1. Nature of our participation
During the Ottawa Charter symposium held in Montréal in October 2006 at the 10es Journées annuelles de santé publique, three presenters participated in a workshop entitled Des approches participatives inspirantes pour la pratique en santé publique: le Projet AVEC et le Programme des services intégrés en périnatalité (Cutting-edge participatory approaches for public health practice: the AVEC project and the Perinatal Integrated Services Program). One of the presenters was herself living in poverty.
- Workshop content and process
Élisabeth Germain and Micheline Bélisle of the Collectif pour un Québec sans pauvreté began by presenting a little skectch that highlighted the preferable nature of an AVEC (WITH) rather than a POUR (FOR) approach in the field of health. After the participants reactions to the sketch, Élisabeth conducted an exercice, i.e. to work out a budget based on the current minimum welfare benefit in Quebec of $543 a month (for recipients with no constraints on employability). Then, with $543 in hand, people were asked to take a pill bottle which contained examples of conflicting expenses that had to be budgeted. For example, would they choose to buy groceries or pay the monthly fee for their medications? Micheline then presented the Collective’s Projet AVEC and the AVEC committee, which somewhat serves as a project follow-up committee.
We then discussed this AVEC approach and related consciousness-raising practices. Essentially, this approach, as used in the Collectif, consists in encouraging persons in authority (professionals, decision-makers, and others) and the general population to make a habit of asking, deciding and taking action WITH people living in poverty, who should be considered the main actors of their own lives. The related consciousness-raising practices consist notably in considering poverty as a social rather than a personal issue, in making participants aware of their oppression and of the fact they are not alone in their situation, and in helping them to become empowered to act on the problem. Similar to the consciousness-raising practice, when using the AVEC approach, professionals work WITH participants to convert their problems into solutions within a socio-political rather than psychological framework without, however, excluding the latter.
After exchanges on the essence of the AVEC approach and the related consciousness-raising practices, Isabelle Laurin, a researcher with the Early childhood, families and community team at the Montréal Public Health Department, presented her participatory research project entitled “Mothers and fathers in the context of vulnerability” (“Pères et mères en contexte de vulnérabilité”), conducted in the context of the SIPPE program (Integrated perinatal and early childhood services for families living in vulnerable situations). Ms. Laurin’s work is founded on the basic premise that given favourable circumstances, people who are oppressed can give meaning to their actions and the circumstances that affect their lives. They can be helped to extract themselves from a position of alienation and open the way to a process that helps them reflect on their trajectories and reclaim their social experiences. Group situations are conducive to such a process since they create spaces for social participation that involve self-work as well as working with others (Laurin et al., in print). Ms. Laurin shed light on the limits of this type of process, notably with some of her colleagues and decision-makers, as well as on its positive aspects.
In conclusion, the differences (limits and advantages) between actions FOR and actions WITH were summarized. We also asked workshop participants about the relevance for their own practice of using a sketch as an awareness-raising exercise.
2. Critical reflection on our participation
- Timeliness of the Ottawa Charter
The Ottawa Charter (World Health Organization, 1986) is increasingly relevant in light of the ever-increasing gap between the rich and the poor. Indeed, according to the Charter, which focuses on health promotion, we cannot succeed without achieving equality between men and women, and between individuals who must benefit from equal opportunities and resources to achieve their fullest health potential. Moreover, the Charter is particularly up-to-date in how it conceives health; it states that an individual or group must be able to identify and realize its aspirations, to satisfy needs, and to change or cope with the environment. Here, the notion of balance is omnipresent. The Charter is also current because of its socioecological approach to health based on the inextricable links between people and their environment, as is seen in the possibility of benefiting from living and working conditions that are safe, stimulating, satisfying and enjoyable.
- Challenges for the future
Future challenges for public health require coordinated action by all concerned: governments, health and related social and economic sectors, non-governmental organisations, regional and local authorities, the corporate world, and the media. Everyone is aware that the interests of some groups and individuals are often conflicting. Although there is sometimes a shared vision of health, the means to reach it can differ widely.
The adoption of a holistic approach to health and of strategies to give concrete expression to this vision of health also poses a challenge. It is not simply a question of perceiving men and women as equal partners but also to develop strategies where people living in poverty and wealthy individuals benefit from the same resources and possibilities to live healthy lives. This is not a given; health inequalities are often perceptible in disease occurrence for the poor and in flourishing health for the rich. How can poor and rich people be guided towards achieving a common ground, a shared vision, a single definition of health so as to successfully implement strategies that can improve and maintain living conditions favourable to the health of all?
Three of the commitments listed in the Charter seem particularly difficult to meet:
· “to respond to the health gap within and between societies, and to tackle the inequities in health produced by the rules and practices of these societies;
· to acknowledge people as the main health resource, to support and enable them to keep themselves, their families and friends healthy through financial and other means, and to accept the community as the essential voice in matters of its health, living conditions and wellbeing;
· to recognize health and its maintenance as a major social investment and challenge; and to address the overall ecological issue of our ways of living.” (World Health Organization, 1986, p. 4-5).
3. Reactions to the exhibition entitled “Objet: Pauvreté”
In addition to co-organising the workshop mentioned above, the Collectif also set up its travelling exhibition entitled “Objet: Pauvreté” (“Object: Poverty”) in the room reserved for exhibitors and poster communications. Many symposium participants had questions about this exhibition, how it came about, as well as about the Collectif itself.
This unusual and original exhibition, which stood out among the other items presented in the room, served to draw attention to the link between poverty and health, to the social inequalities that lead to disease, as well as to the fragility of the life conditions of people living in poverty which often lead to sickness rather than to health.
4. Follow-up since our participation in the symposium
Our participation in this symposium allowed us to raise consciousness on a comprehensive view of health and on concerns related to maintaining a balance among various factors that affect the health of individuals, including economic, social, cultural, biological, environmental, political and behavioural factors.
Far from setting the Ottawa Charter aside, we think it can still inspire our federal and provincial governments as well as regional and local authorities to broaden their vision of health, to make health a priority in their respective agendas and to see that living conditions and health are inextricably connected. The Charter can act as a health promotion watchdog with these governments and authorities. It can also be of interest for health research since it evokes the importance of taking social inequalities into account in medical interventions.
5. Message to pass on to the Vancouver conference
We believe that, when planning and developing strategies to implement health services, we should not forget that those most affected by health inequalities are individuals living in poverty.
We think we should be more centred on participatory research in public health. The research approach presented by Isabelle Laurin shows that the work done to date with participating parents is an eloquent illustration of how conditions that need to be put into place to promote the well being of vulnerable and poor families are first and foremost about implementing action in communities. This involves open, courageous and continuous dialogue between the parents concerned and stakeholders from the community who are working on developing interventions and public policies, as well as implementation of organisational conditions that favour intervention modalities that may disturb usual program logic (Laurin et al., in print).
We also look forward to decision-makers being more open to reflecting on, or even changing, practices and policies based on results of studies that involve the participation of individuals concerned by public health programs. Currently, there is a trend towards the use of evidence-based data in program management; this is true especially in public health because of its affiliation with the biomedical field, which is associated with resistance in considering results of qualitative research.