4.3 Analyses: How This Initiative Illustrates The Mobilization Of Population Health

4.3.1 How the determinants of health are addressed

Coherent with a population health approach aiming for change in the broader determinants of health, the initiative was grounded in an understanding of the root causes of food insecurity in terms of poverty. Food security is itself seen as a health determinant, linked to the capacity of individuals to lead healthy and active lives in conditions that are respectful of human dignity. The initiative also targeted several other determinants as factors in food insecurity, including education, social support, employment and working conditions, personal health practices and coping skills. Success indicators used in the evaluation reflect how these determinants are understood to act. These are shown in the table below.

LEVEL	SUCCESS INDICATOR
Community-based organizations	Implemented activities offer alternatives to food relief.
	Activities allow the creation of friendship and support links.
	Training supplied allows for the development of knowledge, attitudes, skills and behaviours that can help address hunger, poverty and exclusion.
Participating individuals and families	Activities improve revenues to ensure decent living conditions and employment.
	Activities foster social integration through improved self-esteem, harmonious interpersonal relations, and significant personal and social engagement.
	Activities support improved educational attainment by encouraging return to school and by recognition of the training received in the pilot site.
Collectivities	Community-based groups and institutions create links that will support the transition to alternative practices in food security.
	Projects create conditions favourable to their long-term continuity.
	The various stakeholders in food security are equipped with a wider range of means and strategies toward durable food security.

4.3.2 How the focus is placed on the health of populations

The employability initiatives were specifically aimed to reach individuals living in chronic poverty and exclusion, who were willing to become involved in an employability process in the agriculture-food domain. A total of 35 individuals participated in the three employability training programs, of whom 19 found regular employment after the program. As a consequence of the focus on poverty, the initiative naturally tended to include single-parent women, who, in this region as in most others in the country, are disproportionately affected by poverty. For example, in one of the project sites which was evaluated separately for Emploi Québec, eight of the 10 participants were women, six were single mothers, and all were living on either income security, employment insurance or child support payments. Other pilot sites aimed to reach other types of populations living in conditions which could affect their food security: low income seniors and users of community gardens. The initiative also supported a total of 30 positions as supervisors and trainers.

4.3.3 How upstream investment has occurred and how multiple strategies have been applied

The initiative stressed creating greater access to a continuum of actions in order to promote social and economic re-integration and development of sustainable food security resources. The continuum of actions can also be seen as moving the intervention strategies upstream, toward the root causes of food insecurity. Examples of specific strategies within each stage of the continuum are:

Access to food bank services and social supports

• emergency food relief and social involvement
• community meals, coffee house meetings
• community groceries, cooperatives
• collective kitchens, buying clubs
• meals offered in schools, lunchtime conferences.
  
  

Access to adapted training and supports

• healthy eating and food management
• personal and social development
• work readiness
• learning about agriculture and environment.
  
  

Access to local agricultural resources

• community gardens
• community-supported agriculture
• partnerships with local producers.
  
  

Access to semi-specialized training and supervised placements

• work integration platforms in ecological market gardening, landscaping, ecological vegetable handling, food transformation, institutional cooking
• personal and social development
• employability and entrepreneurial development.
  
  

Access to socially meaningful, useful work

• cooperatives in bio-foods and agri-environment: ecological agriculture, composting, meals on wheels and frozen pre-cooked meals, water purification, hydroponics, biological filtration.

Although not all of these strategies were offered in each of the pilot sites, training and other support materials were developed that could be used for each.

4.3.4 What accomplishments are anticipated in the short, medium and long term

The evaluation of the project suggested that it had important short-term effects on participants, over and above assuaging their hunger. Participants reported having developed networks of support, sharing and solidarity. At the same time, the need for psycho-social support resources and adapted learning situations was identified. The evaluation also showed that the work experiences and training provided through the projects were valuable and enriching, contributing to participants' overall employability. For stakeholders in food security in the region, the evaluation results suggested that while the appropriation of alternative means of addressing the problem based on a determinants approach had begun to take hold, more time and supports would be required to ensure a global, intersectoral regional mobilization.

In the short to medium term (one to two years), it was expected that the projects would become sustained within their communities, by obtaining stable funding or evolving into self-sustaining enterprises. At the same time, it was expected that the results of the projects would be disseminated, creating opportunities to further sensitize major players in key government departments, including Health Canada, about the value of the approach. In the medium term, this was expected to lead to the mobilization of regional partners toward the implementation of best practices for sustainable agriculture (Environnement Québec and Environment Canada), work force re-integration (Emploi Québec, Human Resources Development Canada), and healthy lifestyles (Health Canada, Régie régionale, CLSCs). This mobilization was to be consolidated through training for relevant professional and community-based organizations.

In the long term, it was expected that formal engagement for intersectoral collaboration would be obtained from decision makers in these other key sectors, and that work would begin with provincial counterparts toward the development of a food security policy for the province.

4.3.5 How collaboration across levels and sectors has occurred

4.3.5.1 Involvement of specific sectors (5B, 5C, 5D)

See Table 2 in section 10 for a summary of the involvement of specific sectors, along with their financial contributions.

4.3.5.2 Gains and challenges from intersectoral collaboration: sustainability (5E)

Despite the efforts of a number of its key stakeholders, this initiative has not been sustained. There seem to be several reasons for this, although because of the lack of opportunities to triangulate the primary data, these should be regarded as speculations.

First, the most obvious factor was that the major funding source, Emploi Québec's anti-poverty fund, was not renewed. As a result, five of the seven pilot projects either had their funding reduced drastically or ended. As Health Canada's role in this initiative was defined around the evaluation component, it was not in a position to influence the funding situation nor the conduct of the actual project.

Second, and more subtly, its seems that there were some relational difficulties among the network of partners. Both of those stakeholders interviewed reported being aware or becoming aware of some tensions among the pilot sites and the coordinating organization, in the context of existing tensions within the region among community-based organizations about the approaches that should be taken in relation to food security as well as within the higher-level bodies in the employment sector about the value of these types of community-based programs for economic development. Some of these tensions were reflected in the evaluation report; it also seems that the evaluation itself may have acted as a lightning rod for some of the concerns and frustrations being felt at all levels. In any case, it seems that intersectoral collaboration, carried out by organizations without a prior successful history of collaboration, under precarious financial conditions and in a domain which may have encountered a clash between charity and empowerment ideologies, has been unable to carry this mobilization effort forward.

4.3.6 How mechanisms for citizen engagement are employed

Citizens were engaged in this initiative through their participation in the community-based groups which implemented the pilot sites. Some of the activities, conducted in subsidized housing units, welcomed participation from the entire available population, while others targeted individuals in income security programs.

Citizens engaged	Level of engagement
Population at large (in specific locations)	Communication: inform, educate
Community-based organizations	Communication: inform, educate Engage: partnering activities Facilitate: capacity building
Target group members	Communication: inform, educate Facilitate: capacity building

In addition, a regional conference on food security was held in 1999, aiming to mobilize the health, social services, education and community-based sectors around the issue of sustainable, alternative food security strategies. While not specifically aimed at citizen engagement, this conference was intended to increase awareness throughout the region of effective determinants-based practices in improving food security. An output of this activity was the creation of a Regional Food Security Support Network. However, according to interview findings, this Network did not achieve the support of existing coalitions of community-based organizations in the region.

4.3.7 How accountability for health outcomes is increased

A participatory evaluation, sponsored by Health Canada, was conducted on the entire initiative. The aim of this evaluation was to describe and evaluate the effects on the health determinants of the food security development activities carried out in the initiative. The evaluation was facilitated by the ACFD, the coordinating community-based organization. A regional evaluation advisory committee followed the evaluation process, reviewing instruments and findings as they emerged. This committee was composed of representatives from Health Canada, Emploi Québec and the Université de Montréal. The financial resources committed to this evaluation represented about 2% of the total initiative's resources.

The evaluation involved a process of reflection and self-appraisal by the participating community-based groups, structured around a series of evaluation questions developed in conjunction with the advisory committee. Effects were examined at all three levels: on participating individuals, on community-based groups and on the local communities.

According to the evaluation report, the evaluation process seems to have met with some resistance, perhaps because its aims were not completely understood by the participants. Those interviewed for the case study feel that the evaluation process did not have the effects that were hoped for because of the difficulties it encountered.

An evaluation was also conducted of one of the employability initiatives, under the sponsorship of Emploi Québec. This evaluation examined in detail the learning associated with specific aspects of the training program, as well as outcomes in terms of employability, employment and job relevance and quality.

4.3.8 How knowledge development has occurred

Over and above the evaluation work that was conducted, this initiative will contribute to knowledge development through its inclusion in the research program being carried out with a team from the Université de Montréal and the Université Laval. This program will compare the impacts of various forms of food security programs on individuals, groups and communities. Launched in response to a call for proposals from the Conseil québécois de la recherche sociale, it is expected to contribute to the development of a food security policy for the province, in line with the new policy supporting and consolidating the financing and infrastructure of community-based groups. Health Canada is represented on the advisory committee for the research program.

In terms of other learnings from this initiative, especially from its unexpectedly short time frame, without more information it is imprudent to draw conclusions. However, two observations can be made about the implications of intersectoral collaboration as it was used to address health determinants in this initiative. First, in a multi-partner initiative such as this one where activities are jointly financed, the fortunes of one become the fortunes of all. The withdrawal of a major funder limited the potential of the initiative to consolidate and expand the mobilization initiative. Second, successful intra- and intersectoral collaboration is above all a question of the nurturing of networks of successful supportive relationships. In this case, it seems that despite the great potential of the project to act on the health determinants in ways that would improve the health and well-being of the communities and their members, some support systems which would have been helpful to the conduct and continuity of the initiative had not yet been developed to the point where they could have ensured sustainability.

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