People in difficult socioeconomic circumstances seem almost inaccessible to health interventions. While they need them the most: their life expectancy is on average six years shorter than that of others.
Jet Bussemaker and AnneLoes van Staa have found out ways and opportunities how to bridge the health gap in cities of the province of Zuid-Holland during their field research.
Healthcare threatens to become unaffordable, obesity and depression continue to rise. What is going wrong anyway?
AnneLoes van Staa, lecturer in Transitions in Care at the Hogeschool Rotterdam and Scientific Leader of the scientific program Vital Delta: Medical Delta’s journey towards vitality and health: "When I ask first-year nursing or physical therapy students how come there's a health gap, they say, "Because those people don't have a healthy lifestyle. They need to smoke less and exercise more." Students are convinced that it is a person's own choice and responsibility to live a healthy life. That's not the right approach.
Jet Bussemaker, Professor of Science, Policy and Social Impact: 'In our research within Healthy and Happy The Hague, we see that you have to start from the living environment of residents. If highly educated scientists want to convey this is how you should do it, people feel that they are being looked down upon. If you really start talking about what concerns people, you hear about existence insecurity, mold in houses, about an unsafe neighborhood and worries about the children.'
Money worries and mold in the house: what can you do with that as a family physician who wants to help reverse someone's incipient diabetes? Van Staa: 'You have to see what someone comes up with on their own, looking wider than just medical. You have to find out: what is going on in this life? We have developed a simple visual tool for this: the Self-Management Web. For example: someone with a kidney transplant and far too much weight comes to the outpatient clinic. Instead of immediately talking about losing weight, the nurse specialist presents the form. Then it turns out: this lady could not even pick up her pills at the pharmacy because she had no bicycle and no money for the bus. Financial distress, as often happens, caused a cascade of problems.
'I do notice that caregivers are reluctant to take this approach. They fear action embarrassment. They can't help people get rid of money worries, can they? They don't have to, but they can help people solve them themselves.' Bussemaker: 'I know general practitioners in The Hague who started a WhatsApp group with people from the social domain, such as debt relief, social work and the community center. They call them in if they don't know where to take a patient. This is in line with the principle of powerful basic care: it links care and the social domain. We have to get out of our professional boxes, otherwise we are powerless.
General practitioners are the obvious pivot in such a system, but they are severely overburdened. Bussemaker: 'Yes, that's right, many problems come together at general practitioners. That is why it is so important that they, too, are relieved where possible. Think of initiatives such as well-being on prescription, walking and cooking clubs and bridge-builders such as the community sports coach. I introduced the latter fifteen years ago (as State Secretary of Health, ed.) Such a coach and the bridge-builders we are experimenting with in The Hague are the lubricant between compartmentalized organizations.'
Van Staa: "Suppose someone with osteoarthritis is treated by the physiotherapist. Then the improvement in the stiff, painful joints often does not take hold. A community sports coach knows the opportunities in the neighborhood to keep moving and so can support the physical therapist.'
How should policymakers frame this new approach and cohesion, including financially? Bussemaker: 'Insanely little is spent on prevention. Healthcare costs about 5,000 euros per person annually, of which only 25 euros goes to prevention. The Debt Lab has shown that it pays off in The Hague to use healthcare funds to tackle debt. With the stress it takes away, you prevent an enormous amount of somatic and psychological complaints. From the Public Health and Society Council we recently advised Minister Schouten of Poverty Policy on this.'
Van Staa: 'It's not only policy makers who have to make a move. Employers too. A nursing home director told me that one in three of his employees has wage attachments. A survey by Tijdschrift voor Verzorgenden showed that 41 percent of caregivers struggle with money worries. It is low-paying work, often part-time and awkwardly arranged with working hours. Caregivers also have above-average informal care responsibilities. Employers think they are not about it, but it is they who should make these money worries negotiable. They desperately need their people: what can they do for them to ensure, for example, that they have less stress and can work more hours? At every level, people need to come out of their own boxes.'
There is an elephant in the room, though, that politicians keep walking around. We need to cut down on many things: eating, smoking, alcohol, driving. But less is not a business model. Bussemaker: 'In The Hague South-West all kinds of parties are already ready to offer even more unhealthy things. Municipalities must be given the opportunity to put a stop to even more snack bars. That is a precondition, but not the whole solution to unhealthy neighborhoods. It lies primarily in stronger social networks and meaningful daytime activities. Work can be medicine for people who walk with their soul under their arm. We are now working in The Hague on projects about meaningful daytime activities, to prevent health problems. Prevention is much more than just eating healthier and not smoking.'
How do you actually research opportunities to make people and neighborhoods healthier? Bussemaker: "It's difficult. In neighborhoods with complex problems, people often find professionals irritating. These people are also done with researchers. They come to watch and then leave. We have just started citizen science: local residents do their own research. They take pictures and ask questions to their neighbors. What do they notice, what changes? Real co-creation with the people it's about. That's the challenge.'
Once money worries, social problems and lack of meaningful daytime activities are solved, will people start living healthy lives? Van Staa: "Healthy eating sometimes has the reputation of rabbit food. If people with little money have something to spare once, they prefer to buy their children candy rather than apples. It also has to do with learning to like things.' Bussemaker: 'There seems to be a role here for schools, such as with initiatives like the Healthy Primary School of the Future. We are still very little engaged in this in the Netherlands. We noticed that the districts in The Hague where we are conducting research are not yet ready for it. You can't saddle teachers with yet another curriculum while they encounter major social problems in the classroom. We are now looking at how better cooperation between education and care can unburden teachers.
Jet Bussemaker (1961) studied political science. She is Professor of Science, Policy and Social Impact, particularly in healthcare, at LUMC and at the Institute of Public Administration at Leiden University. She is the chairman of Gezond en Gelukkig Den Haag , a field lab aimed at reducing health disparities in the city. She is also chair of the Raad Volksgezondheid en Samenleving and chair of the Social Council of Medical Delta. She was state secretary of VWS and minister of OCW.
AnneLoes van Staa (1957) studied nursing, medicine and cultural anthropology. As lector of Transitions in care (Hogeschool Rotterdam) she focuses on, among other things, promoting the vitality and health of citizens and professionals. She leads research within Vitale Delta, in which students, teachers, citizens, clients, healthcare professionals and healthcare employers work together, and is a member of the Scientific Council of Medical Delta.
Text: Rianne Lindhout
