Making poverty a practice issue

Trends in poverty and changes in service provision are combining to make the promotion of health in poverty a particular challenge to health and welfare practitioners. The evidence suggests that practitioner groups have failed to respond adequately to this challenge. Factors concerned with professional perceptions of poverty, the nature of qualifying and post-qualifying education and the difficulties associated with taking research into practice all appear, in some way, to contribute to practitioners’ failure to incorporate a poverty perspective in their work. A team training approach appears to offer one way forward in the practice-setting. Using a team training approach, the‘Health Promotion in Poverty Project’ has sought to enable the lessons learnt from the broad base of poverty theory and research to be used by practitioners to build responsive and integrated support strategies for low-income families with dependent children.     

Spreading the good work: an integrated approach to community mobilization for HIV / AIDs care and support in South-East Asia

The countries of Southeast Asia are experiencing the HIV/AIDS epidemic in varying stages, and they are coping with the increasing number of individuals infected or affected in different ways. The UN has tried to document the best practices so as to inform the public of ways to deal with HIV/AIDS care and support. Simply translating and making the best practice documents available to the public, however, does not automatically translate into dissemination of such practices from nation to nation. The challenge of dissemination is to adapt a model to other contexts and developing capacities to learn from the model. A chosen model for such dissemination is from Mae Chiang, Thailand, which represents a triaging of community-based HIV/AIDS care and support. The collaboration between the community, the religious sector, and the medical team allows more economic utilization of the limited in-patient resources and increases the ability of the staff to deal with more complicated cases. In addition, partnerships with the education sector and social welfare sector are vital in making the Mae Chiang model work in Southeast Asia. HIV/AIDS is a multisectoral issue and requires a multisectoral solution. Concentrating on a single sector alone (be it health, religion, or education) will deal with the challenge neither adequately nor efficiently.     

Planning the teaching of community health (COPC) in an MPH program

The Community Medicine approach, focussed on an active assessment of health status with a subsequent provision of health care directed to the community as a whole, is recommended today as a means for addressing the fragmentation of health services. In parallel, in recent years the Community Medicine approach has been incorporated in a growing number of health academic institutions. In this paper it is suggested that the teaching of Community Medicine should be an active process in a practical environmental in which students could be involved with real life situations. Our teaching methods are illustrated by the experience of the Community Oriented Primary Care (COPC) Workshop of the School of Public Health and Community Medicine in Jerusalem. This Workshop is included in the curriculum after the core courses in the Israeli and in the International MPH Program at the Braun SPH. The central component of the workshop are the workgroups of 6-8 students with the assistance of a tutor member of the School's staff. The group, resembling a health team, focussed its work in the assignment of planning a proposal for the development of a community health program in the students' communities. The workshop is an illustration of the problem-based learning method carried out by public health workers of different professions background and with diverse practical experience reproducing a real life situation in a classroom environment. Repeated evaluations done by students has shown a positive assessment as measured by a reported adequate acquisition of knowledge, having an useful experience and practicing skills.     

Settings for learning: the community beyond

The primary objective of medical education to medical students should not be the recruitment of specialists or to provide instructions about highly sophisticated clinic medicine. Our responsibility towards them is rather to enable them to learn about medical practice in its most prevalent context, which is the community medical practice, and to contribute to their general medical education and the health welfare of their community. The health needed by the nation cannot possibly be provided by specialists. It is a task for all doctors. If we agree that the ultimate goal of medical education is to secure health and proper care (whether primary, secondary or tertiary) for the population, medical curricula and learning settings should be open for any modifications that ensure a proper approach to our patients' practicalities, resources and needs. A major modification involved in that process would be for the educational setting to move from the hospital into the community and doctors to acquire the skills and conviction of working as part of a health team, in which they are not necessarily the leaders.     

An Interdisciplinary Health Team Training Program for School Staff in Minnesota

ABSTRACT: This paper describes an interdisciplinary health team training program for school-based clinic staff in Minnesota. The project sought to improve team functioning, level of practice, and health care services at the school sites. Participants were interdisciplinary staff members from clinics in senior high, middle, and elementary schools. The program consisted of further development in team training knowledge and skills and educational sessions on issues identified by participants. Evaluations indicated participants reported greater knowledge and improved team functioning experiences from the team training. Gains also were shown in knowledge and skills in specific school topic areas such as violence, resiliency, working with resistant families, and self-care. The program could serve as a model for other interdisciplinary school health team training.     

Providing welfare rights advice in primary care

OBJECTIVE: To evaluate the introduction of dedicated open access welfare rights advice sessions in a general practice setting. DESIGN: A retrospective study of 416 client visits over a 11 month period from August 1995. A prospective questionnaire survey of 34 attendees over a three month period from April 1996. Semi-structured interviews with 11 involved primary care staff. SETTING: An inner city health centre. OUTCOMES: Social characteristics of clients attending; problems presented; benefit uptake; views from the health centre staff and welfare rights advisers and comments on future development. RESULTS: A total of 270 new clients used the service during the study period with 146 repeat visits (35%). Of the new clients, 158 out of 270 (59%) reported that they were disabled and 50% of the 158 had specific disability based welfare rights enquiries. 15% of new clients (40 out of 270) were found to be owed money by the current benefit system. Of these, 24 clients obtained one-off payments totalling ?15,863 and 16 clients obtained regular payments totalling ?539 a week. 58% of interviewed clients had not previously accessed any welfare rights advisory services. The welfare rights service was considered by the primary health care team to be a very useful contribution in a highly deprived area. CONCLUSIONS: The advice service increased the uptake of social security benefits in 15% of all new attendees. An open access service may not have been the most efficient method of delivering such advice. However, the high proportion of new clients who reported having a disability suggested that a health centre setting may be particularly accessible for those reporting disability. Further work is required to explore these findings and the most effective and efficient method of delivering the service in a deprived inner city setting.     

Development of a collaborative model to improve school health promotion in The Netherlands

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.     

‘The unknown becomes the known’: collective learning and change in primary care teams

Context The growing emphasis on teamwork within the National Health Service (NHS) has made it a priority to understand how health care teams learn together and cope with change. Objectives This study aimed to explore how collective learning and change happen in primary care teams and how the process varies across the disciplines of general medical practice, pharmacy and dentistry. Methods This study reports on qualitative data gathered from 10 primary care teams over 1 year, by means of observational visits and 38 semi‐structured interviews. Results Informal collective learning is a powerful team coping mechanism that develops through experiential, evolving and implicit learning processes. These processes are predominantly relational in that they rely on the extent to which team members know and understand one another as people. This makes shared learning an effective but ‘messy’ dynamic, the motivation for which is internally generated by the team itself. Teams report that if they cannot learn together, they cannot meet patient needs. Conclusions These findings demonstrate that teams share their knowledge because they believe it has value, not because they are driven by external incentives or are monitored. This challenges the prevailing assumption that, to be effective, interprofessional learning should be externally managed. As health care develops, it will become increasingly important to consider how to support the internal learning processes of care teams as they navigate complex organisational changes and the shared learning experiences that characterise those changes. Those who support learning and development within the NHS should therefore focus on how relational processes, as well as educational content, contribute to a team’s collective learning capability and the quality of care its members provide.     

Learning about Practice from Practice: A Peer-based Methodology

A recommendation from the Social Work Task Force was that all employers of social workers should conduct a regular “health check” of the social work profession to learn from practice as part of a continuous cycle of improvement. This article documents how the London Borough of Tower Hamlets has gone about this. I describe the methodological and practical pathway we followed so that others can see what we did and why we did it. Like other busy social work offices, we had to set out a plan of methodological action in order that we achieved the learning from practice to inform our health check, and it is the planning work that is engaged with in this article. We have found that by involving and engaging our staff in the health check work, we have gained more than we had set out to find. An organisational commitment to act on what social workers have told us about practice is offering the senior management team new ideas about the best ways of delivering professional and reflective support mechanisms for staff. Learning from practice is now one of the core functions for the new Principal Social Worker.     

Austerity Britain,poverty management and the missing geographies of mental health

This paper presents the lived experiences of individuals with mental illness as they navigate the benefits landscape in an age of welfare reform in the UK. We focus on the impacts upon their well-being and daily geographies. We articulate the relationship between welfare reform and mental health using the concept of poverty management and its ‘missing geographies’, in which everyday well-being and routines are dismissed by the restructuring welfare system. We liken this dismissal to a shift towards a narrower and more unforgiving mode of poverty management, where even the smallest misstep can unravel the entire edifice of everyday survival and well-being.     

Evidence-based research on the value of school nurses in an urban school system

BACKGROUND: With the increasing acuity of student health problems, growing rates of poverty among urban families, and widening racial/ethnic health disparities in child and adolescent health indicators, the contributions of school nurses are of increasing interest to policymakers. This study was conducted to evaluate the impact of school nurses on promoting a healthy school environment and healthy, resilient learners. METHODS: A mixed‐methods approach was used for this study. Using a cross‐sectional design, surveys captured the level of satisfaction that school staff had with the nurse in their school, as well as their perceptions of the impact of the nurse on the efficient management of student health concerns. Using a quasi‐experimental design, data from electronic school records were used to compare rates of immunization and completeness of health records in schools with nurses. RESULTS: This study provides evidence that school nurses positively influenced immunization rates, the accuracy of student health records, and management of student health concerns. This research demonstrates that teachers and other staff consider nurse interventions vital to eliminating barriers to student learning and improving overall school health. A cost analysis revealed the estimated annual cost per school for the time staff spent managing health concerns. CONCLUSIONS: In an environment of scarce resources, school boards need quality evaluation data to justify hiring and retaining school nurses to support improved school health environments.     

What motivates managers to coordinate the learning experience of interprofessional student teams in service delivery settings?

This article addresses the realities of providing interdisciplinary student team placements (i.e., experiential team learning for students) in healthcare settings. Three site coordinators from different clinical settings in Alberta (a geriatric assessment unit, a geriatric dementia care unit, and a primary healthcare centre), who facilitated Student Team Placements from the University of Alberta (UofA) in 2004, comment on their experiences and incentives for participating in interdisciplinary teamwork with students. The coordinators suggest that students provide input into the sites’ continuous quality improvement cycle, contribute to host organizations, and confer benefits for the student preceptors, the staff and the patients who participate. The site coordinators also recognize and accept the responsibility common to all service providers, to model a unique site culture that promotes learning/teaching of team skills for health science students. The experience of others in the literature supports our findings that two systems – the system to educate health professionals and the system that influences the health of the community – can interact so that each realizes a mutual benefit.     

Studying social policy and resilience to adversity in different welfare states: Britain and Sweden.

Is poverty more damaging to health in Britain than in Sweden, and if so, why? Following previous research by the authors that suggested such an effect, a new comparative study is examining whether there are aspects of the social and policy context in Britain that add to and reinforce the health-damaging experience of being poor. Conversely, are there other aspects of living in Sweden that are supportive for people in poverty, which make the experience of poverty less stressful and health-damaging? Stemming from this ongoing study, the aim of this article is to present a framework for understanding the context in which social welfare policies are formed and operate in Britain and Sweden. It then uses the framework to consider the "upstream" influences of ideology, culture, and values on policy development in the two countries and what these developments might mean for the health and well-being of people facing financial adversity in the two societies.     

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

Objective: To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes. Methods: Aboriginal people with diabetes were invited to participate in one of five focus groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team. Results: Participants described colonisation and dislocation from Country and family members’ experiences with diabetes as significant historical influences which, in conjunction with the model of care experienced and the type of interaction with health services, shaped how they came to understand and manage their diabetes. Conclusions: Patient experience of a model of care alone is not what influences understanding and management of diabetes in Aboriginal people. Implications for Public Health: Health service improvements should focus on understanding past experiences of Aboriginal patients, improving interactions with health services and supporting holistic family centred models of care. Focusing on just the model of care in absence of other improvements is unlikely to deliver health benefits to Aboriginal people.     

Pediatric palliative care instruction for residents: an introduction to IPPC

A 1-day training event for pediatric residents with interdisciplinary staff was held, which was modeled after the Initiative for Pediatric Palliative Care (IPPC). Training included relational communication, cultural humility, pain-symptom management, family-centered care, team problem solving, and strategic planning using didactic, small group, and plenary platforms. Two bereaved parents were co-learners and trainers. Twenty-six interdisciplinary staff participated. A positive impact was measured in new knowledge gained, value in collaborative learning with health care professionals and families, and ability to work with professionals outside participants' own unit. Confidence to advocate for improved pediatric palliative care was also noted. The IPPC curriculum is easily adapted for resident education. Incorporating family members as co-learners and teachers is valuable. Advocacy for pediatric palliative care may follow this type of experience.     

SCHIP expansion and parental coverage: an evaluation of Wisconsin's BadgerCare

The Wisconsin BadgerCare program, which became operational in July 1999, expanded public health insurance eligibility to both parents and children in families with incomes below 185% of the U.S. poverty line (200% for those already enrolled). This eligibility expansion was part of a federal initiative known as the State Children's Health Insurance Program (SCHIP). Wisconsin was one of only four states that initially expanded coverage to parents of eligible children. In this paper, we attempt to answer the following question: To what extent does a public program with the characteristics of Wisconsin's BadgerCare program reduce the proportion of the low-income adult population without health care coverage? Using a coordinated set of administrative databases, we track three cohorts of mother-only families: those who were receiving cash assistance under the Wisconsin AFDC and TANF programs in September 1995, 1997, and 1999, and who subsequently left welfare. We follow these 19,201 "welfare leaver" families on a quarterly basis for up to 25 quarters, from 2 years before they left welfare through the end of 2001, making it possible to use the labor market information and welfare history of the women in analyzing outcomes. We apply multiple methods to address the policy evaluation question, including probit, random effects, and two difference-in-difference strategies, and compare the results across methods. All of our estimates indicate that BadgerCare substantially increased public health care coverage for mother-only families leaving welfare. Our best estimate is that BadgerCare increased the public health care coverage of all adult leavers by about 17-25% points.     

Putting policy into practice? Poverty and people with serious mental illness

This paper addresses the effects of chronic poverty on people with serious mental illness. More specifically, we are concerned with the extent to which welfare restructuring, by deepening the poverty facing people with serious mental illness, undermines the expressed intent of mental health policy to improve the quality of life (QOL) of this population. The province of Ontario in Canada forms the setting for the study. The paper first examines recent trends in mental health care and social assistance policy in Ontario. While income support is consistently recognized as a core element of mental health care, welfare restructuring has led to a significant decline in the real value of income supports received by people with serious mental illness. The paper then examines the implications of this trend for the QOL of residential care facility tenants in Hamilton, Ontario. Here, the case study is explicitly connected to QOL scholarship. In addition, the study is grounded in an analysis of the broader transformation of the welfare state in Ontario. Interview data suggest that tenants experience chronic poverty that has a deleterious impact on multiple life domains including basic needs, family, social relations, leisure and self-esteem. Implications for research and policy are discussed.     

Improving health literacy in a Japanese community population—A pilot study to develop an educational programme

Objective

Although a growing number of interventional studies on health literacy have been conducted recently, the majority were designed in clinical settings, focusing mainly on functional health literacy. This study evaluated a programme designed to improve health literacy in a community population, with a scope of going beyond functional health literacy.

Methods

In collaboration with an Approved Specified Nonprofit organization (NPO), we evaluated a five‐session programme designed to provide basic knowledge on health‐care policy and systems, current issues in health care in Japan, patient roles and relationships with health‐care providers and interpersonal skills. In total, 67 of 81 programme participants agreed to participate in the study, and 54 returned the completed questionnaires at baseline and at follow‐up. Health literacy and trust in the medical profession were measured at baseline and at follow‐up. Participants’ learning through the programme was qualitatively analysed by thematic analysis.

Results

Quantitative examinations of the changes in health literacy and degree of trust in medical professionals between the baseline and follow‐up suggested that health literacy significantly improved after implementing the programme. The thematic analysis of participants’ learning throughout the programme suggested that they not only acquired knowledge and skills but also experienced a shift in their beliefs and behaviours.

Discussion

Providing individuals who are motivated to learn about health‐care systems and collaborate with health‐care providers with the necessary knowledge and skills may improve their health literacy, which could enable them to maintain and promote their health and that of their family and other people around them.     

The 'Collaborative Care' curriculum: an educational model addressing key ACGME core competencies in primary care residency training

AIM: The 'Collaborative Care' curriculum is a 12-month senior resident class project in which one evidence-based clinical guideline is designed, implemented and evaluated in our residency practice. This curriculum specifically addresses three of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies: Practice-Based Learning and Improvement, Interpersonal and Communication Skills and System-Based Practices. Additionally, the project enhances the quality of patient care within the model family practice centre in a family practice residency. METHODS: During the project, the third-year residency class selects the disease, develops the clinical guideline, leads its implementation and guides the evaluation process. Select faculty members serve as mentors and coach the resident class through each phase of the project. Specific educational objectives are developed for each content area: evidence-based medicine, clinical guideline development, continuous quality improvement and team leadership. A series of seminars are presented during the project year to provide 'just-in-time' learning for the key content and skills required for each step in the project. By working together to develop the practice guideline, then working with nurses and allied health staff to implement the guideline and review its effectiveness, the resident team gains competence in the areas of practice-based learning and improvement, interpersonal and communication skills and system-based practices. RESULTS: The self-reported level of resident confidence in skill acquisition for each content area was measured for each resident at the time of graduation from the residency programme. Results from the first 2 years of this curriculum are reported (resident n = 12), and demonstrate a high level of physician confidence in the skills addressed and their utility for future practice. CONCLUSIONS: The senior resident seminar and team project model reported here creates learning experiences that appear to address at least three of the ACGME general competency expectations: practice-based learning and improvement, interpersonal communication skills, and systems-based practice. From the initial resident feedback, this educational model seems to establish a high level of physician confidence in the skills addressed and their utility for future practice.     

Sources of stigma for means-tested government programs

Stigma has been shown to discourage participation in means-tested government programs. Prior research cannot explain why this deterrent effect varies in intensity across different individuals and programs. We develop a more comprehensive model of the possible determinants of stigma associated with means-tested programs than has previously been suggested by studies of welfare stigma. We test hypotheses using unique data based on interviews with 1405 respondents in 10 states and the District of Columbia, USA. The results suggest that there are two distinct forms of stigma related to participation in means-tested government programs: one related to self-identity, the other to the anticipation of negative treatment. Both forms of stigma are more pronounced for Welfare compared to Medicaid. The sources of stigma identified by conventional treatments of welfare stigma (e.g., individual attributions of responsibility for poverty) have significant explanatory power, but neglect other important influences. We find that stigma is exacerbated by poor health and by minority status. Stigma is also fostered by the ways in which means-tested programs are implemented, including negative interactions with case workers, long waiting times, and, for Medicaid, applications for benefits in alternative enrollment sites such as health centers or hospitals. These findings suggest new points of leverage for addressing the potentially deleterious consequences of stigma.