Risk, Vulnerability, Resiliency - Health System Implications, NCFV, Public Health Agency of Canada

Risk, Vulnerability, Resiliency — Health System Implications
Background Paper
Roundtable Discussion
Reflections
Selected Applications

The concept of risk has become common place in our discussions of health in a number of ways. Many health services are planned and organized following assessment of risk. This applies to various components of the health care system-e.g., public health, institutional health care settings, and the education of health care professionals. A risk approach is used when considering health and illness issues-e.g., mental health and mental health problems; violence, abuse and neglect; suicide; and deteriorating and disabling physical conditions. Populations are identified who might potentially be at risk for specific health problems-young children; women; youth; seniors; people from ethno-cultural minorities; gays, lesbians and bisexuals; people who live in poverty; people who are socially isolated; and people who live in institutions.

Therefore, the concepts of risk and vulnerability have been apparent through many programs and initiatives of Health Canada. There are a number of examples.

The Mental Health Unit, Health Care and Issues Division, has been working with the concept of risk in relation to mental health problems and serious mental illness. Through a review of the literature on the effectiveness of prevention of mental health problems for those at risk, the Unit identified the complexity of the concept of risk as it applies to mental health.

The Mental Health Unit has also had strong participation in the now completed family violence initiative. The focus was specifically health professionals and the health care system. The Mental Health Unit concentrated attention on knowledge, effective response, and access to information and training. Three areas received major attention. The first was education and training: looking at teaching approaches; how content was handled; the process of change; and interdisciplinary approaches, primarily with the health sciences faculties. This work has had a very broad range of application, across many issues. The second area was health practice and health practice settings. This involved developing guidelines, and particularly involving professions who had not been involved before, for example the dental profession. This work had a strong emphasis on looking at the values of individual practitioners and their life experiences. The third area was abuse and neglect of older adults in community and institutional settings. Concepts of risk and vulnerability were apparent in all of these initiatives.

The Health Care and Issues Division also addresses concepts of long term care, continuing care and palliative care. The Division has identified that individuals, families and groups, in all of these circumstances, can be at increased risk of a variety of adverse outcomes.

Other Divisions of Health Canada have also been involved in concepts of risk and vulnerability. The Childhood and Youth Division has identified the impact on children at risk, particularly young children. The Women's Health Bureau has identified risks for women's health-emotional and physical. The Aging and Seniors Division has been identifying what the concept of risk means for seniors, how it has been defined, and what is contributing to their risk.

In 1994 the Federal, Provincial and Territorial Advisory Committee on Population Health prepared Strategies for Population Health: Investing in the Health of Canadians. This document summarized what we know about the broad determinants of health-the things that make and keep people healthy. It defined population health strategies that address the entire range of factors that determine health, rather than focusing on risks and clinical factors related to particular disease. These strategies also are designed to affect the entire population, rather than individuals who already have a health problem or are at significant risk of developing one.

It therefore became apparent to the Mental Health Unit of the Health Care and Issues Division that there was a need to examine the concepts of risk and vulnerability in a holistic way-to identify the common, and different, elements of risk as they affect various populations and various health outcomes. In order to achieve that, the Unit commissioned: A Background Paper: Risk and Vulnerability - Promise and Potential. This paper was based on a review of a selected number of documents related to risk, vulnerability and potential concerning health and mental health issues. These included suicide, deteriorating health, disabilities and violence, abuse and neglect. Particular emphasis was placed on the following groups-youth, adults, people living in group/institutional settings, seniors and women. The paper included reviews of materials published by Health Canada and sentinel documents identified by Health Canada that were commissioned or funded by them. The paper was not intended to be an exhaustive discussion of the concept of risk and promise as it relates to these issues or populations. Instead, it extracted the important concepts relating to risk and promise that were identified.

Next, the Mental Health Unit invited a group of service providers, planners and researchers to attend this Roundtable discussion. The objectives of the Roundtable were as follows:

Throughout their deliberations, the Roundtable participants identified some important elements to consider when defining risk factors. They are outlined in the following table.

Participants noted that there are different uses of the concepts of risk and vulnerability. These differences depend on people's perspectives on health e.g., medical model versus determinants of health; individualistic versus social context; psychological/scientific versus feminist/political.

The participants identified that much of risk that is experienced by individuals is constructed by the society in which they live. As one participant said,

I am concerned about finding ways to keep a social analysis as part of this context, so that we can focus on individuals who are at risk, but not lose sight of the bigger picture.

Two examples were helpful. The first one was the example of violence against women, and the social norms that contribute to violence.

Women are at higher risk of violence than men, and some sub-groups of women are at higher risk Changing that situation of risk is a systemic thing, it is not about those individual women who are at risk at all. This is one of the most complex parts of looking at risk, that is, how do we address risk looking at it from a systemic point of view? Every woman is at risk, there is nothing particular about one woman that makes her different than the next women. ft is not about women. ft is about how we conduct relationships, the way our system is ordered in general in terms of power and balance, power in society.

A second example was that of poverty. One participant observed that there has been a feminization of poverty, and it appears to be increasing. The gender issues of poverty have not been addressed. And we know that poverty puts people at increased risk of a number of harmful outcomes. The feeling was that if we only address the side issues, or focus on the harmful outcomes, we are not addressing the complete issue.

What do you do when you come up against something that requires a social revolution? We can do the practical pieces that are manageable, and ethically we must do that, but we will continue to bang our heads against this wall. Addressing societal issues requires a longer term timeline, it involves another set of issues, but to not include it is to miss a major point.

This reinforced the importance of taking a determinants approach to understanding health and to responding to health issues. From a service point of view, participants felt that it is important to be concerned about the individual and support for them. From a broader perspective it is important to look systemically.

Otherwise we become focussed very narrowly and that becomes counterproductive.

There was concern raised around the issue of "blaming the victim" for their risk. Two examples were shared. While it has been good for service providers to ask women the right kinds of questions about abuse, it is critical that they not move from identifying individuals to blaming them, or seeing their behaviour as being the cause of the abuse.

When we use the term risk, how can we immediately demand that people ask questions about the larger social context and what gave rise to the risk factors in the first place.

Another example is HIV/AIDS. Gay men were identified as a risk group, and one of the consequences was that people made attributions that blamed gay men and their lifestyle for this illness. We have moved from identifying risk groups based on identity, to identifying risk behaviours.

Risk is inherently a concept of probability. However, one participant identified that risk gets talked about in categorical terms. Each risk factor is really a minor, moderate or major shift in the probability of something happening.

The real question is not If something is a risk factor, but whether the risk it incurs is a meaningless minor shift or a major shift.

We cannot count all risk factors as if they are equal. We have to get past the laundry list of risk factors. We need to identify starting points of risk factors, and cut away the parts of the process that are automatic consequences.

It is important to first identify individual risk factors and throw them into the pot. We have to be inclusive so all risk factors are considered. At some later phase we have to determine that not all of these things count, some are more essential than others. We need methods to shift through that. Down the road, as we study things, we do cut them down. At the beginning of research we will have a proliferation of risk factors. It takes a long time to sift through them and come to what really matters. Therefore, we need long term studies.

Often categorical conclusions are made based on risk factors, rather than recognizing that individual risk factors give us only one dimension of the picture.

We jump from the notion that 50% of schizophrenia is inherited, to the idea that it is genetic. Somewhere along the line the language of continuous variables got turned into categorical conclusions.

.longing for certainty. The addictions field has been looking for years for a genetic link Others have been looking for a cause of sexual orientation. There is a great deal of money that is being spent on the cause of Alzheimer's Disease, when the social and other costs of the disease are huge.

This can lead to inappropriate interventions. The example of diagnosing major depression was shared.

When one diagnoses major depression, if you look at the criteria in most systems there is some magic point, out of the nine criteria symptoms, where someone is called a major depressive. For example, if you have six symptoms you have a major depression, if you have five you do not. There is the illusion that there has been determination that there is a huge qualitative difference in function. That has never been empirically demonstrated. Treatment decisions are made on this basis. Where you put the threshold is determined by a lot of things, not only empirical evidence, money, politics, but also the seriousness or consequences of being wrong.

Causality is an interesting phenomenon in risk. There were differences in opinion among Roundtable participants as to the understanding of causality as it applies to risk.

In most cases, especially those relating to mental health and psychosocial outcomes, it is inaccurate to assume a direct cause and effect relationship between a given risk factor and a specific outcome. The impact of risk factors are multiplicative and they contribute to varying degrees to the outcome.

It is not exclusively causal, there is uncertainty. This does not mean that there is not causality. If we don 't connect the language of causality to risk factors, then why should we intervene?

We often speak about a connection between risk factors and outcomes, e.g., there is a connection between depression and alcohol use. It is not known if the depression causes the alcohol use or vice versa. Causality is uncertain. However, people have the tendency to assume because they fit together there is a causality.

The tendency is to look at risk factors like a checklist, without looking at how much of the population are we talking about, who is determining it as a risk factor, or how much risk it contributes.

The concept of time was identified as important when considering risk and vulnerability. Often we talk about risk as an event, or as events, that happen at a particular point in a person's life with a consequence. However, risk is part of a process.

Even though there may be something that increases the risk, or a traumatic event, what keeps that going over time?

It is at the least a two stage process, the event itself and how that might harm the individual, and what keeps that going over time.

One framework proposed by a participant looked at what influences risk over time in the following way. What are the reinforcing factors-the personal and social resources that can facilitate or increase the probability of harm occurring in terms of life experiences; and the enabling factors, the factors in the community, e.g., attitudes in the community. These co-exist with risk and change over time.

While much discussion and focus around risk is based on individuals, communities can also be at risk. Focussing on the health of communities was seen as a high priority.

The biggest area at risk in Canada is our communities, most of our communities are unhealthy. Then disease emanates, then we drive a lot of public service dollars into attacking the disease. We need a smarter way of going about this.

Furthermore, when we focus only on the individual, the approach has the potential of becoming a pathology model, and we may be focussing our attention on the wrong things. You have to put the individual back in a context; you need a wide angle lens to see if the risk factor is connected to a larger issue. Look at a community health aspect first, and then see the individual in the context.

For example, youth violence is not a youth issue, it is a community health issue. It requires looking at a lot of other symptoms.

Risk must be considered in the context of development. One participant shared the example of youth.

In adolescence it is developmentally normal to take risks. This is somewhat linked to feelings of omnipotence, young people don 't have the concept that they can be harmed. In some areas, it is developmentally normal to engage in violent aggressive behaviours to establish oneself among peers, assert one 's identity in the group. Some risk taking behaviour among youth may be to relieve boredom. If we are labelling that behaviour, or trying to understand it and intervene, it would be rejected by young people.

A developmental approach is not appropriate for all risk situations. For example, for seniors it can be a patronizing approach that denies them control over their lives. It often translates into not "allowing" older people to take risks.

What is defined as "acceptable risk" is often based on society and individual values. Therefore definitions of risk are often subjective.

Older people are often not allowed to take risks, which are considered OK for younger people. If we conceptualize risk on a graph with two axes, harm to self to harm to others on the x-axis, and permissiveness of risk or the level of risk they are allowed to take before anyone intervenes on the y-axis, you would see under what circumstances people will fall into which

It is other people, usually health and other service providers and community agencies, who define risk for individuals and groups. Therefore, the identification of risk will be partially based upon service providers' and agencies' values, biases, experience and knowledge. Often times risk is identified because there has been advocacy work in a certain area of concern or on behalf of a certain group. The social context of society and the particular community, the political agenda and the financial resources available define and provide the basis for addressing risks, as well as do research and investigation.

Choice is an important phenomenon to consider when discussing risk. However, the group identified many different facets to the concept of choice.

One is that ultimately, people will choose to behave in certain ways. The question was raised,

Is there a subset of people in society who will choose to kill themselves no matter what society wants to do about it?

We have people in personal care homes who are supervised for 24 hours a day-they do commit suicide. They decide they are not going to eat anymore, and despite the best efforts of the staff they do die. People will always continue to make those choices.

On the other hand, other participants had concerns that when people live in institutional settings, there is often so little left in terms of choices, for example, choices about eating, dressing, that these choices become very significant.

In the mental health system we have lowered people's functionality so we can just ~ our services. We put people at risk and then we can intervene with the effects of this risk.

However, choice was not always seen as that straight forward. One choice may lead to situations where further choices become impossible.

It gets fuzzy in addictions. You may have started making a choice to take the drug, but then you may not have any choice over what your experience will be with the drug. The only people who have no risk are those who are not taking any. As soon as you take any kind of alcohol and drug you put yourself at risk of developing a problem, because you don't know what the end result will be, you may be someone who can drink socially, or you may be someone who rapidly goes down that road of dependence and lack of tolerance.

Finally, one participant identified that these examples refer to people who are capable, cognitively, of making decisions. There are many people who no longer have their cognitive abilities and are therefore not able to make these kinds of choices.

The concept of choice was not applicable to situations involving abuse and neglect. In these cases, the social situation often limits people's choices. For example, a lack of power balance and equality between the genders in our society contributes to violence against women, and does not provide choices for women.

Some of our systems and decisions take away choice and impose risk on people. For example, early discharge following birth creates potential risk for the newborn. Seniors being discharged one to two days following surgery may be at increased risk. These are risks that are imposed by fiscal allocations. There may be false economies that come with that kind of approach. In these situations, having the support in the community is important. If you go into the community and those supports are not there, then there is a heightening of the probability of some kind of harm occurring.

The group also talked about risk in terms of the ethics of risk, the competing ethical values. If we talk about risk in terms of autonomy, we also need to talk about risk in terms of social justice. An example was shared with regard to seniors.

We tend to focus on issues of self-neglect with elderly. We allow a lot of latitude around individuals neglecting their own nutrition, physical health, safety and less latitude when there is harm /neglect for others. If a senior smokes in his/her own home and is at risk for starting a fire, we are far less likely to intervene than if she/he lives in an apartment where there is harm to other people.

When discussing and defining risk we are influenced by much of the discourse that has come before.

For example, the risk of perpetrating violence is often only described in terms of males, risk of victimization in female terms. That's why we don't have a "violence against men" terminology, even though males may be at greater risk at some ages. Part of this is the history of the advocacy - women's voices have been heard (granted, we still have a long way to go). When we talk about previous victims becoming offenders, we always talk about males, even though female victims also become abusers, and in ways that are different from males. We have to be careful, there are a lot of assumptions about gender that may block us from achieving a more inclusive discourse.

The issue of violence provides a good example of this discussion. The current discourse of risk in the area of violence focuses on the victim. However, it could be changed to see risk as those at risk of perpetrating violence, rather than those at risk of being victimized by violence. Altering the discourse in this case, would lead to different kinds of interventions.

The process of ascribing risk focuses on the negative. It focuses on weaknesses instead of strengths, limitations instead of abilities. This may result in the perception of individuals as being at risk as opposed to at promise (i.e. as individuals with a problem to be addressed rather than as people who provide an opportunity to nurture). That can bias how people are treated and how interventions are designed. Participants identified this particularly with regard to seniors and youth.

In working with older people we have developed assessment tools that dealt with the probability of problems. Over the years we have tried to switch it around, starting to build on strengths, looking at positive aspects, allowing people to take risks. It is a different perspective.

When we are working with older people, we do acknowledge that there are some things that have been lost, but there is a lot that remains. It is capacity that we are working with. For a long time we were only thinking of incapacity, now we are looking at what is the capacity that is there, not only physical, but social and intellectual capacity.

The problem behaviour happens only once in a while. Most of the time they are intact. They are doing something right. As well, all the rest of the kids who do not give us difficulty are generally fine too. There is a well of resiliency that we have not focussed on.

There was a concern expressed that by focussing on incapacity, we will end up saying, "if they are not capable of doing it we will do it for them", instead of working with people.

Focussing on hope was seen as critical by many in the group. One participant shared an example relating to a women's addiction program that looks at the concept of hope as opposed to the concept of problems.

We started to document not only the women 's strengths, but also their perception of how well they are doing. We want to look at the relationship of hope and movement in hope and long term outcome, not just ~f they are sober, but their situation re housing, income, depression, self-esteem, violence. Our intent is to work on their hope, their sense of control.

While seen as a powerful idea, in certain professional domains it was felt to be not accepted as valid. If actions and interventions recommended by program providers are not adopted, the individual's choice may be interpreted as not showing progress.

With regard to high risk youth, the whole idea of "meaning", is often tied to resources. If young people do not have hope, they do not see that they have control in their lives.

One of the keys to successful models of intervention is that the appropriate intervention be offered to the appropriate population. One participant shared a model for effective programming, reported by May, 1995, which is based on risk prevention of fetal alcohol syndrome (FAS). While this model shows what programming based on risk would really mean in the FAS field, it has broad application.

In the world of pregnant women, the vast majority are at the low end of the risk continuum of drinking heavily and having a damaged child. This is primarily because women stop drinking, because they don't want to drink. The risk continuum moves along to high risk at the tip of the triangle, with moderate risk along the way. Most people fall on the left, with a very small percent on the right in the tip of the triangle (?4%). Overall in society approximately 15% of people have drug and alcohol problems in some severity.

P.A. May suggests that in applying the concept of risk in the low and moderate risk groups you think of universal approaches, e.g., warning signs in bars, (in the women's washroom). With these approaches, you need to create the climate. There needs to be some information about FAS or women will not know about it. Furthermore, society depicts positive images about women drinking. This also includes a universal screening process of drinking and pregnancy, e.g., with physicians and public health nurses, people in a position to be talking to pregnant women. Without this we cannot identify women at high risk.

People who are screened to have some level of alcohol use that is too high would receive an early intervention: motivational interviewing by doctors, nurses and other providers. This goes beyond asking questions about alcohol use, but encouraging the woman to think about what she is doing about it. It requires doctors, nurses, transition house workers, etc., to be able to do this.

The British Columbia Government also has a graphical schema, where they list their services as to where they fall under the continuum of risk.

There was discussion about the importance of creating interventions that are human and approximate real life. For example, with youth.

I think that we increase vulnerability and the probability of risk when our interventions are so artificial and far removed from what we really need to create healthy children. For example, why don't we have foster homes for young women who are expecting and want to keep their babies, instead of putting them in institutions? They would be with a family who want to help a young woman raise a child. They can model for her, teach her the things she needs to know. She would not be isolated, marginalized.

High risk kids are unattractive, unappealing clients, so our interventions in residential settings tend to be regimented. Kids need authentic relationships with real adults. The closer our models/interventions/working relationships/programs resemble real life, the more likely we are to connect with those kids, help them heal, find their way. When you look at the costs of doing these things, it will be more cost effective.

Participation of individuals and communities in risk identification, and in planning interventions and services was seen as very important. A number of aspects of this approach were identified.

Harm reduction was seen as an approach that may not only benefit the individual, but also benefit the community.

For example, giving addicts heroin might reduce their likelihood of getting involved in crime. You have to think of how this one act saves the community from further harm.

Harm reduction was identified as an effective approach to risk, that was empowering for individuals. Harm reduction asks the question, "Are there ways to reduce the harm that accompany risk?" It respects choices around risk and is a client focussed approach.

Participants did identify that it is often difficult to shift the power to the consumer. It fundamentally changes the relationship. It raises questions of values.

The whole issue of power in consumer/provider relationships is critical to empowerment. The mental health example was shared by one participant.

One thing that influences this relationship is legislation. The mental health act is an interesting way to assess relational issues between consumers and providers in terms of how much risk an individual can freely take.

One of the interesting aspects in developing mental health legislation is that it brought sectoral interests around the table, it brought the family members, consumers, therapists, bureaucrats who had to design the legislation, it probably did a lot to advance relational issues between consumers and providers.

One participant's experience in reforming the mental health system involved consumer participation. Regional management boards were established, and the composition of those boards was family members, service providers, caregivers and members of the community at large. They were participatory in nature. The result has been a system that is more responsive to consumer needs.

Supportive environments are needed for intervention, regardless of where that intervention takes place. There was much discussion regarding interventions that are institutional based versus community based. This included de-institutionalization as it relates to people with serious mental health problems; institutional versus day treatment of people with addictions; services for youth at risk; and health services for the older adults.

Participants identified that in many ways mental health legislation has helped us to understand that risk is a good thing, if we create systems that give people choice and provide the support that is appropriate, as defined by users as much as by providers. The key is available support as defined by clients. Then risk is seen on a continuum. It may not be an opportunity, but it may be freely accepted. However, if we don't provide the supports and alternatives to the individual, but still put them into that environment where there is risk, they are more likely to be harmed by the risk.

For example, a person with schizophrenia who starts to decompensate and is in his/her apartment. The old way would be we'11 go and get an examination certificate, haul them off get them certified and treat them. The outcome of that in terms of their health was predictable, it led to long term re-institutionalization and it led to poor functional outcomes for people. Part of the risk is if we leave them in that home they are going to get sick.

But if every day we go back and knock on the door, and say "John, are you going to come to the centre and get your medication? "John may say, "get out of here, I don't want to see you ". If the next day we come back and do the same thing, gradually John will accept the risk to a certain point where he will go and get the medication. However, if we put John in the community and don't provide adequate support, we'11 harm him.

This is a key issue if we look at long term care and people in nursing homes and institutional settings.

They are only there because we haven't given them the range of alternatives that enables them to take risks and be more vulnerable in the normal context of living in communities.

Another participant shared an example regarding older adults with significant health service needs.

Historically we thought that 24 hour supervision was the best thing for elderly frail people. Now we are trying to find different approaches, in order to keep them out of institutions, to keep them in the community longer and longer. It is changing the whole nature of our institutions, many of the programs that we had are inappropriate now.

It is important that we carefully ask ourselves, "Who is driving that change?" Participants identified that it makes a big difference if it is older adults who are behind this change, rather than if it is political agendas or finances. We are beginning to shift in terms of creating quasi-institutional settings that may involve more risk for older adults, but provide for better quality of life.

We do not know how this will play out in the end, moving away from the nursing home, moving to the community, supportive housing kind of model.

We have to be careful to recognize that institutionalization is not an all or nothing scenario. One participant used experience with a youth addictions treatment program as an example.

This program tried to help kids live with other families, go to a day program. It involved schooling, sports, a mixture of things in the community. It tried to avoid a rigid, institutionalized treatment approach. Over time, the providers came to realize that they needed a mix of these two things. There are kids who don 't respond to the community approach, so we can 't completely get rid of institutions. There is a whole range ofprograms and services needed. Therefore, we need to get creative about how to make the best match, instead of thinking that there is one way or the other way that will work for all people.

There are other examples where risk is not a good thing, where the continuum model does not apply, for example, abuse and neglect.

There was concern expressed that our interventions, our programs and services, have the potential to increase risk. Since the designers, the conceptualizers of the programs are very removed from the lived experience of the person, the process of delivering service can amplify the risk.

One of the things that often gets missed is how our attempts to intervene may increase the risk.

This could include the situation where there is enforced intervention. For example, some people want to force women who are at high risk of foetal alcohol syndrome (FAS) into treatment.

I don't know if that is right or wrong, mostly I think it is wrong. Forcing people into treatment in the addictions field never seems to he right. The problem seems to be the wrong intervention to the people who need the most intensive help.

In the mental health field the issue of enforced treatment has been a polarized debate, and provides another example. Mental health legislation has tried to create a balance recognizing that treatment outcomes through coercive measures are guaranteed to have repeat admissions and repeat utilization of the same systems. In the legislation there are clear definitional terms on the risk of harm: if you are danger to self or others, if you have the presence of a definable disorder, etc. There are a series of checks and balances. One participant shared the approach to enforced treatment with which he had experience.

By putting in a patient advocate system, removing direct committal by a physician 's signature, and putting it through a tribunal process, other alternatives than putting someone in a hospital on a locked ward are explored. It has brought family members, physicians, individuals to the table before the chair of the tribunal to discuss the situation.

In some cases, involuntary detention is denied and other alternatives are pursued. In other cases, after listening at the table the patient accepts voluntary treatment. As a result, more people are seeking treatment, but they are taking it voluntarily. That suggests we are going to get better outcomes, longer periods of time between re-admissions, and just better health status for the individual.

Another complex area where risk arises is in seniors where mental capability is decreasing. The problems do not arise when the person is clearly defined as a danger, the problems arise in grey areas, as the person is approaching potential harm, when the situation is less clear cut.

In those situations, what is the role of the individual, of family members, of professionals?

Social services and the general system of helping sometimes play out again, the same dysfunctional patterns of relationships and communication that youth experience in their families that harms them.

Research is key to establishing effective interventions. However, there were a number of problems identified in the area of research. Most of that concern came in the use of research, rather than how the research was done.

One participant identified that incomplete research is often utilized in planning programs. Since the effects of risk factors are multiplicative, since they evolve over time, since their effects are not categorical and since social influences are critical, any research that is attempting to identify risk factors for a harmful outcome must be long term. Too often, results of short term studies or incomplete studies are quickly put into practice, when, as the research proceeds, further data and analysis may clarify the effect of the various risk factors.

Along the way I am fearful of programs being put in place because of the apparent popularity of an idea, rather than the validity of the empirical findings. If an idea sounds nice, sounds compelling, if the theory is good, it gets closer to a program. One of the things we don't think of is how risk factors combine with each other. If you really want to add greater effectiveness to programs, it is critical to identify a small set of risk factors, that when they are all present will cause a large increase in the possibility of harm.

Furthermore, often decisions are based on perceptions or anecdotal evidence rather than evidence. A number of examples were shared. There is a perception among many seniors that they are at great risk of violent crime. Is this based on reality or on the effects of media? There is a portrayal in the media that there are great negative effects of divorce on children. The evidence indicates that there are modest impacts of harm. There is a proliferation of mediation programs in schools to deal with bullying and other forms of violence. They are not based on empirical research, but on anecdotal stories.

The thing that overwhelms me is the incredible quality of research in this country and the lack of applicability of that research.

When discussing the research that is being done, it was stressed that often research is based on a need to solve certain problems, combined with whatever is politically favourable. Therefore, a lot of our research models are not value free.

Including people's experiences in research to identify risk, vulnerability and potential was seen as important. We should avoid defining the reality for a person who is experiencing a risk factor.

I want a reality check so that at least lam being more accountable, it is just as important to hear the lived experience of the person. It is important to gather information from a number of sources-literature, service providers, consumers-then to frame our research questions.

At the same time, we have to include other evidence that we have learned and know to contribute to risk.

How do you communicate research and information? Participants identified that it is important to understand the social context of a problem, and to translate the information and research so that it has meaning to the local community.

With regard to youth violence, you may have someone who is in Ottawa and sees that on the average there has been no change in the statistics, and someone else in a local community where there is increased violence. These two will see the world very differently. If program or policy decision is made on research that is the average, the people in the local community will disregard it. We must have a way to continually involve the community and constantly flow the information back.

IDENTIFICATION OF RISK AND VULNERABILITY ISSUES IN RELATION TO PROGRAMS AND SERVICES

One of the frustrations identified was a lack of integration, or working together, of a myriad of sectors.

We put lot of interventions in through many sectors: education, mental health, family, community social services, income assistance, justice. But kids still end up in a prisoners docket. We have to have a better way of responding to people's needs and problems, instead of our isolated, problem, crises focussed approach. We need to do more proactive, integrative things.

There is a lack of integration within the system, a lack of interface between mental health sector and health care sector, and a lack of interface between long term care and acute care. As a result, risk sometimes fall in between the cracks.

As a part of health and social services reform, some participants identified that people are moving into decision-making positions without direct client service experience.

Many decisions are being made by people without experience with people, coming from another perspective. Jam concerned that they do not have contact with the reality of the vulnerability of the people that we are concerned about.

While participants said they always were and always will be committed to building a community based approach with consumer involvement, there was concern that,

The rhetoric around health system reform is rhetoric that someone like myself is comfortable with because it focuses on community. However, often the reality bears no resemblance to real community participation. I think this dissonance has had the opposite effect, creating disillusionment and distancing communities from decision making and confidence in their ability to make decisions and influence decisions. We are in very real danger of losing ground, in fact in the name of making positive changes to the system and reducing risk, we are in danger of having the opposite effect, i.e., increasing risk.

Our political intentions are colliding at this time. As resources shrink, we need to spend our resources better, so we have to evaluate our programs. We all know that in order to create a rigorous design and prove outcomes, you may have to narrow what you do. To narrow your program already starts to lose most of the people because you are having a narrower and narrower focus. The same people who are asking us to use resources more effectively, are asking us to prove outcomes, and as a result, our programs become less effective.

One participant shared a story of a woman and her daughter who were murdered by the husband/father after abuse and harassment. It is essential that the police and mental health system communicate and work together to decrease the risk of harm in situations like these.

Both police and psychiatric services look at the problem through their narrow vision rather than understanding each other. In one example, a voluntary agency is trying to get the police to deal with psychiatric patients more effectively. We have to fundamentally change these systems problems.

The group identified a number of opportunities for linkages to enhance our understanding of risk and vulnerability, promise and potential and to make our work more effective.

There are so many organizations and agencies in communities that are a wealth of information about the people that they serve. At the same time, there are so many students looking for a placement for research. It seems hard to make the linkages. Community agencies say they do not have the time /resources to do research.

This is a major oversight. Computers and technology have made the capability to do research cheaper and faster. Small capital investment could have a big impact.

There are a number of opportunities for placements of health sciences faculty students in the community. However, there has to be respect for knowledge between the university and the community placement agency. There has to be knowledge of confidentiality and the ethical aspects of the service.

One of the reasons that it does not happen is that there is not a mutual respect and understanding between the two.

The BC Women's Hospital and Health Centre went through a process of consulting women about their health and how the hospital's services could be more responsive. They investigated how they could do work that is collaborative and not single issue focussed. After the consultation, they came up with guiding principles for their work. These included: listening carefully; giving women options; enabling women to be in control; being inclusive of diversity; giving women full information; being aware of socio economic, environment factors of women's lives. They are able to lobby the government with what they have learned.

One participant, in a project with the Canadian Mental Health Association, held focus groups with people from the formal and informal sectors, to determine how to work together in a collaborative way to form systems with a consumer focus when dealing with violence against women. Part of the difficulty was the feeling from the informal sector that their experiences and information was not valued by professionals. The professionals, on the other hand, were feeling that they could not be all things to all people. Both groups identified that collaboration is necessary, willingness to work together. There was agreement that a consumer focus is important.

How can we work with our current resources and re-allocate them? It is important to develop respect amongst people, to better understand people 's roles. There generally was a lack of awareness of what people did.

In this climate of health care reform, as major shifts are occurring, participants considered the key areas that require attention, related to risk, vulnerability and promise, in the context of this reform.

The moderator ended the day by asking "If you could do two things, what would they be?" Here are some answers.

In the months following the September 26 - 27, 1996 Roundtable: Risk and Vulnerability - Promise and Potential, participants (and others) had the opportunity to contemplate the proceedings. They were asked to consider a number of questions. Here are their reflections.

What are the most important aspects of risk and vulnerability for attention of policy makers, service providers and program planners?

What are the concerns relating to risk and vulnerability, promise and potential?

This concern is compounded in the present day environment of restructuring. In many work environments there is a lack of security, destruction of morale and competition for funds. This does not create a good climate for the program planning and respect that is needed.

"The opportunities are huge and exciting! We need to bring together consumers, providers, program planners, funders and researchers. As well, we need to bring people together across issues."

What are your recommendations for priority areas of attention for policy makers, practitioners, Educators and researchers?

SELECTED APPLICATIONS OF THE CONCEPTS OF RISK AND RESILIENCY

Five applications are presented:

violence / collaboration between formal & informal services
seniors / risk
women / health
mental health / prevention
youth / violence / sexuality

Joining Together Against Violence: An Agenda for Collaborative Action

by Janice Ristock with the assistance of Lois Grieger
Canadian Mental Health Association, Toronto, 1996

This report is a synopsis of the above cited document.

Joining Together Against Violence: An Agenda for Collaborative Action is a dynamic report that describes ways for all concerned with violence - those who experience it, family, friends, other supportive community members and care givers - to work together to effectively deal with this problem. By working together, the risks of mental health problems and other negative outcomes will, hopefully, be reduced.

The author emphasizes the importance of two different types of systems working together: the formal system and the informal system.

The formal system includes professional and paraprofessional services providers.
The informal system includes non-professional care providers, self-help/mutual aid groups, and family and friends.

Violence in relationships of kinship, intimacy, dependency or trust is a widespread social issue with serious health and mental health consequences. Women, children and older adults are most often the ones harmed by violence, but violence is an exercise of power and control over more vulnerable individuals or groups that occurs regardless of gender, race, culture or economic background.

The Problems

There are many myths about violence that result in blaming the victim for the abuse, or dismissing a person's claims of violence. This context of blame and denial can create a feeling of hopelessness for abuse survivors who feel that no one will believe them or respond to their concerns.

People who are victims of violence often have difficulty in accessing the services they need to help them heal from abuse. The author identifies a number of reasons for this. There are attitudinal barriers, which result from strongly held beliefs about violence, and structural barriers which result from the way systems have been organized. These barriers are connected. As well, when people have mental health concerns as a result of violence, barriers to healing are compounded by the misconceptions about mental health problems. Furthermore, power inequities make individuals vulnerable to violence and create additional barriers to help for particular groups of people-these inequities include affluence and education; geography; culture; and social isolation.

How can we remove these barriers? Some of the barriers can be addressed by service providers taking responsibility for attitudinal and structural changes within their organizations. However, the larger social context can make it difficult for formal and informal service providers to make changes and to collaborate. Cutbacks to funding may mean that groups are in competition with one another. Service providers are already feeling over-worked, adding additional responsibilities like collaborative work may seem unmanageable. Compounding this difficulty is that there is a history of mistrust between grassroots community groups and professionals, partly based on differences in power and access to resources. There needs to be an acknowledgement of these differences, and an understanding that despite a shared goal of collaboration, people are not necessarily coming to the table as equal players. Developing mutual respect, knowledge and understanding of different people's experiences and work roles is crucial to collaborative work.

There are four aspects to services and programs that promote collaboration:

Assessment

Promoting collaboration in assessment involves:

acknowledging that the possibility of violence exists in any relationship of kinship, intimacy, dependency or trust
identifying not only violence but vulnerability to violence
ensuring consumer participation
ensuring good communication and clear assurances of confidentiality

Empowerment

This means:

that the consumer is at the centre of service delivery
including a holistic approach where an individual is seen in totality, mind and body, and as a social person in a context of family, and informal and formal support systems

Team Work with Other Organizations

Services will be more responsive to the needs of consumers if service providers see their role as trying to ensure that they get comprehensive services and other supports. Being aware of services offered by other professional and community resources that respond to the mental health effects of violence will lead to more complete care for the consumer.

Education

Providers should be given opportunity to take the same lifelong-learning approach to violence that we take to other areas of work.

Developing an agenda for collaborative action

The goal of developing an agenda for collaborative action is to unite informal and formal systems of services provision in the effort to support those affected by violence in relationships of kinship, dependency or trust.

The participants are:

the person who has experienced violence, who is at the centre. She/he must be a participant in any decision-making and choices regarding the services and supports that she/he requires.
formal support systems.
informal systems of support.

How Does Collaboration Happen?

We must acknowledge that the mental health and health needs of the individuals exist in their social context.
All participants have a valid role to play in responding to the needs and concerns of the individual.
We must join together so that the individual gets the most comprehensive care.

Beginning to collaborate involves asking questions about how we might work with the various resources that are available for consultation and collaboration.

What programs, consumer groups and services respond to violence? How do they work?
Are there efforts that could be coordinated? Are there areas of duplication? Should they be diversified?
Are there groups/consumers that we never have contact with?
How can consumers, families and community-based groups be involved in the formal service system?
How can nurses, physicians, social workers and other professionals be involved in community-based and consumer groups?
What would consumer groups and individuals like in order to receive more comprehensive care? What have their experiences been? How would they like to be involved in collaborative work?
How do professional and community-based services work with other resources to offer comprehensive care? Do they have a referral list? Are they aware of the needs and concerns that do not fall within their immediate service mandate?

Long-term work in collaboration involves many things.

Developing reformulated programs.
Exploring gaps in existing services and discussing ways of coordinating services together. Consumers, formal and informal services providers all being involved in outreach to various communities.
All participants collaborating to offer education and training workshops for one another. Formal and informal systems and consumers joining together in prevention and social change efforts surrounding violence.

Care providers also need to collaborate with consumers on an individual level as part of their regular, day to day practices. This involves listening to the individual and helping her/him determine her/his needs; sharing information and all decision-making regarding her/his healing process; and discussing policies on confidentiality. Collaboration in day-to-day practices can include:

making appropriate referrals;
getting in contact with the agency or individual you are referring them to;
doing follow-up work to make sure this was appropriate from all perspectives;
being willing to consult for free with other service providers;
being an advocate for an individual;
being willing to listen and learn from other perspectives and see how various resources might be utilized to best meet the consumer's needs;
initiating meetings with colleagues for case consultations.

Seniors at Risk: A Conceptual Framework

Canadian Association on Gerontology
Prepared by Charmaine Spencer
for the Aging and Seniors Division, Health Canada, 1995
Unpublished

This report is a synopsis of the above cited document.

Seniors at Risk: A Conceptual Framework is a thorough review of issues to be considered when employing the concept of risk with older adults. This synopsis describes the conceptual framework for risk and older adults that the report developed.

The author defines risk as the likelihood (probability) of encountering harm or loss.

The author states that risk is not considered a discrete entity, rather than a relative concept. Risks, in fact, exist on a continuum ranging from those that are minimally harmful to a person to those that are life-threatening. Furthermore, personal risks exist on a continuum, from those that people pursue as opportunities, to those over which they have little choice. This is shown in the following diagram.

Risk pursued as
opportunity

Freely accepted risk

Reluctantly assumed
risk

Little or no choice

The author also describes a "social continuum" of risk. Along this continuum risks are defined as those which society is willing to accept, to those risks which are considered unacceptable or unreasonable. While the personal risk continuum is based on choice, the social risk continuum is based on societal notions of acceptable and unacceptable outcomes.

Risk and Older Adults

The concept of risk is applied to older adults more often than any other age group. This is partially due to fact. However, it is more commonly a reflection of stereotypes and generalizations about older adults. The aging process is seen as leaving older adults frail and more susceptible to a number of problems: disease, disability, dependency, dementia and premature death. Older adults are seen as having lesser resources and abilities to deal with these potential outcomes.

It is clear that deciding what is acceptable or unacceptable risk for older adults is not a neutral process. It involves someone, usually not an older adult, envisioning a 'normal' older adult and the 'normal' situation and the quality of life expected for (or by) older adults. These judgements are value based and are also politically and ideologically defined.

The author states that risk is not a neutral concept. It involves determining what are acceptable or unacceptable consequences. Society assigns considerable value to individual autonomy. There is considerable freedom given to the kinds of risks adults can accept for themselves without interference. However, if older adults engage in what is considered risky behaviour, they face a strong possibility that someone will begin to question their sensibility or even their mental competence. In ignoring potential risks, older adults face the possibility of having others dismiss their wishes and make decisions for them.

It is an oversimplification to categorize all older adults as being at risk of some negative outcome. The term 'older adults' represents people of a wide age range, spanning over 40 years and two generations. They are a socially, demographically and economically diverse group. Therefore, different groups of older adults are at more or less risk of various problems.

What Constitutes Serious Risk?

The risks that are considered to be most serious are usually those that deny older adults their basic physical, emotional and social needs. The author also proposes that the seriousness of a risk is a combination of:

the probability of the risk, or how likely it is to happen;
the impact of the risk, or how devastating the consequences are;
the immediacy of the risk, or how soon it may happen.

Probability of Risk

Some problems are considered particularly serious for older adults because they are more likely to happen to them than to the general population. There are a number of examples:

Physical health problems and illnesses such as osteoporosis, heart disease or cancer increase with age.
Older adults are more likely to face multiple health problems that are chronic and disabling rather than acute.
Some older adults may be at increased risk of psychological or social problems such as depression, dementia and isolation; of economic risks, such as poverty or financial abuse; and of environmental risks such as inadequate housing.

Increased risks may result from internal phenomena, such as hormonal and physiological changes accompanying aging, or from external circumstance such as forced retirement or deterioration in neighbourhoods.

Impact of Risk

Other risks are considered serious because they affect older adults more unfavourably than they would younger adults. For example, people of all ages contract influenza each year; however, older adults are more likely to have underlying conditions that makes them more vulnerable to serious outcomes of influenza.

Immediacy of Risk

For older adults, a specific risk is often the result of minor risk factors gradually building up to a crisis point. Interventions are more commonly used for immediate harms (crises), while prevention measures are more commonly used for harms that are emerging more slowly.

A Conceptual Framework for Risk

The author describes risk as the interrelationship of three elements: risk factors, resources and life experiences.

Risk factors are those things which predispose a person to a particular negative outcome.

They are physical, psychological, sociological, environmental or behavioural.
They are predictive in nature.
They help identify people who are more likely than the general population to experience a particular problem.

Resources available are the personal, social and environmental supports:

They operate as protective factors, often counteracting the potentially negative effects of risk factors.
They help individuals to maintain health and well-being, and to cope with life experiences and negative outcomes.
They are both internal and external. Inner resources include psychological resources such as a person's own inner strength and adaptive strategies. External resources include social supports, economic resources and environmental supports.

Life experiences are reflected in the way in which people think of themselves and their environment. They may influence risk positively or negatively in several ways.

They can moderate risks by shaping the person's personality, influencing the way he or she views the situation, or builds his or her personal resources.
They may leave an older adult more at risk of negative outcomes. An example of this is an older adult who lives most of his/her life in an impoverished environment.

Enabling factors may modify the relationship among these three elements.

They facilitate or inhibit the increase of risk;
They are present before the risk has occurred;
They include the availability, accessibility and affordability of health care and community resources;
They include social influences and attitudes toward a specific risk.

Some of the enabling factors relating to the abuse of older adults include: social attitudes about privacy in people's lives; social assumptions about older adults' competence, assuming that they are unable to properly make financial decisions; and social structures that isolate some seniors, thus making it easier for the abuse to occur undetected.

Once the risk has been realized, other factors can reinforce the risk. Reinforcing factors include:

positive or negative reactions from others;
the presence or absence of social support as well as appropriate or inappropriate interventions by professionals, friends or relatives.

A Guide to the Literature on the Effectiveness of Prevention of Mental Health Problems for those at Risk

by Nancy Jonah
Paper prepared for Mental Health Unit, Health Care and Issues Division Health Canada, Unpublished, 1996

This report is a synopsis of the above cited document.

A Guide to the Literature on the Effectiveness of Prevention of Mental Health Problems for those at Risk reviews the literature regarding the effectiveness of strategies to prevent mental health disorders in populations at risk. It is a thorough review that includes contributions from both the research and practice settings.

As a result of this extensive review, the author concludes that the knowledge base for some mental disorders has now, in the opinion of many researchers and practitioners, reached the point where a shift to major prevention efforts is warranted.

The report stresses two important findings.

First, it is not simply the presence of risk or protective factors, but the interaction and accumulation of factors that affects the development of a mental disorder. The complexity of the interaction between risk and protective factors and between biological and psychosocial factors should be the subject of much analysis in the future.
Second, in studying the relationship of mental disorders to various developmental stages, researchers and practitioners have come to recognize the importance of life transition periods or sensitive periods when vulnerability to mental illnesses seems to be heightened, e.g. at entry to adolescence, to adulthood, to retirement or bereavement.

The report identifies a number of mental disorders for which accumulated risk factors can be identified and suggests that major preventive intervention research is now possible for these disorders. This is what the author recommends:

Depressive disorders:		Depression occurs very frequently in the population and there is a fairly large knowledge base. Therefore, certain selected preventive interventions should be undertaken to reduce symptoms of depression in high-risk groups. There is insufficient knowledge at this time to attempt to predict the onset of major depression.
Conduct disorders:		Conduct order in children is described as sustained aggressive, violent or antisocial behaviour. The author cites Offord and Bermett's review of the literature on the long-term outcomes and effects of interventions for conduct disorder which says that aggressive behaviour in childhood predicts aggression and violence in adults in a minority (20%) of children. There is some evidence regarding the effectiveness of specific interventions. However, the effectiveness is limited, and this is due to the lack of specific knowledge about the causes of conduct disorder.
Alcohol/substance abuse:		Research into preventive interventions is still in the stage of identifying high-risk populations. However, since the availability/cost of alcohol is a risk factor, control of availability/cost has been shown to have more impact than education programs.

For other mental disorders, particularly those which are strongly linked to genetic factors such as schizophrenia and Alzheimer's disease, preventive interventions are not currently warranted. However, improved treatment interventions have been recommended for individuals with these disorders in order to improve or delay the course of the illness.

The author identifies that approaches which use risk reduction or protection enhancement may be the most effective. This is because most risk and protective factors are not unique to a single mental disorder. Identifying clusters of related risk or protective factors can be used to identify groups or individuals for whom to target interventions. Risk and protective factors interact in a complex fashion, and involve individual, family and community influences. As well, factors have differing effects at different life stages. Therefore, it is essential that preventive interventions be multi-faceted and appropriately timed with respect to sensitive periods.

Studies have revealed that many people (especially children, adolescents and older adults) do not seek professional help with mental health problems. Therefore, it is important that preventive interventions involve active efforts to reach out to the targeted groups. There are specific components related to intervention design that the author describes as important when addressing this problem:

accessibility of services;
new organizations of service delivery, e.g., mental health teams affiliated with clinics;
consumers participation;
participation of community members;
attempts to de-stigmatize mental illness.

Including these components will help to ensure that prevention efforts are effective and sustained.

The Challenges Ahead for Women's Health:
BC Women's Community Consultation Report

British Columbia's Women's Hospital and
Health Centre Society Consultation Working Group, 1995

This report is a synopsis of the above cited document.

The newly formed BC Women's Health Centre was interested in determining what the provincial role of their facility should be. In order to accomplish this they conducted a community consultation which reached more than 600 women in communities across the province and almost 200 health service providers. Staff from BC Women's formed a core working group to carry out the consultation and a research consultant assisted in the development of the consultation method and the analysis of the information. A steering committee of government and women's health organizations across the province guided the process.

The consultation used two approaches: discussion groups in communities across the province and telephone interviews with health service providers. The discussion groups included women from urban, rural and remote areas of BC. Specific arrangements were made to ensure the inclusion of women with disabilities, women in prison, adolescents, seniors, Aboriginal women living in urban areas and on reserves, visible minority women, immigrant and refugee women, women with experience in the mental health system, lesbians and women from the Downtown Eastside of Vancouver. The resulting report provides an illuminating, personal account of what women in BC believe to be their health issues, the factors that put them at risk of health problems, or help them to stay healthy.

We at times felt overwhelmed by the weight of women 's experiences and by the apparent magnitude of the changes that are required. But we have also been inspired by women resilience and their willingness to work together. We are encouraged by the realization that there are many small changes that can make a significant impact on women 's health and women ~ experiences in the health care system.

What Were The Findings?

When the women talked about health, they talked about their lives. They talked about their lives as wives and partners, mothers, daughters, caregivers, workers, neighbours and community volunteers. They talked about how social and economic factors influence women's health and the way women are treated in the health care system. They talked in particular about:

Poverty

Women were angry and frustrated about the impact of poverty on their own and on their children's lives.

"Understanding of poverty is a definite issue here-you need money to be able to buy food to meet daily food guidelines. It 's well and good to have the guidelines, but you have to know how you can meet them when you're on a fixed income."

Violence and abuse

All ages of women described violence as an issue: young teenage women, women who had small children, middle-aged women and older women.

"He beat me if I looked at another guy, and he would hit my girlfriend because she supported me ... I wasn't allowed to talk to anyone on the phone and could not go downtown. If there was someone to talk to, I would have gone, but I thought there was nothing wrong with the situation."

Social and emotional support

Women talked about their experiences of social isolation. They need more social support. This was particularly of concern to immigrant and refugee women.

"Coming here, I've had extreme emotional problems trying to adjust to life in Canada. Jam so worried about my family. They are in such a volatile situation, I'm not sure when I'll ever see my mom again."

The media

Women, particularly teens, recognized the impact of the media on their lives and health, and how they feel about themselves.

"Self-esteem thing is the biggest problem and it is everywhere. Barbie has a 36 inch bust and a 21 inch waist and no one can live up to this not matter what."

What Did They Say about Health Care?

Women and service providers had very specific ideas about what would make the health care system better.

Women talked about wanting the health care system to be focused on health and wellness, addressing physical, emotional and spiritual well-being. They want health care providers to look at them as whole people, not just "a bunch of symptoms".

Women were concerned about the health care system's current reliance on the medical model, stressing the absence of disease and focusing on the physical dimensions of health. They felt that normal changes occurring in women's lives, such as childbirth and menopause, have become medical events.

On the other hand, women said that in other circumstances, their physical concerns are ignored and attributed to their mental states or reproductive cycles.

Many women and service providers emphasized that mental health services need to be a more integral part of the health care system. They felt that the current mental health system is not meeting the needs of women. There was concern about the amount of psychotropic medications being prescribed.

Women wanted the health care system to be more accessible. They identified a wide range of factors that limit access:

geography;
income;
community dynamics, for example, lack of confidentiality in small communities or in ethnic communities;
discrimination based on race, income level, culture, age,
sexual orientation, disabilities, past history physical abilities;
hours of operation at facilities;
language;
lack of child care.

Women wanted a health care system that is flexible and responsive. They wanted:

to be able to make informed choices about their health care;
to collaborate as equals with professionals in planning their care;
choices of providers, including nurses, nurse practitioners, midwives and holistic care providers;
a supportive environment that creates conditions for women to be empowered;
attention paid to their daily lives;
validation for what they feel;
knowledge and skills so they can take control of their health.

One of the most predominant frustrations the women had, was with the time and attention they received during doctor's appointments. They talked about not feeling heard or validated by health care providers, feeling dehumanized, and having their own knowledge of their bodies discounted. Many service providers saw the need for training to increase the sensitivity of health care workers.

Women and service providers wanted the health system to use resources more efficiently and to be more accountable for producing intended outcomes. Suggested solutions related to a number of areas included:

emphasizing prevention;
integrating services;
improving continuity of care;
supporting patients and families;
providing for independent review of practitioners;
setting standards for care;
increasing funding for women's health.

Violence, Youth and Sexuality -
What it Means for Programs and Services

Report Based on a Round Table Discussion
held in Ottawa, February 25 & 26, 1996
Mental Health Unit, Systems for Health Directorate, Health Canada

This report is a synopsis of the above cited document.

On February 25th and 26th, 1996, a group of service providers, program planners and young people gathered to have a Round Table Discussion on the topic of Youth, Violence and Sexuality: What it Means for Programs and Services. This meeting followed the production of a Discussion Paper entitled, Violence and Its Impact on Youth and Youth Sexuality: Implications for Programs and Services. The purpose of the Round Table discussion was to share concrete examples and stories of what has worked, what is working, the barriers and challenges faced by young people and service providers, and ways to move ahead.

The discussion paper clearly identified that a substantial number of young people come through childhood and youth laden with violence. They are either violated personally, have lived with violence in their home, or knew of other people's violence. It also identified that the experience and fear of violence in the lives of children and young people has the potential of interfering with their healthy growth and development: emotionally, spiritually, physically and sexually. It affects their self-esteem, their sense of autonomy, and their trust in the world and other people, which all in turn influence how they form their sexual identity and how they participate in sexual relationships.

The participants of the Round Table also identified a number of issues that contribute to the risk and vulnerability of young people with regard to violence and their developing sexuality. Four broad categories are noteworthy:

attitudes of society, including organizations and service providers;
support for the helpers;
accessibility and timing; and
relationships between helpers and youth.

Attitudes of Society, including Organizations and Service Providers

There are many attitudes that prevail in society, which are embraced by our institutions and those who serve in them, that can increase risk and vulnerability.

Violence is pervasive in society. Not only do many young people live with violence in intimate relationships, but all young people live with an abundance of media images of violence-of situations where people abuse power and control.
The social construct of gender in our society perpetuates the opportunity for abuse of power.
Attitudes toward sexuality are not always positive and celebratory.
There are many "isms" operating within organizations-racism, sexism and heterosexism.
Young males who are victims are often alienated.
Attitudes towards young people who are gay, lesbian or bisexual often alienate them from existing services and help.

"Gay, lesbian or bisexual young people who are on the street are not served by the agencies for at-risk youth because often these agencies are homophobic. The shelters, the drug programs and the child we~fare system are not safe for these kids."

Support for the Helpers

Support for those who help young people-staff and volunteers-is critical. Resources are dwindling, fewer and fewer people are asked to do more and more. There is the serious potential of loss and burn out. As those who help become more exhausted, the risks of the young people needing help increase.

Peer support programs have been very successful, but we need to protect the peer supporters themselves. They are vulnerable because of what they have gone through in their lives, and they risk "burning out". Given program closures and the increasing numbers of young people who are either coming forward for help, or going into the child welfare and criminal justice system, this problem will only get bigger.
We also need to support adults who provide services for young people. "Usually it '5 tired, exhausted people trying to care for others in terrible conditions ".
Service providers and care givers "can 't take someone else past where they are themselves." This means that it is essential to have pro-staff and pro-adult policies and models in organizations and institutions.

Accessibility and Timing

Our institutions and services are often not accessible to young people. This is for a variety of reasons:

They do not operate during the hours that young people are available, or the hours that they keep.
They do not include a basic respect for young people. They do not embrace young people holistically, inclusive of mind, body and spirit. They do not focus on the experience of individuals as opposed to dealing in stereotypes.
They do not involve young people in their planning, development and operation. Therefore they do not truly address issues and problems in a way that is meaningful for youth.
They are not publicized.
At the level of individual service providers, if young people are not accepted and welcomed when they reach out, when the time is right for them, they can be put off for a long time.

Relationships Between Helpers and Youth

Building trust between care givers and youth was seen as pivotal to supporting young people and therefore decreasing their risk and vulnerability. Unless we are open, honest, and share of ourselves, building this trust will be very difficult.

Adults need to actively listen to youth and watch their own behaviour. They are role models.
At a personal level we need to build trust with others by sharing our human side. By reaching out and revealing who we are, we will begin to develop trusting relationships with young people.

Recommendations

The group made a number of recommendations for action. This is what they said.

At the personal level we need to:

Recognize that we are our brother's/sister's keepers; look out for one another; maintain solidarity; focus on our common cause.
Honour ourselves through self care and nurture our own wellness.
Build trust with others by sharing our human side
Recognize the link between our consumer behaviour and the issues.
Actively listen to youth and watch our own behaviour as adults. We are their role models.

Within our organizations we need to:

Investigate power relations and decision-making processes by looking at the "isms" [racism, sexism, heterosexism] operating within our own organizations. Develop healthy structures.
Focus on our vision for the future and maintain hope.
Act on small, "do-able" tasks to avoid getting overwhelmed,
Question our motivation for doing this work.
Be honest with our colleagues and peers about our jobs, the future, and our performance.
Actively network and communicate.
Have regular, mandatory professional development.

To share program/resource information effectively we need to:

Get the word out on good programs.
Update kits and resources on an ongoing basis.
Communicate with others working in this area; have access to information systems.

To continue networking we need to:

Recognize the necessity of bringing people together face-to-face.
Include policy makers and funders in field work as often as possible.
Have an ongoing forum to continue discussion and sharing of ideas.

To strengthen the level of support and resources for youth issues we need to:

Work to ensure that all levels of government work together and co-fund this work.
Support successful programs.
Integrate, coordinate and strengthen all youth-serving services across the justice, health, social service and recreation sectors.
Involve corporations in youth advocacy.

To develop effective programs/policies we need to:

Involve youth, parents, service providers, schools and peers.
Encourage more youth involvement in policy development and training of professionals.
Recognize youth skills; ensure that youth are involved in decision-making positions of power in our organizations.
Acknowledge our limits, and work together with youth.

In terms of public education, we need to:

Assist youth and adults to be better consumers of services so that the child welfare system, foster parents and governments become more accountable. Inform youth about what they are entitled to. Raise public awareness.
Avoid putting the onus on survivors helping others.
Go to where youth are.
Provide inclusive, welcoming environments in schools, community centres, etc., where people can get information.
Ensure that images and messages in resource materials are inclusive.

In terms of media strategies, we need to:

Use systems, e.g., Internet, in a positive way.
Form assertive partnerships with receptive media, particularly youth-focussed media.
Promote positive youth images. Celebrate the success stories of youth.

In terms of youth-based program ideas, we need to:

Support youth to tell their own stories.