Informing Supportive Environments for a Healthier Population

Sara Kirk 00:01
If you deliberately set out to make people sick, you would make it hard for them to do the things that we know that are important to be healthy. So, you’d make it hard for them to access healthy food, you’d make it hard for them to be active, to have access to nature. And so that’s pretty much how our current environment is set up. And we basically engineered physical activity out of our day, we make it very hard to have healthy food. And so it’s actually makes perfect sense that we’re unhealthy.

Shali Manuel 00:27
I think research matters because it gives me a sense of security when I’m pushing for change. It helps to know that there’s this foundation of solid research, it’s easier to kind of continue nudging and encouraging and trying to make the positive change that we want.

Stephanie Reid 00:50
Welcome to Beyond Research. I’m your host Stephanie Reid. We often hear that we need to take responsibility for our health to prevent chronic diseases. However, it takes considerable effort to adopt and maintain healthy behaviours when our surroundings model opposing choices. Our food is dominated by processed, nutrient-poor options, and our cities prioritize motorized transportation over human-powered movement. Our society and structural environments, our neighborhoods, schools, workplaces, and recreational settings can help or hinder the health of our population. Our guest today discuss research aimed at understanding the environmental factors influencing population health, and explore the broader implications of creating supportive environments for chronic disease prevention.

Sara Kirk 01:49
I’m Sara Kirk, I’m a Professor of Health Promotion at Dalhousie University and the Scientific Director of the Healthy Populations Institute.

Stephanie Reid 01:57
Dr. Sara Kirk is a leader in collaborative research to prevent chronic diseases. She is the Scientific Director of the Healthy Populations Institute, co-lead on the UpLift Partnership, and holds a distinguished research professorship. Dr. Kirk’s work extends beyond individual projects, focusing on the complex factors in our environments that either support or hinder health promoting behaviors.

Shali Manuel 02:24
And I’m Shali Manuel, I’m a Youth Engagement Coordinator with the UpLift Partnership and I’m based out of Truro, Nova Scotia.

Stephanie Reid 02:30
Shali Manuel works on empowering youth to lead initiatives for systemic change. UpLift, a collaborative effort focusing on rural communities, aims to embed a culture of health in schools and their surroundings.

Well, thank you both for taking the time to join us today on the Beyond Research Podcast, very happy to have you both. Dr. Kirk, can you tell us a bit more about the societal and structural challenges in Nova Scotia, that led to the initiation of your research program?

Sara Kirk 03:03
Yeah, so the Atlantic provinces have among the highest rates of chronic disease, things like cancer and heart disease, and we have lower life expectancy than our Canadian counterparts. We have an aging population that’s more likely to live with one or more chronic diseases. So, you know, actually have like heart disease and arthritis, for example. And we also have high rates of obesity. In the health promotion world, we refer to the conditions that influence health and well being as a social and structural determinants of health. And they also have disproportionately impact some communities more than others. So you know, to give you an example, if you deliberately set out to make people sick, you would make it hard for them to do the things that we know that are important to be healthy. So you’d make it hard for them to access healthy food, you’d make it hard for them to be active, to have access to nature. And so that’s pretty much how our current environment is set up. And we basically engineered physical activity out of our day, we make it very hard to have healthy food. And so it’s actually makes perfect sense that we’re unhealthy. We’re living that right now in a healthcare system, which is technically a sickness care system that is struggling to cope with the number of people who are needing to have health care.

Stephanie Reid 04:16
What initially sparked your personal interest in studying supportive environments, those living with chronic disease, and the preventative aspects of it?

Sara Kirk 04:25
I was working as a dietitian, as I say, and I do remember, I was working in a clinic, I would have like 15 to 30 minutes with a patient who came in with say diabetes, and I would open the door at the end of the session, they would go out into an environment that basically undermined everything that I was telling them. And so you know, that 30 minute conversation that I would have about you know, well you know, maybe try and do this and try to do that to improve your food intake was blown out of the water by, you know, the smell of, you know, baked goods in the hallway and, and then just all of these things that then just kind of made it really, really hard for people to adopt healthy behaviors. When you see the conditions that we’re faced with, you know, it’s catastrophic when somebody develops heart disease, or when they develop cancer. But these things are preventable, but we don’t do it. We don’t do prevention well. We only invest a tiny, tiny percent of the health care system budget into prevention. And so I wanted to really understand you know why that was, you know, and think about the ways that we could really change things around. When I first moved to Canada, it was on a Canada Research Chair and I had some funding to do some data linkage. And so I started working with a colleague of mine from Dalhousie University, called Dr. Paul Veugelers. And Dr. Veugelers, had done a really great assessment of the health and well being of students in schools using a dataset from grade five students. And so I was able to bring the money that I had to do some data linkage. And that data linkage helped us to understand how these health behaviors actually were translating into things like additional health care costs. And really try and understand like the impact of creating those supportive environments for students in schools, we did some research around the health care costs associated with obesity. And we found that students who had excess adiposity had 21% higher health care costs and their than their average weight peers. And that is important because this is in children who are then going to go into their adult life with these kind of disease risk factors and problems that will increase the costs of health care as they age. So we really wanted to understand a little bit more about that.

Stephanie Reid 06:51
Why grade five?

Sara Kirk 06:53
The reason for grade five students is because that’s the students typically do a standard attainment test in grade six and so by collecting information about the health behaviors in grade five, you could then actually, Dr. Veugelers is linked that information to standard attainment tests in grade six. Additionally, with the linkage that we did with health card numbers, we’re able to do a whole load of other analyses as well. So we get a really complete picture of you know, how that health behavior at that age impacts health care use, as well as academic performance. And no surprises, healthy kids learn better, they do better in school, and that helps them to achieve more in their adult lives as well. So you know, when we think about intervening in schools to create healthy environments, a big reason of that is because it means that children are able to thrive more in school, and in other ways as well.

Stephanie Reid 07:52
So interesting. And you also wanted to chat about another colleague of yours on the research side.

Sara Kirk 07:57
Yes. Alongside the work that I was doing around the children’s lifestyle and school performance study, I was working with a colleague called Dr. Camille Hancock Friesen. Now Camille is a Pediatric Cardiac Surgeon, and she was working at the IWK at the time. And so what Camille was seeing when she was doing surgery with children is that she could actually see the damage that was being done by the unhealthy environments that children are exposed to. So physical inactivity and unhealthy eating shows up even at a young age in damage done to the heart and the circulatory system. So she was very keen to do some promotion, health promotion and prevention work. And she set up a program called The Heart Healthy Kids project. And this was a volunteer run project operating in schools in Halifax region, and with really trying to sort of work in activity during lunch hour for children in the schools. When she and I collaborated, what we started to do is actually look at, okay, what’s the, what’s another model that we could use to bring this work to life that doesn’t rely on volunteers, it’s sometimes hard to get hold of people who have the time and the capacity to go in and do this work. And we decided that we would actually look at a peer mentoring model, which then involved training grades four, five and six students in elementary schools, to help their peers to be more active. So these students were given a training program. They’re given the opportunity to lead activities and games in the in again in the lunch period in those schools. And what we found from that work and the actual project that we had was funded by the Research Nova Scotia’s predecessor, Nova Scotia Health Research Foundation. And what we found is that that intervention saw the children who are being mentored, increasing their physical activity. But not just that the people who were doing the mentoring, the students themselves, really learn a lot of different skills. So again, from like a learning in academic perspective, the students are actually learning all sorts of different skills around negotiation, compromise, that sort of thing. And so we really wanted to pull all this together. And, you know, recognizing that we had all this research that suggested that the school period is a really important time for intervening to make an environment healthier for children, that we had this opportunity to access some, you know, large amounts of money from the public health agency and from some private sector funding to basically implement the research that we had already done and actually recognizing that this research wasn’t being translated, if you like, properly, so this gave us the opportunities to do that.

Stephanie Reid 10:54
And thus the Uplift Partnership was born.

Sara Kirk 10:57
Absolutely, yeah.

Stephanie Reid 11:01
Shali, I was hoping you could share a little bit about you and your background, and what motivated you to become a Youth Engagement Coordinator with the UpLift program.

Shali Manuel 11:10
So I always had an interest in health from a young age. And I think reflecting on it, it was probably partly due to I had a lot of family members or relatives with chronic disease and understanding at an early age that if people didn’t feel well, it was really hard to enjoy a good quality of life. And at first, I wanted to be a doctor, but then once I got to university, I started to think about the role of prevention and how much more impact you could have if you could prevent people from needing to go into the healthcare system in the first place. And so I did an undergrad and a master’s in health promotion. And then I had a number of different jobs in different focus areas. So I was a community health educator or sexual health educator with, it was Planned Parenthood at the time, it’s called Halifax Sexual Health Centre now, and in that role, I worked with all ages and different populations, but it was always my favorite to work with students, and to go in and do sexual health workshops with students. And then I worked as a physical activity consultant with the provincial government. And again, I worked with all ages and different populations, and it was working with students that was always my favorite. And so I was working as a health promoter in public health, and I was doing a little bit of health promoting schools work in that role, but my manager had just informed me that that was going to change and it wouldn’t be part of my position. And it was perfect timing, because UpLift came along at that time, and the Youth Engagement Coordinator position opened up and it just seemed like the perfect match of health promotion and working directly with students.

Stephanie Reid 12:39
Can you tell us a bit about the UpLift Partnership, and how in your opinion, research has shaped the structure of that partnership in schools?

Shali Manuel 12:49
Sure. First of all, I’m very grateful to Dr. Sara Kirk and the team for doing all the research that initiated this because I feel like I have the best job I’ve ever had in my life. So kind of the central point is that we’ve had a $5,000 one-time grant for every school that participates. So in my Regional Centre for Education, we have about 65 schools, and we have four years to kind of work through them. So we would put a call out for expression of interest from schools, they would need to identify a staff champion, that would be our point person. And so each year we’d have about 12 or 15 schools. And then we would go in and work with the student leadership team. It’s very flexible. So sometimes that has been a full class, sometimes it was four full classes during COVID, sometimes it’s an existing leadership group, like a student council, or a gender sexuality alliance. And then sometimes we form a team just for this purpose. And we can work with all ages. And then we work through a process of assessing the enablers and barriers to health within their school. And usually as a starting place to kind of frame the work that we’re doing, I’ll do an activity with the students, I just call it plant, dog, human. But we’ll talk about the things that a plant needs to thrive. And we’ll also differentiate between the plant is alive versus the plant is thriving. And so you could have a plant that has brown leaves still alive, but not doing great. And then we talk about how as the owner or the caretaker of that plant, if it’s not thriving, we don’t yell at it or blame it for not doing better. We think as the caretakers, what can we do differently to create conditions that will enable this plant to thrive? And so plants are pretty simple. They need the right amount of sunlight and right amount of water and healthy soil. Then we talk about dogs, a pet dog, what would they need, and I love that the children are almost always, one of the first things I’ll mention is that dogs need love and dogs need play. We talk about the food and the activity and can make the kind of realization that if you don’t take your dog for a walk that day, what happens? Often some behavior issues. Again, we often don’t yell at the dog or blame the dog for those behavior issues. We realize that we should have made, we should have kind of created those optimal conditions, we should have made sure it had the exercise that it needed, and whatnot. And then we’ll make a list of what humans need to thrive. And from there, we’ll think about what are the things on this list that the school is able to provide. So things like students will list that they need sleep. But there’s not much beyond education and awareness, there’s not a lot that schools do in the area of sleep. But we’ll think about food, opportunities to be active, relationships and feeling the sense of belonging, the connectedness, fresh air, all of those things. And then from there, we will build a plan to assess the school. So sometimes that is doing an audit walkthrough of the school, sometimes it’s doing a school wide survey, sometimes it’s doing interviews with cafeteria workers or other kind of key adults in the school. And then from there, we identify what are the priority issues that we want to address, and then they’ll come up with a project idea or multiple projects to use that $5,000 grant.

Stephanie Reid 15:54
Oh, neat. So they can identify a barrier that they want to tackle, specifically as a group, and then that 5000 will help them? Can you provide an example, either Dr. Kirk or Shali, of what that has potentially funded in the past?

Shali Manuel 16:08
Yes, I have, it’s funny, I just gave him another presentation to a principal today, and it’s hard for me to choose just one or limit myself in time, because there’s been so many great projects over the years. But I think my favourite one was completed last year, and it’s a pump track at a junior high school, just outside of Truro. And so I worked with two full classes of citizenship nine, which is a mandatory social studies credit. And the kids did the assessment of the school and the thing that stood out the most is that they said the outdoors was boring, and that students often didn’t even go out during break time because there was nothing to do out there. So most of their ideas for the grant were focused on doing something with the outside space. And there was a diehard group of mountain bikers in both classes and they kept talking about a pump track, which is kind of a circuit with hills and embankments that you ride a bike on. And I thought, you know, it was a great idea, but I didn’t, I thought it was more of a niche interest. And I didn’t expect it to win. But when we got to the voting process, it was hands down the winner, and the principal and vice principal were in support. So we worked with the Regional Centre for Education, we got operations on board, and it was actually built in September. It’s definitely the first pump track on a school property in our Regional Centre for Education, but maybe the first one in Nova Scotia, and now we’re working with, part of my role is to kind of make the community partnerships happen. So the Village of Bible Hill has signed on to buy some bikes for the school and then they’ll share them, they’ll have access to the bikes to loan out to community members in the summer. They want to do some after school programming, the Nova Scotia Department of Communities, Culture, Tourism and Heritage, we’re in conversations about some funding for lights, and also to pay for the Phys Ed teacher and the rec director to get trained to do some skill development with the students. A local bike shop has offered to have some students come in and job shadow to learn bike maintenance and repairs. I’ve seen so many projects like this, where it’s one thing at the school level, but it just has so many ripples that go out into the community. So very exciting.

Youth Speaker 1 18:07
My favourite part of working on my UpLift project was the friends I made and the pride I felt and how I was able to be in a safe environment.

Youth Speaker 2 18:18
My favorite part of working on the UpLift project was building my leadership qualities and working together as a team with lots of different students from our school.

Stephanie Reid 18:30
So is that a goal of the partnership to obviously you’re starting in a school environment to teach these young people the importance of making good choices, healthy lifestyles, all of it. Was that the goal? To have that community ripple effect and to have a broader impact on communities and not just the schools?

Sara Kirk 18:48
Absolutely. So again, going back to the health promoting schools model, so UpLift is a school community – university partnership, building on over 30 years of research. So research that predates myself, you know, that we know that when children in school have those opportunities for good health and well being and learning that they can do that they can that they will learn better, they do, you know, have a better quality of life in the school system. So when we, you know, with the funding that we have for UpLift, it’s enabled us to implement this in schools across the province. Not all schools, not all regions. But, you know, we basically always knew that, you know, this is putting the research into practice, this is actually doing the health promoting schools model at that dose that we need it to be at. So, it’s yeah, these are outcomes that we absolutely expected. What I maybe didn’t expect was just how much magic happens when we give young people the opportunity to blue sky what they want to do, you know, I mean, they were really, and this is what the magic is also driven by the Youth Engagement Coordinators. So we’ve deliberately and strategically put these positions into the systems that we were trying to influence. So although the funding comes to Dalhousie, it goes out the door to fund these positions within the Nova Scotia health, or within the education sector. And, you know, we did say that was a strategic decision to make sure that these could be positions that, you know, potentially could be sustained. And, but, you know, the Youth Engagement Coordinators are really doing that upstream work, they’re really doing that connection. They’re building the community, they’re building capacity of the adult supporters in the system, and they’re giving children voice, which is, you know, the thing that gives me goosebumps, actually.

Stephanie Reid 20:38
No that sounds incredible. What does the UpLift program do to help students if anything, who may not have those ideal circumstances for a healthy sleep or access to healthy food? Are there some examples of how the program has supported those groups?

Sara Kirk 20:58
Yeah, they have, and again, you know, we’ve had some of the program or the grants that the students have implemented, we’ve had salad bars, we’ve had greenhouses, you know, we’ve had, there’s a food forest in Scotsburn in Shali region, actually.

Stephanie Reid 21:14
A food forest?

Sara Kirk 21:16
A food forest, yeah.

Stephanie Reid 21:17
What is that?

Sara Kirk 21:18
Basically, it’s, you know, growing fruit trees and things that actually could be harvested by the community.

Stephanie Reid 21:29
Obviously, this whole program was inspired by 20, 30 years of research work, some of your own, what is your vision for the work long term, preventative health, and just hopes and dreams for the future?

Sara Kirk 21:45
Oh my gosh, so many. Yeah, like, we know that health is wealth. And if we can actually try and invest in health promotion, at the places where people are, that will have long term outcomes. And so going back to what, you know, I spoke to at the beginning around like, we have high rates of chronic disease, well, let’s invest early. And, you know, the interesting thing about the work that UpLift is based on, the research that it’s based on, is that there is a really strong return on investment when we do public health interventions like these. It’s about $14 in every dollar invested. I mean, that’s a really, really impressive investment. We create those conditions for health and well being in schools, we also help children to learn better, their behavior is better, you know, all those things have a benefit to the health and the education system. And, you know, when we’re thinking about fixing healthcare, we can’t fix health care until we have a healthy population. I think the piece that really speaks to me is that, you know, when we listen to young people, and we involve them in the decisions that impact their life, and they have a human right for that, you know, they really do make magic. And, you know, we’ve seen greater engagement, so attendance issues that have been addressed, because as Shali’s just explained, you know, when we actually give those kids that opportunity, they want to be part of it. And so, you know, it’s about creating a sense of belonging, it’s about creating a safe environment for them, a community within that school, because they, you know, they do spend a lot of time there. And it’s about valuing their input and making sure that they, you know, they learn something in that, you know, the interesting thing, I think, is that they learned a lot more than you think that they would learn. They learn about financial literacy, for example, because $5,000, it’s not a lot of money, actually, to maybe to an adult, but to child, that’s like huge, so they learn about, you know, about the value of that. They learn about procurement, because you know, actually getting something into your school doesn’t happen overnight. So, and it’s sometimes quite a lengthy process. Some of these kids have moved on into different parts of the school system before they’re, the project that they started actually comes into being. They learn about negotiation and compromise. You know, there’s a whole load of skills that they’re learning that you can’t actually teach in a classroom, actually.

Stephanie Reid 24:11
And how do you envision just the body of knowledge, your research, supporting Nova Scotians in the future beyond this one program? What’s next for you? And where are the opportunities for research in Nova Scotia?

Sara Kirk 24:29
Well, everything that we do, you know, has a research component. So interesting thing is that the last six or seven years have been like working to operationalize the UpLift Partnership. The actual partnership itself is not research, but it is underpinned so much by research. So I have a ton of work to do at the end of 2024, when we start to kind of, you know, actually write the papers that will describe the work that we’ve been doing And, you know, my dream is that this work is sustained, that this is something that government sees the value in and government are part of it already, so you know, to me it makes perfect sense to invest in something that will reduce health disparities, that will promote health and prevent chronic disease. But yeah, the research, just the learnings that we have to impact and impact other research programs, that’s a whole new body of research to do.

Stephanie Reid 25:37
Well, I hope that, you know, this impact carries on long after the UpLift program concludes in its current format, because it sounds like if we put in that little extra effort, it can have, you know, amazing outcomes, but also a lot of unintended outcomes as well. And hopefully it just, you know, serve us as the creation of a healthier population in the future. So, thank you both for the work that you’re doing and for taking the time to chat with us today. Thank you so much. We really appreciate it.

Sara Kirk 26:10
No problem.

Shali Manuel 26:11
Thanks for having us.

Sara Kirk 26:12
Been lovely to talk about it.

Stephanie Reid 26:16
As you heard, Dr. Kirk’s research program addresses the high rates of chronic diseases by involving diverse stakeholders from the outset. By understanding the environmental factors influencing health behaviors, she shaped supportive environments for chronic disease prevention, contributing to the well being of communities and society at large.

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