Spotlight on… Dr. Alexandre Daguzan – Marseille Public University Hospital System
The RECETAS partnership is rich in interdisciplinarity and expertise on topics related to mental health, loneliness and nature-based solutions.
How do our partners work on loneliness? How are they involved in RECETAS? Each month, one or more of our experts answer our questions!
🎤 Alexandre, can you briefly introduce yourself and the purpose of the organization you work for?
I am a social health psychologist by training, and I hold a position as a hospital engineer in the Medical Evaluation Department (headed by Pr. Stéphanie Gentile), in the Public Health Unit at the Assistance Publique Hôpitaux de Marseille. With 4 hospitals and 3400 beds, the Marseille Public University Hospital System is the largest health establishment in the Provence Alpes Côte d’Azur region in France. The AP-HM is one of the most dynamic French structures in terms of research. Within our department, we are a multidisciplinary team that carries out numerous hospital missions (Quality and Safety of Care, Evaluation of Professional Practices, Certification, Patient Experience, Perinatal Care, Patient Therapeutic Education), as well as numerous teaching and training activities (Master’s degree supervisors, continuing education of nursing staff, training of doctors), and we develop innovative research projects in and outside the hospital with disadvantaged populations.
I am also a doctor in Social Psychology (EA 849, Aix-Marseille University). My thesis is entitled « Psychosocial processes and issues associated with the development of empowerment: Investigation and intervention in the context of precariousness in France in the field of health promotion ». The thesis is based on several evaluations of interventions aimed at reducing social inequalities in health that we have carried out in Marseille.
With Pr. Stéphanie Gentile and Lucie Cattaneo, an other social health psychologist in charge of the RECETAS project in Marseille, and with the support of AVITEM , we were able to investigate a new intervention and research theme: Nature-based Social Prescribing (NbSP).
🎤 What are you interested in as researcher?
My fields of interests are many and include interventions aimed at reducing social inequalities in health, community health and the development of empowerment in the context of precariousness, the development of psychosocial skills in young children and in therapeutic education, the transfer of knowledge in prevention and health promotion, the organisation of innovative health pathways in the city-hospital link, and access to care for precarious and homeless people.
In recent years, we have been working, for example, to evaluate the functioning and effects of an emotional and social development programme for children in schools (another thesis has also been completed), we have been recording the number of homeless people in Marseille, we have carried out action research to build and model a health pathway for people living with HIV and in precarious situations, as well as a screening tool for social and health vulnerability in paediatrics.
🎤 Can you explain to us what is Empowerment? And how loneliness impacts the empowerment?
Empowerment is a polysemous concept that was developed in the United States in the 1960s as a result of the social and political movements for civil rights, women’s rights and the rights of minority communities. Empowerment was imported later in Europe and in France in the early 2000s, particularly in the field of mental health. Empowerment approaches oscillate between the development of individual capacities, a new strategy for fighting exclusion, and a process of social transformation to reduce social inequalities. In its operationalisation, empowerment is not just a set of skills to be acquired, it is a profoundly social process because it occurs in community spaces in small groups where people can develop new forms of interpersonal relationships, challenge social inequalities, experience a new relationship with the environment and move towards a process of individual and collective emancipation. Maton (2008) defines empowerment as a group-based participatory process where marginalised or oppressed individuals gain greater control over what is important to them, gain access to essential resources and basic rights, pursue important goals in their lives, and reduce their exclusion from society. For example, Wallerstein (2006) highlights the importance of developing supportive environments and health-promoting policies through the development of self-support groups, user involvement, collective action and dialogue-based approaches. Labonte (1994) has also identified five main strategies in health promotion practices that fall under the umbrella of empowerment: person-centred care, group development, community organisations, advocacy and coalition building, and political action.
The group space allows people to break out of their isolation from society, to break out of their loneliness, to develop new relationships of mutual support, to engage in collective activities, and to develop a sense of belonging. People can build hope, believe in the opportunity to redraw social links, to widen their choices and possibilities, and thus escape from an alienating condition, from the powerlessness and social isolation characteristic of situations of precariousness where people are kept in a state of dependence on services and social protection. At the level of a collective, people can then develop social power through the ability to think and act with each other. When these collectives form community organisations, they are also able to promote structural and regulatory changes that directly affect the health and well-being of people in a locality (Boyce, 2001; Cavalieri & Almeida, 2018; Wallerstein, 2006).
🎤 What is your approach to tackle this issue? What is community empowerment? What does this have to do with health?
Empowerment has a historically relational approach, in contrast to the current individualising empowerment which advocates adaptation, personal capacities and responsibility. Our empirical work, as well as that of the literature, highlights the interest of situating empowerment as a process and at the level of collectives. Empowerment develops in participatory relational spaces in which people can develop a collective consciousness and civic engagement, they recognise situations of inequality and stigmatisation, as well as the opportunities and resources existing in the environment. Empowerment is developed in safe and trusting relational spaces where people can share their common and priority concerns. They provide mutual support, develop leadership, new partnerships and opportunities. Empowerment requires the creation of professional and organisational cultures that are conducive to its development, and to build on these collectives to act at the political and structural level by acting on different social determinants of people’s health and well-being, and by challenging the norms and beliefs that perpetuate social inequalities in health. Empowerment is therefore a process of social action in which people perceive new possibilities to change their living conditions and social environment (Wallerstein, 2006).
Community empowerment thus develops at the level of a collective, a group, a community, an organisation (neighbourhood associations for example, or citizen coalitions, local networks). People learn to cooperate, to develop new resources and skills that they would not have developed alone. Thanks to the dynamics of the group or community organisation, they can gradually emerge from the weight of their conditions of existence, and from an insufficient hold on events and on their life contexts. A community has an existence of its own, it can exist outside of social intervention and community empowerment is not the sum of the empowerment developed by each individual (Ninacs, 2002). Through involvement in the collective and in community organisations, people can develop a social power where they manage to change negative situations and prevent the recurrence of problems (Guttierez, 1990). Small group discussions allow people to explore the links between personal and social problems, and to develop a better understanding of the social determinants of their health. This relational and processual approach to empowerment thus contributes to resituating the space of power of citizens in their capacity to reflect, to organise themselves in community, and to act on the social determinants of their health at different levels up to the point of impelling social change at a political level.
Can you tell us more about initiatives in Marseille aiming to empower vulnerable people?
Marseille is an area where many innovative actions are being tested with socially vulnerable people. For example, the JUST association is developing several projects with people in situations of vulnerability or social exclusion to help create a fairer and more inclusive society. The « Lieu de répit » (A place of relief) is an experimental alternative project to psychiatric hospitalisation that welcomes people in a psychological crisis in a non-medical space and using the Open Dialogue approach. The association also runs the participative action « En passant par les calanques » (Passing through the creeks), which enables socially excluded people to walk in groups along several paths in the creeks of Marseille, which are veritable mountainous natural settings by the sea. Other experiments in Marseille are going on. Since 2004, in Marseille, the Health and Citizenship action for residents of accommodation and social reintegration centres (CHRS) has proposed a participatory approach involving various actors (CHRS teams and management, residents, external professionals) and taking the form of collective workshops with users, the « Health and Citizenship » workshops. Several professionals from the health, social and legal sectors are mobilised to work with residents on the priorities over which people wish to exercise greater control: over-indebtedness, the place of religions, how to eat a balanced diet on a small budget, experiences of discrimination. These last two actions are key partnerships in the implementation of the RECETAS project in Marseille. Since 2011, a precariousness health network has also been created and is supported by an inter-institutional technical committee to promote access to rights, access to care and continuity of care for homeless people in Marseille (projetassab.org). More recently, since 2021, the association La PASS de ville, awarded the Health Innovation Award, aims to fight against the renunciation of care by the most disadvantaged by removing the administrative, linguistic and financial barriers that exclude them from care. Finally, in 2017, we actively participated in a regional inter-researcher dynamic to develop a guide for building, leading and piloting collective and collaborative dynamics favourable to the experimentation, perpetuation and dissemination of interventions aimed at reducing social inequalities in health.
🎤 How are you involved in the RECETAS project? What are you working on at the moment?
According to a study carried out by CREDOC for the Fondation de France in 2014, « 12.5% of French people have no social network and one in ten French people feel excluded, abandoned or useless (…), poverty remains a determining factor in solitude ». People living with less than 1000 euros (60% of the average income) per month are twice as likely to be in a situation of social isolation.
In Marseille, 200,000 people are considered poor (26%, compared to 14.6% in France ), i.e. single people living with less than 1,000 euros per month or a family with two children living on a maximum of 2,500 euros. Among the large French cities, Marseille is the one with the highest concentration of poverty . 5 of the 16 Marseilles districts (1st, 2nd, 3rd, 14th and 15the ) are among the 20 worst off, with poverty rates exceeding 39%. Of the 100 poorest neighbourhoods in France, 25 are in Marseille.
However, the survey carried out by AVITEM and VNL in 2021 identified a total of 392 organisations in Marseille working on loneliness, mental health and well-being, which shows that there is a real local dynamic to tackle social inequalities. Several of them were able to join the RECETAS project and expressed the interest of working on accessibility to nature for these most disadvantaged populations. Following numerous interviews and workshops with professionals from these organisations, it was proposed to develop a double strategy centred on access to outdoor activities, but also on the development of nature in the city, as close as possible to the living environment of isolated individuals and families. At the same time, we carried out participatory observations within collectives or social structures (such as mutual aid groups, or within social residences ) as well as workshops with the public on the themes of food, nature, work, and inspiring women. We have continued this immersion work by relying on the relationships of trust created with users and professionals to formalise the different groups that will be able to participate in outdoor and/or nature-related activities (gardening, walks, discovery of new activities at sea, around an urban farm or relaxation). Through a relational approach to empowerment, we offer participants the possibility to get out of their neighbourhoods, to progressively engage in new activities adapted to their possibilities, to propose activities that are graduated in terms of physical effort, to take up challenges in groups, to open up the activities to families, to favour the free and sustainable nature of the activities, to think about the relationship with nature in an urban environment, to reflect on the necessary changes around nature on the territory to allow for the improvement of the well-being of all the city dwellers of Marseilles