Addressing Health Inequities for Racialized Communities A Resource Guide Acknowledgments The following individuals and organizations contributed to the development of this resource guide: w Subha Sankaran (author) and Suzanne Schwenger (Health Nexus) w Dianne Patychuk, Kwasi Kafele and Christine Oluwole-Aina (Health Equity Council) w Mantreh Atashband, Torshie Sai, Maila Mananquil (students) w Rose Cathy Handy (Project Consultant, French) w Project Advisory Committee members, (for a full list of Advisory Committee members, see Appendix) Local Partners, Presenters and Participants w Cover design idea – Gayathri Naganathan
Disclaimer The resources and programs cited throughout this guide are not necessarily endorsed by Health Nexus and the Health Equity Council. While the participation of the advisory committee contributed to the development of this resource guide, final decisions about content were made by Health Nexus and the Health Equity Council Aussi disponible en français. This document is available online at www.healthnexus.ca/projects/building_capacity/index.htm
This document has been prepared with funds provided by the Government of Ontario. The information herein reflects the views of the authors and is not officially endorsed by the Government of Ontario. Health Nexus and Health Equity Council thank you for your interest in, and support of, our work. We permit others to copy, distribute or reference the work for non-commercial purposes on condition that full credit is given. Because our resources are designed to support local health promotion initiatives, we would appreciate knowing how this resource has supported, or been integrated into, your work ( [email protected] ). s e i t i n u m m o C
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Health Nexus Health Equity Council c a R
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Toll-free: 1-800-397-9567 a e H [email protected] g n i s s e r d d A
A Resource Guide 1 Introduction Ontario is experiencing huge demographic shifts, particularly in the larger urban centres. It is estimated that by 2017, one in five people in Canada will belong to a community of colour. By 2017, more than half of Toronto’s population will be people of colour 1. This growing number of Ontarians belong to what are called ‘ racialized communities’, a term that is replacing ‘visible minorities’ or ‘ethnocultural communities’ . In Ontario, members of racialized communities include newcomers to Canada as well as established immigrant and Canadian- born communities. The percentage of Francophones in racialized groups has also increased in every region. Health equity is about those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable – and thus inherently unjust and unfair. While Ontario does not collect data about racialized communities in a consistent manner, there is growing indication that racialized communities have poorer access to the determinants of health – income, education, employment, housing, etc. – and poorer health outcomes. When the issue of racism and discrimination are added to this, racialized groups become even more vulnerable and inequities in health are compounded. The project literature review discusses this in detail.
Building Capacity for Equity in Health Promotion The Building Capacity for Equity in Health Promotion project 2, funded through the Healthy Communities Fund of the Ontario Ministry of Health Promotion and Sport, focussed on addressing inequities in health experienced by racialized communities especially low income communities. It did this by working with those who promote health in these communities, people in public health, community health centres and in community organizations, to build capacity to reduce health inequities for racialized groups. Specifically, the project focussed on physical activity, mental health promotion, and healthy eating, re-defined by the project as healthy eating/food security. How and why racialized communities face marginalization and exclusion in relation to access to the determinants of health, and positive health outcomes must be understood if we are to reduce health inequities. Policies and practices can systemically disadvantage racialized communities, including racialized francophone communities. This can happen even if it is not intended. Health equity research shows that taking a whole of population approach to health promotion and health education runs the risk of actually widening inequities, because advantaged groups are in a better position to access and take advantage of information, incentives and programs. Because of this, equity needs to be considered at all levels – policy s e i t
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3 Addressing Health Inequities for Racialized Communities
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4 Addressing Health Inequities for Racialized Communities Overview
Definitions and Basic Concepts 3 To be healthy and to have physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living (Ottawa Charter for Health Promotion, 1986). Health inequities are differences in health that are unfair and avoidable because they result from social and health conditions, policies and practices that can be changed. Resources for health include access to the social determinants of health such as adequate income, employment, safe housing and working conditions, nutritious food, and freedom from discrimination and violence, etc. These social determinants of health are based on evidence and also have a foundation in human rights declarations, charters and laws. The social determinants of health (SDOH) and the social determinants of health inequity (SDHI) are not the same. The latter focuses on distributive aspects and on structural and social arrangements that create health inequities. The World Health Organization (WHO) defines health promotion as “the process of enabling individuals and communities to increase control over the determinants of health ” partly through political actions, creating a healthier environment. Health Promotion is not merely about educating people to change their behaviour, although it is often seen as focussing on healthy lifestyles. In actual fact, health promotion is about changing the conditions under which people can lead healthy and fulfilling lives. Racialization is the process where racial categories are socially constructed as different and unequal in ways that lead to social, economic and political impacts 4 . The Ontario Human Rights Commission (OHRC) describes communities facing racism as “racialized.” The OHRC Policy and guidelines on racism and racial discrimination states: The term “racialized person” or “racialized group” is preferred over “racial minority,” “visible minority,” “person of colour” or “non-White” as it expresses race as a social construct rather than as a description based on perceived biological traits. Furthermore, these other terms treat “White” as the norm to which racialized persons are to be compared and have a tendency to group all racialized persons in one category, as if they are all the same. Racialized groups refers to the populations earlier identified by Statistics Canada as “visible
minorities” a term that Statistics Canada has recently discontinued. It has instead been s e i t i replaced by the term “population groups”. n u m m
Statistics Canada’s category of “Population Groups” is based on the Employment Equity Act o C
which defines them visible minorities as “persons”, other than Aboriginal peoples, who are d e z i l
non-Caucasian in race or non-white in color.’ Categories include: Chinese, South Asian (East a i c a
Indian, Pakistani, Sri-Lankan, etc.), Black (e.g. African, Haitian, Jamaican, Somali), Filipino, R
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4 Grace-Edward Galabuzi, 2001. Canada’s Creeping Economic Apartheid, The economic segregation and d A social marginalization of racialised groups. Toronto, ON. CSJ Foundation for Research and Education A Resource Guide 5
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e F a
t u t t c
i
e s l l a l r a c r h i i s t n r o a b i i y e n r t i o n s e e i o z t e o s i r r c o i e , a e f l
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n t a
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t t r n i m c t . i o r q n f s
t c a n y . i c
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u o m t o c c h s n t e l r x r l d a t s l h e n i i f i i ” A , a
s u c t n u s s l p
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i h b
r R r l m t , g n o e u l f t
a i e y y e i s n f d t l , o s ” y e u , r c e
G u i d e
6 Addressing Health Inequities for Racialized Communities Capacity building is recognized as important for sustainable health promotion programs and initiatives. Capacity refers to “the actual knowledge, skill sets, participation, leadership and resources” required by community groups to effectively address local issues and concerns. For people in the field of health promotion, building capacities refers to the particular types of services, programs and even goods they must provide to help communities, individuals or organizations address their health issues. Capacity for health promotion means having the knowledge, skills, commitment, and resources at the individual and organizational levels and in the wider environment to conduct effective health promotion. The Health Promotion Capacity Checklists: A Workbook for Individual, Organizational, and Environmental Assessment , from the Prairie region health Promotion Research Centre in Saskatchewan are useful tools for health promoters and their organizations to assess their own capacity. The figure below is taken from the workbook and helps conceptualize elements of capacity.
Figure 1. The elements of health promotion capacity
ENVIRONMENT Public Opinion
ORGANIZATIONS
Commitment
Ideas INDIVIDUALS and other Resources Culture Political Knowledge Will Resources Skills Commitment Resources
Structures s e i t i n u m m
Supportive Organizations o C
d e z i l a i c a R
r o f
From Health Promotion Capacity Checklists: A Workbook for Individual, Organizational, and Environmental Assessment s e i t i u q e n I
h t l a e H
g n i s s e r d d A
A Resource Guide 7 Continuum from Colour Blind to Anti-oppression Health promotion programs and initiatives are often developed to serve “diverse communities” or “multicultural populations” or “immigrants and newcomers”, rather than addressing health equity for racialized communities. These differences in terminology can hide underlying assumptions and reflect different approaches to health promotion. A useful way of looking at our work is to use the framework to address racialized health inequities developed through the project literature review, from “colour blind” to “culturally appropriate” to “anti-racism/anti-oppression.” The table below provides an overview. For details, see the literature review. s e l p Universalism/ Diversity/Cultural Anti-racism/ m a x Colour blindness Competency Anti-oppression E
n o i t Provide everyone Cultural competence emerged in the Antiracism calls for a critical p i r
c with the same 1990s is defined as “comprehension examination of how dynamics of s e
D treatment. of the unique experiences of social difference (race, class, gender, Majority-group members from a different culture sexual orientation, physical ability, behaviours, values through awareness of one’s own language, and religion, country of are the norm, culture, empathetic understanding origin) influence daily experiences “neutral” . of oppression and critical often through institutions and Focus is on assessment of one’s own privilege, inequitable access to resources and tolerating rather resulting in the ability to effectively power and the historical, social, and than accepting and operate in different cultural political processes that have valuing diversity. contexts” (B). institutionalized and continue to Diversity competence includes maintain such unequal power valuing diversity moving beyond (Dei,1996 Ng1991, Young 1995). accommodating it (J). Anti-oppression perspectives put structures of oppression and discrimination at the centre of analysis, attending to the diversity of oppression and their interlocking nature in order to eradicate oppression. Intersectionality implies examining how identities, social locations experiences and systems of s
oppression, along multiple axes of e i t i n
oppression (including race, gender, u m
class, religion, ethnicity, ability, etc.) m o C intersect in ways that shape d e z i experience and the configuration of l a i c
power in society. Attention only to a R
r o
race or class is insufficient if it f
s e i
neglects the impact of other t i u q
dimensions of identity/location (SH) e n I
h t l a e H
g n i s s e r d d A
A Resource Guide 8 T s a p f U o o n h r s r i m t e o
i R s i n A -
r o e H a g o i o e p p R c t b s o o c t d r t P A I E P m x
r e c r
i p o h y h t e d o f r e e e e z g d c r i r r n i n
s g l a i a
c e s p o a v l r p l a e e p c o o e t a i o u i e t s a n n t e h f e r s a l m n i g e n r i d u
g
l f t d s n , m m l t o e d g - a t e i c n e
i h i e
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l e i r i z
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e E e e s v
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a r h n n i e e i
q h
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G u i d e
9 Addressing Health Inequities for Racialized Communities
T T t s r O T H O l d c r e i T m p a I a m r T h A h m B L b o s n e o a a t h x d n t t h h h h h o a e
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w o o r d c e a e s g s p a l l o
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G u i d e 1
0 Addressing Health Inequities for Racialized Communities p e a I e r a s u f c f s E o s D e Y b T t a r e u t u o x n x n a n n
r h a u n o i r c i a i s p a p c s n d d d d u g e t a i v n t l d m h
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G u i d e 1
1 Addressing Health Inequities for Racialized Communities
w p t t o A d t H p c T F H P Y u i c u m h o a r o o o p r o o e r n
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3 Addressing Health Inequities for Racialized Communities Who is accessing/benefiting from our Key Equity Program programs? Who is not? What are the Evaluation barriers, differentials impacts? Questions What can we do to change that?
Who are the community stakeholders that we Knowledge can exchange knowledge with? How can we Exchange engage them, learn from them? Are we relevant? Understood? Is our information useful? Is there a sense of community ownership over this knowledge?
Why are some people at greater risk? Where are the people we need to learn more about? How can we reach and engage them Research in our inquiry? What is the lived experience of specific groups? How does that experience relate to health outcomes and our goals? How are our actions relevant to specific populations?
What are the unique social and environmental conditions of this Assessment & community? Who is at risk? How can we design data collection to Surveillance learn more about relationships between SDOH and health outcomes, behaviours, and knowledge? How can we improve our surveillance systems and build ones that collect data we need?
From: Patychuk D and Seskar-Hencic D. November 2008. First Steps to Equity. Ideas an Strategies for Health Equity in Ontario 2008-2010. Toronto.
The Community Health Centre model is one that recognizes health inequities, and works from a community based perspective to provide health care as well as health promotion services to local communities. The Association of Ontario Health Centres recognizes health inequity, and operates from an anti-oppression perspective as described above. In Toronto, the Taibu CHC is specifically focussed on working with the Black community, based on a recognition of racialized health inequities. This underlies the work of the whole organization and the programs and services it offers. Another CHC that names and works to address racialized health s e i t inequities is the East Mississauga CHC . i n u m
A useful new resource is the Evidence Informed Practice Workbook, 2nd edition m o C
(September 2010) , from Unison Community and Health Services, Toronto. This practical d e z i resource produced in a Community Health Centre will be of tremendous use to health l a i c promoters and managers in their work. Although framed as evidence-informed practice, it has a R
r o a strong equity focussed analysis that will help in addressing health among racialized f
s e i communities. t i u q e n
Many community organizations are actually doing health promotion, even though they may not I
h t l
describe their own work in that manner. Count Me In is an initiative about inclusion, defined as a e H the feeling and reality of belonging. Inclusion is a health promotion strategy. A toolkit produced g n i by the project helps practitioners develop inclusive and equitable programs with communities. s s e r
Starting from the premise that communities can define what is good for them, it offers a d d discussion, a workbook and worksheets that helps practitioners to engage communities as A they plan programs with them. A Resource Guide 14 The Pan American Health Organization’s Guide for Documenting Health Promotion Initiatives can be adapted for use at the program planning stage, in terms of what an equity focussed health promotion intervention should look for. The following processes are identified that make for a successful health promotion initiative, including equity elements: w Meaningful participation of all stakeholders w Critical dialogue w Shared power and responsibility w Project action planning and evaluation w Evolving leaders hip w Sustained mobilization of resources w Critical reflection and systematic monitoring w Ongoing educational and training opportunities w Develop and attract champions w Generate public awareness of evidence-based project successes w Influence public policy and decision-making bodies w Work with relevant social movements, private sector organizations and advocacy groups w Improve knowledge exchange and community-academic partnerships The National Collaborating Centre for Methods and Tools is a place to find information and self learning tools for your work. Local level data is important for program planning. In 2010-11, all 36 Healthy Communities Partnerships (most of them integrated with the local Public Health Unit) were engaged in extensive data collection to create a snapshot of the overall health of their communities together with recommended actions for 2011-12. This was part of an exciting new initiative undertaken through the Healthy Communities Fund of the Ontario Ministry of Health Promotion and Sport that can have impact on reducing health inequities. To find out more about the Healthy Communities Partnership in your area, please contact your local Public Health Unit. Click here to find your local Ontario public health unit. Primer to Action: Social Determinants of Health , is an electronic resource for health professionals, lay workers, volunteers and activists from different sectors to understand and influence how the social determinants of health impact chronic disease. Set in an electronic, easy to read format, with hundreds of links and resources, it is a practical resource for busy health and community workers, activists, in their capacity as staff, volunteers or community members. s e i t i
Primer to Action provides a point of entry to understand and take action on six health n u determinants: Income, Employment, Housing, Food Security, Education and Inclusion. It offers m m o C concrete suggestions for change in the community, the workplace and the broader society. d e z i l
Toronto Intensive Research on Neighbourhoods & Health Initiative (Toronto-IRONhI) a The i c a
project looks at how “health opportunity structures” differ across neighbourhoods and affect R
r o f health outcomes. Its primary objective is to improve understanding of the pathways and s e i t mechanisms linking neighbourhoods and health and to inform policy and community action i u q about how neighbourhood-based interventions could address health disparities. e n I
h t l a e H
g n i s s e r d d A
A Resource Guide 15 One of the products to come out of this project is the Centre for Research on Inner City Health – Rapid Assessment Tool for Small-Area Health Needs . This tool was developed to quickly and reliably assess small-area health status and health needs for use by decision- makers and service providers as well as community groups and non-profit providers of publicly-funded services. The tool allows users to collect information on several topics including health status, health care use, health behaviours and neighbourhood services. A ’tool kit’ has also been developed that includes a manual and user guide as well as a set of best practices for knowledge translation to guide potential users from the survey planning stage all the way to the final stages of data interpretation and dissemination. Geographic and Numeric Information Systems is an initiative of the Social Planning Network of Ontario that uses Geographic Information Systems as a powerful tool to aid in planning and decision making. People Places Processes is an equity-focussed health promotion workbook from Australia, based on a useful differentiation of equity aspects into equity of access, opportunity and outcomes, suggesting population wide, targeted, place-based, plus a lifecourse approach to interventions. A list of questions to use as programs are planned helps embed equity into the work of health promotion.
Evaluation This resource guide does not contain a separate section on evaluation. However, there are evaluation related suggestions in some of the resources referred to above. Here are some further links. Working Together: The Paloma-Wellesley Guide to Participatory Program Evaluation is a recent publication directed especially to non-profits who provide frontline services. The guide identifies the element of participatory program evaluation. w Proactive and Inclusive w Moves from Fault Finding to Collective Learning w Changes the Invisible to Visible w Increases Relevance and Meaning w Increases Credibility w Builds Evaluation Capacity w Provides Comprehensive Information for Better Decision-Making w Transparent and Accountable s e i t Within this broad equity focussed approach to evaluation, the website Evaluation Tools for i n u
Racial Equity contains a step by step guide with associated tips and tools to assist in m m o
evaluating initiatives to address racial equity. Racial Equity Tools , a companion site provides C
d e
further materials. z i l a i c
This Equity Evaluation Tool from Australia can be used as a guideline for evaluating equity a R
r o components of community interventions. According to it, practitioners must be able to f
s e i a) articulate the equity issue, b) situate their activity and c) describe the pathway linking their t i u q
program or practice to health equity. Each step is broken down into suggested questions to e n I
ask, to build in an equity lens. h t l a e H The Prevention Institute (US) website provides further discussion and tools on evaluation from g n i a health equity perspective. s s e r d d A
A Resource Guide 16 Further Resources w The OHPE and le Bloc-Notes offer searchable databases of information on health promotion w The CERIS virtual library is an excellent source of research w The National Collaborating Centres for Public Health with a focus on knowledge exchange are important sources of information w The Canadian best practice portal on chronic disease prevention has a searchable database of best practices in chronic disease prevention. w Many local health units put out equity focussed reports and fact sheets about their community (e.g. Region of Waterloo, Sudbury and District Health Unit, Toronto Public Health, Peel Health), as do Local Health Integration Networks. w Ontario Council of Agencies Serving Immigrants (OCASI) is an umbrella agency that is a voice for issues of immigrants in Ontario that has a number of papers and reports on their website. w Social Planning Networks and research departments of universities are also good sources of information w Health-evidence.ca w Health Equity and Prevention Primer (US) – http://www.preventioninstitute.org/tools/focus-area-tools/health-equity-toolkit.html w This award winning documentary and educational website www.unnaturalcauses.org (US) has a wealth of information and resources that can support equity initiatives.
Health Promotion Initiatives The following section lists overall health promotion initiatives, as well as initiatives in the three focus areas of Mental Health Promotion, Healthy Eating/ Food Security, and Physical Activity that offer promise for addressing racialized health inequities. In each section are also links to tools and resources that can be used.
Mental Health Promotion Mental health is an integral part of health. Mental health can affect physical health and the other way round. Level of income, job security, access to food, education, social inclusion, etc. are factors that affect us both mentally and physically. A growing body of research into areas of newcomer mental health, indicators of discrimination, refugee trauma, etc., is deepening our understanding of the mental health of racialized communities, and potential areas for action. s e i t The literature review provides ample documentation to show how racism and discrimination i n u
can affect the health of racialized communities. m m o C The Canadian Mental Health Association’s (CMHA) Mental Health Promotion Toolkit is a good d e z i starting point to understand the concept of mental health promotion, and to learn from l a i c
effective practices in the field. a R
r o f The Centre for Addiction and Mental Health resource Best practice guidelines for mental health s e i t promotion programs: Children & Youth offers examples of effective mental health promotion at i u q e
work. It identifies the following guidelines for doing this work. n I
h t l
1. Address and modify risk and protective factors that indicate possible mental a e H
health concerns. g n i s s e
2. Intervene in multiple settings, with a focus on schools. r d d A
A Resource Guide 17 3. Focus on skill building, empowerment, self-efficacy and individual resilience, and respect. 4. Train non-professionals to establish caring and trusting relationships. 5. Involve multiple stakeholders. 6. Provide comprehensive support systems that focus on peer and parent-child relations, and academic performance. 7. Adopt multiple interventions. 8. Address opportunities for organizational change, policy development and advocacy. 9. Demonstrate a long-term commitment to program planning, development and evaluation. 10. Ensure that information and services provided are culturally appropriate, equitable and holistic.
Opening Doors is an innovative project that offers interactive peer-led workshops that address mental health, racism and discrimination. This project is coordinated by the Toronto branch of the Canadian Mental Health Association, Across Boundaries Ethnoracial Mental Health Centre and Access Alliance Multicultural Health and Community Services, and is focused on strengthen - ing, fostering and cultivating healthier communities in Ontario. Click here to view a presentation made at the Facing Racism in Health Promotion event organized as part of the project.
The Centretown Laundry Coop is a great example of an initiative that promotes mental health, even while it is not explicitly stated as such. It provides affordable laundry to people on low incomes in a safe supportive environment where at the same time they can develop and use their skills to improve their quality of life and contribute to the community. The Laundry Co-op is the only one of its kind in North America. www.communitylaundrycoop.ca
PEACH – Promoting Education and Mental health supports at-risk youth and their families by responding to their needs and providing opportunities for quality relationships, education, and skills development. As an alternative to street violence, PEACH offers youth the academic, social and economic tools to stay in school, gain employment and make positive life choices during their formative years 6.
Refugee Mental Health – Promising Practices and Partnership Building Resources is for people s e i t i who work with refugees in Canada, particularly those who provide settlement, health and other n u social support services. The material is written for front line workers, program managers and m m o C the leaders of agencies, and is informed by their ideas and expertise. d e z i l
India Rainbow Community services of Peel runs innovative programs for seniors including a a i c a
highly successful Adult Day Program where seniors are brought to the centre and are engaged R
r o f throughout the day in preventative and curative wellness programs. s e i t i
Women of the World is a program at the London InterCommunity Health Centre that provides u q e n I
a space for women to support each other, develop skills and enhance their health. h t l http://lihc.on.ca/immigrant-and-ethno-cultural-communities/ a e H
g n i s s e r d 6 This description is taken from: http://www.evaluationontario.ca/Events/RossiterWilsonPargassingh.html d A
A Resource Guide 18 m c o a d H c i y C d g t T t a w T F H E T t h t n o o e h o o r d o p e f r h o h e e m o r e i e e a m
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G u i d e 1
9 Addressing Health Inequities for Racialized Communities The Peer Nutrition Program of Toronto public health delivers culturally and linguistically appropriate nutrition programs to parents, grandparents and caregivers of children aged six months to six years in diverse underserved communities. By providing tools, resources and skills in culturally appropriate languages, the program increases knowledge and access to healthy eating on a budget. Community specific food guides for the city of Toronto are available here – www.greenbelt.ca/resources FoodNet Ontario is a food security network whose goal is to support a province-wide network to increase the capacity of Ontario communities to provide access to safe, affordable, nutritious and culturally appropriate food by: w bringing people, ideas and resources together w facilitating communication and collaboration among organizations; w educating the public and key decision-makers about community food security; and w promoting best practices. Food Secure Canada is an organization that works to build food security in Canada and globally. Everybody’s Food Budget Book from Ottawa public health shows how to shop and cook on a limited income. This successful resource is being used by a number of other health units in Ontario, including Durham, Renfrew and others.
Further Resources Windsor Essex County, is one of the areas on the province to have faced growing poverty as a result of the recession. The area has been active in matters relating to food security and recently set up a Food Matters Committee in 2010 to look at food security. http://pathwaytopotential.ca/docs/Windsor- Essex%20County%20Community%20Food%20Matters%20Report.PDF The CHC Food Security Handbook provides a description of food security initiatives undertaken by CHCs in the GTA that will be useful to others who want to start similar initiatives in their communities. Making the Business Case for Good Food Box Programs – this scan outlines what a good food box program is and how to go about setting up one in a community. http://ohcc-ccso.ca/en/webfm_send/501
Physical Activity s e
The importance of physical activity for health cannot be limited to education about this for i t i n members of racialized communities. A shift from lifestyle focussed interventions to the u m upstream conditions under which people can be physically active and healthy, including m o C
income, employment, access to food, education, housing are often more important to d e z i l
address. At the same time, access to facilities for sport and recreation that are inclusive and a i c non-discriminatory are also important. a R
r o f
s e i t i u q e n I
h t l a e H
g n i s s e r d d A
A Resource Guide 20 The Ontario Council of Agencies Serving Immigrants has created an Inclusive Model of Programming in Sport and Recreation for Immigrant and Refugee Youth , that incorporates anti-racist principles. The 12 elements of the model are w Combine education with sports and recreation activities w Introduce familiar and popular sports and recreation activities w Encourage Parental involvement w Develop youth leadership by offering basic training in officiating and coaching w Build working relations and collaborations with other service providers w Ensure that facilities are within geographical reach of youth w Develop supportive internal organizational structure and top management support w Create Funding Opportunities and develop strategies for working with funders w Mobilize Communities w Ensure Programming Reflects diversity and cultural sensitivity w Operate under an anti-oppression and anti-racism framework w Acquire transportation for youth Recommendations include: w Bring together community-based, immigrant- and refugee-serving organizations to implement the model w Promote the model to mainstream sports and recreation organizations w Promote dialogue and collaboration between the settlement agencies and mainstream organizations w Train staff and recreation leaders w CIC should include the sports and recreation component in settlement funding
Systemic ways in which neighbourhoods inhabited by communities of colour can be disadvantaged when it comes to playground facilities can be seen in this story by Catherine Porter in the Toronto Star. Next read about the response of local women – the Thorncliffe Park Women’s Committee – and how their determination and collective action addressed playground access for their children. s e i t i n u m
The YOUNG MUSLIMAHZ program of the Scadding Court Community Centre, Toronto offers m o C a social/recreational program with diverse athletic, social and arts-based activities like cooking, d e z i skating, basketball, arts & crafts, workshops, women’s only swimming, field trips and more. It l a i c
provides a place for Muslim and non-Muslim young women to come together to make friends, have a R
r o
fun, learn, develop skills, build confidence, be active in the community and explore the intersection f
s e i
between different faiths and cultures. t i u q e n I
h t l a
The Recreation Access for Children and Youth of Hamilton’s Diverse Communities: Opening e H
g
Doors, Expanding Opportunities report, outlines the challenges and barriers facing racialized n i s s communities when it come to sport and recreation with excellent suggestions on how to e r d address these. d A
A Resource Guide 21 PADEC (Promoting Physical Activity Among Diverse Ethno-cultural Communities), is a collaborative project between university researchers, public health professionals and peer educators whose role is to work with immigrant communities to increase their healthy behaviours and decrease barriers to health and social services. The programs described in this article from the Ontario Health Promotion E-Bulletin provide further examples of how physical activity programs with an equity focus can be created in partnership with racialized communities.
Service Delivery The best designed programs can fail if they are not delivered appropriately. Programs and services need to be accessible (in all senses of the term), equitable, and delivered in a welcoming and non-discriminatory manner. Recruitment of appropriate staff is important, and training staff in anti-racist and culturally competent service delivery are factors that organizations must pay attention to. Across Boundaries , an ethnoracial mental health centre has deepened its understanding of anti-oppression principles and what they mean for day-to-day work in their agency. This How We Do It manual presents what they have learned over their many years of work. They identify the following principles underlying an anti-racist service delivery model 7: Racism, racial abuse and racial violence affect the health and mental health of individuals and communities . In other words, racism is itself a distinct social determinant of mental health, as well as a root cause of other social determinants of health, such as poverty or inadequate housing. Individual and systemic racism present barriers to quality health and mental health services. These barriers include the inappropriate use of interpreters, culturally-inappropriate treatment methods, and traditional mental health providers who impose their own values and perspective on populations they know very little about. These barriers deter racialized people from using mental health services, or lead them to defer seeking help until they are in desperate need. The way to multiculturalism is through anti-racism. Some organizations aim to improve their services by adopting “culturally competent” approaches. These approaches can be a good first step. But only an anti-racist analysis can truly respond to the underlying sources of ongoing trauma – not just of culture shock, but of ongoing racism and unmet expectations –
or lead to the organizational and structural changes needed in the mental health system. s e i t i n
There is a diversity among racialized people who , in addition to race, may also be u m discriminated against on account of their religion, language, ethnicity, class, gender, sexual m o C
orientation, disabilities, age, country of origin and citizenship status. Truly holistic care must d e z i l
respond to the intersectionality of all forms of oppression. a i c a R
Anti-racist practice is a strategic approach to addressing all forms of oppression in the r o f
mental health system. A focus on racism does not mean we are competing with other “isms” s e i t i or are creating a hierarchy of oppressions. Instead, we see anti-racism as an entry point. We u q e n believe that any substantive progress made through anti-racist practice will lead to meaningful I
h t l change in addressing all inequities and oppression in the mental health system. a e H
g n i s s e r d d A 7 Text taken from actual manual. A Resource Guide 22 A study by Ilene Hyman and Sepali Guruge 8 on promoting health among new immigrant women has the following recommendations to make: w Use behaviourally-focused strategies, recognizing that many cultural concepts with potential relevance to health practices (e.g., collectivism, ethnic identity) have not been adequately researched. w Focus on reducing informational, cultural, linguistic, economic and systemic barriers to care. w Use an empowerment philosophy. w Use community “link leaders”, leadership and the media. w Involve the community in planning, design and delivery of interventions. w Be dynamic, as immigrants’ attitudes, beliefs and behaviours change as part of an acculturation process.
Taking Culture Seriously is a research program that brought together a variety of university and community partners to explore, develop, pilot and evaluate effective community-based mental health supports for people from diverse cultural communities based on principles of self-determination and racial equity.
Values • Individual and community self determination • Dynamic inclusion • Relational synergy
e G c u r i o d f e n i Reciprocal collaboration e R • Mental health policy-makers/planners • Mental health organizations/practitioners • Culturnal-linguistic communities
Outcomes Actions • Improved acceptability and
accessibility of services • Enhanced communities s e i t • Reconstructing the mental i
• Better mental health promotion n and illness prevention health system u m m
• Increased evidence that culture • Building reciprocal o C is taken seriously
relationships d e z i l a i c a R
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Produce f
s e i t i u q e n I
h t l a e H
g n i s
8 s http://www.mendeley.com/research/review-theory-health-promotion-strategies-new-immigrant-women/ e r d d A
A Resource Guide 23
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G u i d e 2
4 Addressing Health Inequities for Racialized Communities Further Resources Strategies for working with newcomer women giving birth for the first time in Canada – this resource has a good discussion of barriers experienced by recent newcomer women and their families (mostly racialized) and many useful ideas and hints that have a wider applicability than just reproductive health. This article contains concrete suggestions on how to work with victims of torture, who may have specific needs.
Some Models and Strategies There are many models that have been found useful by organizations and groups working to eliminate racialized health disparities. Mainstream versus ethnospecific organizations – Ethnospecific organizations often are more successful at serving their communities. Although it is not recent, many points in this literature review by Jeffrey Reitz are still relevant. Related to this is the role that settlement organizations can play in community capacity building. The report from OCASI, When Services are Not Enough , shows how there are positive, unintended consequences that can happen, namely capacity building, even though it is only settlement services that are being funded. The impact of funding cutbacks will run far deeper. One window service – The East Scarborough Storefront is a celebrated example of how a partnership of community members and services working together provides accessible sites for community members of all ages and cultures to find and share solutions they need to live healthy lives, find meaningful work, play and thrive this operates. Peer based service delivery – This report from the Region of Waterloo Public Health offers a good outline of what is meant by a peer program, and what its individual as well as community capacity building and other impacts can be. Peer based models can be beneficial for a number of stakeholder groups: members of the community, the peers who deliver the program, as well as the agencies and local sites where they are delivered, in addition to more long term social impacts. Self-help – Self-help/mutual aid support groups are informal networks of individuals who share a common experience or issue. Members get together to share support. The primary focus of self-help is emotional support, practical support and information exchange. Women’s Health Circles (Ontario Women’s Health Network) – is a tested methodology for educating low income and marginalized women based on field testing with marginalized women and women of colour in Ontario. s e i t i
Photo Voice n – is a more recent tool used to empower communities to take action on issues of u m
concern to them. This example of a research initiative by the Wellesley Institute shows how m o C powerful photovoice can be in addressing health equity issues. d e z i l a Communities of Practice – are a way of people engaging to learn and practice together. An i c a R example of a successful community of practice to address equity issues is one carried out by r o f the Black Creek CHC in Toronto. This was a practical way to enable service providers and s e i t consumers from a defined community to make progress on this issue. The draft report and i u q e
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A Resource Guide 25 Engaging Communities Communities need to be engaged right from the start if health equity issues are to be meaningfully addressed. This takes commitment, time and resources to be done properly. Sometimes frameworks and expectations at the organization end can take precedence over the actual realities of communities, so it is good to build this into the plan itself. “Community engagement is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.” (Fawcett et al, 1995)
Key principles of engagement identified by the Centres for Disease Control and Prevention (US) are: w Purpose w Know the community w Build relationships w Self-determination w Partnership with the community w Recognize and respect diversity w Mobilize community assets, develop community capacity w Flexibility w Long term commitment Read more about community engagement in this report and also in this report . Building community capacity is an important part of health promotion and community development. We begin by looking at community assets rather than deficits and build on these. Read about asset based community development (English), based on the work of Kretzman and McKnight 9. These resources from Health Nexus are based on a similar perspective that communities and groups have strengths that can be mobilized for their improved health. Action for Neighbourhood Change is a series of pan-Canadian initiatives aiming to bring about long term sustainable change focused on community capacity building. This paper s e i t
Asset-based, Resident-led Neighbourhood Development from the Caledon Institute looks i n back at the initial phase of this initiative. The paper “highlights the asset-based, resident-led u m m approach pursued on the ground in the five participating neighbourhoods. It also considers o C
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the roles that government and voluntary sector partners at the national level can play in e z i l a support of such initiatives.” i c a R
Community development is the process by which community capacity is built. On this page, r o f
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A Resource Guide 26 The Ladder of Citizen Participation (see figure below) shows how to engage communities meaningfully. There can be many forms of community involvement, but the key question is how much power communities have to actually influence decision making, and how much accountability there is to communities on the part of decision makers.
8 Citizen Control
7 Delegated Power CITIZEN POWER
6 Partnership
5 Placation
4 Consultation TOKENISM
3 Informing
2 Therapy
NON-PARTICIPATION 1 Manipulation s e i t i n u
From Sherry R. Arnstein – http://lithgow-schmidt.dk/sherry-arnstein/ladder-of-citizen- m m participation.html o C
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A Resource Guide 27 Connecting the Dots is a successful model of community engagement used by Health Nexus to organize over 15 community engagement events over 5 years. CTD is a dynamic, multi-sectoral, community engagement model that helps communities “work together differently” for better health outcomes and improved health for all. Key features: w Creates a climate for creative change and sets the stage for further collaborative work in the community. w Builds capacity through increased knowledge of resources (including people and organizations), as well as specific knowledge about a health-related issue. w Bridges people from across the chronic disease continuum – health promotion, public health, hospitals, community services, and long-term care – and from sectors such as social services, education, housing, and recreation.
Hamilton’s Centre for Civic Inclusion – HCCI is a community-based civic resource centre, committed to working as a catalyst for anti-racist change across Hamilton. HCCI assists Hamilton, its major institutions, business, service providers, and residents to develop transformative processes that promote equity and create racism-free and inclusive environments in all areas of civic life.
Youth Empowering Parents (YEP) – YEP provides the essence of one-on-one tutoring for immigrant parents by utilizing an innovative model. By using one trained ESL instructor, the YEP program is able to teach multiple youths who are fluent in both English and their home native language. These youths then provide one-on-one tutoring to an adult of a similar background – either their own parent/guardian or another parent. The concept for YEP was developed by a diverse group of youths who were seeking to give back to their local community in an innovative way. Following much determination and hard work, the first YEP program was implemented in the immigrant-populated neighbourhood of Regent Park, Toronto.
Further Resources See www.count-me-in.ca for a toolkit on how to engage communities in developing inclusive programmes. This workbook shows how to engage the community to define the outcomes they want, and how to work to influence the determinants of health. Involve Youth 2 is a guide for engaging youth produced by Toronto Public Health, including a s e i
chapter on what it means to engage them using an anti-oppression framework. t i n u
The Vibrant Communities initiative of the Tamarack Institute, engages communities to reduce m m o
poverty. The Tamarack website contains a large number of resources on community C
d e engagement. z i l a i c The Waterloo Public Health Community Engagement Framework is grounded in the new a R
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Ontario Public Health Standards, and provides a four step process of engagement. f
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A Resource Guide 28 The Kit – A Manual by Youth to Combat Racism through Education , is a resource for educators, community leaders, NGOs, peer educators, anti-racism activists – and especially youth – to engage people to take action to combat racism. Anti-Racism Vaccine – This is a winning video for the March 21st, 2006 International Anti-Racism Video Competition done by the students of Holy Names High School in Windsor Ontario. The winning videos were broadcast over various Canadian channels. For more recent winning videos, check out the website: http://www.cic.gc.ca/english/multiculturalism/march21/index.asp Shadeism – this documentary short is an introduction to the issue of shadeism, the discrimination that exists between the lighter-skinned and darker-skinned members of the same community. This documentary short looks specifically at how it affects young women within the African, Caribbean, and South Asian diasporas. Through the eyes and words of 5 young women and 1 little girl – all females of colour – the film takes us into the thoughts and experiences of each. Overall, ‘Shadeism’ explores where shadeism comes from, how it directly affects us as women of colour, and ultimately, begins to explore how we can move forward through dialogue and discussion (description from website).
Partnering and Collaboration Racialized health inequities are complex problems. Because of the intersecting and multidimensional nature of these disparities, solutions must likewise be multi-dimensional, multi-layered and involve all key stakeholders and sectors in a meaningful way. Very often the process of engaging in the partnership will have impacts on the intended outcomes, in addition to strong collaborative relationships that are themselves sought after outcomes.
Ottawa provides a highly successful example of an intersectoral partnership called No Community Left Behind . This is a social development initiative with the objective to prevent crime and address social determinants of health through a collaborative approach and integration of services at the neighbourhood level. No Community Left Behind has now become a strategy development process at the neighbour - hood level in which community development specialists, community policing professionals and neighbourhood activists and almost all concerned service providers collaborate to address factors that lead to communities’ vulnerability, crime, victimization, fear of safety, and social exclusion. Working in close partnership with various other agencies, South East Ottawa Community Health s e i t
Centre (SEOCHC) has effectively engaged and supported communities to restore their sense of i n safety and pave the way for effective service delivery. NCLB has now become a core component of u m m
the City of Ottawa’s Community Development Framework (CDF) for community engagement at o C
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the grassroots level. http://www.nocommunityleftbehind.ca/main_e.htm e z i l a i
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A Resource Guide 29 Diversity Thunder Bay is an anti racism initiative that is taking on racism and discrimination directly through local partnerships. It has multiple partners and continues to grow. A major project has been partnering on institutional change with the police. Their learnings include: w Institutional change, like all change, produces conflict w Institutional change happens slowly, not in a linear way w Perception is reality w Substantiability needs to be built in early to maintain momentum of project work For other anti-racism initiatives in northern Ontario, click here: www.debwewin.ca/antiracisminitiatives.htm
The Region of Peel has taken important steps in addressing in an integrated way the diversity in their region, where large numbers of racialized communities live. These include the multi-stake - holder planning and policy oriented Peel Newcomer Strategy Group , a series of commissioned papers on immigration in Peel , and a Diversity and Inclusion Strategy .
Pathways to Education is a celebrated intersectoral initiative that builds community capacity through supporting youth to stay in school. It began in the Regent Park neighbourhood of Toronto, inhabited mostly by newcomer racialized communities, and is now replicated across Canada. A timely and innovative conference called Building Equitable Partnerships Symposium was organized by the Centre for Addiction and Mental Health and partners in 2008. The report, released in 2011, contains a wealth of insights, learnings and examples of how equity is to be built as partnerships are developed, maintained and evaluated
Further Resources Health Nexus has produced various resources that can help in partnership and coalition building. The Partnerships Analysis Tool from VicHealth in Australia is a “resource for establishing, developing and maintaining productive partnerships” for health promotion. The Partnering Initiative offers a number of tools in multiple languages related to partnering that will be of use to those working in health promotion. Colour of Poverty/Colour of Change is an innovative, multiple stakeholder advocacy based s e i t coalition addressing poverty for people of colour in Ontario. CoP/C is organized through a i n u steering committee and is active provincially through local lead organizations for different parts m m o
of the province. C
d e z i An excellent toolkit for intersectoral action is available from the Public Health Agency of l a i c
Canada . a R
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The Prevention Institute (US) has useful tools to assist in the process of partnering, including s e i t i
how to build coalition as well as a “collaboration multiplier” to interactively assess partner skills. u q e n I
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A Resource Guide 30 Organizational Issues Naming and recognizing racism and other form of discrimination and oppression is fundamental to an organizational foundation that can effectively address health inequities in communities. There can be no wall between change that we wish to make in communities, and the internal structures that facilitate this. Organizations serious about reducing health inequities must build it into their approach and write it into their policies. One of the important things to remember is that intent is different from impact. Organizations may unwittingly discriminate against certain groups of people, and it is not until policies, procedures and practices are examined from an anti-racist, anti-oppression lens that this may become clear. The examples below will suggest ideas and provide a starting place for understanding and action.
An example of an organization that incorporates an anti-oppression analysis into its whole organization is Access Alliance Multicultural Health and Community Services . Based on their anti oppression policy , AA carries out a wide range of programs and services, in health promotion, health care and other areas, and is also a leader in the field of research into issues of racialization and its impact on communities.
Other examples of an anti-oppression policies are those of Sistering, Canadian Council for Refugees , and Immigrant Women’s Services of Ottawa . An example of a project that brings an anti-racist, anti-oppression analysis to the work is the Attachment Across Cultures project in downtown Toronto, working on early child development initiatives.
ACHIEVING CULTURAL COMPETENCE : a diversity tool kit for residential care settings is an excellent resource from the Ontario Ministry of Children and Youth Services which incorporates anti-oppression and anti-discrimination principles at its core. It has an excellent discussion with examples of how there might be visible and non-visible ways in which discrimination and exclusion can occur.
Dancing on Live Embers – challenging racism in organizations is a profound look at racism in organizations and how to address it in a fundamental way. One way to look at how equitable an organization is, is to review and assess policies, procedures and practices through an equity lens. The Diversity Self-Assessment Tool from the s
Health Equity Council provides an excellent checklist for organizations to look at internal e i t i n
policies and practices through an equity lens. u m m
Springtide Resources has produced the following resource that helps organizations o C
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look at their own policies through an anti-oppression lens – Ending violence against e z i l a women – An Integrated Anti-Oppression Framework for Reviewing and Developing Policy: i c a R
A Toolkit for Community Service Organizations is available at r o f http://www.springtideresources.org/resources/show.cfm?id=241 (scroll to bottom of page) s e i t i u q e n I
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A Resource Guide 31 A more comprehensive introduction and workbook is the Creating Inclusive Community Organizations toolkit from the Ontario Healthy Communities Coalition. Cultural Competency – Self Assessment Guide for Human Service Organizations – from the Cultural Diversity Institute, Calgary, Alberta is another tool. OrgWise is a website created through the Organizational Standards Initiative of the Ontario Council of Agencies Serving Immigrants to help set organizational standards in the settlement sector. It contains numerous resources, tools and templates that can be used to build sector capacity.
Further Resources The Ontario Association of Children’s Aid Societies has produced a discussion paper on anti- oppression among children’s aid societies that will be useful for people working in that field. The University of Guelph has produced a useful booklet about racialization, explaining the issue, defining terms, plus offering various suggestions. The Sierra Youth Coalition’s anti-oppression resource guide is another useful resource. The Rant Collective website has a nice discussion of anti-oppression, and offers strategies for how to facilitate workshops using this lens Racial Equity Tools is an excellent site from the US, that has many resources that will be of use in different ways, along many of the ideas discussed in this guide. An Ontario resource is available on this site – Anti-Racist Train the Trainers Programs: A Model by the Doris Marshall Institute, Arnold Minors & Associates, and The Ontario Anti-Racism Secretariat. This secretariat is no longer in existence, but the work done during its time is still valuable. s e i t i n u m m o C
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A Resource Guide 32 Research and Policy These are two critical “upstream” areas where action to address health disparities needs to begin. Frameworks and structures determine in large part what kinds of social outcomes we have. If research and policy interventions do not create the conditions in which advances to equity can be made, then workers and practitioners on the frontline are waging a losing battle. Commitment to a vision, allocation of material and non-material resources, and real (as opposed to tokenistic) accountability mechanisms are needed for real advances in reducing inequities. The People’s Health Equity and Diversity Charter provides a starting point for this. There is growing recognition that health equity needs to be addressed in partnership with communities. The report Act Locally: Community-based population health promotion , by Trevor Hancock, to the Senate sub-committee on population health identifies the key principles on which this is to be based, and highlights examples that show how this can be done. In the absence of such a vision, eliminating health inequities is unlikely to happen. Investing in Community Capacity Building is a paper from the Caledon Institute that discusses the role of community capacity building in neighbourhood revitalization and the implications for the way in which such work is funded. It reviews recent trends in funding practices and discusses the nature of community capacity building, drawing upon the Action for Neighbourhood Change initiative as a case in point. The paper also identifies ten steps that funders can take to advance their efforts 10 . The Prevention Institute (US) identifies the following policy principles to provide guidance for taking on the challenge of addressing health inequities. The principles include understanding the history of racism and segregation, focussing on conditions rather than individual behaviour, meaningful public participation, strengthening neighbourhoods, link equity solutions to global issues, address all age groups especially early life, working across multiple sectors of government and society, measuring and monitoring impact of social policy, giving voice to groups most impacted by inequities, eliminate inequity and invest in community. Research is also needed into the impacts of existing policies. The lit review shows how policies can have unintended, and hidden impacts, contrary to intended outcomes. An excellent example of how policies for schools can widen the gaps is from work done by People for Education . In a report on fundraising by schools, they showed how allowing schools to raise their own funds can result in schools in better off neighbourhoods being able to raise more money, and offer a better education to their students than schools in poorer neighbourhoods. Disparities can widen, even though the initiative was introduced to encourage community participation in schools and education. Facts about poverty tell us that poorer areas are often s
inhabited by members of racialized communities. e i t i n u m m o C
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A Resource Guide 33 The Racial Equity Theory of Change of the Aspen Institute (US) provides a roadmap for how to create social change to address systemic racism and discrimination. Intervention research is an emerging area of research. The Canadian Institute for Health Information has recently published a resource, Population Health Intervention Research Casebook , focussed on health equity based interventions. Health promotion is premised on the idea of population health, rather than healthy individual lifestyles, yet there continues to be a need to understand – and address large populations, sub-populations and individuals. Thus, those aiming to reduce health inequity require easy to use disaggregated data in addition to amalgamated, high-level statistics. This type of data is not yet adequately, or consistently, available, either through data collection by governmental policies and programmes, or through research. The Colour of Poverty/Colour of Change, Access Alliance Multicultural Community and Health Services and the Health Equity Council are engaged in an initiative to streamline access to data collection around racialized health inequities. The Ontario Human Rights Commission (OHRC) resource, Count Me In , provides guidelines for collecting human rights-based data. The Anti-racism and anti-discrimination for municipalities: Introductory manual from OHRC is another useful resource that local governments can refer to. The Office of Equity, Diversity and Human Rights at the City of Toronto contains position papers, reports, and tools, as well as posters and educational materials. The Wellesley Institute is a leading public policy institute focussing on urban health. Health equity is one of its strategic areas of interest. The website contains policy briefs, reports, as well as useful links. This document by Paula Braveman will have wide applicability though intended for poorer countries – Monitoring Equity In Health: A Policy-Oriented Approach In Low-And Middle- Income Countries provides an eight step process in the assessment, intervention and monitoring of reduction in health disparities that is grounded in community involvement which needs to be at the core of reducing health inequities. s e i t i n u m m o C
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G u i d e 3
5 Addressing Health Inequities for Racialized Communities Project Advisory Committee Members
Uppala Chandrasekara , Canadian Mental Health Association (Ontario)
St. Phard Désir , Conseil économique et social d’Ottawa Carleton
Alain Dobi , Réseau de soutien à l’immigration francophone (Centre-Sud-Ouest)
Ann Doumkou , London InterCommunity Health Centre
Peter Dorfman , Toronto Public Health
Elsa Galan , Multicultural Interagency Group of Peel
Michael Kerr , Colour of Poverty
Stephanie Lefebvre , Sudbury and District Health Unit
Sume Ndumbe-Eyoh , Regional Diversity Roundtable of Peel
Cheryl Prescod , Black Creek Community Health Centre
Kelli Tonner , South East Ottawa Community Health Centre
Eta Woldeab , Ontario Council of Agencies Serving Immigrants s e i t i n u m m o C
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