Community Gardens for Improved Community Health

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

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Source: Communitygardens.org

Community Gardens in Developed Regions

Community gardens are either individual plots or collectively cultivated gardens, and there is often some form of public ownership (Jermé & Wakefield, 2013). There are various levels of commitment from local citizens. For example, NeuLand, a community garden in Cologne, Germany is run by a charitable organization with five paid staff members, a managing committee, about 20-30 committed gardeners, and about 40 occasional gardeners (Follmann & Viehoff, 2014).

In the Western World, community gardens have become popular because they are often viewed as a way to advocate for sustainable social and ecological change through a bottom-up approach (Follmann & Viehoff, 2014). Thus, they have proven to have an important impact on the health of citizens in various regions.

Health Benefits

Community gardens have specifically increased access to healthy foods in marginalized regions, consequently, alleviating issues of food poverty (Jermé & Wakefield, 2013). In order to increase the consumption of fresh vegetables, the Victory Garden program was founded in the United States during World War II (Armstrong, 2000; Chan et al., 2015). This led to a 40 percent increase in the consumption of fresh vegetables (Armstrong, 2000). Today, community gardens are still used to ensure that everyone has equitable access to fresh produce. One study revealed that households who did not participate in community gardens consumed fruits and vegetables 3.3 times per day (Alaimo, Packnett, Miles, & Kruger, 2008). In comparison, households with an individual involved in community gardens had a daily consumption rate of 4.4 (Alaimo et al., 2008).   

When community gardens are properly implemented and utilized, they can be an important source of empowerment for local citizens (Follmann & Viehoff, 2014). They can provide a space for productive work, interaction with each other, intercultural engagement and knowledge exchange (Follmann & Viehoff, 2014; Armstrong, 2000; Chan et al., 2015). Thus, they become a symbol of unity and increase neighborhood pride (Armstrong, 2000). This social capital is important to increase psychological support (Chan et al., 2015). As a result, community gardens have been established as a component of health promotion (Armstrong, 2000).

Policy Development and Citizen Engagement

Overall, the focus on community gardens is to foster a greater quality of life and community rather than consumption and individualism (Follmann & Viehoff, 2014). In order to continue to foster sustainable community gardens, policy development processes must be examined (Jermé & Wakefield, 2013). Local citizens must be able to participate in the development of policies, and the policies must ensure that citizens have access to gardens that are fairly allocated (Jermé & Wakefield, 2013). Success also depends on a collaborative approach between the various government agencies involved (Jermé & Wakefield, 2013).

References:

Alaimo, K., Packnett, E., Miles, R. a., & Kruger, D. J. (2008). Fruit and Vegetable Intake among Urban Community Gardeners. Journal of Nutrition Education and Behavior, 40(2), 94–101. doi:10.1016/j.jneb.2006.12.003

Armstrong, D. (2000). A survey of community gardens in upstate New York: Implications for health promotion and community development. Health & Place, 6(4), 319–327. doi:10.1016/S1353-8292(00)00013-7

Chan, J., DuBois, B., & Tidball, K. G. (2015). Refuges of local resilience: Community gardens in post-Sandy New York City. Urban Forestry and Urban Greening, 14(3), 625–635. doi:10.1016/j.ufug.2015.06.005

Follmann, A., & Viehoff, V. (2014). A green garden on red clay: creating a new urban common as a form of political gardening in Cologne, Germany. Local Environment, 20(10), 1148–1174. doi:10.1080/13549839.2014.894966

Jermé, E. S., & Wakefield, S. (2013). Growing a just garden: environmental justice and the development of a community garden policy for Hamilton, Ontario. Planning Theory & Practice, 14(3), 295–314. doi:10.1080/14649357.2013.812743

Part III-Your Work is Never Finished: Why Iterating after You Launch Should Be Part of Your Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

If you missed our last three blog posts in this series on human centered design, you can learn about what human centered design is here, read a case example of how we build empathy with health works in Nepal, and see how we’ve used prototyping to test a new monitoring and evaluation dashboard in Benin.

Our final post is going to explore the concept that your project is never complete; even after you launch, it’s important to continue to get feedback. In this post we’ll share an example of how we’ve iterated on our software based on feedback from health workers and ministry officials in Benin.

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A health worker sorts through paper records. Source: VaxTrac.com

The Problem
The World Health Organization (WHO) and the Benin Ministry of Health issue a country-wide immunization schedule that recommends when children should receive their immunizations, beginning from the moment they are born and lasting through the first year of life. Health workers in urban clinics manage hundreds of children’s schedules using paper records. Keeping track of which children are due for which vaccine during any given vaccination session is a time-consuming task.

Parents of these children lead busy lives and often live far from the clinic. It takes hours out of their day to bring their child to vaccination sessions. While parents value vaccines, health workers don’t always communicate clearly to parents about when to come back to the clinic for the child’s next vaccination. A direct consequence of this is that children often miss their appointments.


Our Solution: Callback List 1.0
Clinics that use VaxTrac to record childhood immunization data have an advantage: as long as children are registered in the VaxTrac system, the system can automatically generate a list of children that are due for upcoming appointments. This can save health workers from several hours of paperwork each week.

Our team of software engineers saw this as an opportunity and developed a basic callback list. The first version of the callback list pulled a list of children that were due for an upcoming appointment along with basic information, such as date of birth, village and contact information. But health workers weren’t using it. We wanted to know why.

Back to the Drawing Board: Stay Responsive to User Needs through Iteration
Technology is meant to change over time. VaxTrac’s software engineers like to remind our team that the software is never finished; it’s constantly evolving and adapting to user needs.

When we began developing our mobile (Android)-based system, we brought health workers together to get their feedback on what they wanted from a callback list feature. We used a number of human centered design methods to elicit feedback, such as prototyping [link to prototype blog], brainstorming lists of what they do during vaccination sessions, and breaking into groups to sketch out what they wanted the callback list to look like.

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Meredith leads a focus group with health workers. Source: VaxTrac

We asked them to create the callback list over again from scratch. We asked guided questions: Is any of the information available on the callback list useful? If so, what is it used for? What other information should it include? How would they like to see the callback list organized? What rules should the callback list follow? How long should a child stay on the list?

Having health workers sketch their answers to these questions helped all of us think through these abstract questions together.

We found key insights:

• Health workers were using the callback list, but not in the way that we had originally intended. Instead of using it to contact the parents of children who were due for upcoming vaccinations, they used it to track down children who had missed an appointment.
• Phone numbers change often so we needed to make it easier for them to update parents’ contact information.
• In order to be more useful, the callback list would need to be interactive, allowing health workers to sort the information in a variety of ways.

Hearing the health workers’ perspectives helped us rethink the purpose of the callback list and how to redesign it.

Build, Do, Learn, Repeat: VaxTrac’s Philosophy on Iteration
Build: Our software engineers took our learnings from the user feedback session and went to work on building a new and improved callback list. In addition to the callback list, we created a defaulter list, providing health workers with a list of patients that have missed their appointment. We also made both lists sortable by any category (village, date of birth, sex, date of appointment, etc.) And lastly, we made it easier to update contact information.

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Callback List. Source: VaxTract

Do: After our software engineers updated the callback and defaulter lists, we made sure health workers received adequate training on how to use it. Our Benin-based team visited clinics for additional training.

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VaxTrac staff training health workers. Source: VaxTrac

Learn: After a few months of using the new callback list, we held a focus group with health workers to learn more about what they thought of the different VaxTrac features, including the callback list. We learned that health workers would like to be able to sort by the mother’s name in addition to sorting by the other categories. We also learned that health workers would like a way for the callback list to help them contact parents of children who are due for upcoming vaccination sessions.

Repeat: Each time we add new features and users, we get new perspectives. All of the feedback that we’ve gotten from health workers have helped us make our callback list and defaulter list more user-friendly. But we’re not done yet! We are currently conducting a study to assess the possibility of incorporating an appointment reminder feature to the callback and defaults lists, so health workers can use the system to contact parents directly, possibly through SMS or Interactive Voice Response (IVR).

Once we learn everything we can, our cycle will repeat again.

The more we iterate, the stronger our product becomes because it’s based on feedback from the people who use our system. While it can be daunting to go back to the drawing board, adding iteration into your project plan from the beginning can save you time and resources down the line.

We’ve embraced the philosophy that our software is never finished. And we can’t wait to see how far it’ll take us.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources[link: http://www.designkit.org/resources/1.

Part II-Prototypes Bring Ideation to Life

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Welcome to the second installment of our blog series on human centered design. In our introductory post we broke down what human centered design means for designers and implementers of international development projects. Our most recent post gave a case example of how we’re building empathy with health workers in Nepal. This post will share a case example of how we’re prototyping different iterations of a monitoring and evaluation (M&E) dashboard for our staff in Benin.

Once you have worked with your project partners to determine what you want to design or test, the most effective way to get useful feedback from the people you’re designing for is to prototype what you want to test.

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Sam facilitating the feedback session on VaxTrac monitor

Prototyping allows you to get feedback on something concrete rather than abstract. It is the difference between asking someone to describe their perfect cup of coffee versus giving them three different cups of coffee to critique. They will have a better grasp of what you are trying to design, and you will get more specific and useful feedback.

Prototyping also gives you the flexibility to test a variety of unique ideas without spending the resources on a project that might not work the first time.

The Problem
Our team in Benin needed a new, more efficient way to monitor our project. As we trained new health workers to use VaxTrac and added an entirely new health zone to our scope of work, our field team had to process more data than ever before.

Each field supervisor had devised his own method of monitoring how health workers use the tablets, what bugs occur in the software, and how to compare tablet-based reporting to paper-based reporting. Meanwhile, back in DC, our Learn team stayed busy exporting data from CommCare reports and spending a lot of time converting data into a more useful format.

It quickly became clear that we needed a more efficient way of tracking data so that our field-based team could spend less time entering data into spreadsheets and more time responding to health worker needs, prioritizing resources and tracking progress over time.

Prototyping Solutions to Test the Best Ideas
To solve this problem, we have been working with our team to design a monitoring tool that will allow our field supervisors to monitor the project more easily. After a series of feedback sessions interspersed with a variety of paper monitoring tool prototypes, we decided the best solution would be to design a web-based data dashboard that can automatically populate with data from CommCare, such as when a form is submitted, the time it takes to complete a form, when a child is fully immunized, among other pieces of data. We are also working to incorporate additional pieces of data such as, data use, battery level of the tablet and the last time the tablet had an internet connection.

In order to get feedback from our team in Benin, we designed a live prototype of a monitoring and evaluation (M&E) dashboard:
 

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M&E Dashboard Prototype

Our DC staff brought the prototype to our Benin staff during a trip to Benin a couple weeks ago. We held a focus group and asked our team questions about the types of data they want to monitor on the dashboard, how data should be grouped, how data should be displayed and how they would use the dashboard.

By providing a concrete example of an M&E dashboard, we were able to elicit specific and useful feedback from our team in Benin. The designing of the dashboard is an ongoing project. We will continue to get feedback and iterate on our designs until we come up with a solution that meets everyone’s needs.

Check out the final post in our series about human centered design, where we’ll give examples of how we keep iterating on our projects even after we implement.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources.

Part I- To Get Inspired, Build Empathy into Your Project Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Build Empathy First
In our first blog post about human centered design, we talked about building empathy for design thinking. But what does “empathy” really mean, and how does it translate into research methodology?

To have empathy is to understand another’s perspective. If your goal is to build empathy with the community you’re designing for, it’s important to budget time, space and resources to talk to a variety of project stakeholders about the challenge you’d like to solve before the project starts. While it’s difficult to convince donors to spend money on an extended R&D phase, giving communities a voice at the onset of your project can save your organization time and money by allowing stakeholders to voice their opinions and be active participants in the design process.

The methods we use to build empathy are reminiscent of the research methods found in academic settings. Human centered design is especially akin to the philosophy of community based participatory research (CBPR), which also recognizes that when given a voice, communities are best equipped to identify sustainable solutions to challenges they face. Like CBPR and more traditional qualitative research methods, human centered design relies on interviews, focus groups, observations, surveys, card sorts, among other interactive methods, such as role plays, immersion and community mapping to elicit feedback from stakeholders.

Let’s dive into the case example of how we are building empathy with health workers in Nepal to improve our user interface and workflow.

The Problem
The clinics we work with in Nepal are fundamentally different than the clinics we work with in Benin. In Benin, the clinics are urban and busy. There are vaccination sessions almost every day. Caregivers bring their children to the clinics for vaccinations.

By contrast, the clinics we work with in Nepal are rural. The population is dispersed. As a result, vaccinations only happen a few days a month. There may be one or two sessions that take place at the main clinic, but there are usually also a number of outreach sessions, in which the health workers walk several hours to sub-health posts within their catchment areas. Since the population is small, only a few children come to each session.

Building Empathy through Brainstorming and Workflow Cards
There are a number of methods we could use to get into the mindset of the health worker. The key is to remember that health workers are the experts. They understand their job better than anyone else. Our job is to listen, build empathy for what they experience in their jobs and translate that into our software design.

We are starting with the goal of understanding health workers’ workflows in different situations. In other words, what do health workers do to prepare for a vaccination session? What happens during a session? What happens after?

Our DC-based team started by brainstorming objects, people and actions involved in a vaccination session. We scoured the internet for images to represent everything that we came up with. We put together sample workflow cards and brought it to our project partners in Nepal.

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Draft Workflow Cards (Source: vaxtrac.com)

Seeing the sample workflow cards inspired our in-country partners Amakomaya to continue the brainstorm. They looked at our cards and told us what images worked and which images did not convey the right meaning. They grabbed a marker and started brainstorming their own list. We sketched images together.

We designed an interactive activity with health workers to use the workflow cards to get a better understanding of the different workflows they use during vaccination sessions. We are currently working to add Amakomaya’s feedback into an updated version of the workflow cards, which we will test out with a group of health workers early this year.
Using cards with simple images on them is a great way to get health workers talking about how they do their work. Cards are tangible objects that health workers can put in their hands and arrange in different ways. It gives the group a visual to refer to when someone has a question. It allows our team and health workers to identify gaps in the work flow as well as pain points.

We hope that by understanding current workflows and processes, we can understand the challenges that health workers face in their daily jobs and iterate our software so that it improves their workflow.

Check out our next post in our series about human centered design next week, where we’ll give examples of how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin.
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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

How to Incorporate Design Thinking into your ICT4D Projects: A Blog Series

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on the VaxTrac blog

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2015 was a year abuzz with talk about human centered design in the international development community. Words like “human centered” and “design thinking” may sound like international development buzzwords on par with “sustainability” and “capacity building” (thanks Devex), but behind the words are tangible methods you can use to elicit feedback from the people your project serves and use their insights to build better, smarter solutions.

If we break down the jargon, human centered design means to listen to the people that you are building a program for – before, during and after implementation. You listen to them because they are the experts. If you are designing an app for health workers to register patient data, you listen to health workers because they are experts on their workflow and needs. If you are designing an educational SMS system for youth, youth are experts in understanding what they want to know and how they want to discover that information. Simply put, human centered design is a series of methods implementers can use to engage with users throughout a project’s lifespan.

The human centered design process walks us through methods we can use during three key phases

1. Inspiration: defining the problem, the audience, understanding facilitators and barriers
2. Ideation: brainstorming ideas, testing out prototypes, finding the best solution
3. Implementation: choosing the best idea and implementing it, while still getting feedback and iterating

While human centered design is typically thought about in terms of technology projects, in recent years, the concept has been applied more broadly to solve complex global health challenges. In an interview with WIRED magazine, Melinda Gates, Co-Chair and Trustee of the Bill and Melinda Gates Foundation, described human centered design as “meeting people where they are and really taking their needs and feedback into account.” It sounds intuitive that we would want to understand the needs of the people we serve, but we often lack the tools and resources to do this well.

We are writing a three-part blog series to share our own experiences designing a mobile vaccine registry system for health workers. Our blog series will give case examples of the methods we used at various stages of the human design process. The first post will focus on how we are building empathy with health workers in Nepal to improve our user interface and workflow. The second post will look at how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin. Lastly, our final post will emphasize the importance of iterating after implementation by sharing our experience customizing our software, based on user feedback in Benin and Nepal.
We hope you will be able to use our experience to incorporate human centered design into your own projects.

To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

World Hepatitis Day 2015 - Focusing on Prevention

~Written by Theresa Majesty (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

The World Health Organization (WHO) states that approximately 1.5 million people die each year from the various types of hepatitis caused by hepatitis viruses A, B, C, D, and E. It is estimated that half a billion people worldwide are infected with hepatitis B or C virus, the strains responsible for the majority of cases of liver cirrhosis and liver cancer.

In order to bring attention to the large global burden of disease caused by viral hepatitis, 2015’s World Hepatitis Day is July 28th. This date was chosen to honor the birthday of Nobel Laureate Professor Baruch Samuel Blumberg who discovered the hepatitis B virus and developed the first hepatitis B vaccine. This year the emphasis is on prevention, with the slogan “Prevent hepatitis. Act now.”

We can prevent hepatitis by providing safe food and water (hepatitis A and E), vaccines (hepatitis A, B, and E), screening blood donations and providing proper equipment to maintain infection control (hepatitis B and C). While hepatitis B and C can be treated, many people in low- and middle- income countries lack access to treatment due to a lack of screening and the high cost of treatment. Until screening and treatment options become more accessible and affordable, prevention messages are incredibly important.

To help people learn how to prevent hepatitis, the WHO World Hepatitis Day 2015 campaign focuses on four key prevention messages:

1. Prevent hepatitis - know the risks
2. Prevent hepatitis – demand safe injections
3. Prevent hepatitis – vaccinate children
4. Prevent hepatitis – get tested, seek treatment

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Figure 1: A poster from World Hepatitis Alliance. 

If you’d like to get involved in raising awareness about hepatitis, please visit worldhepatitisday.org. There you’ll find some ideas on how to get involved, information on what social media campaigns have been formed, and materials to share to help spread the word that hepatitis is preventable.

The future of the fight against hepatitis looks promising. WHO has been increasing its efforts to fight hepatitis by establishing the Global Hepatitis Programme in 2011, and in 2014 moved that program to the cluster of HIV/AIDS, Tuberculosis, Malaria, and Neglected Tropical Diseases to help facilitate work between HIV/AIDS and hepatitis programs (due to the high number of people around the world living with both HIV and viral hepatitis). Furthermore, WHO, in conjunction with the Scottish Government and the World Hepatitis Alliance, is organizing the first ever World Hepatitis Summit in Glasgow, Scotland over 2-4 September 2015. This invite-only summit will bring together policy makers, patients, and other key stakeholders to determine how best to make lasting progress to reduce the global burden of hepatitis.

There is still progress to be made by the global community in order to win the fight against hepatitis. Key efforts, such as establishing events to publicize the global burden of viral hepatitis and holding summits to bring together the stakeholders that can make a difference, are contributing to saving lives in the fight against viral hepatitis.

The Complexity of Health and Wellbeing

~Written by Karen Hicks - Senior Health Promotion Strategist, Auckland New Zealand (Contact: Karen_ahicks@hotmail.com)

Achieving health and wellbeing goes beyond the absence of disease as it is determined by a range of factors such as the environment, culture, gender, biology, and politics and is in fact complex and multi-dimensional.

As a health promoter I suggest that to address such a complex issue requires:

•  An understanding of what being healthy means to those with whom we are working
• An understanding of the social determinants of health
• A holistic approach to health

For practitioners wishing to improve health outcomes we need to explore what being healthy means to those individuals and communities with which we are working. Practitioners often have their own ideas of what healthy means and our contracted outcomes and outputs may also identify what this means but it may not be the reality of our communities. To achieve sustainable health outcomes we need to ensure that we are meeting the needs of our communities.

We also need to understand what affects people’s health and communicate this effectively to the communities with which we work and our colleagues both within and outside of the health sector. The Dahlgren and Whitehead diagram is a few years old but is effective in explaining the range of determinants that influence health both positively and negatively and the interconnectedness of each determinant. 

Another effective resource is the Robert Wood Johnson Foundation frame developed in 2010 to effectively talk about the social determinants of health which has involved translating determinants of health messages for lay audiences such as Health starts where we live, learn, work and play.  For detail on the research and process- http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/a-new-way-to-talk-about-the-social-determinants-of-health.html

As practitioners we need to stop working in silos and with topic or issues based approaches. A holistic approach to health is the most effective approach to achieving sustainable health outcomes. Within New Zealand there is a holistic health model named Te Whare Tapa Whā (Durie, M. 1998). A Māori health model that supports a holistic approach to health and identifies the four cornerstones (or sides) of Māori health. With its strong foundations and four equal sides, the symbol of a house illustrates the four dimensions of well-being which are physical, mental and emotional, social and spiritual well-being.  Should one of the four dimensions be missing or in some way damaged, a person may become unbalanced and unwell.

The approaches identified are ways in which to undertake effective health promotion that reflect its values and principles of empowerment, inclusiveness and respect based on evidence and effective health promotion competencies. The approaches above provide opportunities to communicate with communities and work with them to provide solutions to the complex and multi-dimensional health and wellbeing issues affecting us all locally, nationally and globally.

Reference:

Durie, M. 1998. Whaiora: Maori health development, Auckland: Oxford University Press

Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.

References:

http://www.cdc.gov/polio/updates/

https://news.vice.com/article/afghanistan-confirms-new-polio-cases-as-pakistans-outbreak-reaches-grim-milestone

http://www.theguardian.com/society/2014/sep/07/us-nearly-600-measles-cases-this-year-cdc

http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/

http://www.polioeradication.org/

http://www.washingtonpost.com/blogs/worldviews/wp/2012/10/17/taliban-polio-vaccines/

http://www.bbc.com/news/world-asia-26121732

http://www.npr.org/blogs/goatsandsoda/2014/07/28/330767266/taliban-in-pakistan-derails-world-polio-eradication

The Politics of Health Promotion

~Written by Karen Hicks, Senior Health Promotion Strategist (Contact: karen@hauora.co.nz)

As an individual with over twenty years’ experience in the health sector in clinical, managerial and health promotion roles, I am passionate about the role of health promotion as an approach to reduce health inequities.

In addressing health inequities, health promotion is very political, as people’s health is influenced by the resources and opportunities available to them.  As health promoters we need to question who is responsible for such resource allocation, how are allocation decisions made, and who has the power to allocate these resources?

As health promoters we witness how the approach of health promotion is increasingly affected by neoliberalism, where neoliberal governments promote minimal government interaction with a person’s freedom to choose.  The result is that some communities experience victim blaming when ‘choosing’ unhealthy health behaviours and the government’s health outcome graphs don’t improve. Such communities are identified as failing and accountable for their ill health and poor lifestyle choices.  

Effective health promotion places people and communities at the centre, working with communities to find their own solutions in influencing the determinants of their health and wellbeing. As health promoters we have declarations and reports such as the Ottawa Charter for Health Promotion and the WHO Commission on Social Determinants of Health that identify best practice health promotion.

The WHO “Closing the gap in a generation, health equity through action on the social determinants of health” report clearly identifies that:

"..inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces."

So while we know that empowering communities and addressing the social determinants of health is the best health promotion approach, why do governments continue to provide contracts that focus on individual behaviour change? 

• Offering contracts with behavior related outcomes are easy to measure e.g. how many individuals attended the health day, how many individuals have lost weight or become smoke-free. While these outcomes are laudable we know that such health outcomes and behaviour change are often unsustainable if a person’s environmental, socioeconomic and cultural settings also do not change. 
• Short term contracts focusing on behaviour change also fit neatly into electoral terms so governments have something to report against in the hope of being re- elected for such commendable work.
• Committing to long term planned outcomes in partnership with the community to address the social determinants of health takes time and does not generate the same media coverage as purchasing hospital beds or employing doctors.
• Focusing on personal responsibility also means that governments can continue their relationships with large multinational companies such as the food industry, relationships that could be put under strain if healthy eating legislation was put in place.

What can we do?

• As health promoters wishing to address health inequities and improve the health and wellbeing of our communities we must communicate that health inequity is a moral and justice issue, and the role of governments in addressing these.
• We need to communicate with and involve our communities in addressing the social determinants of health that continue to influence their health and well-being.
• We need to strengthen the capacity of the health promotion workforce ensuring they understand their vital role in improving health locally, regionally and globally.

As health promoters we have a role in providing evidence on best health promotion practice to strengthen the value of health promotion in the wider public health field and to clarity its role and ability to respond to global health challenges.