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This presentation provides insights on health equity.
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St. Michael's Hospital
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This presentation offers ways to leverage a health equity strategy in order to inspire public action.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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This presentation provides insight on health equity and public action in Canada.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
Health Equity Impact Assessment Workshop: Healthy Connection Wellesley Institute
This presentation provides insights on health equity.
Anthony Mohamed, Aboriginal Health CAP
St. Michael's Hospital
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This presentation offers ways to leverage a health equity strategy in order to inspire public action.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
Driving Health Equity in Canada: From Strategy to Action and ImpactWellesley Institute
This presentation provides insight on health equity and public action in Canada.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
Drawing Out Links: Health Equity, Social Determinants of Health and Social Po...Wellesley Institute
This presentation provides insight on health equity, social determinants of health and social policy.
Bob Gardner, Director of Policy
Steve Barnes, Policy Analyst
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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This presentation offers insights on how to advance health equity by building on community-based innovation.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This presentation provides insight on how to drive health equity into action at a community level.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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This presentation offers insight into the policy challenges that inhibit health equity.
Bob Gardner, Director of Policy
Steve Barnes, Policy Analyst
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This presentation offers critical insights on thinking and acting on health equity.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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Bob Gardner, Director of Policy
Steve Barnes, Policy Analyst
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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In this assignment students will explore the powerful connection and influence of culture on nutrition and health. The purpose is to emphasize that culture influences our values, beliefs and practices related to nutrition. Evidence base research shows that by understanding the nutrition habits specific to a cultural group the nurse can individualize the care of the patients. Which certainly facilitates patient wellbeing and health.
Each group of students will choose a culture and explore concepts such as why it is significant for health professional to understand the importance of culture on nutrition.
The purpose of this project is not to stereotype or make assumptions about a person based on his or her culture. But to enhance cultural awareness and individualize patient care.
Course Outcomes
This assignment enables the student to meet the following course outcomes:
1. CO1. Discuss the cultural implications of food on nutritional status of different ethnic groups. (POs 1, 2, 4, and 6)
2. CO2. Describe the significance of the role of nurse in assessing nutritional status of clients belonging to different culture. (POs 1, 3, 4, 8 and 11)
Due Date
See the Course Calendar for due dates. Students are required to post their discussion on canvas to open a robust discussion on the relationship between culture and nutrition.
Points Possible: 80 points
Requirements
1. As a group, choose a culture from the list provided. Focus is on researching and understanding the ethnic group or culture and their nutritional practices.
2. If you wish to research a culture which is not on the list kindly review your choice with your instructor to assure the choice is feasible for this assignment.
3. Research the approved culture using books, websites, journal articles, or any other reputable source.
Use at least three (3) reliable sources.
4. As a group, you will share your findings and research and post it on canvas. As with all group projects, each member is expected to participate in the preparation of this discussion.
Each group will discuss at least 5 of the following 13 concepts:
1. Why it is imperative for health professionals to understand cultural diversity?
2. Health beliefs and practices of cultural group (you selected) related to nutrition.
3. Why the nurse should understands the deep connection and influence of culture on an individual's food intake, attitudes, behaviors and health?
4. How does this specific culture define health?
5. What foods are commonly eaten in this cultural group?
6. When, how, and with whom foods are eaten. (Timing, frequency of meals. Family dinners)
7. Which foods are eaten on holidays, celebrations or special occasions?
8. Are there any restrictions? Is there fasting?
9. Are there common practices to maintain health (Jews do not mix diary with meet, Halal meat for Muslim patients)
10. How do they treat the sick (herb ...
Acting on Social Determinants and Health Equity: An Equity Toolkit for Public...Wellesley Institute
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Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
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Bob Gardener, Director of Policy
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In this assignment students will explore the powerful connection and influence of culture on nutrition and health. The purpose is to emphasize that culture influences our values, beliefs and practices related to nutrition. Evidence base research shows that by understanding the nutrition habits specific to a cultural group the nurse can individualize the care of the patients. Which certainly facilitates patient wellbeing and health.
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2. CO2. Describe the significance of the role of nurse in assessing nutritional status of clients belonging to different culture. (POs 1, 3, 4, 8 and 11)
Due Date
See the Course Calendar for due dates. Students are required to post their discussion on canvas to open a robust discussion on the relationship between culture and nutrition.
Points Possible: 80 points
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2. The TOC Process
Data collection and analysis (identify problems)
2. Use causal analysis to create a problem tree
3. Create a solution tree and identify pathways of change
4. Identify assumptions and articulate rationales
5. Prioritize outcomes the project will address
6. Identify intervention outputs
7. Transfer the TOC to the logframe
8. Identify indicators for TOC components
9. Complete complementary documentation
10. Review annually at minimum
2
You are here !
3. Session Objectives
• To understand how to used causal analysis to create a
problem tree
• To identify strong and weak causal linkages in sample
problem trees
• To practice drafting concise problem statements for all
problem levels
• To critically analyze and organize problems and causes
into a logical flow
3
4. Holistic problem analysis
• Improves ability to design and implement
integrated programs that improve well-being
outcomes.
• does not mean bigger broader programs by one
institution
• is a non-sectoral or cross-sectoral approach
• sectors and stakeholders working together to adopt
complementary strategies to address common issues
• Relies on rigorous causal analysis
• the identification of common constraints and
opportunities, feedback loops, and underlying causes of
food and nutrition insecurity
4
5. Causal Analysis
•Helps to understand why a key problem
exists
•Explores cause-effect pathways,
including cross-causal linkages
•Identifies specific causes that can be
acted upon
5
6. Problem Trees
•Represent a systems-thinking approach
to analyzing cause and effect
• helps to identify multiple causal
linkages
•Most critical (and overlooked) element
of rigorous project design
6
7. Prioritize an Overarching Problem
Overarching problems will be selected based
primarily on such criteria as:
• The significance or scope of the problem (i.e., the
number of people it impacts or the degree to which
society considers it a serious problem)
• The degree to which resolution of the problem will
result in well-being for the impact group
• In FFP-funded Activities the overarching problem is
often pre-determined to be food and nutrition
insecurity.
7
8. Identify key problems, underlying causes,
contextual conditions
Start with an inventory of problems/causes
Then, organize/arrange/filter into:
• Key problems – broad conditions that negatively affect
people (e.g., low income, poor health status), and
contribute to an overarching problem.
• Underlying / root causes – specific contributors to key
problems (often the effects of other root causes).
• Contextual conditions – social, economic, political, or
natural conditions that contribute to underlying causes
and often are the result of key problems (cycle of
vulnerability).
8
9. Underlying Cause
9
What’s going on at the ------
HH and individual
constraints (e.g.,
behaviors,
knowledge and skill
levels, and attitudes)
that limit
opportunities to
achieve positive
livelihood outcomes
Weak community
cohesion or lack of
shared values that
hinder the delivery
and maintenance of
social and economic
infrastructure.
Constraints that are
external to the
community, such as
government
policies, the delivery
of social services,
and market and
social forces outside
the community’s
control.
Household and
individual level?
Community level? Systemic level?
12. High rates of HIV/AIDS
Infection
Problem Low Farm Family
Income
Cause Declining Crop Yields
People engage in unsafe
sex practices
Cause Severe Soil Erosion
Cause Farmers use improper
plowing techniques
Condom use is limited Cause Farmers unaware of
benefits of contour
plowing
Condom use has
negative cultural
connotations
Cause No access to extension
services or information
Beliefs/
Knowledge
Behavior
Condition
(broad)
Examples of Causal Streams
12
Condition
(broad)
Condition
(specific)
Behavior/
Attitude
Systemic
Knowledge
Behavior
13. 13
Underlying
Causes
Problem 1
Example: Limited food
availability
Problem 2
Example: Low income
security
Problem 3
Example: Inadequate
nutrition
Behavior
and
practices
Farmers do not use
improved practices
Early marriage negatively
affects girls’ education,
leads to low wages for
women
Intra-household
disparity re: allotted
food
Households sell
nutritious foods
produced
Knowledge,
skills,
attitudes,
beliefs
Farmers do not want to
risk investing in crops they
are not familiar with
People do not have
entrepreneurial skills
People, esp. women are
not educated
Limited nutritional
knowledge.
Taboos re: what PLW
eat.
Systemic
constraints
Markets unavailable and
unreliable
HH do not have land title
deeds
Poor extension services
Low prices for crops
No institutions offering
business development
training.
Predominant religion
considers borrowing with
interest a sin
District level health care
services are
understaffed.
Existing staff are not
able to share nutritional
knowledge with health
clients
14. Problem Statements
• WHAT: determine the limiting condition
• WHO: identify the population affected by the condition
• Overarching problem (impact population)
• Underlying causes (if a subset of impact population)
• WHERE: the location of the population
• Necessary for overarching problem; optional for underlying causes
• Food insecurity for vulnerable pastoralist households
in Fafan zone of Ethiopia.
14
15. Problem Statements: Identify subset impact
populations
Impact group identified
in overarching problem
statement
Subset group identified
for underlying cause
Food insecurity for
vulnerable pastoralist
households in Fafan
zone
Inadequate amount of nutrients consumed
by children under age 5 in Borena zone
Women have limited access to extension
services
Low agricultural yields for agro-pastoral
households
If a problem disproportionately affects a subset of the
population, specify it.
15
16. 16
PROBLEM: Food insecurity among rural households
Low crop production
Low
literacy
levels
No institutions
offering
business
development
training
Low income security
Limited access
to education
Low livestock production
Inadequate
agricultural labor
Less productive
labor
No access
to credit,
savings &
insurance
HH do not
have titles to
land (no
collateral)
High animal
mortality
Regular exposure to tropical
storms, hurricanes, seismic activity
Limited capacity
to challenge
factors
contributing to
marginalization
Weak governance, structures,
systems (disabling environment)
Limited access
to health care
services
Limited
crop /
husbandry
knowledge
and skills;
poor NRM
Increased incidence
livestock disease,
malnutrition
Limited
access
to drugs,
animal
health
services
Poor soils
Denuded
landscapes,
unsustainable
water mgmt.
Inadequate
access to farm
inputs
Damaged crops
and seed stock as
a result of shocks
Limited animal
draft power
Markets
unavailable and
unreliable
Inadequate
farm
income
High
prevalence
of illness
Reduced capacity to
earn income from
non-agricultural
activities
Increased damage to
already poor road
systems
Limited number
of transactions
Global economic
volatility
Poor
extension
services
Few financial
institutions
Large-scale
migration in
search of
work
Inability to
replace lost
assets
following
shock
Limited early
warning
systems
Identify strong and flawed causal linkages in this sample
17. 17
Identify strong and flawed causal linkages in this sample
PROBLEM: FOOD INSECURITY AMONG RESOURCE POOR RURAL FAMILIES
Low Income Security
Limited
entrepreneurial
skills
Low literacy
levels
No institutions
offering ED training
Inadequate Nutrition
Low dietary
diversity
Limited
nutritional
knowledge
Parents are
not educated
Community places low value
on education
Limited Food Availability
Low crop
production
Poor soil
fertility
Inadequate
access to farm
inputs
Limited crop /
husbandry
knowledge
and skills
Poor
extension
services
Inadequate
agricultural labor
Less productive
labor
Increased
impact of
HIV/AIDS
Limited
HIV/AIDS
education
Few income
opportunities
No access
to credit
HH have no
collateral
HH do not have
land title deeds
Limited animal
draft power
High animal
mortality rate
Increased incidence
livestock diseases
Limited access
to drugs
Markets
unavailable and
unreliable
Few financial
institutions
Limited infrastructure
Limited variety
of foods
produced
Inadequate
farm
income
Low prices
for crops
Structures and Systems (i.e. Government Policy, Laws, Culture)
Limited capacity to
challenge factors
contributing to
marginalization
19. Summary
• Different populations or different regions may appear
to have the same broad categories of problems, yet it is
critical that we identify context-specific underlying
causes.
• Causes occur at multiple levels (household, community,
and systems) and in various forms (behaviors/
practices; knowledge, skills, attitudes, beliefs; and
systemic weaknesses).
• A problem tree helps us to visualize the non-linear
causal logic of problematic conditions.
• A problem tree with strong causal logic can be easily
transformed into a TOC with strong causal logic.
19
20. Group Activity 2.1
• Use your group’s preliminary analysis
1. Prioritize an overarching problem and write a
problem statement:
• WHAT: Determine the condition the project is intended to
address.
• WHO: Identify the population affected by the condition
(e.g., target population).
• WHERE: The area or location of the population.
2. Identify key problems (broad conditions) and draft
concise statements.
Create a problem tree
20
21. Group Activity 2.1
• 3) Document underlying causes on sticky notes
• Write as concise statements
• Make it clear if a problem disproportionately affects a
subset population
• Be sure to include the various types of causes (systemic;
knowledge, skills, attitudes, beliefs; behavior/practices)
• Note the evidence base for each identified cause. If
supporting data do not exist in your data set, note the data
gap on the flip chart!
21
Create a problem tree
22. Group Activity 2.1
• 4) Begin causal analysis to develop the problem tree
• Organize causes to demonstrate how they occur
sequentially or simultaneously.
• Start by putting contextual constraints at the bottom of
the tree.
• Next work your way down from the key problems
• Ask “ what are the key reasons problem X
exists?” Keep asking “any other reason”, until all
causes that can explain most of the problem are
identified.
Create a problem tree
22
23. Group Activity 2.1
• 4) Once a causal stream is in place re-check
causal logic:
• Move down the stream using statements such as
“Condition X exists…….because of Condition Y”. For
example, there is a high prevalence of livestock disease
because there is limited adoption of improved husbandry
practice.
• There is limited adoption of improved husbandry practices
because there is limited access to animal health care
supplies (deworming meds; vaccinations, etc. ) and limited
knowledge of how to protect livestock health
• Check causal logic moving up the stream, e.g., Condition X
and Condition Y and Condition Z are the main reasons
Condition A exists.
• 5) Check the balance of types of constraints
Create a problem tree
23
25. Group Activity 2.1
• 6) Once the logic begins to hold, capture the problem
tree in an electronic format
• If the diagram cannot fit legibly on one page, create a
separate page for each key problem.
• Be sure to show how the problems link to one another
across pages. (Handout 2.1c)
Create a problem tree
25
A holistic analysis improves your ability to design and implement integrated programs. We all know the value FFP and other donors are placing on integrated interventions.
Integrated programming refers to a sector-neutral or cross-sectoral approach, with sectors and stakeholders working together and adopting complementary . strategies to address common issues. It’s a “we’re in this together” methodology.
Holistic analysis does not necessarily mean bigger broader programs must be implemented by your organization, it simply means that you and your team have looked at the ‘big picture’ and that big picture view of problems will help you develop a “big picture” TOC, which in turn, helps you to identify the most effective response and approach for your program.
Understanding the “big picture” is critical to the development of a TOC, because an effective TOC diagram will portray a holistic picture of how a goal might be reached, including the efforts of external actors.
Holistic problem analysis relies on rigorous causal analysis, the identification of common constraints and opportunities, feedback loops, and underlying causes of food and nutrition insecurity before going further in the design process.
Causal analysis allows program planners to identify the pathways between causes and effects, including cross-causal linkages between problems. For example, why might a community experience low income security? Perhaps the causes leading to this problem include negative health issues, low crop production, or any number of other factors that are not directly within a finance and/or economic pathway. Any problem that interacts with one part of a system also interacts with other parts of the system. Thus, holistic problem analysis always aims to investigate cross-causal linkages.
By rigorously exploring cause-effect pathways, we are better able to identify the specific causes that can be acted upon.
If you are not working on a FFP DFSA, draw on your Module 1 analysis where you identified the most challenged well-being outcomes. Otherwise, we’ll start with Food and Nutrition Insecurity.
Should not be thinking about logistics (e.g., cost of program delivery) at this point. We are simply looking at the data and trying to discern the biggest problem.
For the purposes of this training, problems are a condition or set of conditions that negatively affect people (e.g., death, infectious diseases, poor access to health or extension services, low agricultural production, inadequate housing) and contribute to compromised well-being outcomes.
Once you identify an overarching problem, use your evidence base (all your organized data) to list an inventory of problems. Writing the various problems down on sticky notes or index cards makes it easy to organize, arrange, or filter them into three types of problems.
Key problems are the broad conditions or causes that contribute to an overarching problem. For example, in the case of food insecurity, it is common to identify low income and poor health status as key problems.
For the purposes of this training, problems are a condition or set of conditions that negatively affect people (e.g., death, infectious diseases, poor access to health or extension services, low agricultural production, inadequate housing) and contribute to compromised well-being outcomes.
Underlying (or root) causes are the entire collection of specific contributors to the identified key problems.
Contextual conditions are the social, economic, political, or natural conditions (discussed in Module 1) that contribute to underlying causes and, at times, result from the overarching problem (i.e., the cycle of vulnerability).
When we are sorting through our data and asking What else? Ask “ why does this problem exist?” Go through a checklist of HH , community, systemic causes.
Paying attention to causes at the systems level is critical as FFP rolls out the 2016 -2025 strategy. It also
ensures that we have a comprehensive understanding of transformative resilience capacities.
This slide demonstrates the first basic sorting step, where we organize the evidence-based problems into various categories, and positions, which provides the start to our problem tree.
Key problems are broad conditions we recognize in many poorer parts of the world (poor health, inadequate income, etc.) that directly contribute to the overarching problem. A FFP RFA typically identifies key problems (e.g., low income, poor health status, inability to manage risk), but you should use your evidence base to confirm that they are the main contributors to the overarching problem. Place key problems directly under the overarching problem.
Contextual conditions influence all of the above; therefore place them at the very bottom of the evolving problem tree.
In the middle of the evolving problem tree will be an assortment of underlying causes. They include:
Systemic weaknesses include problems such as low institutional capacities or limited access to basic infrastructure. These weaknesses are primarily influenced by contextual conditions, and often end up in lower tiers of the problem tree.
Knowledge and skill levels, beliefs, and attitudes include problems such as limited knowledge of optimal nutrition practices or conservation techniques, low financial literacy, a belief that women should never travel alone outside their community, or a youth’s attitude that there is no future for them in agriculture. Knowledge and skill levels, beliefs, and attitudes are rooted in contextual conditions and are influenced by systemic weaknesses. They often end up in lower to middle tiers of the problem tree.
Problematic behaviors and practices include limited adoption of WASH, agriculture, or IYCF practices, limited use of health and nutrition services, limited use of risk management strategies, or low participation of women and youth in local decision-making bodies. Behaviors and practices are greatly influenced by knowledge, skills, attitudes, and beliefs, as well as systemic weaknesses and contextual conditions. These problems often end up in the middle to upper tiers of a problem tree.
Finally, some underlying causes do not fall into any of the three categories above. We can refer to these as specific conditions. They are typically the result of behaviors and practices and we often find them in the upper tiers of a problem tree, directly below the key problems. They include problematic factors such as high prevalence of early marriage, high rates of HIV/AIDS infection, low agricultural production, severe soil erosion, or low employment for young adults.
This is another simplistic example of how a chain of causes/conditions leads to a large problem. The arrows demonstrate that a lower cause leads to a higher problem. However, it is important to begin discussing the slide at the top and work down. For example, ask participants:
What are the causes of high rates of HIV/AIDS infection? (One answer: people engage in unsafe sex.)
Why do people engage in unsafe sex practices? (One answer: Condom use has negative cultural connotations.)
Also explain to participants that a causal stream is never this simple and linear. The higher we are on the causal stream the more underlying causes we can identify that feed into a problem.
Ask group to provide other examples.
This organizing tool is on your USB. Is an example of what you could send out to various team members as you are in the process of causal analysis. Can be a preliminary exercise to the causal analysis & problem tree that you send to various team members, to help with the cross-checking process. ….. Country level staff, to get their input.
During the pre-design assessment phase it is a useful tool for organizing data as it comes in from the field.
Once an overarching problem is identified, it needs to be specifically phrased so that it identifies what, who, and where. This sets the stage for constructing a strong overarching goal in your TOC. For example:
Food and nutrition insecurity for vulnerable pastoralist households in Fafan zone of Ethiopia.
Sometimes a problem disproportionately affects a subset of the impact population (e.g., women, children, youth, elderly, farmers, the chronically food insecure, or people in one District or agro-ecological zone). In these cases, specify the subset impact population in the problem statement.
This will set the stage for specific TOC outcome statements and ensuring that intervention targeting tightly aligns to the causal analysis.
Before 1st click: Have participants identify “key problems”
Next click: Identify underlying “conditions” .
Further explore the problem tree together. Identify causes at the household, community, and external levels.
Some notable flaws:
FLAWED HYPOTHESIS- Limited knowledge of conservation/ ag skills is the only cause noted for low use of conservation ag techniques. Knowledge is necessary but not sufficient. Need resources ( sufficient human labor, physical resources, cultural acceptance of new practices, ability to take risk and try something different, etc. )
LOGICAL ORDER. Switched the order of “limited access to business development services” and “low entrepreneurial literacy”. Logic doesn’t flow here.
“high pest and disease” is not a cause of “low use of organic fertilizers
Limited knowledge of conservation ag skills does not cause limited access to farm inputs.
3.
Use a sample problem tree on next slide to demonstrate this type of checking.
Once a causal stream is in place re-check causal logic.
Move down stream
Move upstream.
Check balance of types of constraints.