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Canadian Public Health Association - Amgen Award for Innovation in Family Health

About the Award

The CPHA-Amgen Award for Innovation in Family Health was created to recognize the achievements of an organization, project or program for innovation in family health. This new award recognizes innovative public health practice committed to promoting the health and well-being of communities through society’s fundamental social unit, the family. The award encourages new and better ways for promoting family health and the uptake of innovative practices by relevant organizations across Canada.
 

About the Recipient

Ts’ewulhtun Health Centre, located in the Cowichan Valley of Vancouver Island, British Columbia, was established in 1992 following a transfer of health services from the federal government to Cowichan Tribes Council. The Health Centre provides public health and communicable disease control programs and services for the single largest First Nation in the province with a registered population exceeding 4000 members. The Centre strives to promote the well-being of its community members and their families through the delivery of health services that are guided by Cowichan values and grounded in the traditional knowledge and understanding that family is the heart of life. As a health partner, the Centre is recognized for providing an ethical space to collaborate by creating safe and respectful opportunities for people to come together. The Centre is also recognized for bringing voice to First Nations people, being inclusive, and navigating inter-jurisdictional challenges. Ts’ewulhtun Health Centre is the first recipient of the CPHA-Amgen Award.
 

Innovation and the Recipient

The Centre has a long-standing history of path-setting* achievements recognized across the country. Almost two decades ago, the Centre was one of the first Aboriginal organizations in Canada to recognize the problem of baby bottle tooth decay, an infectious disease problem associated with early childhood caries (ECC). In response to the problem, the Centre instituted a preventive dental health program to educate and promote healthy feeding practices among parents and caregivers. Leading by example, the Centre developed and modeled ways by which this preventable disease could be addressed, including the promotion of breast-feeding. From a traditional First Nations perspective, breast milk is viewed as a sacred gift, a medicine that a mother gives to her child. Studies now show that this gift or medicine associated with breast-feeding does reduce the incidence of tooth decay and promotes well-being and health in children through various protective factors.

The Centre is also distinguished for being the second First Nations organization in the country, under special federal legislation, to institute a tax on cigarettes sold on reserve, the proceeds of which go to improve the health of the community. From a policy perspective, the institution of this tax at a community level is viewed as a harm reduction strategy from which benefits can be derived at the individual, family and community levels. It is viewed as a mechanism by which overall tobacco use is discouraged and reduced among individual community members. It is also seen as a means to:

  • reduce the number of smokers in the population;
  • protect family and community members from second-hand smoke; and
  • derive benefits that can help to address health inequities among community members.

There are established terms of reference for funds generated from cigarette taxes, which support initiatives such as the:

  • purchase and repair of appliances for the elderly;
  • provision of food and fresh produce to community members and families requiring support; and
  • purchase of mobility aids for members with special needs.

More recently, the Centre was recognized for its development of Mustimuhw, an information system designed for First Nations that provides community-centered electronic medical records. This technological innovation is unique in that it focuses on tracking health and well-being, which serves both multi-disciplinary health services staff and community members. The system was specifically designed to actively engage community members in working towards personal and family level health goals. At any given time, community members can view their individual records and the records of their children. When receiving services, health records are reviewed with community members to support self-responsibility, individual and family goal setting, and to support mutual planning and health monitoring. In addition, Ts’ewulhtun Health Centre staff are able to use the system to systematically track and report on health services provided through the Centre. The system also facilitates the tracking of community-specific health indicators, accountability measures, and the generation of reports. This system is currently benefiting over 50 First Nation communities in British Columbia, Saskatchewan and Manitoba.
 

Innovation in Family Health

Ts’ewulhtun Health Centre is recognized for being centered by Cowichan teachings, its ability to balance traditional and contemporary knowledge, and its collaborative inter-jurisdictional partnerships. Cowichan teachings, which represent a way of life, are viewed as fundamental to promoting health and happiness. Accordingly, Cowichan values guide how programs and services are considered, structured and provided by the Centre. Similarly, these same values guide the nature, manner and management of all relationships and partnership initiatives.

The Centre has also committed itself to function as a learning organization focused on:

  • building capacity to create results;
  • promoting creative thinking;
  • supporting well-thought-out change;
  • nurturing collective aspirations;
  • encouraging continual learning; and
  • learning together and with others.

This ability to blend and balance traditional and contemporary knowledge and approaches has been credited with providing pathways for improving community health and well-being, organizational growth and innovation.

Organizational practices centered on traditional and contemporary knowledge
Operating as a learning organization using contemporary organizational theory, the Centre conscientiously attends to factors related to social capital. At the same time, the Centre’s organizational practices remain centered on traditional knowledge of the social determinants of health and the central fundamental Cowichan teaching that the family is the heart of life. The Centre focuses on:

  • building day-to-day connections and relations with families and the community;
  • bridging relations with other organizations within and outside the community; and
  • actively establishing formal linkages with multi-sectoral service providers, other First Nations communities and organizations, government and educational institutions.

The Health Centre regularly organizes meetings and community events so that community members can actively voice their health concerns and needs. Community members and their families participate in these events, bringing together the voices of several generations. During these meetings, community members are encouraged to provide input and direction on the provision of health services and programs. Information emerging from these meetings is used to inform and guide the strategic directions of the Centre. These events also serve to build connections among community members, Health Centre staff, and community partners in health service delivery.

Program delivery balanced by tradition and contemporary knowledge
All programs are specifically modeled to provide circles of care to individuals and their families. These circles of care work to ensure that basic physiological needs are met, that a sense of security and belonging is fostered, and that success, health and well-being are nurtured throughout the life cycle. Within this traditional Cowichan perspective, programs and services are developed to meet the needs of community members and their families. Many programs and services are also augmented with outreach components.

Culturally-centered program values and approaches
The health of community members and their families is supported along the spiritual, emotional, physical, and mental dimensions of personal development and well-being using a lifespan approach. The Centre functions with the understanding that personal health, the health of the community as well as the health of the environment are all interrelated. These culturally centered values are fundamental to all programs and services offered through the Centre. Following the lifespan approach, healthy families and lifestyles are advanced by:

  • promoting a healthy start for children;
  • supporting healthy development and choices among youth;
  • providing early detection, treatment and management of health issues among adults; and
  • managing age-related needs of Elders.
     

Family Health Across the Lifespan

Using the lifespan approach, circles of care begin with the staff of the Health Centre. Staff serve and support community members by nurturing interactions as one large extended family. This perspective promotes self-responsibility in relation to each other, with each individual being valued as a contributing member of the family and the community. The importance of self-esteem, empowering staff and community members, and an appreciation for traditional ways are vital elements to all programming efforts and circles of care.

Programs and services attend to a broad range of needs in view of the social determinants of health. At the same time, programs and services also address developmental and age-related needs and issues based on the life cycle. Within this framework, the Centre’s programs seek to seamlessly interconnect across age groups and programs and with other Cowichan Band departments related to employment, education, social services and housing. Primary circles of care are focused on prevention and wellness. Additional circles of care include the treatment and management of health-related issues and expand to involve other community and health service partners. Circles of care and caring are reinforced in very practical ways by supporting community members to receive and attend programs. These practical support measures include regular telephone check-ins by staff to encourage, connect and inquire about any challenges that community members and their families may be experiencing. Further support to those community members requiring assistance is made available through the provision of transportation and child-minding services.
 

Healthy Families and Healthy Lifestyles

The lifespan approach to health services provided by Ts’ewulhtun Health Centre supports individuals, families, and the community through the different stages of life. This inherent appreciation and understanding of the life cycle ensures that programs are both interconnected and targeted to developmental and age-related needs through family-centered values and approaches. As community needs shift, the Centre’s health programs and services are modified to address changing needs. The Centre’s core values and approaches, however, remain constant over time. Growth and transition through the life cycle are supported by approaches that are intrinsically rooted in values that:

  • nurture individual strengths and well-being;
  • encourage proactive and healthy choices;
  • work to reduce risks; and
  • promote positive aspects of living in the context of family and community.
     

CHILD – Promoting a healthy start

Beginning the cycle of life with new births, every child is welcomed into the family through a Celebration of Life initiative. The initiative, modeled after one of the Cowichan Tribes traditional ceremonies, involves mothers and family members preparing for and celebrating the arrival of a child. Preparations include mothers and Elders coming together to spin wool and weave blankets for the baby, as well as gatherings with family members to talk about expectations, parenting and traditional teachings associated with family roles and responsibilities important to the child’s life. Once the baby arrives, the child is welcomed as a new family member and is introduced as a new community member through a blanketing ceremony. There are different types of blanketing ceremonies, each of which holds special significance. The blanketing ceremony associated with the Celebration of Life welcomes the child into the family as a special gift to be respected and honours the parent of the child. The ceremony also bears witness to and acknowledges the respective importance of each family member’s role in supporting the child’s health and well-being.

A healthy start is further promoted in relation to the child’s age and developmental stages. Initially new mothers are supported with services such as breast-feeding support, well-baby clinics and information on safety for children. As the child develops, education and support for positive parenting is made available. In addition, early childhood immunizations as well as regular developmental screening and follow-up are provided. Children experiencing developmental delays or medical conditions and their families receive additional support that is tailored to address the special needs of the child and the family.

Play-based learning and early literacy are also promoted through initiatives such as the Treasure Box. Children and parents come together to read, work on crafts and enjoy healthy snacks while exploring the contents of treasure boxes containing books and crafts. All services are structured to bring community members together in a safe and supportive environment. Many of the services offered specifically strive to bring together and connect first-time and new mothers with each other. Opportunities are also created to bring together mothers and their babies with grandparents and Elders. In this way, relationships are nurtured and strengthened across generations.

Under the umbrella of the Children’s Oral Health Initiative, a program developed by Health Canada, the Centre is dedicated to promoting children’s oral health. Educational sessions and materials concerning oral hygiene, proper brushing and flossing as well as low sugar diets are provided regularly. Dental staff routinely visit on-reserve day care centres and schools to raise awareness of the importance of good oral health through interactive, hands-on educational sessions. Dental health is promoted primarily using family- and community-based approaches, which often find dental staff collaborating with other local community services and participating in local community and toddler fairs.

As one of the first Aboriginal organizations in Canada to address early childhood caries through prevention, Ts’ewulhtun Health Centre’s circle of care for dental health continues to model and advance preventive services. These services are provided for pregnant women, infants, children, adults and Elders and cover a full range of services including dental screening, intervention, restorative services, walk-in emergency services and treatment referrals. While services are comprehensive in nature, the primary service goal is focused on improving oral health by reducing the incidence of oral disease and the need for dental interventions and treatment.
 

YOUTH – Supporting healthy development and healthy choices

As children mature, healthy development continues to be encouraged through exercise, social activities, and the promotion of healthy choices. Youth are encouraged to participate in youth groups, join in community events, connect with the Elders and participate in sports groups in the community. Parents and Health Centre staff participate in sports events and consciously choose to model healthy lifestyles for youth. On their personal time, Centre staff have also volunteered as coaches! Healthy development and healthy choices are further supported through educational offerings dealing with such topics as dating, healthy relationships, drugs and alcohol, bullying and sexual health. General Life Skill Training is also made available to youth.

A key prevention program for youth aged 13-25 years of age is Canoe Journey, Life Journey. Each year, this life skills program brings together youth and Elders over a 14-week period. Activities are focused on preparing youth to undertake a coastal canoe journey. Program activities include building the canoe, physical training, the journey itself and a celebration of youth accomplishments. Using these culturally-centered approaches, aspects of the canoe journey are used as an opportunity for Elders to teach youth life skills such as goal setting, communication and decision-making. Families and the community proudly come together formally and informally to support the youth involved in the program. Any youth participating in this program will find themselves benefiting from coaching and mentoring provided at an individual level, within the group, by their families, as well as by the community at large. Community members and Health Centre staff routinely introduce youth participating in the program to visitors, nurturing and honouring with great pride the efforts of their youth.
 

ADULT – Providing early detection, treatment and management of health issues

As young adults enter into their reproductive years, the focus and attention of health services for them shifts towards maternal and child health and the support of young, new and growing families. The Centering Pregnancy initiative provides expectant mothers with similar due dates and their partners with pre-natal and early post-partum care, education and support by fostering a circle of care among peers. Following the birth of their children, parents can join groups for first-time and new parents. In addition, stay-at-home mothers are supported through Mother’s Morning Out while socially isolated mothers receive support through outreach services. The services offered are dedicated to supporting and guiding parents on their child’s developmental milestones and encouraging positive parenting, guidance and discipline. All programs and services combine traditional and cultural childrearing practices with present-day information and approaches.

Healthy living among adults of all ages is also nurtured through the promotion of exercise, healthy eating and early screening for health issues. Exercise is supported through training for annual community runs and walks, exercise classes and access to recreational facilities and a swimming program. Healthy eating is promoted and modeled by ensuring that healthy foods are provided at community-wide gatherings and Health Centre events. Involvement in the preparation of traditional foods as well as access to traditional food sources such as berries, salmon, cod, halibut and clams are also actively promoted and supported.

The Good Food Box initiative also ensures that nutritious food is made available to families and individuals in particular need of nutritional support and aid for daily living. These approaches promote the overall food security of families by working towards ensuring that all community members are supported in having physical and financial access to sufficient, safe and nutritious food to support their basic needs.

Early screening initiatives are conducted on a regular basis for conditions such as diabetes and hypertension. These initiatives are highly promoted, very visible and structured to ensure that early screening is made accessible to as many community members as possible. Community-wide immunization clinics are also highly promoted and accessible. Accessibility is facilitated by scheduling clinic times that accommodate busy family schedules associated with work, school, daycare, childcare and Elder care arrangements. Clinics reach out to community members by way of alternating clinic dates, times and service locations as well by scheduling evening and weekend clinic times.

Cowichan community members are also supported through the provision of mental health services through the Kwun’atsustal program, which means ‘hand in hand’. Within this circle, as with all other programs, care begins with prevention through education, self-development and peer support groups. Educational sessions and peer support groups address a range of issues such as dating, sexual health, parenting (Embracing Healthy Families and Healthy Futures), sobriety (Native Sobriety), anger management (Taming the Lion), grief and loss, and healing in relationships. The circle of care associated with Kwun’atsustal expands to include individual, couple and family counseling. Counseling services are strengthened by the involvement of Elders, traditional spiritual healers and language interpreters. Further care also includes the provision of emergency services for community members and families in crisis.

An important program initiative supporting the provision of emergency services is the Aboriginal Suicide and Critical Incident Response Team known as ASCIRT. This initiative was developed as a response to high rates of attempted and completed suicides in First Nations communities. The initiative brings together skilled facilitators and professionals who support communities in addressing the problem of suicide. Training and ongoing development of the team is maintained which in turn supports communities to provide educational workshops and respond to critical incidents and suicide.

In addition, circles of care are naturally extended to ensure that support is also provided to community members for the management of acute and chronic health issues and disease conditions. This extended circle of caring includes collaborating health service providers, organizations, specialists and locally-based groups. Health Centre programming is extended through a partnership network of support groups that are coordinated to assist community members with special needs. Two key groups are a Fetal Alcohol Spectrum Disorder (FASD) Support Group and an HIV Support Group. The FASD Support Group provides access to information and support to families and caregivers affected by fetal alcohol syndrome while the HIV Support Group promotes awareness of at-risk behaviour, supports prevention activities and provides care for HIV-positive community members.
 

ELDERS – Managing healthy aging needs

The wellness of the Sul’hween (Elders) is very important to the well-being of the whole community. When the Sul’hween are well and independent, they are able to pass on Cowichan culture, traditions and teachings to the next generations. Honouring and recognizing the vital role of Elders, the Centre strives to provide committed and attentive services to Elders and their families. Maintaining independence and mobility for daily living is actively promoted through exercise, swimming programs, day programs and annual Tribal journeys. Circles of care are structured to be responsive and attuned to the evolving age-related needs of each community Elder along spiritual, emotional, physical and mental dimensions. Changing needs are assessed and monitored every six months and more frequently as needed.

Elders requiring higher levels of support for daily living can rely on services such as help with personal care, assistance with the purchase and repair of appliances and Elders lunches. Elders’ Good Food Boxes are also provided; these supply fresh fruit and vegetables along with recipes and information about storing and preparing fruits and vegetables. Cowichan Tribal Elders can receive one of these boxes each month at no cost. Extended circles of care are coordinated as needs for long term, palliative and end of life care emerge. Family members caring for Elders are supported with options for respite care.
 

Program Successes

The reach and results associated with Ts’ewulhtun Health Centre’s programs are readily evident at multiple levels and in a variety of ways. On an annual basis, participation in the Centre’s health initiatives has increased steadily while the number of community members accessing services over the past five years has increased by 42.5 percent. The scope of this reach is clearly reflected at the program and service delivery level by successes such as the following:

  • a community-wide H1N1 immunization drive reaching over 1,400 community members;
  • a 56% drop in less than 10 years in the number of children under the age of five experiencing tooth decay;
  • quintupled participation in less than 3 years in the ‘Celebration of Life’ program modeled after a traditional Cowichan blanketing ceremony, welcoming newborns into the family and community; and
  • increased access to the Kwun’atsustal Program of mental health services correlated with working ‘hand in hand’ with community members to destigmatize seeking help in crisis situations.

Gradually and progressively, the scope of the Centre’s reach is also being reflected in the population that it serves. The growing level of access and involvement in the Centre’s programs and services is translating into the adoption of healthier lifestyles among community members. This increasing level of influence towards promoting healthier lifestyles is attributed to the Centre’s commitment to the development of healthy individuals, families and community. In particular, program successes influencing community health are being linked to the Centre’s active promotion of community engagement strategies through family-centered activities.

At community gatherings, community members regularly discuss and share both their challenges and successes in leading healthier lifestyles. Community Elders are fond of discussing positive changes to their diets, a change initiated and promoted through the Health Centre. The Elders particularly enjoy talking about the many ways they have challenged and advised their caregivers over the past several years. Increasingly, Elders are providing their own advice to visiting health care professionals as to how to go about improving and changing poor dietary habits among older individuals.

As a visitor sitting beside an Elder and sharing a meal, you are more than likely to be engaged in visiting and storytelling that leaves you with useful dietary information that has been interwoven with some form of traditional wisdom. As a visitor, you leave with gifts of information passed on to you for your consideration, reflection and well-being. In general, Elders are now more actively engaged in encouraging younger community members and their families to make healthy food choices and to exercise. On their own initiative, Elders are assuming a larger and more active role in communicating knowledge based on traditional and modern-day wisdom. The Elders emphasize the importance of family, the importance of family roles and responsibilities, leading a healthy and balanced lifestyle throughout one’s years, prevention and proper chronic disease management and healthy aging.

This growing level of awareness, knowledge and sharing about healthier lifestyles is increasingly being echoed among all age groups in the community. With encouragement, role models in the community are emerging and stepping forward to involve themselves in Health Centre activities. These role models recognize the importance of sharing their personal stories, discussing lessons learned, offering testimonials as well as supporting and encouraging others in their journey to better health. Role models view their involvement as a family- and community-centered responsibility that ensures the health and well-being of future generations. The community is proud to have role models such as young mothers who have successfully completed their education, community members who have overcome addictions and community members who are mentoring each other in the effective management of chronic disease conditions such as diabetes and arthritis.

The reach of the Health Centre is also evident through the many circles of extended care that have been established through its partnerships. Shared experiences and learnings are traditionally passed on for the benefit of the community and the common welfare of others. For example, in dealing with a community-wide crisis associated with unintentional fire-related deaths, Ts’ewulhtun Health Centre was able to nurture and establish a multi-disciplinary, multi-agency, community-service partnership network. Based on the community’s experience and lessons learned, the Centre developed a crisis response model supported by policies. This crisis response model is now being shared throughout Vancouver Island area by the partnership network. In the event of a community crisis, this network of community-service partners has developed the capacity to respond to and provide on-site services to almost any community on the island.

Building on these types of experiences, the Ts’ewulhtun Health Centre’s programs have been further enhanced by the establishment of the Hul’q’umi’num Health Services Group. This group was formed to develop an integrated service delivery model for the provision of services to Aboriginal people and their families in the Cowichan Valley in partnership with Vancouver Island Health Authority (VIHA) and the First Nations and Inuit Health Branch (FNIHB) of Health Canada. The efforts associated with this multi-jurisdictional partnership effort have extended benefits to families well beyond the immediate community served by the Centre.
 

Opportunities and Challenges

Given the rapid rate of the health centre’s growth, it has had to evolve quickly in terms of its own capacity. In order to meet the growing needs of community members and their families, the Health Centre has had to seek out external project funds to augment government funding. Targeted government programs are funded through contribution agreements at levels below the current need. Low levels of program funding in combination with program successes and a commitment to excellence have created both capacity-building opportunities as well as challenges related to program sustainability.

Driven by basic necessity to meet community needs, the Health Centre has been challenged to quickly develop a wide range of organizational skills such as:

  • proposal writing;
  • working with contracted staff;
  • human resources management;
  • financial management;
  • program development skills and knowledge;
  • project coordination and administration;
  • multi-jurisdictional and multi-partner project capability;
  • electronic health record management expertise; and
  • mentorship experience.

As the health service demands have grown, the Health Centre has had to manage an equally fast-paced need to build organizational capacity. The domino effect of developing its own capacity has advanced the Health Centre into a leadership role that reaches well beyond its own immediate service boundaries. This in turn has led to planned and unplanned opportunities and challenges. Consequently, the Centre’s expanded leadership role has increased the size and complexity of its program delivery, management and monitoring. It has also moved the Centre towards functioning as a Centre of Excellence for Aboriginal health.
 

Pathways to Success and Innovation

The pathways attributed to the Centre’s successes are linked to several key factors. One pivotal factor is that the organization is driven by the culturally-centered core values of ONE HEART – ONE MIND – RESPECT – and TRUST. Program successes and the Centre’s capacity for innovation are also linked to its commitment to holistic approaches in view of the social determinants of health. Another vital factor is that Ts’ewulhtun Health Centre views culture as a primary determinant of health that is integral to a holistic approach to health and well-being and the delivery of health services. This view is based on the understanding that a lack of cultural roots and identity is linked to many health and social problems facing First Nations people today. This foundation is reflected in the Centre’s unwavering focus on advancing holistic approaches centered by Cowichan values, teachings and traditions. This unwavering focus is combined with contemporary knowledge and the active and strategic use of community engagement strategies through family-centered activities.

As a learning organization, the Centre sets high expectations and commits itself to excellence while actively recruiting well-qualified Aboriginal staff. As a learning organization, Ts’ewulhtun Health Centre has also committed itself to its own learning and supporting the learning needs of others. An example of this commitment is the Centre’s partnership in Learning Circles for Aboriginal Nursing. This initiative aims to recruit and support the development of First Nations nurses as well as to develop health services that are culturally appropriate. This commitment to learning for mutual benefit involves more than 15 multi-jurisdictional partners.

The Centre’s pathways to success parallel emerging themes in public health practice with Aboriginal communities, which include:

  • establishing self-determined governance;
  • understanding culture as a determinant of health;
  • advancing holistic models of health service delivery;
  • addressing the determinants of health;
  • using culturally relevant and aligned approaches;
  • combining traditional and contemporary knowledge-based approaches;
  • developing individual-, family- and community-level capacity;
  • supporting community engagement strategies;
  • promoting cultural safety; and
  • developing good relationships with external institutions and organizations.

As the Centre navigates its growth and evolution, it believes its vision in strong, resilient and healthy individuals, families and community, centered on Cowichan teachings, will continue to be the focus of its efforts. The Centre plans to continue its work in bringing voice to the interests, concerns and aspirations of its community members. In doing so, the Centre envisions higher levels of community engagement, the emergence of long-term partnerships, new challenges and new opportunities to develop path-setting innovations that embrace indigenous and western knowledge.

The word “Huych q’ u” means thank you. The image was drawn by focus-group participants (mothers) involved in the Infant Development Program as part of the Centre’s five-year evaluation. Evaluators asked the group to draw something that represented what the program meant to them.
 

* Path-setting – a counterpart term to groundbreaking – is considered more reflective of Aboriginal worldviews relating to holism while differentiating from language that infers fragmentation.