promotion is huge but they lack the time and resources in order to effect change. “Health promotion is desperately needed on the island but it is the last thing done. If you have someone who comes home from the hospital, continuing care takes priority. Health promotion has always been put on the back burner and that is the problem.” Reasons why

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

this situation persists are understandable, “You cannot do any health promotion and education if you have too much paperwork or too many clients to see or if you don’t get any relief coverage.” Workers cited the need for early intervention, “We need to get up to the school and educate the youth. That is something that needs to be done but it’s very difficult to do that when you don’t have the time to go. We are at our full capacity over here.” Staff were also keen to take health promotion out into the community and suggested doing blood pressure checks in the grocery store, the ferry line up and the post office. Staff and professionals also had a grounded understanding of what was required over the long-term, “We need to say, okay, maybe our focus should now be on this generation. In this decade we need to probably focus on promotion and keeping people healthy longer so that the health system is providing people with the education and the assistance needed to stay healthy longer and more productive. Doing so will decrease the cost to the health care system for chronic conditions.”

Educating the public is paramount Without exception, health care professionals cited the need to educate the citizenry regarding health promotion and, as importantly, chronic care. “People are not educated on why it is dangerous to smoke. A lot of people just don’t know. I think if we had the opportunity to educate, on the whole, they would probably be able to make better life decisions regarding smoking and diet. Your everyday activity is a problem, nutrition and alcohol abuse.” Caregivers also zeroed in on the “need to educate the public on diabetes, cholesterol and so on, so people are aware of the problem and how they can fix it.” Developing effective strategies and the right staff complement for implementing education programs was just as important. “Patients need to be able to go to some place and get the education and assistance to deal with these issues rather than the physician’s clinic because the physician does not have the time nor do the two community health nurses and one mental health counselor.” Education around self-care is also an issue. “Education is the biggest thing. A lot of them will say. I went to see the doctor today and they gave me this pill, what’s it for?” There appears to be a real need for a coordinated program of health promotion and education around chronic conditions. “We need far more teaching: diabetes, blood pressure, B12 deficiency, and types of food to eat. Education is also a big part of continuing care. We have to educate people regarding health problems, what to do, what not to do.” Moreover there need to be improved communication channels, “There is no

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focus on pamphlets or information that folks can take home.” Presently two of the nurses in the Health Centre have special training in diabetic education but they do not have the time to initiate an education program. In addition to education around healthy behaviours and chronic disease management, Health and Community Services staff cited the need for parenting classes and teaching adults how to care for the elderly.

How we use the Health Centre could be reworked The drop in number of long-term care residents has given rise to speculation that the long-term care wing might be closed. If this is to occur there are questions as to what would happen to that space. “The hospital here, I don’t know if it is fully utilized to its capacity. Realistically we have this big facility and I don’t know if it is utilized effectively.” Others envision a real use for that space, “We have the facility, the services and the resources but need to rearrange the pieces so people have a place to come to get health promotion services.” Other professionals caution that the number of seniors on Bell Island is actually increasing and that in the not-too-distant future the need for long-term care may actually increase. In fact, between the time that the field work ended and the writing of the report began, long-term care at the Health Centre was once again operating at full capacity with a waiting list.

How do we know what we’re dealing with? Without an electronic health record or formal chart review at the Health Centre, it is impossible to ascertain the exact number of cases, for example, of Type II diabetes or bowel cancer. Following are the informed impressions of those in the health care delivery system. “The major health problems here are cardiovascular disease and obesity. No, smoking is number one. Poor nutrition is number two. Those two contribute to cardiac problems. We also see lots of ulcers related to diabetes and cardiac disease.” Professionals also state that they see a lot of cancer, “We see a lot of breast cancer for women, and lung cancer for men. Gastric and bowel also stand out.” Some of these claims are substantiated by the trends noted earlier in the most common diagnosis categories among those admitted for inpatient treatment. This is particularly true for comments regarding diseases of the digestive system which was in the top three ‘most common diagnosis’ categories for all but one of the age groups examined. ‘Diseases of the circulatory system’ was also a common diagnosis category, particularly for those aged 60 – 79 years. It was particularly difficult to get a consensus on whether or not mental health was an issue on the island. As previously noted,

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the challenges around data acquisition and husbandry make it very difficult to ascertain even rough numbers which would inform the choice and design of health services. Health and Community Services also reports being information challenged, “Statistics are gathered manually to ensure an equitable distribution of staff resources for Child, Youth, Family Services, Continuing Care and Community Living and Supportive Services through the region including Bell Island, but hopes for reports that could be generated through the (Client Referral and Management System) CRMS have not materialized.” Specific challenges include: absence of postal codes and absence of a specific code for Bell Island as a ‘district’, lack of historical data, and so on. In addition, the data that is collected by Health and Community Services regarding caseloads is compromised due to lack of standardized recording practices. For example, if services provided to a client were completed and the client program was not closed before the end of a reporting period, the case will still be counted. This means that the number of clients that appear to be receiving treatment in any given month may actually be inflated. On the other hand, the numbers reported each month refer only to cases that are active at the end of the reporting period. New client cases that are opened and closed during the month-long reporting period may not be counted. This means that the number of clients receiving any of the services provided by Health and Community Services may actually be higher than reported.

Communication with the outside world continues to be a challenge Management at the Dr. Walter Templeman Health Centre has a recent high speed connection with St. John’s which enables better communication with remote administrative colleagues in St. John’s, but clinical staff and the Health and Community Services offices at the Health Centre have dial up only. Dialup supports the required applications but communication is frustratingly slow. By way of comparison, the Bennett Street Health and Community Services office has been converted to terminal services which are connected to the terminal services server farm at Cordage Place via a broadband link to the Provincial Government’s network. This system is fully funded by the Department of Human Resources, Labour and Employment which is located on the ground floor of the Bennett Street site. To summarize: challenges to a seamless interface between the technology and practice include: slow connections; sharing computers; time-consuming electronic charting; and, double documentation in continuing care due to the many forms to complete by

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hand. Health and Community Services staff also cited the need for additional training if the Client Referral and Management System software is to be used for continuing care.

Identification, diagnosis and treatment of atrisk behaviours requires a big picture Both the community and health professionals recognize that gambling is a problem, “Gambling, I see it as a significant issue, especially the VLTs and all the social ills that come with that. It is quite problematic on Bell Island.” Presently, health professionals offer a very grounded, one-on-one approach to gambling and its associated problems. “Basically the only thing we can do right now is give people an assessment. So you sit down and find out about their abuse. How much as they using, now much are they spending, how often do they go, is the family at home and are they missing out on their activities. So how does gambling impact their life? And that is how we would determine if it is a problem or if it is not a problem for a person.” However, there isn’t the means for arriving at even a rough estimate of how many persons in the community have a problem with gambling. Health professionals have been able to get a better sense of need throughout the community in relation to alcohol abuse, “I usually see it in the younger adults and the middle age adults, you just see it throughout even the elderly up to the 70s and 80s – not so much in adolescence – mostly in the middle 20s and up.” Findings from this study relating to the prevalence of at risk behaviours including gambling and alcohol point to the need for a comprehensive plan to address at risk behaviours to include: obesity, smoking, gambling, drinking, and street and prescription drugs.

Communication between agencies and between the agencies and the community need strengthening At the time of this study, the Health Care Corporation of St. John’s provided clinical services while its partner, Health and Community Services, provided public health and social services. Workers within the sister systems consistently cited the need for better communication between these two systems and between the system and the community. “Agencies can help by working together. One group doesn’t know what the other group is doing.” Because workers of these two agencies are not all working out of the same location, staff thought that it must be hard too for the community to understand how the two systems and resulting programs fit together. “In terms of the Healthcare Corporation, they have to let people know using memos or the newsletter that we

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

(Community Health Nurses and Addiction Services) are part of the same system. We are in the same building. It is just a matter of making those connections more available.” Others suggested that everyone would benefit if they were all under the same roof. “It would be nice to have one primary care setting and have everything in one building. There are two Health and Community Services sites here on Bell Island. If we were all under one roof we could work as a team – be on the same wavelength.” Providers and staff also stressed that communication between the Health Centre, Health and Community Services and the public had to be improved. “I know many people that I work with who look around and say, we don’t have that here or we don’t have that service here, I can’t get that. But you can, you can access things. Just making people aware that there are services, that there are supports is really needed. I think that the coordination of services and tapping into the resources that are here is important.”

Primary Health Care Reform Staff and providers are aware and supportive of Primary Health Care Reform (PHCR), “I think Bell Island is on the cutting edge. It could develop a true primary health care centre with all the resources in a place.” Professionals working on the island recognize the need for the network and core teams that PHCR proposes. Networks and core teams would include a customized combination of the pharmacy, physician, nurse practitioner, social worker, community health nurse, physiotherapist, occupational therapist, mental health / addictions counselor, registered nurse, licensed practical nurse, speech language pathologist, dentist, social worker, and, an audiologist. Bell Island’s professionals also cite the need to add a dietitian, optometrist, podiatrist and massage therapist to the ‘basket of services’. Regardless of the final composition of the network or core team, the challenges inherent in getting back and forth to Bell Island remain a significant stumbling block to implementing the model on Bell Island. In principal, the health services and programs on Bell are aligned with the four pillars of Primary Health Care, namely, information, teams, access and healthy living. The challenge will be to successfully modify and deploy the PHCR model in this rural and remote island community.

We need a plan and public campaign to eradicate family violence, abuse and neglect As noted in previous chapters, expertise on how to deal with elder abuse is limited. Professionals cited the need for education as to what constitutes abuse. It was also pointed out that more resource materials and an effective means of distribution were needed for

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victims, abusers and professionals. In the event that someone does present with abuse, “usually referrals would be made out of Mental Health Addiction Counselor who deals with abuse and alcohol abuse and physical abuse, all sorts of abuse.” However, after 4:00 pm, abuse becomes an out-patient issue. In the words of one staff member, “You are on Bell Island. Where are you going to go in the middle of the night? Once he beats you up where are you going to go? You are going to come to the hospital but then you are going back home. Hospital staff are powerless because we don’t have the resources to offer the person. Once resources are offered, for example a shelter, how do they get there? How do they contact the social worker at five in the morning? It’s a huge decision. There is no place readily available. You have to wait until the next morning to decide. We can’t keep you in the hospital.” There have been times on Bell Island when there have been up to six months between mental health / addictions workers so “Those people that required services [as a result of family violence], or who were probably in a crisis situation went without for those six months. There would be the St. John’s crisis number that they could call.”

Sometimes the island has limited ambulance coverage There are two privately owned ambulances on the island that are subsidized by the government. One has specialized up-to-date equipment, the other does not. “At night, the boat ties up on the Portugal cove side and returns to Bell Island if needed for an emergency. It takes approximately an hour for a patient to be stabilized at the Walter Templeman Health Centre before they are ready to go on the ferry so having the boat tied up on the other side works

out. However, if the ambulance comes over at two in the morning with an emergency the ferry will not take the ambulance back to Bell Island unless the doctor is traveling with the ambulance.” The ambulance owner argues that the ferry should wait the hour that it takes for him to return to the ferry terminal after dropping someone off at the Health Sciences or St. Clare’s. “The ferry workers argue that there is a six hour consecutive rest period under transport Canada and taking the ambulance back could compromise their ability to run the service and as a result, in the morning you would have 400 people now trying to get to work.” The ambulance owner is concerned that there would be no response if there was a big accident or two accidents occurred at one time on Bell Island.

Summary of challenges x services and programs that encompass the entire health care delivery continuum, to include acute interventions, chronic disease management, primary care, prevention, health and wellness x effective strategies for reaching out and meeting the health and well-being need of Bell Island’s citizenry living below the low income cut off (LICO) x systematic identification, diagnosis and treatment of persons at risk due to gambling, alcoholism, smoking, obesity, street and or prescription drugs x support and overnight accommodation for staff detained on Bell Island due to unfavorable weather and ferry conditions x allied health professionals to complement and leverage the health and well-being efforts of the existing primary health care team x management in St. John's to better understand the context and inherent challenges of working on Bell Island x securing backfill staffing for physicians, laboratory and x-ray technicians, community health nurses, child social workers, mental health / addictions counselor, and so on x need for specialized staff, for example: nurse practitioners; adult and senior social workers; mental health addictions personnel; health education and prevention specialists, and so on x ubiquitous access to broadband on Bell Island supporting PACS, telehealth and community-based television x revisit the vision, philosophy, use and layout of the Health Centre and Bennett Street sites

FERRY CROSSING THE TICKLE. PHOTO COURTESY OF REGINALD DURDLE.

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

x an overarching and integrated plan to address domestic abuse and family violence

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x improved communication between the Health Care Corporation and Health and Community Services and between these institutions and the community x standardized data acquisition and access resulting in valid and relevant analysis of health data x meaningful indicators for new and extant health services and programs x allocation of staff time and resources to address education needs around prevention, health and wellness and chronic disease management x detailed protocols to address challenges faced by support staff and patients when arranging for and following up on medical treatment and appointments in St. John’s and surrounding environs x leverage potential relationships with: Memorial University; College of the North Atlantic; MUN Office of e-Health; the provincial Office of Primary Health Care Reform; MUN Medical School Primary Care Research Institute; and, the province’s Centre for Applied Health Research

Suggestions for consideration These suggestions may be of interest to individuals, the community and the health care system working together or independently. Although many of these suggestions were raised at the community level they are revisited here because the focus in this chapter is on the health system. Big picture: Findings from this study point to the need for a comprehensive plan that takes into account the Twelve Determinants of Health and spans the entire health-care delivery continuum to include acute interventions, chronic disease management, prevention, health and wellness. If Primary Health Care Reform is the chosen vehicle, Bell Island will want to be well represented on the Primary Health Care Advisory Committee that covers Bell Island. High unemployment, in combination with the data on at risk behaviours, notably smoking, gambling, obesity, inactivity and alcohol consumption, street and prescription drugs, underscores that band-aid solutions are no longer tenable. Health and well-being on Bell Island requires an overarching plan that engages the health system, Bell Island’s citizens and their community. Phase Two of the Needs Assessment is the next step in determining that big picture. Follow up to Phase One and Two would be to ensure that the Primary Health Care Advisory Committee is fully aware of the scope and findings from the Needs Assessment and that Bell Island is represented on the Primary Health Care Advisory Committee. Reaching out: This study failed in its efforts to satisfactorily canvass and engage the health and

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well-being needs of the working poor and persons on social assistance. Moving forward with Phase II of the Needs Assessment, it is imperative that these parties become proactively engaged in the process. One strategy would be for all participants to team up with and involve someone living below the LICO throughout Phase II. Also ensure that representatives from those on social assistance and the working poor become active members of the Bell Island Health and Wellness Committee. Emergency accommodation and support for stranded staff: Which perception is more likely to increase professional staff and allied health workers interest in providing services and programs on Bell Island: “They’ll take really good care of you” or “You’ll probably get stranded.” To reiterate the proposal set out in the chapter on community, employers and the community should have a backup plan covering food and accommodation for employees detained on the island due to bad weather or ferry breakdown. Knowing that there is a community volunteer plan that comes into play in the event of an emergency sends a clear message to health professionals that it is an organized and caring community that values the services that commuting health professionals bring to the island. Knowing that this option is in place might also address some of the issues that impede backfilling staff vacancies. The plan could be as simple as a rota of citizens willing to volunteer meals and / or overnight accommodation. Basket of services: Staff and health professionals espouse the need for allied health professionals and social workers with the expertise needed to work with adults and seniors. Once the community has worked their way through Phase II, the best complement of health professionals and how to support and integrate same will become clearer. Regardless, this is an ongoing process because the community’s needs are changing. For example, each year the number of seniors is increasing. Progress towards the best possible complement of staff will be both incremental and ongoing. Information and communication technologies (ICT): The higher the bandwidth and the more ubiquitous the technology, the more options Bell Island will have to support telemedicine, telehealth and tele-education. Moreover, broadband supports cable television and, as noted in previous chapters, a community owned and operated Bell Island Health and Well-Being television channel may be the most effective population health promotion tool. The concept is a community television channel featuring content generated by Bell Islanders for Bell Islanders. The Bell Island Health and Well-being channel would play in private homes,

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in the waiting-rooms, in the post office, and on the ferry. There could be interviews with a nutritionist in the grocery store highlighting healthy foods and food preparation. There could be a laboratory technician making a ‘reality’ home visit with a senior who is housebound. There could be a course on parenting or how to care for the elderly. Children could generate adds advocating dental hygiene and youth could focus on staying tobacco free or upcoming employment opportunities. Eastern Health is well positioned to collaborate with the community on lobbying government to get the very best information and communication infrastructure possible. Reworking where health services and programs are provided: Bell Island’s health professionals repeatedly cited the advantages of housing all clinical and Health Centre and Health and Community Services staff under one roof. The rationale for doing so is increased opportunities for collaboration and improved communication and coordination of programs and services. Institute monthly ‘Grand Rounds’ and have persons from the Health Centre and Health and Community Services take turns presenting cases. In addition to having all of Eastern Health’s staff under one roof is it also possible to provide space for itinerant allied health professionals, such as a physiotherapist, occupational therapist, optometrist, dietitian, massage therapist and so on? As in the case of the dentist, the health centre would be accommodating a combination of private and public health services. The decision of where to consolidate services might not be clear cut as the building on Barrett Street appears to have ample room and be in good condition. Domestic abuse and family violence: What programs and services does the government provide to meet the needs of victims of domestic abuse and family violence in rural and remote communities across the province? Moreover, how can Bell Island avail itself of these programs and services? If nothing exists, can Bell Island become a living laboratory for the research, development and deployment of such programs and services? Domestic abuse and family violence as well as senior abuse and neglect must be acknowledged by individuals, the health system and the community, but the health system has to take the lead when it comes to public education and provision of services and programs for adults and families. The community is presently working with the children in the schools, The Boys’ and Girls’ Club and through programs offered by the RCMP. What additional programs and services can the health system provide to better address domestic abuse, neglect and family violence? Valid and timely data: The Health Centre and Health and Community Services are challenged when it comes

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to standardized data collection, storage and analysis. Yet reliable data are fundamental to determining need and the requisite programs, services and resource allocation required to meet those needs. Eastern Health is an organization in transition. Moreover, it will be many years before the province has a functional and fully integrated electronic health record. In the interim, and as part of Phase II, Health Services could identify key data streams to track manually, for example, the number and type of diabetics being treated on Bell Island, cause of death, number of diagnosed asthmatics and so on. As time goes on it will also become increasingly important for Bell Island to standardize outpatient emergency data. Collecting valid and timely data will require the assistance of a statistician / data analyst with a solid understanding of database design. Commuting patients: Strike a working group involving support staff, representatives from the ferry users committee and a cross-section of patients and caregivers experienced in commuting for medical treatment. Working together, identify the full spectrum of challenges from booking a workable appointment time to getting priority passage over and back on the ferry. Identify solutions. Produce pamphlets and posters that set out the principles and guidelines for commuting patients. Distribute the information directly to patients who have to commute for medical reasons. Isolation: Bell Island has everything required to become a living / learning laboratory for rural and remote primary health care. It has a dynamic and forward looking administration and staff, an engaged community and a discrete population which allows changes in health status to be measured. Bell Island could become a showcase for primary health care reform as well as a pilot site for the research, development and deployment of information and communication technologies supporting the full health care delivery spectrum. Chronic disease management and health and well-being on Bell Island have the potential to become an industry.

Suggested indicators Indicators allow individuals, the community and the health care system to establish a baseline and monitor change over time. The following list is a starting point for discussion. The wording of these indicators would be formalized in Phase Two if the Needs Assessment. The end goal is to identify indicators that are truly meaningful for Bell Island’s health care system. 1.

Number of programs or interventions across the health care delivery spectrum to include: acute interventions; chronic disease management; primary care; prevention; and, health and wellness

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Percentage of population living below the LICO participating in health and well-being initiatives on the island

Percentage of Eastern Health under one roof

Type and number of visits by allied health professionals

Number of client visits per clinic to an allied health professional

programs and services offered by allied health professionals such as physiotherapists, occupational therapists, dietitians, message therapists and so on, to a rural and remote island community like Bell Island? 3.

What is the best combination of public and private programs and services to be provided by allied health professionals in rural and remote communities?

Percentage of the population that avails itself of resources supporting victims and families of domestic violence and / or abuse and / or neglect

Determine the barriers and motivators for allied health professionals to provide a combination of public and private services on Bell Island.

Number of patients and staff using the internet for telehealth, telemedicine and / or tele-education

What baseline data should rural and remote health centers collect? How should data collection be standardized?

Total number of programming hours on the community TV channel devoted to health and well-being related topics

Why is Diseases of the Digestive Tract one of the top three ICD-10 reasons for hospital admissions across all admission sites and all age groups?

Number of meals and overnight accommodations used by Eastern Health staff or allied health professionals detained on the island due to extenuating circumstances

What programs and services does the province provide to meet the needs of victims of domestic abuse and family violence? Are these resources accessible by rural and remote communities across the province? What ICT infrastructure would help victims and their families avail themselves of these resources?

How does the model for Primary Health Care Reform map onto health care delivery on an island that is in essence rural and remote and as such doesn’t meet the criteria for a stand-alone network?

Are current dental services meeting the needs of Bell Islanders? If not, what are the barriers and motivators to optimal dental hygiene and dental care for Bell Islanders and how can these barriers be addressed and the motivators leveraged?

10. Number of staff days not backfilled 11. Number of per capita physician visits 12. Number of per capita dentist visits 13. Membership numbers for Alcohol Anonymous, Gambling Anonymous, Weight Watchers, and so on 14. Total and per capita cost of the Senior and Provincial Income Support Drug Programs 15. Number of Grand Rounds

Topics for further research These research topics relate directly to the material in this chapter. The intent of putting these topics forward is to encourage undergraduate and graduate students to integrate this research on Bell Island into their studies. Doing so will help establish Bell Island as a living / learning laboratory under the auspices of the Bell Island Health and Well-Being Committee. 1.

What information and communication technologies (ICT) could be researched, developed and deployed to support the health and well-being of individuals living in rural and remote communities? What information and communication technologies could support the virtual delivery of

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10. Conduct an in-depth comparative analysis of Bell Islander’s use of emergency services on and off Bell Island. 11. Determine the per capita cost of health and wellbeing services on Bell Island compared with per capita costs in St. John’s. 12. Determine why the per capita cost of the Provincial Income Support Drug Program is so high. 13. Determine why recipients of the Provincial Income Support Drug Program appear to require, on average, 26 prescriptions annually. Does this pose a health risk to the recipients and broader community?

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References and resources References listed here include those mentioned in the chapter, as well as suggestions for further reading. Bell Island Ferry Users Committee. [online]. (April 2006). http://www.bellisland.net/ferry_users/index. htm Bell Island health and well-being needs assessment community profile. (2004). Dr. Walter Templeman Health Centre. (2003 – 2004). Overview of services. Government of Newfoundland and Labrador Office of Primary Care.

Government of Newfoundland and Labrador. Provincial government reports. [online]. (April 2006). http://www.gov.nf.ca/publicat/pub.htm Health Canada. Violence and abuse. [online]. (April 2006). http://www.hc-sc.gc.ca/hl-vs/violence/index_ e.html Health Care Corporation of St. John’s. (2001 – 2004). Inpatient and outpatient admission data. Public Health Agency of Canada. National clearing house on family violence. [online]. (April 2006). http://www.phac-aspc.gc.ca/ncfv-cnivf/ familyviolence/

Government of Newfoundland and Labrador Provincial Drug Program. [online]. (April 2006). http://www.health.gov.nl.ca/health/guide/other.html

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8 DAR E TO COMPAR E BELL ISLAND AND GR AND M ANAN

The Bell Island Health and Wellness Committee asked that Bell Island be compared with a sister community. Committee members chose the island of Grand Manan located in the Bay of Fundy, New Brunswick. Bell Island and Grand Manan have approximately the same size population, but strikingly different community profiles. As in previous chapters, the comparison between the two islands is structured around the Twelve Determinants of Health. The purpose of the comparison between Bell Island and Grand Manan is twofold. First, it helps put the data presented in previous chapters in a context. In other words, what we think of as the norm for our community might not be the norm for another community. Second, the comparison provides us with a window on what we might want to change and the possible impact that those changes could have on our community. After reflecting briefly on the comparative data for each determinant, questions are posed to assist discussion.

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Statistics Canada divides Bell Island into two regions, the town of Wabana (population: 2,679) and the outlying regions of Freshwater and Lance Cove (population: 399). There are also two regions for the comparison community, Grand Manan (population: 2,577) and White Head (population: 180). The community of White Head is a 30 minute boat ride from Grand Manan. For the purposes of the following analysis, data from each of the communities of Bell Island as well as the Grand Manan and White Head regions will be combined. Data for this comparison came primarily from the 2001 Census and from the Newfoundland and Labrador Community Accounts website. Less formal data came from the Grand Manan and White Head website (http://www. grandmanannb.com) and from the Bell Island Website (http:// www.bellisland.net). Health data were provided by the Health Care Corporation of St. Johnâ&#x20AC;&#x2122;s, Newfoundland (HCCSJ), the Grand Manan Hospital and the Atlantic Health Sciences Corporation (AHSC), in Saint John, New Brunswick.

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Table 8: Dare to compare: Bell Island and Grand Manan. A comparison using the twelve determinants of health.

Background Information

INDIC ATOR

Duration of ferry ride

Size of island

BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

20 minutes

www.bellisland. net

1.5 hours

www. grandmanannb. com

9 km x 3.5 km

www.bellisland. net

28.4 km x 12.4 km

www. grandmanannb. com

3,078

2001 Census

2,798

2001 Census

- 14.5 %

2001 Census

+ 2.85 %

2001 Census

Population Change in population 1996 – 2001 # of babies and preschoolers, ages 0 – 4

115

2001 Census

150

2001 Census

# of children, ages 5 – 14

435

2001 Census

405

2001 Census

# of teens, ages 15 – 19

285

2001 Census

180

2001 Census

# of adults, ages 20 – 39

645

2001 Census

800

2001 Census

# of adults, ages 40 – 64

1130

2001 Census

805

2001 Census

# of seniors, ages 65 +

460

2001 Census

475

2001 Census

76 yrs

Community Accounts, 2005

78 yrs

Grand Manan Hospital, 2006

Life expectancy 2004

Observations x There are more babies, preschoolers and young adults on Grand Manan. x There are more adults aged 40 – 64 on Bell Island. x Bell Island and Grand Manan have approximately the same number of seniors.

Questions 1. What keeps young families on Grand Manan? 2. Why do people live longer on Grand Manan? 3. Why is Bell Island’s population decreasing and Grand Manan’s population increasing?

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first determinant

Income and social status

INDIC ATOR

BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

44.4% (2001)*

Community Accounts, 2005

4.6% (2004)*

Family and Community Services, Government of New Brunswick, 2006

Median household income

$17,500

2001 Census

$40,921

2001 Census

Median family income for lone-parent families

$17,000

2001 Census

$35,696

2001 Census

Total income composition: employment income, 2000

41.5%

2001 Census

67.5%

2001 Census

Total income composition: government transfers, 2000

43.5%

Community Accounts, 2005

22.6%

2001 Census

Total income composition: other, 2000

13%

2001 Census

9.8%

2001 Census

Per cent of the population living below the Low Income Cut Off, 2001

51.4%

2001 Census

5.6%

2001 Census

Percentage of the population on social assistance *It was not possible to determine the proportion of the population on the two islands for corresponding years.

Observations x Almost twice as much government money is transferred to Bell Island as is transferred to Grand Manan. x The median household income, on Grand Manan, is more than twice the median household income on Bell Island. x There are ten times as many people living below the Low Income Cut Off on Bell Island, as there are on Grand Manan (1,582:158).

Questions 1. Why is there a more equitable distribution of wealth on Grand Manan? 2. Why are there so few persons on Grand Manan on social assistance? 3. Why is it that, in comparison with Bell Island, Grand Manan appears to be a thriving community?

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second determinant

Social support networks BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Total lone-parent families

250

2001 Census

115

2001 Census

Number of lone parent families with more than three children

2001 Census

Single seniors living with families

2001 Census

Single seniors living with others

2001 Census

Single seniors living alone

155

2001 Census

140

2001 Census

Total couple seniors

175

2001 Census

315

2001 Census

195*

2001 Census

165*

2001 Census

225

2001 Census

INDIC ATOR

Total single seniors *This figure includes only those seniors living in private dwellings and excludes those who are institutionalized.

Number of children 25 years or older living at home

Observations x Bell Island has more than twice as many lone-parent families as Grand Manan. x Bell Island also has more then four and a half times as many lone-parent families with more than three children. x Bell Island has two and a half times the number of seniors living with family members as Grand Manan. x Bell Island has over three and a half times as many children 25 years and older living at home. x There are approximately twice the number of senior couples living on Grand Manan.

Questions 1. Why are family structures on Bell Island so different from those on Grand Manan? 2. How do these family structures on Bell Island impact the health and well-being of family members and the community as a whole? 3. Why does Bell Island have more lone-parent families and older children living at home than Grand Manan? 4. Couples are said to live longer than single persons. Is this one of the reasons why people live longer on Grand Manan?

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third determinant

Education and literacy BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

GR AND MANAN AND WHITE HEAD

DATA SOURCE

NB Community College, extension courses on demand

www. grandmanannb. com

Adult literacy program

No, but there are persons on Bell Island who are trained in the Laubach Method

Community Profile, 2004

Community Academic Services Program (CASP): offered spring, fall, winter; during the day and evenings; part-time and full-time; 31 – 40 weeks in length

Provincial Partners in Literacy web site

Tele education in 2004

At the Dr. Walter Templeman Health Centre for medical education

Dr. Walter Templeman Health Centre overview of services

NB Teleeducation

www. grandmanannb. com

MananNet: internet access and computer training located in the high school

www. grandmanannb. com

45:68

St. Michael’s Regional High School and Dept of Education, Government of Newfoundland and Labrador

27:30

Grand Manan Community School and Dept of Education, Government of New Brunswick

Total population ages 15 – 24 attending school full time

285

2001 Census

125

2001 Census

Total population ages 15 – 24 attending school part time

2001 Census

Total population aged 20+ with less than a grade 9 education

635

2001 Census

325

2001 Census

Total population aged 20+ with less than a high school certificate

475

2001 Census

485

2001 Census

Total population aged 20+ with a trades school certificate

520

2001 Census

Total population aged 20+ with a college certificate or diploma

135

2001 Census

275

2001 Census

Total population aged 20+ with a university certificate, diploma, or degree

135

2001 Census

170

2001 Census

INDIC ATOR

Adult education in 2004

Online adult education in 2004

Ratio of the number of students who graduated from high school in 2005 to the total number of students who entered the 9th grade in 2001*

DATA SOURCE

None

*Note that the number of high school graduates does not factor in students lost due to emigration between 2001 and 2005.

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Observations x Of the grade nine class of 2001, 34% did not graduate from St. Michael’s Regional High School in 2005; whereas, only 10% of 2001’s grade nine class did not go on to graduate from Grand Manan Community School. x Almost twice as many persons on Bell Island have less than a grade 9 education. Twenty-eight percent of Bell Island’s population has less than a grade nine level education compared with only 16% of the population in Grand Manan. x Roughly equivalent proportions of adults on Bell Island and Grand Manan have less than a high school certificate: 21% and 23% respectively. x More than eight and a half times as many persons on Bell Island have trade school certificates. Twenty-three percent of Bell Island’s population has trade school certificates compared with only 3% of the population in Grand Manan. x Twice as many persons on Grand Manan have college degrees. Thirteen percent of Grand Manan’s population are college educated, compared with only 6% of the population on Bell Island. x Slightly more individuals on Grand Manan have obtained a university certificate, diploma, or degree. Eight percent of the population in Grand Manan is university educated compared with 6% on Bell Island.

Questions 1. How does Grand Manan ensure that their youth graduate from high school? 2. What face-to-face and online adult education programs could Bell Island put in place? 3. How can Bell Island build on its successful history of trade school graduates? 4. What happened to the Bell Island youth who did not graduate from high school? 5. What population is attending school part time on Grand Manan and what programs does Grand Manan have in place, that allow students to attend school part time? 6. What steps did Grand Manan take to get the Community Academic Services Program (CASP) in adult literacy in place? Is it successful? Does the Province of Newfoundland and Labrador have a comparable program?

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fourth determinant

Employment and working conditions BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Manufacturing, healthcare, education, transportation

Bell Island Community Profile, 2004

Fishing, manufacturing, tourism, aquaculture

www. grandmanannb. com

21.2%

Community Accounts, 2005

55.7%

2001 Census

41%

Community Accounts, 2005

17.9%

2001 Census

Number of persons engaged in manufacturing, 2000

2001 Census

170

2001 Census

Number of persons engaged in the tourism industry, Number of tourists and Total tourist dollars spent

n/a

INDIC ATOR

Main industries

Labour force employment rate, 2000 Labour force unemployment rate, 2000

Total $ produced by the fishing industry in 2004

Landed Value: $3,964

Total $ produced by the fishing processing industry in 2004

Production Value: $1,400,000 (Sea urchins are trucked to Bell Island to be processed)

Total number of persons employed in the fishing industry, 2000

30 Fishers 45 Fish processing workers

n/a

Fisheries and Oceans Canada, 2006

Landed Value: $18,474,000* *Does not include aquaculture

Fisheries and Oceans Canada, 2006

Production Value: n/a Plant Owner, 2006

Community Accounts, 2005

(These data are not collected by DFO, the Canadian Food Inspection Agency, the GM Fisherman’s Association, or the provincial government)

469 Registered Fishers part and full time Fish Processing Workers unknown

Fisheries and Oceans Canada, 2006

Observations x Over two and a half times as many persons are employed on Grand Manan, as are employed on Bell Island. x Industries on Bell Island appear to be related to the infrastructure required to run Bell Island, whereas employment on Grand Manan relates to primary and secondary industries. x Although the tourism industry is perceived to be a key component of both islands’ economies, no data are collected on the number of tourists that visit either of these islands, the dollars that tourists contribute to the local economy, or the number of persons employed in the tourist industry. x It is equally difficult to readily ascertain data on the fishing industry on the two island, to include seafood caught and processed and the number of workers involved in this sector.

Questions 1. Has the long ferry ride to Grand Manan resulted in the island being more self sufficient? Does Grand Manan’s relative isolation actually increase the island’s economic opportunities and the government’s commitment to infrastructure? 2. Does the fact that Grand Manan’s adult population is better educated, translate into an ability to create and sustain employment? 3. What different kinds of tourism-related employment opportunities are available on Grand Manan, that are not available on Bell Island?

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fifth determinant

Social environments BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Volunteer fire department, 2004

Yes

Bell Island Community Profile, 2004

Yes

www. grandmanannb. com

Volunteer school lunch and or breakfast program, 2004

Yes

Bell Island Community Profile, 2004

Yes

Grand Manan Community School

Average monthly number of families served by the food bank, 2004

200

Bell Island Community Profile, 2004

Grand Manan Village Council

Community Seniors Program, 2004

Yes

Bell Island Community Profile, 2004

Grand Manan Village Council

Bell Island Health and Wellness Committee

Elementary Home & School; Also a High School Parent School Committee which meets with the principal once a month

Grand Manan Community School

Grand Manan Village Council

INDIC ATOR

Active School Councils (formerly Parent Teacher Associations), 2004

Women’s shelter, 2004 Participation rate in most recent municipal elections

Participation rate in 2003 provincial elections

Elementary school only

51% – 2005

Wabana Town Council

55% – 2004

Grand Manan Village Council

70% – 2003

Elections Newfoundland and Labrador www.elections. gov.nl.ca

58% – 2003

Chief Electoral Officer www.gov.nb.ca/ elections

Unable to determine

Participation rate in 2004 federal election

Churches in 2004

48%

Elections Canada www.elections.ca

Bell Island Community Profile, 2004

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Note: Only a portion of the voting results were available as there were no polling stations accessible to the people of Grand Mannan on elections day. The only available results were those from advanced polls which indicated that 134 votes were cast by the people of Grand Manan.

Elections Canada www.elections.ca

www. grandmanannb. com

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INDIC ATOR

Services clubs and associations in 2004

BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

Kiwanis Knights of Columbus St. Anne’s Guild Masonic Royal Canadian Legion Ladies Auxiliary Historical Society

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Bell Island Community Profile, 2004

Chamber of Commerce, Fishermens Association, Freemasons, Historical Society, Rotary Club, Royal Canadian Legion, Scouting Association, Tourism Association, Wildlife Association and many other informal groups

www. grandmanannb. com

Observations x 10 times as many Bell Island families use the food bank as Grand Manan families. x Historically, Grand Mananers and Bell Islanders have ascribed to very different service clubs and associations. x The Grand Manan Community High School has a very active school council. x Grand Manan has more than twice as many churches as Bell Island.

Questions 1. What accounts for the differences in the types of community organizations and associations found on these islands? 2. Do these associations and organizations reach out and engage an entire cross section of the community or are segments of the population, namely those on social assistance and the working poor, inadvertently excluded? 3. What difference has an active PTA or school council made to the high school students and to the community as a whole? 4. Are the monies spent on at-risk behaviours (gambling, drinking, smoking) impacting the sustainability of the churches, organizations and associations on the two islands?

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sixth determinant

Physical environments BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

1,215

2001 Census

1,125

2001 Census

Dwellings owned

890

2001 Census

925

2001 Census

Dwellings rented

325

2001 Census

195

2001 Census

New construction 1996 – 2001

Community Accounts, 2005

2001 Census

$103,000

2001 Census

Department of Education, Government of Newfoundland and Labrador

2 K – 5* and K – 12

Department of Education, Government of New Brunswick

INDIC ATOR

Occupied Dwellings

Average house cost

Schools in 2004

Boys’ and Girls’ Club, 2004

Banks in 2004

Accommodations, 2004

Recreational facilities, 2004

Farmers Market

Water and sewage, 2004

$36,846

2 K – 6 and 7 – 12

*note K – 5 school located in White Head

Yes

Bell Island Community Profile, 2004

Yes

www. grandmanannb. com

www.bellisland. net

1 Bank of Nova Scotia

www. grandmanannb. com

1 seasonal Bed and Breakfast

1 apartment rental 19+ cottages 7+ bed and breakfasts 4+ Inns and Hotels 1 Motel 4 Campgrounds including wilderness camping

www. grandmanannb. com

Arena, Softball Fields, Hiking Trails, Moto-cross Track

Fitness Centre, Tennis Courts, Outdoor Swimming Pool, Outdoor Ice Rink, Golf Course, Soccer Field, Baseball Diamonds, Shooting Range, Hiking Trails

www. grandmanannb. com

Saturday morning: June through September

www. grandmanannb. com

Wells and septic tanks (No Boil Water Order in recent past)

www. grandmanannb. com and Grand manna Village Council

Bell Island Community Profile, 2004

none

Town water and sewage system / wells and septic tanks (On-going Boil Water Order in Wabana)

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Bell Island Community Profile, 2004

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BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Private garbage pickup Limited recycling (beverage containers)

Bell Island Community Profile, 2004

Private garbage pickup Limited recycling (beverage containers)

www. grandmanannb. com

5 and 2 auxiliary police

Bell Island Community Profile, 2004

4 – 5 officers

www. grandmanannb. com

46:31

Bell Island Mayor’s Report, 2004

7:7

Grand Manan Mayor’s Report, 2004

9:7

Bell Island Mayor’s Report, 2004

3:2

Grand Manan Mayor’s Report, 2004

AB37 Theft under $5,000: reported and actual

16:15

Bell Island Mayor’s Report, 2004

2:2

Grand Manan Mayor’s Report, 2004

AC29 Property Damage under $5,000: reported and actual

66:56

Bell Island Mayor’s Report, 2004

10:10

Grand Manan Mayor’s Report, 2004

AT71 Impaired operation of a motor vehicle: reported and actual

5:5

Bell Island Mayor’s Report, 2004

1:0

Grand Manan Mayor’s Report, 2004

AT72 Driving a motor vehicle w/blood alcohol level over 80 mg: reported and actual

2:2

Bell Island Mayor’s Report, 2004

0:0

Grand Manan Mayor’s Report, 2004

AD41 Marijuana possession VIII: reported and actual

5:5

Bell Island Mayor’s Report, 2004

1:1

Grand Manan Mayor’s Report, 2004

AD45 Marijuana possession VII

2:2

Bell Island Mayor’s Report, 2004

0:0

Grand Manan Mayor’s Report, 2004

Aliant Bell Island Town Council

Serviced solely by Aliant 50% high speed access (DSL) 50% dial up connections (will replace with DSL in the near future)

Aliant Grand Manan Village Council

Since 1988, located in the Boys’ and Girls’ Club. Technology classes, supported by Industry Canada, are tied into the high school curriculum.

Grand Manan Boys’ and Girls’ Club

3 round trips daily during the winter months: 13 round trips daily during the tourism season

Grand Manan Ferry Schedule

INDIC ATOR

Landfill, 2004

RCMP in 2004

AA44 Assaults (Level One): reported and actual AB02 Break and Enter Residence: reported and actual

High Speed Internet Access Availability in 2004

Cable TV Channel

Ferry service: trips per day, 2004

Dialup and limited high speed. Serviced solely by Aliant

20 round trips daily

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Bell IslandPortugal Cove Ferry Service

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Observations x Nine and a half times as many new houses were built on Grand Manan in 2001, than on Bell Island. x Houses are worth almost three times as much on Grand Manan, as they are on Bell Island. x Grand Manan appears to be more committed to information and communication technology programs and infrastructure in their schools and community. x Grand Mananâ&#x20AC;&#x2122;s reduced winter ferry service means that all the teachers, health care professionals, clergy live on Grand Manan and potentially are integrated into the community. x Grand Manan has many different accommodation options for tourists. x There appears to be a higher incidence of crime on Bell Island: approximately four and a half times as many Level One Assaults; five and a half times the incidence of property damage; and seven times as many arrests for possession of marijuana.

Questions 1. Why is there a housing boom on Grand Manan? Who is building these houses? 2. What impact do the enhanced recreational facilities on Grand Manan have on the health and well-being of its population? 3. What keeps the bank branch on Grand Manan? 4. Grand Manan and Bell Island appear to have the same degree of water and sewer infrastructure but there are no Boil Water Orders on Grand Manan. Why is this? 5. Do Grand Mananers use their cable channel to promote and support health and well-being on the island? 6. Is there a relationship between the number of Level One Assaults and the number of drinking establishments on Bell Island? 7. What accounts for the difference in incidences of Property Damage under $5,000 on Grand Manan and Bell Island? 8. Why do there appear to be more street drugs on Bell Island?

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seventh determinant

Personal health and coping skills BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Proportion of adults reporting their health is good to excellent, 2004

40%

Bell Island Needs Assessment , 2004 Telephone Survey

36.5%

Grand Manan Hospital

Total number of influenza immunizations for adults and seniors administered by physicians, in 2004

485

Dr. Walter Templeman Health Centre

n/a

Grand Manan Hospital

Diseases of the Circulatory System

HCCSJ

Chronic Heart Disease and Cancer

Grand Manan Hospital

INDIC ATOR

Leading cause of death, 2004

Gambling Total number of sites with VLTs, 2004

Atlantic Lottery Corporation

Average income per tavern from VLT machines

$33,480

Atlantic Lottery Corporation

$1,629

Atlantic Lottery Corporation

Total VLT sales, 2004

$1,157,937

Atlantic Lottery Corporation

$15,845

Atlantic Lottery Corporation

Total online, breakaway, scratch and win, 2004

$822,824

Atlantic Lottery Corporation

$525,048

Atlantic Lottery Corporation

Total number of VLTs, 2004

Average Bell Islander age 20 and up contributed $886 to VLT or online, breakaway, and scratch & win in 2004

Average Grand Mananer age 20 and up contributed $260 to VLT or online, breakaway, and scratch & win in 2004

*Note: Estimates forBell Island are based on individuals ages 20+. It was not possible to obtain comparable population figures. The census breaks its age categories down such that 18 and 19 year olds fall into the 15 – 19 age category. It was not possible to separate the individuals with the ages of interest from their younger counterparts. As such, the figures presented here may be slightly inflated.

*Note: Estimates for Grand Manan are based on individuals ages 20+. It was not possible to obtain comparable population figures. The census breaks its age categories down such that 18 and 19 year olds fall into the 15 – 19 age category. It was not possible to separate the individuals with the ages of interest from their younger counterparts. As such, the figures presented here may be slightly inflated.

Number of citizen’s aged 20+ per VLT establishment in 2004

280

1,039

Number of citizens aged 20+ per VLT in 2004

520

Average Canadian 18 and older contributed $481 to government operated revenues 2002 – 2003 (Canadian Partnership for Responsible Gambling)

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Drinking Number of bars / taverns in 2004 Number of citizens aged 20+ per drinking establishment in 2004 Total beer sales in 2004 Total wine and spirits sales in 2004

Bell Island Community Profile, 2004

280

www. grandmanannb. com

2,078

$1,117,475.97

NFLD Liquor Corp

$603,768

Liquor Store NB

$507,489

NFLD Liquor Corp

$600,111

Liquor Store NB

Average Bell Islander age 20 and up contributed $727 to beer or wine and spirits in 2004

Average Grand Mananer age 20 and up contributed $579 to beer or wine and spirits in 2004

Smoking

Percentage of respondents aged 20+ who smoke on a daily basis in 2004

32%

Bell Island Health Services and Needs Assessment Survey 2005

$1,714,606*

Estimated annual spending (cigarettes) in 2004

*Calculation based on the average number of cigarettes smoked per day per smoker in NL X 365 Days X estimated cost of single cigarette X number of smokers. Could be significantly less if using ‘roll-yourown’

Estimated annual spending per smoker (cigarettes) in 2004

Grand Manan Hospital, 2006

$988,936* Tobacco Fast Facts, 2004 (for average number of cigarettes smoked / day by smokers in NL)

*Calculation based on the average number of cigarettes smoked per day per smoker in NB X 365 Days X estimated cost of single cigarette X number of smokers. Could be significantly less if using ‘roll-yourown’

Canadian Tobacco Use Monitoring Survey (CTUMS) 2004 (for average number of cigarettes smoker / day by smokers in NB)

$2,377*

$2,398* *Calculation based on the average number of cigarettes smoked per day per smoker in NL X 365 Days X estimated cost of single cigarette. Could be significantly less if using ‘roll-yourown’

20%

Telephone Survey, 2004 for number of identified smokers

*Calculation based on the average number of cigarettes smoked per day per smoker in NB X 365 Days X estimated cost of single cigarette. Could be significantly less if using ‘roll-yourown’

Atlantic Health Corporation for number of identified smokers

Observations x Bell Islanders spend 73 times as much on VLT’s than their counterparts in Grand Manan. x Bell Islanders spend more than three and a half times as much on gambling, as persons living on Grand Manan. x Bell Islanders spend more than one and a half times as much on beer, as persons on Grand Manan. x Bar owners on Bell Island make over 20 times as much in commissions from VLTs as bar owners on Grand Manan.

Questions 1. Why are there so few drinking and gambling establishments on Grand Manan? Grand Manan had 13 VLTs in 2001 – 2002 but only four VLTs by 2003 – 2004. Why did the number of VLTs decrease and how did Grand Manan accomplish this end? 2. What do persons living on Grand Manan do with the monies that they don’t spend on gambling and alcohol? 3. Are health outcomes on the two islands any different? 4. Do the islands have the best complement of health services and programs in place, to help their citizens who are struggling with at-risk behaviours (alcohol, gambling, smoking, obesity, street and prescription drugs)?

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eigth determinant

Healthy child development BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Infant mortality rate in 2004

Health & Community Services SJ

Grand Manan Hospital

Births to adolescents (age 10 â&#x20AC;&#x201C; 17) as a proportion of live births in 2004

Health & Community Services SJ

Grand Manan Hospital

INDIC ATOR

Number and rate of confirmed abuse and neglect cases among children 19 years of age and under in 2004 Proportion of 2 year-old children who have received all age-appropriate vaccines in 2004 Brighter Futures

% of babies breastfed in 2004

Unknown

n/a

100%

Health & Community Services SJ

98%

yes

Bell Island Community Profile, 2004

38%

Health & Community Services SJ

61%

Grand Manan Hospital

Observations x A greater proportion of infants reap the benefits of breast milk on Grand Manan than on Bell Island. x Because of privacy and confidentiality issues in small rural and remote communities, it is often not possible to publish the number of children taken into custody. Unfortunately, this makes a comparative analysis, which could potentially be very enlightening for the community, impossible.

Questions 1. What makes Grand Manan mothers more likely to breast feed their babies? 2. Why does Bell Island have a Brighter Futures program and Grand Manan does not?

ninth determinant

Biology and endowment Observations x No comparitive data were available for this determinant.

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tenth determinant

Health services BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

Dr. Walter Templeman Health Centre Overview of Services

1, but advertising for a second doctor

Atlantic Health Sciences Corporation (website)

24/7 Emergency; primary care, 20 beds: 12 long term, 6 acute, 2 palliative / convalescent / respite; x-ray and lab facilities

Dr. Walter Templeman Health Centre Overview of Services

24/7 Emergency, primary care, 8 beds, ambulance transfer, pediatric and family medicine, teleradiology services, 2 treatment beds

Atlantic Health Sciences Corporation (website)

Once a week

Dr. Walter Templeman Health Centre Overview of Services

1 full time

www. grandmanannb. com

1 full time

Bell Island Community Profile, 2004

1 full time

www. grandmanannb. com

Dr. Walter Templeman Health Centre Overview of Services

Grand Manan Hospital

Number of emergency ambulance transfers to a larger centre, 2004

127

Dr. Walter Templeman Health Centre Overview of Services

Grand Manan Hospital

Number of emergency ambulance transfers requiring the ferry to operate after hours, 2004

Bell Island Ferry Users Committee

Grand Manan Hospital

INDIC ATOR

Number of physicians in 2004

Health facility in 2004

Dentist in 2004

Pharmacy in 2004

Number of air transfers to larger medical centre in 2004

1.4*

Per capita physician visits, 2004

Total annual budget for Health Centre, 2004

Total Inpatient visits, 2004

Total Outpatient visits, 2004

*This value is not representative. The local physician services approximately 1/3 of the islandâ&#x20AC;&#x2122;s population in his family practice. The remainder of the island residents see MDs on the mainland.

Dr. Walter Templeman Health Centre Overview of Services

$2,131,825

Dr. Walter Templeman Health Centre Overview of Services

$1,391,479

Grand Manan Hospital

124

Dr. Walter Templeman Health Centre

101

Grand Manan Hospital

2,089

Dr. Walter Templeman Health Centre Overview of Services

1,427

Grand Manan Hospital

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

Grand Manan Hospital

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BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

2,100

Dr. Walter Templeman Health Centre Overview of Services

3,521

Grand Manan Hospital

$426,389

HCCSJ

n/a

Grand Manan Hospital

Total amount spent on Provincial Senior Citizen’s Drug Subsidy Program, 2003 – 2004 Fiscal Year

$441,321.36 $861.96 / capita

Newfoundland and Labrador Provincial Drug Plan

$246,429.00 $815.99 / capita

New Brunswick Provincial Drug Plan

Total number of claims made under the Provincial Senior Citizen’s Drug Subsidy Program, 2003 – 2004 Fiscal Year

11,205 prescriptions 22 claims / capita

Newfoundland and Labrador Provincial Drug Plan

5,875 prescriptions 19 claims / capita

New Brunswick Provincial Drug Plan

Total amount spent on Provincial Income Support Drug Program, 2003 – 2004 Fiscal Year

$828,234.63 $768.31 / capita

Newfoundland and Labrador Provincial Drug Plan

$38,586 $223.04 / capita

New Brunswick Provincial Drug Plan

Total number of claims made under the Provincial Income Support Drug Program, 2003 – 2004 Fiscal Year

28,288 prescriptions 26 claims / capita

Newfoundland and Labrador Provincial Drug Plan

980 prescriptions 6 claims / capita

New Brunswick Provincial Drug Plan

INDIC ATOR

Total outpatient emergency visits seen by physician or nurse practitioner after hours, 2004 Total annual budget for Health and Community Services for 2004

Number of community health nurses, 2004

Number of Community Supports / Youth Corrections social worker Number of child social workers, 2004

Dr. Walter Templeman Health Centre Overview of Services

Grand Manan Hospital

Health & Community Services SJ

Services provided on as needed basis

Grand Manan Hospital

Bell Island Community Profile

Services provided on as needed basis

Grand Manan Hospital

Number of social workers for adults, 2004

Health & Community Services SJ

Services provided on as needed basis

Grand Manan Hospital

Number of social workers for seniors, 2004

Health & Community Services SJ

Services provided on as needed basis

Grand Manan Hospital

Dr. Walter Templeman Health Centre Overview of Services

Mental Health: .5 Addictions: .2

Grand Manan Hospital

1 day a week

Dr. Walter Templeman Health Centre Overview of Services

Full time

www. grandmanannb. com

None

Dr. Walter Templeman Health Centre Overview of Services

2 visits per year

www. grandmanannb. com

None

Dr. Walter Templeman Health Centre Overview of Services

Occasional visits

www. grandmanannb. com

Mental Health / Addictions Counselor, 2004

Dentist, 2004

Optometrist, 2004

Chiropractor, 2004

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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INDIC ATOR

Number of nurse practitioners, 2004

BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

1 locum (fill-in physician) sharing on-call

Dr. Walter Templeman Health Centre Overview of Services

Grand Manan Hospital

Observations x Bell Island has more social workers than Grand Manan. Grand Manan brings in a social worker for adults and seniors on an as-needed basis. x The budget for the hospital on Grand Manan is $740,000 less than the Health Centre on Bell Island. x The Health Centre on Bell Island makes almost three times as many emergency transfers as Grand Manan. x The two islands have more or less the same coverage for addictions and mental health but Bell Island has significantly higher rates of at-risk behaviours. x Seniors on Grand Manan and Bell Island receive almost the same level of support from the Senior Citizen’s Drug Subsidy Program, but Bell Islanders participating in the Provincial Income Support Drug Program receive almost three and a half times the support that individuals do on Grand Manan. x Bell Islanders (under the Income Support Program) made over four times as many drug claims as their counterparts in Grand Manan. Bell Island seniors also made more drug claims than their counterparts on Grand Manan – on average, three claims more per beneficiary in 2003 – 2004. x Grand Manan Hospital has over one and a half times as many emergency visits as the Health Centre on Bell Island. x Bell Island and Grand Manan have roughly equivalent numbers of inpatient admissions.

Questions 1. Is there a lower incidence of dental caries on Grand Manan given the presence of a full time dentist? 2. Does the difference in the age of the facilities contribute to the difference in the budgets for the Bell Island Health Centre and Grand Manan Hospital? 3. Why does Bell Island have more emergency transfers? Is it because the entire population is slightly older on Bell Island? Is it a reflection of the population’s overall health status? Or, is the difference a reflection of proactive intervention on the part of dedicated health professionals? 4. Is the higher number of ‘after hour emergency visits’ on Grand Manan related to the fact that only one third of Grand Mananers get their primary care from the local physician? In other words, rather than travel to see their physician off the island, do persons utilize the hospital’s after-hours emergency services? 5. Why is the per capita spending on the Provincial Income Support Drug Program almost three and a half times higher for recipients from Bell Island as opposed to their counterparts in Grand Manan?

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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eleventh determinant

Gender

INDIC ATOR

BELL ISL AND (WABANA , FRESHWATER, AND L ANCE COVE) MALES

FEMALES

$12,600 2003

$12,700 2003

Gender differences in self-employment

Gender differences in number of loneparent families

DATA SOURCE

GR AND MANAN AND WHITE HEAD

DATA SOURCE

MALES

FEMALES

Community Accounts, 2005

$25,993 2000

$16,453 2000

2001 Census

185

2001 Census

245

2001 Census

100

2001 Census

Gender differences in informal care-giving (persons reporting hours looking after children, without pay)

305

515

2001 Census

420

520

2001 Census

Gender differences in informal care-giving (persons reporting hours of unpaid care or assistance to seniors)

125

275

2001 Census

185

285

2001 Census

Gender differences in median yearly income (ages 15 years and older) *Data for comparable years were not available.

Observations x There are no differences between Grand Manan and Bell Island in the proportion of male and female lone-parent families. In both communities, there are huge differences in the proportion of male and female lone-parent families: 9% (male) and 91% (female). x On Bell Island, approximately twice the number of females provide informal, unpaid care to children than their male counterparts. In Grand Manan, this difference is not as pronounced: less than one and a quarter times the number of females report providing informal, unpaid care to children than their male counterparts. x On Bell Island, over twice the number of females provide informal, unpaid care to seniors than their male counterparts. In Grand Manan, this difference is again not as pronounced: one and a half times the number of females report providing informal, unpaid care to seniors than their male counterparts.

Questions 1. Why are men on Grand Manan more involved in child rearing and caring for seniors?

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8 | DARE TO COMPARE: BELL ISLAND AND GRAND MANAN

twelfth determinant

Culture BELL ISL AND (WABANA, FRESHWATER, AND L ANCE COVE)

DATA SOURCE

GR AND MANAN AND WHITE HEAD

Born outside province

170

2001 Census

390

2001 Census

Born outside Canada

2001 Census

20 minute car ride and 20 minute ferry from St. John’s

www.bellisland. net

1 hour car ride and 1.5 hour ferry ride from Saint John

www. grandmanannb. com

INDIC ATOR

Satellite of a major urban centre versus self sufficient island

Proximity to the United States

Thousands of miles

DATA SOURCE

Close to the border

Observation x Over two times as many persons ‘from away’ have settled on Grand Manan, than on Bell Island. x It takes persons from Grand Manan more than three and a half times as long to Saint John, NB as it does Bell Islanders to get to St. John’s NL. x Grand Manan is much closer to Maine’s culture of natural foods, organic meat and vegetables, and recycling.

Question 1. Does having people ‘from away’ influence the types of available foods, activities and industries in these communities?

Summary As evidenced in this preliminary comparison, the Twelve Determinants of Health Framework is a powerful analytical tool, leaving little doubt as to the common, yet unique impact, which these interrelated determinants have on the health and well-being of a community. We will now turn out attention to the priorities and strategies for moving forward set out in the final chapter.

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9 TOWARDS PHASE TWO

LEAVING BELL ISL AND. PHOTO COURTESY OF REGINALD DURDLE.

The goal and objectives set out by the Bell Island Health and Wellness Committee for the Phase One: Bell Island Health and Well-being Needs Assessment have been met. This report constitutes a baseline. As findings from the 2006 census data become available, it will be just as important to benchmark those data against the findings in this report. It is understood that the provisional indicators, suggested at the end of each preceding chapter, will need to be winnowed and honed during Phase Two of the Needs Assessment. They will also need to complement the efforts of the Provincial Wellness Advisory Council. The importance of pushing through and establishing key indicators for citizens, the community and the health system cannot be overstated. The Twelve Determinants of Health gives us a baseline. However, it is the process of identifying and prioritizing indicators that will be instrumental in moving us forward.

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The use of Health Canadaâ&#x20AC;&#x2122;s Twelve Determinants of Health Framework has highlighted the need for a comprehensive plan to guide future directions. Following this report, there is no doubt that the community, its citizens and the health system have equally important roles to play in achieving optimal health and wellness for Bell Islanders. The challenge will be for the three stakeholders to partner and collaborate in new and innovative ways that ensure incremental progress towards sustainable health infrastructures, programs and services. The challenges facing Bell Island are significant, but with this report the players now have the tools needed to meet those challenges head-on. Following is a summary of the meta challenges and suggestions for consideration as well as opportunities for further research.

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High level findings for individuals, the community and the health care system The meta challenges listed below have importance for all three groups of stakeholders: citizens, the community, and the health system. Detailed findings relating specifically to the community, all age groups and health services can be found at the end of each respective chapter. Overarching challenges to achieving optimal health and wellness on Bell Island include: 1.

The stigmatization and marginalization of persons on social assistance

The pervasiveness of ‘at-risk’ behaviours (obesity, gambling, alcohol and tobacco consumption, and use of illegal and prescription drugs)

The need for improved literacy levels, formal education and training

The need for a robust information and communication infrastructure

The need for allied health professionals

High level suggestions for consideration ‘Next Step’ decisions ultimately rest with The Bell Island Health and Wellness Committee working in concert with the community, individuals and the health care system. Recognizing this, the following thematic suggestions for consideration are offered solely as starting points for discussion in Phase Two of the Needs Assessment. 1.

Social Status: ensure proportional representation of persons on social assistance in Phase Two. Also make sure that persons on social assistance are members of the Bell Island Health and Wellness Committee. Their involvement in setting priorities is key to the community moving forward in any meaningful way.

At-risk Behaviours: enable citizens, the community and the health system to work together to successfully tackle the community infrastructures and cultural norms presently supporting at-risk behaviours, namely: obesity, gambling, alcohol and tobacco consumption, and use of illegal and prescription drugs.

Education: use incentives to promote improvements in health, academic achievement levels, literacy training, and job training.

Information and Communication Infrastructure: provide ubiquitous broadband information and communication infrastructure that will

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support data collection and management as well as distance and online: diagnosis, treatment, education, support and self-care. 5.

Allied Health Professionals: provide access (real and virtual) to combined public and private services of allied health professionals to signal a shift in focus from acute events to prevention, wellness and chronic disease management. Services would include but not be limited to: physiotherapy, podiatry, dietary consults, occupational therapy, massage therapy, optometry, dental hygiene and dental care, and chiropractic services.

High level opportunities for further research and collaboration Each of the preceding chapters in this report includes a tailored list of opportunities for further research. However, there are a number of broader research opportunities that resonate across age groups, the community and the health system. Findings from these research topics would have relevance for many small communities across rural Newfoundland and Labrador.

Pilot the research and development of a grass-root, Bell Island Health and Wellness TV channel (Bell Island Community Channel – BICTV) The concept is for Bell Island to have a community-owned and operated television channel. Content for the channel would be produced by Bell Islanders for Bell Islanders. Content could include: children’s ads promoting dental hygiene; the broadcasting of: exercise sessions at the Wabana Complex; school council meetings at the elementary and high school; a weekly SuperNanny or Nanny 911 parenting club; a Nurse Practitioner and Community Health Nurse providing instruction on how to care for the elderly at home; youth discussing ‘at risk’ behaviours or upcoming employment opportunities; community postings of ‘Boil Water Orders’, and so on. According to findings from the Bell Island Needs Assessment 2004 Telephone Survey, after health professionals, television is the most common source for health information. Production values for the cable channel would be similar to CBC’s highly popular programs, ‘Here and Now’ or ‘Cooking with Carl’. This suggestion, of a community TV channel, is in direct response to the increasing number of aging adults with low literacy rates and the dire need for education and positive role modeling around healthy lifestyle choices, such as activity and diet, chronic disease management (diabetes, depression), dental care (hygiene),

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families (caring for the elderly, modeling healthy family behaviours), alternative health and wellness options (homeopathic medicines, massage) and so on. In addition to being available in citizen’s homes, BIC-TV could ride the television airwaves on the ferry, in the Health Center’s waiting room, the post office and in school hallways.

Research the impact of emerging family structures on health and well-being outcomes Using a Participatory Action Research (PAR) methodology and PHOTOVOICE, investigate the drivers, socioeconomic impact, health and well-being outcomes of: 1.

adult children living with their parents (225: 2001 Census);

single parent families (29% of all families: 2001 Census); and,

single seniors living alone (79%: 2001 Census).

Commission an in-depth case study to fully investigate and understand the impact of gambling in this rural and remote community More specifically: 1.

study the community’s extant cultural norms and taboos around gambling (VLT’s, tear-aways, Bingo and other gambling-based activities including online gambling);

determine the impact of gambling on the health and welfare of children and families in the community;

investigate the relationship between gambling, prescription and street drugs and alcohol consumption on the island and their impact on health and well-being outcomes;

identify and examine the impact of gambling on community organizations and their ability to raise monies and reinvest those monies in the community;

determine the impact of VLT gambling on the community’s economy and the impact were gambling to be curtailed or removed;

from the perspective of the individual, the community and the health care delivery system, explore how gambling can be addressed;

compare findings with the provincial 2005 report, Newfoundland and Labrador Gambling Prevalence Study, November 2005. Identify the differences and determine how the findings, specific to a small rural and remote community, can inform

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policy for the community, the health care system and government; and, 8.

formalize the process and results of doing all of the above, so best practices can be replicated in other rural and remote communities in Newfoundland.

Research and develop innovative uses of new and old information and communication technologies supporting primary health care in rural and remote communities Many small isolated communities in Newfoundland share the challenges that Bell Island currently faces: gambling and alcohol addictions; care of the elderly; restricted access to allied health professionals, to name but a few. Nancy Milroy-Swainson, Director of Health Canada’s Primary and Continuing Health Care Division said that “Primary Health Care is about being responsive to changing circumstances and health needs of Canadians.” Ten years ago, who would have predicted gambling of this magnitude on Bell Island? Moving forward, we need to investigate and realize the potential and financial advantages of web and telephone technologies to support diagnoses, treatment, education, support and self-care. For example, 1–800 numbers could be used to host virtual meetings of Alcoholics Anonymous or Gambling Anonymous. Online desktop computers and 1–800 numbers could be used to connect virtual communities of patients and caregivers with specific needs. Leverage the lessons learned, around hosting virtual support groups, from experienced providers like Massachusetts General Hospital in Boston, arguably one of the world leaders in virtual patient and caregiver support groups.

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Potential stakeholders are not limited to Newfoundland and Labrador. Other universities, institutes and federal agencies with a special interest in communities, health and wellness and the determinants of health may well be interested in partnering with the Bell Island Health and Wellness Committee. In particular, universities with programs in urban / rural planning, occupational therapy, dentistry, pharmacy, health economics and policy. Institutes focused on rural and remote community economic development, seniors and community involvement in health and wellness, are also potential partners. Industry is another option. Potential partners could include: Google, the Royal Bank, the Microsoft Foundation and so on. Finally, one would anticipate federal agencies such as: Health Canada; the Canadian Institute for Health Information; the Canadian Institute for Health Research; Canada Health Infoway; and the Canadian Population Health Initiative would be interested in the opportunities for research and development that a living / learning laboratory on Bell Island affords.

added service, by Bell Islanders, to other rural and remote communities in Newfoundland and Labrador and beyond.

Priorities moving forward There are four priorities moving forward. 1.

Optimize the membership of the Bell Island Health and Wellness Committee so it has the collective skill-set needed to broker community outreach, research, funding and commercial opportunities.

Under the auspices of the Committee, position Bell Island as a living / learning laboratory for community-based, collaborative primary health care research and development. This would involve formalizing the membership and status of the committee, exploring appropriate citizen participation models and appointing a scientific director.

Who will be interested in this report? Bell Island is a rural and remote community, with a discrete population, literally on Memorial University’s doorstep. Moreover, it has a highly functioning interdisciplinary committee coming to the table with clearly articulated needs and a baseline. Bell Island’s potential to function as a living / learning laboratory supporting community-based collaborative health and wellness research and development, presents invaluable research and development opportunities. This report will be of interest to politicians, administrators, educators, researchers, students, industry and institutes.

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A APPENDIX

BELL ISLAND COMMUNIT Y PROFILE Table A1: Community Profile Bell Island, NL 2006

POPUL ATION DISTRIBUTION (2001 CENSUS)

Community Profile Bell Island, NL 2006 AGE C ATEGORY

NUMBER

0–4

120

5–9

165

10 – 14

270

15 – 19

285

20 – 24

130

25 – 29

120

30 – 34

180

35 – 39

220

40 – 44

240

45 – 49

270

50 – 54

255

55 – 59

180

60 – 64

185

65 – 69

150

70 – 74

130

75 – 79

80 – 84

85+

TOTAL RESOURCE T YPE

3078 LIST OF COMMUNIT Y RESOURCES

SOCIAL

CHURCHES

St. Cyprians Anglican Church x Services: Sunday at 11:00 AM x 50 or less attend regularly St. Mary’s Anglican Church x Services: Sunday at 2:00 PM x 20-30 attend regularly

x Anglican Minister resides off-island x Approximately 300 Anglican families

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APPENDIX A | BELL ISLAND COMMUNITY PROFILE

St. Michael’s Roman Catholic Church x Services: Tuesday and Thursday at 7:00 PM; Wednesday and Friday at 9:30 AM; Saturday at 5:00 PM; Sunday at 10:30 AM x Number attending during weekdays varies; on weekends 205+ attend regularly

x Roman Catholic Priest resides on island x 2500 parishioners

Jackson Memorial United Church x Services: Sunday at 6:30 PM x 12 or less attend regularly

x United Church Minister resides off-island x 35 United Church families

Community Pentecostal Church x Services: Sunday x 6 or less attend regularly

x Pentecostal Pastor resides off-island x Six Pentecostal families COMMUNIT Y CENTRES

x no community centre for community gatherings

SOCIAL (CONTINUED)

COMMUNIT Y HOMES

Seniors Complex

x Run by the Bell Island Co-Op, subsidized by Newfoundland and Labrador Housing x Facilities: 16 units x Available only to pensioners

Island Manor Personal Care Home

x Privately owned and operated x Facilities: 10 beds x Three methods of payment accepted: 1. Private payment with no subsidy 2. Pension supplemented by government monies 3. Social Services

Health and Community Services

x 3 Social Workers

Human Resources Labour and Employment

x 3 Client Service Officers COMMUNIT Y SERVICE GROUPS

Kiwanis Club

x 14 members (all male)

Knights of Columbus

x 94 members (all male), affiliated with the Roman Catholic Parish

St. Anne’s Guild

x 10 member (all female), affiliated with the Roman Catholic Parish

Masonic

x 30 members (all male), own Masonic Hall

Legion

x 104 members (all male), own Legion

Ladies Auxiliary

x 16 members (all female) PARENT SUPPORT GROUPS

Brighter Futures

x x x x x x

Services parents with children ages 0 – 6 years Employs 1 adult, 2 regular volunteers Meets bi-weekly: Wednesday and Friday from 12:15-2:15 PM Parents and children are provided with free transportation Approximately 20-25 parents attend regularly Hosts the Healthy Baby Club for at risk mothers (i.e., teen moms or moms with low income). Participants in the Healthy Baby Club receive 1 dozen oranges, 1 dozen eggs, and 7 litres of milk. Each Tuesday babies are weighed and the breastfeeding group meets in conjunction with Community Health YOUTH GROUPS

Cadets

x 37 members (males and females ages 12-19 years) x 5 officers and supported by the Department of National Defence

CLB

x 20 members (males and females ages 5-18 years) x 4 leaders

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SOCIAL (CONTINUED)

APPENDIX A | BELL ISLAND COMMUNITY PROFILE

Wabana Boys and Girls Club

x 385 members (males and females ages 5-18 years) x Cost: 13 years and under ($3.00/year) 14 years and over ($5.00/year) x Employs 4 adults, 6 youths (2 tutors, 4 mentors) x Has 30-40 volunteers x Club run by a Board of Directors

Senior Resource Group

x Run in conjunction with the Seniors Resource Centre in St. John’s who meets with the Bell Island group one a year to discuss topics of interest for the following year. x 4-6 members x Group meetings take place once a month at the Wabana Complex with a guest speaker at each meeting x All seniors are invited to attend, free of charge

Dr. Walter Templeman Health Centre

x Facilities: 20 beds, 12 long term; 6 acute care; 2 beds for either palliative, respite or convalescent care, lab/x-ray services x Employs 2 doctors, 8 registered nurses, 14 licensed practical nurses, 2 community health nurses, 2 lab technicians x Locums and a nurse practitioner share on call duties for Thursday evenings and weekends x Dental services offered by visiting dentist once a week x Mental Health Services offered with 1 full time mental health counsellor x Hospital Ladies Auxiliary

SENIORS GROUPS

HEALTH

HOSPITAL

CLINICS

Clinic at Health Centre

x Operates Monday to Friday x Special Men’s and Women’s clinic offered once a year for prostate exams, breast exams, PAP smears, weight, blood pressure checks, and blood sugar testing x Doctors and nurses provide referrals for equipment loans from St. John’s Red Cross

Private Health Clinic

x Operates Monday to Friday PHARMACIES

x Operates Monday to Friday (9 AM-5:30 PM) and Saturday (2:30 PM-4:30 PM)

Family Drug Mart

LIFEST YLE

EXERCISE / WEIGHT LOSS ORGANIZ ATIONS

All ages exercise group

x Privately run group for all ages. x Meets bi-weekly at a local school x Cost: $4.00/session

Older adult exercise group

x x x x

Informed Weight Loss Group

x Meets and the Dr. Walter Templeman Health Centre for weight checks once weekly

For adults ages 50+ Meets bi-weekly at the Wabana Complex Cost: Free Approved by Seniors Resource Centre and Arthritis Society

SPORTS/RECREATION FACILITIES

Monsignor Bartlett Arena

x Offers minor hockey, junior hockey, men’s recreational hockey, figure skating, curling

St. Michael’s High School

x Offers volleyball, hockey (in planning)

Wabana Boys and Girls Club

x Offers a variety of sports programs all year long

Ladies and Men’s softball leagues

x During summer months only

SUPPORT GROUPS FOR PROBLEM BEHAVIOURS

x Meets every Wednesday night at the Dr. Walter Templeman Health Centre x Currently have 3 members

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APPENDIX A | BELL ISLAND COMMUNITY PROFILE

BUSINESS PROFILE

x x x x

Businesses that Employ 10-20 individuals

x Foodland x Wabana Town Council

ECONOMIC

Businesses that Employ 30+ individuals

Businesses that Employ 10 or less individuals

Health Centre School Board Fish Plant (40-70 from May to October) Ferry (50)

x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Department of Highways Post Office Bayview Grocery B&E Mini Mart Ridgeway Variety My Friends Place Dicks Snack Bay Home Hardware House of Stoyles Stoyles Meat Market Linda’s Grill/Kings Irving Homemade Kitchen Crafts & Décor Brad’s Convenience Island Manufacturing/Galvanizing Tina’s Unisex Styling Island Wide Taxi Lahey’s Taxi Fitzgerald’s Taxi Bakery Service Station Hammond’s Construction Hurley’s Construction Hurley’s Distributing SAG Enterprises Kelloway’s Bus Service & Charters Boones General Contractors Ken Mar Construction Wedgewood Insurance Gosine Trucking Noseworthy’s Hair Design Princess Pub JB Pub West Mines Sports Bay G & S Contracting Pendergast’s Funeral Home Family Drug Mart Wabana Medical Clinic Mr. Home Movie North Atlantic Oil The Coffee Shop Touch of Class Shirley’s Style Salon Murphy’s Garage The Curling Club Easy Save Gerard Contracting Howco’s Wholesale Parson’s Lounge Tremblett’s Ambulance Service Royal Canadian Legion The Green Depot Co-op (Business Development): x 500 members ($10/share) x operates the bakery and the senior complex **This list may not be complete

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ECONOMIC (CONTINUED)

APPENDIX A | BELL ISLAND COMMUNITY PROFILE

Home-Based Businesses

x x x x x x x x x x

Vacant Businesses

x 13

Bell Island Home Care Inc. Hammond’s Hair Design Debbie’s Hair Salon D & L Imaging Henry’s Photo & Plaques Judy’s Sewing Derek’s Appliance Island Hide-A-Way The Photo Shoppe Sam’s Auto Repair

BUSINESS IMPROVEMENT

Island Advisory Services

x HRDC initiative x Run by a Board of Directors to foster and lead economic development on Bell Island x Employs one full-time Community Economic Development Officer (Paul Connors)

ENVIRONMENT

GARBAGE DISPOSAL

Wabana

x Landfill site operated by the Wabana Town Council, open Monday-Friday (7:30 AM – 3:00 PM) x Garbage is bulldozed daily x Garbage is collected once a week by a private contractor paid by the Town Council)

Freshwater/Lance Cove

x Garbage is collected by a private contractor and trucked to St. John’s x Citizen’s pay individually for garbage removal

Wabana

x Individual wells or town council water supply. A chlorination system has been installed but a boil order is in effect until such time as the chlorination system is fully operational.

Freshwater/Lance Cove

x Individual wells or community water system

WATER SYSTEM

WASTE SYSTEM

x Individual septic tanks x Town council septic system REC YCLING

The Green Depot

x Privately owned and operated x Only recycles beverage containers (bottles and cans) x Recycling is not mandatory on the island

EDUC ATION

SCHOOLS (K-12)

St. Augustine’s Elementary

x x x x x x

Grades kindergarten through six 212 students enrolled 18 teachers 3 student assistants 5 member school council Volunteers run a daily lunch program (cost: $5.00 for 5 meals)

St. Michael’s High School

x x x x x

Grades seven through twelve 233 students enrolled 25 teachers 2 student assistants 12 student tutors (Tutoring for Tuition Program) LOC AL EDUC ATION

RCMP Newsletter

x Distributed every six weeks

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EDUC ATION (CONTINUED)

APPENDIX A | BELL ISLAND COMMUNITY PROFILE

Library

x Offers free internet access x Employs one librarian

Community Bulletins

x Located in most stores

Literacy Program

x Laubach Program x Operates free of charge through Brighter Futures x 11 people on the Island are trained literacy instructors

Headstart

x x x x x x

DAYC ARES

Located at Wabana School Complex Open June – September Cost: $10/half day (subsidized by Social Services) 27 children enrolled ages 2 – 6 years Employs three individuals

EMERGENC Y RESPONSE ORGANIZ ATIONS

Fire Hall

RCMP

SAFET Y

Ambulance

Foster Homes

Emergency Medical Services

Foodbank

x Operated and maintained by Volunteer Fire Department x 4 fire trucks and 1 rescue wagon x 18 volunteer firemen x x x x

1 Corporal 4 Constables 2 Auxiliary Police Offer two programs at local schools: DARE (Drug Awareness Resistance Program at St. Augustine’s Elementary and PALS (Police Attending Local Schools at St. Michael’s High School)

x x x x

1 privately owned service 2 ambulances 3 EMR 3’s 1 EMR 1

x x x x

Operates through Social Services Department 1 licensed 1 per diem license Youth Alternative Measures Program operated through Social Services Department in conjunction with RCMP x 1 Social Worker x 6 – 8 Volunteers x Dr. Walter Templeman Health Centre x Operates 24 hours/day x x x x x

Located in Boys and Girls Club Average of 200 families use the foodbank per month Opened daily Recipients receive a standard 2 day supply of food once a month 80% of food supplied by the St. John’s Food Sharing Network, 20% fundraising

MISCELL ANEOUS

COMMUNIT Y ASSETS

Tourist Attractions

x x x x x x x x x x x x x x

Post Office

x 3 postal codes (A0A 4H0, A0A 1H0, A0A 2V0) x Employees: 2 full-time, 1 part-time x Mail is hand delivered in Lance Cove

Mining Museum Lighthouse Murals Gun Site Trailer Park Grotto Seamen’s & Ferry Disaster Memorial Swimming Sports Hall of Fame Grebes Nest Sandy Beach Lance Cove Beach Natural Walking Trails Whale watching (in season)

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B APPENDIX

THE THR EE MOST COMMON R EASONS FOR BELL ISLANDERS FROM AGES 0 THROUGH 79 TO BE ADMITTED TO HOSPITAL FROM 2001 – 2004

Table B1: Provincial Drug Plan comparisons (Bell Island, NL vs. Grand Manan, NB).

The three most common reasons for bell islanders from ages 0 through 79 to be admitted to hospital from 2001 – 2004 Age

Top Three Diagnoses 1

3 2

0 – 4 years

Persons encountering health services in circumstances related to reproduction1

Diseases of the digestive system

n = 142

55 (39%)

20 (14%)

11 (8%)

Diseases of the digestive system

Diseases of the middle ear and mastoid

Diseases of the endocrine, nutritional and metabolic systems 4

8 (18%)

3 (7%)

5 – 9 years

n = 44

12 (27%)

Diseases of the middle ear and mastoid3

10 – 14 years

Diseases of the digestive system

Symptoms, signs, and abnormal clinical findings not elsewhere classified5

Diseases of the respiratory system6

n = 45

14 (31%)

7 (16%)

5 (11%)

15 – 19 years

Pregnancy, childbirth, and the puerperium

Diseases of the respiratory system

Diseases of the digestive system

n = 76

21 (28%)

9 (12%)

8 (11%)

20 – 24 years

Pregnancy, childbirth, and the puerperium

Diseases of the digestive system

Factors influencing health status and contact with health services7

n = 58

20 (35%)

10 (17%)

8 (14%)

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APPENDIX B | COMMON REASONS FOR BELL ISLANDERS TO BE ADMITTED TO HOSPITAL

Age

Top Three Diagnoses 1

25 – 29 years

Pregnancy, childbirth, and the puerperium

Diseases of the digestive system

Factors influencing health status and contact with health services

n = 79

19 (24%)

17 (22%)

13 (17%)

30 – 34 years

Pregnancy, childbirth, and the puerperium

Diseases of the respiratory system

Diseases of the genitourinary system8

n = 94

22 (23%)

18 (19%)

15 (16%)

35 – 39 years

Diseases of the digestive system

Diseases of the genitourinary system

Symptoms, signs, and abnormal clinical findings not elsewhere classified

n = 126

23 (18%)

20 (16%)

13 (10%)

40 – 44 years

Diseases of the musculoskeletal system and connective tissue9

Diseases of the genitourinary system

Diseases of the digestive system

n = 159

30 (19%)

27 (17%)

25 (16%)

45 – 49 years

Diseases of the digestive system

Symptoms, signs, and abnormal clinical findings not elsewhere classified

Diseases of the genitourinary system

n = 167

43 (26%)

22 (13%)

20 (12%)

50 – 54 years

Diseases of the digestive system

Diseases of the circulatory system10

Diseases of the genitourinary system

n = 155

29 (19%)

20 (13%)

18 (12%)

55 – 59 years

Diseases of the musculoskeletal system and connective tissue

Diseases of the bloos and blood forming organs11

Diseases of the digestive system

n = 201

34 (17%)

33 (16%)

27 (13%)

60 – 64 years

Diseases of the circulatory system

Diseases of the digestive system

Diseases of the respiratory system

n = 226

42 (19%)

31 (14%)

27 (12%)

65 – 69 years

Diseases of the circulatory system

Diseases of the genitourinary system

Diseases of the digestive system

n = 230

43 (19%)

41 (18%)

24 (10%)

70 – 74 years

Diseases of the circulatory system

Diseases of the genitourinary system

Malignant neoplasms12

n = 224

43 (19%)

28 (13%)

26 (12%)

75 – 79 years

Diseases of the circulatory system

Diseases of the genitourinary system

Diseases of the digestive system

n = 155

29 (19%)

21 (14%)

18 (12%)

refers to the total number of individuals in each age grouping

May include conditions like tonsillitis, asthma, pneumonia, and laryngitis

May include conditions like vaginal and caesarean births and low birth weights

May include follow up examinations, sterilization, constipation

May include conditions like dental caries

May include renal disease, calculus of kidney, urinary tract infection

May include low back pain, spinal stenosis, joint pain

May include conditions like chronic serous otitis media

May include Diabetes Mellitus Type I

May include conditions like chest pain, nausea, vomiting, and some emotions

10 May include heart disease, angina, and stroke 11 May include thrombocytopenia 12 May include myeloma and neoplasm of prostate

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

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C APPENDIX

PROVINCIAL DRUG PLAN COMPAR ISONS ( BELL ISLAND AND GR AND M ANAN )

Expenditures and number of drug claims for eligible beneficiaries from Bell Island and Grand Manan were compared for the Provincial Senior Citizen’s Drug Subsidy Programs as well as the Provincial Income Support Programs in Newfoundland and Labrador (NLPDP) and New Brunswick (NBPDP). At the community level, all calculations were based on total expenditures and total drug claims for each of the plans involved divided by the total number of eligible beneficiaries. All numbers refer to the 2003 – 2004 fiscal year. In order to ensure that comparable figures were used, the number of eligible beneficiaries was used to calculate per capita rates as opposed to the number of active beneficiaries. Eligible participants simply refer to all those individuals who were eligible to receive benefits under the Income Support Drug Program.

Active participants refer to those individuals who made at least one claim during the fiscal year. During this time period, Newfoundland’s Income Support program assigned ID numbers to family units. The data provided to us by the NLPDP provided us with an estimate of the total number of individual eligible beneficiaries only. Therefore, all comparisons were made based on the numbers of eligible program participants. Initially, only comparisons of total and per capita expenditures were calculated. Because of the notably large difference in per capita expenditures for the Income Support Programs in both communities additional calculations were made comparing the number of drug claims made by beneficiaries in each community. We wanted to be sure that the noted difference in expenditures was not due to differences in Drug Plan Administration.

Table A1: Provincial Drug Plan comparisons (Bell Island, NL vs. Grand Manan, NB).

Provincial Drug Plan comparisons (Bell Island, NL vs. Grand Manan, NB)

COMMUNIT Y

Total expenditures # of eligible beneficiaries Per capita spending Total number of claims Per capita claims

PROVINCIAL SENIOR CITIZEN’S DRUG SUBSIDY PROGR AM

PROVINCIAL INCOME SUPPORT DRUG PROGR AM

BELL ISL AND

GR AND MANAN

BELL ISL AND

GR AND MANAN

$ 441,321

$ 246,429

$ 828,235

$ 38,586

512

302

1078

173

$ 861.95

$ 815.99

$ 768.31

$ 223.04

11,205

5,875

28,288

980

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APPENDIX C | PROVINCIAL DRUG PLAN COMPARISONS: BELL ISLAND AND GRAND MANAN

The Income Support Drug Programs in Newfoundland and New Brunswick are administered differently. For example, the New Brunswick plan requires beneficiaries to pay for a portion of the drugs they receive. This is not the case in Newfoundland where the entire cost of the drug and the dispensing fee is paid by the government. Comparison of the total number of claims made by participants in Bell Island and Grand Manan allowed for a more clear understanding of the differ-

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ence. However, it must be noted that we do not know if the number and type of drugs covered by each of the Provincial Income Support Drug Plans are comparable. Further study into spending on Income Support Drug Plans, in particular, is warranted. Figures for spending on the Provincial Senior Citizens Drug Subsidy Programs for Bell Island and Grand Manan were comparable.

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D APPENDIX

ABBR EVIATIONS AND DEFINITIONS

BIC-TV:

Bell Island Community Television (proposed)

BIHWC:

Bell Island Health and Wellness Committee

BMI: CASP: CIHI:

MUN:

Medical Care Commission Medical Information Technology software Memorial University, Newfoundland and Labrador

Community Academic Services Program

NBPDP:

Canadian Institute for Health Information

NLCHI:

Newfoundland and Labrador Centre for Health Information

NLPDP:

Newfoundland and Labrador Prescription Drug Plan

NRC IIT:

National Research Council, Institute for Information Technology

NL:

Drug Abuse Resistance Education

DFO: Department of Fisheries and Oceans EKG:

MEDITECH:

Body Mass Index

COP: Community of Practice DARE:

MCP:

Electrocardiogram

FTE: Full-time Equivalent

OT:

New Brunswick Prescription Drug Plan Newfoundland and Labrador

Occupational Therapy

General Education Degree, General Education Development, General Education Diploma or General Educational Development

PACS:

Picture and Archiving Communication System

PALS:

Police at Local Schools

HRLE:

Human Resources Labour and Employment

PHCR:

HRU:

Health Research Unit, Memorial University, Newfoundland and Labrador

GED:

PAR: PTA: RCMP:

Participatory Action Research Primary Health Care Reform Parent Teacher Association Royal Canadian Mounted Police

IAS:

Island Advisory Services, Bell Island

The Front:

Commercial strip in Wabana

ICT:

Information and Communication Technologie(s)

The Tickle:

Body of water between Portugal Cove and Bell Island

LICO:

Low Income Cut Off

BELL ISLAND HEALTH AND WELL-BEING NEEDS ASSESSMENT: PHASE ONE | 2006

VLT:

Video Lottery Terminal

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R EPORT SCHEM A

INTRODUC TION (1) (5) METHODOLOGY BELL ISL AND

WHO WE ARE AND WHERE WE LIVE (9)

(13) THE COMMUNIT Y INFANTS AND PRESCHOOLERS (33) CHILDREN (44) YOUTH (52) ADULTS (60) SENIORS (73) (83) HEALTH SYSTEM (103) DARE TO COMPARE

BELL ISL AND, NL

TOWARDS PHASE TWO (123)

GR AND MANAN, NB

P PERSONAL NOTES

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P | PERSONAL NOTES

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P | PERSONAL NOTES

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Bell Island Health and Well-Being Needs Assessment: Phase One June 2006

ISBN 0-9780873-0-5

Prepared for the Bell Island Health and Wellness Committee, Bell Island, Newfoundland and Labrador. The Bell Island Health and Wellness Committee can be contacted by emailing: bellislandhwc@gmail.com