Engaging Vulnerable Populations Where Its Needed Most With VotER

As a result of the COVID-19 crisis, inequities within our healthcare system are on full display, and it further exposes how our most vulnerable are treated when seeking care. The disparities around who gets tested, access to testing, and whether they can even be seen by a health care provider are even more apparent during this crisis. Politicians, celebrities, and athletes are reporting access to testing while this is not the lived experienced of everyday Americans.

Even with the advancement of technology and an encouraged reliance on telehealth, these inequities in our health care system are the reflection of a country with barriers to civic engagement for its most vulnerable. We live in a country where 51 million potential voting-age adults are not registered to vote.

Disproportionately, those who are not registered to vote fall into one of three categories – the young, the poor, and those of color. For example, 36 percent of eligible African Americans and 48 percent of Hispanics were not registered to vote in the 2014 presidential election. And rates among young citizens are not much better; just 50% of millennials voted in the 2016 election, compared to 69% of Baby Boomers and 63% of Generation X.

It turns out that the same demographic groups that are not registered to vote also disproportionately utilize ERs at higher rates across the country for non-emergency care because they lack access to primary care. In other words, patients who are young, people of color, and have low income are frequently coming to the emergency room for non-life threatening conditions. 

Consider, the annual visit rate was 45.1 ED visits per 100 persons for the average patient in America. But when stratified among patients of color the visit rate was almost two times higher at 85 visits per 100. I’m an ER doctor and I see this phenomenon nearly every shift, but how do we empower our most vulnerable in order to create change?

Why not use the opportunity to register them to vote in the ER and in other health care settings where marginalized communities get their health care?

VotER Gets Patients Registered to Vote While They Wait

VotER is a new civic engagement organization that registers patients to vote in health care settings as described here in the Boston Globe. VotER was launched through a collaboration between Massachusetts General Hospital, TurboVote, and ideas42 and we build platforms that offer non-emergency patients a chance to register to vote in 90 seconds or less using a combination of iPad kiosks and behaviorally informed posters, stickers, and discharge paperwork while non-emergency patients wait in ERs and community health centers.

Our early pilots have resulted in significant demand from over 50 hospitals across the country in two months – and we are confident this model will lead to large increases in voter registration rates when paired with effective integration with engaged and social justice oriented staff like social workers in chosen health care settings. 

How We Work

iPad Based

VotER uses ipads contained in freestanding kiosks in areas where low acuity patients wait in the ED. The ipads are programmed to only allow voter registration. Above the ipads are large signs that invite voter registration. 

Patient Phone Based

We deploy posters in the ED that have a text to register feature which allows patients to text a ‘short code’ to a specific number which lets them register using their phone or use a QR code to initiate the same process.

Second, we have developed patient handouts that have embedded QR codes and URL links that connect patients to the same Turbovote voter registration platform. 

Social workers as innovators in civic engagement

Studies demonstrate that social workers participate in political activities more than other professions and vote at higher rates than the general population. Indeed the institution of The Human Service Employees Voter Registration and Education Campaign (Human SERVE) and the successful National Social Work Voter Mobilization Campaign (Voting is Social Work) demonstrate that the social work profession has always known that voter registration and voting support a robust democracy, a just society, and an equitable health care system.

Moreover, social workers have a long track record of success doing voter registration at rates higher than other traditional voter registration groups. During the 1984 election, for example, just 1% of those working with Human SERVE voter registration campaign registered 275,000 people nationally

At VotER, we know that for decades social work has been out in front doing the hard work of voter registration in health care settings — and the tide is now turning. Hospitals are now becoming engaged participants, and VotER is letting them do this in a way they’ve never been able to before.

We value the legacy of activism and empowerment among the field of social work and know that VotER needs input from social workers to blend our novel approach with on the ground tactics and real-world applications inspired by you. We also know that while VotER’s early pilots have resulted in demand and excitement from hospitals across the country, we need the input and insight of the field of social work to truly scale this effectively. 

We know that without participation from those most hurt by the healthcare system, politicians will continue to turn a blind eye to the needs of disenfranchised patients. Do you have ideas on how to partner effectively? Do you have suggestions on how social workers can use part, or all, of the VotER platform in the 2020 election and beyond? We’d love to hear your thoughts and suggestions here.

Call to Action and How You Can Help

We need your help and ingenuity to address this challenge — specifically, to explore how healthcare workers and spaces can support patients with voter registration via VotER. If you are interested in partnering with us, fill out this form to connect with us

Will Trump’s Executive Order Stop the Cycle of Violence or Further Damage Hurting Communities

On February 9, 2017, President Donald J. Trump signed an executive order stating the purpose of the order would help reduce and prevent crime within our “inner cities.” Among the host of things the order calls for, it primarily allocates more power to police officers and more supports to protect law enforcement. In its present form, the order lacks any explicit support for the citizens of these communities, nor does it provide any protection for children who have witnessed violence and continue to live in violent environments within these communities.

President Trump states, “we will protect all Americans,” however his order in its current status is silent on how to help our most vulnerable children heal. The lack of public discourse around the emotional health of children who live in neighborhoods of concentrated poverty suggests that there is no relationship to poverty, children’s mental health, crime, and negative adult outcomes Yet, in 2009 the Department of Justice reported, “Children exposed to violence are also at a higher risk of engaging in criminal behavior later in life and becoming part of a cycle of violence.”

Research has found that the current funding stream does not produce successful outcomes. Incarcerating children in juvenile justice programs, or in psychiatry wards, increases the probability of costly adulthood behavior. “Zero Tolerance” policies in schools have created a “school to prison pipeline” resulting in approximately 68% of males in state and federal prison not having graduated high school.  These children are better served in community mental health programs.

Children living in poverty suffer more, and have fewer resources to build resilience to traumatic experiences. Researchers Evans and Cassells state, “The economic and human costs of early childhood poverty are immense, ranging from dramatic achievement gaps and elevated psychological distress to greater morbidity for every major chronic physical disease, eventually resulting in premature mortality.” Mental Health is listed as the 4th most expensive chronic disease in our country.

Affected populations are not isolated to childhood; related behavioral challenges evolve along with children as they age and include outcomes such as incarceration, psychiatric related hospitalizations, and unemployment. These outcomes have the power to destroy communities through the erosion of individual self-worth, and the demoralization of hope. Indeed, the National Institute of Health reports there is a positive connection between suffering a traumatic life event in childhood and the likelihood of developing a serious mental illness such as schizophrenia, bipolar disorder, post-traumatic stress disorder or major depression later in life.

Whereas Trump’s Executive Order focuses primarily on strengthening law enforcement as a way of preventing crimes, it’s important to highlight a central component of the Affordable Care Act.  “ACA” defines Population health as, “Preventing problems before they occur reduces human suffering and preempts costly punitive responses to these problems from education, law enforcement, child welfare, mental health, or juvenile justice system.”

Increasing reimbursement opportunities for population health initiatives has driven mental health professionals, educators, and medical professionals to develop preventive and early intervention services to children, which directly address issues early in their evolution rather than seeking to control their later manifestations. Prevention and early intervention services do that work of decreasing and in some cases curing the problem before it takes root.

If we are to improve the lives of children living in areas of concentrated poverty we cannot take this approach. One child witnessing or being victimized by community violence is enough to warrant actions. All children deserve the chance to live healthy and productive lives.

The development of future generations is reliant upon an inclusive care based approach rather than an exclusive, penalizing reality. This task is a moral one for our new administration, and the question is will they meet it?

Why Psychologists Are Marching Against Austerity

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As a profession, British psychologists have traditionally been slow to rush to the forefront when it comes to societal, political or social injustices. This is in spite of available information and data – the British Psychological Society, which represents psychologists in the UK, has a list of articles related to Government and Politics alone.

Dr. Libby Watson of the University of East London wrote, “Rather than sitting in ivory towers or locked in clinic rooms, we as a profession need to get out – reach out to communities in need; talk to the people with the ‘power’”. In Keith Tuffin’s Understanding Critical Social Psychology, he notes that political ‘neutrality’ has led to a lack of reflection on where psychological research and practice sit within society – notably, what ideas and values underlie certain research topics.

There has been a call to go ‘beyond the therapy room’ and for psychologists to ‘speak out’ about things that matter. ‘Things that matter’ to psychologists might include the overuse of deadly anti-psychotic drugs in dementia, the personal and social implications of psychiatric diagnoses, gender disparity in ‘attempted’ and ‘completed’ suicides (the article’s terminology), and race differentials in treatment for ‘schizophrenia’. More recently, however, the United Kingdom’s austerity measures have mattered. They have mattered a lot. The key question is – why does austerity matter to psychologists?

Arguably, psychologists’ “speaking out” action has started with petitions. There were some intra-professional actions, for example psychologists have joined initiatives to provide free psychotherapy to the poor. However, now psychologists have started to march, and they marched 100 miles from Leicester to London.

The Walk the Talk 2015 campaign was set up by psychologists who wanted to walk alongside those affected by austerity – most notably, the benefits system, food poverty, and homelessness. They state that the UK is the second most unequal country in the world; over 25% of British children live in poverty and the use of food banks has quintupled since 2010. “Social inequalities have been shown to have a detrimental impact on mental health and well-being, as well as physical health and academic achievement, across the lifespan”.

What of these claims? Take the first point, the UK benefits system. Sanctions drove one gentleman to set his car alight, with him inside. Another man hanged himself due to his disability benefits being cut and the coroner ruled the benefits cuts as an unequivocal cause. Stephanie Bottrill wrote in her suicide note, after being subject to the ‘bedroom tax’, “The only people to blame are the government”. Calum’s list, a memorial for those who have ended their lives due to cuts, put the number at 60+. And the deaths don’t end there.

Between 2011 and 2014, 90 people per month died after their Employment and Support Allowance was stopped and approaching half of these had appealed the decision; this does not support causal effect, but proportions of deaths were higher than the general population. Indeed, research from the World Health Organisation suggests that the life expectancy of people with disabilities in 2010 should be 68.6 (compared to 79.9 for people without disability) – how many ‘working age adults’ whose benefits were stopped have reached close to 68.6 years old? Research by UK mental health charity The Samaritans found that poorer men are 10 times more likely to end their lives than richer men; ideas of money and power being salient in cultures with toxic societal ideals of masculinity.

Few people would disagree that food poverty is detrimental to wellbeing. We have this understanding in all areas of Western life, from a well-known chocolate bar suggesting “You’re not you when you’re hungry”, to psychologists talking about Maslow’s hierarchy of needs (Maslow & Lewis, 1987). The hierarchy of needs suggests that a human needs a foundation of being well-fed and physically safe and secure to pursue other goals that facilitate wellbeing. However, it may be reductionist to suggest that food is only at the bottom of the ‘needs’ pyramid.

More broadly, food is an important ritual – friends meet for coffee, birthdays are celebrated with meals in restaurants, gifts are often edible or drinkable, people may invite close ones to their house for dinner. Food poverty can exacerbate social isolation, as one is unable to partake in such seemingly ordinary social rituals. The group Psychologists Against Austerity have specifically noted the social shame of having to attend food banks. Malnutrition affects a child’s cognitive development. A lack of breakfast has little effect on a well-nourished child, but affects malnourished children.

Homelessness, which no doubt exposes people to food poverty, paints a bleak picture of people’s psychological wellbeing, according to the American Psychological Association. Crucially, there are a number of interlinking factors that leads to lack of housing having an impact on mental wellbeing. Feeling low or ‘depressed’ is characterised by loss, powerless and guilt (not necessarily all at once, or by all theorists), problems with anxiety or anger are related to threat, substance abuse can be related to ‘numbing’ difficulties.

Add to this an uncertain, transitory lifestyle, condescending or abusive social environments, the increased risk of sexual assault and physical assault – not to mention traumatic events that might have led to homeslessness, or ongoing physical of mental health problems – and we have an utterly deplorable picture. Problems such as poor hygiene (hair, teeth, clothes, body…), sleeping lightly or sporadically, exposure to unsavoury weather conditions, and a lack of basics such as deodorant or shaving equipment have a huge part to play in our self-image and overall wellbeing.

So yes, it seems that psychologists do have a stake in the UK’s current austerity measures.

And psychologists are by no means the only group invested. The anti-austerity movement is growing across the county. Psychologists aren’t just walking with other mental health professionals. On October 4th 2015, Psychologists Against Austerity marched against austerity in Manchester, with tens of thousands of British people – from disabled people against austerity, an alliance of psychotherapists, anti-fracking groups, concerned parents, charity workers, student assemblies, human rights activists, junior doctors, university lecturers, anti-racism campaigners, politicians, trade unions, although not all of these groups got a mention in the media. Indeed, the media is reporting numbers up to 40,000 people fewer than the “100,000 and growing” number given to those who attended the march before it had even started moving.

Notable clinical psychologists David Smail wrote extensively about the effects of society on the individual – his “radical environmentalist theory of personal distress” rejects the idea that personal problems are inside an individual and their immediate environment, and advocates consideration of macro, political factors. The British Psychological Society is to hold a conference in his honour in November 2015, crucially stating “David proposed that to understand why we are unhappy, rather than insight, we must cultivate ‘outsight’ into the world around us. This perspective – which encourages personal modesty, appreciation of luck, compassion, and recognition of our common humanity – is today more relevant than ever”. More relevant than ever.

So – psychologists are marching because it’s necessary. They’re marching because it makes sense. They’re marching, crucially, because even an apolitical profession in an apolitical organsation is unable to stand by and keep quiet whilst austerity measures disempower, disable, and dismiss British citizens. Whilst people beg, and die begging. That’s not what national wellbeing looks like. That’s not what basic humanity looks like. And until things begin to change, psychologists will continue to march.

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