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in Low-Income, Racialized Halifax” Communities in North End, Halifax
Report Written by: Report Written by: Ingrid R.G. Waldron, Ph.D. Ingrid R.G. Waldron, Ph.D. Assistant Professor Assistant Professor School of Occupational Therapy School of Occupational Therapy Faculty of Health Professions Faculty of Health Professions Dalhousie University Dalhousie University Halifax, Nova Scotia Halifax, Nova Scotia
Submitted to: Submitted to: North End Community Health Center North End Community Health Center North End, Halifax 2165 Gottingen Street Halifax, Nova Scotia B3K 3B5
December 1st, 2010
December 3rd, 2010
Table of Contents
Acknowledgements………………………………………………………………….......................4 Executive Summary……………………………………………………………………………....5 • • • • Summary of Project Description........................................................................................................5 Key Messages……………………………………………………………………………....5 Research Objectives………………………………………………………………………..6 Summary of Key Recommendations………………………………………………………..6
I. Project Description......................................................................................................................................8 II. Project Partner: North End Community Health Center..............................................................11 III. The North End: A Profile..................................................................................................................11 IV. Context & Background.........................................................................................................................14 • • • • • Part One: Aboriginal & African Nova Scotian Communities: A Profile…………………...14 Part Two: Defining Occupational Participation………………………………..……….…15 Part Three: Defining Meaningful Occupations……………………………………………17 Part Four: Inequality & Discrimination…………………………………………………...19 Part Five: Meaningful Occupations & Health...............................................................................21
V. Research Questions ….…………………………………………………………………….29 VI. VII. • • • • Research Objectives…………………………………………………………………...…29 Conceptual Models & Theories…………………………………………………..............29 Part One: Canadian Model of Occupational Performance & Engagement………………...30 Part Two: Model of Human Occupation……………………………………………..........31 Part Three: Occupational Justice Theory……………………………………………...........32 Part Four: Intersectional Analysis…………………………………………………….........35
VIII. Methodology…………………………………….…………...................................................36 • • • Part One: Sample & Recruitment…………………………………………………………37 Part Two: Data Collection………………..……………………………………………….39 Part Three: Data Analysis…………………………………………………………………39
IX. Findings ……………….….……………………………………………………………...….41
X. Discussion…………………………………………………………………................................77 • • • • • • Part One: Conceptualizations of Meaningful Occupations..........................................................77 Part Two: Personal, Social & Economic Factors Shaping Access to & Participation in Meaningful Occupations....................................................................................................................79 Part Three: Engaging Community Members in the North End in Meaningful Occupations.........................................................................................................................................81 Part Four: The Relationship Between Meaningful Occupations & Health...............................83 Part Five: Broadening the Applicability of Occupational Therapy Models to Low-Income Racialized Communities.....................................................................................................................84 Part Six: Health Equity………………………………………………………………….....88
XI. Conclusion…………………………………………………………............................................89 XII. Key Messages………………………………………………………………………..............89 XIII. Recommendations………………………………………………………………………...90 XIV. Model for a Community-Driven Initiative in the North End………………………........93 XV. Knowledge Sharing Activities......................……………………………………………....…94 REFERENCES……………………………………………………………………………..…...98 APPENDICES: Appendix A: Interview Guide for Community Members…………………………….108 Appendix B: Interview Guide for Community Agencies…………………………….110
Principal Investigator Ingrid R.G. Waldron, Ph.D. Assistant Professor School of Occupational Therapy Faculty of Health Professions Dalhousie University Halifax, Nova Scotia E-mail: firstname.lastname@example.org I would like to thank the North End Community Health Center for its involvement in this project: North End Community Health Center Jane Moloney, Ph.D., Executive Director Sharon Lawlor, MN, Health Team Manager Jessie Jollymore, PDt, CDE, Dietician, North End Community Health Center I would also like to thank the following individuals for their assistance and support: Research Assistants
Sharon Johnson Shawn Parker Danielle Root Samira Thomeh Erica Budding School of Occupational Therapy Graduate Students Brittany Cameron Navreet Reen
Summary of Project Description This research unpacks the concept of “meaningful occupations” through the voices and stories of Aboriginal and African Nova Scotian community members in North End, Halifax. Occupational therapy defines “occupations” as goal-directed activities and pursuits that occupy people’s time and lives, including work, study, recreation and leisure. This research uses narrative data to examine the various factors that offer or limit opportunities for accessing and participating in meaningful occupations in these communities. It focuses on the subjective experience of occupation, in particular, how the choice of and participation in specific occupations convey and express individual and community values, beliefs, identity, spirituality and community belongingness. Also of concern in this research is the relationship between occupation and environment, in particular how the environment in the North End shapes occupational choices. Finally, the research examines the relationship between meaningful occupations and health, with health being understood holistically as the interconnection between spiritual, emotional, mental and physical health and well-being. Key Messages This research identified the following five (5) key messages: • Aboriginal and Nova Scotian community members in the North End conceptualize “meaningful occupations” as those that provide them with opportunities to build and nurture a sense of community belongingness and connections with others; to feel accepted, valued and worthy; to make a difference in the lives of others; to develop and share professional, personal and creative skills, competencies and talents; and to instil cultural pride in their own communities, as well as share their cultural heritage with the broader community; Community agencies in the North End must develop meaningful programs that reflect the everyday challenges that Aboriginal and African Nova Scotian communities face relating to inequality, exclusion and discrimination; low-income and poverty; unemployment and underemployment; insecure housing and homelessness; childcare; transportation; and health and mental health; Culturally-specific health policies and services in Nova Scotia must acknowledge the relationship between access to and participation in meaningful occupations (work; study; leisure; recreation; healthcare) and the physical, psychological, mental and spiritual health and well-being of African Nova Scotian and Aboriginal community members in the North End; Creating safe and healthy communities in the North End involves engaging North End residents in meaningful occupations through a multi-pronged effort that involves collaborative health promotion strategies; community outreach; internet and social networking/media; television, radio and newspapers; and distribution of promotional documents (brochures, flyers etc); and Tackling health disparities in the North End and in Nova Scotia requires that health equity policies focus on reducing and eliminating the social, economic and political inequalities that limit and prevent the unemployed and under-employed, under-represented and misrepresented and under-engaged from participating in meaningful occupations.
Research Objectives The main project objective is to identify how community agencies in the North End can engage low-income racialized communities in meaningful occupations. The project`s other objectives are: • • To examine how low-income racialized individuals and communities in the North End conceptualize meaningful occupations; To identify the personal, social and economic factors that may create barriers to accessing and participating in meaningful occupations among low-income racialized individuals and communities in the North End; and To examine how organizational structures, policies and service delivery within community agencies determine access to meaningful occupations among low-income racialized individuals and communities in the North End.
Summary of Key Recommendations The project identified the following key recommendations: Developing Meaningful Occupations for North End Residents • • • • • • • Develop employment workshops that assist community members in finding jobs; Develop youth employment opportunities; Support community members in obtaining educational diplomas and degrees; Develop seniors programs and clubs that engage seniors in activities inside and outside their homes, e.g. knitting, crocheting, card games etc.; Provide opportunities and spaces for youth, adults and seniors to share experiences and build a sense of community through meaningful interactions, connections and social networks; Hire community organizers to develop sport and recreational programs and events for youth; and Develop health promotion workshops that involve multiple stakeholders, including community members, health professionals, educators and spiritual leaders.
Engaging North End Residents in Meaningful Occupations Creating a Welcoming Environment • Offer programs and services during the days and evenings and on weekdays and weekends that bring the whole family together and eliminate the challenges parents experience finding affordable childcare and Develop increased inter-agency partnerships in the North End that provide agencies with opportunities to draw on diverse skills, experiences and networks, learn from one another, eliminate redundancy in programming and respond collaboratively to community needs.
Creating Awareness about Programs & Services • • Hire outreach workers to conduct outreach in the community in order to identify community needs around services and programs, particularly for hard-to-reach individuals and Create awareness of agency programs and services through the following promotional strategies: community outreach and direct communication; posters, brochures, newsletters and flyers; community newspapers; email listserv; webpage; Kijiji; social networking websites; Halifax North Memorial Public Library; church; radio and television; and a Directory of Community Services, Programs and Resources.
I. Project Description
This research project unpacks the concept of “meaningful occupations” through the voices and stories of Aboriginal and African Nova Scotian community members in North End, Halifax. Occupational therapy defines “occupations” as goal-directed activities and pursuits that occupy people’s time and lives, including work, study, recreation and leisure. It uses narrative data to examine the various factors that offer or limit opportunities for accessing and participating in meaningful occupations in these communities. The project focuses on the subjective experience of occupation, in particular, how the choice of and participation in specific occupations convey and express individual and community values, beliefs, identity, spirituality and community belongingness. Also of concern in this project is the relationship between occupation and environment, in particular how the environment in the North End shapes occupational choices. Finally, the project examines the relationship between meaningful occupations and health, with health being understood holistically as the interconnection between spiritual, emotional, mental and physical health and wellbeing. Occupational therapy begins from the notion that occupations - what people do in their everyday lives -affect health and well-being. Occupational therapy defines “occupations” as goaldirected activities and pursuits that occupy people’s time and lives. These include work (paid, unpaid, vocational); sport and athletics; study (apprenticeship and training etc.); personal care (eating, dressing, personal hygiene etc.); household and life maintenance (housework, laundry, shopping, cooking etc.); retirement; travel; recreation; and leisure (hobbies, media, relaxation etc.). According to Christiansen and Townsend (2004), leisure refers to discretionary time and a “state of mind philosophy” characterized by activities that offer freedom of choice in participation and that don’t require participants to have a particular goal other than enjoyment. Christiansen and Townsend identify two broad categories of leisure: a) casual leisure and b) serious leisure. Casual leisure includes occupations that are pleasurable, of short duration, intrinsically rewarding and that do not require any special training for enjoyment. Serious leisure includes amateurism, hobbyist pursuits, self-development and volunteering, all of which offer significant personal effort and allow participants to acquire knowledge, training and skills. Leisure participation not only fulfills important psychological needs, it also has economic implications since historically individuals who had the time to participate in leisure were those who had the income to do so. Thibodaux & Bundy (1998) argue that the way in which one experiences leisure is determined by one’s current life circumstances, past interests and interests of one’s own social circle. Moreover, the decision to participate in specific leisure activities may be determined by the following: • • • • economic issues; cultural issues; personal issues; and ideology
The meanings that leisure and other occupations hold for individuals connect directly to occupational participation and engagement, as well as to how individuals perform in their daily occupations. When individuals are fully engaged in occupations that are meaningful to their lives, they are temporarily absent from the preoccupation of life’s many stresses. Consequently, occupational participation is not merely a means of physically engaging individuals in rehabilitative activities; it is also a distraction from suffering and a means to enhance well-being (Gutman & Biel, 2001). In order to efficiently apply this notion to this project, it is important to first understand the 8
influences that affect participation in occupations at both the personal and community levels. Participation in the everyday occupations of life is a vital part of human development and lived experience. It is through participation that we acquire skills and competencies, connect with others and our communities and find purpose and meaning in life (Law, 2002). Moreover, meaning is an issue which has been recognized as a core component of occupational engagement and performance in the field of occupational therapy. Christiansen and Townsend (2004, p. 2) state that: “Occupations are invested with a sense of purpose, meaning, vocation, cultural significance and political power through which some occupations are paid because of their economic value, while others are not....” This research will unpack the concept of “meaningful occupations” by examining how meaning is conceptualized and articulated by racialized community members in the North End. The term “racialized” is a sociological term that is often used to refer to non-white and non-European heritage communities that lack social, economic and political power in white dominant societies. Meaningful occupations are those which fulfill a goal or purpose that is personally or culturally important to the individual who is engaging in the occupation (CAOT, 2002). Every individual has unique interests and occupations which they find meaningful and satisfying (Law, 2002). They also have unique understandings of what they consider to be a meaningful occupation. This understanding is dependent on the individual’s unique motives, roles, habits, abilities, and limitations (Kielhofner, 2007). In addition to unpacking the concept of “meaningful occupations”, the project fleshes out the intimate relationship between the individual, place and occupations (Townsend & Wilcock, 2004 a) by examining how social, economic and political hierarchies of power and privilege determine how occupations are organized racially, culturally, economically and geographically. It will also probe the extent to which power, privilege and disadvantage unravel and operate through racist, classist, sexist, heterosexist and ableist structures, institutions and everyday practices to shape access to, participation in and the experience of occupations for racialized individuals and communities in the North End. The invisible nature of privilege is illustrated in the naturalization, standardization and normalization of belief systems and worldviews held by those who hold majority status and privileged social positions in every society, including whites, heterosexuals, able-bodied individuals and men. Consequently, this project extends Nelson’s (2007) concept of “power blindness” as it relates to race to examine the social privileges and disadvantages that are also associated with ablebodied-ness, gender, class, sexual orientation, religion/spirituality and other social identities. For example, Simoni and Walters (2001) observe that the privileged status that heterosexual individuals hold has much to do with the fact that they share the sexual orientation of the majority, which affords them various unearned institutionalized entitlements and advantages. This project also addresses the issue of identity in order to examine how race, social class, gender, sexual orientation, disability and other social identities shape understandings of meaningful occupations. It will consider how social identities influence participants’ values, traditions and practices and how those shape occupational choices, as well as the individual meanings that are attached to those choices within dominant and normative value systems and traditions in EuroWestern society. Finally, the project examines how social institutions accommodate occupational choices that reflect the diverse values, traditions and practices of Aboriginal and African Nova Scotian communities. Consequently, in probing how social factors shape human occupation, the project seeks to reveal how the built environment, social and public policies and institutional processes and practices are informed by ideologies around race, culture, social class and other social factors to structure individuals and communities within specific occupations and to create barriers to and/or opportunities for accessing and participating in meaningful occupations. The objective, then, 9
is to interrogate the concept of “meaningfulness” in occupational therapy to engage with diverse and, perhaps, alternative conceptualizations of meaning that diverse groups hold. It is an analysis that extends the profession’s focus on the inherent power inequities between occupational therapists and clients (particularly the privileges that occupational therapists hold with respect to the therapeutic relationship, authority to discharge, access to information etc.) to a broader understanding of how social identities such as race, income, culture, age, gender, sexual orientation and disability situate clients differently and unequally within social structures, social discourses, ideologies and knowledge traditions. Kumas-Tam (2005) argues that acknowledging clients’ multiple identities will enable occupational therapists to interrogate their own and their profession’s participation in social structures, social discourses, ideologies and knowledge traditions that may limit clients’ access to and participation in occupations that are meaningful to them. The implications for occupational therapy and occupational science are significant, primarily because such a discussion points to how privilege and disadvantage are expressed in clients’ lives and limit or offer opportunities for participation in meaningful occupations. As Kumas-Tam (2005) notes, a multi-level approach to difference oriented to social change in occupational therapy involves an understanding of how social structures, discourse and knowledge production connect with the “person-environment-occupation system” (PEO). The PEO model, which draws upon environmental theories, characterizes the transactional relationship between three main elements that influence occupational performance - the person, the environment, and occupation. According to this model, occupational performance will be maximized if a person’s interests and abilities are matched to job demands in a work environment that enables their full participation in work activities. The “person” factors include aspects of affect, physical functioning, cognitive abilities, and spiritual beliefs. The concept of “environment” includes the social (co-workers and other people in the workplace), physical (the workplace itself) and cultural (how the workplace is imbued with expectations that are shaped by everyday behaviours and workplace rituals). The “occupation” factors characterize the job tasks and other meaningful activities performed in the workplace. Occupational performance, then, is a product of the interaction between factors of the person, environment and occupations. Occupational therapists use the information from the PEO model to determine which of the three factors need to change to support clients’ occupational performance (Gupta & Sabata, 2010). The subject of diversity in the meanings assigned to occupations is a complex one and, consequently, has a tendency to spark critical analysis. This concept is well highlighted by Hammell (2004), who critiques the simplistic categorization of occupations into self-care, work (productivity) and play (leisure) because it excludes prayer, meditation and caring for children. She challenges occupational therapists to apply a more critical lens to the value patterns and assumptions embedded in the profession’s theories in order to more effectively enable participation in meaningful occupations. She also suggests that this categorization reflects a Euro-Western worldview that values individualism over connectedness. Moreover, she argues that that the conceptualization in the profession of leisure and work as divisible is a culturally specific one because it fails to reflect the experiences of individuals living in simple societies for whom leisure and work may be one and the same. Hammell (2004, p. 297) points out that this categorization is not only limiting, but is also “a value-laden and inherently political” process that is troubling considering the variety of meanings a single occupation may have. Take for example the action of walking. On its own it is simply an activity and not an occupation, until one attaches meaning to it. The same activity can be thought of as self-care (walking to maintain health) or leisure (taking an enjoyable stroll in the evening). She further states (2004, p. 297) that “consistent themes across diverse studies suggest that occupation might best be understood, not as divisible activities of self-care, productivity and leisure, but as dimensions of doing”. Therefore, in order to effectively bring about positive change in an individual 10
or community it is imperative that we understand the ways in which diverse individuals conceptualize “doing”. Finally, the project examines the relationship between access to and participation in meaningful occupations and the health of individuals and communities, including spiritual, emotional, mental and physical health. The project understands health as a product of social, economic, political and environmental forces acting upon individuals and communities. Consequently, the project interrogates one of the central premises of occupational therapy that suggests that the healthy individuals and communities are those that are engaged in occupations that are meaningful to them. Hammell (2009) argues that the assumptions held by occupational therapists are often not challenged, particularly around the nature of occupations, the role of occupations for human well-being and conceptualizations of meaningful occupations. For example, she challenges the profession’s conceptualization of meaningfulness as positive, arguing that the experience of meaning that some individuals get from occupations may be boredom. While Hammell is cautious about supporting the profession’s claim that there is necessarily a positive relationship between occupation, well-being and health, she implies that more research needs to be conducted to examine the meaning of health and well-being in diverse communities.
II. Project Partner: North End Community Health Center
The project partner on this research was the North End Community Health Center, which is located in North End, Halifax. The North End Community Health Center was founded in 1971 by a group of local residents who identified a need for health services in their community. Today the Centre operates as a non-profit, collaborative and interdisciplinary center that provides health and other services to North End residents. It has a unique collaborative team approach that brings together physicians, nurses, mental health care workers, a dietician, and other health care professionals. Each member of the health care team works to ensure that the Center addresses clients’ total health and well-being in order to improve their lives. The Center uses a holistic health approach that includes attendance to clients’ physical and emotional health. It offers many services for registered clients and residents of the area, including health care and health promotion programs ranging from diabetic nutrition counselling to well baby appointments. The Center’s services are based on social determinants of health approach that considers how health is shaped by the social circumstances in which people live, such as poverty, lack of resources, lack of education, low literacy levels, lack of affordable housing, nutrition, addiction and mental health issues. Through education, it works to strengthen clients’ ability to take responsibility for their health and well being, and offers advice to clients on accessing the help and resources they need.
III. The North End: A Profile
The North End is a neighbourhood located in the urban core of Halifax, Nova Scotia and is bounded on the east and north of the Halifax Harbour and the Bedford Basin, although the boundary originally ended at North Street. During the nineteenth century some of Halifax’s elite social classes were located on Brunswick Street in the north end of the city. Gottingen Street became the pulse and thriving heart of the north end, bustling with shops, dining establishments and other activities. It had 10 different restaurants and cafes, two movie theatres and several physicians, dentists, lawyers and tailors. Unfortunately, over a 50 year period until the year 2000, the total 11
number of retail and commercial services on the four block area of Gottingen Street declined from 130 to 38. In addition, the number of social and community services grew from one in 1960 to 19 in 2000. Melles (2003, p. 93) states that: “The abundance of social agencies, vacant buildings and vacant land evident by year 2000 has changed the form and function of this four-block commercial district. In fact, one can no longer consider this portion of Gottingen Street a true commercial district…the social agencies attract only service users while the underutilized spaces discourage any[other]type of street activity - a complete transformation from its previous expressions and multipurpose utility”. In 1966 many of the residents that were expropriated out of Africville moved into Uniacke Square in the North End, a public housing complex. By this time, Gottingen Street was well on its way to decline. The area has a disproportionately high incidence of low-income households and is often linked to crime and poverty. Many of its residents belong primarily to the working class. The negative impression of the North End generates controversy with the residents who feel that they are targeted due to racial and/or socio-economic reasons. Thus begins the context of racialized poverty which becomes a vicious cycle: severe poverty; low levels of education; lack of self-esteem; drugs and addictions; dealers; violence; need for money to feed the addictions; lack of job opportunities; crime; and street sex exploitation. The North End has become very popular for Halifax’s growing university population due to the fact that students can find more affordable housing in this area. This new population has given birth to a growing artistic community. The low cost of rent and the availability of commercial properties have contributed to the gentrification of the area, which is defined as restoration of a poor, working class neighbourhood. This is evident by the onslaught of condominiums and townhouses on prime peninsular land. Some individuals perceive this as particularly beneficial to the area because it spruces up a deteriorating area and increases property values. However, the poorer residents rarely see any of that money and much resentment is felt by those who have lived their entire lives in the area. The closure, in 2011, of one of the two remaining schools in the neighbourhood is a blow to the community. Due to declining enrolment, the Halifax Regional School Board could no longer justify keeping this school operating. In addition, this community has lost many of its banks, a grocery store and a post office and has only one remaining pharmacy. There are over 20 organizations and several non-profit agencies, many of them underfunded, which provide support to North End residents. For example, the Halifax North Memorial Public Library has been a popular landmark in the community since 1966. It was built in memory of those who lost their lives in the Halifax explosion in 1917. The Library is a welcoming environment that reflects the diversity of this vivacious North End community and offers a range of programs for people of all ages. The North End Parent Resource Centre, which is located in Uniacke Square, opened in 1986 and offers a range of services and supports to low income parents, mainly young single mothers. The Enterprise YMCA is located on Gottingen Street next to the Library and offers a range of services for young people, such as an employment centre. The North End Community Health Centre, which was established in 1971, offers much needed medical services, community outreach and community building. Community Action against Homelessness and the Halifax Coalition against Poverty play an important advocacy role for those who are homeless and underhoused. The George Dixon Recreation Centre runs a wide range of programs, including youth leadership, and offers job opportunities to the youth in the area. The community police office is located in Uniacke Square and is staffed with two police officers. There is an expectation for the private sector to invest in this declining neighbourhood and to develop economic opportunities. 12
Although there are businesses in the area, they don’t seem to employ many of the residents in the neighbourhood. The objectives of the service agencies are: • • • • • • To explore ways to coordinate better services; To involve residents and clients in program development and delivery; To increase capacity to develop partnerships; To develop community economic development and self-help initiatives; To advocate on behalf of clients to address gaps in service delivery; and To work to increase public awareness on issues related to issues of poverty.
There is also a responsibility for the three levels of government to provide support and funding to the organizations and agencies in the community. Although the Municipal Government does not have jurisdiction over the social service programs, there is an expectation for them to do the following activities: • • To strengthen and improve relations and understanding between the business community, police and the clients they serve and To develop goals in the context of regional planning.
The Provincial Government is responsible for the social assistance program, health services and housing. Therefore, there is an expectation for this level of government to do the following: • • • To provide leadership in developing a “continuum of care” for clients that rely on the services they provide; To invest in a facility for those who do not access the current emergency service and may have behavioural problems with multiple needs; and To provide better coordination of support services for those who may have been in an institution and face homelessness.
The Federal Government provides funding for many agencies, therefore the expectation is for this level of government to do the following: • • • • To support the development of a “continuum of care model” by coordinating programs and services they fund; To invest in a facility for those who do not access the current emergency service and may have behavioural problems with multiple needs; To provide better coordination of support services for those who have been in an institution and face homelessness; and To accept responsibility for funding programs for urban Aboriginal people, immigrants and refugees in order to reduce incidents of despair in the lives of these communities.
With an investment by the three levels of governments, the committed work carried out by the organizations and agencies, as well as the desire of residents in the area, the North End could become the vibrant and safe community it once was - a place where many call home.
IV. Context & Background
This project is informed by Occupational Justice Theory, which was developed by occupational therapists Anne Wilcock and Liz Townsend to question and address issues around social inequalities and social justice relating to the everyday practice of justice and enabling empowerment through occupation (Christiansen & Townsend, 2009; Townsend & Wilcock, 2004). The literature in occupational therapy and occupational science have been increasingly attending to social justice and occupational justice, particularly as they relate to the relationship between the effects of social injustice and the negative influences on occupational participation (Braveman & Suarez-Balcazar, 2009). Occupational justice is distinguished from social justice through its focus on individual and group differences, enablement of diverse participation in society, as well as the distribution of rights and resources. It is concerned with humans as occupational beings whose participation in occupations is paramount for their development and survival, as well as their health and quality of life. Occupational justice also focuses on enabling different access to opportunities and resources in ways that acknowledge individual differences (Christiansen & Townsend, 2009). While occupational therapy has long examined the relationship between meaningful occupations and health, the focus has been primarily on persons with disabilities, older adults and individuals living with mental illness. Other marginalized groups such as racialized, low-income and LGBTT communities have largely been ignored in the literature. Consequently, this project fills a gap by examining how multiple identities (race; low-income, gender etc.) intersect simultaneously to shape the experiences of individuals and communities. Moreover, this project understands access to and participation in meaningful occupations as being shaped by those multiple social phenomena acting together to structure the lives of individuals and communities.
Part One: Aboriginal & African Nova Scotian Communities: A Profile
Aboriginals Aboriginal and African Nova Scotian communities make up the largest segment of the population in North End, Halifax. The population of Nova Scotia was 913,462, in 2006, which is approximately 3% of the Canadian population. Aboriginals made up approximately 3% of the population of Nova Scotia in 2008. The number of Aboriginal people was higher within rural areas of Nova Scotia than urban centres in 2008. Many Aboriginals reside in rural Nova Scotia, but this continues to change as more Aboriginals move to urban areas (Saulnier, 2009). The Mi’kmaq are the founding people of Nova Scotia and the dominant Aboriginal group within the province. When the Mi'kmaq first encountered Europeans in the 16th and 17th centuries, their territory stretched from the southern portions of the Gaspé Peninsula eastward, to most of modern-day New Brunswick and all of Nova Scotia and Prince Edward Island (Office of Aboriginal Affairs, 2010). As allies to the French, the Mi'kmaq community was accepting of limited French settlement. After France lost political control of Acadia in 1710, the Mí'kmaq engaged in intermittent warfare with the British with the help of the Acadians, using military force to resist the founding of British (protestant) settlements in Dartmouth and Lunenburg, Nova Scotia. During the French and Indian War, the Mi'kmaq assisted the Acadians in resisting the British during the expulsion of the Acadians. The military resistance ended with the French defeat at the Siege of Louisbourg (1758) in Cape Breton. After the war, the British seized much of their land without payment. Between 1725 and 1779, the 14
Mí'kmaq signed a series of peace and friendship treaties with Great Britain, although none of these were land cession treaties (Wikipedia, 2010). African Nova Scotians People of African descent have been residing in Nova Scotia for almost 300 years. African Nova Scotians accounted for 2.1% of the population in 2006, an increase of 6.2 since 1996 (Saulnier, 2009). In Acadia, from the early to mid 1700s, there were more than 300 people of African descent in the French settlement at Louisbourg, Cape Breton. Between 100 and 150 people of African descent were among the new settlers, now known as the Planters, who came from New England after the British gained control over Nova Scotia in 1763. Planters were slaves who were used by plantation owners to do field work and other jobs. Peoples of African descent who came from slavery and war were called Black Loyalists. They left New York and other ports for Nova Scotia between 1783 and 1785 as a result of the American Revolution. They were also taken to the West Indies, Quebec, England, Germany, and Belgium. Between 1783 and 1785, over 3,000 Black people came to Nova Scotia as part of the Loyalist migration. They settled in Annapolis Royal and in the areas of Cornwallis/Horton, Weymouth, Digby, Windsor, Preston, Sydney, Fort Cumberland, Parrsboro, Halifax, as well as Shelburne, Birchtown, and Port Mouton. In New Brunswick, Black Loyalists were settled in Saint John and along the Saint John River. In 1796, 550 people, known as the Maroons, were deported from Jamaica to Nova Scotia and then were relocated to Sierra Leone in 1800. Approximately 2,000 escaped slaves came from the United States during the War of 1812, under conditions similar to those of the Black Loyalists and were offered freedom and land in Nova Scotia. They moved into the Halifax area to settle in such areas as Preston, Hammonds Plains, Beechville, Porter's Lake, the Lucasville Road and the Windsor area (The Nova Scotia Museum, 2010).
Part Two: Defining Occupational Participation
This project examines how personal, social and economic factors influence occupational participation among Aboriginals and African Nova Scotians in the North End. According to Law (2002), healthy human development is partly dependent on the opportunities that individuals have to participate in the everyday occupations of life. Participation in occupations may impact positively on health and well-being because it produces a sense of purpose and meaning in life through connections with others and through the development of skills and competencies. One of the main goals of occupational therapy is to enable individuals and communities to participate in everyday occupations that are meaningful and that engage them in everyday life with others. Occupational therapy defines participation as involvement in formal and informal everyday activities. Formal activities include structured activities defined by rules or goals and that have a formally designated coach, leader, or instructor (e.g., music or art lessons, organized sports, youth groups). Informal activities include those activities that have little or no planning and are instigated by an individual (e.g., reading, hanging out with friends, playing). Individuals and groups participate in occupations in a variety of locations and environments, including work, school, play, sport, entertainment, learning, civic life, and religious expression. Recreation and leisure are significantly related to the development of social support networks and to quality of life and well-being for adults. Meaningful participation requires that there be a balance between the challenge of an activity and the skills of the individual, a feeling of choice or control over the activity, a supportive environment to facilitate easy attention to the activity, a focus on the task and not on the long-term consequences and a sense of mastery. 15
Participation is facilitated by the social environment, social attitudes and availability of social support. It is also determined by differential availability of opportunities, which is influenced by race, gender, socioeconomic status and other social factors. The International Classification of Functioning, Disability and Health (ICF), which provides an international and inter-professional scientific basis for understanding and studying health, outcomes and determinations, uses the term “participation” in its framework. The current framework was developed in 2001 and occupational therapy rapidly incorporated the ICF concepts into its perspectives (Hemmingsson & Jonsson, 2005). The ICF defines participation as “involvement in a life situation” (Hemmingsson & Jonsson, 2005, p.570) .The ICF distinguishes “participation” from “activity” in that “activity” represents the capacity to engage in a task, while “participation” describes the observable performance within a life situation. Based on this notion, individuals may have the capacity for occupations but may not be participating in those occupations due to various personal and contextual factors (Hammel et al., 2008). The Model of Human Occupation (MOHO), which will be discussed later in more detail, utilizes the term “occupational participation” to describe when an individual “engages in work, play or activities of daily living that are part of their socio-cultural context and that are desired and/or necessary to their well-being” (Kielhofner, 2007, p. 101). Occupational participation is collectively influenced by performance capacity, habitation, volition and environmental conditions (Kielhofner, 2007). Therefore, an individual’s participation in occupations is personal since it is influenced by their unique motives, roles, habits, abilities and limitations. It is also contextual since the environment can play either an enabling or restricting role in occupational participation (Kielhofner, 2007). Hammel and her colleagues (2008) conducted a study which examined what participation means to individuals with disabilities, how they characterize it and what types of barriers and supports impact their participation. Through qualitative focus groups, it was established that there was no gold standard for ideal or optimal participation and that participation can be experienced quite differently by different individuals. Participants described needing to be free to define and pursue participation on their own terms as there should be no predetermined societal norm or standard regarding what types of activities or what frequency of engagement constitutes full participation. There are many factors influencing the occupations an individual engages in every day which contributes to the complexity of occupational participation. Environmental factors such as the physical accessibility of buildings and the attitudes of community members can affect one’s occupational participation. Personal factors such as physical skills and abilities, social competence, communication, problem solving skills and decision making skills also play a vital role in occupational participation (Law, 2002). Factors Shaping Access to and Participation in Meaningful Occupations As discussed earlier, the environment and experiences of an individual influence the ways in which particular occupations are conceptualized. Diverse individuals may feel that their differences create inequities and barriers which prevent access to and participation in meaningful occupations. These differences, or personal factors, such as race, culture, age, disability, gender and sexual orientation often influence the occupations that one engages in. In addition, societal structures and institutions (e.g., education and health systems) may promote inclusion or present barriers to access and participation. Occupational justice is a concept within occupational therapy which recognizes the occupational rights of all individuals regardless of any differences they may have. Nilsson and Townsend (2010) describe occupational injustice as the restriction of participation in occupations by social policies which give power to some but not others. For example, individuals of low social class may experience exclusion in a variety of desired occupations and settings (Beagan, 2007). To 16
illustrate, a single mother who is dependent on social assistance may be unable to afford extracurricular school programs for her child. The cost associated with these programs, which would have been established by the School Board/provincial government, is the barrier. School policies should recognize the importance of both access to and participation in meaningful occupations since the effects of exclusion may extend well beyond childhood (Beagan, 2007). Programs which are free of cost or subsidized should be more readily available, especially within low-income communities. This would encourage inclusion by permitting equal access to all children. Inclusion within such activities would give children the opportunity to build relationships with one another while participating in something which is meaningful and enjoyable. In addition to social class, race plays a role in limiting opportunities for individuals and communities within a variety of settings, including schools, healthcare facilities and private or public businesses. For example, in the workplace environment, discrimination in promotion may result in targeted, non-white individuals feeling that they do not have the intelligence or skills required to advance (Beagan & Etowa, 2009). If one were to experience such discrimination repeatedly it may begin to reflect on how that individual views him/herself and the opportunities which are unavailable to them as a result of their race. Discrimination in both hiring and firing further establish the lack of power and privilege that members of racialized groups experience and prevents access to meaningful work. If an individual is not able to maintain a steady income, participation in other occupations may become compromised. For example, one may not be able to afford healthy foods for the maintenance of self care or leisure occupations. Because of barriers preventing individuals from obtaining work, stereotypes regarding laziness and lack of motivation across racialized groups may be further strengthened.
Part Three: Defining Meaningful Occupations
Occupational meaning, which is a basic element of human occupation, describes the meaning that individuals attach to occupations. Occupations that may be considered meaningful are those that allow individuals to express and convey their identities and skills or express virtue in some way, such as through friendship. According to Griffith, Caron, Desrosiers and Thibeault (2007), meaning is a product of the subjective and dynamic experience of an individual and the worth it is given by his or her society. The human drive to find meaning and to understand the fullness of life is a natural impulse, as necessary for life as food and drink. Law (2002) argues that for an individual to consider an occupation meaningful there must be a feeling of choice or control over the activity, a supportive environment to facilitate easy attention to the activity, a focus on the task as opposed to the long-term consequences, a sense of challenge from the activity and a sense of mastery. The fit between the activity and the individual is considered the “just right challenge”. Consequently, for an occupation to be meaningful, a balance between the challenge of the activity and the skills and interests of the individual is required (Moneta & Csikszentmihalyi, 1996). Participation in a meaningful occupation contributes to one’s sense of purpose, perceptions of competence, capability and value and also affects one’s quality of life (Hammell, 2004). Gray (1998) stated that an occupation which is whole, purposeful and meaningful can affect individuals psychologically, emotionally and socially in ways that occupations which are not meaningful cannot. Meanings, for instance, are said to be “culturally-situated” (Clarke et al., 2005) because they are often influenced by values that are culturally-based. In order to understand the unique conceptualizations that individuals hold of meaningful occupations, it is essential to pay attention to the voices of the individuals being studied. There are elements of “well-being” for instance, that can be objectively measured, but also subjectively measured, leaving room for an individual to define for 17
themselves what well-being means or in this case, what a meaningful occupation consists of (Clarke, Liu-Ambrose, Zyla, McKay & Khan, 2005). To address how meaningful occupations are conceptualized by diverse individuals and populations, the question needs to be asked: “What makes an occupation meaningful?” The answer will vary depending on who answers the question. The answer will also likely be influenced by the combination of person and environmental factors, and will therefore change as a function of the context to whom and in which it is asked. Members of particular communities may tend to value certain occupations more than others, which may be influenced by inherent aspects of belonging to certain demographics or cultures. However, it is important to recognize that there can be several factors that converge to create meaning that is unique to an individual. Occupational therapy is well-suited to understand these unique standpoints due to the value it places on client-centeredness. Bazky & Bazyk (2009) examine the impact of an after-school, occupation-based group for adolescents in urban, low-income neighbourhoods. This study reviews what adolescents valued about the group and sheds light on what occupations they found meaningful and valuable. Due to the qualitative nature of the research, adolescents also had the opportunity to explain why they enjoyed certain occupations. According to this study, these “socio-cultural aspects such as poverty, lack of resources, and inequality of access to needed resources”… may lead to “occupational deprivation and to the inability to express one’s occupational nature” (Bazyk & Bazyk, 2009, p. 69). Moreover, vandalism and gang activity may be used to meet needs that are not being met otherwise. People in this demographic are thought to engage in “passive forms of leisure” and to seek stimulation due to a lack of meaningful engagement. What adolescents reported valuing in the group was that it was fun and provided them with enjoyment. They appreciated the opportunity to talk about their feelings and enjoyed doing new, structured, creative and challenging leisure occupations. It was also noted that they liked working together in a cooperative manner, interacting with group leaders in a caring, supportive and nurturing context, and participating in groups that were more child-centered than adult-focused. Overall, it seemed that the group was afforded opportunities that were both occupation-based and socially-based that provided meaning in ways that they did not feel was always granted within a classroom or in comparison to other after-school programs. Similarly, a study by Famworth (2000) explored time-use of young offenders and revealed that young offenders often spend a higher percentage of their time in “passive leisure” activities compared to nonoffenders. One theory that addresses time-use in youth and particularly youth at risk showed that behavioural disturbances in classrooms often lead to suspension or expulsion. This often leaves the youth with less structured time that would otherwise be provided by the school system. As a result, this influences the occupations that youth have access to and what social and institutional factors might be helping or hindering the “ability” for them to do so (Farnworth, 2000). A group of elderly, immigrant women in Canada took part in qualitative research (Brown, 2008) that examined the occupations they find meaningful and the ways in which their unique circumstances shaped their participation in those occupations. Some of the issues that they experienced in relation to their status were loss of meaningful roles and participation and status in family life. These women often immigrate to Canada to be with their families and to experience increased financial security and safety, but often experience more isolation and loneliness. This is an example of cultural context in relation to prescribed meaningful occupation and highlights the discord that can exist in comparing the culture individuals immigrate from to the new culture in the host society. This is exemplified, for instance, when someone who does not drive moves to an automobile-centered society such as North America. There are also differences in culture with respect to the roles that individuals hold in the family. For example, in Asian cultures, cohesive family units and communities tend to be valued more than in North American culture, which is often characterized as being more independent and individual-centered. While a group of older 18
women with osteoporosis defined meaning and well-being for themselves in a variety of ways, common themes of autonomy and the ability to have choice around what one does was valued in relation to occupation (Clarke et al., 2005). For example, Harmer and Orrell (2008) asked “what makes activity meaningful for people living with dementia?” Results showed that participants identified meaningful activities as those that promoted inclusion in a group such as social, family and musical activities, as well as activities that reinforced identity such as reminiscing with family or music. In addition to social, cultural, institutional and spiritual factors that may contribute to conceptions of meaningful occupations, a more recently acknowledged addition to these factors would include sexual orientation. The meaning of “sexual orientation” and the way in which it might be experienced is also contextual and culturally-dependent. For instance, if an individual is unable to participate in particular occupations because of their sexual orientation, this would constitute occupational injustice. A study examining the lived experiences of individuals who identify as homosexual showed that some individuals have avoided certain occupations out of fear of discrimination or acts of prejudice (Bergan-Gander & von Kurthy, 2006). As these examples have shown, contextualizing meaningful occupations within a socio-cultural context requires an interrogation of how inequality shapes access to and participation in meaningful occupations by diverse individuals and communities.
Part Four: Inequality & Discrimination
Articulating how inequality shapes access to and participation in meaningful occupations is a central issue in this research. One of the main objectives of this research is to interrogate how structural and institutional inequalities and everyday inequities and discrimination shape access to and participation in meaningful occupations in the North End. Structural inequality refers to the policies of institutions and the behaviour of the individuals who implement these policies and control these institutions, which are race/ethnic/gender/sexuality neutral in intent but which have a differential and/or harmful effect on marginalized groups. It also refers to the cumulative and persistent inequalities that operate through the laws, norms and rules of governance in every society. Institutional inequality, on the other hand, refers to how inequality is manifested and embedded in the processes, practices and policies within institutions that are informed by ideologies about race, gender, sexual orientation and other social identities in order to accord privileges to certain groups and subject other groups to disadvantage. It focuses on the availability and quality of societal and institutional resources, such as income, housing, social services, educational resources and health and how these resources are distributed along race, class and gender lines. Finally, everyday inequities characterize those conscious and unconscious unjust actions that occur in interpersonal relationships and daily interactions between individuals, including overt and covert and intentional and unintentional practices committed by individual persons acting alone. They are expressed in verbal communication, gestures and behaviours that are not always consciously experienced by their perpetrators, but that may be experienced in negative ways by victims. These behaviours of individual members of one group (e.g. heterosexual individual) are intended to have a differential and/or harmful effect on the members of another group (e.g. gay individual). The concept of social location is important for articulating how hierarchies of race, culture, gender, sexual orientation and other identities work independently and interdependently to position individuals and communities differently within historical, structural, institutional and everyday contexts, resulting in unequal access to social, political, economic and educational resources and opportunities (Johnson, Angelucci, Howey, Lawlor, Townsend & Waldron, 2009). Socially conscious 19
and self-reflexive practice in occupational therapy and other health professions requires an understanding of how social location shapes professional practice, including health professionals’ relationships with clients. Low-income, poverty, low education levels and racism continue to be the most significant issues impacting the lives of Aboriginal and African Nova Scotian communities in the North End and in Nova Scotia in general. Much has been made in recent times about poverty continuing to be a pressing social problem for many families in Canada as the income gap between rich and poor Canadian families continues to widen. However, while the incomes of wealthy families have increased, it is among poor families that incomes are more likely to stagnate or worsen (Statistics Canada, 2008). Across Canada, experiences of poverty are not shared equally among individuals and families. Racialized, immigrant, Aboriginal, and lone mother families, in particular, are among those groups mostly likely to experience incomes that fall below Statistics Canada’s lowincome cut offs (LICOs) (Gazso & Waldron, 2009 a; Morissette & Picot 2005; National Council of Welfare 2006). Other social factors such as disability, homelessness, gender, age, rural residence and education level also have significant implications for income disparities between groups. People with disabilities were found to account for 20% of Nova Scotia’s population. They were also found to be a population with the most persistently high levels of poverty in Nova Scotia. Some of the economic barriers this population faces include: lower employment rates, higher costs of living than individuals without disabilities, and higher reliance on income security programs. In 2006, 52.6% of people with disabilities had paid employment, compared to 79.1% of people without disabilities. It is important to point out that people with disabilities may include individuals with other potentially limiting contextual factors, such as gender or age, which would need to be considered when determining methods for resolving issues around poverty (Saulnier, 2009). Poverty is one of the most pressing issues facing homeless individuals in Halifax. Approximately 266 individuals were experiencing homelessness in Halifax, with the majority being single (94%); 67% were male compared to 33% female; average age was 35 years old; and 16% were from a racialized community. The explanations that participants gave for their homelessness included: substance dependence (26%); inability to find accommodations (23%); lack of income (19%); and mental illness (14%). This population experiences significant gaps in service, including inaccessibility to mental health and addiction services, a lack of social supports, and insufficient affordable housing (Saulnier, 2009). In 2006, 13.8% of Nova Scotians were living in low income. The highest rate of living in low income occurred in Yarmouth at 27%, and the second highest was Amherst at 19.4%. Halifax had a low-income rate of 14.3%. The lowest low-income rate in Nova Scotia was in Antigonish County at 9.4%. Nova Scotia was found to have the second-lowest average weekly earnings in Canada in 2006. Low-income rates in Nova Scotia in 2006 were higher in women than in men, at 10.3% and 8.9%, respectively. In elderly residents (65 years or older) in Nova Scotia, women had a higher incidence of low-income, at 17.4%, than men at 7.5%. Also, single-mothers in Nova Scotia were living at a much higher rate of poverty than two-parent families. Poverty rates in Nova Scotia, unlike other Canadian provinces, were higher in rural areas than urban centres because there was a shift from an economy that was primarily resource-based to a more service-based economy between the 1970s and 1990s (Saulnier, 2009). Racialized communities in Nova Scotia experience some of the lowest income levels. Unemployment, underemployment, and poverty are pressing issues for Aboriginals in Nova Scotia. This community experiences high levels of poverty, social exclusion, and material disadvantage. Fifty percent of Aboriginals living on reserve relied on income assistance or another form of government money. The average income for Aboriginals in Nova Scotia was just over half of that of the provincial average in 2005. In 2002-03, 52% Aboriginals made less than $10,000 per year. The average income of Nova Scotia’s Aboriginal people was $13,311 compared to an average of $25,295 20
for the province in that same year. The unemployment rate for this community was 15.5% in 2006 (compared to a provincial unemployment rate of 9.1%), down from 21.9 in 2001 and 24.6% for those living on reserves, down from 30.2%. Only 50% of Aboriginals living on a reserve were employed in 2006, which was unchanged from 2001 (Statistics Canada 2008). Low rates of employment were due to low levels of education, different residency patterns (i.e. living on a reserve or off reserve), and inequalities amongst the population (i.e. gender inequalities). According to Statistics Canada (2008), 27% of Aboriginal peoples in Nova Scotia have not completed high school compared to 19% of the general population. In addition, 12% of working aged Aboriginals had a university degree in 2006, compared to 20% among the general population (Statistics Canada 2008). Income is also shaped by gender in this community, with women, like those in the rest of the Canadian population, earning less pay than men for equal work. Aboriginal women working full time have a pay gap of $6,000 per year compared to their non-Aboriginal counterparts (Saulnier, 2009). Compared to White Nova Scotians, African Nova Scotians experienced higher rates of unemployment, educational underachievement, illiteracy, incarceration and poor housing in 2003. African Nova Scotians with a university degree were earning on average $12,000 less than other Nova Scotian graduates. Black women in Nova Scotia were living at one of the highest rates of poverty in Canada at 39.7%. Several factors account for this, including lower levels of education, racism, and higher rates of chronic disease (Saulnier, 2009). In 2000, 39.7% of Black women in Nova Scotia were living in low income which was one of the highest rates of poverty in Canada. Forty-four percent of Black children in Canada live in low-income households and of that number, 19% live in Nova Scotia. The Task Force of Government Service reports that the challenges faced by African Nova Scotia seniors were due to little or no access to quality education or decent employment opportunities when they were younger. Consequently, most have lived in low income with all of the barriers associated with this way of living (Saulnier, 2009).
Part Five: Meaningful Occupations & Health
Impact of Occupational Participation on Health Like other health professions, occupational therapy is increasingly attending to how diversity in culture, ethnicity, language and immigration status affects health and health care (Hopton & Stoneley, 2006; Kingsley & Molineux, 2000; Kirsh, Trentham & Cole, 2006). However, while the profession has been moving to a broader consideration of the historical, social and political contexts in which clients live, the dominant approach is still premised on “cultural competency” and “diversity” models that focus primarily on cultural differences and, that consequently, obscure or undermine how power inequalities due to race, gender, socio-economic status and other social factors are implicated in occupational experiences and health. For example, while several studies in occupational therapy (Hopton & Stoneley, 2006; Kingsley & Molineux, 2000; Kirsh, Trentham & Cole, 2006) have examined groups that are diverse based on culture, ethnicity, language, and immigration status, they have tended to focus more on the challenges of providing sensitive and competent care than on how hierarchies of power shape access to material resources (health, housing, employment, education), produce social, economic, educational and political inequalities and contribute to health disparities. The focus on culture at the expense of other factors such as race in discussions on diversity in much of the occupational therapy literature demonstrates a curious reluctance to grapple with the discrimination, inequalities, exclusion and marginalization racialized communities experience. Moreover, the failure to acknowledge or address power differentials and privilege in society (and not simply between therapists and clients) in much of the occupational 21
therapy literature has the potential to dis-empower those clients whose views on health and illness differ from the dominant Euro-Western belief systems around health and illness (Waldron, 2010). Although culture clearly shapes occupational engagement and performance and impacts on health and well-being, this project will move beyond that to ask how hierarchies of power based on race, low-income, poverty, social class, gender and other social factors affect health and well-being through access to and participation in meaningful occupations. Power relations then, not cultural differences, will be at the center of the analysis. According to Townsend & Wilcock (2003), occupational justice rests on two principles: • • belief that occupational participation is a determinant of health and principle of empowerment through occupation
The World Health Organization (2001) defines health as a dynamic interaction between person and environment; that is, health is the ability to participate in meaningful activities within the context of everyday life. In a just world, individuals will succeed if they are able to engage in occupations that are useful and meaningful to them and their community (Blakeney & Marshall, 2009). There is a growing body of evidence to support these principles and the central role occupation can play in modifying health and well-being. There is an abundance of research that indicates that occupation is a necessary element in providing those that have had their life disrupted from illness and disability with a source of meaning and purpose. Occupational therapists recognize this notion and employ occupation to facilitate the neurological substrates of health and well-being. When one is fully engaged in an occupation that is meaningful, they are temporarily absent from the preoccupation of life’s many stressors. It follows, then, then, that occupation is not merely provided as a means of physically engaging a person in rehabilitation, but as a distraction from their suffering and a means to enhance their mental well-being. For example, Gutman and Biel (2001) found that when an individual who is suffering from depression is fully absorbed in an occupation, a number of neurologic phenomena can transpire. If the occupation requires the use of more left brain functions and feelings of depression are mediated by the right hemisphere, it is likely that feelings of isolation and anxiety can be alleviated. This shift in mood is itself a mode of facilitating a more positive outlook and the associated changes that can bring about a better quality of life. Optimism is improved when one believes that they have control and choice in their life (Hammell, 2004). Advancements in research regarding motor learning theory provides further evidence for the crucial role that occupation plays in recovery from physical injury (Gutman & Biel, 2001). In a study on spinal cord injury, Hammell (2004) found that there was a negative correlation between mortality rates and life satisfaction. In fact, higher levels of social and vocational activities lead to a longer lifespan in the face of disability. Hammell addresses the notion of “biological disruption” in a critical discussion on the dimensions of daily occupations. In the absence of disability, it is easy to take for granted the norms and values that guide our existence. Hammell considers what would happen if an individual had to reassess every avenue of his/her life and suggests that when faced with such circumstances, this individual is often forced to re-evaluate occupational choices, life priorities and use of time, therefore changing the meaning of occupation. Occupations that were once a priority come second to the act of seeking enjoyment and sense of purpose in the little subtleties of life and taking the time for personal expression through occupation. For example, spending time with special people may be more meaningful than accomplishing the more mundane day to day activities (Hammell, 2004). In this regard, mental illness secondary to disability can be averted by having the opportunity to gain personal meaning in day to day occupations and in doing so change the meaning of disability as well. 22
Very little is known with respect to how persons with mental illness participate in daily occupations, but research to date suggests that they tend to live a more isolated life (Eklund, Hansson & Ahlqvist, 2004). Employment rates for this population are as low as 10-20% which may demonstrate this isolation (Eklund et al., 2004). A study by Eklund (2004) found that for persons with mental illness of any diagnoses, involvement in paid work leads to greater symptom improvement and less instances of hospitalization. It is interesting to consider that the majority of this population indicated that it was not the productive nature of work or the pay that made their occupations meaningful, but rather “participation”. The opportunity to engage in meaningful socialization with others outweighed any other benefits of working, in terms of fostering a sense of well -being and a positive state of mental health. Bejerholm & Eklund (2007) investigating the quality of life for persons with schizophrenia and found that a higher level of occupational engagement outside of the home was also associated with fewer psychiatric symptoms and wellbeing. Research has shown that health and well-being for working aged women is dependent entirely on occupational balance within everyday life dimensions, such as employment, domestic work, social life and recreation (Hakansson, Lissner, Bjorkelund & Sonn, 2009). Regardless of what measure was used to rate health, the ability to manage occupations that are associated with these dimensions was given highest priority in terms of defining good health and well-being. Higher levels of stress were associated with “life stressors” versus “work stressors” (Hakansson et al., 2009). This suggests that for woman of working age, gainful employment is important but balancing occupations related to domestic, social and recreational life is most meaningful to them and defines their sense of well-being and overall physical and mental health. According to Wicks (2006), people need to participate in purposeful and meaningful occupations to sustain health/well-being. A growing area of study for occupational scientists and occupational therapists is climate change and its potential impact on population health, especially for older adults living in the community (Pereira, 2009). Pereira (2009) argues that occupational deprivation often results from harsh climate changes such as droughts and water restrictions. The elderly population, which is already considered to be highly sensitive to social barriers, has also been found to be greatly affected by climate change (Periera, 2009). For example, many elderly adults find gardening around the home, walks in the community and visits with friends and family to be very meaningful occupations. However, climate change can impact their ability to participate due to the nature of these occupations. Isolation and the inability to engage in physical and social activities outside of the home can cause a plethora of “earth-related mental illnesses” for the elderly population (Albrecht et al., 2007, p.95; Wilcock, 2006). A study done by Blakeney and Marshall (2009) examined a community in the Mountains of Kentucky that experienced a case of ground water pollution. It found a distinct link between the availability of water, an essential natural resource, and the ability of people in the community to participate in necessary and meaningful human occupations. Activities of daily living, routines and activity demands were investigated during interviews with community members regarding the impact that the water crises had on their lives. They found that water pollution induced barriers in just about every avenue of day to day living. Every activity, from washing dishes, bathing and cooking to leisure activities such as boating, gardening or swimming, was impacted. Even opportunities for socialization outside of the home were reduced, as people described feeling embarrassment from not having clean clothes to wear. Community members experienced occupational alienation (discussed later in this report), as they no longer had control over their daily occupations due to the environmental barriers they were experiencing, which resulted in exhaustion and stress. The health of residents in this community was directly related to their inability to engage in valued daily occupations due to a naturally occurring environmental barrier. The World Health Organization (2001) declares that health is a state of complete physical, mental and social well-being. The 23
promotion of healthy human development is a core concept that underlies health promotion at the community level (Hancock, 2009), thus it is fitting that social well-being would be included in a definition of health. The history, natural and built settings, economic resources, institutions and individuals and communities are all factors that shape the essence of a community and therefore must be considered in order to appreciate how communities are organized and resources distributed (Raphael, 2002). Every community is different, so it follows that there is not a single universal model which can be applied to achieve a foundation of population health promotion (Hancock, 2009). The poverty that is being experienced by many Canadian communities is a direct result of increasing income disparities and the weakening of social safety nets and other social supports (Raphael, 2002). Individuals living in low-income households or in at-risk neighbourhoods, individuals with lower levels of education, and racialized individuals experience lower rates of health (Hancock, 2009). Poverty is experienced in a number of ways including poor diet, inadequate housing, unsanitary conditions, and lack of recreational places, safe neighbourhoods, employment opportunities and education. The stigma of poverty has negative effects on overall well-being, including physical and mental health (Reutter et al., 2009). Men and women who experience poverty or low income report lower levels of self-rated health and higher levels of distress (Orpana, Lemyre & Gravel, 2009). Low-income communities experience deprivation relating to access to recreational and leisure occupations. For many low-income individuals, these types of occupations are crucial for maintaining a sense of balance and well-being. A recent study showed that university educated individuals, married individuals and individuals with incomes above $60,000 were the most likely to participate in active leisure activities (Hurst, 2009). Stewart and colleagues (2008) examined participation in a range of social, recreational, volunteer, work and family occupations and found that people of higher income tend to participate in activities that promote a common experience and inclusion within the community. Although research suggests that finances are indeed a major barrier to participation for low-income individuals and families, it is important to consider other social factors that contribute to this disparity. For example, fear of neighbourhood crime is high in lowincome communities, especially for elderly individuals and youth. A study reported that 18% of urban residents that are fifteen years or older report feeling unsafe in their neighbourhood after dark (Fitzgerald, 2008). It is difficult to imagine how one could feel included in their community if they fear venturing outside of their homes. Poor health is indeed associated with a lack of community inclusion; about 64% of people who rate themselves as having poor mental health also identify with a weak sense of community belonging (Fitzgerald, 2008). Diers (2008) suggests that in order to change and improve the state of health of low-income communities there must be a strong and inclusive network of people behind the change. Therefore, regardless of what model may be used to foster health promotion, it is important that it focus on the values of the community, enablement, empowerment and equality (Raphael & Bryant, 2002). Occupational therapists stand by these notions and recognize that in order for any human to develop to their maximum capacity they must be supported at every level in society. Therefore, in considering how to improve health, enable individuals and communities and facilitate change, social policies must examine the links between occupational access and participation and the distribution of resources, power, and privilege and health. Impact of Inequality on Health Low-income, poverty, race, poor housing, unemployment and educational underachievement often put individuals and communities at risk for various health and mental health problems. This project examines health from the perspectives of individuals and community 24
and is premised on the following factors, which are outlined by the Ontario Healthy Communities Coalition (2010): • • • • physical, mental and social well-being; social, environmental and economic factors; self-determination and self-empowerment; and collaborative community initiatives in which diverse sectors of the community are willing to share their knowledge, expertise and perspectives in order to create a healthy community.
A Healthy Community process involves participation and involvement by all sectors of the community, as well as the creation of health policies that promote social prosperity and community health. In addition, the philosophy of the Ontario Healthy Communities Coalition is that a healthy community is premised on full and equitable access to resources and opportunities (economy; peace; food; water; shelter; income; safety; health care services; work and recreation; opportunities for learning and skill development), equity and social justice, as well as to supportive networks and communities. This research uses a “social determinants of health” approach to probe if and how social, economic, and political factors have the potential to compromise the health and well-being of Aboriginal and African Nova Scotian communities in North End, Halifax. Raphael (2007) identifies some of these social determinants as Aboriginal status; race; early life; education; employment and working conditions; food security; health services; income and income distribution; social exclusion; social safety net; unemployment; employment insecurity; and poor housing. A report by Access Alliance Multicultural Community Health Centre (2007) also identifies the following social determinants as compromising health and well-being: lack of access to services and transportation; lack of formal or informal child care; exposure to violence; criminalization and racial profiling; educational streaming; racial/cultural stereotyping; unequal access to information; and concentration in racially segregated neighbourhoods. Wilkins, Berthelot & Ng (2002) found that these social determinants produce a host of health and mental health problems, including accidents; anxiety; alcoholism; drug dependency; depression; suicide; and homicides. The underlying rationale of a “social determinants of health” approach is that healthy communities and neighbourhoods can be fostered if they are engaged and connected to surrounding communities and neighbourhoods and are socially, economically and politically viable and selfsustaining. This approach is also premised on the notion that the health of low-income and marginalized individuals can be optimized if feelings of social exclusion and alienation due to social and economic inequalities are reduced and eliminated. Until recently, frameworks in medicine and health research attributed racial disparities in illness and disease to biological, genetic, cultural or lifestyle choice differences between racial groups. However, it is now believed that an analysis of the social context of inequality is important for understanding why race and other social factors are such important predictors of health status. Health disparities between more and less-advantaged groups are often attributed to the racial, socio-economic and other inequalities that impact negatively on health, deter or prevent individuals from accessing health services and that result in the mistreatment of racialized groups by health professionals. While many patients may be unaware of the often subtle and seemingly benign institutional processes within healthcare that jeopardize their health, they are often acutely aware of how ideologies about race, socio-economic status, gender, religion, sexual orientation, language, disability and other social identities influence the treatment they receive from healthcare professionals, which are often expressed as misunderstandings, insensitivity, bias, disrespect and discrimination. It is also important to point out that mistreatment is also manifested in clinical care, including diagnosis, treatment and follow-up care. 25
In Canada, racialized, immigrant and refugee groups are most at risk for experiencing the negative health effects that result from persistent health disparities because race, socio-economic status, poverty, citizenship status and other social determinants expose them to various levels of inequalities that produce poor health outcomes, including those that arise out of historical, structural (e.g. laws, policies), institutional (e.g. education, health, etc.) and every day processes and events (e.g. relationships and interactions with others). Several Canadian studies show that the main determinants of health are not rooted in medical or behavioural factors, but, rather, in a host of social and economic barriers, such as race, immigrant and refugee status, poverty and neighbourhoods (Access Alliance Multicultural Community Health Centre, 2007; Etowa, Bernard, Oyinsan & Clow, 2007; Etowa, Wiens, Bernard & Clow, 2007; Kisely, Terashima & Langille, 2008; O’Mahony & Donnelly, 2007; Raphael, 2007; Tang, Oatley & Toner, 2007; Waldron, 2010 a; Waldron, 2010b; Waldron, 2008; Waldron, 2005; Waldron, 2003; Wilkins, Berthelot & Ng, 2002). Wilson, Elliott, Law, Eyles, Jerrett & Keller-Olaman (2004) investigated the association between perceptions of neighbourhoods to the self-assessed health of the residents of the neighbourhoods in Hamilton, Ontario. The authors wanted to compare both physical and social perceptions of the neighbourhoods and their association to three given health outcomes – self-assessed health status, chronic conditions and emotional distress. They found that individuals in neighbourhoods with lower socio-economic status reported poorer health and more emotional distress. Measures of socioeconomic status, age, and lifestyle were all associated with poor health outcomes. Physical environment seemed to be more of a focus than social concerns of an environment. Also, physical problems were significantly associated with chronic conditions; reports of physical likes were associated with both lower odds of reporting poor self assessed health status and lower odds of scoring above the General Health Questionnaire-20 cut-off point. For Aboriginals and African Canadians, various social determinants converged to impact on their physical and mental health, resulting in higher rates of HIV/AIDS, cancer, cardiovascular disease, depression, suicide and other health problems when compared to the general population. Individuals living in low-income households or in at-risk neighbourhoods, individuals with lower levels of education, and racially diverse individuals experience lower rates of health (Hancock, 2009). The Health of African Canadians in Canada & Nova Scotia Hierarchies of power and inequality structure the health experiences of African Nova Scotians and Aboriginals in unique ways. While African Nova Scotians residing in rural and remote regions experience similar cultural barriers accessing responsive health care services to those living in urban environments, their experiences are further compounded by geographic isolation. This makes it even more difficult to find culturally sensitive health professionals, programs and facilities available in close proximity to their community. These issues contribute to the higher incidents of heart disease, cancer, high blood pressure, diabetes and death among this community compared to white Nova Scotians (Saulnier, 2009). This community utilizes preventive health services less often, and when they fall ill, the health of their families and communities typically suffers as well. It is also important to consider how gender intersects with race to expose racialized women to a host of health and mental health problems. An understanding of health and illness for racialized women must acknowledge their history as a racialized group (slavery, genocide, relocation), the existence of gender inequalities that accord them secondary status in the social, legal, economic and political institutions of society (e.g. discrimination in employment, housing and society; unequal protection under the law) and their complex relationships to their own communities that simultaneously buffer them from the hard edge of discrimination and subject them to lingering internal problems due to a legacy of oppression that is inherent to racialized communities. Etowa, 26
Bernard, Oyinsan & Clow (2007) investigated health status, health care delivery, and the use of health services among African Nova Scotian women living in remote and rural regions of Nova Scotia. They found that these women are particularly vulnerable and more prone than White women to illnesses associated with social and economic deprivation, including heart disease and diabetes. In addition, racism, poverty, unemployment or under-employment, limited access to appropriate social, economic and health services, and unpaid care-giving roles were key determinants of poor health for these women. Thomas Barnard (2003) found that for African Nova Scotian women, the cumulative effect of systemic racism in their lives puts them at an increased risk for a host of chronic diseases and other health and mental health problems, including depression and suicide; fear; mistrust; despair; alienation; loss of control; damaged self-esteem; drug and alcohol abuse; violence; high stress and stress related diseases; short lifespan; poor pediatric care; hypertension; cardiovascular disease; high blood pressure; stroke; psychological stress; diabetes; lupus; and breast cancer. African Nova Scotians have a higher cancer mortality rate than the general population. Benton and Loppie (2001) attributed the higher cancer mortality rates in this population partly to systemic racism which operates within social institutions, including the health care system. A preference for herbal and natural remedies learned from African ancestors, unavailability of medical care until the late 1930's, the use of medical services in emergencies, a legacy of diseases contracted by early African settlers (tuberculosis, cancer, heart disease) and racial discrimination dating back to the enslavement of members of this community may also help to explain health disparities between African Nova Scotians and other populations. Evans, Butler, Etowa, Crawley, Rayson & Bell (2005) examined the ways in which gender, class, race, culture, and other social determinants impact the experience of African Canadians living with cancer by exploring the cultured and gendered dimensions of African Nova Scotians’ experiences of breast and prostate cancer. They conclude that there is a need for culturally appropriate and meaningful health interventions and that health care professionals need to consider how gender, class, and race intersect to shape the health experiences of African Nova Scotians. Walcott-Francis (2010) discusses recent statistics that indicate that HIV is at a crisis level in black communities in Canada. Black Canadians are over-represented in the new HIV infections and AIDS cases. The Public Health Agency of Canada (PHAC) reported that test reports from 1985 to 2007 indicate that the Black Canadians represented 10.3% of the total reported HIV cases in the country. And, while the virus is on the decline in the White population (down from 75.7% to 58.4%), it has been on the increase in Aboriginal and the Black populations. PHAC also found that Black Canadian women are over-represented among the persons living with the virus, representing 16.3% of all the reported cases in the country between 1985 and 2007. The Health of Aboriginals in Canada & Nova Scotia Aboriginal peoples, as a community, experience disparities in both health status and access to health services in comparison to non-Aboriginal peoples. Steenbeek, Tyndall, Rothenberg & Sheps (2006) found that the health status of Canadian Inuit people is lower than that of their ancestors. The westernization of the Inuit population has, in many ways, forced them to abandon their traditional beliefs, medical practices, and the valuable information and insights that have been handed down through generations. This disconnection has had a negative influence on their health practices, and has lead to widespread health problems and communicable diseases. Of particular importance is the way in which a disruption in the flow of information through generations has contributed to an increased risk for sexually transmitted infections (STI). Also contributing to the spread of STI in this community is the struggle to establish an Inuit identity. Through various mechanisms, (forced acculturation, residential schools, defilement of land) colonialism disrupted 27
socio-cultural activities and economic systems in Aboriginal communities. These systems were important for developing and maintaining social networks and connecting Aboriginal people to their land and culture. Colonialism also resulted in shifting patterns of health as the colonizers brought with them new diseases, and as traditional practices and beliefs were replaced by Western health practices. Such after-effects contribute to the health and social inequalities that are occurring across Canada’s Aboriginal population, resulting in decreased life expectancies, increased infant mortality and infectious diseases, and increased rates of non-communicable diseases, accidents, violence, and suicide (Richmond, 2007). Smith, Varcoe & Edwards (2005) argue that although residential schools no longer exist, the effects of outward colonialism still resonate and contribute to the health experience and socioeconomic status of many Aboriginals in Canada. Such effects are manifested in the systematic barriers that prevent Aboriginals from accessing appropriate healthcare. Reimer (2005) examines the role that gender plays in creating the barriers that Aboriginal women living with HIV/AIDS experience accessing health services. With respect to traditional Aboriginal wellness services, she found that a slightly higher percentage of women (40.6%) compared to men (34.6%) feel that their needs are not being met by traditional service providers. This is due to lack of knowledge about the existence and location of these services in their area and the lack of logistical support such as transportation to centres where such services are offered, or to home communities where familiar traditional wellness resources exist. In the case of primary medical services, women with HIV/AIDS visit hospital emergency centres at a significantly higher rate (67.6%) than do males living with HIV/AIDS (54.9%). Despite this, 40% of these women are dissatisfied with hospital emergency services, primarily because of the long wait times. These women’s needs are also not fully met at local health clinics because they believe that confidentiality and privacy were compromised, and because they did not receive knowledgeable care for specific HIV/AIDS health matters. In a study conducted by NAHO (2010), it was found that the incidence rate of breast cancer among Aboriginal people is on the rise. Compared to non-Aboriginal people, Aboriginal people are more likely to be diagnosed at a later stage of the disease, perhaps due to limited access to breast cancer screening and treatment services. In addition, the survival rate for breast cancer is significantly worse for First Nations women in Ontario compared to the non-Aboriginal population. Loppie & Wien (2007) found that while the adult Mi’kmaq population in Nova Scotia experienced similar health conditions as other Nova Scotians, such as arthritis, high blood pressure, back pain and allergies, they experience higher rates of diabetes – around 20 % of the adult population, compared to 6 per cent for Nova Scotians. This disparity is linked to obesity, nutrition and physical activity indicators. When gender is analyzed, findings indicate that less than half of Mi’kmaq males with diabetes are attending diabetes clinics, and of those who do not attend, 38 % choose not to do so. Mi’kmaq adults are also more likely to have been injured from events such as falling, tripping, sports and physical assault. Persons with disabilities account for 18 % of the Mi’kmaq population and require services such as home maintenance support, personal care and light housekeeping. The most significant barriers that this community faces are long waiting lists, issues related to poverty (such as lack of transportation and child care costs), and lack of coverage from the Non-insured Health Benefits Program.
V. Research Questions
The main research question in this project is: “What are the strategies for engaging low-income racialized communities in meaningful occupations?” The project also asks the following key research questions: • How do structural, institutional and everyday inequalities and inequities based on race, culture, low-income, poverty, socio-economic status, disability, religion/spirituality, gender, age and other social differences determine level of participation in meaningful occupations among lowincome Aboriginal and African Nova Scotian communities in North End, Halifax?; How do organizational practices, processes and policies limit, deter or prevent participation in meaningful occupations among members of these communities?; and How can community agencies reduce and/or eliminate the barriers preventing these community members from participating in meaningful occupations?
VI. Research Objectives
The main project objective in this project is: To identify how community agencies in the North End can engage low-income racialized communities in meaningful occupations. The project’s other objectives are: • • To examine how low-income racialized individuals and communities in the North End conceptualize meaningful occupations; To identify the personal, social and economic factors that may create barriers to accessing and participating in meaningful occupations among low-income racialized individuals and communities in the North End; and To examine how organizational structures, policies and service delivery within community agencies determine access to meaningful occupations among low-income racialized individuals and communities in the North End.
VII. Conceptual Models & Theories
The research presented here utilizes the following four main models/theories to articulate how various social identities shape access to, participation in and the experience of meaningful occupational participation among Aboriginal and African Nova Scotian communities in the North End of Halifax: • Canadian Model of Occupational Performance and Engagement (CMOP-E); 29
• • •
Model of Human Occupation (MOHO); Occupational Justice Theory; and Intersectional Analysis
Part One: Canadian Model of Occupational Performance & Engagement (CMOP-E)
This project uses the Canadian Model of Occupational Performance and Engagement (CMOP-E) (Townsend & Polatajko, 2007) to articulate the experiences of Aboriginal and African Nova Scotian communities in accessing and participating in meaningful occupations. The CMOP-E is a client-centred model of practice that proposes that health is determined by the interaction between the person, occupation and the environment. CMOP-E characterizes occupational performance as the carrying out of an occupation in the context of the interacting relationship between the person, occupation, and environment. The person is analyzed through their spiritual, affective, cognitive, and physical needs. Environment is understood in four main ways: physical (natural and man-made elements), cultural (race, religion, values and beliefs), social (an individual’s roles and people involved in his or her life) and institutional (political, economic and legal). The physical environment in the CMOP-E refers to the objects and spaces in a person’s surroundings. For example, a person who regularly walks to work may decide to drive or take a bus if the weather is cold or rainy. The environment in this situation has created a barrier to the person engaging in a meaningful occupation. By the same logic, one can imagine that a person is more likely to buy fresh vegetables if there is a grocery store in the immediate area, or engage in social activities when there is a large physical space that is easily accessible. The social environment refers to other individuals present in an individual’s environment, as well as their thoughts and attitudes. This social environment can have a significant impact on occupational participation. This is often exemplified by “peer pressure” situations in which a person engages in an activity or occupation that has little or no meaning to them simply to please others present in the environment. It is also important to consider that from the time a person is born they are constantly interacting with others in their environment. The outcomes of these interactions are internalized by the individual and help shape their values and the activities they associate with certain roles. This will undoubtedly further impact the occupations that a person finds meaningful and chooses to participate in. The cultural environment refers to the prominent cultural identity that is present in the person’s environment. Most cultures have certain events, celebrations or holidays which are steeped in tradition and can significantly impact a person’s occupations. The impact that a cultural environment may have on the occupations an individual participates in will be directly influenced by how much the person identifies with and embraces the culture. It is important to mention that the culture a person identifies most strongly with may not be the prominent culture in their environment, which may raise many additional issues. The institutional environment refers to the policies, laws and governing procedures that are present in the person’s environment. These policies and laws may have a direct impact on the occupations individuals engage in. For example, in Canada, policies govern how much money a person on social assistance can make before having this assistance revoked. This may discourage the person from even attempting to access paid employment although it may be very meaningful to them. However, this same policy may facilitate participation in volunteer type employment which may be equally meaningful to the individual. Understanding the impact of external forces is vital when considering both meaningful occupations and occupational participation. In order for a person to successfully participate in an occupation they must first have 30
access. Conversely, a person may have access to, and participate in a particular occupation although it may not have meaning to them. As previously discussed, meaning is assigned by the individual and what may be meaningful to one may be meaningless to another. The CMOP-E aids in our understanding of what makes the practice of an occupational therapist different from the practice of other healthcare professionals. The CMOP-E focuses on the dysfunction in occupation, rather than skill performance (Boniface et al., 2008). Therefore, the CMOP-E can be used to help define the role of an occupational therapist in clinical settings (Warren, 2002). Clarke (2003) discusses the strengths and limitations of using the CMOP-E for clientele in a forensic rehabilitation hospital. The CMOP-E offered four main advantages for this clientele compared to other occupational therapy models of practice – client centeredness, an occupational performance focus, a correlated assessment and evaluation tool, and its ease of use. A significant weakness of the CMOP-E that was noted by Clarke (2003) was its inability to explain the affect of occupation on health and well-being, a feature that exists in the Model of Human Occupation.
Part Two: Model of Human Occupation (MOHO)
This project also uses the Model of Human Occupation (MOHO) to articulate how opportunities to participate in meaningful occupations for Aboriginal and African Nova Scotian communities are determined by the social environment. This Model proves useful in exploring what makes occupation meaningful. The MOHO works to further contextualize the CMOP-E by focusing more closely on occupational participation. The MOHO explains occupational participation as the engagement in an occupation (self-care, leisure, or productivity) for one’s wellbeing (Townsend & Polatajko, 2007). It examines how social environments determine available opportunities to participate in occupations, as well as how expectations affect individuals’ engagement in particular occupations. According to this Model, an individual’s identity is formed through the relationship between four subsystems: 1) the motivation for occupation (volition); 2) internalized patterns of action (habituation); 3) skills or the necessary actions for occupational performance, including communication and interaction skills; motor skills; and process skills (performance); and 4) physical and social dimensions, including physical space and interactions with social groups (environment). Volition refers to the choosing of an occupation based on values, interests, and personal causation, which is understood as one’s sense of competence and effectiveness. It pertains to the underlying motive for occupations, the innate realization that there is some need that must be met and individuals’ ability to take actions to meet this need. Additionally, volition refers to a person’s thoughts and feelings about doing certain things. It is an ongoing process which changes over time as people choose occupations, participate in them and interpret their performance. Habituation describes the consistency of behaviours in relation to specific occupations and is based on habits and internalized roles. It refers to the somewhat automatic patterns of behaviour people exhibit in response to familiar physical, social and temporal surroundings. As we interact with these surroundings we internalize patterns of actions and attitudes in response. For example, when people identify as parents they tend to participate in occupations that reflect this status. Performance includes all of the physical and mental skills and competencies required to perform occupations, as well the subjective experience of those skills and competencies. The MOHO describes the component of performance capacity as the ability to do things dependent on physical and mental systems. This component also incorporates the impact of subjective experiences which is the person’s own interpretation of the outcome of an event. Finally, environment is characterized by its 31
physical and social dimensions. Physical dimensions include physical spaces and the built environment, while social dimensions include interactions with social groups, as well as available occupations that are available in society for various communities (Kielhofner, 2008; Kielhofner, Fogg, Braveman, Forsyth, Kramer & Duncan, 2009; Stamm et al., 2006). The MOHO stresses that it is a combination of the circumstances within the environment and within the person that influences the motivation, behaviours and the occupational performance of a person (Lee, 2010). Lee, Taylor, Kielhofner, and Fisher (2008) conducted a national survey in the United States of occupational therapists who used the MOHO theory in their practice. Therapists reported that the ideas in the MOHO were effective in practice and intervention planning. It is considered to be a valuable model because it is client-centered, occupation-focused and supports a holistic and evidence-based practice. The MOHO is now the most widely used occupation-based model in the world (Lee & Kielhofner, 2010). Although the CMOP-E is a separate entity from the MOHO, the two are in essence describing slightly different aspects of the same issue - meaningful occupations. When considered in concert, these models provide a clear definition of meaningful occupation and also provide a useful framework for studying the various factors that influence occupational participation. The MOHO provides an excellent overview of how a person’s identity and intrinsic factors shape what activities and occupations they find meaningful and stresses that these intrinsic factors interact with the environment to create motivation and occupational performance. The CMOP-E, on the other hand, stresses the interacting relationship between the characteristics of the person, the environment and the occupation and goes further by defining these characteristics. Through the CMOP-E we begin to gain a comprehension of the complex interacting systems that are involved in choosing occupations and assigning meaning to them. One of the main links between the CMOP-E and MOHO lies in their focus on the environment, particularly how it determines opportunities to participate in occupations. While the MOHO states that human occupation is an interaction between the person and the environment, it simply identifies the environment as spaces and objects. However, the CMOP-E considers the environment in a broader context which is helpful in further shaping our understanding of the many external influences impacting occupational participation. It is always important to consider these external influences as we consider why individuals choose to participate in certain occupations. This project uses Occupational Justice Theory to further contextualize the role that the environment plays in affording or denying individuals and communities opportunities to participate in occupations.
Part Three: Occupational Justice Theory
The research presented here critically interrogates the principles and assumptions underpinning Occupational Justice Theory in order to build on and broaden its applicability to marginalized communities, such as low-income racialized communities. Occupational Justice Theory addresses how to enable participation in the occupations of daily life regardless of the inequities in society that limit individuals and impact on their health and well-being. The Theory was developed by occupational therapists Anne Wilcock and Liz Townsend to question and address issues of justice that are of concern to occupational therapists, particularly issues of social inequalities and social justice with respect to everyday practices of justice that enables empowerment through occupation (Braveman & Bass-Haugen, 2009; Brown, 2008; Christiansen & Townsend, 2009; Townsend & Wilcock, 2004; Wilcock & Townsend, 2000). According to Braveman & Bass-Haugen (2009, p. 9), occupational justice is defined as, “equitable opportunity and resources to enable people’s engagement in meaningful occupations”. It is based on the notion that humans are inherently 32
occupational beings that need to be occupied in order to have a meaningful life and that they have rights, responsibilities and liberties to participate in occupations of their choice. Occupational Justice Theory is premised on three main factors: • • • structural factors; contextual factors; and occupational outcomes
Structural factors include issues that are external to the individual that lead to occupational injustice, such as the economy; regional policies; health and community supports; income supports; housing; education; employment; transportation; and other social determinants. Contextual factors include individual, group or community characteristics that impact the lives of individuals and communities. In this research, the focus will be on how community characteristics such as race, ethnicity, gender, socio-economic status, disability shape the experiences of Aboriginal and African Nova Scotian communities. The community characteristics that this research examines will also include the spatial contexts in which these communities reside, particularly how health access and health outcomes are linked to residence in a low-income and under-resourced neighbourhood. Finally, occupational outcomes refer to the outcomes of occupational justice or injustice relating to the achievement of occupational rights. It looks at the link between the creation of illness in individuals, families and communities and injustices relating to the denial of individuals’ right to benefit from social inclusion and fair privileges for participation in all aspects of society. Occupational Justice Theory reflects the definition of health outlined in the Ottawa Charter for Health Promotion (World Health Organization Regional Office for Europe, 1986), which describes health as the ability and opportunity to live, work and play in safe, supportive communities. The promotion of health through occupations is premised on the notion that healthy individuals and communities can be fostered if they are physically active and engaged in meaningful activities that make them feel useful (Christiansen & Townsend, 2009). According to Occupational Justice Theory, physical and psychological well-being is impacted by lifestyle, as well as the choices one has to participate in meaningful occupations (Townsend & Wilcock, 2004 b). However, while health can be promoted through occupation, occupation does not always promote health, particularly occupations that are perceived by individuals as meaningless, degrading and debilitating. According to the Theory, empowerment is experienced when individuals participate in occupations that are enriching and meaningful and have opportunities to share in the social and economic advantages of a given society. An occupationally just society is one that is diverse, inclusive and equitable. Consequently, Occupational Justice Theory is concerned with how to enable occupational potential by improving conditions, developing enabling policies, laws and economic practices and supporting disempowered and occupationally deprived individuals and communities in developing their occupational potential. Occupational Injustice Occupational injustice refers to the factors that limit individuals’ occupational participation, as well as the sense of disempowerment that individuals experience participating in occupations. Townsend & Wilcock (2004 b) identify various examples of occupational injustice, including right to experience occupation as meaningful and enriching; right to develop through participation in occupation for health and social inclusion; right to exert individual or population autonomy through choice in occupation; and right to benefit from fair privileges for diverse participation in 33
occupations. They also identified several occupational injustice outcomes that can impact negatively on health and well-being, including occupational marginalization, deprivation, alienation, apartheid and imbalance. Occupational marginalization operates invisibly to exclude individuals from participating in occupations such as employment and leisure, often as a result of normative standards and expectations about how, when and where people should participate. Occupational deprivation is said to occur when external factors deprive individuals of opportunities and resources to participate in meaningful occupations. Christiansen & Townsend (2004, p. 222) describe it as “a state of prolonged preclusion from engagement in occupations of necessity and/or meaning due to factors which stand outside of the control of the individual”. Occupational deprivation recognizes that individuals are often not provided with equitable opportunities to participate in occupations of their choosing or that have meaning due to social, economic, environmental, geographic, historic, cultural or political factors. Examples of occupational deprivation include unemployment and incarceration. Occupational alienation refers to the state of meaninglessness and purposelessness that individuals experience engaging in daily occupations. It is conceptualized as a social condition of injustice and not a psychological state. In addition, occupational alienation examines individuals’ prolonged experiences of disconnectedness, isolation, emptiness or lack of positive identity. Examples of occupational alienation include a community’s experience of being physically removed from their own cultural occupations (e.g. slavery, refugee confinement, institutionalized people) and, in the case of the communities that are the focus of this research project, the removal by the residential school system of Aboriginal children from their homes for placement in Christian-run schools and the eviction of black families from Africville, a small unincorporated community located on the southern shore of Bedford Basin in Halifax. Occupational apartheid considers how segregation based on race, gender, disability and other social identities restrict individuals and communities from access to and participation in meaningful occupations. Finally, occupational imbalance refers to equal opportunities and privileges to share in the labour and benefits of economic production, including the right to equal privileges and pay for equal work. It also characterizes how individuals allocate their time to occupations, resulting in a variation between selfcare, work and leisure occupations. Three aspects to occupational imbalance have been identified: un-occupied, under-occupied and over-occupied. Occupational Justice Theory also addresses the occupational experiences of communities that flounder and fail to flourish due to the unavailability of occupations, the lack of experiences of shared occupation and the limitations imposed by the built environment. Such communities are said to lack experiences of interdependence, shared history and opportunities for community members to develop a sense of identity within a supportive, interconnected and respectful communal environment. In addition, these communities often lack occupations that enable community members to express a diversity of routines, rules, artistry, magic, religion and science. Consequently, floundering communities are those that lack supportive organization and structures and limit and deprive individuals from participating in occupations. Application of CMOP-E, MOHO & Occupational Justice Theory The research project presented here uses the CMOP-E, the MOHO and Occupational Justice Theory to contextualize the experiences of Aboriginal and African Nova Scotian communities residing in the North End in several ways. It uses these models/theories to examine how access to and participation in meaningful occupations in the North End are shaped by four environments: 34
• • • •
The built or physical environment of the North End; The cultural environment (e.g. inequalities due to race, gender, social class, age and other social identities); The social environment of individuals that includes their family roles and social interactions with others; and The institutional environment, which includes their interactions and relationships with political, economic and legal systems
Environment includes the home/family, daycare, school, workplace, recreation, chronic care-settings, neighbourhood and community, region, society and nation/state. Occupational Justice Theory, in particular, is useful for highlighting how hierarchies and inequalities of race, social class, socio-economic status, gender, sexual orientation, age, disability and other social identities influence level of access to and exclusion from meaningful occupations for racialized and low-income “settings” or environments, such as the North End. All of the models and theories, however, provide insight into how health is influenced by the “settings” or environments in which we live, learn, work and play. They are particularly useful for probing how the health of individuals and communities in low-income environments is influenced by access to meaningful occupations. Health is understood as the outcome of individual, community and societal interactions with the biophysical, socio-cultural and political-economic environments.
Part Four: Intersectional Analysis
While CMOP-E, MOHO and Occupational Justice Theory provide the framework for the project, an Intersectional Analysis will be used to contextualize how access to and participation in meaningful occupations among racialized, low-income communities in the North End are shaped by the intersections and relationships between race, social class, socio-economic status, education gender, sexual orientation, age and disability. For the purposes of this research project, an Intersectional Analysis is crucial for examining how race, low-income, poverty and other social factors intertwine and are expressed in disparate chances for health and well-being. An Intersectional Analysis recognizes that individuals hold multiple identities simultaneously and that these identities privilege them in some circumstances and put them at a disadvantage in others. It also demonstrates how various structures and processes within societies stratified by socially constructed markers of difference (race, gender, and class etc.) impact on social relations and human interaction and how individuals and communities are positioned differently within hierarchies of power. Moreover, an Intersectional Analysis seeks to reveal the processes through which inequalities are produced and reproduced within institutional structures, and questions the power, privilege, and dominance that result from unequal relations between people and between people and institutions. Salazar (2005) argues that a focus on only one identity (e.g. race or gender) is inadequate for describing the experiences of marginalized communities, including racialized communities. Rather, understanding the complex experiences of individuals and communities requires attendance to the multiple and overlapping identities these individuals hold simultaneously. For example, an individual may be a member of the dominant or majority group with regard to several identities (e.g., White, middle class, male), and simultaneously hold membership in a marginalized group with regard to one or more identities (e.g., gay, with a disability). The concepts of simultaneity and salience are important for understanding Intersectional Analysis. Black feminists (Collins, 1993; King, 1988) argue that race, gender, sexual orientation and 35
other social identities cannot be separated since they function interdependently and accompany an individual into every interaction or experience. The notion of salience posits that although multiple identities are always present for individuals, they are not all salient or relevant in every situation. The importance of any one particular identity in explaining an individual’s experiences or circumstances will vary depending on the particular aspect of that individual’s life under consideration. According to Gazso and Waldron (2009a; 2009b), challenging monolithic conceptions of communities requires an understanding of how multiple social identities (race, ethnicity, gender, disability, age etc.) operate in and through one another to produce diverse experiences. Such an analysis appreciates the complex relationality of these multiple identities that frame individuals’ social, economic and political lives. Moreover, individual/personal factors (e.g., racial/ethnic identity, level of education, age) and institutional/structural factors (e.g., educational and labour market opportunities, availability of health and child care) are assumed to intersect, interact and converge in multidirectional and fluid ever-changing relationships to produce diverse experiences for individuals and communities. In addition, an Intersectional Analysis requires attendance to the historical, material and structural contexts and conditions that produce societal inequality and the meanings assigned to it, as well as an interrogation of white privilege and power, and their accompanying ideological rationales for dominance. For example, in discussing women’s poverty in developing nations, Mohanty (1991) demonstrates how an Intersectional Analysis can be used to eschew conventional Western and positivistic notions of poverty as a stable, unified concept (e.g., one is poor if one's income falls below a low income cut off) and women who are poor as a homogeneous group. In doing so, it understands poverty as being discursively produced and as an experience that is produced within and arises out of the unique and specific life experiences of specific groups of women within the context of historical, structural, institutional and personal processes and events. Following Few (2007, p. 453), this research uses an Intersectional Analysis to challenge monolithic, stable and uniform conceptualizations of Aboriginal and African Nova Scotian communities in the North End. From this analysis, the objective is to more critically consider and engage in a deeper probing of when, where, and how multiple identities converge to produce specific experiences for specific individuals and communities in different moments and contexts. Consequently, the project offers an alternative to biomedical frameworks that tend to homogenize difference or complexity by separating race from socio-economic status and gender as discrete, rather than mutually constitutive concepts. It also challenges biomedical research paradigms that present race, gender and other social identities merely as characteristics of individuals rather than as social relations shaped by hierarchies of power and that, consequently, disconnect those social identities from the historical, social and political processes from which they emerge and shape individual and community experiences.
This project utilized qualitative approaches to data collection and analysis because they allow for a complex articulation of the intricacies of the human experience and validate knowledge that emerges from subjective, personal, emotional, experiential, and intuitive frames of reference, all of which are the focus of this project. The qualitative approach that was used in this project was naturalistic inquiry. The fundamental principle of all naturalistic designs is that phenomena occur or are embedded in a context, natural setting or field. This research was embedded in the experiences of racialized, low-income communities in Halifax. Fieldwork is also an aspect of naturalistic inquiry. It involves the researcher entering an identified setting to experience and 36
understand the setting without artificially altering or manipulating the conditions, which was the case with this research. Naturalistic inquiry also focuses on observing and understanding so that theory may be described, explained and generated. This research utilized a narrative design to illuminate the voices, stories and experiences of North End community members. Narrative design yields a contextually embedded text that can be subjected to multiple interpretations and discursive analysis. The methods to obtain narrative data are diverse and include interviewing, which was the data collection method used in this research. Interviews are, perhaps, the most effective means by which to hear the voices, stories and experiences of marginalized participants. Limitations of the Study The main challenge in this research related to the recruitment of LGBTQ community members in the North End who self-identified as belonging to that community. Although the study does include two participants who identified as gay and transgendered, the project would have been strengthened by the inclusion of a greater number of participants from that community. In addition, the project would have been strengthened by the inclusion of more members of the disabled community.
Part One: Sample & Recruitment
Sample Recruitment of the sample and data collection occurred simultaneously between July and October, 2009. The sample consists of 20 participants, including: 16 individuals from Aboriginal and African Nova Scotian communities residing in the North End and four (4) community agencies in the North End. These agencies included ARK, North End Community Health Center, Cornwallis Street Baptist Church and Stepping Stone. Profile of 16 Community Members: The sample of community members included: four (4) Aboriginal women; two (2) Aboriginal men; three (3) multiracial individuals (two men; one transgendered disabled individual); four (4) African Nova Scotian women (including one disabled woman); and three (3) African Nova Scotian men (including one gay man): • • • • • • • • • • Aboriginal woman, 23 years old Aboriginal woman, 25 years old Aboriginal woman, 21 years old Aboriginal woman, 31 years old Aboriginal man, 43 years old Aboriginal man, 56 years old Multiracial transgendered individual (Aboriginal, Black and White), 45 year old, with a physical disability Multiracial man (White, Black and Indian), 78 years old Multiracial man (Black and Aboriginal), 50 years old African Nova Scotian woman, 57 years old 37
• • • • • •
African Nova Scotian woman, 23 years old, with a neurobehavioural developmental disorder African Nova Scotian woman, 71 years old, born in Halifax African Nova Scotian woman, 81 years old African Nova Scotian man, 44 years old, gay African Nova Scotian man, 46 years old African Nova Scotian man, 57 years old
Profile of 4 Community Agencies: North End Community Health Center, the project partner on this research project, provides primary health care for individuals and families. The Center serves individuals who are living on the margins who are homeless, insecurely housed and living in poverty. Stepping Stone is the only organization in the Maritimes that deals specifically with street life and sex work from a harm reduction model. It is a one-stop shop for access to services such as: one-onone peer counselling; workshops on health and legal issues; recreational and personal growth activities; and computer access and educational opportunities. Cornwallis Street Baptist Church, originally known as the African Baptist Church, was organized in 1832. It was founded by the Reverend Richard Preston, the son of a slave. The Church offers a variety of ministries, including a teen girls group, a Family Learning Initiative, a Positive Parenting workshop, a youth ministry, and an opportunity to express worship through dance, along with its long-standing ministries of music and men and women's lay groups. ARK is a drop-in center that offers a safe place to call home for street-involved and homeless youth between the ages of 16-24. It offers individual support with follow up during the week, assistance accessing emergency shelter and finding long-term housing, support through the court system and correctional facilities and assistance with emergency travel (bus tickets). Recruitment Sampling and recruitment were conducted in two phases. An initial phase of purposive sampling was used to recruit participants from the community and from community agencies. Purposive sampling starts with a purpose in mind and the sample is thus selected to include people of interest and exclude those who do not suit the purpose. In other words, it is used to access a particular subset of people. This technique was used to recruit community members who selfidentified as African Nova Scotian and Aboriginal individuals residing in the North End. Purposive sampling was used to recruit these participants in three main ways: • • • circulating a recruitment flyer by email to community agencies; approaching individuals who were attending programs run by community agencies; and contacting agencies and colleagues to request referrals to suitable potential participants from these communities.
In this phase, purposive sampling was also used to recruit managers/programmers at community agencies who provide services to members of these communities. These individuals were recruited in two main ways: • • sending the recruitment letter through email and following up with a phone call to provide more information on the project.
In the second sampling and recruitment phase, snowball sampling was used, which is where existing participants recruit future participants from among their acquaintances. Thus the sample group appears to grow like a rolling snowball.
Part Two: Data Collection
Interviews were used to collect information from participants. Interviews and preliminary analysis occurred simultaneously in order to allow for continual adjustments to interview guides and the recruitment of participants. Semi-structured interview guides were developed to collect interview data because they allow for some flexibility in wording during the interview process. Two different semi-structured interview guides were used for the two groups of participants: community members and community agencies (please see Appendix A and Appendix B). In general, the research questions and objectives developed for this research were used as guides to flesh out the project’s research questions (outlined earlier) for both interview guides. The interview guide developed for community members asked questions about the following issues: • • • • experiences participating in various “meaningful occupations”, including employment, leisure, recreation, volunteerism, healthcare, spirituality and education etc; challenges accessing these occupations in the North End due to race, culture, poverty, citizenship status, disability etc.; the impact of these challenges on their emotional, spiritual, psychological and physical health and well-being; and suggestions about how community agencies and health agencies could provide more opportunities for these communities to access and participate in meaningful occupations in the North End.
The interview guide developed for community agencies posed questions about the following issues: • • • the agency’s history serving North End community members; challenges engaging these communities in “meaningful occupations”; and suggestions on new meaningful community activities that could engage these communities.
Part Three: Data Analysis
Data analysis was conducted using NVivo qualitative software. NVivo is a qualitative data analysis (QDA) computer software package produced by QSR International. It has been designed 39
for qualitative researchers working with very rich text-based and/or multimedia information, where deep levels of analysis on small or large volumes of data are required. NVivo is intended to help users organize and analyze non-numerical or unstructured data. The software allows users to classify, sort and arrange information; examine relationships in the data; and combine analysis with linking, shaping, searching and modeling. The researcher or analyst can test theories, identify trends and cross-examine information in a multitude of ways using its search engine and query functions. They can also make observations in the software and build a body of evidence to support their case or project. The following steps were followed to analyze the data using NVivo: 1/Interview transcripts were reviewed to get a general sense of main themes: • • • Main themes of each participant’s responses were noted; Emerging themes were coded according to broad categories; Initial free nodes were based on social determinants of health framework (e.g. culture and ethnicity; income and finances; education and literacy; children; youth; community; health and health promotion etc.); Initial coded passages were used to create more free nodes based on the project description; Transcripts were re-read to populate new nodes; A set of tree nodes were created based on initial reading; The new tree nodes were sorted according to themes; Child nodes were added to the richest and most relevant nodes (barriers to engagement; community; meaning of and from involvement; strategies for outreach); and Overlapping nodes were condensed (e.g. coping skills into health, exclusion into community)
• • • • • •
2/Transcripts were reviewed and coded again according to new coding structure: • New child nodes were created again when necessary.
3/Coded passages were reviewed several times and transferred into more appropriate categories, and the nodes were then revised. 4/Coding and nodes were refined further (iterative process) and transcripts were reviewed several times. 5/Participants’ attributes were classified according to several dimensions (age; gender; race; culture; children; marital status; and other statistical information) in order to allow for some analysis by assigned attribute. The main themes that arose in the data and that were categorized in the analysis using NVivo include the following: • • • • conceptualizations of community; conceptualizations of meaningful occupations; barriers engaging low-income, racialized community members in meaningful occupations; community outreach; 40
• • • • • • • • • •
power, inequality and discrimination; physical environment; safety and crime; employment and social assistance; inclusion and accommodation; parenting and childcare; family and social support networks; schooling and education; health and mental health; and coping
The findings demonstrate an understanding of the complex ways in which some Aboriginal and African Nova Scotian participants residing in the North End conceptualize their connections to and relationships with community and community agencies, as well as their accounts of their experiences accessing meaningful occupations. Six main interrelated themes were identified in the data: • • • • • • conceptualizations of and participation in meaningful occupations; barriers to community engagement; strategies for engaging communities; building a sense of community; health and coping; and health and mental health promotion
Conceptualizations of & Participation in Meaningful Occupations Participants discussed four main aspects of meaningful community initiatives: • • • • making a difference; personal growth; supportive relationships; and a sense of belonging
Making a Difference Participants discussed the importance of making a difference in their community by becoming an advocate and voice for their own community as well as for the broader community. Some participants stated that they often find meaning through opportunities that enable them to make decisions on behalf of the community about the development and implementation of community programs and other initiatives. The representative from ARK observed that her clients often take advantage of opportunities to share their talents with others:
“....An opportunity to share from their experience in some way or also sharing their skill, like doing the silk screening studio, you know it’s not about their experiences as homeless youth, that’s about their experience as an artist, so opportunities like that . . . many of our folks love animals so there has been opportunities to take care of another person’s talk and walk, do a walking service. They also are very compassionate and interested in helping others, so one guy had started an odd jobs business and did services for other people, yeah so something that somehow is meaningful out of their life.” (ARK) One participant stated that he finds meaning in sharing his experiences with others: “Cause I think of.....I’ve seen a little bit of life..I’ve had to get through a lot..I’ve experienced a lot. I’ve had some experiences. I’ve had to learn from them, I’ve had to overcome a lot of things, I still have to overcome a lot of things. I still have a lot to learn. But the things I learn perhaps these are things I can help other people with, from benefitting from my knowledge. The reason I’m going to school, same thing, a good friend of mine that I went to school with here, committed suicide and . . because he didn’t have someone to help him deal with his problems and hopefully when I get through school that’s when I can start helping people to help the next generation. There are children here that are committing suicide”. (Aboriginal, 43 year old man) Personal Growth Participants also found meaning in activities that enabled them to challenge themselves, learn and develop new skills and boost their confidence. They observed that their own personal growth often involves encouraging the personal growth of others by providing opportunities for others to share and express their talents in a safe and positive environment. As Reverend Rhonda Britton at Cornwallis Street Baptist Church noted, providing opportunities for individuals to grow through creative expression can provide a sense of meaning: “There is opportunity. They come because they have a chance to exercise particular gifts that they may have. So, for example we encourage our kids, our teenagers, they have . . .we have a girl here she sings beautifully, she’s not in the choir, but I often ask her if she will just sing a solo or something because she has a beautiful voice and I want to encourage it. We have a liturgical dance troupe that’s starting now because I like to give our kids an opportunity to be expressive in whatever way they do, they are often allowed to do little hip-hop things or some kind of a little skit, so I think it’s a place where if I don’t have anywhere else to go, or anywhere else where I can express my gifts, I can do it in church, all I have to do is ask the pastor and she’ll say yes because I love to see kids do stuff. And....and I think that it’s also a place where people. . . you mentioned the spiritual aspect, yeah that’s it but they want to grow, they want to see how that’s connected to the rest of their lives so it kind of gives them a fuller life, a full life experience, it’s kind of like it’s not just in a compartment over here but if I study something on Sunday or Wednesday that can help me on Monday, at my job or whatever I’m involved with then it’s worth it. And so when I do a series, a teaching series on something in particular, people are like really 42
interested, it’s kind of like. . .cause now things, you deal with a topic for a long time and things kind of start to click together.”(Cornwallis Street Baptist Church) One participant noted that opportunities that enable community members to challenge themselves and develop new skills are often quite meaningful: “I’m presently about to start a workshop…..that’s part of the traditional methods as part of the healing programs. The program centered basically on spiritual healing through creative expression, it’s a big part of what the programs are and the boat building will be same thing, maybe a bit more of a challenging workshop for the people within the program to allow them to test their abilities, challenge themselves, and at the end of it hopefully, they will have seen it through to the and they’ve accomplished something difficult they can get a sense of accomplishment, self-esteem and . . .the train of thinking, I’m thinking small accomplishments lead to bigger accomplishments, that’s where I’m going with this. This is a...perhaps these are lessons they can apply in their daily lives, allow them to challenge some of their beliefs, feel confident in accepting new challenges, going outside their comfort zone, trying new things and feel that they are capable of accomplishing much more in their life.” (Aboriginal, 43 year old man) Supportive Relationships Community programs often provide meaningful opportunities for community members to build supportive relationships with one another because they bring together individuals with shared interests and experiences, consequently reducing feelings of isolation and loneliness. Community role models that care about helping others in their time of need are particularly important for building meaningful relationships and for encouraging individuals to share their feelings about the challenges they face in their lives. For example, the representative from the North End Community Health Center observed that programs that encourage team building and supportive relationships are empowering and meaningful: “The second thing that’s meaningful is if we’re talking about physical activity, that’s how I came with the idea of the walking program. Well here we are with all kinds of...we’re in the inner city, the community is beautiful, there’s lots to see so why not have maps developed of community routes right here. And get people out ‘cause one of the things I found people talked about is they didn’t like to do things on their own. They didn’t feel comfortable going out walking in the community by themselves or do a physical activity by themselves so that’s where the idea came with the group. So, having people walk together I found that people found that very meaningful to them because they got to speak to their neighbours, they got to check in once a week with what’s going on in the community and they got to walk in solidarity as a team and it really built a feeling of family in the. . it’s been six years that we’ve been together now and there’s almost forty members that walk all year long through the winter and they will not stay home even if I call to say that it’s cancelled. They don’t want to stay home.....and they like the food and they miss their buddies. So it’s gotten. . it’s meaningful for them to connect so that whole....I just see this whole.... what I’ve gotten in the community is looking at the value of working with inter43
connectedness because everything is connected.”(North End Community Health Center) According to the representative from Stepping Stone, supportive relationships are based on a desire to look out for others: “Yeah, my favourite part about working here is when someone grabs you on the street and gives you a hug and says I don’t know what I’d do if you guys weren’t around and all you say is hey how’s your night going. People just want an outlet to know that someone actually likes them for who they are, that’s the best part about working at Stepping Stone. All of our . . as a staff and as a Board and as other sex workers too that come through this door completely accept one another when we walk through that door. It’s really funny to watch two women who could be having a fist fight a block down the street, two minutes later both of them walk through the door and change their tune cause they know that the fist fight happened on the street but while they’re in Stepping Stone they’re going to be friends and that’s o.k. Someone stole from someone the night before they don’t even talk about it, they don’t even worry about it. It’s really interesting. The amount of time….like when people getting incarcerated, the amount of cards that we get from someone saying oh I was just thinking about you guys and I’m so glad that you’re there and I can call from inside and I know that you guys are still there. That kind of stuff, it’s really impressive and people I think sometimes forget how big a heart sex workers really have and as one of the staff people I’m able to see that because they show it to us. It’s really quite amazing the amount of love and support that they give each other when they’re here and that they get from us too. Like the amount of times I get hugged on the street when I hand out somebody some condoms, hey and I get a big hug. It’s great, I think that creating a space where people have access to a community is so important. Back twenty years ago sex workers definitely had a community and they looked out for each other and they watched each other, and they all knew each other, and it’s still like that in a lot of places but for socioeconomic reasons, things have become a lot different in Halifax and so you know Halifax has become a lot poorer and it causes a huge division in people but for some reason when they walk though that door they will put all that stuff aside”. (Stepping Stone). In addition, programs that enable community members to share their cultural heritage with others are also important for developing supportive relationships because they highlight the positive aspects of one’s cultural community and encourages a sense of connectedness. As one participant stated: I just started working about a month ago, so my job is to develop cultural aspects for society, like the way that we used to live, the different ceremonies, songs. . .mostly the sweat lodge, different things like I find that people that pray together, stick together. . we do a lot of it at home so you just do the same thing here only on a bigger scale. Same with the prisons. We just build a brotherhood or a sisterhood in here, it’s basically the same idea. You want to develop a community where everybody connects, like you know. . . I find you’re full of energy, you’re smiling, trying to have a good attitude and everybody sort of gets. . . you get a sense, well especially for 44
Native people like a lot of us our culture was taken away so we have to get that back so that’s what. . that’s basically my job. I do it anyway but I just happen to be getting paid for it.” (Aboriginal, 56 year old man) Sense of Belonging As one participant observed, belonging to a community was important to many community members:
“North End period. We always, no matter what, we’re always tight like a family.
When someone knows you’re there they just know you, they text you when there’s something going on, we do like there’s community - down there and we all went to that, we all pull together especially for the kids, I don’t know if they’ve heard about them before but we all just stick together, all go on trips together, whatever, we’re just tight, I don’t know I can’t explain it, like a family.” (African Nova Scotian, 46 year old man)
Community belonging is established through membership in a racial or cultural group, according to one participant: “Native and the North End, non-Native….this is where…my community is the Native community, the center of that is at the Mi’kmaq Friendship Centre, and that happens to be in the North End and most of the people I know within the Native community live within the North End. So…the community here in the North End is important to me, the Native community interacts at a societal level and how it’s accepted. . .because in the end the communities can only be strong, can only grow if there’s interaction, understanding…I’m at a loss for words, I’m having a hard time describe some of those thoughts in my head.” (Aboriginal, 43 year old man). Barriers to Community Engagement Participants observed that the challenges that community agencies in the North End experience engaging Aboriginal and African Nova Scotian communities in programs and services related to the following issues: • • • • • • • • • • community members not feeling valued; lack of inclusive services and programs; clients not feeling welcomed and accommodated by community agencies; exclusion and discrimination; lack of interest and motivation; lack of childcare; scheduling conflicts and lack of time; lack of access to transportation; physical environment; and violence and crime 45
Community Members Not Feeling Valued Participants discussed the emotional and psychological impact that the stigma of poverty has had on some North End community members, including poor self concept, low self-esteem and lack of self worth and value. These sentiments are partly influenced by negative perceptions of lowincome and poor communities in Canada and contribute to a sense of powerlessness and, consequently, little motivation by some individuals to make meaningful change in their lives or positive contributions to their community. Many individuals are hesitant to volunteer their time in the community because they believe that they are not valued by others and that they have little to offer. In addition, they feel that they are “stuck in a rut” due to the many challenges they face in their daily lives, which are often brought on by experiences of unemployment, low income, poverty, stigma and discrimination, all of which intersect in ways that are disempowering. Attending programs, then, is often not a priority for many of these individuals in the same way that dealing with the day to day challenges of life may be. The representative from the North End Community Health Center discussed these sentiments in the following way: “You know their lives are so full of chaos, there’s….like with the garden this year we had two kids removed out of their home…there’s so many things going on in people’s lives that I wonder how empowered or how confident they may feel in actually being able to make a change so if a healthy-living program is offered to them I wonder like how they really feel that they can make that change that’s being offered to them. You know like so I may be out there in the community, offering the cooking classes and you know nutrition on a budget and that, but if they’re having a problem getting up in the morning because they’ve been trying to work late nights at a job to feed their kids and they’re having problems, domestic problems, not being able to afford the food to eat, a healthy living program is probably something that they find a little….overwhelming maybe or just not on their list of priorities, they’re just trying to get through the day.” (North End Community Health Center) Similarly, one participant observed that some community members lack self-esteem, which contributes to a belief that they have little to contribute to their community:
“Well people from low socio-economic backgrounds feeling usually....and
experienced the problems that go along with the feelings of self-worth or lack of that go with it. When you lack self-esteem you don’t think you have something positive to contribute so you aren’t a helper, you’re usually the one that’s having to go and ask for help.” (Aboriginal, 43 year old man) Lack of Inclusive Services & Programs Participants observed that the tendency for individual community agencies to offer programs for one racial or cultural group demonstrates a lack of inclusiveness and a desire to “stick with their own race”. There were concerns expressed about agency rules that govern whether certain racial and cultural communities can participate in programs being offered by certain agencies. For example, one participant stated that although African Nova Scotian and Aboriginal communities are
the two largest communities in the North End, it was important that community agencies acknowledge other racial and cultural communities residing in the area:
“It’s just that a lot of the communities don’t put it out there enough, it seems that
they stick with their one little group and don’t talk to anybody else. They want to provide services for this one group and this one group only. Instead of saying I have this service and it can be provided to White, Native, Chinese…..” (Aboriginal, 23 year old woman). Lack of inclusive services was mentioned by another participant as contributing to the sense of exclusion that some community members experience in the North End: “Having a community center is a good thing, having a Black community center, you’re only helping one part because the other people don’t feel they belong there. And, you even have people of mixed race wondering if they should go.” (Multiracial, 45 year old transgendered disabled individual) Clients Not Feeling Welcomed & Accommodated by Community Agencies Many community members speak highly of the Mi'kmaq Native Friendship Centre as a welcoming space where they are able to express themselves, their culture and their identity. However, in general, many community members often feel unfairly treated by agencies in the North End who require that they fulfill certain requirements and disclose private information in order to access services. Participants also discussed the need for programs and services to be more accommodating to the everyday needs of clients, particularly those who face financial challenges. For example, more mothers would be able to attend programs and events in the community if agencies accommodated them by offering a space for children or childcare where children could be supervised while mothers are attending programs. In addition, providing dinner for clients during evening programs would also support parents with children and families and those who are experiencing financial challenges. In fact, it is a tradition in the Aboriginal community to provide feasts during their events, which accommodates community members who have financial challenges. Not feeling welcomed by frontline staff was identified as a significant barrier to accessing services and programs in the North End, according to one participant: “ Sometimes people don’t feel as welcome especially where it’s a new place or they don’t know if they are allowed to go up here or. . . it all depends on the person greeting I guess. It needs to be very welcoming inside and some people might go in and the people who work somewhere might think that everyone is coming in knows that this is the room where you go and get coffee or tea or this is where you go and speak to someone about an issue but people who have never been in those places before need the guidance I guess and that’s what I find is lacking in some different organizations around here.” (Aboriginal, 21 year old woman) The representative from ARK stated that the stigma associated with youth, unemployment and homelessness intersect in ways that result in some community members feeling discriminated against and unwelcomed by frontline staff at various agencies in the community:
“There’s a lot of judgment based on appearance, a lot of….appearance and discrimination because of their youth that it’s their fault that they’re living in poverty, it’s their fault that they’re homeless, if they would only go out and get a job, that sort of negative perspective and because they…living and growing up on the street that’s been put on them in a lot of different ways so over years that….it really weighs on them.” (ARK) One participant mentioned that many African Nova Scotians are hesitant to participate in volunteer groups because they find it difficult to “break the ice” and approach these groups, many of which don’t appear to be receptive to “outsiders”. As one participant noted, many community members also assume that they have to know someone in order be accepted by one of these groups:
“I’ve noticed particularly a lot of the volunteer groups themselves I’ve noticed to be
predominantly White and it’s for some Black people to have to go ahead, they just don’t want to. . .I don’t know, break the ice for lack of term, but I think they think it’s pretty damn hard ice to break. They see families and really close friends be in the group, that’s the clique and to get in there they see it as being a hard thing to do. Believe me I know there are people who do volunteer and although….well we don’t need you…….Yeah, it seems like whoever it is who accepts the volunteers, who approves the volunteers, is more inclined to take their friends and family than they are somebody they don’t know even though they…they act as if they’ve got everybody in position. They’re not going to push somebody aside who’s been there to bring somebody else in if they don’t need to. And to them they don’t need to, they make themselves so important that . . .things can’t run without them.” (African Nova Scotian, 57 year old man) Another participant observed that as a long standing multiracial person in the Halifax Pride (LGBTQ) community, she has witnessed and felt racism from the LGBTQ community: “You know….my statement has always been you have to go to them and I mean that’s easier said than done but and I’ve said it to every group. I have probably been the long standing token minority with Halifax Pride since its conception.... there’s a lot of racism there, they don’t see it but anyhow, they’re always well if those people want to come why aren’t they here, you have to go to them, they don’t feel welcomed and the same as. . .now I think for me to go to the Friendship Center, they kind of have to come to me now, I don’t think I want to go, you can only take so many ‘no’s.” (Multiracial, 45 year old transgendered disabled person) Exclusion & Discrimination Participants indicated that stereotypes, stigma, challenges and barriers associated with race, culture, religion and spirituality, gender, sexual orientation, income, education, literacy and learning, cognitive and developmental disabilities play a significant role in excluding community members from participating in programs and other activities.
Race& Culture Some participants stated that individuals often feel judged because of disability, race, poverty and homelessness, resulting in little respect meted out to them in public places. For example, some participants discussed what is often referred to as “neighbourhoodism”: the stereotypes that are attached to some North End residents in Halifax because of race and culture and where they live, including perceptions of them as “crackheads”, alcoholics, lazy, uneducated and only capable of basic skills training. One participant gave an example of this phenomenon: “Trying to find work in lots of different areas, retail and just pretty much everything and….I ended up working for my father for a while and that was fine but when you go to apply for a job, I’m pretty well educated and there’s nothing wrong with me, I dress appropriate when I go for interviews and such but then the whole big cultural difference and then they see where you live and….I mean they look on paper and they see kind of where your address is, where you live, and then they’re just kind of scared or shunned up by that as opposed to if I was living on Robie Street or something instead of living on Uniacke Street.” (Multiracial, 50 year old man). One participant observed that in certain areas of Halifax, such as Spryfield, the white community often expresses harsh racist behaviour towards Aboriginals and shows little interest in working with, getting along with or understanding the Aboriginal community: “As a Native person? I’ve grown up in that….in the Spryfield area in the White world and I’ve experienced some pretty brutal racism first hand because of my ancestry and. . .so yeah. And I don’t think that mainstream society is really that interested in the Native community getting along with them, aren’t cognizant to the needs of the Native community, they don’t understand how people from the Native community think, how they learn, what’s important to the Native community. Things that may seem important to the mainstream society, they’re not always the same as that are important to the Native community and what the Native community considers important is not necessarily what mainstream society consider important.” (Aboriginal, 43 year old man) Religion & Spirituality An Aboriginal participant discussed the need for community agencies to become more inclusive of diverse faiths and religions other than Christianity. He pointed out that the principles of Christianity are inconsistent with Aboriginal culture and beliefs. The church has been perceived by some Aboriginal participants as an institution that keeps Aboriginals powerless because it restricts them from practicing their own faith, an issue that has been illustrated by the experiences of Aboriginals in the residential school system. Through successive generations, Aboriginals were inculcated with the belief that Christianity was “the right way” and that their own culture and belief systems were wrong, resulting in shame and confusion amongst Aboriginals about their role in society. One Aboriginal participant, who is a residential school survivor, discussed the role that the church and residential schools have played in destroying various aspects of Aboriginal culture and tradition through the imposition of Christian beliefs and principles on generations of Aboriginal people: 49
“And they can’t seem to let go off that. I was in a residential school up in Calgary and there was one of these ministers I don’t know from what church but he was way up there and I said can I ask you a question. And there were a couple thousand people. I said why do you continue to push your religion on our people? He sat there and he stood there and he couldn’t answer, I knew what the answer was, but he just looked at me in a blank stare and so that church keeps us powerless….whether it’s an individual or a nation, that church is there key to keep us powerless, plus the government. And Indians can’t recognize that whether…and I knew the answer, and I just asked him out in public but he couldn’t answer me or he wouldn’t. . . Oh to keep us powerless, they continue to impose. . see part of that is they went to residential, that type of poison blankets, they went to annihilation, then they went to assimilation, then they went from that to conformity. Now it’s conformity which leads to deformity. So they want everybody to conform to be a certain way. So what we’re doing is we’re flipping the finger at the creator saying you made us Indian but we don’t need you so we’re going to do this.” (Aboriginal, 56 year old man) One participant was of two minds when discussing Cornwallis Street Baptist Church. She argued that, on the one hand, the church’s historical focus on African Nova Scotians excludes other races and cultures. On the other hand, she observed that while sermons focused primarily on the Black experience, Reverend Britton made great efforts to discuss the experiences of other cultures, such as Aboriginals and whites. Although most of the church members were African Nova Scotians, a few Aboriginal and white community members attended services. According to Reverend Britton, church plays a significant role in helping African Nova Scotians deal with experiences of discrimination: “Yes, well for example the one that I talked about the positive parenting, that’s not the name of it, but something parenting, but that one is specifically geared towards African Nova Scotians and helping children deal with the issue of race and I would say most of time besides the Sunday services, and the Wednesday services, most of the extra things that we do as far as program delivery are geared towards African Nova Scotians in helping them to better navigate society. Now, that being said, they are not necessarily closed to others. It depends. That program specifically asking for African Nova Scotians but we don’t have any other programs that we specifically ask for African Nova Scotians, we just feel that it’s important that we not . .. that we not overlook in our delivery, that we don’t make the same mistakes that the public school system has made or something like that in not gearing our materials and things around the experiences of African Nova Scotians.” (Cornwallis Street Baptist Church) Gender & Sexual Orientation According to one participant, gender plays a significant role in the availability of services in the North End, with men receiving less support from community agencies in the North End than women: “Participating in community, it’s more difficult for men to get help than it is women. There seems to be more access to funding for women’s initiative programs. This stems from the stereotype that men should suck it up you know, be a man, deal with 50
it, don’t ask for help right and we’re . . .you don’t need help, stand on your own two feet. But women well she’s deserving of sympathy and pity, and all that there they’re deserving of it and you know….these are some old sexist ideals that persist today same as the stigma towards mental health issues. It’s very difficult for the Seven Sparks program, the men’s healing program, was in the Native Friendship Center to get funds, and it’s very difficult, took years to get that started. The women’s program, women are the medicine, it was very quick, there are different organizations that are....the status of women in particular the funds are there right.” (Aboriginal, 43 year old man) As the representative from Stepping Stone observed, the experiences of sex workers illustrate the fluid nature of gender and sexual identity and, consequently, challenge societal myths and stereotypes about the LGBTQ Community: “The really interesting thing about sex workers is they completely blow apart the myth that sexuality and gender are binary things, that it’s either gay or straight or bisexual or that’s male and female and nothing else. They completely shatter those expectations because sex work is such a fluid thing, you have to be an actor. And to be an actor in sex work that sometimes means you have to perform for someone you have no sexual attraction to whatsoever. So for instance we work with a lot of men who have never once had any sort of sexual inclination towards other men. But men are paying clients in Halifax, women are not paying clients in Halifax. So if you’re a sex worker and you’re male, chances are you’re going to have to sleep with men. The great thing about people coming to Stepping Stone is they know that everyone in the building who works here and comes here is dealing with the same thing that sexuality is so fluid that we’re never going to make an assumption about anyone’s sexuality whatsoever.....And the great thing about Stepping Stone is that we’ve never really had to deal with. . .our clients never say anything remotely homophobic. They do say things that are sexist but I think that’s a cultural thing that gets sort of ingrained and some of the things that come out of women’s mouths about other women is shocking, but I think that’s a cultural thing and I think that’s just how we in society approach things.” (Stepping Stone). Income Residents in the North End comprise a substantial proportion of the unemployed and under-employed, low-income and poor population in Halifax. Many are on social assistance, which does not provide sufficient income to cover the cost of rent, transportation, utilities, programs and other expenses. For many individuals, it makes more sense to rely on social assistance than to take advantage of minimum wage jobs, particularly jobs that don’t offer advancement opportunities, wage increases or are unstable and temporary. One participant discussed the financial challenges that many Aboriginals in the North End experience daily trying to survive: “Yeah these are all very real things, the vast majority of Native population is unemployed, on social assistance. Sometimes, and they are dealing with other problems as well, sometimes the money isn’t there for food, for a roof over their heads, for their children, they can’t put money towards community initiatives.” (Aboriginal, 43 year old woman) 51
The representative from ARK observed that homeless youth experience multiple challenges around low-income and poverty, often finding themselves in a catch 22 situation where they are unable to receive social assistance since they don’t have a permanent address: “And then there’s folks who are living on income assistance, who are on a community disability and that as well is an experience of a lot of stress because though there’s month to month stability with the income that comes with that it’s also quite inadequate for the actual expenses that they have so . . .many of them you know cover their rent with income assistance and depend on a place like our place here for meals, for toiletries, for telephone use computer use, like all the other necessities that really because their income is so imbalanced that they need our support to make it. And then there are many folks who aren’t able to access income assistance because they don’t have an address for one, you can’t access it without a permanent address, if you’re under 19 you can’t access support unless you’re living in a support living environment and….again for youth who come here they’re very much kind of . .their experience is unique and outside of the system in many ways so a supportive shelter environment isn’t going to work for their particular situation. So 16 to 19 is a really hard time for them and for other youth who may not be on income assistance, they would be surviving by panhandling, “squeegeeing” and other means of kind of alternative income doing odd jobs, busking, making music, selling art, those sorts of things.” (ARK) Education & Literacy Poor literacy and lack of English language proficiency are some of the barriers that some community members in the North End experience securing employment. According to the representative from ARK, education has often not been a top priority for some community members since they are more focused on surviving life’s daily challenges than on completing school:
“I think it’s interesting, many of our folks have left school around grade eight so….
and I think that’s telling perhaps of the lack of support or the trauma or stress that was going on in their lives during those early years, so their education wasn’t top priority because they were really focused on surviving. So literacy then becomes quite a challenge when you are 19, 20, 21, 22 and trying to find employment or pursue education in some ways. So kind of in general I think literacy may be lower than for the general population of youth.” (ARK) The representative from the North End Community Health Center encouraged agencies to identify solutions for supporting individuals with diverse literacy and educational levels: “Well it varies a lot oh yes in the health center, I find there’s quite a diversity with literacy levels and education levels and….but I would say . . .yeah it’s so varied. You know probably about….maybe about 10% of people I see I wouldn’t be able to give any handouts to so we would have to work with visuals as much as possible. Then maybe there’s another 15% maybe that it would be….I would have to work out something, we’d type up something, I wouldn’t be able to give them a handout.
We’d work on very basic key things I’d be putting down on paper for them. It’s a fair bit.” (North End Community Health Center) Learning, Cognitive & Developmental Disabilities Community members who have learning, cognitive and developmental disabilities experience numerous challenges participating in programs.One participant observed how important it is to be inclusive of individuals with learning difficulties: “Yes, there are different women who do have not so much a disability but trouble with learning and so we realize that there’s different ways that we have to maybe do it a little differently for them but we can always count them in. Like we’re not going to say that they can’t participate because they can’t read.” (Aboriginal, 21 year old heterosexual female). According to the representative from Stepping Stone, disability often has a “domino effect”. This domino effect begins with the individual experiencing academic difficulties in the school system, dropping out of school, finding a minimum wage job, living in poverty and, finally, accepting a job in the “non-mainstream” sector of the job market, such as sex work: “But other than that, we do work with people with mental health issues, that’s through the roof and that’s a chicken and an egg situation, but we also work with a lot of people with cognitive delays. I mean if you think about say you’re struggling with something that the mainstream school system can’t deal with and this we see a lot. So something like someone who has Attention Deficit and Hyperactive Disorder (ADHD) twenty years ago in 1970 and they didn’t really fully understand how to deal with someone who has ADHD. That person gets frustrated with the school system, leaves the school system, spends the next five years living in abject poverty, working minimum wage jobs and then finally just decides o.k. well screw this I’m actually going to do something that I have access to doing for better money which is sex work. We run into that situation a lot. I don’t know if you would classify education level as something that would be a disability but it definitely does impact how people are able to function in the “straight” world and why a lot of them have to turn to alternative means of raising funds. If you don’t have an education, you don’t get proper work, and if you don’t have proper work you don’t get housing, and if you don’t have access to housing then you’re stuck on the street, you can’t find a way to get education. So it’s this wonderful cycle that we definitely see with a lot of our clients.” (Stepping Stone). Lack of Interest & Motivation Lack of interest or motivation to get involved in community programs, activities and initiatives presents other barriers to participation in meaningful occupations in the North End. This stems primarily from a failure on the part of agencies to involve the community in decisions about the kinds of programs that are being developed and implemented. One participant discussed how important it is to provide the community with opportunities to discuss their concerns about existing programs, make suggestions about new programs and participate in program development: 53
“Something that’s made up by the community, by what the community is actually interested in, cause that’s a big problem. They’re bringing in these programs and the kids are saying well I don’t want to do this, you mean I have to go and travel to this place in order to do this, I want to just stay here. And there are programs that not all the kids are interested in.” (Aboriginal, 23 year old woman) Another participant noted that community members that are dealing with the challenges of day to day life, in particular seniors, often don’t have the motivation or incentive to get involved in community program and activities:
“People in this building they really don’t do a lot of anything. They live from day to day. And what I say is we all do that. Cause what is there for us to do at our age?” (African Nova Scotian, 71 year old woman)
Also contributing to a lack of motivation and interest in participating in community programs and activities are lack of information about programs, loss of social skills due to the prominence of technology and media such as television, the internet and video games, stress and lack of energy from working all day. A sense of hopelessness compounded by mental health and substance dependence issues also contribute to the lack of interest or motivation in participating in programs and events for some community members. The relationship between participation in community programs and health was not lost on the representative from the North End Community Health Center, who observed that community members often become more motivated and interested in available programs once they recognize how their health and well-being is positively impacted by involvement in physical activity programs:
“Like in the walking group... most of them have diabetes and they’ll say that their blood sugars have improved so much because I encourage them to walk through the week too. We have little contests on for walking through the week so many of them are out walking four or five times a week. But it’s coming through the back door. They can see the tangible results in the fact that they’re getting towards our goal. We walked across Canada last year, so they’re walking towards a goal, and I put the big map up but really the back end is that they’re losing weight and their health is improving. But where they have so many other things going on in their lives, thinking that health may be overwhelming, something they feel they can’t work at cause of other things but going across Canada and I was calling other health centers across Canada on the speaker phone, we would have little sessions and they were mailing pictures back and forth and we got a little thing going across Canada, well that was fun and so we. .. we just come in the back door so it’s all about that meaning again.” (North End Community Health Center) Lack of Childcare Programs that fail to acknowledge the challenges parents face finding affordable childcare pose significant barriers to community participation in programs. Parents are less likely to attend programs and services if agencies fail to provide affordable childcare or meaningful opportunities that bring the whole family together, which would eliminate the financial burdens of childcare. For Aboriginals living on reserves, the care of children by extended family and friends is a central feature of their culture, unlike in other cultures and in Halifax, where nuclear-based families tend to be more 54
prominent. According to one participant, these provisions would foster more inclusiveness and a sense of community and, most importantly, would eliminate the anxieties that many families have around the care and well-being of children: “I think a lot of it has to do with child care. Because there are women who have children and who would like to participate in different activities but it’s the child care that they can’t afford or they . . .transportation is another one that they would love to join not this but they don’t have a way to get there or a way to get home. I think that’s two huge ones.” (Aboriginal, 21 year old woman) Another participant reiterated that sentiment by suggesting that agencies offer programs that bring the whole family together, which would alleviate some of the challenges families experience finding affordable childcare:
“Maybe have it not just centralized on kids or adults but as whole family events where you’re not scrambling to try to find child care for your baby, you’re bringing your baby with you. It’s o.k. if that baby cries in the middle of it, we’ll all pass it around and see who it likes. Just more things that’s going to include the entire family. A lot of families don’t do stuff enough anymore because you need a babysitter for the baby because they’re too young for these activities, or kids are too old to go to the baby activities. Something that’s going to involve everybody from the little four-month old right up to the grandparents, so that might help a little bit if people weren’t scrambling for a babysitter cause if you can’t bring a baby but everybody else wants to go, who wants to stay at home with the baby, which I’ve seen happen a few times.” (Aboriginal, 23 year old woman)
Scheduling Conflicts & Lack of Time Some participants mentioned that they struggle to live a balanced life and often don’t have time in their schedule to take advantage of the programs being offered in the community due to work, family, school and other commitments. They suggested that individuals would be more motivated to attend programs more frequently if these programs were offered for the whole family at various times during the day and evening throughout the week and on weekends, which would accommodate individuals who work full time and have family commitments. This sentiment was illustrated by one participant: “My work responsibilities tended to get in the way simply because I was working at a dollar store, they expected me to do evenings and weekends, so when you’re doing school in the morning doing evening and weekend work you tend to ignore the programs that are going on in the community because by the time you get home you’re wondering where’s my kid. . . I need to see him, ‘cause you’re wondering am I going to forget what he looks like in another week. So a lot of times work does get in the way for people simply because programs are set up at a wrong time, supper time, that’s not the best time for a program, or programs that are set for little kids, any time after nine most parents aren’t going to want to go. Because if I take my four year old out after nine, I’m going to have one time on my hands. Because he’s ready for bed at that point, so programs offered at that time aren’t always available and then a lot of times programs aren’t offered on weekends, it’s during the week. And 55
then you’re going well I’ve got a full week already, I’ve got to cook supper, clean my house, pick my kid up from daycare, work and do all this other stuff, I’m not going to have time for that program and then you’ve got nothing to do on the weekends.” (Aboriginal, 23 year old woman) Lack of Access to Transportation Transportation is one of the key factors preventing community members from participating in community programs and initiatives. As one participant noted, financial challenges often make it difficult for some community members in the North End to afford the transportation required to travel to and from programs and services: “The only time it becomes an issue is with travel and stuff like that ‘cause a lot of people don’t have the money for travel, speaking from a parent’s point of view, also a student’s point of view, and a youth’s point of view, so yeah a lot of times when it comes to having to pay admission or travel, like they’ve got a wonderful boxing program down here but I have not got the money to go in there.” (African Nova Scotian, 57 year old man) Another participant offered suggestions for supporting individuals who have challenges around transportation: “For the North End and up here, I would like, if it would be possible, for . . . you take these people that can’t get out, right to go to church or go to anything that’s going on. Why couldn’t they have some kind of transportation right even I think the people on Gottingen Street are very fortunate to be able to get out. Now there’s…the North End would include Cornwallis Street, right the church o.k. I brought this up so many times. They could have a bus, now if something was going on out to North Preston, the North End could have a bus or make arrangements for people to get on that bus to take them to North Preston, Cherry Brook or wherever they want to go. And if there was some way of renting this bus and even if it’s just once a month . . there are people in Cornwallis Street church that would like to go certain places but they can’t go cause . . .well I can’t take you ‘cause my car is loaded, things like that. That’s what I would like to have.” (African Nova Scotian, 71 year old woman)
Physical Environment A participant observed that since Gottingen Street was used by Halifax residents every weekday to travel to downtown Halifax or Dartmouth, the business establishments along Gottingen Street should find ways to become more appealing in order to attract new customers and stimulate more business in the area: “And there are a lot of people who drive straight down Gottingen Street...it’s a main route for anybody coming from Dartmouth to downtown Halifax. Almost everybody goes along that road at least one time during the week and if they had something that was visual to attract people to come in to see the programs, the businesses, and the different things that are offered that people in Dartmouth and stuff like that don’t necessarily know but.” (Aboriginal, 23 year old woman) 56
She also suggested that a clean-up project be implemented in the community: “Maybe a community clean-up project. There are so many people that complain about how dirty this community is but I haven’t seen one of the them bend over and pick up a piece of trash themselves. So that would be something that would probably be quite meaningful to a few people in this community. We have a fair bit of pride in this community but we don’t seem to be showing it in how we treat our community, there’s not a big clean up, it’s starting now. . we do have. . they have started cleaning up and making gardens and stuff like that, that’s something that I would love to see expanded. More community gardens and areas where instead of relying on food banks you can have help with the rest of your community to grow food for people who don’t have as much. Just more community interaction that way because I don’t know. . .I think it would help a lot of people to be able to interact and help each other. You know if more people could help each other less people would starve as they all say.” (Aboriginal, 23 year old woman) Violence & Crime Safety from violence and crime was a highly contested issue in discussions with participants, with some participants feeling safe in the North End and others feeling unsafe. There is a general perception in the community that youth are responsible for most of the crime in the North End, particularly homicide. A senior participant observed that while crime has increased in the area, security has decreased in her apartment building. Another participant discussed the hesitance by some community members to alert the police when a crime has been committed in the neighbourhood: “I can go down there and I’m well known to the people, but if I go down there with the wrong attitude or with a look at somebody the wrong way, these young kids they don’t care, they’ll pull a gun. They might not shoot you, but they’ll pull it out to scare you. Anybody would be scared if they put a gun in your face. And who can you go to? You can’t call the cops. You call the cops, you’re a rat. You’re kicked out of the community or you’re not allowed in certain areas, so you’ve really got to sit back and take whatever is coming at you. And these are young kids, if I did that when I was a kid, I’d still be picking my teeth out of my lips.” (Multiracial, 50 year old man). However, another participant observed that he felt safe in the community: “Ah. . I’m not worried at all if I’m walking down the street, it could be lunch time or it could be twelve at night, I know who I’m going to run into and they know who I am and there’s not really any issues about . .or any concerns about being anywhere at any time or with anybody. Just a certain type of closeness.” (African Nova Scotian, 57 year old man) Some participants perceived the police as being part of the community. One participant observed that the police should be credited for reducing crime in the community:
“And, there’s so many beat cops down here, beat cops….we know most of them, they come out, they stand in front of the Friendship Center and we harass them all the 57
time, like I think I can get a picture taken with one of them…she asked to be handcuffed but they wouldn’t do it. So even the cops down here, it’s a well-watched community for the most part as far as I’ve seen. Well we’ve got the main police station just down the road and we’ve even got a community station just down the road a little bit so they’re a big part of the community. And I find a lot of them do fit in fairly well, they know how to become a part of the community and not just walk by. They actually, you know if they see some kid being picked on, they’ll stop it. If somebody drops something, they’ll make sure that it’s brought somewhere, all kinds of stuff.” (Aboriginal, 23 year old woman) Another participant observed, however, that the police need to deal with crime by going out into the community more: “I think there should be because the police down there at Uniacke. I sit down at my girlfriend’s place and we see everything and the police are just there in that unit. But some of them I guess they just wait for a certain time to do their job so really you can’t blame everything on them but then again they should be out there doing their job and getting this kids, cause these are little kids. Killing one another. And then the big guy he’s going to Florida every week.” (African Nova Scotian, 46 year old man) The church has been criticized in the past by some members for turning a blind eye to crime in the community and for not taking a more proactive stance in helping to resolve the problem. Reverend Britton indicated that the church responded by organizing a march to create more awareness about crime prevention: “The violence, the crime that goes on….We’re just really, we’re on an anti-violence campaign right now in the church and we’ve been holding a series of marches around the community just to say, the church is here and we care because sometimes people think that well you’re just having your service in that building and you don’t really know what’s going on out here in the streets. So we’ve been walking around the neighbourhood on Sundays, we get out of church early so that we can march and stop and pray and sing in different spots, just to say we are here and we do care about what’s going on with our kids. And…last Sunday we had a march and it was really good in that we had a few people who were on the street who actually joined the march, of course people always come out and stand in front of their house and sing with us, clap their hands, some people are in the window waving, cars are driving by honking, but this time we actually had people who joined the march which was nice. So we probably had 75 people, 80 people on the street. And we just walked, we walked down Brunswick Street all the way down to the George Dixon, crossed over there to the Square and then back up Creighton Street and back down Gottingen and then back to here. And. . .so I think that for us to have a center like that, our main aim would be towards crime prevention and showing our kids an alternative because so many of them think that there’s nothing else to life, you know. And they’ve just kind of lost hope or they’ve gotten caught up in a lifestyle that they haven’t been able to figure out how to untangle themselves from even if they don’t really want to be in it. We had a tragedy here of one young boy who decided he was going to get out and almost immediately after having a conversation with his grandmother, I wasn’t raised this way, I’m getting out of this, I’m done, I’m going to 58
turn my life around, and then the next day he was shot dead. In fact the same day or the next day that he was leaving her house and he was just shot dead in the street.” (Cornwallis Street Baptist Church) One participant suggested that a neighbourhood watch program be implemented to deal with crime in the community:
“A neighbourhood watch would be great. Even if you had just people in the
community, just patrolling, even just walking the streets, even if there was a number to call say Miss so and so who’s 70 years old needs to go to the corner store cause she needs whatever, you know, is there someone that can walk her to the store and walk her back home or just to say I can go and do that for you, just a number to call, just to feel comfortable, younger people that are responsible and are willing to do that.” (African Nova Scotian, 44 year old gay man) Strategies for Engaging Communities Participants identified the following strategies for engaging Aboriginal and African Nova Scotian communities in meaningful occupations in the North End: • • • • responsive community programming and services; community outreach; promotion and publicity; and inter-agency partnerships
Responsive Community Programming & Services Several participants observed that developing services and programs that more closely reflect the lived experiences and day-to-day challenges faced by Aboriginal and African Nova Scotian communities in the North End was important for engaging these communities in meaningful occupations. For example, one participant indicated that engaging the community through food is a central feature of Aboriginal culture and tradition:
“A big one within the Native community is food and give-aways, those have been
used to get Native participation. A feast, feast is very traditional within the Native community, it’s how the people get together, interact, at any event sometimes that’s been . . let’s say job fairs within the Native community. Say it’s going to be a feast, say there’s going to be give-aways, door prizes, get them in you know. Bait them with this and then give them that later.” (Aboriginal, 43 year old man) Another participant suggested that agencies provide both meals and childcare to engage community members in programs and services: “I feel that if it is a thing, say for supper, you need to feed the kids and get them ready for bed and find someone to take care of them so you can go and join a group say maybe one night. Then maybe that group could help and say we will prepare 59
supper for you, you don’t have to take care of that and we will have someone to look after the kids, and then they don’t have to worry about what are they going to do for supper that night, and what are they going to do for their children. Everything can be taken care of and it’s their time to go out and join in.” (Aboriginal, 21 year old woman). Participants also observed that community members could be more successfully engaged if more programs were developed to respond more effectively to their day-to-day challenges and needs. They suggested that the following types of programs be implemented or made more widely available: • • • • employment programs; workshops and peer support; seniors programs; and children and youth programs
Employment Programs: Some participants observed that lack of skills and training and a general unpreparedness make it difficult for some North End residents to secure employment. One participant suggested that job training programs and an employment referral service be implemented: “Well just one way of dealing with it is….is put on like workshops, like before years ago, in the old days, not saying the old days like I’m old, but back twenty years ago they had programs like when people got released from custody or people in the chesterfields, like stuff, like put on programs like….walk you back into the workforce, like have something like a temporary, like some temporary agencies, there’s some out there but they don’t have something specifically for the North End, for the projects. If they had something like that, some kind of temp agency right into the projects that could focus on the people that needs the work. They get a phone call in the morning saying o.k. we need ten guys, like it’s right in the projects, people would know that it’s in the projects and o.k. I know this guy, he’s desperate, call him up say hey do you need a job for the day? Or I’ve got a job for like a week, I mean then it will probably make a difference in the community. Like a lot of guys in the projects, women and men, they get up in the morning…they’re sitting around the house doing nothing. If they were to get a phone call saying do you want to go to work for a day? No matter how bad they are or how bad a drug addict they are, they’re going to go.” (African Nova Scotian, 46 year old male) Another participant suggested that employment officers should be hired to work directly with community members who are looking for work: “Yeah, like on the spot….if they can put a community police station in there, if they can put a community….like a day camp, they’ve got something else down there, I don’t know what it is, then they can put an employment center or a job bank or something, somebody from social services, with an office in there that will get to know the people. I mean the police officers they go down there and they can call the 60
people by name. Like if you’ve got somebody that’s an employment officer or a job counsellor that works right in the community with people. . and let’s say a job comes up, let’s say me and you we see each other on a daily basis, you get to know me so if someone calls you and says I need a specific person for this job, you can say yeah I know this guy cause you got to know me, you know I can do that job, you can trust me. You can say I’ve got somebody for you, you can call me, listen.. do you know what I mean, something like that there, cause you get to work with people and it creates more jobs too….now if you sent me to do a job and that person calls you and says yeah I like that, that was great, the guy did a good job, that person might call you back three months, a week down the road and yeah we need someone else. Something like that there would be good.” (African Nova Scotian, 46 year old male). Workshops & Peer Support While there is a wide variety of workshops available in the North End to meet the needs of community members, including family activities and other activities and events designed to get people out of their homes, participants stated that there is still a need for more workshops and peer support programs that support community members with the many life challenges they face. One participant suggested that agencies offer workshops on finding housing, money management and other issues: “Maybe guidance, organization to try to teach you different ways to deal or get through stuff like. . . a lot of people are looking for different housing or things like that or employment issues, or ways to save money. I know they had a cooking group, healthy food cooking group and that was good, to help you save money on the food you buy, you could also eat healthier, that was good but just I don’t know…more awareness.” (African Nova Scotian, 23 year old female) Another participant suggested that workshops that help community members survive on low incomes would be beneficial: “Definitely something that has to do with economics because of the North End being like a lower income community I find that more awareness I guess, maybe people need to know how to live on a low income instead of the norm of people having a regular pay cheque and what not. So something that kind of opens people’s eyes that says you know what, you only have this but this is what you can do with it instead of staying in that rut. Like a program to help with surviving I guess with the economy today and kind of bettering themselves for the future, like a plan like that would be helpful here I think. And another one would be drug and alcohol abuse. People might not think it’s a problem but at the same time they might not see it. Definitely, awareness on different programs like the alcohol….even selfboundaries, kind of growing as a person, helping….there is a program, it’s called the heart program, it deals with boundaries and self-esteem and drug abuse. It focuses on growing as a person I guess. It is….it’s very welcoming for people and very knowledgeable so definitely something to put into play for everyone to come and join. And it’s also good for bonding I guess in a community.” (Aboriginal, 21 year old woman) 61
Seniors Programs: Seniors in the North End often find it difficult to participate in programs and activities because of mobility and health issues, concerns around violence, crime and safety and a lack of services designed specifically for seniors. Participants stated that developing more seniors programs would help to reduce the sense of isolation and loneliness that many seniors experience. For example, one participant suggested that a seniors club offering a variety of activities should be developed to bring seniors together:
“Like for a little club for seniors for knitting or crocheting or something like that to give them something to do. Or like card games, I see a lot of them playing cards in here so something like that.” (African Nova Scotian, 71 year old woman).
This participant also suggested that programs hire volunteers to visit seniors and engage them in activities in their own homes since fear of violence inhibit some seniors from going out alone: “What they should do to help people is to get out more, get out and meet the people and find out their likes and their dislikes you know and see what they’d like to do and years ago they used to have the children from the schools come in to the seniors’ buildings to visit the seniors because apparently some adults don’t have anybody and if they do, they’re just left alone. And, it’s sad, it really is sad.” (African Nova Scotian, 71 year old woman). Children & Youth Programs: Participants stated that more activities need to be developed for youth in the North End. Unlike rural areas, the city has few resources that engage youth in outdoor recreational activities. Several participants noted that youth that have little to do are more likely to loiter and engage in delinquent and criminal behaviours. In addition, some participants stated that more free or subsidized youth programs need to be developed for parents who cannot afford to pay to put their children in camps or clubs. In addition, information should be made available to low-income families on where they can obtain help in registering their children in youth programs. According to the representative from ARK, keeping youth motivated is one of the keys to successful youth programming: “We have to be able…..we have to be in a place where we can offer them an alternative so if I can say to that same young girl listen you need to go back to school, if they haven’t been in school, you need to go back to school, you need to apply yourself in school and what I’m going to do is I’m going to offer you a tutor who is going to come alongside you and help you to get caught up so that you don’t feel overwhelmed by what you have to do, I want to check in with you, I want to find out that you’re o.k., if you have a certain need, if there’s something going on in the home, we need to fix that, if it’s a matter of well I want to go to school, somebody who’s finished high school, I want to go to community college, I have no money, let me see if I can get you in a program, I know the people at the community college. We have to be able to offer them alternatives...it’s not good enough to say you need to change your life. O.K. help me to change then, help me to change it and very often 62
if you take things and you help people to…because it seems overwhelming, so if you can just help them one bit at a time and say o.k. . .this is the first, let’s just concentrate on step number one, step number one is this, let’s do that. O.K. I can do that. And then we do that, o.k. what’s the next step? This is step number two and just get them to see this is how you approach life, just take it one step at a time. Yeah, it is overwhelming, we can’t fix all the violence in the streets with a single march but if we take one step at a time and say that boy was a boy who was getting into trouble and now somebody has taken him under their wing, got him off the street, try to teach him a better way, he’s beginning to see the light, then that’s one less boy who’s going to get into trouble.” (ARK). Reverend Britton observed that while there are a few agencies that offer youth programs in the community such as the George Dixon Center and Palookas, many of them are not open after school or in the evenings beyond just a few hours: “Our biggest dream right now is to have like an after school center for our kids, where our kids can come and just be. And they could get help with their class work, the could do recreational things, we could have a computer lab, we would really love to do that. Now that being said, it’s being done, they just opened up one at Palooka’s, but Palooka’s is only from 4:00-6:00…I think it’s Monday through Friday, but it’s only from 4:00-6:00 and our kids need a place to stay sometimes until 9:00 or 10:00 at night that’s safe.” (Cornwallis Street Baptist Church) Community Outreach Lack of community outreach was identified by several participants as one of the main factors underlying the challenges community agencies face engaging North End residents. The representative from the North End Community Health Center stated that organizations need to go out into the community and interact directly with community members in order to identify their needs:
“Well, a huge thing is the commitment to outreach, there’s a big commitment to go to where people are at, where they’re most comfortable and doing home assessments, it’s a big thing you know that has made a huge difference and working with a collaborative approach so if somebody is with home visits and that it’s like they can still get a team approach there even in their home which is awesome. Those two things are huge, doing outreach programs, home assessments, so the outreach program is really committed to going to where people are at and really committed to serving the community in the best way that the community has identified as their needs.” (North End Community Health Center)
Another participant reiterated that sentiment in the following way:
“Exactly, somebody who’s got a little respect, somebody that’s some way that’s not just going to go there and say o.k. I’m getting paid, somebody that will actually like not a police officer but somebody along the lines of a police officer, they get out there among. . .they mix among the people, like not just sit behind a desk and answer the phone. Somebody who will go and say I’ve got nothing to do today I’m going to go 63
on people’s doors and say how are you doing, I’m the community organizer, just here to see how things are going, if there’s anything I can do, if you have any suggestions. I mean somebody like that because now you’re showing concern that you want to help. Don’t let people come to you and ask for help. You go there and say hey buddy what can I do to help you?” (African Nova Scotian, 46 year old man) Promotion & Publicity Several participants indicated that there was a general lack of awareness among community members about available services and programs because agencies fail to effectively publicize and promote their services and programs and community members don’t often access agencies for information. They offered several suggestions for effectively promoting and publicizing programs and services, including word-of-mouth; posters, brochures, newsletters and flyers; community newspapers; email, websites and social networking; the Halifax North Memorial Public Library; church; radio and television; and a Directory of Community Services, Programs and Resources. Word of Mouth Several participants observed that word-of-mouth promotion is the most frequently used and most effective method for creating awareness about programs, services and community events because it is a direct and straightforward method for sharing information. Word-of-mouth promotion often occurs between community members or through community outreach conducted by some community agencies. Individuals who learn about programs and events by reading flyers and bulletin board postings will often share that information with others in the community. Communicating information about programs through word of mouth often catches the attention of community members who will often pass on the information quickly to others and be more motivated to participate in an event or program, particularly if the information is of interest to a wide variety of individuals. The more opportunities individuals have to express their ideas and opinions, the more likely decision-makers will hear these ideas and opinions and act on them. One participant stated that while many individuals are hesitant to speak up at community meetings, they often walk away from meetings with opinions and ideas and communicate those to others in the community: “Exactly cause once you get people talking about a certain subject then they’re more willing to say well why doesn’t this get done and a lot of times when you set up a big meeting some things get left out. When we have meetings usually there’s at least one thing left out every meeting but when things are going around word of mouth a lot of times you end up learning more because there’s those people that don’t necessarily speak up. They’re the ones at the meeting, going oh excuse me, while there’s the other people like myself, who if we have an idea I go hey over here I have an idea.” (Aboriginal, 23 year old woman) Another participant noted that the local church communicates information about programs and events through word-of-mouth: “From other people in the community if I go to the local church you know how the church they announce if something is going on in the community. If I do go to church, I don’t go that often or I learn from somebody in the community oh yeah we 64
have a community event, something like fundraising or something like that. Other than that there’s nothing posted, nothing on the radio.” (African Nova Scotian, 46 year old man) Posters, Newsletters, Flyers, Brochures & Community Papers One participant suggested that posters and other written information on programs, services and events be posted or distributed at a central location in the community: “I mean like have meetings, they should know what’s going on, so there’s got to be somebody in the community that knows what’s going on that can pass the information on, even if it’s got to be at a church meeting or post it up on the bulletin board at the….and the community would have a laundromat or something, but right now I don’t see none of that, and I live in the community, I don’t see none of that.” (African Nova Scotian, 46 year old man) Another participant stated that that a weekly or monthly brochure, newsletter or bulletin be placed in an accessible location where community members are most likely to frequent: “I don’t know maybe like a newsletter, what’s going on, like every month…I don’t know where they could put it but like maybe, I don’t know how they could do that. Maybe more word of mouth. People come in all the time for their health issues. I don’t know how to voice it. .. it’s not like they’re going to go knocking on everybody’s door and telling them every day what’s going to happen, but maybe like a newsletter. I don’t know how that would get out or across.” (African Nova Scotian, 57 year old man) Widely used and established online and print can also be effective in sharing information to the community, according to one participant:
Even in the Metro, just advertisement, just getting it out there. I read the Metro every day, if there was an ad in the Metro or even on Kijiji, there’s all these other resources out there that could be out there.” (Aboriginal, 31 year old woman)
Participants also noted that disseminating written information on programs and services does not go far enough in creating awareness about programs and services in the community. The representative from ARK observed that a strategy that involves both the distribution of written information and outreach (discussed earlier) at schools, youth centers, seniors complexes and other locations may be the most effective method for creating awareness about programs and services:
“Like organizations like this, make phone calls, go to the people, do
something, don’t sit in your office cause we ain’t to know about you all basically. Don’t think you’re going to put a poster on one door, your door that people are going to cross the street and read it, it ain’t going to happen that way, actually go to offices, go to places and put it out. Fax them. . .I do that, do anything.” (ARK) 65
Library One participant indicated that while it is possible to communicate information on programs, services and events through the Halifax North Memorial Public Library, it is not always possible: “See the old idea was that’s what I talked about the library was going to do that. The library is a lot of well-meaning people but you know what, other people can do that, the library I don’t think that they . . I know the people that work at the library, but you know they’re not be all and end all but I mean the library here is sort of like the old community store, everything revolves around it but there are other people who can help and do things. And then there’s the flip side you got to try and help the library and something like that but because of their union you can’t so…like some things you can and sometimes you can’t ‘cause you’d be taking up the librarian’s space.” (Multiracial, 45 year old transgendered disabled individual) Church According to Reverend Britton, information on community events and programs are often communicated to church members: “Yeah, bulletin, bulletin, bulletin, every week we have a bulletin and it’s full of all kinds of announcements. We have a bulletin board in the church that’s got all of the information that people send to tell us about.” (Cornwallis Street Baptist Church) Some participants noted that church leaders can be quite influential in convincing youth to participate in community activities, stay motivated and make positive life decisions since many of them have life experiences that are relevant to youth, making it easier for youth to relate to them. One participant observed that youth are more likely to participate in youth programs and activities organized by the church if these programs and activities have strong leadership: “They would have to have a leader…they would have to have a leader to tell them right from wrong. They would have to have someone that’s much older and been down that road and….even if they had a church member come in, here I go again with this church, but if they had a church member to come and talk to them, have him say o.k. we’re going to have a program Wednesday night, I want all the boys to come there... and if that person would tell these young boys and girls the experience that they had maybe that would do it right. But….I don’t know, that’s the only thing I know.” (African Nova Scotian, 71 year old woman) Radio & Television One participant noted that radio is an expedient way to share information on programs and events: “Advertising through radio and stuff like that. A lot of radio stations won’t charge for you for a non-for-profit organization so it’s no problem to go down to the radio stations, a lot of them are only a short walk away, and they’ll advertise the different 66
things that are going on in the community. Well I find Q104 a lot of times does, there’s also Z103 which is just around the corner and every time that we’ve asked them to do an announcement for the Youth Group, they’ve done one for the Youth Group.” (Aboriginal, 23 year old woman) Another participant noted that advertising programs and events on television may not be cost effective for some community agencies in the North End: “It’s probably not cost-effective, television advertising would probably be fairly effective, everyone watches t.v., not everyone uses a computer or if they do they use a computer for things other than accessing information but …commercial advertising, it’s there, it’s in your face every….it’s on a wider level …” (Aboriginal, 43 year old man) Email, Websites & Social Networking Websites Several participants mentioned that Facebook, a webpage and email were the most effective methods for creating awareness about community programs and services, since many community members, regardless of age, had access to computers and email either at home or at the library. One participant noted that social networking is effective for sharing information: “Yeah, Facebook, Twitter….not really Twitter, more Facebook....that would be a very good way. Yeah you’re on Facebook or something then everybody would be able to access that and then once you sent out information about what’s going on everybody would be able to kind of right there they got it.” (African Nova Scotian, 23 year old woman) According to another participant, communicating information through an email listserv can be effective: “Even if like you had a list of people’s email, I know it’s very time-consuming, if there’s an event going on, you could just email people and let them know what’s going on.” (African Nova Scotian, 44 year old gay man). Directory of Community Services, Programs & Resources Reverend Britton suggested that a directory of resources be developed and disseminated to communicate information about programs and services: “Well…..I have a Facebook account but it’s funny, it just sits. . . every now and then I go out and I look and see what my friends are saying, and every now and then will say where are you. . . I don’t see how you all find time for this. I don’t think that would help me with Facebook…well maybe if you had like a North End, I don’t know if you had a North End resources page, I don’t know....Email is better for me but that doesn’t make it easy…like the BBI (Black Business Initiative) puts out this directory every year it would be great to have that.”(Cornwallis Street Baptist Church) 67
Inter-Agency Partnerships Participants also discussed the need for increased partnerships between North End agencies. Inter-agency partnerships can be effective in bringing together leaders in different agencies and organizations to identify and respond collaboratively to community needs. Inter-agency partnerships can be effective if they combine the unique and varied skills and experiences of employees and draw on diverse networks. The most successful partnerships tend to be among agencies that share common goals and mandates and provide services and programs that respond to specific issues, such as substance dependence, poverty or homelessness. Meaningful partnerships also require a level of trust between agencies and a willingness to think outside the box by networking with agencies that have different mandates, learning about other cultures and engaging directly with community members. Partnerships also prevent redundancy in programming, particularly in North End where several agencies offer similar programming and compete for the same clients. The representative from ARK noted that partnerships provide more opportunities for community networking, sharing, growth and advancement: “We do a lot of networking in the community with other agencies, especially with the North End Community Health Center, with the MOSH program that was just started, Direction 180, Dal Legal Aid, different shelters and the drop-ins within the city as well..... I think we facilitate that by a healthy relationship with the North End Clinic and also through MOSH, the Mobile Outreach Street Health, two of the nurses come here twice a week and just meet with people, their faces are known so there’s a building of trust and familiarity and also an ability to come here to meet people and set up times that are going to work when we’re open and kind of be easy to meet with them. And that’s also true for mental health share care, there’s a person who comes and is a familiar face and is building kind of a presence here that helps to kind of span some of the barriers that exist.... I think right from the beginning ARK has been really committed to networking and connecting with others in the community and those relationships have really evolved over the past decade and yeah and a commitment to those and kind of being in solidarity together as a community has been effective I guess in creating better ways of providing care.” (ARK) There are a number of reasons behind the hesitance to develop partnerships, including competition over clients, competition for funding and competing programming agendas, all of which can create conflicts and animosities. According to the representative from the North End Community Health Center, a “scarce-minded” mindset is at the heart of these tensions: “Well I find that so many people are doing great things that we know nothing about and I find that when I got the money from the Black Business Initiative, they said the one stipulation is that I had to put together a committee for the garden and I did the thing of inviting other agencies and .. . I did get a few community members but sometimes when you have other organizations I forget that they already have their own agendas, they have to ‘cause they’re structured that way and so that has been, there’s been some inner conflicts because other people. .more structured organizations have their own ideas of how things should proceed in a structured way and the competing for funding. And competing for community members because I’ve learned that some other agencies say well we have the kids in our programs here and not seeing well why can they be part of two different programs, you know there’s 68
that. . . I think that there’s a big gap in working together. I mentioned earlier, the inter-connectedness is there whether you want to acknowledge it or not and we are inter-connected and I think that we could really be working with the community so much more effective if we worked more together without . . .but I feel just as sometimes we see people as coming from scarcity I think as agencies we have a scarcity mind set, that there’s not enough funding or there’s not enough people to participate in our programs or there’s not enough resources and I find sometimes that that scarcity way of thinking is in our own organizations.” (North End Community Health Center) Building a Sense of Community Participation in meaningful occupations helps build a sense of community, particularly in communities where individuals are dealing with challenges such as unemployment and underemployment and low-income and poverty. Participants’ discussions on building a sense of community in the North End centered around two issues: 1) a sense of belongingness to a community and 2) social support networks. A sense of belongingness to a community was discussed earlier as a central aspect of how community members conceptualize meaningful occupations. This section extends that discussion to articulate how the concept contributes to community spirit in the North End. Social support networks that comprise of family, friends, community agencies and other individuals are not only vital in building a sense of community, but they also provide a buffer against health and mental health problems. Belongingness to a Community Several participants discussed how the development of a sense of community belongingness enables individuals to feel part of their community and of society, in general, because it helps stave off the mundane aspects of life and sets an example for future generations of youth. Participants also discussed the need to feel appreciated by the community for the work they do. For many community members, church provides a sense of community because it offers a place where community members can go to feel wanted, accepted and needed and where they can use their skills, talents and gifts to give back to the community. Several participants observed that a sense of community belongingness stems from the interactions and bonds that people have with one another, resulting in community growth that can only happen when community members have grown together as part of a community for generations. Also important for building community is a sense of trust among community members which involves consistency, particularly a commitment to finish what was started. The Mi'kmaq Native Friendship Centre has long been the heart of the Aboriginal community in the North End and has played a significant role in contributing to a sense of community for Aboriginals residing in the area, as well as for other Aboriginals who migrate to the North End. Cornwallis Street Baptist Church also takes seriously its role in providing a comfortable, supportive, fun and casual space for its members. According to the representative from the North End Community Health Center, consistency is one of the most important ingredients for creating community belongingness: “Yes because often times we can…you know find meaning, to me it’s all about, that’s why I like occupational therapy, it’s working with meaning and so to me it’s like finding that meaning and bringing it to life and following through. You talk to people, this is a great idea…I can see that happen but having it come-to-life and 69
having a follow through and having consistency. Because I believe a lot of people in this community don’t have consistency, they’ll have something start and once the funding is gone, it’s over. They’ll have somebody come and visit but you know the second visit something dwindles off or it changes so really making it come alive and really. . I find consistency is huge too and that’s what happened with that walking group. We walk no matter what the weather, I’m here so if somebody shows up then we’ll do it. And they know every single Tuesday with the garden, it’s every single Thursday, you know every… that consistency of somebody is going to be there. So they can really feel that they have somebody in their corner.” (North End Community Health Center) One participant observed that involving oneself in the community provides a sense of community belongingness: “It’s nice to get out of the house, be involved in your community, it gives you a sense of actually belonging. You’re not just living and passing through somewhere, you actually live there. It’s the fact that I can get out with my son and set up connections for my son for when he gets older, he’s going to be able to come down to this community and he’s growing up with the kids that are going to be able to take over this place eventually. And providing the connections for my kids as well as myself and it’s . . . I don’t know it’s just . . . .” (Aboriginal, 23 year old woman) For many participants, community was perceived as not simply a place to live, sleep, leave and return each day, but as a space that people feel connected to, that offers many opportunities to build enduring and evolving meaningful relationships that they can share with their children for generations to come. These connections and relationships enable community members to come together to solve problems and share successes. One participant articulated this understanding of community: “Well if. . . I could say that in here, like if something is going on we all. . .one person knows right and like if we have a problem we all are involved into it, we go to one another and we always look after one another. Especially these two, right here, now there is some. . . people here that if we don‘t see them and they’re seniors, if we don’t see them, whoever’s home if we don’t see them, they’ll say well did you see so and so and probably I say no. . . well let’s go down and see how she’s doing today. And we go down and maybe she’s not feeling good. We go in, we sit and we talk to her and then probably the next day we see her, how are you feeling, I feel good, your little talk did me good and that’s how we are connected here. And the same over in the other building, I have a friend over there and I knew her twenty-five, thirty years and we are very connected.” (African Nova Scotian, 71 year old woman) Social Support Networks Social support networks play an important role in supporting community members who are dealing with the challenges of daily living. Participants discussed strategies for nurturing community connectedness and meaningful relationships, such as being friendly, participating in social activities, and creating programs that bring the community together in a relaxing and non-threatening environment. For many community members, building a sense of community is premised on a level 70
trust that develops as individuals develop meaningful connections and relationships with one another. These relationships and connections often develop as individuals gradually begin to share common challenges and experiences pertaining to children, family and community development. Some participants indicated that these relationships are easier to build in the North End, where people are more open and friendly, are willing to offer their knowledge and insights, and tend to look out for one another. One participant discussed this further: “Well my own community I feel connected cause everybody is outside, walking around, I live on a tiny back street so you tend to recognize your neighbours after a certain time. After a few months you nod and after a few more months you start discussing weather, and after that you start discussing those damn kids and why hasn’t the government salted these roads yet, so yeah we’re fairly connected down here, it’s very homey, it’s more of a community than you find say down the South End where everybody has their door closed up tight and they have this beautiful manicured lawn that nobody ever plays on….” (Aboriginal, 23 year old woman) The representative from the North End Community Center discussed the efforts she has made to nurture meaningful relationships among community members: “And so I always remembered that you know working in community and I thought it’s always those little things that mean a lot. And so that connection to work with inter-connectedness in the community and to acknowledge where people are at and to acknowledge them even by name, those little things, the reaching out to people in small ways and I find that is … that brings meaning out because they feel less resistance to me. Cause dietitians do have a bad rap right so I just feel that in that meaningful… meaning to me means engagement and connection and the simple things of saying hello, how are you, shaking their hand when I meet them for the first time, just those little things allows them to tell me where they’re at easier and bring meaning to our interaction when we’re together. And that’s all I’ve done in the working group is try and bring connectedness alive, it’s there anyway, but just try and foster it and I foster it through the food, and through having social time after the walk when we come back, through community causes and that’s huge in a lot of my programs. So I foster the power of contribution so we always work together, every year with the walking group for a community ‘cause we walk, they get a million steps in and I find $500 somewhere, writing grants and stuff like that and they spend it in the community, on a community initiative. And that has built a huge bond.” (North End Community Health Center) While many participants stated that North End residents feel like a close-knit family that sticks together, they indicated that keeping seniors connected to the community has been particularly challenging. Some community members often go out of their way to visit seniors to ask them how their day is going, which improves their spirits and makes them feel connected to the community. However, as the representative from ARK pointed out, the notion of “family” is often conceptualized in unique ways in different cultural communities, resulting in different levels of commitment and support provided to youth in the community: “Well when we were starting we were talking a little but about perhaps homelessness is experienced differently in different cultural groups in Canada for example we 71
wondered if maybe in our city anyways, that we don’t see very many from Native communities because the community structure is more cohesive and maybe youth end up growing up with a grandparent or aunt or kind of held by the community in a different way than maybe a person who’s from a Caucasian background or from less of a cohesive cultural group, that’s what we wondered with why the demographics are in our space. And feel that way perhaps as well with African Canadian folks especially in this city that there is quite a culture of family and community maybe in a different way than the majority of Caucasian folks that come here...... We wondered then perhaps particularly African Canadian communities in our city, cause that’s where we’re working, maybe there’s still a more cohesion as far as primary family and then extended family and then church family or around the school that there’s a stronger network of support perhaps. Yeah. . . now though there are many youth who come here who have been raised by grandparents or an aunt or something like that so you know. . .when I start thinking about it, I’m not sure exactly, that’s really a generalization I guess.” (ARK) It can be observed, however, that over successive generations, individuals in all communities increasingly have a lessened sense of family connectedness, resulting in youth falling through the cracks and getting left behind. One participant stated that she often relies on a social support network that includes family, extended family, friends and others in the community: “Actually with my family not at all simply because I have a wide support group, I’ve got… my fiance’s mother babysits, my grandmother babysits, my mother, my brother, my godfather, I’ve got a community full of babysitters..... Oh yeah and pretty much all the women that have come down here that I seen, there’s two women that come down with their children, they’ve just had babies, one girl it was her first time out with her baby and she came down here, and she’s like I just need someone else to hold her because I haven’t had a break. And that’s it, she went into the women’s room and she lay down while somebody else held her baby.” (Aboriginal, 23 year old woman) Many agencies in the North End acknowledge that they are an integral part of community members’ social support network that includes family, friends, service providers and other professionals. For example, ARK focuses on building meaningful and long-term relationships among homeless youth and between the agency and the youth by creating a comfortable and relaxed environment for youth who need a place to stay and who have various other needs, such as meals, laundry, a shower and medical care. Many homeless gay male youth have been abandoned and disowned by their families because of their sexual orientation. According to the representative from ARK, youth that access services at ARK often come from broken, abusive home environments: “O.K. well youth experiencing homelessness are doing so for a whole variety of reasons. Though I would say that a large percentage of the folks that come here have in their younger life experienced trauma of some kind, maybe in an abusive situation or some break down of the home or just lack of support in some way and many of them have been on their own, homeless in a variety of ways since they were quite young maybe nine, 11, 14.”(ARK)
Health & Coping Various factors operate independently or in tandem to compromise health and well-being, particularly in low-income, racialized communities, such as the North End. As mentioned earlier in this report, health is a product of historical, structural, institutional, social and personal/individual factors and processes that shape the life experiences of individuals and communities. Mental health problems and substance dependence, which are often related issues for some community members, are two health issues that many struggle with in the North End. While both issues carry a good deal of stigma, mental illness is perceived as particularly taboo in African Nova Scotian and Aboriginal communities. Several participants indicated that Aboriginals often suffer with these issues in silence because they find it difficult to ask for help from non-Aboriginal mental health services. In fact, many community members in the North End are hesitant to discuss mental illness or to seek appropriate help. Homeless youth who are dealing with undiagnosed mental illness often do not have access to care. Either because of a hesitance to seek help for mental illness, stigma around mental illness, unavailability of mental health services or a failure to access these services, many North End residents suffer in silence and self-medicate, which often leads to addiction issues. One of the challenges that health professionals face is determining whether a client’s depression is caused by genetic factors, substance dependence or other daily life challenges. This project illustrates how important it is to consider the impact of external and environmental factors on individual and community health and well-being. These factors include: • • • • • • • • • • • • exclusion and discrimination; physical environment of the North End; exposure to violence and crime; access to transportation; education and literacy levels; cognitive, learning and developmental disabilities; income level and poverty; access to jobs; meaningful connections and relationships; social support networks; access to responsive and inclusive programs and services, including recreation, childcare, youth and seniors programs and healthcare; and access to information about available programs and services
Environment plays a significant role in health and wellness, particularly for homeless and mentally ill individuals who face barriers accessing services that could improve their health and wellbeing. Reverend Britton discussed how challenging it can be to support community members in living healthier lifestyles: “So I was saying that of course poverty, under-education, certainly. . .I mean we have people who come here for food vouchers but I don’t know if they know what right choices to make when they go to the store with that food voucher. And we know that people who are at the poverty level they typically are not the healthiest of eaters because to eat healthy costs money. I think joblessness, we find that a lot of the men that have not been able to find any gainful employment for any length of time who 73
start to hang around the street, then start to fall into habits of just smoking, then drugs and stuff like that. Not taking care of the body anymore so that becomes an issue health wise for them.” (Cornwallis Street Baptist Church) One participant indicated that financial challenges make it difficult for her to adopt healthier eating habits: “Just in general, just to have that support and just you know.....like I can’t afford to go on Weight Watchers..it’s pretty expensive and it’s cheaper to eat something fast, you know what I mean like and it’s really...I’m diabetic and I know that I’m not supposed to eat unhealthy but I do, and I know I shouldn’t and I don’t exercise enough.” (Aboriginal, 31 year old woman) Another participant stated that many community members who suffer from depression and suicidal ideation find it difficult to seek help: “When it comes to health, I mean most people’s health is pretty good to a point. Most of the people’s health that I see that’s bad has more to do with a lot of drug addicts who will allow their health just to run down. Now why they don’t want to go to a doctor I think is because they have half a feeling of wanting to die in the first place. And that’s depression. I know depression, I’ve experienced depression to the point where I’ve gone and tried to commit suicide. Thank you lord, you didn’t let it happen so.” (African Nova Scotian, 57 year old man) The representative from ARK indicated that her clients often deal with multiple mental health problems, as well as learning and developmental disabilities: “O.K. I think . . .you were asking as well about mental disability and I think that’s reality too that there’s people with learning disabilities and developmental I guess it would be disabilities as well, which that exists and then also in addition, youth mental illness or yeah there’s again a whole spectrum of mental health related things, surviving on the street is very hard on the body and soul, spirit of a person so there’s many youth who experience depression, suicide, thoughts of suicide, and then the age group of youth who come here, there are maybe youth who haven’t been diagnosed schizophrenic or bipolar but would appear to be becoming mentally unwell and sometimes during the time that we’ve known them they do access care and are diagnosed or treated for illness kind of around those things.” (ARK) One of the most common complaints voiced by participants was the challenge that community members face finding and accessing mental health services and counselling support in the North End. For example, one participant stated that she has had return to the reserve to receive her medications since she encountered difficulties finding a doctor in Halifax: “Yeah, I know they have other clinics, I was told that I wasn’t allowed to participate in them unless my doctor was there and my family doctor…I didn’t have. . my family doctor at the time. . it took me almost two years to find a family doctor here in the city so my family doctor was in Shubenacadie where my reserve is and I would go to outpatient to get my care and when I went home he would give me my refills, my 74
insulin and all my other stuff, but if I needed anything I would have to go to outpatient which really stunk. But I did try to go over there but they were like well you have to be a patient, but at that time I didn’t know if we were going to stay longer or not so I didn’t switch doctors, so that kind of discouraged me too a little bit. Just being told that I couldn’t come...’cause I know there’s a walk-in clinic that I think they have but you have to be a patient so I just assumed that if you’re not a patient type of thing.” (Aboriginal, 31 year old woman) Health & Mental Health Promotion Accessing appropriate health and mental health services is challenging for many North End residents for a number of reasons, including lack of information, unavailability of culturally-specific health and mental health services in the area, lack of education and the stigma surrounding mental illness in their community. Several participants observed that health and mental health promotion must be a collaborative effort that involves inter-professional partnerships involving health professionals, community members, educators and the church. Health professionals are responsible for developing and implementing health policies and programs that target the specific health challenges facing specific communities. Community members can play a role in health promotion by sharing information on their experiences accessing and receiving health services to other community member. Educators can also play an important role in health promotion by leading workshops in the community that create awareness in the community about available services and programs. Finally, in guiding the spiritual life of community members, the church plays a central role in empowering and inspiring community members to take an active role in their spiritual, emotional, mental and physical health and well-being. Participants discussed the need for more effective health and mental health promotion in the North End. One participant indicated that while there is an abundance of information on health, information on mental health is less available: “Yeah, there’s lots of information out there about health, I mean people know how to be physically healthy if they want to. There’s a lot of information you see form the government, it’s on t.v., books written, 100 different books on physical health. But there’s not much promoted for mental health, it’s almost like a dirty little secret, we don’t want to talk about it.” (Aboriginal, 43 year old man) He also observed that mental health services need to be provided within specific cultural communities since many individuals are hesitant to access services outside their community: “Lack of self-esteem, lack of confidence, depression, anxiety, self-worth, they’re all there. I’ve seen it many times in the children and the adults, they tend. . they can’t ask for help, they won’t ask, from the non-Native society. There needs to be more help within their own community...people that understand on a cultural level. ‘Cause it makes these negative mental health problems that are causing them. . .and the lack of ability to get help within the mainstream society that causes them to self-medicate and as a result of so much of the drug and alcohol problems, the suicides. So many people I know are dead now because there was nowhere to go.” (Aboriginal, 43 year old man)
Mental health programs will only be effective if the stigma surrounding mental illness is reduced and eliminated, according to this participant: “Healing and wellness initiatives is another one that I feel fairly strongly about. Psychological counselling, physical health, problems within the Native community are some of the same that are within the Black community, diabetes, physical health, obesity rates. . addiction, and the addiction problems as I’ve stated before these are problems. . there are some problems or program rehabs but there are no mental health programs that would allow people to fix the problems to cause people to go for it, go towards addiction as a means of self-medication. That’s how people use drugs or alcohol to try to make themselves feel good, why are they trying to feel good, because they feel bad right. But. . .in order for mental health programs to work the stigma has to be taken off and people have to feel that it’s not a sign of weakness, they won’t be looked down upon for trying to access help, or they have to made aware that they have problems, be willing to admit that they have problems but if they don’t know how to define what those problems are, if there’s no education about what the problems are then they don’t know that they have to ask for help. It goes to lack of promotion of mental health, lack of education about mental health issues.” (Aboriginal, 43 year old man) Several participants stated that effective health promotion for North End residents involves providing services in the context of their lives, i.e. where, when and how they need it. The representative from ARK indicated that the agency collaborates with MOSH to provide health services to community members in the context of their daily life: “Well I’m kind of repeating myself but I think community is a big part of overall well-being and health, so for all of us who are here, people who work here, volunteer and come here, this community contributes to our wellness. Should I be more specific. . and then also kind of the reality I think is that many of the folks who come here find barriers to accessing health care for example dental health because of finances, maybe someone doesn’t have identification, many of our folks because of how they appear or discrimination sort of things by how they appear keeps them from receiving care at an emergency ward for example or just walking into a clinic and being able to see a doctor so there’s barriers like that that someone wouldn’t be able to access care. As well because of the nature of life around the street and the rhythm of it, it’s very hard to keep appointments and meet the requirements for getting into to see a psychiatrist or something like that. So kind of all those realities are . . we’re sensitive to them and try to make it so our folks here can access the care that they need and I think we facilitate that by a healthy relationship with the North End Clinic and also through MOSH, the Mobile Outreach Street Health, two of the nurses come here twice a week and just meet with people, their faces are known so there’s a building of trust and familiarity and also an ability to come here to meet people and set up times that are going to work when we’re open and kind of be easy to meet with them. And that’s also true for Mental Health Share Care, there’s a person who comes and is a familiar face and is building kind of a presence here that helps to kind of span some of the barriers that exist.” (ARK)
The representative from the North End Community Health Center discussed the various health promotion initiatives she has implemented in the North End: “For myself the programs that are non-clinical, I have a walking program/nutrition program that I do at the Health Center but we also have it in various other parts of the community as well and that is walking and we come back and prepare a meal and we eat together and our focus is on healthy living as a holistic part of our health in community. And I have a community kitchen that is outreach and that has been running for seven years through Metro Non-Profit and we prepare a meal together and healthy living messages. Then I also have a program at Direction 180 that is nonclinical focusing on healthy living. There is. . I have a weight loss program that I put together in partnership with community members that is a nine-week program that runs a few times a year and let’s see the others I think are mostly around diabetes and hypertension which are a little more clinical but still healthy-living based and they’re also outreach, I do them at other centers in the community and I’m just starting a new one actually next month and that is in partnership with Palooka’s Gym and they’re doing an after school program with the kids using visual arts and I’m going to be a nutrition component, healthy living with the kids, interactive, you know snack making and things like that.” (North End Community Health Center)
This section summarizes the research findings by addressing the research questions and objectives (outlined earlier) that the research sought to answer and achieve, respectively. First, the concept of “meaningful occupations” will be articulated based on participants’ own conceptualizations. Second, the personal, social and economic factors that hinder or prevent some North End residents from accessing and participating in meaningful occupations will be addressed. Third, this section examines how North End community members can be more effectively engaged in meaningful occupations. Fourth, the link between meaningful occupations and health will be examined to provide insight into how health may be positively or negatively impacted by exclusion from or access to meaningful occupations. Next, this section discusses ways to broaden the applicability of occupational therapy models to marginalized communities, in particular low-income and racialized communities. Finally, this section concludes with a brief discussion on health equity.
Part One: Conceptualizations of Meaningful Occupations
The project used an Intersectional Analysis to articulate participants’ diverse conceptualizations of meaningful occupations. It was concerned with examining how the intersections of race, culture, low-income/poverty, gender, sexual orientation, disability, age, education and other social constructs influence how participants understand and conceptualize meaningful occupations. Each individual perceives the world through a cultural lens that is informed and shaped by the aforementioned social identities, as well as by family upbringing and life experiences. Consequently, this project sought to challenge normative conceptions of meaningful occupations by allowing community members in the North End to articulate their own perceptions of the occupations they consider to be meaningful to them. For many participants meaningful occupations were those that enabled them to make a difference in the lives of others, grow 77
personally and professionally, build supportive relationships and feel a sense of belonging to their community. Occupations that were considered to be particularly meaningful were those that allowed them to participate in endeavours that reflected their cultural heritage and traditions, spirituality, age and sexual orientation and to cope with everyday experiences, realities and challenges, such as financial challenges, insecure housing, unemployment, education, family and health and nutrition. North End residents also conceptualize meaningful occupations as those that provide them with opportunities for self-development, including those that allow them to hone, utilize and volunteer their skills, talents and creativity to support their own cultural community and the wider community. Many of these occupations reflect the goal-directed activities and pursuits that occupy people’s time and lives that have been identified in the occupational therapy literature, such as work (paid, unpaid, vocational); study (apprenticeship and training); leisure; recreation and sport; and healthcare. Leisure occupations are culturally defined and shaped by social and cultural norms and evolve and transform across the lifespan. Many participants indicated that meaningful leisure participation, in particular, plays a central role in not only providing them with a sense of enjoyment and relaxation, but it also offers them meaningful opportunities to participate in activities that are intrinsically rewarding and that support the community in dealing with challenges around finances, health, substance dependence, employment and violence. Participants discussed the various ways in which their leisure pursuits enabled them to engage in activities that provide them with a sense of belongingness, cognitive stimulation, self-expression, creativity and service to the community. For community members in the North End, the history and traditions of their cultural and racial communities play a significant role in their choice to participate in certain leisure occupations. For example, both Aboriginal and African Nova Scotian participants indicated that they were interested in participating in cultural programs that provide meaningful opportunities for other North End residents to participate in activities that highlight various aspects of their heritage, culture and traditions. Leisure pursuits that enable them build a sense of community through meaningful interactions and connections with youth, adults and seniors were also mentioned as particularly important. Specific examples that were given of such leisure pursuits include youth mentorship programs and seniors clubs that engage seniors in games and activities such as cards, knitting and church services. The issue of identity and occupation was addressed in this research through an examination of how diverse identities (race; culture; gender; sexual orientation; age etc.) are constructed through engagement in and performance of occupations for diverse individuals and communities. Magnus (2001) articulates the relationship between occupations and identity by arguing that certain occupations give individuals a sense of meaning in their lives and conveys to others who they are, what they do, how they feel about what they do, or what they would like to spend more time doing. This research found that leisure pursuits shape identity construction for community members in the North End because they enable them to define their ever-evolving identities through meaningful engagement in activities that confirm, support and solidify their identities as Aboriginals, African Nova Scotians, women and men and as gay, lesbian and transgendered, among other identities. Consequently, leisure provides some members of the community with a sense of belongingness to their own community and to the wider community. Thibodaux & Bundy (1998) argue that in addition to cultural and personal issues, leisure participation is shaped by economic issues, which is particularly true for the communities that were the focus of this research. Individuals who typically have the opportunity to participate in leisure are those that have the income to do so. Consequently, participation in leisure activities often takes a back seat to dealing with the realities of everyday life, such as financial challenges, finding a job, obtaining more education and dealing with family and childcare responsibilities. Despite these challenges many community members recognize the importance of participating in occupations that 78
help them cope with daily life challenges and the sense of social exclusion and marginalization they experience. In this way, participants noted that their participation in various leisure occupations gives them a sense of agency in dealing with and challenging experiences of exclusion and marginalization due to inequality, discrimination, low-income and poverty. They specifically noted that the occupations that tend to hold the most meaning to them are those that make them feel accepted, valued and worthy and that allow them to make a positive difference in their own lives and the lives of others. Please refer to the Recommendations section of this report for more detailed information on participants’ suggestions for developing more meaningful occupations in the North End.
Part Two: Personal, Social & Economic Factors Shaping Access to & Participation in Meaningful Occupations
The issue of power, which was central to this research project, was explored in two main ways: • • empowerment through occupations and power inequalities
The project examined how marginalized community members become more empowered through access to and participation in occupations that they have been excluded from, such as work, leisure and healthcare. Occupational Justice Theory is concerned with the principle of empowerment through occupation, which emphasizes that possibilities for feeling or acting empowered in everyday occupations is often determined by the structure and organization of society. Disempowerment through occupation is often experienced as occupational injustices, such as the lack of purpose, meaning and fulfillment that individuals experience participating in certain occupations. Empowerment through occupation, on the other hand, is often experienced when individuals have the opportunity to participate and engage in occupations that are meaningful and enriching. Enablement of occupational potential involves collaborative interpersonal forms of helping, combined with the development of enabling policies, laws and economic practices to support all people individually and collectively in developing their occupational potential. For occupational therapists working with diverse clients, including low-income and racialized clients, this suggests how important enabling participation among marginalized community members is in helping to reduce the social, economic and political exclusion that many of these individuals experience and, consequently, empowering disempowered and occupationally deprived individuals and communities. This project also sought to articulate how power inequalities due to hierarchies of race, culture, socio-economic status, poverty, gender, sexual orientation, age and disability shape access to and participation in meaningful occupations for communities in the North End. While the occupational therapy literature has examined power differences, the discussion has virtually always been at the level of power relations between clients and therapists (Hays, Dean & Chang, 2007; Hopton & Stoneley, 2006; Kingsley & Molineux, 2000; Kirsh, Trentham & Cole, 2006). The discussion has rarely pertained to how power relations (such as those connected to poverty, race, culture, gender, citizenship status) affect health through: 1) access to material resources, such as housing, jobs, education and health and 2) access to meaningful occupations. And, while there has been much focus in occupational therapy on the role that culture plays in shaping access to occupations, discussions on race and privilege have largely been ignored. Moreover, the occupational therapy literature has largely failed to consider how race intersects with low-income, gender and 79
other social factors to produce specific experiences of marginalization, exclusion, inequality and discrimination for low-income and poor racialized individuals and communities. The concept of “person, place & occupations” in occupational therapy (Christiansen & Townsend, 2004) is a useful one for examining how social context and environment shape access to, participation in and experiences of meaningful occupations and impact on health. In considering the relationship and interaction between person, place and occupation, this project touched on two related issues: • • the cultural, economic, geographical, social and political organization of occupations and the role that geography and the built environment play in occupational access and participation
This project articulated the experiences and subjectivities of low-income racialized communities in relationship to the places and spaces in which they reside, move through, create and shape through their experiences, interactions and participation. It examined how issues of race and racialization, social class, income, poverty and other social identities intersect with spatial/ environmental/territorializing practices, discourses, and politics in a low-income community in Halifax. Moreover, it probed how the experiences and identities of these individuals and communities come to structure narratives, ideologies, discourses, practices, and politics in relationship to built and “natural” environments in the North End. In other words, the project demonstrates that the process of racialization occurs in and through places and spaces through acts of social, economic and political domination arising out of hierarchies of race, culture, social class, gender and other social identities. Consequently, the process of marginalization, subordination, inequality and oppression in these communities can be said to connect to spatial/environmental processes. For example, some of the participants in this project illustrated how acts of domination and power are legally accomplished through the expropriation of lands and the creation of racially segregated neighbourhoods in Nova Scotia, both of which impose limits to the extent to which Aboriginal and African Nova Scotian communities are able to engage in activities that provide for full satisfaction of basic needs, including employment, healthcare, transportation and access to social and government services. Participants also discussed how living in a low-income, racially and economically segregated and unsafe environment prevents them from participating in various occupations (work; leisure; health, etc.) that could support them in meeting their basic needs. This suggests that the socio-economic and political nature of place or space (e.g. unsafe, low-income and racially homogenous neighbourhoods) often limits participation in the occupations of daily life in the North End. According to Christiansen & Townsend (2004), “floundering communities” are those that deprive community members of opportunities to participate in meaningful occupations. While it is important to use caution in applying that concept to a community such as the North End that has great potential for growth, it is important to consider how the economically segregated nature of that community (i.e. high concentration of low-income racialized individuals), as well as the physical, social and cultural environments reproduce and sustain poverty and social exclusion and, consequently, serve to deprive community members from access to meaningful economic (e.g. jobs) and social (leisure etc) opportunities. In discussing the racialization of poverty in Canada, Galabuzi (2001) observes that the racialization of space and the existence of cultural and racial enclaves in urban centres such as Toronto contribute to and sustain growing poverty rates among racialized communities. Following Galabuzi and similar to the Toronto case, this project illustrates that the increasing concentration of racialized groups in urban centres, racial enclaves, and low-income 80
neighbourhoods such as the North End, intensifies the experience of poverty for these groups by creating barriers to occupational participation which, consequently, may jeopardize the health of individuals and communities. Despite the strengths of community members and potential for growth in the North End, residents face challenging and persistent individual circumstances, including low income, low educational attainment, unemployment and underemployment, single parenthood, violence and crime and poor health. For example, in their study on the individual/personal and institutional/ structural barriers that prevent Aboriginal, immigrant, and racialized mothers in Toronto from meeting basic needs, Gazso and Waldron (2009 b) found that the broader socio-political and economic context within which mothering (conceptualized as an occupation in occupational therapy) is performed presented both challenges and opportunities. For example, mothers had multiple needs in several areas, including housing; child care; transportation; income; food; community support; employment; neighbourhood safety; language; respite care; recreation; and health. They were aware of the various opportunities available to them in meeting their own and their family’s needs, such as community-run recreation programs that offer leisure activities for children. However, mothers shared that they faced several challenges in meeting all of these needs, particularly with respect to economic resources. It is also important to consider how health may be impacted by features of the built environment, such as residential surveillance, physical exteriors and barriers that separate the residential area into manageable sectors (Perkins, Brown & Taylor, 1996). For example, some features of the physical environment in low-income neighbourhoods, such as the North End, present risks in the form of noise, pollution, traffic, lack of recreational amenities and physical environments that make residents vulnerable to negative elements. Moreover, other aspects of the built environment may convey that residents do not value or take pride in the public spaces in their community, such as litter, dilapidation, graffiti and lack of shrubs, trees and gardens, an issue that was addressed by one participant who suggested that a clean-up project be implemented to transform various unattractive elements in the North End into a more aesthetically pleasing space. These conditions contribute to the ongoing stigmatization of these communities and promote a climate that is not conducive to healthy communities (Perkins, Brown & Taylor, 1996).
Part Three: Engaging Community Members in the North End in Meaningful Occupations
Community engagement was mentioned by several agency representatives as particularly challenging in the North End. Community members discussed various factors that inhibited or prevented them from engaging in work, leisure, recreation and other occupations in the North End, including not feeling valued by agencies and in the wider community, in general; lack of culturally inclusive services and programs; not feeling welcomed and accommodated by community agencies; past experiences of exclusion and discrimination in Halifax and in the North End; a general lack of interest and motivation; lack of affordable childcare; scheduling conflicts; lack of time; lack of transportation; and fear of violence and crime. Community engagement involves proactive multisectoral collaborations involving community members, agencies, government and other interested parties that are premised on a meaningful vision for the future. It is a process that brings together diverse stakeholders in order to enable collective change and mobilize communities to address local issues and priorities and create solutions to community needs. Most importantly, however, community engagement empowers community members by locating them at the center of 81
the community engagement process. The Tamarack Institute for Community Engagement (2010; 2005) identified seven key criteria to community engagement: • • • • • • • A broad range of people are participating and are engaged; People are trying to solve complex issues; The engagement process creates vision, achieves results, creates movement and/or change; Different sectors are included in the process; There is a focus on collaboration and social inclusion; The community determines local priorities; and There is a balance between community engagement processes and creating action
Youth engagement, in particular, has been defined by the Laidlaw Foundation (Tamarack, 2010; 2005) as a process of meaningful, voluntary participation of people 12 to 24 years in the decision making and governance of organizations and programs which results in: • • • • • an impact or contribution towards change; an increase in youth’s understanding of what impacts them; shared power between youth and adults; youth opinions, perspectives valued; and youth building their vocabulary of experiences
It is particularly challenging to engage community members for whom the cycle of poverty, and the stigma associated with it, often results in a sense of hopelessness and powerlessness that can be debilitating, leaving some community members with little motivation to participate in community programs and services that may help them make meaningful changes in their lives. For example, some participants who are on social assistance believe that they are set up to fail because social assistance discourages some individuals from working (since their income will be deducted if they work over a certain amount of hours) and forces other individuals to look for alternative means to generate income, including criminal activity, sex work and non-traditional work. Homeless individuals may find themselves in a “catch 22” situation since their lack of a permanent address makes them ineligible for social assistance. When hopelessness, powerlessness and discouragement are compounded by mental health and substance dependence issues, it may be particularly challenging for some community members in the North End to engage fully in their own community. Consequently, many community members feel as if they are “stuck in a rut” and lack the know-how, guidance or will to move forward in their lives. Therefore, surviving the day to day challenges of life will, undoubtedly hold more priority for some individuals than engaging in various community initiatives and programs that, on the surface, don’t seem to satisfy many of their basic needs. One issue that inhibits community members from engaging in community initiatives and programs is the tendency for some agencies in the North End to offer services for one specific racial and cultural community or to focus too narrowly on immigrants or seniors, which, some participants believe, reinforces existing social, cultural and racial divisions amongst community members and poses barriers to effective partnerships between agencies and between community members. Moreover, several participants stated that they experience various levels of exclusion and discrimination due to stereotypes and stigmas associated with race, culture, sexual orientation, religion and spirituality, education and literacy, disability and age in the wider community and within 82
community agencies in the North End. Participants observed that, in general, there are unique outcomes for youth and seniors who are not being adequately engaged: some youth may be more apt to get involved in negative behaviours, such as crime; seniors experience isolation and loneliness, which may be compounded by a reluctance to venture out from the safe confines of their homes due to fear of violence and crime. Also posing significant barriers to community engagement for some participants is the failure of some agencies to adequately accommodate community members’ needs or to validate the daily challenges they face, particularly around finances, childcare and transportation. Participants identified several strategies for engaging Aboriginal and African Nova Scotian communities in meaningful occupations in the North End, including developing more responsive community programming and services; community outreach; promotion and publicity; and building and nurturing increased partnerships between agencies in the North End. The specific responsive programs suggested by participants include employment programs; workshops and peer support; seniors programs; and children and youth programs. The need for increased partnerships between North End agencies was also identified by agencies and community members as particularly important for fostering a sense of community in the North End, particularly between community agencies and community members who feel disconnected and disengaged. These partnerships will only succeed, however, if there is a willingness to move beyond “professional turf barriers” to develop more meaningful collaborations that draw on diverse experiences, skills and knowledge of community agencies and, most importantly, community members.
Part Four: The Relationship Between Meaningful Occupations & Health
The link between meaningful occupation and health and well-being has been welldocumented in the occupational therapy literature and was discussed earlier in this report. Participation in occupation has been found to play a crucial role in giving purpose and meaning to individuals whose lives have been disrupted by illness and disability. Occupational therapists recognize that the stress of daily living is often reduced when individuals are fully engaged in meaningful occupations that distract them from their suffering (Gutman & Biel, 2001). It is important to point out here that the notion of suffering in this research is understood in holistic and multi-dimensional ways, i.e. as the interconnection between spiritual, emotional, mental, psychological and physical health and well-being. In addition, this project demonstrated that health is a product of historical, structural, institutional, social and personal/individual factors and processes. In other words, health is not simply about biologically or genetically based illnesses, but also about levels of exposure to inequality, discrimination and oppression; income; residence in economically deprived, under-resourced and unsafe environments; lack of information about and access to inclusive and responsive services and opportunities, such as work, health care, childcare, transportation, recreation, leisure; education and literacy; and availability of social support networks. Having strong social support networks has been found to be vital in offsetting the stresses of daily life, particularly for marginalized individuals. According to Doreian & Stokman, “the simplest and most fundamental definition of [network] structure is a set of social actors with a social relation defined over them [such as] a small group of ‘people’ and the relation friendship” (1997, p. 1). Early theorization of the contribution of social environment to mental health (Cassel, 1976; Cobb, 1976) puts the foundation on social ties on mental health and, later, developments by Berkman & Glass (2000, pp.137-173) expanded this concept to include social networks and social integration. Several Canadian studies have focused specifically on how social support networks buffer or alleviate mental health problems. In summary two types of mental health supports are noted: buffering effects and 83
alleviating effects. For example, researchers have shown that social network has a buffering effect on mental health service use with as much as a 52% reduction in mental health service use when the frequency of contacts among network members increases (Maulik, Eaton & Bradshaw, 2009). More support leads to the lessening of the burden of mental illness and increased use of mental health services. Two Nova Scotia based research projects revealed that Black communities rely on a variety of supports for dealing with depression, including church and blood family members, spiritual practices, talking to others, proactively ‘doing’ things to take control of their lives and family doctors, the latter being consistent with the higher overall incidence of psychiatric disorders (Etowa, Keddy, Egbeyemi & Eghan, 2007; Kisely, Terashima & Langille., 2008). Health is a particularly significant issue for communities that suffer from a legacy of oppression, discrimination, low-income and poverty, insecure housing, unemployment, educational underachievement and other social determinants of health. A Healthy Community perspective (Ontario Healthy Communities Coalition, 2010) was at the core of this research project as it probed how barriers accessing meaningful occupations impact on participants’ emotional, spiritual, mental and physical health and well-being; how engagement in occupations, such as work, education, recreation and leisure foster a sense of connectedness to and social inclusion in one’s own community and the wider community and impacts on health and well-being; and how safe and healthy communities can be fostered through meaningful occupational engagement by marginalized communities. Moreover, a Healthy Community process is premised on the participation and involvement of all sectors of the community and the creation of health policies that promote social prosperity and community health. Consequently, this research was premised on the notion that a healthier North End community can be fostered if community members are given more meaningful opportunities to participate in occupations that are self-determining and self-empowering. Moreover, the research argues that healthier communities require collaboration among diverse stakeholders (community agencies; community members; health agencies; social service providers; religious/spiritual organizations; educators etc.) who are willing to share their knowledge, expertise and perspectives. Finally, this project demonstrated that healthy communities also require that community members have full and equitable access to resources and opportunities (economy; food; shelter; income; safety; health care services; work and recreation; opportunities for learning and skill development), equity and social justice and to supportive social networks and communities. These issues have important implications for health policy and services in Nova Scotia, particularly around the development of more culturally-specific health policies and services that address the health challenges of all Nova Scotian populations whilst simultaneously acknowledging the specific and unique challenges that put Aboriginal, African Nova Scotian and other racialized communities at increased risk for various health problems due to exclusion, inequality and discrimination.
Part Five: Broadening the Applicability of Occupational Therapy Models to Low-Income Racialized Communities
This research considered how three main occupational therapy models and theories can be applied more broadly to capture the experiences of low-income, racialized communities such as those residing in North End, Halifax. The models/theories include: 1) Canadian Model of Occupational Performance and Engagement (CMOP-E); 2) Model of Human Occupation (MOHO); and 3) Occupational Justice Theory. CMOP-E is a client-centred model of practice that proposes that health is determined by the interaction between the person, occupation and environment. It considers how the physical (natural 84
and man-made elements), cultural (race, religion, values and beliefs), social (an individual’s roles and people involved in his or her life) and institutional (political, economic and legal) environments shape occupational performance and engagement. Applying and contextualizing this Model to the specific experiences of low-income racialized communities in the North End requires an understanding of how ideologies and hierarchies of race, culture and social class shape policy decision-making related to communities deemed worthy of obtaining necessary resources. Individuals who reside in neighbourhoods that have high concentrations of low-income, racialized individuals often experience exclusion, marginalization and disadvantage due to long-standing political, economic and legal inequalities, limited access to resources and weak ties to the local community, the larger metropolitan area and the power structure (Ross, Mirowsky & Pribesh, 2002). Moreover, while these communities are often characterized by dense networks and local patterns of friendship, they remain vulnerable since those relationships rarely extend beyond the local area. In this way, the interaction between environment, person and occupation is a particularly pernicious one when one considers that the availability of occupations (e.g. jobs), in particular, meaningful ones, is low in neighbourhoods where residents are excluded from decision-making processes. The Model of Human Occupation (MOHO) is particularly useful for articulating the various factors that make participation in occupations meaningful for individuals and communities. It helps illuminate even further how participation in meaningful occupations is determined by availability of occupations that reflect individuals’ values, interests, motivation and sense of competence and effectiveness (volition); the physical and mental skills and competencies required to perform specific occupations, as well as individuals’ own interpretation of the outcome of an event (performance); the physical space and built environment, social networks and interaction and the availability of occupations for various communities (environment); and habits, internalized roles and identity and patterns of behaviour in response to familiar physical, social and temporal surroundings (habituation). Law (2002) elucidates this concept of habituation by arguing that coffee shops, recreation centers, churches, bowling lanes and other environmental settings result in behaviours (e.g., level of noise, degree of formality) that persist over time in certain settings. Through socialization over the life span, individuals learn these patterns of behaviour and activity and, consequently, participation patterns and interactions with others in the course of daily life routines develop in a wide variety of settings. When applied to the experiences of low-income individuals and communities specifically (e.g. North End residents), the MOHO can be used to examine the extent to which neighbourhoods with high concentrations of low-income, racialized communities provide individuals with institutional support to participate in occupations that reflect their identities, roles, interests and values, education level and professional skills and competencies. The motivation that these individuals have for continuing to access and participate in these occupations is often determined by their evaluation of the outcome of their participation in occupations, i.e. the extent to which it has had a positive impact on their daily life and has helped to alleviate some of the immediate day-to-day challenges they face. For example, communities like the North End that face challenges around income and poverty, insecure housing, unemployment and underemployment, childcare and health will be most concerned with participating in occupations that support them in dealing with these issues. Therefore the motivation to continue participating in occupations may stem more from external incentives (money; jobs; childcare; stable housing etc.) than from internal ones. Consequently, programs and services developed for low-income, racialized communities must focus on providing these communities with resources that will support them in coping with daily challenges and meaningful opportunities (.e.g. workshops; education and training; information; referrals) that assist them in making more positive, long-term and permanent changes in their lives through the development of personal, social, academic and professional skills and competencies. 85
Finally, while Occupational Justice Theory is useful for providing insight into how inequalities influence access to and participation in meaningful occupations in “floundering communities”, it has largely failed to probe in any critical way how race and racial discrimination limit occupational participation for low-income, racialized individuals and communities. So, while the Framework of Occupational Justice (Christiansen & Townsend, 2004, p. 336) lists numerous contextual factors that play a role in occupational justice or injustice (age; gender; sexual preference; ability/disability; income/wealth; employment status; ethnicity; religion; national origin; political beliefs; urban/rural location; homelessness; family/friend support; health status), race is conspicuously missing from the list, leading one to believe either that the concept of race is subsumed within the concept of “ethnicity” in the Framework of Occupational Justice or that the profession of occupational therapy does not perceive race as playing a sufficiently important role in limiting and preventing certain individuals from accessing and participating in occupations. This is problematic since sociologists have long argued that race and ethnicity are not interchangeable concepts and should have independent analytical status. While ethnicity refers to the shared sense of identity, inclusion and exclusion that individuals experience due to a common heritage, language, religion, nationality, kinship and ancestry, race refers to the shared sense of identity, inclusion and exclusion that individuals experience due to visible markers of difference, such as skin colour, facial features and hair texture. The history of Aboriginal and Black peoples in Canada and Nova Scotia demonstrates quite clearly that these “visible markers of difference” were used by European colonizers to implement policies that served to exclude, marginalize, discriminate and oppress and continue to inform ideologies and perceptions of different groups in contemporary societies. Moreover, while some policies from a bygone era have long since been eradicated, their impact on these communities linger today as Aboriginal and African Nova Scotian communities in Canada and Halifax, in particular, continue to face exclusion, discrimination and disadvantage in the social, economic, educational and political spheres (discussed earlier in this report), all of which compromise opportunities to access specific occupations (e.g. work; education) by these communities. Moreover, the failure of Occupational Justice Theory to appropriately contextualize the experiences of individuals and communities through an Intersectional Analysis that considers the intersecting relationships between the contextual factors that have been listed in the Framework of Occupational Justice suggests a limited scope in understanding the complex ways in which, for example, gender, race, income and employment status intersect and interact simultaneously to produce specific life experiences for low-income, unemployed African Nova Scotian women that may be different in many ways than the experiences of low-income, unemployed Aboriginal women or high-income, employed White women. It is also important to consider how the outcomes of occupational injustice listed in the Framework of Occupational Justice (Christiansen & Townsend, 2004, p. 336) can provide a deeper probing of the factors that shape access to and participation in occupations for low-income, racialized communities in the North End. These injustices include: occupational marginalization, occupational deprivation, occupational alienation and occupational imbalance. For example, while Christiansen and Townsend observe that occupational marginalization often operates invisibly to discriminate against individuals because of age, gender and disability, their failure to include race as a contextual factor in the Framework of Occupational Justice (discussed earlier) ignores and denies how hierarchies of race and the resultant power differentials between communities of diverse races play out in the structures and institutions of society and in the everyday interactions between individuals. Consequently, as this project demonstrated, low-income, racialized communities, such as those in the North End, are often not afforded opportunities to access and participate in certain occupations due to long-standing ideologies about race and socio-economic status in Canada and Nova Scotia that position African Nova Scotians and Aboriginals on the lowest rung of the social, 86
economic and political ladders. For many of the women who participated in this research, gender and income intersect with race and social class to limit their opportunities for accessing and participating in occupations. For example, the financial struggles that many of these women experience are compounded by their social class standing, single parent status, unemployment and under-employment, as well as their failure to acquire educational credentials. Consequently, these factors have played a significant role, according to some of these women, in limiting their opportunities to access and participate in certain occupations, such as work. Occupational deprivation is another occupational outcome listed in the Framework and refers to the limitations experienced by individuals, families, groups, communities and populations engaging in occupations of necessity and/or meaning due to external factors beyond their control. It is an outcome that characterizes the experiences of some Aboriginal and African Nova Scotian men in the North End for whom lack of access to jobs and other opportunities may lead them to a life of crime and, consequently, incarceration. In Canada and Nova Scotia, ideologies about race and gender intersect to produce a particular characterization of Black, Aboriginal and other racialized men that contribute to higher rates of racial profiling, over-policing, use of force and incarceration (Henry & Tator, 2006). As one participant who had recently been released from prison observed, more programs need to be developed that support individuals in re-entering the workforce after incarceration. While involvement in criminal activity has been identified as an occupation in occupational therapy, it is an occupation that exists at high rates in communities where individuals lack access to jobs and other opportunities. Occupational alienation characterizes individuals who engage in occupations that are not spiritually, emotionally and mentally enriching and who, as a result, experience life as meaningless and purposeless. For several participants in this research, the desire to obtain more education and training was directly related to the lack of fulfillment they were experiencing in their current employment and their desire to find more meaningful employment. Other participants offered suggestions for developing leisure and recreation activities that addressed the everyday challenges that individuals in the North End experience and that, consequently, had connections with meaning in the broader context. Occupational alienation is a significant occupational outcome in low-income, racialized communities because low education, low income, poverty and discrimination deprive these communities of meaningful occupational choices. These choices are typically afforded to those whose education, social class, race, gender, age, income and connections to supportive social networks provide them with access to opportunities in the social, economic and political spheres of society. Finally, occupational imbalance is a concept that refers to the imbalance that occurs when individuals allocate little or too much time to certain occupations and, consequently, lack a variation in productive, self-sustaining and leisure occupations. This particular outcome was articulated often by participants in this research who indicated that work and school responsibilities left them little or no time to participate in leisure and recreational activities. Many of these individuals perceive participation in leisure and recreation as a luxury in the context of the day-to-day challenges they face around unemployment, finances, childcare and insecure housing. Consequently, many participants stated that they spend more time dealing with those challenges than partaking in leisure and recreation, such as exercise, sports and volunteering. This suggests that some individuals in the North End tend to be over-occupied in occupations that support them in dealing with many of life’s challenges and under-occupied in other occupations that fulfill other emotional and spiritual needs. Occupational injustices are said to lead to stressful occupational experiences that culminate in “disease” for individuals, families and communities. Christiansen and Townsend (2004) use the term “disease” to refer to individual fatigue and immune system disorders, international civic disturbance and social disintegration of health, education and other systems. However, while the 87
authors distinguish between illnesses that have their root in internal, genetic or biological factors and those that result from environmental factors and processes, the term “disease” is misleading because it suggests a biomedical/internal/genetic/biological understanding of health, rather than an understanding that acknowledges the various external determinants that impact on health. Interrogating how social structures “get under the skin” and disrupt our biology may be one way to understand how various social processes and determinants impact health. In other words, while it is important to appreciate that poor health is about having problems with one’s organs and being exposed to social problems, it may be even more important to understand health as being a product of how social problems affect the organs (California Newsreel, 2008). The “social determinants of health” is an area of increasing interest in occupational therapy because of its focus on the impact of external events and factors on health (e.g. marginalization; inequality; discrimination; poverty; crime; environmental hazards; segregated neighbourhoods; insecure housing etc.) and because it illustrates the role that social policy plays in shaping the health of individuals and communities. In fact, some health professionals argue that public policy is health policy since the absence of policies for marginalized communities creates the poor social conditions that lead to unhealthy communities.
Part Six: Health Equity
Differences in population health, or health disparities, can be traced to unequal economic and social conditions that arise out of historical, structural, institutional and everyday inequalities. Health disparities between more and less advantaged populations describe the differences in health experience and health outcomes based on social structure (education system; labour market); an individual’s social position (socio-economic status; geographic area; age; disability; race; gender; sexual orientation, etc); intermediary factors (environment; health behaviour; health access; and social care) and health outcomes (e.g. illness or good health). It may also be explained by disparities in neighbourhood and environmental characteristics such as those relating to opportunity structures or stresses in the physical and social environment. Given the many external and environmental determinants that continue to impact on the health of communities, in particular marginalized communities, health equity policies are viewed as integral for reducing and eliminating health disparities between more and less advantaged communities. Health equity policies are concerned with improving health by first focusing on the organization of society, particularly how social and economic resources are distributed unequally by gender, race, class and other factors. In other words, health equity involves tackling health disparities by broadening our lens to bring into view the ways in which jobs, working conditions, education, housing, transportation, crime, income insecurity, food insecurity, social inclusion, discrimination and political power impact individual and community health. Eliminating the challenges low-income racialized communities in the North End face around those issues is as much a health promoting initiative as traditional health promotional strategies such as healthy eating and exercise campaigns. Consequently, developing more culturally-specific health services and programs will not only assist health professionals in responding more effectively to the specific social, economic and political factors that drive health in these communities, but it will also help to reduce and eliminate persistent and long-standing health disparities between white and racialized communities in Nova Scotia that are the consequence of public policy and the unequal distribution of societal resources along race, gender, class and income lines.
In conclusion, this research has several important implications for occupational therapy practice, particularly in relation to low-income, racialized and other marginalized clients. First, it is important that therapists consider how differences between them and their clients with respect to race, social class, education, income, gender, sexual orientation and other social identities may shape their interactions and relationships with clients. Moreover, therapists must acknowledge that supporting and enabling clients who hold multiple identities simultaneously (e.g. an African Nova Scotian, 66 year old lesbian disabled woman) may involve identifying and helping clients deal with the multiple structural, institutional and everyday inequalities, inequities and barriers that clients face due to those multiple identities. It may also involve teasing out one or more identities that are particularly salient for a client and supporting her or him in challenging and overcoming multiple barriers by first focusing on and dealing with a barrier that is particularly salient. Second, enabling occupational potential in clients requires that occupational therapists take more seriously the issue of power – not simply the inherent power inequities between clients and therapists, but also the power inequities that arise out of hierarchies of race, social class, gender and sexual orientation in society and that structure the relationships that clients have with organizations, agencies and other individuals. In other words, client centeredness is not merely about assessment and problem identification, planning in partnership, outcome assessment, client decision-making, respect for and support of client values, strengths and priorities and client self-efficacy and enablement. It must also be about locating and centering clients’ experiences and capacities in the context of historical, structural, institutional and everyday phenomena, events, practices and processes. This is particularly important for low-income racialized communities who have been located and centered in ways that have been particularly disempowering. Consequently, therapists need to consider the kinds of accommodations that need to be made with respect to muting or reducing power differentials between them and their clients in order to effectively guide, enable and support clients in accessing and participating in occupations of their choice, including those occupations that they have experienced barriers accessing. Finally, the research touched on and points to important issues that must be addressed in future occupational therapy research, including racialized access to resources; political ecologies of race, space, and urban environmental practice; intersectional engagements with race, gender, sexuality, class and other identities; and environmental and climate justice.
XII. Key Messages
This research identified the following five (5) key messages: • Aboriginal and Nova Scotian community members in the North End conceptualize “meaningful occupations” as those that provide them with opportunities to build and nurture a sense of community belongingness and connections with others; to feel accepted, valued and worthy; to make a difference in the lives of others; to develop and share professional, personal and creative skills, competencies and talents; and to instil cultural pride in their own communities, as well as share their cultural heritage with the broader community; Community agencies in the North End must develop meaningful programs that reflect the everyday challenges that Aboriginal and African Nova Scotian communities face relating to inequality, exclusion and discrimination; low-income and poverty; unemployment and 89
underemployment; insecure housing and homelessness; childcare; transportation; and health and mental health; Culturally-specific health policies and services in Nova Scotia must acknowledge the relationship between access to and participation in meaningful occupations (work; study; leisure; recreation; healthcare) and the physical, psychological, mental and spiritual health and well-being of African Nova Scotian and Aboriginal community members in the North End; Creating safe and healthy communities in the North End involves engaging North End residents in meaningful occupations through a multi-pronged effort that includes collaborative health promotion strategies; community outreach; internet and social networking/media; television, radio and newspapers; and distribution of promotional documents (brochures, flyers etc); and Tackling health disparities in the North End and in Nova Scotia requires that health equity policies focus on reducing and eliminating the social, economic and political inequalities that limit and prevent the unemployed and under-employed, under-represented and misrepresented and under-engaged from participating in meaningful occupations.
This section provides recommendations for community agencies in the North End in two main areas: • Developing meaningful occupations for North End residents and • Engaging North End residents in meaningful occupations Developing Meaningful Occupations for North End Residents • • • • Develop employment workshops that assist community members in finding jobs; Develop youth employment opportunities; Develop a referral service that connects clients to available jobs opportunities; Develop a program to assist individuals who have been released from custody in re-entering the workforce. These programs should train these individuals in developing practical job skills such as making upholstery and furniture etc. Support clients with different education and literacy levels; Support individuals in obtaining educational diplomas and degrees; Offer computer training workshops; Develop workshops on financial planning; budget management; fitness and weight loss; healthy eating; creative expression; spiritual healing; self-esteem; and parenting; Provide ongoing education and training to agency staff on how the following issues impact the health of clients: discrimination; access to transportation; education and literacy levels; cognitive and learning disabilities; financial issues; access to jobs; and support networks; Develop programs that instil cultural pride in Aboriginal and African Nova Scotian communities, including youth; Develop seniors programs and clubs that engage seniors in activities inside and outside their homes, e.g. knitting, crocheting, card games etc.; Provide more opportunities for community members to contribute to decisions around the development of programs and services; 90
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Implement a “clean-up project” in the North End that brings community members together to clean up the North End; Develop a car pooling service for community members who lack access to transportation; Implement a “neighbourhood watch” program that hires volunteers to support community members who feel unsafe in the neighbourhood, including accompanying seniors on errands etc.; Provide opportunities and spaces for youth, adults and seniors to come together to share experiences and build a sense of community through meaningful interactions, connections and social networks, e.g. recreational and sports activities, such as ball and basketball tournaments and outdoor games (e.g. “horse shoes”); Provide a program that provides opportunities for youth to reach out to and connect with seniors in the community, e.g. a program that enables youth to volunteer a few hours of their time every week visiting seniors in their homes; Provide community members with meaningful opportunities to participate in activities that enable them to develop, express and share their professional and creative talents and skills with others; Offer after-school programs during the days and evenings and throughout the week and weekends that provide youth with opportunities to participate in recreational, school and creative activities; Develop youth programs that are offered during the days and evening and throughout the week, weekends and summer that engage youth in outdoor recreational activities; Develop youth mentorship programs that provide opportunities for adults and seniors to share their own life experiences with youth; Hire community organizers to develop sport and recreational programs and events for youth; Offer free exercise classes to community members; Develop more culturally-specific health programs that reflect the worldviews and cultural traditions and practices of Aboriginal and African Nova Scotian communities; Offer free mental health support groups that provide supportive and holistic health services for clients who are dealing with daily life challenges; Develop individual and group youth counselling programs that focus on sexual health and education, youth parenting, financial management, housing and other issues; Develop more effective health and mental health promotion strategies that focus on the following: increasing awareness about physical, emotional, mental and spiritual health issues; reducing and eliminating stigma around mental illness; promoting healthy lifestyles; providing information on and referrals to available substance dependence and mental health and counselling support services; assisting and supporting clients in accessing health and mental health services; and Implement collaborative health promotion strategies involving diverse stakeholders, including health professionals, community agencies, community members, educators and the church; These strategies must provide opportunities for community members, health professionals, educators and spiritual leaders to provide information on the following: experiences accessing and receiving health services; available health, mental health and substance dependence services; and guidance on leading healthy spiritual lives.
Engaging North End Residents in Meaningful Occupations Creating a Welcoming Environment • • Ensure that frontline workers and other staff provide a welcoming environment for new and long-term clients; Ensure that frontline workers and other staff are aware of clients’ sensitivities around disclosing private, sensitive and personal information, which is often required of them in order to access services and programs; Provide training to staff that support them in confronting their own assumptions and stereotypes around race, culture, sexual orientation, religion, poverty, disability, homelessness, mental illness and other challenges faced by clients; Validate and be inclusive of the diverse religions and spiritual belief systems of all cultural communities represented in the North End; Acknowledge the challenges that clients experience around finances and childcare by providing spaces where children could be supervised while parents attend programs and services; Offer programs and services during the days and evenings and on weekdays and weekends that bring the whole family together and that, consequently, eliminate the challenges parents experience finding affordable childcare; Consider how programs and services can be more inclusive of and accessible to clients with cognitive, learning and developmental disabilities, low levels of education and varying levels of English literacy skills (e.g. helping clients fill out forms and reviewing other documents and guidelines with them in person); and Develop increased inter-agency partnerships in the North End that provide agencies with opportunities to draw on diverse skills, experiences and networks, learn from one another, eliminate redundancy in programming and respond collaboratively to community needs.
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Creating Awareness about Programs & Services • Develop referral services that provide adults, seniors and youth with information on community resources, services and programs, such as housing, food banks and health and counselling services etc.; Assist parents in registering their children in youth programs, including free or subsidized youth programs; Hire outreach workers to conduct outreach in the community in order to identify community needs around services and programs, particularly for hard-to-reach individuals; Develop more effective outreach to men in the community in order to increase their awareness of and access to programs and services (since men tend to access services less than women); and Create awareness of agency programs and services through the following promotional strategies: community outreach and direct communication; posters, brochures, newsletters and flyers; community newspapers; email listserv; webpage; Kijiji; social networking websites; Halifax North Memorial Public Library; church; radio and television; and a Directory of Community Services, Programs and Resources.
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XIV. Model for a Community-Driven Initiative in the North End
This Model for a Community-Driven Initiative provides community agencies in the North End with a loose framework for developing a community-driven initiative that engages youth, adults and seniors of diverse cultures and races in the North End. It combines some of the suggestions made by participants in this research, which are outlined in the Recommendations section.
Model for a Community-Driven Initiative in the North End Objectives
• • To provide opportunities for community members to develop, implement and lead a community initiative that brings together seniors, adults and youth of diverse races and cultures; To bring together and engage diverse stakeholders, including seniors, adults and youth and community agencies, health professionals, educators and others to develop meaningful relationships and support networks, share experiences and learn from one another through activities, such as recreation, workshops and mentorship; and To develop community members’ employment skills by providing them with opportunities to participate in decision-making and program development and to organize and lead workshops and recreational activities for youth, adults and seniors.
• • Recreational Activities: activities that engage seniors, adults and youth of diverse races and cultures, including games, sports, art and creative expression, cultural activities, socializing etc. Employment Skills Development & Training: workshops conducted by professionals and community members on finding employment, re-entering the workforce after illness, incarceration etc., preparing resumes and cover letters, job interviews and computer training. Education/Study: workshops conducted by professionals on literacy, academic upgrading, completing high school, applying to university etc. Mentorship: opportunities for adults and seniors to provide guidance, information and support to youth. Health & Mental Health: workshops conducted by professionals and community members on self-esteem, health, healthy eating, weight loss, exercise, etc.; and Childcare: safe space for parents to bring children while participating in activities outlined above; Potluck: participants provide food and refreshments; and Social Networking/Media: develop Facebook group to engage and foster communication between community members.
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This Model for a Community-Driven Initiative in the North End seeks to empower community members by utilizing the community knowledge, expertise and skills of seniors, adults and youth as resources to engage community members in meaningful occupations. Its communitydriven agenda proposes that community members will take ownership of the initiative by 93
developing, implementing and leading planned activities. It proposes to bring together diverse stakeholders (community members, community agencies, health professionals, educators) in order to foster more meaningful connections and collaborations between individuals, neighbourhoods and communities. The initiative seeks to connect individuals to their neighbourhoods and communities in more meaningful ways by providing them with opportunities to take on leadership roles in program development, social development, community leadership and community education. Participants of this initiative will have the opportunity to develop intellectual, technical and practical skills that will enhance their access to training and employment opportunities, educational opportunities, leisure and recreation and health information and other resources. The initiative is premised on the notion that collaborative efforts among diverse community members and stakeholders build a sense of community, foster important social networks, empower communities and, consequently, promote healthier neighbourhoods.
XV. Knowledge Sharing Activities
Diverse and innovative knowledge sharing activities are at the core of this research project. The key messages outlined earlier will be communicated, disseminated and shared to diverse knowledge users (community members; community agencies; service providers; health agencies; health professionals; health policy makers; university professors; researchers; university students) using diverse and innovative knowledge sharing approaches that allow for collaboration, feedback, knowledge co-creation and joint problem-solving. These activities will create awareness about the research findings among knowledge users and will be used to engage knowledge users in ongoing discussions around the issues presented in this report in more direct, immediate and accessible ways, particularly since these knowledge users don’t often have opportunities to engage with one another in meaningful ways. Knowledge sharing activities for this project will involve the synthesis, dissemination and exchange of knowledge to support the development of more meaningful occupations by North End agencies. These activities will also be used to share findings that will inform health programs, services and policies by demonstrating the link between meaningful occupations and health for Aboriginal and African Nova Scotian communities. The knowledge sharing activities that will be implemented are premised on the notion that innovation and transformative change relies on effective collaboration with others. The premise of the knowledge sharing approach used in this project is that knowledge users are more likely to be mobilized to action around the development of programs, clinical practice and policy if they are impacted and engaged cognitively and, most importantly, emotionally by the experiences of Aboriginal and African Nova Scotian community members and if communication barriers between these professionals and the marginalized community are reduced and eliminated. Most importantly, however, knowledge sharing activities will be aimed at putting research findings and knowledge to active use in ways that impact positively on low-income and poor racialized groups, particularly around the development of initiatives and policy geared towards reducing and eliminating their access to and participation in meaningful occupations. In addition to the partnerships already forged through this project with the North End Community Health Center, the project partner, and other agencies, partnerships with other community agencies and individuals in the North End will be fostered to share knowledge from this research through multiple knowledge sharing avenues. Knowledge sharing activities will involve a multi-pronged approach that will proceed in the following way: • community report; 94
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presentation of findings to community groups, Mayor’s Office and other agencies; community program development; policy briefs; community newspapers (print; online); DVD film; DVD viewing event; social media (e.g. Facebook; Twitter); peer-reviewed journal articles; and academic conferences
1) Community Report: A summary report of the research project will be disseminated to the North End Community Health Center, the project partner, as well as the agencies that participated in this project. These agencies include ARK, Stepping Stone and Cornwallis Street Baptist Church. The report will also be disseminated to other community agencies and government departments that focus on health inequities, social justice and social inclusion specifically related to Aboriginal, African Nova Scotian and other marginalized populations in Nova Scotia. These agencies include the Mi’kmaq Native Friendship Center; the Office of Aboriginal Affairs; the Health Association of African Canadians; the Office of African Nova Scotian Affairs; the Nova Scotia Department of Health; and the Nova Scotia Department of Health Promotion and Protection. The report will also be disseminated to the Branch Manager of the Halifax North Memorial Public Library. Findings will be used to inform the development of programs, services and policies for Aboriginal, African Nova Scotian and other racialized communities in the North End and Halifax. knowledge users: health agencies; health professionals; health policymakers; community agencies; service providers; researchers and academics. 2) Presentation of Findings to Community Agencies: Presentations of the research findings will be conducted at several agencies and organizations, including the North End Community Health Center; The Mi’kmaq Native Friendship Center; the Health Association of African Canadians; the Mayor’s Office (Halifax Regional Municipality); Office of African Nova Scotian Affairs; and the Office of Aboriginal Affairs. These presentations will summarize the findings of the research to key community agencies serving Aboriginal and African Nova Scotian communities. knowledge users: health agencies; health professionals; policymakers; community agencies; and service providers. 3) Community Program Development: Meetings will be held with members of the Health Team at the North End Community Health Center to discuss how recommendations from this report may be used to develop and enhance new and existing initiatives. Given that unemployment and underemployment are the most pressing issues facing North End residents, the focus will be on identifying more effective ways to connect meaningful leisure and recreational activities to skills development and upgrading, employment training for youth and adults and education. knowledge users: health agencies; health professionals; and service providers.
4) Policy Briefs: policy briefs outlining policy recommendation will also be disseminated to key policy decision-makers, including the Office of the Mayor at the Halifax Regional Municipality. These briefs will be developed to inform the development of social and health policies targeting Aboriginal and African Nova Scotian communities in the North End. In considering how the research can impact policy, it is important to note that policy comes in different forms (guidelines; legislation; procedures; standards) and at different levels (organizational; community; community agencies). Moreover, influencing decision-making at the policy level involves identifying and sustaining dialogue with one or more key policy decision-makers and representatives from community agencies who can advocate for change. knowledge users: policymakers at the Halifax Regional Municipality. 5) Community Newspapers (print; online): Research findings will be communicated through print and online community newspapers in order to create awareness among community members about the research findings, the DVD film and the DVD viewing events. knowledge users: community members. 6) DVD Film: The research presented in this report received a Knowledge Sharing Support Award from the Nova Scotia Health Research Foundation in October 2010 to produce a DVD film based on the research findings and key messages outlined earlier. This film will be distributed to various community agencies and organizations. A video production company in Halifax will be hired to produce the film in which actors will be hired (to protect the anonymity of research participants) to communicate emotionally engaging stories based on the research findings and key messages. The main objective of the DVD film is to impact health policy and decision-making around the development of meaningful occupations in the North End. knowledge users: health agencies; health professionals; health policymakers; community agencies; service providers; community members; university students; university professors. 7) DVD Viewing Event: The DVD film will be screened at viewing events in the community in collaboration with agencies in the North End and Halifax. Diverse knowledge users/stakeholders will be invited to attend these viewing events, including community members, community agencies, health agencies, health professionals and health policymakers. This event will be used to engage potential knowledge users in sharing information and experiences relating to the film in direct, meaningful and emotionally engaging ways and to forge networks and partnerships that will sustain knowledge sharing and dissemination beyond the event. The DVD film will also be used to impact health policy and decision-making around the development of more meaningful occupations in the North End. knowledge users: health agencies; health professionals; health policymakers; community agencies; service providers; community members; university students; university professors; researchers. 8) Social Media: After the DVD viewing events, The DVD film will be launched through a local online broadcaster, which will be hired to market the film through social media (Facebook; Twitter; iPhone; and iPad). The use of social media has the potential to impact decision-making because it provides decision makers with access to a larger and more diverse community voice and, 96
consequently, more diverse ideas. Moreover, it has the potential to enhance communication, networking and partnerships amongst diverse knowledge users. knowledge users: community members; health agencies; health professionals; health policymakers; community agencies; service providers; researchers. 9) Peer-Reviewed Journal Articles: Articles based on the research will be published in peerreviewed journals in occupational therapy, occupational science, sociology of health, community development, social work, community health, public health and health policy and will be situated in the current existing body of knowledge in those fields. Given that these articles will be published in a wide variety of journals, they have the potential to reach a wide audience (professors, researchers and students) and to inform research in diverse fields. knowledge users: university professors; researchers; students. 10) Academic Conferences: Research findings will be presented at academic conferences in the fields of occupational therapy, sociology and health, including the Canadian Association of Occupational Therapists and the Canadian Sociological Association. Findings from this research have the potential to impact a wide academic audience, including professors, researchers and students and to inform research activities in diverse fields. knowledge users: university professors; researchers; students
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APPENDICES Appendix A Interview Guide for Community Members
Introduction I would like to thank you for agreeing to be interviewed for this research project. This interview will be no longer than one hour and will ask you questions about your involvement in your community. I am interested in finding out about what activities you are involved in as part of your community that may benefit you and members of your community. I would also like to find out some of the reasons why you may not be involved in activities in your community. Finally, I would like to get your suggestions on the kinds of community activities you think should be developed by the North End Community Health Centre that would be of interest to you and members of your community. Participation in Community Initiatives 1/Do you feel a part of/connected to your community? Why or why not? 2/ How does it make you feel to be a part of/connected or not part of/connected to your community? 3/What would make you feel more a part of /connected to your community? 4/Have you ever been involved in any community development projects in your community or neighbourhood through the North End Community Health Centre or at another agency in the community? Please tell me about your involvement in these activities. 5/ What are some of the reasons why you have been involved in these community development projects ? 6/What are some of the reasons why you have not been involved in these activities? (for participants who have not been involved). 7/ Do you think that any of the following issues have made it difficult for you and others to take part in those community development projects?: racial background, cultural background, financial problems, work responsibilities, childcare/family responsibilities, school, location, language problems, education level, immigration and settlement issues, housing issues, religious beliefs, physical or mental ability, health issues, age, sexual orientation. Please discuss. Suggestions for New or/and Improved Community Initiatives 1/What types of community development projects are most meaningful to you and why?
2/ What types of new community development projects would you be interested in taking part in and why? 3/How could existing community development projects at the North End Community Health Centre? 4/What should agencies do to make it easier for community members to participate in these projects? 5/How should the following issues be acknowledged in developing new community development projects or improving existing community development projects initiatives at the North End Community Health Centre and other agencies in your community: a) racial background, b) cultural background, c) financial problems, d) work responsibilities, e) childcare/family responsibilities, f) school, g) location, h) language problems, i) education level, j) immigration and settlement issues, k) housing issues, l) religious beliefs, m) physical or mental ability, n) health issues, o) age, p) sexual orientation. Please discuss. 6/How could the North End Community Centre make it easier for you and other community members to receive other services and programs at the North End Community Centre, such as health services, education and training programs, immigration and settlement programs, childcare programs, sports, recreation and leisure programs.
Appendix B Interview Guide for Community Agencies
Introduction Thank you for agreeing to participate in this study. This interview will be no longer than one hour and will ask you questions about community development programs and initiatives at your agency. I am particularly interested in finding out about how you engage members of the lowincome and poor visible minority community in participating in community development initiatives at your agency and in the community in general. I am specifically interested in knowing about some of the challenges you face engaging these communities in these initiatives, the barriers these individuals face in participating in these initiatives due to race, low income and poverty, culture, citizenship status, language, religion and other issues and the organizational challenges you face implementing these initiatives and engaging these communities. Finally, I would like to get your suggestions on meaningful community initiatives that need to be developed that would better engage these communities, foster more social inclusion in these neighbourhoods and communities and increase community members’ access and engagement in other services and programs, including health, education and training, housing etc. General Questions about Community Members’ Access to Services & Programs 1/What kinds of services and programs does your agency provide? 2/ What are some of the reasons why this community accesses or does not access your programs and services? 3/ How do you think the following issues influence participation in your services and programs by low income and poor visible minority individuals: a) racial background, b) cultural background, c) financial problems, d) work responsibilities, e) childcare/family responsibilities, f) school, g) location, h) language problems, i) education level, j) immigration and settlement issues, k) housing issues, l) religious beliefs, m) physical or mental ability, n) health issues, o) age, p) sexual orientation. Please discuss. 4/ What actions does your agency take to reduce and eliminate barriers to participation in programs and services by these communities? Engaging Community Members 1/What community mobilizing, leadership and capacity building projects has your agency developed for the low income and poor visible minority community in Halifax? 110
2/ Has your agency been successful in engaging these communities in these projects? Why or why not? 3/ How do you think the following issues influence participation in community development projects by low income and poor visible minority individuals: a) racial background, b) cultural background, c) financial problems, d) work responsibilities, e) childcare/family responsibilities, f) school, g) location, h) language problems, i) education level, j) immigration and settlement issues, k) housing issues, l) religious beliefs, m) physical or mental ability, n) health issues, o) age, p) sexual orientation. Please discuss. Developing New or/and Improved Community Initiatives at Community Agencies 1/ What community initiatives do you think are meaningful to the low income and poor visible minority community you serve in Halifax? Why? 2/What types of new community initiatives should be developed by your agency or other agencies in the community to more effectively engage these communities and why? 3/How should the following issues be acknowledged in developing new community initiatives or improving existing community initiatives at your agency or other agencies: a) racial background, b) cultural background, c) financial problems, d) work responsibilities, e) childcare/family responsibilities, f) school, g) location, h) language problems, i) education level, j) immigration and settlement issues, k) housing issues, l) religious beliefs, m) physical or mental ability, n) health issues, o) age, p) sexual orientation. 4/Please identify and discuss some specific strategies for engaging low-income and poor visible minority communities in community leadership, mobilizing and capacity-building initiatives
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