The Ailing Heart of Nova Scotia
Cape Breton Island is well known for its beautiful landscape, world-renowned golf courses, and rich history but it is not as widely known for its high rates of cardiovascular disease (CVD). The Canadian Institute for Health Information (2022) reports an average hospitalized heart attack rate of 297 per 100,000 people (considered below average performance compared to the rest of Canada). The same report contains a breakdown of health regions within the province and shows that the zone encompassing Cape Breton (CB) has an average hospitalized heart attack rate of 384 per 100,000 residents, indicating a higher than normal incidence of CVD in that area. I have chosen to discuss heart disease in Cape Breton utilizing the Dahlgren-Whitehead model of health determinants.
According to the Public Health Agency of Canada (2017), CVD is the second leading cause of death in Canada. “Over 70% of CVD cases can be attributed to a small cluster of modifiable risk factors.” (Yusuf et al, 2020, p. 803). This study notes that hypertension and tobacco use appear to be the largest risk factors and that obesity, depression and excess alcohol consumption were considered moderate contributors. Sodium consumption, passive air pollution, and low education levels were considered minor contributors. The treatment for CVD varies from risk factor modification to open heart surgery depending on individual patient needs.
The Dahlgren-Whitehead model was developed to “visually illustrate the layers of influence on population health and provide a simple framework for thinking about the policy response of the different sectors involved in tackling these determinants” (Dahlgren & Whitehead, 2021, p. 20). The model consists of five layers (Figure 1). The innermost layer relates to an individual’s non-modifiable factors (age, sex, genetics). The second layer considers an individual’s lifestyle factors – their personal habits and behaviors. The third layer is the social and community networks – it considers the social and community support an individual has (i.e. local community groups, bus service, friends and family). The fourth layer depicts living and working conditions and includes education, work environment, health care services, housing, water and sanitation, unemployment and agriculture and food production. The fifth layer involves general socioeconomic, cultural and environmental conditions.
Figure 1
The Dahlgren-Whitehead Model
Note: From “The Dahlgren-Whitehead Model of Health Determinants: 30 Years on and Still Chasing Rainbows,” by G. Dahlgren and M. Whitehead, 2021, Public Health 199 p. 20-24 (https://doi.org/10.1016/j.puhe.2021.02.009). Copyright 2021 by The Royal Society for Public Health.
The Dahlgren-Whitehead model above (2021) can be applied to identify potential factors leading to an increased incidence of CVD in Cape Breton, Nova Scotia. I believe this model is a useful tool for looking at this issue from a much broader perspective than individual health.
Layer 1- Age, Sex, Constitutional Factors
· The median age in CB is 49.8, 11 % higher than the rest of the province (Areavibes, 2021).
· In 2016, the population was 47% male and 53% female (Point2Homes, 2016).
Layer 2 - Individual Lifestyle Factors
· CB has a rate of obesity of 41.9% in adults over the age of 18, significantly higher than the national average of 26.6% (Public Health Agency of Canada, 2020).
· The rate of substance related deaths is 15.4 per 100,000 when the national rate is 8.4 per 100,000 (Nova Scotia Department of Health and Wellness, 2020).
· A news report by the CBC (Ayers, 2016) report that over 5% of 20 - 34 year olds said they drank (alcohol) heavily in one month, compared to national average of 34%.
· The rate of cigarette smoking in CB was 28% in 2015 (Doctors Nova Scotia, 2015) while the province of Nova Scotia had a rate of 20%.
Layer 3 - Social and Community Networks
· CB has limited public transportation (bus service is only in the urban center), creating challenges for residents who live in the more rural parts of Cape Breton which is the majority of its geography.
· There are various social and community support groups and services across the island. Unfortunately, like public transportation, most are centrally located in Sydney. Others are available within First Nations communities, of which there are five in CB.
Layer 4 - Living and working conditions
· The current unemployment rate in CB is 13.9%, while the provincial rate is 7.0% (Government of Canada, 2022). CB consistently holds the highest rate of unemployment per economic region in Nova Scotia.
· 42.3% of the population reports post-secondary education attainment (Townfolio, 2017).
· CB has the highest rates of child poverty in Canada (Child Care Canada, 2020).
· There is a lone regional health care facility in Cape Breton, located in Sydney, on the eastern side of the island. Seven smaller medical facilities cover the rest of the island. These smaller facilities suffer regular closures due to staffing issues, which results in a longer transport time to health care for those in the affected areas.
· Cardiology services are limited in CB; all patients requiring cardiac surgery or cardiac catheterization (a time sensitive intervention when an individual is suffering a heart attack) need to go to the QEII Health Sciences Centre in Halifax for that level of treatment. “Patients presenting furthest from Halifax were the least likely to be transferred, suggesting that geography remains an important barrier to lifesaving care” (Boyd et al., 2017, p. 202). To put it in perspective, that is a five-hour drive to definitive care. Other subspecialty services such as neurology, neurosurgery, vascular surgery and trauma have similar limitations.
Figure 2
Map of Cape Breton, Nova Scotia with identified hospital, helipad and airport locations
Legend
Hospital: Hollow Red Circle
Helipad: White Cross (+)
Airport: Pink Circle
Note: From Traer, D (2022, February 24) EHS LifeFlight New Employee Orientation [PowerPoint Presentation]. Halifax Nova Scotia. Not for unauthorized distribution. Several private airports not shown on this map.
Layer 5- General socioeconomic, cultural and environmental conditions
· Historically, the economy of CB was dominated by the coal mining industry. With the use of coal declining in Nova Scotia (Mining Association of Nova Scotia, 2019), CB is transitioning to a less lucrative service based economy.
· CB Island is connected to mainland Nova Scotia by a causeway that is occasionally closed during periods of high winds and winter storms.
· There is one central airport, and three smaller private airports.
· The Port of Sydney provides entry for cruise ship activity, as well the Newfoundland ferry.
Initiatives
The Cape Breton Regional Municipality developed a Community Health Plan for 2019-2022. The plan was developed utilizing social determinants of health and health equity as its foundation. The planning committee identified four areas of priority: access to services, social support networks, economic conditions and physical environment. Each of these priorities were accompanied by two recommendations for improvement, many of which could reduce CVD of those living in the area.
Another initiative to improve cardiovascular health is the development of the Cape Breton Cardiac Rehabilitation Program. It was instituted in 2017 by the YMCA, and is a 12-week program where those who have had cardiac events (surgery, heart attack, cardiac stents) learn about CVD, nutrition, and begin exercise programs (Patterson, 2020).
In early 2021, the cardiology team at the Cape Breton Regional Hospital noted a trend in unexpected deaths from heart failure and that a member of the cardiovascular team had not seen 75% of those patients (Ayers, 2022). The team surmised this was related to an overwhelming cardiac patient load. They decided to create a clinic targeting heart failure patients that allows the team to see patients faster and more regularly. A drug company provided initial funding, but additional financial support is required from the Provincial Government in order to maintain and to expand the program.
Summary
As outlined in the Dahlgren-Whitehead model (2021), CB has multiple layers negatively affecting the islands population health, especially in relation to CVD. By utilizing this multilevel model to examine an illness, it is easy to see that health care initiatives are only successful with exploration of the determinants of health from all levels as opposed to analyzing a single factor contributing to illness. The strain of overwhelmed hospital resources, and transportation to definitive care are the two most predominant influences that affect my world the most, especially when managing the challenges within the flight environment. In 2020, 34% of all LifeFlight adult missions originated from CB, over half of those were cardiovascular in nature. “Early detection of cardiovascular disease can be the difference between life and death.” (Cardio-Phoenix, 2020, para. 6).
References
Areavibes (2021). Cape Breton, Nova Scotia Population & Demographics. Retrieved February 18, 2022, from https://www.areavibes.com/cape+breton-ns/demographics/
Ayers, T. (2021, October 4). Cape Breton’s High Rate of Drug Use Has Devastating Effects. CBC News. https://www.cbc.ca/news/canada/nova-scotia/cape-breton-high-rate-of-drug-use-1.6196823
Ayers, T. (2022, January 12). New Cape Breton clinic aims to improve survival rate after heart failure. CBC News. https://www.cbc.ca/news/canada/nova-scotia/cape-breton-medical-staff-create-new-heart-clinic-1.6311296
Boyd, J. C., Cox, J. L., Hassan, A., Lutchmedial, S., Yip, A., & Legare, J-F (2017). Where You Live in Nova Scotia Can Significantly Impact Your Access to Lifesaving Cardiac Care: Access to Invasive Care Influences Survival. Canadian Journal of Cardiology 34(2), 202-208. https://doi.org/10.1016/j.cjca.2017.11.021
Canadian Institute for Health Information (2022). Nova Scotia—Hospitalized Heart Attacks. https://yourhealthsystem.cihi.ca/hsp/indepth?lang=en&_ga=2.198987887.1358637256.1645297216-491652180.1642952237#/indicator/039/2/C2000/
Cardio-Phoenix (2020). The Importance of the Early Detection of Cardiovascular Disease. Retrieved March 13, 2022, from https://www.cardiophoenix.com/blog/the-importance-of-the-early-detection-of-cardiovascular-disease
CHB+Community+Health+Plan+2019-2022+web+copy.pdf. (n.d.). Retrieved February 20, 2022, from https://static1.squarespace.com/static/58d93c67b8a79bb89e7df56c/t/5c3e27f8758d462ae6596481/1547577350968/CHB+Community+Health+Plan+2019-2022+web+copy.pdf
Child Care Canada (2020, December 14). Cape Breton advocates say child poverty numbers “unacceptable” https://childcarecanada.org/documents/child-care-news/20/12/cape-breton-advocates-say-child-poverty-numbers-unacceptable
Dahlgren, G., & Whitehead, M. (2021) The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health 199, 20-24. https://www-clinicalkey-com.libraryproxy.nshealth.ca/#!/content/journal/1-s2.0-S003335062100336X?scrollTo=%23hl0000182
Doctors Nova Scotia (2015). Smoking Statistics. Cape Breton Post. Retrieved March 13, 2022, from https://www.pressreader.com/canada/cape-breton-post/20150330/281633893740163
Government of Canada (2022, January 24). Tables about unemployment, median wages, 10-day speed of service. Retrieved February 18, 2022 https://www.canada.ca/en/employment-social-development/services/foreign-workers/service-tables.html
Mining Association of Nova Scotia (2019) Coal | Not Your Grandfathers Mining Industry, Nova Scotia, Canada. Retrieved March 2, 2022, from https://notyourgrandfathersmining.ca/coal
Nova Scotia Department of Health and Wellness. Mortality rate by health zone (filter by drug type) | Open Data | Nova Scotia. (2020). Retrieved February 22, 2022, from https://data.novascotia.ca/Health-and-Wellness/Mortality-rate-by-health-zone-filter-by-drug-type-/x3nv-iwy3
Patterson, E. (2020, February 13). Exercise program keeping Cape Breton cardiac patients healthy SaltWire. Retrieved February 20, 2022, from https://www.saltwire.com/atlantic-canada/lifestyles/regional-lifestyles/exercise-program-keeping-cape-breton-cardiac-patients-healthy-410904
Point2 (n.d.). Cape Breton Island, NS Household Income, Population & Demographics.
Retrieved February 20, 2022, from https://www.point2homes.com/CA/Demographics/NS/CapeBreton-Island.html
Public Health Agency of Canada (2017). Heart Disease in Canada [Education and awareness]. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/heart-disease-canada.html
Public Health Agency of Canada. (2020). Obesity in rural and urban Canada—Data Blog—Public Health Infobase. https://health-infobase.canada.ca/datalab/canadian-risk-factor-atlas-obesity-blog.html?=undefined&wbdisable=true
Townfolio (2017). Cape Breton, NS - Education. Retrieved February 18, 2022, from https://townfolio.co/ns/cape-breton/education
Traer, D. (2022, February 24). EHS LifeFlight New Employee Orientation [Powerpoint Presentation]. Halifax, Nova Scotia.
Yusuf, S., Joseph, P., Rangarajan, S., Islam, S., Mente, A., Hystad, P., Brauer, M., Kutty, V. R., Gupta, R., Wielgosz, A., AlHabib, K. F., Dans, A., Lopez-Jaramillo, P., Avezum, A., Lanas, F., Oguz, A., Kruger, I. M., Diaz, R., Yusoff, K., … Dagenais, G. (2020). Modifiable risk factors, cardiovascular disease and mortality in 155,722 individuals from 21 high-, middle-, and low-income countries. Lancet (London, England), 395(10226), 795–808. https://doi.org/10.1016/S0140-6736(19)32008-2
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