Empowering Ontario Public Health Nurses to Address the Causes of Poverty: A Qualitative Descriptive Study

Research has demonstrated repeatedly that income and income distribution are powerful determinants of health. While Ontario public health units are mandated to promote health and reduce health inequities, they have done little to help eliminate poverty, instead focusing on individual behaviours such as smoking, diet, and physical activity – an approach likely to worsen health inequities, rather than mend them. Public health nurses (PHNs) across Canada recognize poverty as a powerful determinant of health, yet have expressed challenges in their ability to take meaningful action to address it (Cohen, 2006b; Reutter & Ford, 1996). The study sought insight into how Ontario public health units can strengthen PHNs socio-political efforts to address the causes of poverty. A qualitative descriptive design was used to explore PHNs’ views, while an Appreciative Inquiry approach was used to draw on participants’ successful past experiences in addressing the causes of poverty and their thoughts for the future. Organizational factors thought to empower PHNs’ socio-political efforts to address the causes of poverty were identified using Kanter’s Structural Theory of Power in Organizations as a starting conceptual framework. Fifteen PHNs participated in face-to-face or telephone interviews. Qualitative content analysis was used to describe participants’ affirmative experiences, empowering organizational attributes, and desired actions and supports for the future. Three overall themes emerged with respect to empowering organizational attributes: authorities within the health unit ‘permit and provide’, active associates ‘help each other out’, and external allies ‘contribute and collaborate’. Factors beyond the health unit that would support anti-poverty work were also identified. Findings suggested that action to address the causes of poverty is within the reach of PHNs, and is consistent with their role and the public health mandate, but requires leadership support and political buy-in in order to maximize its effectiveness. EMPOWERING ONTARIO PUBLIC HEALTH NURSES 3 Empowering Public Health Nurses to Address the Causes of Poverty: A Qualitative Descriptive Study Although Canada’s Gross Domestic Product (GDP) per capita ranks it as one of the wealthiest countries in the world (Central Intelligence Agency, 2008), its child poverty rate is one of the worst of all nations belonging to the Organization for Economic Co-operation and Development (OECD). In Canada, 15.5% or almost 1/6 children live in poverty (UNICEF Innocenti Research Centre, 2000). Studies and reports confirm over and over that poverty is damaging to health and can lead to premature death. Based on an analysis of data from the Canadian Community Health Survey, The Wellesley Institute and Social Planning Council of Toronto concluded that, “[P]overty is making Canadians sick – robbing hundreds of thousands of their health and creating huge costs for the health care system” (Lightman, Mitchell, & Wilson, 2008, p. 1). Indeed, several Canadian studies demonstrate income gradients whereby the richer fare better than the poorer on a range of health indicators, including self-rated health, stress and mental health, disability, endocrine and metabolic conditions, circulatory and respiratory diseases, responsiveness to cancer treatment, and basic abilities in children (i.e., vision, speech, mobility) (Booth, Li, Zhang-Salomons, & Mackillop, 2010; Bryant et al., 2010; Lightman, Mitchell, & Wilson; Lightman, Mitchell, & Wilson, 2009; Orpana, 2008; Ross & Roberts, 1999; Street Health, 2007; Wilkins, Berthelot, & Ng, 2002). Negative outcomes also are demonstrated in studies analyzing the effects of neighbourhood or community poverty, including increased risk for preterm birth and low birth weight, decreased verbal abilities in young children, and increased numbers of child homicide (Birken, Parkin, To, Wilkins, & Macarthur, 2009; Kohen, Brooks-Gunn, Leventhal, & Hertzman, 2002; Urquia, Frank, Glazier, & Moineddin, 2007). Population-level statistics furthermore point EMPOWERING ONTARIO PUBLIC HEALTH NURSES 4 to increased risk for poverty among Canadian women, unattached adults, individuals from racialized communities or of Aboriginal identity, and those with a disability (Campaign 2000, 2010; Statistics Canada, 2006; Statistics Canada, 2009; The Colour of Poverty, 2007). Since 2001, the percentage of unattached Canadians living in poverty has remained high at around 30% (Statistics Canada, 2009), while in Ontario family poverty has grown steadily (Campaign 2000, 2007). Many have argued that an inequitable distribution of wealth (e.g., less progressive tax structures that privilege the rich) is to blame for elevated and increasing poverty rates in Canada [Campaign 2000, 2010; Canadian Centre for Policy Alternatives (CCPA), 2010; Raphael, 2002a]. Census data show for example that, from 1980 to 2006, the richest 20% of Canadians had median income increases of 16.4%, while the poorest 20% had a 20.6% drop in earnings (CCPA). Award-winning economist Yalnizkan (2010) observed that, “This generation of rich Canadians is staking claim to a larger share of economic growth that has preceded it in recorded history” (p. 3). Indeed, income inequality – or the gap between the rich and the poor – has been argued to be equally, if not more important to health, than absolute income (Canadian Council on Social Development, 2001; Raphael, 2003b). Research has shown that when there is greater inequality in the distribution of income, there are greater disparities and inequities in health (Collison, Dey, Hannah, & Stevenson, 2007; Kennedy, Kawachi, & Prothrow-Stith, 1996;