The aim of Access Health is to provide primary health care that enhances the health and well being of : Marginalized/ st

2. The aim of Access Health is to provide primary health care that enhances the health and well being of: • Marginalized/ street- based injecting drug users • Street sex workers • People experiencing homelessness

3. Multiple sectors • Funded from D&A • Staffed from mainly multi-disciplinary health • Auspiced/located in community/welfare service

4. Primary Health Care an approach to care and a philosophy of care

5. As an approach to health care • first point of contact • close to where people congregate • first element of a continuum of health care • a balanced system of illness treatment, rehabilitation, disease prevention and health promotion

6. As a philosophy, PHC aims to: • improve health and reduce health inequalities • address the determinants of health (social, political, environmental, economic)

7. Principles of PHC: • Equity • Participation • Responsiveness • Social acceptability • Local, sustainable responses • Affordability • Accessibility

8. Ottawa Charter for Health Promotion “The process of enabling people to increase control over, and to improve, their health” (WHO 1986) “Health promotion is a process it is not an outcome but a means to an end..” (Nutbeam 1998)

9. Ottawa Charter • Advocate for conditions favourable to health • Enable people to achieve their health potential by focusing on equity in health • Mediate between differing interests in society beyond the health sector

10. Ottawa Charter Areas for action • Build healthy public policy • Reorientate health services • Create supportive environments • Develop personal skills • Strengthen community action

11. PHC & HP - global strategies for reducing health inequalities through equity of access to services, emphasis on prevention & action outside the health sector • In Western countries - have tended to become a more limited approach to responding to selected diseases eg. heart disease etc (Baum & Sanders, 1995)

12. “Many health promotion programs still have a strong focus on directly changing behaviour, despite the evidence that doing so meets with very limited success..” (Baum & Simpson 2006) This is especially relevant to disadvantaged and vulnerable groups.

13. Social determinants of health “The social conditions in which people live powerfully influence their chances to be healthy. Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities….” (WHO 2004)

14. Levels of factors affecting health • Downstream (micro)- physiological/biological factors eg. intervention - pharmacotherapies • Midstream (intermediate) – health behaviours eg. intervention - harm reduction strategies • Upstream (macro) – policy, systems, government and organisations eg. intervention - reducing discrimination & stigma, poverty, improved access to health services, harm reduction policies

15. It is the upstream factors that are the fundamental causes of poor health & inequalities • Structurally determined v’s individually chosen lifestyles • Behaviour risk factors such as smoking and problematic drug and alcohol use are often portrayed as ‘freely chosen’ (WHO, 2004)

16. Health inequality and the example of smoking (from Jarvis & Wardle 1999 in Marmot & Wilkinson) • Disadvantaged groups more likely to smoke & less likely to give up Why? Possible reasons… Higher rates of smoking initiation, less resources to tolerate withdrawal eg patches , more peer influence and smoking environments, higher levels of nicotine dependence, other life stressors/other priorities = Social determinants – poverty, unemployment, education, unsuitable housing, stress

17. Health inequality and the example of smoking (from Jarvis & Wardle 1999 in Marmot & Wilkinson) • There is no evidence to suggest that disadvantaged groups are less likely to want to give up • Public health strategies to increase cost of cigarettes can lead to: • switch to cheaper and higher nicotine brands (or locally ‘chop chop’). • Reducing spending in other areas eg food = even greater increase in health inequalities

18. What are we doing at Access Health? • Developed a framework for health promotion- guided by PHC philosophy • Undertook health promotion needs assessment

19. What are we doing at Access Health? • Utilised the Ottawa charter action areas as a framework for a 2 year action plan • Developed an overarching priority of creating a supportive environment for health including reducing health inequalities

20. What are we doing at Access Health? • Developed priorities areas for health promotion action: • Food security and nutrition • Mental health and social inclusion • Blood borne viruses and sexually transmitted infections • Drug safety

21. What are we doing at Access Health? • Mediating and advocating for action outside the health sector – co-location within community and welfare sector • Increasing access to health care by utilising the principles of primary health care – equity, participation, responsiveness, social acceptability, affordability and accessibility

22. What are we doing at Access Health? • Reorientating health services to an accessible primary health environment eg specialist services such as psychiatry • Promoting social inclusion of marginalised groups • Advocating for system changes and policy development and access to mainstream

23. What are we doing at Access Health? • Developing specific programs and strategies for vulnerable groups eg indigenous access, street based injecting drug users, women

24. What strategies does the WHO suggest to reduce health inequalities? • Education – in the broad sense • Invest in the early years of life • Social & community inclusion • Reduce unemployment • Increase access to health services • Multi-sectoral collaboration • Create healthy work environments (WHO, 2004)

25. Reducing health inequalities - Integrate health equality objectives into existing programs including housing, education and health services • How does this policy or program affect the health of different social groups? • What can be done to optimise positive health impacts for vulnerable or disadvantaged groups? (WHO, 2004 )

26. Disease specific strategies – tackling the determinates of a specific condition • Risks limiting to downstream factors but sometimes is useful to mobilise community action • Special attention is required to link strategies to programs/policy that focus on broader social and economic determinants of health (WHO, 2004)

27. Settings approach – specific geographical area or place eg school • Risks relying on local community approaches when wider policy is needed. • Needs attention to vulnerable and marginalised groups who may not have a voice. (WHO, 2004)

28. Group specific strategies eg people experiencing homelessness or elderly people • Specific strategies for vulnerable groups need to be used in combination with broad strategies for addressing determinants of health. (WHO, 2004)

29. “Work to deal with problems of both legal & illicit drug use needs not only to support & treat people who have developed addictive patterns of use, but also to address the patterns of social deprivation in which the problems are rooted”. (Marmot & Wilkinson, Social Determinants of Health: The Solid Facts, 2003 WHO)

30. Thank you and acknowledgement to Sue White Manager of Access Health

31. References: Baum, F & Sanders, D ‘Can health promotion and primary health care achieve Health for All without a return to their more radical agenda?’ Health Promotion International, 1995, Vol.10, No.2 Baum, F & Simpson, S ‘Contact details for knowledge networks of the WHO commission on social determinants of health’, Health Promotion Journal of Australia, Dec. 2006, Vol 17, No.3 Dahlgren, G & Whitehead, Levelling up (part 2) A Discussion Paper on European Strategies for tackling social inequities, 2004, World Health Organisation,www.euro.who.int/document/e89384.pdf)  Marmot, M & Wilkinson, R (ed) Social Determinants of Health, 1999, Oxford University Press Nutbeam, D. ‘Evaluating health promotion – progress, problems and solutions”, Health Promotion International, 1998, Vol 13, No. 1