The aim of Access Health is to provide primary health care that enhances the health and well being o

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

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• Multiple sectors
• Funded from DA
• Staffed from mainly multi-disciplinary health
• Auspiced/located in community/welfare service

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• Primary Health Care
• an approach to care
• and
• a philosophy of care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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• Thank you and acknowledgement to
• Sue White
• Manager of Access Health

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