When it comes to wellness, you are not alone — although you used to be.
While public health officials in Florida wrangle with the new coronavirus alongside the old chronic diseases, there’s some work going on behind the scenes to move beyond public health to a new model to help people become more resilient. This new model is called community wellness.
The old “personal responsibility” model of wellness often narrowly focuses on the physical, with diet and fitness equating wellness. Perhaps there’s a nod toward mental wellness by acknowledging stress reduction and meditation. But even with this view, which includes social aspects — yoga classes, group cardio sessions, recreational sport competitions — the onus remains upon the individual to show discipline, willpower and fortitude against their perceived personal laziness, weakness and tendency to succumb to temptations.
“In an ideal world that would work,” said Deb Logan, executive director of the Blue Zones Project Southwest Florida, an initiative sponsored by the NCH Healthcare System to improve wellness within its service area. “That’s the old public health model — if you educate people enough, incentivize them or maybe even shame them — they will stop smoking, they’ll eat better, exercise and stick to it. But we do understand that we’re a product of the environment in which we live, and those influences within our environment impact our choices.”
You’ve probably felt the struggle if, for example, you’ve adopted healthy eating habits, but someone in your office brings in a box of doughnuts to share every day. Or, perhaps, you’d like to take up running, but the infrastructure in the area where you live prevents you from doing so safely.
“We make over 250 health-related decisions every day,” Ms. Logan noted, “and most of them are just automatic pilot. If we leave it up to the individual and they keep having environmental influences that are so strong, they’re really trying to fight an uphill battle against it.”
In contrast, community wellness takes public health to a new level by shifting the model of the personal fitness battle to one where the greater community supports wellness both through modifying surroundings and through social collaboration. This concept recognizes that individuals do not live separated from their surroundings, so those surroundings can have profound effects upon their wellness — in either positive or negative ways. Also, the goals move beyond mere physical fitness toward creating an environment where all community members may thrive because wellness has instilled resiliency into these individuals.
Community wellness initiatives attempt to modify the environment so that the effects upon individuals are positive and support wellness. How the initiatives attempt to make positive, supportive changes varies by community, which makes sense since the problem — and, therefore, the needs — vary by community. What’s common is that, no matter the focus of each initiative’s lead agency, they are all trying to help their populations thrive.
The Keys: keeping with tradition
In Monroe County, community wellness work is being done following a more traditional public health model. Unlike the other counties, there is no snazzy name or catchy slogans. There is not a standalone website dedicated to engaging the public; however, reports such as the county’s Community Health Improvement Plan are publicly available on the health department’s website. A CHIP is a long-term plan to address public health issues identified through a community health assessment. The plan provides desired public health outcome goals. Every county health department in Florida is required to write a CHIP. While a CHIP may influence the wellness initiatives in other counties, the plan drives the focus in the Keys, since the Florida Department of Health in Monroe County serves as the lead agency for wellness in the area.
Facilitated by the Florida Department of Health in Monroe County, partner agencies go about working on the county’s CHIP goals through subcommittee meetings. Public community wellness events take place less frequently than in other counties. Although this seems surprisingly bureaucratic and low-key for a place as centered around public life and community as the Keys, it reflects the fact that Monroe County has very different community wellness needs as compared to other parts of Florida.
“We haven’t really had any overarching events,” said Alison Kerr, health education program consultant with the Florida Department of Health in Monroe County. “Part of the reason Monroe County didn’t select activities or exercising is because our data doesn’t really show a need, because we don’t really have an obesity issue here. Plus, our residents — at least, based on the data — seem to make use of our parks a lot more than other places do, which is a good thing.”
What aren’t good things are the three issues that were selected, through input from local partners as well as public surveys, as needing work for Monroe County’s CHIP: health in all policies (HiAP), access to care, and mental health and substance abuse.
The HiAP goal addresses changes for community wellness at an institutional level, such as engaging the many government agencies not typically involved in health matters to consider health implications when making their policies. This might include adding bike and pedestrian improvements to master planning. Regarding the access to care goal, Monroe County wrangles with a surprising problem that again requires addressing at an institutional policy level rather than a public engagement level.
“Access to care — that’s one of our most challenging, especially because Monroe County has always had a problem with keeping and retaining doctors,” Ms. Kerr said. “A lot of times you get health care providers coming down happy to see that they’re going to get paid a lot more than other places, but they don’t realize that the cost of living … is a lot more than they imagined … so that’s why you see a lot of our (provider) numbers going down.”
Ms. Kerr said that, to improve the issue, Monroe County’s hospitals have started securing housing for health care providers, as well as working out flexible contracts where providers come down to work in the county once or twice a month. As to public events for access to care, the health department had arranged to bring the University of Miami Health Care System’s Game Changer medical RV to provide cancer screenings in Monroe County this spring. However, that public event had to be postponed because of the pandemic.
The CHIP goal offering the most public engagement components has been the one to improve mental health and substance abuse issues in the Keys. Monroe County has seen a decrease in opioid deaths. The health department collaborated with the Sheriff’s Office to set up drop-off locations for no longer needed prescriptions. Monroe is also one of the few counties in Florida that offers Narcan, the opioid overdose intervention drug, to anyone who asks for it, Ms. Kerr said.
As part of its mental health goal, the health department collaborated with the Centers for Disease Control and Prevention to conduct a Community Assessment for Public Health Emergency Response study when Monroe County’s suicide rate spiked in the months after Hurricane Irma made landfall in the Keys. Local volunteers paired with health staff and conducted the study door to door in May 2019, and they collected 231 responses from residents throughout the Keys. Community partners hosted a suicide awareness walk in Key West in November 2019, and now more people are seeking mental health services in the Keys.
“The Guidance Care Center, which is our only mental health service provider that serves the whole county, reports . . . we had over an 87% increase in the number of people served between last year and this year . . . and part of it is because we worked as a team to secure funding to provide more services for residents after seeing a huge spike in suicides in Monroe County after Hurricane Irma,” Ms. Kerr said. “That was a pretty traumatic experience and had an effect on our residents. We’re most proud of our mental health and substance abuse issue because a lot of work has been done with all of our partners, seeing that this is one of our top issues.”
A culture of wellness
This concept of community change to support improved wellness for the population may sound like an overwhelming undertaking, but it is not unprecedented in this country. We have done it before — to combat drunken driving.
The government changed laws to criminalize drunken driving in order to reduce deaths and disabilities caused by this preventable health hazard. However, this was only one step since a police officer could not be stationed at the exit of every establishment selling alcohol. More was needed to enforce the law. It took a change of culture.
Bars started designated driver recognition programs. Public health education programs introduced the idea that individuals needed to take care of their friends. With “Friends don’t let friends drive drunk,” it became socially acceptable and expected to intervene. Taking car keys and calling a cab was both for the friend’s safety and for the safety of the public out on the roads.
It took more than a law; it took a change of culture to combat drunken driving. If the community could agree to change cultural acceptance of drunken driving, supporting optimal wellness for everyone shouldn’t be that great a cultural shift. Instead of community wellness, perhaps the concept should be called a culture of wellness. ¦