Board of Health July 9, 2020

Home , Haldimand County, Trapped (Gardner novel)

CHANGE TO THE AGENDA July 7, 2020

ADDITION OF COMMUNICATION ITEM

7. A) Jason Burgess 69 Re: Agricultural Advisory Board’s position on preferred practices with COVID19 and Management’s response

ADDITION OF GENERAL ANNOUNCEMENTS (ITEM 11) (remaining agenda items to be renumbered accordingly) Haldimand-Norfolk Health Unit – Board of Health

July 7, 2020 2:00pm Council Chambers 2nd Floor County Administration Building 50 Colborne Street South, Simcoe

1. Approval of Agenda/Changes to the Agenda

2. Disclosure of Pecuniary Interest

3. Consent Items

A) Staff Report HSS 20-08 3 Re: Children’s Oral Health Information Report

4. Adoption/Correction of Board of Health Meeting Minutes

A) Special Board of Health - June 30, 2020 (Open and Closed) 9

5. Deputations

6. Presentations

A) Staff Report HSS 20-04 13 Re: Social Determinants of Health

B) Staff Report HSS 20-07 21 Re: Vector-Borne Disease Program Update

7. Communications

8. Staff Reports/Discussion Items

A) MOH COVID-19 Update (no copy)

B) Staff Report HSS 20-03 31 Re: Community Needs Assessment Report 9. Notice of Motions

A) Member Columbus and Member Martin 65 Re: HNHU Consultation with Norfolk County Agricultural Advisory Committee

10. Motions

11. Confirming By-Law

A) By-Law 2020-08-BH 67 Being a By-Law to Confirm the Proceedings of The Board of Health for the Haldimand-Norfolk Health Unit at this Board of Health Meeting held on the 7th of July, 2020.

12. Adjournment

Contact Information

Stephanie, Deputy County Clerk

[email protected]

Meeting schedules available online at http://www.norfolkcounty.ca/council_meetings/ Return to Top

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Advisory Committee Meeting – June 18, 2020

Board of Health – July 07, 2020

Subject: Children’s Oral Health Information Report Report Number: HSS 20-08 Division: Health and Social Services Department: Haldimand Norfolk Health Unit Purpose: For Information

Executive Summary:

This report provides an update to the Board of Health on the children’s oral health programs. The objective of oral health programs is to improve oral health by providing preventive and referral services for low income children and youth families.

Background and Discussion: Good oral health is essential to overall health and quality of life. Good oral health means being free of mouth and facial pain, cavities, periodontal (gum) disease, and any other negative issues that impact our mouths (World Health Organization). The Health Unit’s Oral Health Program provides programs and services as outlined in the Ontario Public Health Standards (2018) and related protocols.

Oral Health Screening The Oral Health Screening Program in schools and community clinics identify children with urgent and non-urgent dental needs. Oral Health staff then facilitate referral to care so that children receive necessary dental care. This program screens all junior kindergarten, senior kindergarten, and grade 2 students. In schools that have been identified as needing a higher screening intensity, students in additional grades are also screened. In 2018/2019 screening occurred at all 38 publicly funded elementary schools and two private schools.

Oral Health Screening indicators 2018/2019 school year Deliverables Achievement % of JK, SK and grade 2 students screened 100% # of children screened (any grade) 3,352

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% of children identified with urgent need 10% % of children identified with non-urgent need 7.2%

Healthy Smiles Ontario (HSO)

HSO is an Ontario government-funded basic dental program. HSO provides preventive and restorative services for children and youth of low income families, who are 17 years of age or under. Oral Health staff facilitate enrollment in HSO based on clinical need identified during screening and financial eligibility. If a student has large and obvious decay into the second layer of the tooth, pain, trauma, infection, pathology or hemorrhage, they are considered in urgent need of treatment. These students clinically qualify for the Essential or Emergency Services Stream (EESS) of HSO. The EESS stream of HSO is delivered by participating dental offices in the community. Students that have smaller decay in the enamel of tooth are classified as having non-urgent decay. These clients can access preventive care through HSO clinics at HNHU office locations in Simcoe, Dunnville and the Langton area.

Due to higher rates of tooth decay, the Mennonite population of children living in the Southwest area of Norfolk are considered a priority population for the Oral Health Program. To better serve families, dental staff attend the Help Centre Night one evening per month to provide oral health screening, topical fluoride varnish applications and facilitate enrollment in HSO.

Healthy Smiles Ontario Program Indicators, 2019 Deliverables Achievement # of unique HSO-PSO clients receiving PSO clinical 465 services # of children screened in HSO preventive clinics 1,020 # of children identified through HSO preventive 421 clinics with urgent needs # clinical appointments in preventive clinics 491

Targeted Oral Health Programs

The Health Unit also provides targeted interventions to schools that screen at a high risk intensity level. One program offered is a tooth brushing initiative where students brush as part of their daily school routine. The other school level intervention is the fluoride program where students can receive fluoride varnish applications at school two times per year. Due to limited resources, these programs are only offered to one or two schools per year.

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Oral Health Program, targeted intervention indicators, 2018/2019 school year Deliverables Achievement # students participating in tooth brushing program 359 # fluoride varnish treatments applied through 530 school program

As seen in Figure 1 below, the oral health of children and youth in Haldimand and Norfolk Counties has improved. This is evidenced by the decreasing percentage of screened children identified with urgent and non-urgent dental needs over the past five years. In the 2014/2015 school year, 14.2% of those screened were identified as having urgent dental concerns and in the most recent 2018/2019 school year this number dropped to 9.6%. There was a more significant decrease observed in children with non-urgent tooth decay from 17.5% in the 2014/2015 school year to 7.2% in 2018/2019 school year. When urgent and non-urgent are combined, the decrease is from 31.7% to 16.8% of children with decay or other dental issues.

Figure 1. Percentage of children screened in schools with urgent dental needs and non-urgent decay 2014-2019

40.00% 35.00% 30.00%

25.00%

20.00% 15.00% 10.00% 5.00% 0.00% 2014/2015 2015/2016 2016/2017 2017/2018 2018/2019 School Year

Urgent Need of Treatment Non-Urgent Decay Urgent and Non-Urgent

Financial Services Comments:

Norfolk The report as presented does not contain any direct financial implications.

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The Approved 2020 Haldimand-Norfolk Health Unit Operating Budget includes $97,300 for the Oral Health Program funded by the Ministry of Health ($62,200), Norfolk ($20,800) and Haldimand ($14,300) Counties.

The Approved 2020 Haldimand-Norfolk Health Unit Operating Budget includes $326,500 for the Healthy Smiles Ontario Program funded by the Ministry of Health ($193,400), Norfolk ($78,900) and Haldimand ($54,200) Counties. Note that the program was previously funded at a 100% capped expenditures model in 2019 and has since changed to a 70%/30% cost share model in 2020, resulting in a year-over-year funding decrease of $136,300.

Expenditures not funded by the Ministry are shared between Haldimand and Norfolk Counties as per the cost sharing agreement.

Haldimand Haldimand Finance staff have reviewed this report and agree with the information provided by Norfolk Financial Services.

Interdepartmental Implications: Norfolk

Haldimand Staff have reviewed this report and have no further comments.

Consultation(s): N/A

BOH Strategic Plan Linkage: Communication: enhanced HNHU’s internal communication process through development of this Board of Health report.

Healthy Supportive Environments: continue to create healthier spaces for children and youth by providing dental screening in all schools and dental services in communities of need.

Strategic Plan Linkage: This report aligns with the 2019-2022 Council Strategic Priority "Focus on Service".

Explanation: HNHU focuses on seamless delivery of service in health promotion and disease prevention to the residents of Haldimand and Norfolk Counties and local stakeholders.

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HNHU staff facilitate the enrollment of children and youth into the HSO program to help ensure they receive the dental care they need. HNHU strives to build strong partnerships with community partners and continues to develop its relationship with the public and separate school boards. This relationship has led to smooth oral health screening in schools.

It also supports Haldimand County’s vision to meet community needs and make Haldimand County a great place to live.

Conclusion:

HNHU’s ongoing oral health programs continue to work towards program outcomes to improve the oral health of children and youth and to improve access to oral health care for children and youth from low-income families.

Recommendation(s) of Health and Social Services Advisory Committee: As presented in Staff Report HSS 20-08

Recommendation(s): THAT Staff Report HSS 20-08 Children’s Oral Health Information Report be received as information.

Attachment(s): None.

Submitted By: Reviewed By: Marlene Miranda Dr. Shankar Nesathurai General Manager, Health and Social Medical Officer of Health Services For more information, call: For more information, call: 519-426-6170 ext. 3260 519-426-6170 ext. 3120

Prepared By: Prepared By: Syed Shah Julie Richardson Manager, Health Promotion Program Manager, School Health Team For more information, call: For more information, call: 519-426-6170 ext. 3749 519-426-6170 ext. 3370

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Haldimand-Norfolk Health Unit – Special Board of Health

June 30, 2020 2:00pm Council Chambers 2nd Floor County Administration Building 50 Colborne Street South, Simcoe

Present: Mayor Kristal Chopp, Tom Masschaele, Roger Geysens, Michael Columbus, Chris Van Paassen, Ian Rabbitts, Ryan Taylor, Amy Martin, Kim Huffman

Absent with Regrets:

Also Present: Jason Burgess, Paula Boutis, Marlene Miranda, Dr.Shanker Nesathurai, Andy Grozelle

Approval of Agenda/Changes to the Agenda (Item 1)

1. (Martin/Huffman) THAT the agenda be approved as presented.

Defeated.

2. (Columbus/Huffman) THAT the rules of order be waived to a Closed Session discussion be added to the agenda to receive legal advice on personal legal liability of Board of Health members pursuant to Sections 239 2 (e) and (f) of the Municipal Act 2001, as the subject matter pertains to advice that is subject to solicitor client privilege and litigation or potential litigation including matters that are before an administrative board or tribunal. Carried. 2/3rds vote

Disclosure of Pecuniary Interest (Item 2)

None were declared.

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Adoption/Correction of Board of Health Meeting Minutes (Item 3)

A) Board of Health - June 19, 2020

The minutes of the Board of Health Meeting dated June 19, 2020, and open and closed, having been circulated for review and there being no errors or omissions noted were declared as adopted, signed by the Chair and County Clerk and affixed with the Corporate Seal.

Deputations (Item 4)

A) Lisa Livingston Re: COVID-19 Long Point on June 30

3. (Columbus/Geysens) THAT the deputation from Lisa Livingston regarding COVID-19 and Long Point be received as information. Carried.

Communications (Item 5)

A) Trish Fournier Re: Section 22 Migrant Worker Order

4. (Columbus/Geysens) THAT the communication from Trish Fournier regarding the Section 22 Migrant Worker Order be received as information. Carried.

B) Brett Schuyler Re: Memorandum from CMOH - Moving Forward

5. (Masschaele/Columbus) THAT the Board of Health waive the rules of order to directly consider a motion to reconsider Resolution No. 7 of the June 19, 2020 meeting.

Chair Chopp requested a Recorded Vote.

The Motion was DEFEATED upon the following recorded vote (2/3rds required).

Yeas: Geysens, Columbus, Martin, Van Paassen, Masschaele Total: 5 Nays: Rabbitts, Huffman, Taylor, Chopp Total: 4

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6. (Geysens/Columbus) THAT the communication from Brett Schuyler regarding Memorandum from CMOH - Moving Forward be received as information. Carried.

C) Brett Schuyler Re: Example Isolation Plan

7. (Rabbitts/Masschaele) THAT the communication from Brett Schuyler regarding Example Isolation Plan be received as information. Carried.

Staff Reports/Discussion Items (Item 6)

A) Shanker Nesathurai, Medical Officer of Health Re: Advice from Chief Medical Officer of Health on Issuing Section 22 Class Orders under the Health Protection and Promotion Act to Employers of Temporary Workers to Reduce COVID-19 Transmission on Farms

8. (Huffman/Rabbitts) THAT the communication from Shanker Nesathurai, Medical Officer of Health regarding Advice from Chief Medical Officer of Health on Issuing Section 22 Class Orders under the Health Protection and Promotion Act to Employers of Temporary Workers to Reduce COVID-19 Transmission on Farms. Carried.

A) MOH COVID-19 Update (no copy)

Dr. Nesathurai and Marlene Miranda provided an update to the Board of Health with the aid of a PowerPoint presentation. Staff responded to questions of the Board of Health.

9. (Huffman/Martin) THAT the update from the Medical Officer of Health be received as information. Carried.

Added Closed Session (Item 8)

A) Legal Advice (verbal) Re: Personal Liability of Board of Health Members, Section 22 Order Appeal

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10. (Taylor/Columbus) THAT the Board of Health convene in Closed Session at 4:45 p.m. to receive legal advice respecting personal liability pursuant to Section 239 (2) (e) and (f) of the Municipal Act 2001, as the subject matter pertains to legal advice that is subject to solicitor client privilege including communications necessary for that purpose and litigation or potential litigation including matters before administrative tribunals affecting the local municipality or board.

Carried.

11. (Columbus/Rabbitts) THAT the Board of Health reconvene in Open Session at 5:07 p.m. Carried.

Chair Chopp indicated that the Board had received legal advice in Closed Session and had nothing to report out at this time.

Confirming By-Law (Item 9)

A) By-Law 2020-07-BH Being a By-Law to Confirm the Proceedings of The Special Board of Health for the Haldimand-Norfolk Health Unit at this Board of Health Meeting held on the 30th of June, 2020.

12. (Rabbitts/Masschaele) THAT By-Law 2020-07-BH Being a By-Law to Confirm the Proceedings of The Special Board of Health for the Haldimand-Norfolk Health Unit at this Board of Health Meeting held on the 30th of June, 2020, be approved, signed by the Mayor and Clerk and affixed with the Corporate Seal. Carried.

Adjournment (Item 9)

13. (Columbus/Rabbitts) THAT The Special Board of Health meeting for Friday, June 30, 2020 adjourned at 5:09 p.m. Carried.

______County Clerk Chair

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Advisory Committee Meeting – June 18, 2020

Board of Health – July 07, 2020

Subject: Social Determinants of Health Report Number: HSS 20-04 Division: Health and Social Services Department: Quality, Planning, Accountability and Performance Purpose: For Information

Executive Summary: The health of communities are profoundly affected by different societal factors such as income, employment status, social safety net and food security. Collectively, these factors and others are known as the Social Determinants of Health (SDOH). The differential distribution of these factors within communities is closely associated to the differences observed in health outcomes within communities.

In 2018, The Ministry of Health (MOH) deemed health equity a foundational standard in the Ontario Public Health Standards (OPHS). As such, the standards require that Boards of Health (BOH): 1) have an increased awareness of how health outcomes are impacted by the social determinants of health, 2) assess and report on the health of local populations, including the existence and impact of health inequities, and 3) provide increased support for actions that help to decrease these inequities in health.

This report, the first of three education reports, provides the Board of Health (BOH) with information on five social determinants of health: income and income distribution, employment and working conditions, unemployment and job security, social safety net and food insecurity. This report also highlights how these determinants interact with one another to impact the health outcomes of individuals and populations.

Discussion:

Income and Income Distribution Income is a key social determinant of health. Not only does income influence health behaviours and psychological functioning, it also determines overall living conditions. It

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also strongly influences the other social determinants of health such as food insecurity and housing.1 Evidence demonstrates a ‘social gradient’ in health, which means that every step up the socio-economic ladder leads to an increase in health.2

Although income plays a major role on an individual level, the impact of income inequality on the health status of populations is significant. Income inequality, which is the degree to which total income is unevenly distributed throughout a population, has been linked to differences in health outcomes such as life expectancy, infant mortality, hospitalization, and mental health.3, 4

Employment and Working Conditions

Employment and working conditions are also known social determinants of health. Employment status is closely related to income as earning an income makes it more likely for people to be and remain healthy. On the other hand, unemployment is associated with having poor health; this is associated with increased stress which is a risk factor for conditions such as stroke, heart attack, heart disease and arthritis.5 It is also important to note that poor working conditions, i.e. jobs with imbalances between demands and rewards, often leads to significant health problems.

It is important to note that, while the unemployment rates are low in Ontario, the number of people working in low paying/minimum wage employment has been increasing.

Unemployment and Job Security

In 2014, it was determined that nearly a third of the Canadian working population were in unstable employment situations.6 It has been demonstrated that people in precarious employment have poorer health outcomes when compared with those in secure employment.7 This is likely as a result of the effect of precarious employment and job security on stress levels which in turn leads to poor health outcomes.

Social Safety Net

In Canada, there are programs and services that support individuals and families going through changes in their lives. These supports are collectively referred to as the “social safety net” and include social assistance payments, unemployment insurance, contributory pensions, as well as health insurance (publicly and privately administered). Ongoing challenges have been identified with these programs and services. For example, over a million people in Ontario depend on the social assistance program but benefit amounts have not been increased with inflation. This creates a stressful situation for the beneficiaries as the rates are insufficient to cover the essential costs. Food Insecurity

Food insecurity is associated with the lack of access to food of adequate quality due to insufficient income. Food insecurity is a major public health concern as it is associated

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with inadequate nutrition, poor mental health and increased risk of chronic disease such as heart disease, hypertension and diabetes.8 The 2013-2014 Household Food Security Survey Module in the Canadian Community Healthy Survey (CCHS) found that 1 in 9 households in Haldimand and Norfolk are food insecure.9

According to the 2019 Nutritious Food Basket (NFB) survey, the average cost to feed a family of four in Haldimand and Norfolk Counties rose 6.4% since 2018, which was the second largest year-over-year increase in 10 years. Incomes have not kept up with the increase in cost of food.10 For example, as shown in Appendix A, in Haldimand and Norfolk, an individual on Ontario Works requires an additional $87 each month to afford rent and food alone.

Food banks are good in emergencies but cannot be considered a sustainable solution; with only a small percentage (21.1%) of people accessing food banks.11, 12 Therefore, continued monitoring to allow for food system redesign and upstream solutions such as systemic policies focused on sufficient incomes are needed.13

Financial Services Comments: Norfolk There are no direct financial implications outlined within the report as presented.

The Approved 2020 Haldimand-Norfolk Health Unit Operating Budget includes $241,200 for SDOH programs, funded by the MOH ($157,100) and Norfolk ($49,800) and Haldimand ($34,300) Counties. Levy funding is determined based on the cost sharing agreement between both Counties.

Haldimand Haldimand Finance staff have reviewed this report and agree with the information provided by Norfolk Finance staff.

Interdepartmental Implications: Norfolk N/A

Haldimand Haldimand staff have no further comment to provide on this report.

Consultation(s): N/A

BOH Strategic Plan Linkage: Healthy, Supportive Environment: an understanding of the social determinants of health and its impact on health equities will enable the Board of Health to advocate for, and support the development of healthy public policies that facilitate health through the reduction of health inequities.

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Quality and Performance: an understanding of the social determinants of health and its impact on health equities will enable the Board of Health to prioritize, plan, and implement programs and services that reduce health inequities.

Strategic Plan Linkage: This report aligns with the 2019-2022 Council Strategic Priorities "Foster Vibrant, Creative Communities". Explanation:

The report provides the BOH with information on how income as a social determinant of health impacts the vibrancy and creativeness of the community. In acknowledging and educating our community on the effects of income and other related social determinants of health on health outcomes, it provides us the opportunity to begin the important work of advocating for public policies to support those most negatively impacted by these determinants.

Conclusion: This report highlights the role played by these five determinants of health on the health outcomes of individuals and populations. In sum, employment status, social safety net, and food insecurity are closely tied to income. In the same vein, lack of income is associated with increased stress which is a risk factor for a number of poor health outcomes. It is incumbent on us as public health professionals to engage with the community and other stakeholders to develop public policies that support health equity and ensure that all people have the opportunity to achieve and maintain optimal health.

Recommendation(s) of Health and Social Services Advisory Committee:

Recommendation(s): THAT Staff Report HSS 20-04 be received as information;

AND THAT the Board of Health continue to remain receptive to ongoing updates on the social determinants of health.

Attachment(s): Appendix A - Food Insecurity in Haldimand and Norfolk 2019 Infographic

References:

1 Mikkonen, J. and Raphael, D., “Social Determinants of Health. The Canadian Facts”. 2010. http://thecanadianfacts.org/The_Canadian_Facts.pdf 2 Rowlingson, K. The Joseph Rowntree Foundation “Does income inequality cause health and social problems?” 2011. https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/inequality-income-social- problems-full.pdf

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3 MasterClass, “What is Income Inequality?” January 17, 2019. https://www.masterclass.com/articles/what-is-income-inequality 4 Inequaltiy.Org., “Facts Inequality and Health.” https://inequality.org/facts/inequality- and-health/ 5 How does Employment, or Unemployment Affect Health? The Robert Wood Johnson Foundation, March 12, 2013. https://www.rwjf.org/en/library/research/2012/12/how- does-employment--or-unemployment--affect-health-.html 6 Canada Without Poverty, “Un- and Under-employed, The “New Normal” of Precarious Work.” 2017. http://www.cwp-csp.ca/2017/04/un-and-under-employed-the-new-normal- of-precarious-work/ 7 Registered Nurses’ Association of Ontario., “Income security for better health,” 2018. https://rnao.ca/sites/rnao- ca/files/Income_security_for_better_health_QPD_2019_Final_Public.pdf 8 Vozoris NT, Tarasuk VS. Household food insufficiency is associated with poorer health. J Nutr. 2003;133(1):120-126. 9 Canadian Community Health Survey 2013-2014, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. Derived variable. High sampling variability, interpret with caution. 10 Tarasuk, V, Mitchell, A, Dachner, N. (2016). Household food insecurity in Canada, 2014.Toronto: Research to identify policy options to reduce food insecurity (PROOF).Retrieved from https://proof.utoronto.ca/ 11 Dietitians of Canada. Addressing household food insecurity in Canada: Position statement and recommendations from Dietitians of Canada. https://www.dietitians.ca/Downloads/Public/HFI-Position-Statement-and- Recommendations-DC-FINA.aspx. Published Aug, 2016. Accessed Dec, 2019. 12 Tarasuk V, Fafard St-Germain A, Loopstra R. The relationship between food banks and food insecurity: insights from Canada. Voluntas (2019) doi:10.1007/s11266-019- 00092-w 13 Ontario Society of Nutrition Professionals in Public Health Food Security Workgroup. Income-related policy recommendations to address food insecurity. www.osnpph.on.ca/membership/documents. Published November 2015.

Submitted By: Reviewed By: Marlene Miranda Dr. Shanker Nesathurai General Manager, Health and Social Medical Officer of Health Services For more information, call: For more information, call: 519-426-6170 ext. 3260 519-426-6170 ext. 3120

Prepared By: Reviewed By: Alison Dunn Chimere Okoronkwo SDOH Public Health Nurse Director, Quality, Planning, For more information, call: Accountability and Performance 519-426-6170 ext. 3211 For more information, call: 519-426-6170 ext. 3751

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Prepared By: Margot Fournier SDOH Public Health Nurse For more information, call: 519-426-6170 ext. 3252

18 Return to Top FOOD INSECURITY IN HALDIMAND & NORFOLK 2019 Food insecurity means inadequate or insecure access to food due to financial constraints. THE ROOT CAUSE IS POVERTY

Approximately 1 in 9 *Food 35% % * 73 t households are food insecure in n e R

Haldimand and Norfolk*

* f

% % t

2 F

o Family of 4

t One person e

Ontario Works Ontario Works

R 3

% %

-10% Left over: -$87 Left over: $864 Low Income *Food 29% Left * ov e r 7 8 %

% %

Food Insecurity t

* Family of 4 3

Single parent with

n Median Ontario

e 2 children 4

R 0

% %

% Income after tax

Ontario Works

n e

Left over: $967 Left over: $6224 Higher rates of Money left over must cover all other basic necessities. Mental Heart Diabetes Illness Disease Which would you choose?

Increased healthcare costs Personal care Transportation Hydro Telephone

Medication Costs Clothing Child Care Heat Related to Disease What can YOU do? Support income-based strategies to improve food insecurity (e.g., increased social assistance rates, training and employment opportunities, affordable housing and a living wage) Volunteer or donate to local organizations that help those in need Share this message with others Learn more about food insecurity in your community at hnhu.org/food-insecurity

* 10.9% of households were food insecure according to the most recent data from the 2013-2014 Canadian Community Health Survey (CCHS). Ontario chose not to monitor food insecurity rates in the 2015-2016 CCHS. ** Cost of Nutritious Food Basket priced in Haldimand & Norfolk, May 2019, Haldimand Norfolk Health Unit. 19 Return to Top

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Page 1 of 9 Advisory Committee Meeting - June 18,2020 Board of Health Meeting – July 7, 2020 Subject: Vector-borne Disease Program Update Report Number: HSS 20-07 Division: Health and Social Services Department: Haldimand Norfolk Health Unit Purpose: For Information

Executive Summary: This report provides information about the Haldimand- Norfolk Health Unit’s (HNHU) comprehensive vector-borne disease (VBD) program that is in place to monitor local tick and mosquito populations for diseases such as Lyme Disease (LD), West Nile Virus (WNV) and Eastern Equine Encephalitis (EEEv). This report highlights the public health initiatives that encourage the public to take preventative measures against tick and mosquito bites. As well, there is a discussion of vector-borne program activities in previous year, and an overview of plans for 2020.

Discussion: VBDs are human illnesses that are caused by bacteria, viruses and parasites. These illnesses or infections are transmitted to humans by vectors such as mosquitoes, ticks, flies, sandflies and fleas. Mosquitos are known for transmitting the majority of vector- borne diseases.

The VBDs addressed in this report include LD, WNV, EEEv.

The HNHU has formulated a plan to mitigate the risk of VBDs to the community. However, this plan will not completely eliminate the risk.

Surveillance of VBDs includes mosquito trapping and tick dragging. This is supplemented by a review of official reports and statistics from other public agencies. The objective is to determine the trends and risks of VBDs locally. The HNHU communicates the results of surveillance initiatives to health care providers. With this information, health care providers (HCP) are able to better diagnose and treat patients.

Lyme Disease

1. Transmission and Presentation

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LD is an infectious disease caused by the Borrelia bacterium that is transmitted to humans by the bites of infected deer ticks (blacklegged tick). The deer tick must be attached to a person for at least 24 hours before the bacteria can spread.

The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans or bull’s-eye rash. This rash, typically, appears at the site of the tick bite about a week after it occurred. Other early symptoms may include fever, fatigue, headache, muscle pain, joint pain, as well as paralysis of facial muscles.

2. Clinical and Surveillance Data

a) Active Tick Surveillance:

In 2019, the HNHU did not identify any new risk areas for LD. In 2019, there were 1025 confirmed human cases of LD in Ontario. This number has almost doubled since 2018 when there were 612 confirmed human cases.

Estimated risk areas are locations where deer ticks have been identified or are known to occur and where humans have the potential to come into contact with infected ticks. Estimated risk areas are calculated as a 20 km radius from the centre of a location where deer ticks were found through drag sampling.

Three locations in HNHU were dragged for ticks in 2019. Ticks were found in all three locations in the spring, however deer ticks were only found at one location near Port Dover. The site near Port Dover was once again dragged for ticks in the fall but no deer ticks were found.

b) Human Case Surveillance:

In 2019, there were 11 human cases of LD identified within HNHU, compared to 3 human cases in the previous year. 9 of 11 cases were diagnosed with laboratory results and 2 of 11 were diagnosed through clinical assessment (i.e., without laboratory test confirmation).

Doctors currently use clinical evidence and laboratory testing to diagnose patients with Lyme disease. Clinical diagnosis involves determining the circumstances of the patient’s exposure to the tick such as:

• the length of time that the tick was attached to the patient • the tick being engorged with blood • signs and symptoms of the patient • the geographical area in which the patient was bitten

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Laboratory diagnosis involves the testing of the patient’s blood for the presence of antibodies to the LD causing agent Borrelia burgdorferi. Both methods of diagnosis allow the HCPs to determine if their patient is infected and if treatment is required. Currently, laboratory testing is recommended to only be used to supplement clinical findings and not be used as a basis for diagnosis for early LD.

3. 2019 Public Awareness Activities

a) School Promotional Campaign

The HNHU was involved in promotional campaign focused on schools. The aim was to raise awareness and build supportive environments to prevent, mitigate, and respond to children and school staff being exposed to tick bites. Creating awareness among young people is likely to lead to discussions about Lyme disease in their household.

The HNHU met with the Grand Erie District School Board to present on the risks of LD within the region. HNHU highlighted the value of schools giving considerations for:

• notifying parents to tick exposures • personal protective measures being taken by staff and students visiting known tick habitats • removing ticks attached to staff and students • Other strategies to mitigate the risk of LD in the student population.

Educational LD resources were provided for students with varying levels of information based on their grade. The purpose of the resources was to educate the students and parents on identifying ticks, what to do if they find a tick, personal protective measures, and the risks associated.

b) Public Education A number of public education awareness activities for LD were performed from May to December 2019. This information was provided through radio, social media, newspapers, the HNHU website, and smart TV ads.

4. Vector Borne Disease Program Plans for 2020

a) Tick Surveillance: As most of Norfolk County has been identified as a risk area for LD. The 2020 tick dragging activities will focus on sites found within Haldimand County. Three sites were identified for tick dragging this year.

The identification of LD areas within both Haldimand and Norfolk counties will allow residents and visitors to become aware of the risks within their

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community and take necessary precautions against LD. It will also assist HCPs to manage patients that have been exposed to ticks in these risk areas.

Estimated risk areas are calculated as a 20 km radius from the centre of a location where deer ticks were found.

b) Public Education

The HNHU will continue to develop promotional campaigns to raise awareness and build supportive environments to prevent and mitigate tick bite exposures via social network messaging and other methods.

The health unit is also working with partners to replace worn tick signage where necessary. Tick signage were historically placed in LD endemic areas (Turkey Point and Long Point Provincial Parks) to notify visitors and residents about the risks of Lyme Disease and tick exposure as ticks are found throughout Norfolk County.

Tick promotional materials and presentations provided to the Grand Erie District School Board are proposed to be extended to other School Boards, including the Catholic School Board.

The health unit plans to promote internet based tools such as “Etick”, an online public platform for image-based identification and population monitoring of ticks in Canada.

Finally, HNHU will distribute more “tick kits” containing tick removal tools and tick identification information to local provincial parks that can then distribute them to their patrons.

West Nile Virus

1. Transmission and Presentation

West Nile fever is an infection by the WNV, which is typically spread by mosquitoes. In about 80% of infections, people have few or no symptoms. About 20% of people develop a fever, headache, vomiting, or a rash. In less than 1% of people, there is inflammation of the brain or spinal cord. This can be associated with a stiff neck, high fever, confusion and seizures; in these cases, recovery may take weeks to months, and may be incomplete. On occasion, infection may be fatal.

WNV is a virus mainly transmitted to people through the bite of an infected mosquito. Mosquitoes transmit the virus after becoming infected by feeding on the blood of birds that carry the virus.

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2. Clinical and Surveillance Data

a) Mosquito trapping and testing There were 8 mosquito trap locations, 4 in Norfolk County and 4 in Haldimand County. Traps were set up bi-weekly between June and September.

In 2019, there were no positive WNV mosquito pools identified in Haldimand and Norfolk counties. WNV activity in Haldimand and Norfolk, as well as most of the province, was lower than the previous year. This is likely due to the spring and summer’s cooler conditions.

b) Human case surveillance There was 1 human case of WNV identified in 2019, compared to 6 human cases in the previous year. In 2019, there were 21 human cases of WNV in Ontario.

3. 2019 Public Awareness Activities

A number of public education awareness activities for WNV were performed from May to December 2019. This included radio, print and smart TV advertisements. As well, there were communications via social media and the HNHU webpage.

4. Vector Borne Disease Program Plans for 2020

Trapping of mosquitoes and laboratory analysis will continue in Haldimand- Norfolk in 2020 to maintain the mosquito surveillance program. Trapped mosquitos will continue to be tested for WNV and EEEv.

This year HNHU WNV program will focus on surveillance, case management, promotion and responding to standing water issues. The HNHU will continue to remind the public that WNV is endemic to Ontario and precautions are needed throughout the mosquito season.

Eastern Equine Encephalitis

1. Transmission and Presentation

EEEv, also known as sleeping sickness, is a disease that is spread to humans and horses by mosquitos. The onset of the illness is usually 4 to 10 days after being bitten by an infected mosquito. The progression and severity of the illness depends on the age of a person and immune system. The disease can result in system or neurological illness. Some people become infected but may not have signs or symptoms.

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2. Clinical and Surveillance Data

a) Mosquito trapping and testing Mosquito trapping efforts also did not find any mosquito pools positive for EEEv.

b) Human case surveillance No human or equine cases of EEEv were identified in 2019 within HNHU. In 2019, provincially there were 7 cases of equine EEEv identified. This is lower than the previous year.

3. 2019 Public Awareness Activities A number of public education awareness activities for EEEv were performed from May to December 2019 through radio, social media, newspapers, the HNHU website, and smart TV ads.

4. Vector Borne Disease Program Plans for 2020 Trapping of mosquitoes and laboratory analysis will continue in Haldimand- Norfolk in 2020 to maintain the mosquito surveillance program. Trapped mosquitos will continue to be tested for EEEv.

Emerging Diseases:

Mosquito-borne Diseases There are a number of emerging VBDs that the HNHU continues to monitor. Some of the most important emerging VBDs include Zika Virus, dengue fever and chikungya.

Tick-borne Diseases Across Canada, there has been a rise in tick-related infections beyond Lyme disease. Other tick borne diseases that can impact human health include Anaplasmosis, Babesiosis, Powassan virus.

The HNHU’s Vector Borne Disease program will continue to monitor for new cases of these diseases. As these diseases are transmitted through bites from infected ticks and mosquitos, public health messaging around the use of personal protective equipment, landscaping precautions, and awareness remain the main methods to help protect the public.

Financial Services Comments: Norfolk The report as presented does not contain any direct financial implications.

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The Approved 2020 Haldimand-Norfolk Health Unit Operating Budget includes $34,700 for the Vector Borne Diseases program, funded by the Ministry of Health ($23,600), Norfolk ($6,600) and Haldimand ($4,500) Counties. Any levy costs are shared between both Counties as per the cost sharing agreement.

Haldimand Haldimand Finance staff have reviewed this report and agree with the information provided by Norfolk Financial Services.

Interdepartmental Implications: Norfolk N/A

Haldimand The Health Unit has historically practiced various marketing strategies to address the Vector-borne Disease Program as outlined in this report. Staff are requesting that marketing educational materials (i.e. brochures, website links, etc.) continue to be shared to allow Haldimand County the ability to provide educational information to residents and visitors alike.

Consultation(s): In January 2020 consultations occurred with Public Health Ontario to review 2019 Vector-borne disease results and discuss program activities for the 2020 season. Norfolk County communications department were consulted for considerations regarding 2020 promotional materials and strategies.

BOH Strategic Plan Linkage: Communications: The Vector-borne Disease Program has an education and awareness component that provide an opportunity for the Health Unit to:

1. Share information about preventative measures the public can take to protect themselves from mosquito and tick bites.

2. Be transparent and keep the public informed on:

a. How active mosquitos and ticks are during the season

b. The number of confirmed human cases of WNV, LD or EEEv.

Collaborations: The VBD program provides an opportunity for the Health Unit to collaborate with partners such as health care providers to ensure effective public health and health care services are provided to the community. Information collected from active surveillance program, helps in the management of persons suspected of having vector-borne diseases.

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Strategic Plan Linkage: This report aligns with the 2019-2022 Council Strategic Priorities "Focus on Service".

Explanation:

The Vector-borne program will focus public health services required to protect the health of the community. The key is education of the community with the goal of minimizing the likelihood of exposure to mosquito and tick bites.

Conclusion:

The purpose of the VBD program is to monitor mosquito and tick populations to determine the risk of LD, WNV and EEEv to the public. The information gathered through surveillance will help HNHU make decisions regarding the development and implementation of vector control plans.

VBDs continue to be a significant public health challenge in Haldimand and Norfolk Counties. In light of this, the HNHU continues to make public education and promotion the cornerstone of it VBD management program.

Recommendation(s) of Health and Social Services Advisory Committee: N/A

Recommendation(s): THAT Staff Report HSS 20-07, Vector-borne Disease Program Update, be received as information;

AND THAT the Board of Health support the HNHU’s Vector-borne program activities which include active surveillance, and education regarding prevention strategies for vector-borne diseases.

Attachment(s): N/A

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Submitted By: Marlene Miranda Prepared By: General Manager, Health and Social Kostya Lysenko Services Public Health Inspector For more information, call: For more information, call: 519-426-6170 ext. 3120 519-426-6170 ext. 3212

Reviewed By: Reviewed By: Dr. Shanker Nesathurai Stephanie Pongracz Medical Officer of Health Manager, Health Protection For more information, call: For more information, call: 519-426-6170 ext. 3260 519-426-6170 ext. 3216

Reviewed By: Kwesi Douglas Program Manager, Environmental Health For more information, call 519-426- 6170 ext. 3271

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Advisory Committee Meeting – June 18, 2020

Board of Health Meeting – July 07, 2020

Subject: Community Needs Assessment Report Report Number: HSS 20-03 Division: Health and Social Services Department: Quality, Planning, Accountability and Performance Purpose: For Information

Executive Summary: A Community Needs Assessment (CNA) aims to identify and understand the needs of the population within a region and supports the formulation of public health priorities for the population1,2. When used to understand health needs, a CNA should be designed to understand the needs of the population as well as to understand the factors that individuals need to feel healthy, safe, and protected in their community. A CNA typically involves three key steps: (i) assessment; (ii) dissemination; and (iii) implementation.

In the fall of 2019, Haldimand Norfolk Health Unit (HNHU) completed the assessment phase (data collection and analysis phase) of a CNA. This involved four components: a community profile, a community survey, focus groups, and interviews. The data has been analyzed and incorporated into the attached Summary Report (Attachment A). Additional report (Appendix B: 1-page Visual (Infographic Report) of the CNA findings) is available and attached to this Board of Health (BOH) Report. It is instructive to note that the attached reports are reflective of health and social services, however in this BOH Report, only results relevant to public health are presented.

This report provides an overview of the CNA findings and marks the beginning of a wide reaching dissemination phase. The information gained from the CNA will ultimately contribute to future planning of the Health Unit and inform programs and implementation strategies. The CNA informs key public health priorities for action and advocacy.

Discussion: Methods The CNA employed a community-based approach that used both quantitative and qualitative methods to gather data. These key elements included: (i) a community profile, (ii) a community survey; (iii) focus groups and (iv) interviews.

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Community Profile The community profile is a method of using previously collected data to describe the overall community and priority populations of Haldimand and Norfolk counties. Typically, this data which is obtained from public sources include indicators (i.e. variables) for demographics, health status, and social services.

Community Survey The community survey was used to collect data from members of the general population; the goal was to understand the perspectives of residents as well as gain insights into the health and social behaviours of the community. The survey was distributed via online platforms on HNHU social media, and across social media accounts for Haldimand and Norfolk counties. Paper versions were also available at several locations across the two counties, including libraries, churches, hospitals, county fairs, and community agencies.

Focus Groups and Interviews The focus group sessions and interviews were utilized to elicit the perspectives of experiences of community members. This information may not have been obtained through the community profile and/or survey. A purposive (i.e. targeted) snow-ball (i.e. stepwise) sampling strategy was employed for both focus groups and interviews. Both focus groups and interviews were conducted using a semi-structured approach. Transcripts were analyzed to identify themes or similarities across discussions.

Data Culmination Following the initial analysis of all of the collected data (i.e. community profile, community survey, focus group discussions and interviews), the data was compared across the different sources for similarities. Major themes emerged as common community needs that the participants in all elements of the CNA prioritized.

Results

Mental Health and Addictions Supports Mental health and addictions supports were one of the top priorities described by participants in the focus group discussions and interviews. Participants described the need for mental health and addictions supports as being very high, and the availability of services as being very low. Participants noted that access to clinical services was hampered by long waitlists, transportation challenges, and/or prohibitive costs.

Physical Health The CNA indicated that physical health is a major concern for residents in Haldimand and Norfolk counties. Participants described several local key physical health concerns, including nutrition, high cancer rates, and sexual health. Participants also noted a lack of available family physicians in this community.

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Poverty Poverty as manifest by the lack of ability to purchase and/or obtain food, housing, and other necessities of life, was articulated by the participants as a significant public health priority. Participants also stated that experiencing poverty results in increased psychological stress and adversely affects physical health, and is also a contributing factor to the high demand for mental health and addictions services.

Availability of Products and Services Participants noted poor access to products and services with emphasis on issues around transportation, childcare, food, and youth programming. These issues were often linked to rurality and the assumption or explanation that services were simply too difficult to provide in a vast geographical area with a relatively low population density.

Organizational Structures Participants noted that the organizational structures of the Health Unit may contribute to the difficulty clients experience using and accessing services. Organizational structures referred to collaboration, communication, meeting people where they are, operational changes, and anti-oppressive actions. The participants were able to offer actionable recommendations.

Conclusion: Participants in the CNA provided a wealth of information that should be considered when developing recommendations and actions to address the needs of the community. The results identify several key areas for the BOH to address in order to meet the needs of residents in Haldimand and Norfolk counties. These key areas include mental health and addictions supports, and recognition of the role poverty plays on physical and mental health. Next steps for action on the findings of the CNA are to develop a new Strategic Plan in 2020 for HNHU.

Financial Services Comments: Norfolk There are no direct financial implications within the report as presented. Once the new 2020 Strategic Plan for the HNHU has been developed, there could be financial implications based on the Board of Health’s decisions.

Quality, Planning, Accountability and Performance (QPAP) department costs are allocated out to other departments within Health and Social Services based on the amount of time QPAP staff spend working with the respective department. Expenditures within those departments that are not funded by the Province are shared between Haldimand and Norfolk Counties as per the cost sharing agreement.

Haldimand Haldimand Finance staff have reviewed this report and agree with the information provided by Norfolk Finance staff. Any future initiatives resulting from the 2020 Strategic Plan should be ranked and evaluated during the appropriate budget process, and would be cost shared based on the relevant cost sharing agreement, if applicable.

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Interdepartmental Implications: Norfolk

Haldimand The data collected from the CNA is important to support Haldimand County’s Community Vibrancy and Healthy Community Corporate Strategic Pillar; and understand that the data will help to provide recommendation of program implementation and delivery.

Consultation(s):

BOH Strategic Plan Linkage: Quality and Performance: the findings of the CNA provides the BOH with an opportunity to understand the public health needs of the community, develop effective and efficient programs and services to address these needs.

Communication: the findings of the CNA provides the Board of Health with an opportunity to communicate the value of the public health interventions being implemented to address the identified needs.

Strategic Plan Linkage: This report aligns with the 2019-2022 Council Strategic Priorities "Focus on Service".

Explanation:

The CAN provides the BOH with information on the pressing public health needs of the community. This information will enable the BOH to develop programs and services that are responsive to the community needs and priorities thereby enhance the community’s experiences with our programs and services.

Conclusion: The CNA allows the BOH to meet an operational mandate within the Ontario Public Health Standards (OPHS) to ensure that public health programs and services are reflective of local population health issues. This report also ensures that community stakeholders are aware of the factors that determine the health of the local population.

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Recommendation(s) of Health and Social Services Advisory Committee:

Recommendation(s): THAT Staff Report Community Needs Assessment report, be received as information

AND THAT the Board of Health endorse the use of the findings to develop a new Strategic Plan for the HNHU, and continue to build and maintain strong relationships with community stakeholders.

Attachment(s): Appendix A: Summary Report of the CNA Appendix B: 1-page Visual (Infographic Report) of the CNA findings

Reviewed By: Prepared By: Chimere Okoronkwo Katherine Bishop-Williams, MSc, PhD Director, QPAP Program Evaluator For more information, call: For more information, call: 519-426-6170 ext. 3751 519-426-6170 ext. 3274

References: 1. Windsor-Essex County Health Unit, Community Needs Assessment Full Report, 2016. 2. CDC (Centres for Disease Control and Prevention). (2014). Community Health Assessment and Health Improvement Planning.

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Community Needs ASSESSMENT Summary Report 2019

Report of Findings

Haldimand Norfolk Health and Social Services (HNHSS)

Report prepared by Quality, Planning, Accountability and Performance (QPAP)

12 Gilbertson Dr. • Simcoe, ON • N3Y 4N5 hnhss.ca

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Acknowledgements

Authors: Katherine Bishop-Williams CNA Project Lead, Program Evaluator, HNHSS Damola Akinbode Program Evaluator, HNHSS Jackie Esbaugh Program Evaluator, HNHSS Overseeing Committee: Chimere Okoronkwo Director of Quality, Planning, Accountability, and Performance, HNHSS Dr. Shanker Nesathurai Medical Officer of Health Marlene Miranda General Manager and Chief Nursing Officer, HNHSS Management Team HNHSS Acknowledgements: We would like to thank the team that contributed to the success of this project at Haldimand Norfolk Health and Social Services (HNHSS) and across Haldimand and Norfolk counties. Thanks to the individual and agency participants. Thank you to HNHSS staff, especially the Research Advisory Council; Quality, Planning, Account- ability, and Performance Department; Communications; and the Health and Social Services Advisory Committee and Board of Health.

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Table of Contents

Introduction...... 6 Rationale for HNHSS CNA 2019...... 6 Objectives...... 6

Methods...... 7 Approach...... 7 Community Profile...... 7 Community Survey...... 7 Focus Groups with Priority Population Groups and Key Informant Interviews ...... 8 Triangulation ...... 8

Community Profile Results...... 9 Demographics...... 9

Social Services...... 9 Income and Poverty...... 9 Employment and Education...... 9 Housing and Homelessness...... 9 Social Networks...... 10 Safety...... 10 Childcare...... 10

Health and Wellness ...... 10 General Health and Wellbeing...... 10 Chronic Disease and Injury...... 10 Mental Health and Addictions...... 11 Maternal and Child Health ...... 11 Infectious and Vector-borne Diseases...... 11 Environment...... 11

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Community Survey Results...... 12 Survey Respondents...... 12 Demographics...... 12 Self-Identification...... 12

Social Services...... 12 Income and Poverty...... 12 Employment and Education...... 12 Housing and Homelessness...... 12 Social Networks...... 13 Safety...... 13 Childcare...... 13 Services...... 13

Health and Wellness ...... 13 General Health and Wellbeing...... 13 Chronic Disease and Injury...... 13 Mental Health and Addictions...... 14 Maternal and Child Health ...... 14 Infectious and Vector-borne Diseases...... 14 Environmental Health...... 14 Community Experiences...... 14 Service Experiences ...... 14

Focus Group & Interview Themes...... 15 Participation in Qualitative Research...... 15 Mental Health and Addictions...... 16 Physical Health ...... 16 Poverty...... 16 Housing...... 16 Rurality...... 17 Availability of Products and Services...... 17 Organizational Structure ...... 17

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Discussion & Recommendations...... 19 Representativeness...... 19 Mental Health and Addictions Supports...... 19 Mental Health Provisions...... 19 Physical Health...... 20 Medical and Health Service Provisions...... 20 Poverty...... 20 Provision of Necessary Goods...... 20 Advocacy for Increased Incomes...... 21 Affordable Housing...... 21 Affordable Housing Ideas...... 21 Availability of Products and Services...... 22 Transportation Ideas...... 22 Childcare...... 22 Food...... 22 Youth Programming and Recreation...... 22 Organizational Structures ...... 23 Collaboration...... 23 Communication...... 23 Meet People Where They Are...... 24 Operational Changes...... 24 Anti-Oppressive Actions and Empowerment...... 24

Conclusions...... 26 Additional Information...... 26 Recommended Citation:...... 26

References...... 27

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Introduction

Introduction Rationale for HNHSS CNA 2019 A Community Needs Assessment (CNA) aims to identify This is the first time that a CNA has been formally conduct- and understand the needs of the population within a region ed across the Division of HNHSS. The HNHSS CNA 2019 and identify factors that must be addressed to meet the process is intended to inform actions and next steps for population’s needs1,2. When used to understand health and the Division. The HNHSS CNA will inform key community social service needs, a CNA should be designed to under- priorities for action and advocacy. Data collected in a CNA stand the needs of the population as well as to understand can be used to guide agency planning, inform resource the factors that individuals need to feel healthy, safe, and allocation, and improve service offerings for the public1. protected in their community. A CNA typically involves Further, community engagement throughout the CNA can three key steps: (i) assessment; (ii) dissemination; and (iii) improve relationships with community members, local implementation1,3. agencies, and other groups. Finally, targeting interventions according to the mandate of the Ministry of Health (MOH) The assessment phase of the Haldimand Norfolk Health will also increase the effectiveness and cost efficiency of and Social Services (HNHSS) Department CNA involved programming in both health and social services1,4. four elements: (i) a community profile; (ii) a community survey; (iii) focus groups with priority population groups; Objectives and (iv) key informant interviews. This report provides a The specific objectives of this CNA were to: summary of findings of the CNA 2019. i. Describe current health, social status and needs of all residents in Haldimand and Norfolk counties; The HNHSS CNA will contribute to future planning and ac- ii. Identify needs and gaps for extended health and tions of the Division and will be used by Senior Leadership, social programming in Haldimand and Norfolk coun- Program Managers and Program Staff to inform program ties; offerings and implementation strategies. The information iii. Support evidence-informed decision-making and gleaned through the CNA process is as representative of program planning for health and social services in the the diverse populations of Haldimand and Norfolk counties region. as possible. The multi-faceted approach helped to ensure this diversity and representativeness.

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Methods

Methods Community Survey Approach The purpose of the community survey was to collect data Overall, the HNHSS CNA employed a community-based from members of the general population and to investi- participatory mixed-methods approach (i.e. we used gate demographics, perspectives, and health and social quantitative and qualitative research methods together). behaviours. The community survey collected quantitative Ethical protocols for this study were evaluated by the (i.e. numerical) information via closed-ended (i.e. yes/no) Research Advisory Council (RAC) at HNHSS. questions. The survey tool was adapted from an existing validated tool1. The adaptations to the tool included Community Profile updating of terms to reflect the most culturally appropriate language of the time, inclusion of questions specific to The purpose of the community profile element of the CNA rural communities, the inclusion of a section related to was to describe the general residents and priority popula- the environment and climate change, and the addition of tions within Haldimand and Norfolk counties. To generate questions for social services needs and program utilization the community profiles, a list of indicators (i.e. variables) (Full report: Appendix A). for demographics, health, and social services was developed. The indicators were identified from a variety of The survey was distributed via online platforms on sources, including the HNHSS Program Operational Plans, HNHSS social media, and across social media accounts the CNA for Windsor-Essex County Health Unit1, and in for Haldimand and Norfolk counties. The survey was also discussion amongst HNHSS staff. distributed via paper versions that were available at several locations across the two counties, including libraries, Data to provide evidence for each of the identified indica- churches, hospitals, county fairs, and community agen- tors was collected by Quality, Planning, Accountability, and cies. Participants had to be ≥18 years of age to consent Performance (QPAP) staff from available sources. Sources to participate in the community survey. Participants who varied depending on the indicator (please see citations in completed the survey were eligible for inclusion in a draw results for more information). When available, data were for one of three grocery store gift cards. collected for Haldimand County, Norfolk County, Haldi- mand and Norfolk counties combined, and for Ontario. Data were analyzed via descriptive statistics, which Data were aggregated and analyzed to provide rele- included frequencies and proportions. Descriptive sta- vant measures for the region and to generate summary tistics were further interrogated by stratification by measures of the data (e.g. rates, means, medians, modes, gender (male, female, prefer not to answer), age (18-25 ranges). Data were investigated for emerging trends years, 26-40 years, 41-60 years, 61-75 years and >75 that may differentiate the Haldimand and Norfolk region years), income bracket (<$30,000, $30,000-<$50,000, from other parts of Ontario (i.e. higher, lower, or different $50,000-<$70,000, $70,000-<$100,000, ≥$100,000), distributions). and county (Haldimand, Norfolk). Data were analyzed via Select Survey (Norfolk County) and Microsoft Excel ©.

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Focus Groups with Priority Population analyses (i.e. working through data to identify themes or Groups and Key Informant Interviews similarities across discussions) according to a codebook The purpose of the focus groups with priority population (i.e. guide for analysis) generated by members of the 6 groups and the key informant interviews was to intention- research team . The codebook included data-driven (i.e. ally elicit and incorporate lived-experiences that might not emergent, found in the transcripts of the discussions) and otherwise be included in the CNA. Focus groups were con- theory-driven (i.e. determined a priori from the literature) ducted with community members with lived-experiences codes. Thematic analyses were conducted in the software from a variety of different backgrounds and knowledge in Dedoose vs. 8.2.14 ©. groups of 3-8 participants. Key informant interviews were primarily conducted with agency representatives for health Triangulation and social services-related organizations. Where appro- The data collected from the four elements described above priate or desired by participants for a variety of reasons were not analyzed in isolation. Triangulation (i.e. cross-da- (e.g. anonymity), lived-experiences were documented via ta comparison) was used to synthesize the findings from key informant interviews rather than via focus groups. A the various data collection strategies to identify areas of purposive (i.e. targeted) snow-ball (i.e. stepwise) sampling agreement and disagreement in the data7. The synthesis strategy was employed for both focus groups and key process results in stronger support for the conclusions informant interviews. drawn from the data.

Both focus groups and interviews were conducted using a semi-structured (i.e. conversational), participatory (i.e. engaging) interviewing techniques5. Focus group and interview guides were developed a priori (i.e. before the study began) and modified conversationally as needed to collect the most relevant and useful information from each participant. Conversations were recorded with consent from participants. Recordings of focus groups and interviews were tran- scribed by members of the QPAP team. Transcripts from focus groups and interviews were analyzed via thematic

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Community Profile Results

Community Profile Results households compared to Ontario’s rate of 14.4%. Demographics • There are approximately 1,192 individuals access- • Haldimand and Norfolk counties are defined as rural ing Ontario Works in Haldimand and Norfolk, which 9 regions because over 50% of the population in each includes 2,043 beneficiaries . The average percent of county live in rural communities (i.e. <150 persons per caseloads exiting to employment was 16.5% per month square kilometer)8. in Haldimand and Norfolk in 2018, compared to 18.0% • 109,787 residents live in Haldimand and Norfolk in Ontario; however, proportions of caseloads exiting to counties combined (41.5% in Haldimand County and employment were higher in Haldimand and Norfolk from 58.3% in Norfolk County)8. September to December 2018 (28.55%) than Ontario 10 • There are a higher proportion of residents over 65 (18.32%) . years in Norfolk County (22.5%) than in Haldimand • Residents in rural areas need to make a monthly County (18.1%) or Ontario (16.7%)8. income of at least $1,639 to afford a basic standard of • There are approximately 4,100 seasonal agricultural living. Clients on Ontario Works receive $733 per month, workers in Haldimand and Norfolk counties9. leaving a shortfall of $906 per month. Clients on Ontario • Approximately 3.9% of the population of Haldimand Disability Support Program receive $1,169 per month, a 11 and Norfolk counties speak German as a first language9. shortfall of $470 per month . There are an estimated 5,000 Low-German speaking • Food costs were estimated to have increased 5.8% 12 Mennonites in Haldimand and Norfolk counties. This from 2014 to 2019 . population is sometimes migrant between Ontario and Mexico9. Employment and Education • Approximately 3.2% of the population identify as • Employment rates across the counties vary: Haldi- Indigenous, which is higher than the proportion of Indig- mand employment rate is 61.2% and Norfolk employ- enous peoples in Ontario (2.8%)8. ment rate is 55.2%, compared to the Ontario employment rate of 59.9%8. • The most common employment industries in Haldi- Social Services mand and Norfolk counties are manufacturing (14.3%) Income and Poverty and health care and social services (11.5%)8. • Median income in Haldimand County is $76,117and • The proportion of residents in Haldimand and Nor- $67,338 in Norfolk County compared to the province folk who have not completed a high school diploma is 8 ($74,287) . 20.9% and 24.1%, respectively, compared to Ontario at • The variability of Haldimand and Norfolk residents 17.5%8. living in low-income households is quite substantial across the region; this percentage ranges widely from 5.5% in Caledonia to 21.1% in Dunnville (based on the Housing and Homelessness Low-income Measure, After Tax)8. Overall, 11.7% of res- • There are 826 rent geared to income or affordable idents in Haldimand and Norfolk are living in low-income housing units in Haldimand and Norfolk counties (65%

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Over 95% of residents in in Norfolk County and 35% in Haldimand County). The average waitlist for rent geared to income housing is Haldimand and Norfolk 343 people, which equates to approximately 1-3 years for priority cases, 3-4 years for the majority population counties report feeing ‘safe’ or and seniors, and up to 8 years for a one bedroom unit in ‘very safe’ in their community8. Simcoe9. • There are 25 rooms available for emergency housing • supports in Haldimand and Norfolk. The average length of stay in these rooms ranged from 0-136 nights. The Childcare 18 vacancy rates for these rooms are variable but typically • Data from the Early Development Instrument (a tool quite low9. that considers the health at school entry) demonstrate • The 2018 homeless persons enumeration identified that 25% of children in Haldimand and Norfolk are 79 homeless residents in Haldimand and Norfolk, with vulnerable on at least one EDI domain compared to 30% more residents experiencing homelessness in Norfolk of Ontario kindergartens. Approximately 10% of children compared to Haldimand (68% compared to 32% of the were identified as having one or more special concerns total homeless population)13. as part of the Early Development Instrument Study in 2017-2018. • Following an engagement session with the Child Care Social Networks Operator groups in February 2019, the key priorities • Nationally, about 62% of Canadians reported a some- identified for the priorities of licensed childcare systems what strong or very strong sense of belonging to their for the next five years were: affordability, access, quality, local community. In Ontario, about 70% of the population and responsiveness9. reported a somewhat strong or very strong sense of • There are 45 registered (i.e. licensed) childcare pro- belonging to their local community. Local data are not viders in the region; 19 in Haldimand and 26 in Norfolk9. available for Haldimand and Norfolk counties8. • Nationally, about 86% of Canadians reported being satisfied or very satisfied with their life. In Ontario, about Health and Wellness 93% of the population reported being satisfied or very General Health and Wellbeing satisfied with their life. Locally, 93% of residents in • 36% of Haldimand and Norfolk residents reported Haldimand and Norfolk reported being satisfied or very being active during leisure time compared to 30% of all satisfied with their life14. Ontario residents14. • Self-reported adult obesity rates in Haldimand and Safety Norfolk counties were similar to Ontario (20.5% com- • In 2019, Norfolk County was ranked one of the safest pared to 20.3%14. communities to live in Ontario, based on the Statistics • Significantly fewer residents of Haldimand and Nor- Canada Uniform Crime Reporting Survey15. folk counties reported brushing their teeth at least twice • The crime severity index in Norfolk County decreased a day (76.5%) than all Ontario residents (81.4%)14. by 5% from 2014 to 2019. Data were not available for • There are 57.8 physicians per 100,000 people in Haldimand County15. Haldimand and Norfolk, compared to national rates of • In 2016, 673 motor vehicle collisions were reported 241 doctors per 100,000 people across Canada9. in Haldimand County, a decrease of 9.9%, of which, 5 included one or more fatalities. In the same year, 872 Chronic Disease and Injury motor vehicle collisions were reported in Norfolk County, • Haldimand and Norfolk counties has significantly a decrease of 12.2%, of which, 9 included one or more higher rates of hospitalizations for all injuries combined 16,17 fatalities . compared to Ontario (927.2 vs. 552.8 per 100,000)14. 10 • Haldimand Norfolk Health and Social Services (HNHSS) | hnhss.ca 45 Return to Top

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• Haldimand and Norfolk Counties has similar incidence counties reported smoking during pregnancy compared of all cancers compared to Ontario (534.8 compared to to Ontario (12.4% vs. 7.1%)14. 531.2 per 100,000)14. • Approximately 25% of children in senior kindergarten • Haldimand and Norfolk Counties has significantly in Haldimand and Norfolk Counties were identified as higher rates for both hospitalization (1104 (1048-1159) vulnerable on at least one developmental domain, com- admissions per 100,000 population) and mortality (236 pared to approximately 30% across Ontario18. (211-261) deaths per 100,000 population) for chronic • Approximately 10% of children in senior kindergarten cardiovascular disease compared to Ontario (hospitaliza- in Haldimand and Norfolk counties were identified as tion: 903 (898-907) admissions per 100,000 population; having one or more special needs18. deaths: 170 (168-172) deaths per 100,000 popula- • Haldimand and Norfolk counties have a significantly tion)14. higher pregnancy rate compared to Ontario (62.3 vs. 53.1 per 1,000 females of reproductive age)14. Mental Health and Addictions • Rates of hospitalization for intentional self-harm are Infectious and Vector-borne Diseases significantly higher in Haldimand and Norfolk counties • Immunization coverages for infectious diseases compared to Ontario (91.3 vs. 71.1 per 100,000)14. mandated under the Immunization of School Pupils Act in • Annual counts of death by suicide in Haldimand and Haldimand and Norfolk counties among 7-year old stu- Norfolk Counties ranged from 10-20 individuals per year dents were: Measles 91%; Mumps 91%; Rubella 91%; (Mental Health Promotion and Resilience Program 2018). Diphtheria 95%; Pertussis 95%; Tetanus 95%; and Polio • The self-reported rate of exceeding the Low-Risk 95%. These proportions were comparable to Ontario 9,21. Drinking Guidelines is 52% for residents of Haldimand • Confirmed enteric infections of public health signifi- and Norfolk counties compared to Ontario (44.4%)19. cance were reported in approximately 1.8 per 100,000 • The self-reported current smoking rates for adults people in Haldimand and Norfolk counties in 2018, were similar in Haldimand and Norfolk counties (19.5%) compared to 4.15 per 100,000 people in Ontario9,22. to the provincial rates (18.1%)14. • Sexually transmitted infections of public health signif- • Opioid related emergency department visits were icance were reported in approximately 305 per 100,000 67.9/100,000 in Haldimand and Norfolk counties com- people in Haldimand and Norfolk counties in 2018, pared to 63.4/100,000 in Ontario14. compared to 467 per 100,000 people in Ontario9,22. • Opioid related general hospitalizations in Haldimand • There were 2.7 confirmed cases of Lyme disease and Norfolk counties were 23.2/100,000 compared to per 100,000 people in Haldimand and Norfolk counties 14.6/100,000 in Ontario14. in 2018, compared to 4.0 cases per 100,000 people in Ontario9,22. Maternal and Child Health • There were 5.4 cases of West Nile Virus per 100,000 • Approximately 20% of mothers in Haldimand and people in Haldimand and Norfolk counties in 2018, com- Norfolk counties exclusively breastfeed up to 6 months, pared to 0.85 cases per 100,000 people in9,22. according to the Infant Feeding survey, which defines exclusively breastfeeding as feeding breastmilk only to a Environment baby, and have not introduced any other formula, solids • Population density in Haldimand County is 35.97 or liquids20. people/km2, and 39.25 people/km2 in Norfolk County8. • 30% of mothers in Haldimand and Norfolk counties • Haldimand and Norfolk counties combined cover reported using folic acid supplements prior to and during 2,859km2. Of this land, approximately 1.9% is park pregnancy compared to 31.5% across Ontario20. lands and 68.3% is agricultural land8. • Significantly more mothers in Haldimand and Norfolk

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Community Survey Results

Community Survey Results Social Services Survey Respondents Income and Poverty • A total of 492 individuals responded to the survey. • The majority of survey respondents reported an • In total, 57 responses were excluded for empty re- annual household income of less than $30,000 (32%, sponses (i.e. no data), 4 responses were excluded for not n=118) or of more than $100,000 (22%, n=82). living in Haldimand or Norfolk counties (i.e. did not meet • In the past 12 months, 16% (n=59) of survey respon- inclusion criteria), and 4 responses were excluded for not dents reported using food bank services. providing consent to participate. • Therefore, 427 responses were included in the final Employment and Education analyses. Participants were able to skip questions if they • In the past 12 months, 10% (n=39) of survey respon- chose, thus n-values are provided for context throughout dents reported they were unemployed, not by choice. the survey results. • In the past 12 months, 15% (n=58) of survey respondents used Ontario Works or Ontario Disability supports. Demographics • 11% (n=45) of survey respondents felt they were • Survey respondents over-represented females (80%, qualified for a better job than they could get and 26% n=336), and adults aged 26-60 years (76%, n=314). (n=103) of survey respondents felt there were not • The majority of survey respondents had a college enough job opportunities in Haldimand and Norfolk. certificate or diploma (35%, n=142) or a high-school diploma or equivalent (24%, n=99). Housing and Homelessness • The majority of survey respondents were employed • In the past 12 months, 5% (n=21) of survey respon- for wage or salary (48%, n=215) or retired (21%, n=61). dents reported requiring affordable or social housing but being waitlisted. Self-Identification • Of the 20 survey respondents who reported accessing • 25% (n=95) of survey respondents identified as a affordable or social housing, 55% identified as a person person with a disability and 10% (n=38) identified as a with a disability, 15% as a visible minority, 10% as a caregiver of a person with a disability. religious minority, 5% as an Indigenous person, and none • 14% (n=56) of survey respondents identified as a identified as LGBTQ2S+. single parent. • Nearly half of participants (48%, n=151) ranked more • 5% (n=19) of survey respondents identified as a housing supports as one of the top three services need- visible minority and 4% (n=18) of survey respondents ed to improve the social health of their family. identified as a religious minority. • In the past 12 months, 3% (n=10) of survey respon- • 3% (n=11) of survey respondents identified as dents reported being homeless or forced to couch surf, LGBTQ2S+ or gender non-conforming. and 5% (n=21) of survey respondents reported being • 2% (n=8) of survey respondents identified as Indige- forced to live with family or friends because they had nous. nowhere else to go.

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• 72% (n=207) of survey respondents agreed or • The most commonly faced barriers for accessing strongly agreed that Haldimand and Norfolk needs more social services were waitlists (29%, n=81), costs (23%, social housing shelter spaces. n=64), and being unsure where to go (19%, n=55).

Social Networks Health and Wellness • 12% (n=47) of survey respondents reported feeling General Health and Wellbeing socially isolated where they live. Further, 12% (n=50) of • Many survey respondents (43%, n=131) reported survey respondents reported that they felt they had no or that they had very good or excellent personal physical little social support network. health. • The most commonly identified social supports were • Survey respondents reported an average consump- family (81%, n=241), friends (77%, n=217), and doctors tion of 2.9 servings of fruits and vegetables per day. or healthcare providers (52%, n=154). Further, 24% (n=57) of survey respondents reported an • 11% (n=26) of survey respondents reported that average consumption of 0-1 servings per day. there were social support providers that they would like • When asked to list the top three services that they to be able to access but have not been able to. needed to make or keep their family healthy, survey respondents listed more recreational opportunities as a Safety top-three need most often. Specifically, 53% (n=167) • 1% of survey respondents reported being arrested of survey respondents reported wanting or needing with cause in the past 12 months. more recreational opportunities to improve their physical • 2% (n=8) of survey respondents identified their health. romantic relationship as dangerous. • Oral health was a commonly listed top-three educa- • 22% (n=89) of survey respondents reported experi- tion need for survey respondents. 18% (n=56) of survey encing sexual or domestic violence. respondents wanted more education about dental services for adults, compared to 10% (n=32) for children, Childcare and 10% (n=31) for seniors. • 8% (n=31) of survey respondents reported struggling • 33% (n=103) of survey respondents reported that to find childcare for work. they would like to be able to access a healthcare provid- • 71% (n=203) of survey respondents agreed or er that they have not been able to see. strongly agreed that Haldimand and Norfolk counties • 76% (n=231) of survey respondents agreed or need more childcare services. strongly agreed that they knew how to find the health • 36% (n=114) of survey respondents ranked more services that they need for themselves and their family youth-focused healthy activities, such as fitness, as a top in Haldimand and Norfolk. three need for health of their family. Chronic Disease and Injury Services • When listing the top three health supports or services • 72% (n=231) of survey respondents agreed or needed to make their family healthy, cancer screening strongly agreed that they knew how to find the social was listed 26% of the time, making it the third most services that they needed for themselves and their commonly listed support or service needed for healthy family. families in Haldimand and Norfolk. • The most commonly reported sources of information • When listing the top three health supports or services for social services were doctor or health care provider needed to make their family healthy, falls prevention for (46%, n=144), websites (43%, n=134), and family or older adults was listed 7% (n=22) of the time, and falls friends (41%, n=128). prevention for children was listed 2% (n=6) of the time.

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Mental Health and Addictions Community Experiences • 4% (n=14) of survey respondents self-identified as • 72% (n=231) of survey respondents agreed that addicted to alcohol; 2% (n=12) self-identified as addict- Haldimand and Norfolk is a good place to raise a family. ed to drugs, and 13% (n=53) identified as addicted to • 79% (n=250) of survey respondents agreed that tobacco. Haldimand and Norfolk is a good place to grow old. • Nearly half of all respondents reported experienc- • 78% (n=249) of survey respondents agreed that ing depression and/or anxiety (46%, n=183) and 18% Haldimand and Norfolk is a safe place to live. (n=72) reported experiencing non-depression mental • 78% (n=248) of survey respondents agreed that health difficulties. Haldimand and Norfolk is a safe place to be true to myself. Maternal and Child Health • 15% (n=45) of survey respondents reported that Service Experiences post-partum supports after a new baby as a top three • 78% (n=248) of survey respondents agreed that they mental health support needed to keep their family safe. knew where to find the health services that they needed • Services related to maternal and child health that for themselves or their family in Haldimand and Norfolk. were reported as a top three need for a healthy family by • 72% (n=231) of survey respondents agreed that they survey respondents included: 9% for breastfeeding sup- were able to find the social services that they needed for ports; 7% for family planning or sexual health supports; themselves or their family in Haldimand and Norfolk. and 7% for prenatal care. • Only 19% (n=56) of survey respondents considered themselves very familiar with the programs offered by Infectious and Vector-borne Diseases HNHSS. • The most commonly requested infectious disease • The most commonly reported services used at HNHSS topics that survey respondents wanted more information in the past year were printed materials (40%), spoken about were vector-borne diseases (14%, n=43) and to a nurse (18%), and used HNHSS websites or social vaccination and immunizations (11%, n=35). media (15% each). • 41% (n=111) of survey respondents agreed or Environmental Health strongly agreed that it is easy to seek assistance from • 55% (n=164) of survey respondents felt that climate HNHSS. change was impacting their family’s health. • 42% (n=114) of survey respondents agreed or • 37% (n=116) of survey respondents ranked more strongly agreed that they have always received good safe places to walk and/or play as one of the top three service from HNHSS. services needed to help them improve their own health. • 48% (n=131) of survey respondents agreed or • 71% (n=211) of survey respondents agreed or strongly agreed that HNHSS shows they care. strongly agreed that Haldimand and Norfolk counties • 50% (n=135) of survey respondents agreed or need more access to active transportation opportunities, strongly agreed that they trust HNHSS to have accurate, such as bike lanes. up to date information. • In this Lyme endemic area, 75% (n=224) of survey respondents reported that they check their bodies for ticks after outdoor activities.

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Focus Group & Interview Themes

Focus Group and Interview Themes Participation in Qualitative Research • 78 people participated in interviews as part of the data collection processes. Another 46 people participated in seven focus groups. In total, the qualitative components of this research included 124 participants. • Participants included HNHSS staff, partner organization representatives, and individuals with various lived-experiences.

Figure 1. Web of major themes and sub-themes for focus group and interview discussions. The green circles indicate the 7 major themes identified in the data. The light green rectangles indicate sub-themes that emerged from one or more major themes. The lines linking a major theme to a sub-theme indicate areas where the sub-theme was relevant to a major theme(s).

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Mental Health and Addictions Support Programs. Further, many participants described • Mental health and addictions was one of the most how wages were not enough to provide a good standard commonly discussed ideas or themes in all interviews of living. and focus groups. It was commonly discussed in con- • Participants commonly discussed issues of gener- junction with the ideas for greatest need in the commu- ational poverty (i.e. poverty from one family generation nity. to the next) as a major barrier. Some conversations • There was a general consensus among participants reflected how parents who experienced poverty could not that having a mental health condition or an addiction was provide alternatives to their children while others reflect- associated with substantial experiences of stigma. ed the trauma associated with experiences of poverty • Participants in both focus groups and interviews and the difficulty to overcome that. reported that major barriers to accessing services for • Again, participants discussed a stigma around poverty mental health and addictions were the long waitlists for and accessing services such as Ontario Works, Ontario treatment, lack of local professionals offering services, Disability Support Programs, food banks, and more. and the distance required to get to a treatment facility. The judgements felt for accessing services were often This contributed to the overall opinion of participants that enough to discourage participants from utilizing services mental health and addictions services were not accessi- that they felt that they needed. ble in Haldimand and Norfolk. • Transportation was a major barrier to accessing health and social services that was reported to drasti- Physical Health cally impact those living in poverty. Participants who had • Several different physical health needs were men- lived-experience of poverty or who worked with individ- tioned in interviews and focus groups, including sexual uals experiencing poverty felt that this was exacerbated health, aging populations, and the impacts of substance by the rurality of the region and the distance to get to use on physical health. various services. • One of the most commonly discussed needs of the • Many individuals with lived-experiences of poverty communities in Haldimand and Norfolk was the lack of also discussed how lack of education and employment family physicians and specialists in the region. This con- opportunities in Haldimand and Norfolk exacerbated tributed to long wait times with the available providers or issues with poverty. long distances to travel to see specialists. • Participants also noted that several types of physical Housing health needs that they may visit the health unit for, such • Like mental health and addictions, housing was one as sexual health services, were stigmatized and made of the most commonly discussed ideas or themes in all people feel vulnerable in the waiting areas of the health interviews and focus groups. It was commonly discussed unit buildings. in conjunction with the ideas for greatest need in the community. Poverty • Affordable housing was a major concern for partici- • Poverty was discussed as both a prominent theme pants in both Haldimand and Norfolk. Participants were and an underlying cause of many issues in the focus concerned about the rising prices of rented and owned groups and interviews. Participants felt that the rates of homes in the communities, as well as the decreasing poverty in the community were very high and that pover- available stock of housing. Many participants linked ty impacted many of the other needs locally. these changes to the expansion of the Greater Toronto • Participants commonly described how the cost of and Hamilton areas and cost of housing there. living was simply too high to survive on the government • Homeless prevention services were also mentioned funding provided by Ontario Works or Ontario Disability regularly as an increasingly visible homeless population

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are noticed in the Haldimand and Norfolk communities. inaccessible due to distance (i.e. no grocery stores in Those with lived-experience typically described this as a many communities) or due to cost (i.e. all food or healthy long-ongoing issue that requires resolution while those food was too expensive). from some agency and government positions saw this • The lack of available family physicians and special- as a new issue that required resolution for other reasons ists was also noted in context of availability of essential (i.e. impacts on businesses). services. • As with several other issues noted in the focus • Several participants noted a lack of youth program- groups and interviews, participants felt that individuals ming and a lack of youth and general recreation oppor- experiencing homelessness were experiencing substan- tunities that were linked to mental health and substance tial stigma, driven in part by their visibility in parks and abuse changes among the local youth population. near businesses. • Childcare was commonly cited as a necessary service that was not available for families that needed it. Specifi- Rurality cally, many participants cited this as a barrier to employ- • The rurality of the Haldimand and Norfolk communi- ment. ties was a theme that underlay several of the needs and • Waitlists and hours of operation both at HNHSS and barriers described by participants. other agencies were other common barriers to accessing • The rurality of the communities and of peoples’ necessary services in the communities. homes was a common factor in feelings of loneliness or • Further, a general lack of awareness of available isolation in their home towns. services at HNHSS and other agencies impacted the • The communities were commonly described as being familiarity with and use of services. At times, programs very far apart and taking a long time to travel between. currently available within HNHSS were cited as needs in As a result, location was a commonly listed barrier for the community, demonstrating a lack of awareness of accessing services from HNHSS and other agencies. service provisions. In particular, distance between communities was often cited by key informants from agencies as the barrier to Organizational Structure providing transportation services. In contrast, distance • Participants identified several factors that influenced between communities was often cited by those with utilization of and quality of available services at HNHSS. lived-experience and the individuals serving them as the • Both staff and agency participants reported insuffi- main reason for requiring transportation services. cient availability of local data. Further, what was reported • Additionally, the rurality of Haldimand and Norfolk was often included Haldimand and Norfolk with other coun- often cited as a reason for why participants felt there ties that shifted the data to be less representative of were limited employment opportunities in the region. these communities. Data that was available was report- edly not well shared between agencies. Availability of Products and Services • A lack of available financial resources to run or • Participants often explained that various necessities expand programs was a commonly discussed structural were not available in their communities or in the counties issue for both health and social services. more broadly. • There was a general consensus from key informants • Again, transportation was a major concern for par- that there was insufficient staff to provide some services. ticipants who felt the currently available services were HNHSS staff reported feeling overwhelmed by the work- not enough and who noted how many communities were load while agency participants reported that HNHSS staff entirely excluded from the services. sometimes seemed unavailable due to workloads. • Despite Norfolk County being considered “Ontario’s • Other structural issues that presented barriers for Garden” participants commonly stated that food was participants to use services were the location of the

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HNHSS buildings, a relative lack of presence in the com- • Similarly, communication, both internally and ex- munities, and the hours that services were available (i.e. ternally, were cited as both a strength and an area for 8:30-4:30, Monday-Friday). growth. Some participants felt communication was very • The most commonly described area for growth and smooth and open while others felt that communication further improvement to address the needs of the com- should be improved to address community needs. munity was stronger collaborations between HNHSS and other agencies.

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Discussion & Recommendations

Discussion and Recommendations ing the greatest needs in Haldimand and Norfolk, the Following the triangulation of the quantitative data (i.e. following discussion, recommendations, and conclusions community profile and community survey) and the quali- should be interpreted in context of those we heard from tative data (i.e. focus group discussions and key informant most. interviews), the major themes emerge as common community needs that the participants in all elements of the Mental Health and Addictions Supports CNA prioritized. Further, three major exacerbating factors Mental health and addictions supports were one of the top were described: generational poverty, rurality, and lack of priorities or greatest needs described by participants in available products and services. both the focus group discussions and key informant interviews. In the survey, mental health and addictions supports Community members, agency staff, and HNHSS staff were ranked as a top three need for healthy families often. provided a wealth of information that should be considered Further, in discussions with participants, this was often when developing recommendations and actions to ad- stated as one of the greatest priorities for the community. dress the needs of the community. Recommendations and actions have been summarized into key themes. Participants described the need for mental health and Representativeness addictions supports as being very high, while describing The survey data and focus group data are not entirely the availability of services for mental health and addictions representative of the communities in Haldimand and Nor- as being very low. Participants stated that supports often folk counties. In particular, the respondents to the survey had long waitlists that delayed entry into programs, were over-represented females and under-represented males. difficult to travel to, or had costs that they could not afford. Additionally, the survey over-represented adults compared to seniors. Finally, the survey over-represented participants Mental health and addictions issues were often described with higher levels of education compared to those with as exacerbated by poverty and rurality. Poverty was seen lower levels of education. as a stressor that often initiated mental health and/or addictions issues, further compounded by a generational In contrast, the participants in focus group discussions trauma of poverty or addictions. Additionally, rurality as a typically over-represented those with difficult lived-ex- cause for loneliness or isolation, as well as boredom, was periences, such as those living in poverty, facing mental often considered a contributing factor for the high demand health and addictions issues, and experiencing precarious for mental health and addictions services. housing. However, interviews commonly balanced this data with individuals who worked for agencies. However, Mental Health Provisions the opinions of the focus group discussion and interview According to the Ontario Public Health Standards4 (OPHS), participants do more often reflect those experiencing more public health units are required to either provide mental hardship in this region. health services or to assure that the community agen- Therefore, while important and relevant, and still address- cies are sufficiently filling and meeting the needs of the

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community. However, given the data collected through In and of itself, poverty was described as the outcome both quantitative and qualitative methods for the CNA, the of lack of employment opportunities in Haldimand and community feels that currently available provisions are Norfolk counties, insufficient government funding from not sufficient. HNHSS should, consider opportunities to Ontario Works and Ontario Disability Support Programs, increase supports for mental health and addictions in the and limited educational attainment and opportunity in this community such as health promotion activities for mental region. Further, poverty was described as a contributing health. Alternatively, advocating to external agencies to factor to the high demand for mental health and addictions provide additional supports such as youth mental health services, and as a stressor in general life that lowered programming. perceived overall health of many participants.

Physical Health Poverty issues were often described as being exacerbated The quantitative and qualitative data collected as part of by a generational poverty system, by the relative rurality of this CNA indicate that physical health is a major concern the communities, and by a lack of available services. Ru- for residents in Haldimand and Norfolk counties. Survey rality was described as an exacerbating factor for poverty respondents and focus group and interview participants because many participants suggested this was the reason described several key physical health concerns, including for less employment and education opportunities. nutrition, high rates of cancer, and sexual health. Further, and perhaps most pronounced of all, respondents and Provision of Necessary Goods participants both described a lack of available family physi- Several types of recommendations related to the provision cians in this community. of necessary goods for community members arose in the focus group discussions and interviews. Recommendations Medical and Health Service Provisions centered on both what HNHSS and other agencies could HNHSS is not mandated to recruit doctors or other medical be providing to help community members who were strug- service providers directly; however, without sufficient family gling with accessing necessary goods as a result of pover- doctors and/or specialists in Haldimand and Norfolk, some ty. These types of goods were often food, family planning additional responsibilities may fall to HNHSS4. supplies (i.e. condoms), and cold-weather clothing. While HNHSS is not mandated to provide necessary goods4, As such, HNHSS could improve access to services by these goods were often described as necessities that advocating5 to council for the enactment of incentives allowed staff to more meaningfully engage with clients. that will encourage physicians as well as other health That is to say, clients who were struggling with access to care specialists to practice within Haldimand and Norfolk. necessary goods often had too many co-morbidities and Further, collaboration with the local hospitals and the new issues to address before the services were able to really Ontario Health Teams may also serve to reduce this barrier assist them. over time. As a recommendation to HNHSS, it would be valuable to Poverty consider continuing to advocate on behalf of the commu- Poverty was described as both a major community issue nity residents who are struggling with access to necessary and a major exacerbating or contributing factor to other goods. Some participants recommended that HNHSS needs in the community. Poverty was seen as a barrier to continue to provide through donations to clients who come accessing many of the things that individuals needed to for services. Others recommended that HNHSS curate lists be healthy, such as a safe place to live and healthy food, of available goods in each community, such as with the and as a stressor that heightened the experience of other list of meal programs and food banks available by com- needs, such as mental and physical health. munity. In addition to having these provisions available,

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there were several recommendations about how to most ends meet each month. Many felt that their shelter costs equitably provide these goods. For example, participants were a driving factor for their experiences with poverty. recommended that a private space where individuals could Further, the lack of available housing stock was often enter and take what they needed without feeling watched described as being worsened by the rurality of Haldimand or stigmatized by other clients at HNHSS would help. and Norfolk counties.

Advocacy for Increased Incomes Affordable Housing Ideas The second major recommendation for poverty alleviation As housing was a major theme of the focus group and and to reduce the chronicity of poverty in Haldimand and interview discussions, recommendations for alternative Norfolk was for HNHSS to consider advocating on behalf of affordable housing were also common. After describing the the residents of the communities for increased government current problems with affordable housing in this region, it subsidies. In both the quantitative and qualitative data col- was often a natural progression for participants to provide lected, participants call for changes to Ontario Works and ideas for solutions or recommendations to address the Ontario Disability Support Program. Participants explained issue. Commonly described recommendations were to shift how they could not afford to access enough food or healthy legislation to allow for the development of “Tiny House” food, or could not access safe shelter when restricted by communities, provide a wrap-around style housing service the amounts of the government subsidies. For example, the through organizations that maintain the affordable housing Market Based Measure for an affordable standard of living stock to support individuals who are seeking employment suggests that residents in rural areas, such as Haldimand or addictions supports, and provide communal spaces and Norfolk counties, need to make more than double the where each client or resident has private spaces but might current Ontario Works subsidy to achieve a basic standard share a kitchen or living area. of living. As front-line workers who interact with our clients regularly, HNHSS is in a prime position to advocate for and Many clients claimed that affordable housing was designed with clients for increased subsidy amounts and thus, an for families of four or more and did not account for single improved standard of living. people or couples without children seeking smaller, more affordable spaces. In these cases, participants often rec- Affordable Housing ommended smaller units or communal spaces with private Affordable housing was the other top priority or greatest bedrooms. These recommendations were particularly need (i.e. alongside mental health) described by partici- relevant given the long wait times for a one bedroom unit pants in both the focus group discussions and key infor- in Simcoe. mant interviews. This need was reiterated in the community survey. Given the “Housing First” philosophy employed at It was recommended that HNHSS could act on this via HNHSS and at many other agencies, it was not surprising three main pathways: advocate for the development of that this was considered a major need in Haldimand and affordable units or Tiny Houses by external organizations, Norfolk. Participants with lived-experiences also explained release a call for proposals related specifically to the how the lack of affordable housing and low availability development of some of the affordable housing ideas of housing stock was a major factor in maintaining their mentioned above and oversee the projects, or take on the family’s health. building themselves. From a feasibility perspective, the first two options are much more viable than the third. However, Affordable housing was described as exacerbated by HNHSS could consider advocating to shift legislation to poverty and rurality as well. With regards to poverty, low allow for Tiny Houses or could continue to explore alterna- incomes and high costs of housing were coupled to make tive methods for providing affordable and rent geared to many families feel they could barely or could not make income housing.

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Availability of Products and Services for full-day childcare for children 0-4 years and for be- A lack of access to products and services was frequently fore and after school care. Further, participants discussed discussed in the qualitative data and supported by the existing subsidies for childcare that are currently managed quantitative data. Specifically, issues around transporta- by HNHSS from government bodies. These subsidies were tion, childcare, food, and youth programming abounded described as very helpful and successful and participants in the data. These issues were often linked to rurality and called on HNHSS to continue to redirect funds directly to the assumption or explanation that services were simply families using childcare services to make it more afford- too difficult to provide in a vast geographical area with a able whenever possible. relatively low population density. Further, with regards to a lack of services, the lived-experiences of poverty were Food often described as exacerbated because of the lack of A lack of available products and services was described in transportation to access supportive services (e.g. food context of food in two key ways: a lack of available grocery banks) or the lack of childcare to be able to seek employ- stores in some areas (i.e. food deserts) and an inability to ment opportunities. afford the foods that were available in their area. While it would be helpful to increase the number of grocers avail- Transportation Ideas able, particularly in communities like Jarvis without such Transportation was discussed as a subtheme of several stores currently. HNHSS has a role to play in considering major themes, including rurality, available products and advocating for increased government subsidies or wages services, and organizational structures. However, as with so that families can access healthy food or advocating for housing, suggestions for solutions to transportation issues subsidies to access healthier choices. Other actions that were also common. While some recommended extending HNHSS could implement included: training to make healthy existing transportation services, such as RIDE Norfolk meals for one, training to make healthy meals on a limited into other communities and into Haldimand, many partici- budget, and advocating for additional subsidies to access pants recommended new and innovative ideas to address healthy foods. transportation needs. Two specific recommendations for transportation ideas were to mimic the Uber ™ ride-share Youth Programming and Recreation model from Innisfil (i.e. subsidized transportation costs in Participants in both the quantitative and qualitative ele- owner-operated vehicles) and to introduce a bike-share ments of the CNA described one of the greatest needs system that linked the key areas of the communities for a locally as a lack of youth programming and recreation for simple deposit cost (i.e. no user fee). all ages. In the survey, increased access to recreational HNHSS could advocate to the Haldimand and Norfolk facilities was the most commonly desired service to make Municipal Councils on the benefits of the ride-share and families healthier. bike-share systems, encouraging the councils to provide the service themselves or seek bids from external agencies Youth programming was described as the greatest need to offer the service. for youth in Haldimand and Norfolk in nearly every instance where youth needs were described. Participants explained Childcare how youth were bored and/or lonely and often linked this Another service that was frequently discussed as be- to experimentation with vaping, tobacco, alcohol, and ing unavailable or insufficiently available in Haldimand drugs. and Norfolk counties was childcare. Childcare was often described as being entirely full (i.e. no available spaces) or General recreation for all age groups was also a common too costly for families to access. With regards to solutions, desire. Participants described a need for recreational facili- participants recommended that more spaces were needed ties in context of high rates of obesity, low physical activity,

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feelings of isolation in a rural community, and in context other departments in their own organizations, including of the current barriers they faced to access recreational within HNHSS. Inter-agency collaboration was discussed opportunities, such as hours, distance, and costs. Partici- in the context of reducing the duplication of some services pants reiterated many times the importance of recreational and the gaps in other services that were not well ad- opportunities that were affordable for families on limited dressed due to a lack of collaboration. incomes. One tangible idea for addressing these collaboration issues HNHSS can act on this recommendation by applying for arose frequently; this idea reflected a stance of coordinat- grant funds to build and expand recreational facilities in the ed care, as has been initiated in some of the communities region. Having done this recently, the County is recognizing within Haldimand and Norfolk more recently. The idea of the need of the community and responding with appropri- coordinated care models was that HNHSS and other agen- ate actions, HNHSS is meeting its mandates in this area. cies in the region would be more aware of each other and Further actions that could be investigated or considered their priorities, and that duplication could be reduced to ad- are the possibility of subsidies to allow families to access dress current service gaps. A second tangible item related recreational programming and intentional diversification of to collaboration was communication. available programming to include lower-cost activities such as swimming and baseball, beyond the commonly noted Communication availability of hockey in Haldimand and Norfolk. The second most commonly discussed idea for solutions or recommendations to improve the health and social ser- Organizational Structures vices provided in Haldimand and Norfolk was to increase Barriers to services in Haldimand and Norfolk, and spe- communication. This idea was presented by both focus cifically at HNHSS, frequently involved organizational group discussion participants and key informant interview structures that made it difficult for clients to use or access participants; however, it was clear that the idea of com- services. For example, organizational structures referred to munication meant two different things across participant collaboration, communication, meeting people where they groups. Agency participants typically spoke of commu- are, operational changes, and anti-oppressive actions (see nication in conjunction with collaboration, as a response below for more information). However, these were often or solution to the ideas of service duplication and service the most actionable and feasible recommendations made gaps. In contrast, participants who were speaking from a by participants in both the quantitative and qualitative perspective of lived-experience felt that HNHSS needed elements of the CNA. There were many recommendations to do more to communicate their program offerings to the related to organizational structures. general public, specifically to those priority populations who required services. Collaboration The most commonly discussed idea for solutions or rec- Tangible ideas for communication abounded in the in- ommendations to improve the health and social services terviews and focus groups. One of the most commonly provided in Haldimand and Norfolk was to increase intra- discussed ideas for communication was to increase staff and inter-agency collaboration. Both focus group discus- awareness of available programming. Some recommend- sion participants and key informant interview participants ed methods or processes to consider for increasing staff recommended that collaboration would strengthen and awareness of programming included information sessions improve the available services at HNHSS and other health with HNHSS staff in other departments, to learn how to and social services in the communities. When discussing best refer their current clients to other services. It was also intra-agency collaboration, participants referred to some- suggested that HNHSS provide these types of sessions to times having a lack of awareness of services provided by other agencies. Additionally, updated and regularly revised

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print communications was another recommendation. Ideas HNHSS was not employing a trauma-informed lens for for communicating with the public also included regularly providing client-facing services. Several participants reit- updated print communications about available programs, erated that HNHSS typically works with vulnerable clients and included ideas for increased or different media pres- who are experiencing various forms of trauma, such as ences, related more to day-to-day services. While HNHSS generational poverty, abuse, or substance-related issues, currently produces several print materials and maintains a and who should be treated in an informed way so as not to media presence, the data suggests that the community did exacerbate existing traumas. For this barrier, recommenda- not feel this was enough to be familiar with the breadth of tions primarily centered on providing trauma-informed care available programs. training to staff at HNHSS.

Meet People Where They Are Operational Changes The third most commonly discussed idea for solutions Another recommendation for increasing accessibility of or recommendations to improve the health and social HNHSS was to extend operating hours to serve families in services provided in Haldimand and Norfolk was to inten- the evenings and on weekends. If HNHSS considers the tionally meet clients where they are. This referred to both opportunity that staff were encouraged to flex their day to physical location and emotional state. work 12p.m.-8p.m. one day per week, the client-facing programs, such as sexual health, oral health, and vaccine From a physical perspective, participants in both focus preventable diseases would be more accessible to working group discussions and key informant interviews felt that families and families whose children are in school full time. HNHSS had a lower than optimal presence in many of the Hours could be extended to 8p.m. Monday to Thursday to communities. HNHSS provides services at the offices in accommodate the needs of the community. Simcoe, Dunnville, and Caledonia, and a few drop-in style clinic services in locations like Langton. However, it was Anti-Oppressive Actions and Empowerment often stated that this excluded many of the communities Participants in both focus group discussions and key in Haldimand and Norfolk making it difficult to access informant interviews, as well as the community survey, services. Further, many participants also noted that the described feelings of stigma related to using several HN- current locations of the three HNHSS offices were also dif- HSS services. Stigma was commonly described in context ficult to get to as they were not downtown (e.g. Simcoe), or of other clients or program users, however, some partici- they were near other services that clients may be avoiding pants also described feelings of being stigmatized by staff. (e.g. parole or police stations in Dunnville and Caledonia). Typically, participants felt that HNHSS was making prog- Participant recommendations primarily focused on more ress in client empowerment and anti-oppressive actions to satellite locations and the introduction of a health bus to address stigma, but often felt that HNHSS could continue provide services in communities where an office was not to do more in this space to reduce feelings of stigma. Not a feasible solution. HNHSS could investigate and consider only did participants feel that HNHSS could be doing more the opportunity to “hotel” (i.e. use existing spaces for short to address these issues, many participants felt that HNHSS periods of time) in non-HNHSS county buildings in Haldi- was missing an opportunity to be a community leader in mand and Norfolk counties. By working out agreements to this space. Relatedly, the Chief Public Health Officer of use spaces in other county-owned buildings, HNHSS could Canada’s Report on the State of Public Health in Canada feasibly provide services in many of the communities not 2019 calls for similar actions23. Dr. Tam calls for Canadian currently feeling a community presence. public health programs to build on the Canadian values of multiculturalism while openly naming and recognizing is- From an emotional perspective, participants felt that sues such as racism, homophobia, transphobia, and other

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stigmas of social identity23. Additionally, Dr. Tam describes included in decision-making processes, program planning how the elimination of stigmatizing behaviours can improve discussions, and in more intentional ways, such as via this overall health and wellbeing in our communities23. CNA. Participants described the ways that informing programming by lived-experiences practically addressed the Related to meeting people where they are emotionally and needs the community members wanted to prioritize. For empowering individuals, a distinct subtheme of recommen- HNHSS, that may include considering a regularly scheduled dations for informing practices by lived-experiences also CNA every 5 years, inclusion of individuals with lived-expe- emerged. These recommendations focused on the idea riences on program planning committees, and more. that individuals with lived-experiences of all sorts should be

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Conclusions

Conclusions Additional Information The data collected as part of the CNA for HNHSS 2019 A full version of the CNA report is available by request from came from many sources in an attempt to triangulate the the Director, QPAP, HNHSS. data and present the most comprehensive and representative conclusions possible. The results suggest that HNHSS Recommended Citation: is doing a good job, but that there are several key areas Haldimand-Norfolk Health and Social Services (2019). to continue addressing to meet the needs of residents in Community Needs Assessment Summary Report. Simcoe, Haldimand and Norfolk counties. Major needs in the com- ON, Canada. munity included mental health and addictions supports, affordable housing, and poverty alleviation. Further, many of the issues being experienced in Haldimand and Norfolk were exacerbated by generational poverty, rurality, and a lack of available products and services, such as transportation, childcare, and recreational opportunities. However, from a solutions-oriented perspective, the community participants shared several exciting, tangible, and important recommendations to continue to improve the services available through HNHSS. It is important that HNHSS and the counties continue to work together to implement the recommendations and serve the communities to the best of their ability. Not all of these recommendations can be met by HNHSS and the counties alone—collaboration and communication with other agencies, residents, and the Board of Health will be essential for success. Next steps for action on the findings of the CNA are to develop a new Strategic Plan in 2020 for HNHSS, build and maintain strong relationships with partners, and prioritize the recommendations presented above.

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References

1. Windsor-Essex County Health Unit, Community Needs Assessment Full Report, 2016. 2. CDC (Centres for Disease Control and Prevention). (2014). Community Health Assessment and Health Improvement Planning. 3. Baird S. (2013) Evidence In-sight Request Summary: Conducting a Community Needs Assessment. 4. Ontario Public Health Standards (OPHS) 2018. Protecting and Promoting the Health of Ontarians. Available from: http:// www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Ontario_Public_Health_Stan- dards_2018_en.pdf 5. Dunkle S, Mariner JC. (2013) Participatory Epidemiology: A Toolkit for Trainers. Nairobi, Kenya. 6. Braun V, Clarke V. (2006) Using Thematic Analysis in Psychology. Qualitative Research in Psychology, 3:77-101. 7. Creswell, JW, Miller, DL. (2000) Determining Validity in Qualitative Inquiry. Theory into Practice, 39:124-130. 8. Statistics Canada. Census Profile, 2016, Haldimand-Norfolk, Census division, Ontario. Available from: https:// www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E&Geo1=CD&Code1=3528&- Geo2=PR&Code2=35&SearchText=haldimand%20norfolk&SearchType=Begins&SearchPR=01&B1=All&TABID=1&type=0 9. Haldimand Norfolk Health and Social Services Division (2019). Internally reported or measured data. 10. Ontario Works. (2019) Ontario Works Operations Performance Report. 11. Feed Ontario. (2019) Hunger Report: Ontario’s Changing Landscape and Its Impact on Foodbank Use. Available from: https://feedontario.ca/wp-content/uploads/2019/11/Hunger-Report-2019-Feed-Ontario-Digital.pdf 12. Nutritious Food Basket Study. (2019) Nutritious Food Basket. 13. OrgCode. (2018) 2018 Norfolk and Haldimand Counties Homeless Registry Week Final Report. October 15, 2018, Revised April 11, 2019. 14. Public Health Ontario Snapshots. (2019) Toronto Public Health. Available from: https://www.publichealthontario.ca/en/ data-and-analysis/commonly-used-products/snapshots 15. Brownwell, C. (2018) These are the Safest Places in Canada. Maclean’s Society. Available here: https://www.macleans. ca/news/canada/canadas-safest-places-2019/ 16. Ontario Provincial Police (2016a). 2017-2019 Action Plan and 2016 Progress Report, Haldimand County Detachment. 17. Ontario Provincial Police (2016b). 2017-2019 Action Plan and 2016 Progress Report, Norfolk County Detachment. 18. Early Develop.m.ent Instrument (2018). Early Develop.m.ent Instrument: a population-based measure for communities. Summary Report, Senior Kindergarten Students in the province of Ontario, Norfolk County School year 2017/2018. 19. Mental Health Promotion and Resilience Program (2018). Environmental Scan. Collaboration between the Canadian Mental Health Association Hamilton Branch & Centre de santé communautaire Hamilton/Niagara, March 2017 - July 2018. 20. Haldimand Norfolk Health and Social Services (2019b). Infant Feeding Survey. 21. Panorama Vaccination Data. Ontario Agency for Health Protection and Promotion (PHO). Date Last Extracted: Aug 1, 2019 from Panorama. 22. Annual Infectious Disease Surveillance Report (2018): Disease of Public Health Significance (DOPHS) Cases for January to December 2018: Available from: https://hnhu.org/wp-content/uploads/Annual-ID-Report-2018.pdf 23. Tam, T. (2019) Addressing Stigma: Towards a More Inclusive Health System; The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2019. Available from: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/addressing-stigma-toward-more-inclusive-health-system.htm- l?utm_medium=email&utm_source=stakeholder&utm_campaign=cpho-19.

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63 Return to Top COMMUNITY NEEDS ASSESSMENT

The Haldimand-Norfolk Health and Social Service’s (HNHSS) Community Needs Assessment (CNA) aimed to identify and understand the needs of the community. This will contribute to the planning of HNHSS programs. Method

community profile community survey focus groups key informant interviews with priority populations Community Profile Median Income Employment Rate 76,117 Haldimand County 61.2% Haldimand County 109,787 67,338 Norfolk County 55.2% Norfolk County Population of Haldimand and Norfolk 74,287 Ontario 59.9% Ontario

Community Survey 22% 53% have poor or want more recreational fair health responded opportunities to improve 492 to survey physical health

8% struggle 18% 11% to find childcare experienced unable to for work non-depression access social mental health support providers 46% experience 16% used food bank 6% homeless depression 12% hungry, could not and/or anxiety afford food

Health Addicted to: Care 19% very familiar 13% tobacco 33% like to access a with HNHSS 4% alcohol healthcare provider programs 2% drugs Education Topic of Interest

47% wanted stress 30% management wanted to know available and coping skills children’s services

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Haldimand-Norfolk Board of Health

RESOLUTION # DATE: July 7, 2020

MOVED BY Member Columbus .

SECONDED BY Member Martin .

THAT the rules of Order be waived to allow a Notice of Motion to be considered directly as a Motion;

AND THAT the Board of Health Direct the Health Unit to undertake consultation with representatives from the Norfolk County Agricultural Advisory Board prior to implementing any substantive program or service changes impacting the agricultural community;

AND THAT Health Unit staff be required to provide routine updates to the Board of Health upon consultations with the Norfolk County Agricultural Advisory Board.

2/3rds required ______Defeated Carried

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______Defeated Carried

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The Board of Health By-Law 2020-08-BH

Being a By-Law to Confirm the Proceedings of The Board of Health for the Haldimand-Norfolk Health Unit at this Board of Health Meeting held on the 7th of July, 2020.

WHEREAS Section 56 of the Health Protection and Promotion Act, R.S.O. 1990, c.H.7, as amended, provides that every Board of Health shall pass a by-law respecting the calling and proceedings at meetings;

AND WHEREAS it is deemed expedient that the proceedings of the Board at this Board of Health Meeting be confirmed and adopted by By-Law.

NOW THEREFORE the Board of Health for the Haldimand-Norfolk Health Unit hereby enacts as follows:

1. That the actions of The Board of Health for the Haldimand-Norfolk Health Unit at this Board of Health Meeting held 7th Day of July, 2020, and each motion and resolution passed and other action taken by The Board of Health for The Haldimand-Norfolk Health Unit at this meeting are hereby adopted and confirmed as if all such proceedings were expressly embodied in this By-Law.

2. That the Chair of the Board of Health and proper officials of the Haldimand-Norfolk Health Unit are hereby authorized and directed to do all things necessary to give effect to the actions of The Board of Health referred to in the preceding section hereof.

3. That the Mayor and Clerk are authorized and directed to execute all documents necessary in that behalf and to affix thereto the Seal of Norfolk County.

ENACTED AND PASSED this 7th Day of July, 2020.

Chair

County Clerk

67 Office of the CAO 50 Colborne St. S. Simcoe, ON, N3Y 4H3 Tel: 519-426-5870 Ext:

Memo

To: The Board of Health

From: Jason Burgess

Date: July 6, 2020

Re: Agriculture Advisory Board’s position on preferred practices with COVID19 and Management’s response

The Board of Health had directed me to reach out to the AAB to confirm our understanding of what the agricultural sector would like to see as far as measures to deal with COVID19.

The AAB provided us with their preferred position and their rational on June 27, 2020. Their full response is provided in the appendix of the attached document.

The following is a summary of staff’s initial response. Staff will be seeking to meet with the AAB to discuss further. The response is a summary response and is not designed to provide fulsome detail to each proposal suggested by the AAB.

The response is also written in a manner to ask probing questions to the Board of Health as they contemplate these issues, these are the same types of questions staff utilize to formulate public policy.

We apologize for the late timing on this memo, however we were attempting to provide a response as quickly as possible. As always staff would be more than happy to address any questions or concerns.

7/6/2020

COVID19 - Farming and Haldimand Norfolk Health

Response to Agricultural Advisory Board Position on Public Health Management of COVID-19 Related to Worker Accommodations During COVID19

July 2020

AAB’s Position

We requested from the Agricultural Advisory Board (AAB) that they provide their preferred approach to the following: 1) Self-Isolation Period after arrival to Canada (Travel quarantine protocols) 2) Post-isolation period for the remainder of the stay.

We have provided the full commentary from the AAB in Appendix A from the Board of Health.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 2

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AAB’s Position A summary of their position is as follows: During the initial 14 day travel self-isolation period – The position outlined is that workers would undertake their initial quarantine period in the bunkhouses with spacing to accommodate 2 meters of social distancing. They would also want to translate the quarantine capacity in the bunkhouse as an expression of their normal capacity (up to 70% of the normal occupancy capacity). The farmers would also propose having a worker co-ordinate health checks with reporting to the farmer. Note – it was not clear from the AAB position how they would handle new arrivals into the farm during a group’s 14 day self-isolation period. If new people enter the self-isolation period the clock should start over for everyone in the bunkhouse. This may make the logistics more difficult for individual farms to manage and more detail should be obtained.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 3

AAB’s Position A summary of their position is as follows: Post Travel Isolation Period – The position outlined is that farmers would attempt to maintain 2m separation when possible, however be allowed to utilize their full occupancy limit of the bunkhouses. This would include the use of bunkbeds with some type of separation or barrier being utilized. The AAB’s would also propose utilizing work or group cohorts as part of their plan. The AAB’s position is to also allow for positive asymptomatic individuals to continue to work.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 4

2 7/6/2020

Response to AAB’s Position

Though there are certain items that are The four way test looks at the impacts of the options to the supported by the Health Unit, overall the AAB’s key stakeholders. The four position would be one of the higher risk questions we would ask is: approaches in Ontario and would be more aligned with Windsor Essex’s original approach What is the risk or cost to the (though it might have higher risk elements). The worker? Health Unit does not believe increasing risk is What is the risk or cost to the appropriate. farmer? What is the risk or cost to the broader community? Overall, the Health Unit is not supportive of the What is the risk or cost to the AAB’s Position as it does not pass the 4 way test Counties or Board of Health? and increases our current amount of risk.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 5

Stakeholder Interest

Farming Sector interests: This includes When one looks at each ensuring economic viability as well as being a stakeholder’s interest the good employer and community member. suggested solution does Worker interest: Their health and economic not work for all parties. interest. The AAB’ position Community interests: Reducing community transfers significant risk to spread, cost to the taxpayer. the Worker, the Community and the Public Health interest: Reducing community Public Health authority. spread, being able to manage risks and resources.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 6

3 7/6/2020

Applying The Four Way Test – Travel Self Isolation - AAB Proposition Test Impact to the The worker has an increased risk of obtaining COVID19 and or another disease as each additional Worker worker in self isolation increases the inherent risk to the worker. (See Appendix B) You can be asking healthy people to self-isolate with sick people. If the worker gets sick it impacts their health and their financial well being. Impact to the This could be the lowest cost option to the farmer and potentially utilizes existing housing capacity Farmer more fulsomely. However an outbreak on the farm in quarantine will negatively impact the farmers to a greater extent due to the increased lost of workforce as well as the cost to handle outbreak management.

Risk to the Broader The risk to the broader community increases as there are increased risks of self isolation failures, Community however during the self isolation period this should be contained to the farm during this period.

Risk to the County Outbreaks in this scenario would be larger outbreaks which carry an increased resource burden and cost to the County and other health partners.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 7

Applying The Four Way Test – Post Travel Self isolation – AAB Proposition Test Impact to the Worker Maximizing bunkhouse occupancy has an increased risk of obtaining COVID19 and or another disease the spread in bunkhouses has been well documented. If social distancing measures can be undertaken to reduce capacity and risks, this may have some positive impact to the worker. Impact to the Farmer This is potentially the lowest cost option to the farmer and utilizes existing housing capacity more fully. However an outbreak on the farm can be devastating as each outbreak that has happened has extensively impacted the workforces at farms, with significant cost to the farmer. Risk to the Broader The risk to the broader community is significantly increased as farm outbreaks are large and the Community chance of a community infection increases. often extending to other farm workers, families and the broader community. Increases with positive asymptomatic cases. Risk to the County Outbreaks are expensive to the taxpayers. When one looks at the impact to Health Unit Resources, community medical resources, hospital resources as well as the cost to the farmer – each outbreak is financially significant and resource intense. With our one outbreak we had a number of hospitalizations, 7 ICU admissions, 2 transfers to London hospitals and one death.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 8

4 7/6/2020

Backdrop - Constraint Issues There are two major constraints that form part of the backdrop to this issue in Norfolk County: On Farm Accommodation Issues – On farm accommodations are limited and significant changes will take time and large displacements of workers will require additional accommodations which are limited in the County. Public Health Capacity Issues – The temporary farm workers add a material increase in the population to Norfolk County and the health district. The total amount of resources the health unit has as well as the broader health system in the County is limited. The ability to execute extensive programs or to deal with multiple large breakouts is very limited.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 9

Accommodation Options

There are a broad range of options to accommodate farm workers during the travel quarantine period and thereafter. The lowest risk model is where each individual has their own room, washroom and eating facility. However it is recognized that this is not possible currently. The highest risk model is in a congregate setting with shared sleeping, washroom and kitchen facilities (see Appendix B) Each option would have different demands on the accommodation infrastructure as well as the cost to the farmer. The following chart outlines the risk continuum of these options.

Health Unit's Response to AAB's recommendations on COVID19 practices July 2020 10

5 7/6/2020

Risk Continuum Overview Current Position AAB’s Position

Haldimand Norfolk Brant County Windsor Essex Best in Class Very Good Good Fair Risk Increased High Risk Adjusted Risk Quarantine Individual (1 to Individual (1 to Individual (1 to Cap isolation Cap isolation Congregate Congregate Period a room) a room) a room) size units (“3 – size units (“3 – with 6’ of with 6’ of rule”) rule”) Separation Separation Travel Risk Low Low Low Low Low High High Outbreak Work Period on Individual living Small pods of Congregate Congregate Congregate Congregate Congregate Farm arrangements individuals with 6’ of with 6’ of living with 6’ of living living together Separation Separation Separation On Farm Low Low Medium Medium High Medium High Outbreak

Risks of Outbreak on Farm and in Community Increases

Accommodation Not possible Not possible Not possible Not possible Possible Possible – with Possible** Constraints difficulty Farmer Costs High High High High Low - Medium Medium Lowest

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Comparing the Positions Public Health Position AAB Position Create small isolation groups of up to three. Minimum standard of 6 feet of separation and Focus on high risk areas of shared bathrooms, social distancing and for ease of approval and Travel Self kitchens and sleeping areas. Concentrate scale – utilize a percentage of normal occupancy Isolation resources to ensure good compliance. (BURN (70%). OUT VIRUS APPROACH prior to going to the farms) Post Travel Self Utilize the bunkhouses fully, encourage social Same as Public Health. Isolation Period distancing and other measures Public Health is willing to undertake a higher post There are concerns if the travel self Isolation travel self Isolation period risk, if the travel self period is not well executed, we can have multiple Commentary isolation was executed strictly the risk of illness is outbreaks. reduced from the travel period. This requires more accommodations for the self This is potentially the lowest cost option that Isolation period but this is only for 2 weeks and could utilize existing accommodations to the Constraints and not the full season, this has some incremental fullest, however it can cause issues on public costs costs. health resources, increases the risk to the worker and create significant farm operation disruption.

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Key Questions

1) How much additional risk should the Board of Health suggest to the MOH to take on? 2) Is now the right time to take on the risk? 3) How would you compare risk tolerance for migrant workers to other parts of our society such as approaches to beach use, return to school, university dorms or even use of ice rinks? These are all more limited exposure times with limited use of high risk areas like washrooms (except for dorms) – but communities are risk adjusting with major capacity reductions or other significant measures for these activities.

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Overview of the Proposition There are positive approaches to the position provided by the AAB such as: • More active health screening. • Moving towards increased separation and physical barriers is a positive approach that will reduce occupancy and reduce risk of outbreak and size of outbreak. However the effectiveness has its limitations. • Creating cohorts is also a positive step forward and supported. It should be noted that the health unit has worked with a farmer to socially distance several bunkhouses and the reduction in capacity was significant (more than 40%). If farmers did move to this it could create a significant demand for more housing. We would encourage this, however this might need to be part of a longer term strategy.

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Final Conclusion • The position brought forward by the Farmers has some positives, that should be capitalized on. However increasing risks around the initial travel self-isolation period would move the Health Unit closer to the original practices of Windsor Essex which has not been effective for that community. • We understand that there is additional cost for the quarantine period. However this is only a 2 week challenge and not a full season challenge that would occur if we started to require full social distancing in bunkhouses for the full year. • Movement towards the farmer’s position increases risks to the worker, farmer and community.

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A Way Forward

Solutions moving forward for both the short term and the longer term

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Near Term Solution

Key considerations • There are still significant numbers of workers to come for this year. • We understand the strain farmers are under. • We have constraints with regards to accommodation resources and health resources. • Communities have been held back due to outbreaks and we are working hard to be included in the next phase. There are concerns of a “second wave”.

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Near Term Solution

Solution: Hotel solution partially funded by all parties (Federal, Provincial, Health Unit and the Farmer). This passes the 4 way test: 1) Workers are safely isolated without additional risk to them. 2) If there is additional government support, this does not put undo financial pressure on the farmer and they reduce their risk. 3) The Health Unit would be able to better manage this risk. 4) The Community risk is reduced. 5) This approach does not constrain the existing accommodation supply and has been working in other Provinces.

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Near Term Solution

Solution: Hotel solution partially funded by all parties The cost of an large (Federal, Provincial, Health Unit and the Farmer). outbreak can easily reach The Cost – If we assume $1,800 per worker for the $1 million when factoring isolation period plus their wages for this period of time. in all costs including Funding: farmer costs for isolation • $1,500 is already being contributed by the Federal and hospital costs. government. • The County has already offered to take the This funding will support administration and monitoring which would be the hotel industry, the significant. farm industry and take • If the Province matched the Federal Funding, the pressure off of local Farmers would need to contribute $300 per worker communities and for the 2 week isolation period. hospitals

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Longer Term Solution

Solution: There needs to be a transition to In the Windsor area a new more effective accommodations for approach to housing migrant migrant workers. This will be years in the workers is nearing making and until new accommodations can completion where only two be brought on line – we will need to move workers share a washroom to managing risks more aggressively. and a bedroom, they all have individual access to the outside. This was designed before COVID19 but should be used as a model going forward.

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APPENDIX - A

Agricultural Advisory Board Position

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Appendix A – AAB Position AAB Consideration of the Housing of Temporary Foreign Workers

We wanted to begin by taking into account the Health perspective of this issue. To do this we looked to relevant, recently released documents by Health professionals within the Province of Ontario. We have referenced three documents below and have highlighted areas we feel are important to take into while considering agriculture’s position with regards to the housing of Temporary Foreign Workers.

1. Workplace Safety & Prevention Services: Guidance on Health and Safety for Agricultural Employers Using Temporary Help During COVID-19, June 17/2020: https://d1ow5xpphy0w2p.cloudfront.net/common/covid-19-agriculture-employers-using-temporary-workers-health-and-safety-guidance.pdf?mtime=20200622090134&focal=none  This document outlines many best practices for farmers to adopt.  Use of group cohorts – once a worker is assigned they should not be reassigned, each living/working group should be separated from each other and those workers living off-site to protect employees from those living off the farm and outside their living unit .  Common areas – keep the number of users as small as possible, i.e., maximum occupancy limits per time of use, assign schedules of use, separate busing needs, hand washing procedures before and after use, wipe down surfaces after use, etc.  Physical distancing to ensure employee safety – stagger break times so workers do not congregate in common spaces. .  Active screening to ensure the Health Unit can identify and trace positive cases early – worker symptom & temperature testing 2x per day 2. Ministry of Health, Ontario: COVID-19 Guidance: Congregate Living for Vulnerable Populations, May 28/2020: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_congregate_living_guidance.pdf  This document outlines many best practices for use in congregate settings.  Staggering meal & break times, creating schedules for common areas or shared bathrooms, etc. to reduce employee exposure to those within their living units.  Adequate space between residents while eating, watching tv, etc. Cleaning and disinfecting after use.  Moving furniture & creating visual cues, i.e., tape on floor for 2m to help employees protect themselves with physical distancing.  Shared bedrooms with beds 2m apart. Consideration of temporary barriers between beds.  Cleaning high touch surfaces daily. Bathrooms 2x per day. 3. The Province of Ontario: Windsor-Essex County Health Unit Plan, June 24/2020: https://news.ontario.ca/opo/en/2020/06/ontario-takes-immediate-action-to-stop-covid-19-outbreaks-in- windsor-essex.html  This document outlines a coordinated plan between the province, federal and local authorities to reduce transmission on farms and support agriculture as an essential service. There are several key elements.  Early identification of those not showing symptoms helps significantly reduce potential spread among both employees and members of the community. Proactive ongoing and expanded on-site testing.  Allowing positive asymptomatic workers to continue working as long as they follow the public health measures in their workplace to minimize the risk of transmission to others,

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Appendix A – AAB Position

 thus, providing workers with economic certainty. Economic certainty will aide the Health Unit in getting their cooperation with testing and symptom identification.  Further, temporary foreign workers are entitled to the same benefits and protections as any other worker in Ontario. . Workers' compensation benefits . Protections afforded by the Employment Standards Act and under Ontario's new infectious disease emergency leave provisions: a worker's job is protected while they take unpaid leave due to COVID-19. . Temporary foreign workers may also be eligible to apply for the Canada Emergency Response Benefit (CERB). To access the federal benefit, workers must have earned $5,000 in the last 12 months or in the previous year.  Clarity that upon positive test results, Local Public Health will assist in developing a plan to meet 2 objectives: . Ensuring essential workers return to work safely . Meeting business-critical operational needs on a case-by-case basis, so the farmer can ensure they meet their obligation to provide the essential service of food production.  “By providing both farmers and employees with economic certainty, this three-point plan will allow the rapid scaling up of testing in the agri-food sector… will allow us to better identify and isolate cases,” said Health Minister, Christine Elliott.

Additional considerations/comments from the AAB board:  It has always been the position of the agriculture community that they are looking for something scalable to the size / capacity of the accommodation.  The current outbreak in the County happened post isolation, even when single person occupancy had been followed during the 14 days under the program that was approved by the local health unit.  It has been reported that some employees involved at the current outbreak did not report symptoms. We can only speculate that there may also have been hesitation to share symptoms given the prospect of spending more time alone, isolated in a hotel room, while being unsure of the economic affect on those of their family and their fellow workers. If we can provide assurances to workers that they have economic certainty they will be more apt to be open about their condition. Windsor-Essex recognizes this and is allowing asymptomatic workers to continue working as long as they follow public health measures to minimize risk. Also, workers qualifying for CERB, WSIB, etc. while sick and in isolation will help in this regard.  Creating a shortage of help has resulted in the use of local and contract labour, which has added risk at the farm and likely contributed to the transmission of COVID-19. The greater number of offsite individuals, the greater the exposure to various community transmission points and social circles.  The 3-person per bunkhouse rule means that bunkhouses currently cannot be optimally used to minimize the risk to those that are using them post-isolation period. Accommodations need to be cleared to prepare for the next isolation approval, so that the Health Unit will approve the travel of staff. o On farms with large communal housing, this rule has the unintended consequence of having less space available to spread out post-isolation workers while having space far in excess of what would be required during isolation to sufficiently distance workers.

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Appendix A – AAB Position

o It means farmers are forced into wasting space that could be used to protect the entire workforce by being able to follow the guidelines as outlined in the documents referenced above.  Some flexibility in the current section 22 order would take the pressure off the labour situation and allow for farm business managers to adjust their workload and concentrate on farm worker safety.  The majority of agricultural enterprises across the County cherish the workers that come to work at their farms and have a high level of desire to have their workers isolate at the farm. They feel that workers would be in a more comfortable, familiar setting where they can be better looked after and cared for.  The majorities do not support any minorities that do not take worker health and safety seriously.  The details of the section 22 orders recently released by the Brant and Windsor-Essex Health Units set a standard and tone for something that is approachable to agriculture enterprises in Norfolk County.  We need to immediately turn the focus to proactively monitoring for symptoms so that outbreaks can be contained.  There is a risk in all business that rely on congregate work / living environments.

AAB recommendations of migrant worker quarantine and post quarantine

1. During the travel related 14-day quarantine period:  Farmers need to have a scalable solution to be able to provide on farm isolation of the workers they require to produce and harvest their crops. This solution should be developed around maintaining a 2m physical distancing.  In respect to occupancy, and following evaluation by farmers and their workers, there should be a consistent adoption of a concept that limits occupancy to less than 70% to allow for additional space during this critical time. Respecting a 2-meter distancing, the 70% number is something that would help across the board. This number is supported by spacing beds 2m apart, not using top bunks, and using occupancy limits in common areas to allow for social distancing. This will allow farmers to better plan for timely arrivals of workers and will simplify the approvals process for the Health Unit.  If the employer is able to demonstrate proper facilities, social distancing and protocols, a higher % may be approved, pending the case-by-case analysis. (i.e., similar to how some bunkhouses across the county were approved for more than 3/household due to ability to demonstrate functionality).  Policy use of occupancy limits in common areas, such as kitchens and bathrooms (POSTED SIGNAGE and schedules if need be).  Appointing a worker appointed “quarantine steward” who is responsible for health & bunkhouse checklists. This individual would act as a communication pipeline to the employer to promote transparency as well ensure the onus upon each individual unit to take all steps seriously. This step gives workers a more unified voice in expressing their concerns with respect to employee safety. 2. Post quarantine period: We recommend that employers/employees maintain 2m when possible. Many best practices are going to be able to continue post-quarantine, but our standpoint is that

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Appendix A – AAB Position

 the agricultural community would like to continue their existing occupancy limits post-quarantine.  Recognizing 3 documents we reviewed (referenced above), two of which have been posted in the last week and the other in the last month, as information for best practices.  That a list of Best Practices be developed that consider; i. Demonstrating 2m distancing of beds ii. Use of barriers where 2 m distancing is not possible iii. Occupancy limits in common areas based on square footage iv. Assigning a leader in each accommodation to do daily wellness checks, and bring suggestions forward on how to better be able to maintain 2m social distancing v. Group cohorting: having housemates work and travel together, staying separated from other housing units to limit the potential spread of COVID-19.  In addressing bunkbeds, that we look at a way of adding practical separation devices, traffic dividers and other protection to allow the use of these units, if possible.  We recognize that we need both worker and farmer cooperation, in order to provide the safest path forward, including active testing. Providing economic certainty in the event of an outbreak will go a long way to achieving this cooperation. Thus, allowing positive, asymptomatic workers to continuing working with appropriate restrictions and procedures is something we would like to adopt, similar to that of the Windsor-Essex model. Further, we feel that ensuring workers understand that they are eligible to receive CERB and other employee financial protections if they in strict quarantine (positive and symptomatic) is critical to their cooperation.

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APPENDIX - A

The difficult task of social distancing effectively in a bunkhouse

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Bunkhouses and Social Distancing

With the current inventory of bunk houses, it has proven be virtually impossible to maintain social distancing.

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Bunkhouse Code

• Modern Bunkhouse standards were developed in 2005. • 7.44 sq. meters (80 sq ft) per individual. This includes living, sleeping, and eating areas. It does not include washrooms. Note these areas can be in another building that is conveniently located. • 1 washbasin for every 7 individuals, 1 shower for every 10 individuals and 1 toilet facility for every 10 individuals.

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Social distancing of two AAB’s Position people is 70% of the 80 sq ft. (56/80). However this ratio cannot be applied easily when looking at actual physical layouts. We have undertaken this with a number of bunkhouses and the capacity was reduced to Area = 56.6ft2 Area of a 6’ circle = around 50%. Even with 28.3ft2 this reduction it is still a high risk situation.

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Congregate Settings are at High Risk for COVID-19 3 Bathrooms

Shared Bedrooms High Risk Areas

3 Kitchens

Shared Common Areas

Health30 Unit's Response to AAB's recommendations on COVID19 practices July 2020