There are several variations to the definition of health. According to the World Health Organization (WHO) (n.d), health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The Ottawa Charter for Health Promotion (1986) recognizes that there are several other aspects of health such as social, economic and environmental factors. Bradley et al. (2018) suggest that the definition of health should acknowledge that disease and disability can co-exist with health, while Brook (2017) suggests that tolerance should be included as an element of health. Ultimately, the definition of health is an ongoing evolution as society progresses.
Throughout this semester, I have been exploring a complex health issue, cardiovascular disease (CVD) in Cape Breton (CB), Nova Scotia, an island situated on the eastern side of the province. Due to the expanse of the topic of CVD, my particular focus is the realm of ischemic heart disease. When I selected this topic, anecdotally, I understood the residents of CB were at a deficit in terms of access to definitive care for acute on chronic cardiac conditions, such as myocardial infarction and cardiogenic shock. In my current role, I am involved in the coordination of critical care air transport of this population to the provinces’ tertiary care center, which would normally be a five-hour venture via ground ambulance. My perception of this issue was that there should be more cardiac care support in this area of the province, such as the addition of an interventional cardiologist to perform higher-level cardiac procedures. While I realize this is impractical for several reasons (availability of specialty trained nurses, cardiac surgeon on standby, specialized operating room), I failed to consider the upstream approach to this chronic illness. This course has reminded me that solutions are more than what appears to be an “obvious fix”, that root cause analysis and targeting the determinants of health may be the key to alleviating some of the strain this multifaceted chronic illness places on the health care system.
When examining CVD, the determinants of health play a significant role in the development, severity, and individual management of the disease process and progression. The WHO (n.d) describes determinants of health as the social, economic, and physical environment plus an individual’s characteristics and behaviors as factors that influence health status. An article by Kreatsoulas & Anand (2010) notes that individuals of lower socioeconomic status are more vulnerable to CVD than those of a higher socioeconomic status. Genetic predisposition, unhealthy lifestyle behaviors, access to health services, and culture are a few of the other determinants that are germane to CVD.
A multilevel model is a conceptual framework that can be utilized to structure your analysis of the determinants of health as they apply to a health issue. I employed the Dahlgren-Whitehead model (Dahlgren & Whitehead, 2021), a socioecological model, in a previous blog post (Richards, 2022) exploring CVD in CB. I examined each layer of the model and was able to identify the dynamic way the levels of influence associate with one other. For example, an individual living in rural CB does not have access to bus service, potentially creating difficulty getting to the urban center of the island where the regional hospital, the majority of social services and amenities are located. If you cannot afford a vehicle, you would need to rely on family or friends for transportation or remain without access to some necessities. There are other multilevel models that can be utilized to examine health, each seem to have similar holistic themes. For example, Bronfenbrenner’s Ecological Systems theory (Guy-Evans, 2020) examines child development and the influences of relationships within the child’s surrounding environment from the child’s immediate family relationships through to broad cultural values, laws, and customs with each of these systems being interrelated with one another.
According to the Public Health Agency of Canada (2019), 44% of Canadian adults over the age of twenty have at least one of ten common chronic conditions. Chronic disease presents a significant challenge and burden to an overwhelmed health care system. Elmslie (2016) states that the treatment of chronic diseases represents 67% of all health care costs a staggering 190 billion dollars annually. Recognizing the financial impact of chronic disease, with the aging population, and need for a change to primary health care services (shortage of primary care providers and increasing complexity of patient care needs), Health Canada (2007) developed the Primary Health Care Transition Fund. This federal initiative provided financial support to provinces and territories with targeted objectives to encourage a collaborative approach to the delivery of primary health care. Nova Scotia participated in this initiative, utilizing their approved contribution enhance primary health care services, support costs associated with alterations designed to strengthen primary health care networks, and to support the transition to an electronic patient record. Cape Breton developed a Community Health Plan (n.d) in collaboration with residents of the area, the Nova Scotia Health Authority and other stakeholders. This report identifies key priorities and recommendations for CB, specific to its diverse population, social and economic conditions, and health care needs. For example, access to services was identified as a priority area of concern; one recommendation is to support community involvement to improve access to services with a focus on improved health outcomes. In the context of CVD, access to primary care, medication, and healthy food are keys in the prevention and management of this illness.
CB is home to Nova Scotia’s highest proportion of Indigenous people, 6% (Kennedy, 2021). Five of the provinces thirteen First Nation communities are located on the island, including the largest, Eskasoni. “Indigenous Peoples in Canada still face significant inequalities in their access to health care when compared to non-Indigenous Canadians. They also carry a greater burden of health problems requiring acute health care, particularly in regards to pulmonary, cardiovascular, traumatic and psychiatric illnesses” (Vigneault et al., 2021). In Canada, the responsibility of health care for First Nations people falls to the federal government, and the only active national-level legislation is the Indian Act of 1876. Richmond & Cook (2016) examined how the Indian Act influences contemporary Aboriginal health inequity and discusses the concept of reconciliation as it relates to public policy and the potential for achieving positive change toward Aboriginal health equity. This paper also acknowledges the need for community based research as well as advocates for health equity ranging from community members to federal leaders in order to achieve success. On a positive note, The Truth and Reconciliation Commission of Canada: Calls to Action (2015) identified ninety-four calls to action in an effort to redress the legacy of residential schools and advance the process of Canadian reconciliation. Several of these were related to inequity in Aboriginal health care and I am optimistic that active measures are being taken to improving gaps in health care. One example of this is an inclusion in the 2021 federal budget to provide $126.7 million to address anti-Indigenous racism in health systems (Truth and Reconciliation Commission of Canada, 2021).
In my opinion, the future of health care is exciting and promising. Virtual care and telemedicine have expanded drastically with the challenges of the Covid 19 pandemic in an effort to deliver health care while adhering to public health protocols (Bokolo, 2020). Virtual care can provide several benefits to the health care system including increased accessibility, affordability and efficiency (KareXpert, 2022). There are also considerations to take into account during the provision of virtual care, such as digital literacy, connectivity, affordability of necessary technology and patient privacy. Health equity needs to remain at the forefront of current and future developments of virtual in order to avoid further marginalizing vulnerable populations. Shaw et al. (2021) examined the literature on health equity and virtual care during the pandemic and identified three strategies for promoting health equity through virtual care; simplifying complex interfaces and workflows, using supportive intermediaries, and creating mechanisms through which marginalized communities can provide input into the planning and delivery of virtual care.
Cardiovascular disease is a multifaceted chronic health issue. Causes of this illness are normally a combination of genetic and lifestyle factors (University of Ottawa Heart Institute, n.d.). Lifestyle factors are considered modifiable and are closely tied to the determinants of health and health equity. For example, acquiring healthy food may be challenging for an individual who has limited access to transportation, or is on a fixed income. The Indigenous population is already at a detriment, as their ethnicity puts them at a higher risk of developing heart disease (University of Ottawa Heart Institute, n.d.).That, combined with a health care system delivery model (Indian Act of 1876) that is antiquated and seemingly unjust, it is easy to see how this vulnerable population is particularly disadvantaged. This course has afforded me the opportunity to re-examine my perception of health and my response to health care system issues. It is easy to look for the band-aid solution in a time of crisis instead of investing time, effort and fiscal resources on the root cause and providing solutions utilizing an upstream approach.
References
Bokolo Anthony Jnr. (2020). Use of Telemedicine and Virtual Care for Remote Treatment in Response to COVID-19 Pandemic. Journal of Medical Systems, 44(7), 132. https://doi.org/10.1007/s10916-020-01596-5
Bradley, K. L., Goetz, T., & Viswanathan, S. (2018). Toward a Contemporary Definition of Health. Military Medicine, 183(suppl_3), 204–207. https://doi.org/10.1093/milmed/usy213
Brook, R. H. (2017). Should the Definition of Health Include a Measure of Tolerance? JAMA, 317(6), 585. https://doi.org/10.1001/jama.2016.14372
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/playContent/1-s2.0-S003335062100336X?returnurl=null&referrer=null
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Kennedy, T. (2021, December 13). How many First Nations communities are there in Nova Scotia? About Canada. https://cubetoronto.com/nova-scotia/how-many-first-nations-communities-are-there-in-nova-scotia/
Kreatsoulas, C., & Anand, S. S. (2010). The impact of social determinants on cardiovascular disease. The Canadian Journal of Cardiology, 26(Suppl C), 8C-13C. https://doi.org/10.1016/s0828-282x(10)71075-8
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Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(1), 2. https://doi.org/10.1186/s40985-016-0016-5
Shaw, J., Brewer, L. C., & Veinot, T. (2021). Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review. JMIR Formative Research, 5(4), e23233. https://doi.org/10.2196/23233
Truth and Reconciliation Commission of Canada (2015). Truth and Reconciliation Commission of Canada: Calls to action. National Centre for Truth and Reconciliation. http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf
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University of Ottawa Heart Institute (n.d.). Risk Factors. Coronary Artery Disease Patient Guide. Retrieved February 20, 2022, from https://www.ottawaheart.ca/coronary-artery-disease-patient-guide/risk-factors
Vigneault, L.-P., Diendere, E., Sohier-Poirier, C., Abi Hanna, M., Poirier, A., & St-Onge, M. (2021). Acute health care among Indigenous patients in Canada: A scoping review. International Journal of Circumpolar Health, 80(1), 1946324. https://doi.org/10.1080/22423982.2021.1946324
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