A introspective look at COPD using concepts and elements learned in MHST 601
As I look back and reflect on my journey through MHST601, my learning was guided by my personal and professional experiences. As a Respiratory Therapist (RT), my learning was linked to diseases specifically related to my profession. I related course units such as social determinants of health, vulnerable populations, multilevel models of health, vulnerable populations and future directions of health to Chronic Obstructive Pulmonary Disease (COPD). COPD patients are a big component of a Respiratory Therapists career. Using my experiences as a RT working in Surrey Memorial Hospital, I was able to visualize and conceptualize how these concepts and frameworks related to patient care in Canada’s health care system. Through the weekly readings and content curations, I was able to construct critical foundations in health disciplines that will forever shape my current practice.
Chronic Disease: COPD
In 2000, Canada chronic diseases accounted for $31.6 billion in direct patient costs (BC Ministry of Healthy Living and Sport, 2010). Since than the cost of chronic diseases has drastically risen. It is estimated that chronic diseases account for $68 billion in direct patient costs (Chronic Disease Prevention Alliance of Canada, 2018). And as our population continues to age, these costs are only expected to continue to rise. Currently in Canada, 44% of adults 20+ have at least one common chronic condition (Health Canada, n.d.). 10% of these individuals are affected by COPD (Health Canada, n.d.).
COPD is a chronic disease that is characterized by persistent and progressive airflow limitations that is caused by an enhanced chronic inflammatory response in the airways and the lungs to noxious particles or gases (Qureshi et al, 2014). It has been widely documented that smoking is the number one leading cause of COPD (Canadian Lung Association, n.d.). COPD is estimated to roughly affect 16 million adults in the United States (Bollmeier & Hartmann, 2020). In 2011-2012, COPD roughly affected about 2 million Canadians aged 35 years and older (Government of Canada, 2018). The number of Canadians affected by COPD today is expected to be much larger. In BC alone, approximately 138,500 individuals aged ≥ 45 years in BC have been diagnosed with COPD (Government of BC, n.d.). This makes up roughly 6% of British Columbians aged ≥ 45 years (Government of BC, n.d.). This number however may not represent the true number of people living with COPD as many individuals go undiagnosed.
Multi-faceted strategies are needed when developing chronic disease prevention and maintenance strategies. Strategies that focus on prevention and maintenance will help reduce the amount of re-hospitalization. For preventative and maintenance measures in COPD, Qureshi et al (2014) recommend smoking cessation, pulmonary rehab, disease management programs and an appropriate pharmacological regiment for patients. In BC, the provincial government and the various health authorities place a huge focus on educating patients. This is accomplished through the use of community RTs and RTs who work in clinics. These RTs provide education on smoking cessation, education regarding technique and optimal use of medications and help educate patients to recognize COPD flare-ups and how to initiate self-management for COPD flare-ups (Fraser Health, 2021). Patients are also educated and advised on when they should seek medical attention (Fraser Health, 2021).
COPD outpatient clinics also aim to optimize care in COPD patients according to best clinical practice (Providence Health, n.d.). This is achieved through a multidisciplinary team and the team is composed of a respirologist, a respiratory therapist, a dietitian, and physiotherapist (Providence Health, n.d.). These COPD clinics use interprofessional collaboration to provide quality care and better meet the needs of COPD patients. Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and solve variety complex issues (Green & Johnson, 2015). In health care it is generally believed that collaborative efforts yield better health outcomes (Green & Johnson, 2015). These COPD clinics provide education and tips on how to better manage COPD condition at home. Programs that involve a multidisciplinary approach that include exercise therapy and patient education, have been shown to improve quality of life in patients with COPD (Bollmeier & Hartmann, 2020). These programs give patients the tools they need to keep charge of their lives and not succumb to being prisoners to COPD.
Vulnerable Population:
The smoking population is the most vulnerable to COPD development. It is well documented that the Incidence of COPD is highest in patients who smoke or have a history of tobacco use (Bollmeier & Hartmann, 2020). 80% of the individuals who have COPD in Canada have smoked at some point in their life (Osman et al, 2017). Additionally, Osman et al (2017), found that current smokers are five times more likely to have COPD compared to individuals who have never smoked. Over the years the prevalence Canadian smokers has and continues to decrease. However, roughly 20% of the population still smokes (Government of Ontario, n.d.). As of 2021, five million Canadians still smoke according to Health Canada (CBC Radio, 2021). This clearly shows a large proportion of Canadians still smoke. Many of these individuals can contribute their smoking addiction to social and environmental factors that have influenced their lives.
Social Determinants of Health:
The World Health Organization (WHO) identifies social determinants of health (SDoH) as the non-medical factors that influence health outcomes (WHO, n.d).The government of Canada elaborates further by defining SDoH as specific group of social and economic factors within the broader determinants of health. These determinants of health are broken down into 12 main determinants by the government of Canada (Government of Canada, n.d.). These factors include income, education, employment, childhood experiences, physical environment, social supports/coping skills, access to health services, genetics, gender, culture, and race (Government of Canada, n.d.). It is noted that SDoH can influence an individual’s health equity in a positive or negative way depending on the conditions where they are born, grow, work, live, age and the political systems in place (WHO, n.d). All these factors make up an individual’s health status.
When applying SDoH to the smoking population, Brady (2020) found a strong correlation within smokers associated to low education and income. In a study conducted by Osman et al (2017), it was found individuals reporting an annual income of <$20,000 and individuals with less than a secondary school graduation had the highest rates of COPD. Clearly demonstrating that a low socioeconomic status directly impacts an individual’s smoking prevalence. A study conducted by Pakhale et al (2021) supports this notion as they found the prevalence of COPD is significantly higher in Ottawa’s urban poor population compared to general Canadian population. Furthermore, Brady (2020) states gender, race/ethnicity, cultural characteristics, social marginalization, stress, lack of community empowerment and unequal distribution of resources and services as additional SDoH that are present in and affect smokers. All these social factors influence whether an individual will smoke or not.
Smokers and SEM:
Socio-Ecological Model (SEM) of health is the multilevel model of health that recognizes the broader interplay of influencing factors and how they interact with one another (Early, 2016). It breaks down these influencing factors into the individual, interpersonal (relationships), organizational, community, and societal/policy factors (Early, 2016). The SEM of health recognize individuals are entrenched within larger social systems and the interactions of an individual’s characteristics and environment result in health outcomes (Earp & Golden, 2012). As a result, when examining the SEM of health, we must consider SDoH. The SEM of health clearly demonstrates how an individual’s health is not determined by just disease and genetics but is also determined by social factors.
For change the SEM recommends implementing interventions that tackle every level simultaneously. Interventions at the individual and interpersonal level need to be aimed at education, beliefs and skills. Additionally, at the interpersonal-level and organizational-level, interventions need to be designed to create change in social relationships and organizational environments. For changes at the community level, interventions need to be community-focused. Finally, implementing public policies with regards to health need the backing of politicians and public outcry for these interventions to work (Earp & Golden, 2012).
Using and applying the SEM to smokers clearly demonstrates their vulnerability as a population. These individuals are negatively affected at each level and these influential factors tend to promote smoking habits.
Individual Level:
Low socioeconomic status plays a huge role in the individual level of SEM. Many individuals who smoke have low levels of education and low income. At the individual level, Pierce and Kealey (2021) recommend tobacco education and tobacco free schools.
Interpersonal Relationships Level:
It is noted that individuals with parental and peer smokers in their lives exponentially increases the odds of smoking (Australian Government, n.d.). Additionally, nicotine exposure during childhood plays a major role in enabling smoking behavior (Australian Government, n.d.). Promoting smoke-free homes could help prevent individuals from smoking (Pierce and Kealey, 2021).
Organizational Level:
Many individuals are more likely to smoke depending on the organizations they belong to. An example of this is an individual’s job. It is noted that physically demanding jobs were linked with heavy smoking. Work that involves high physical exertion is associated with heavy smokers, roughly 2.5 times more than people whose jobs involve low physical exertion (IWH, 2019). Creating smoke-free workplaces may help create an environment that promotes smoking cessation.
Community level:
Adults that live in rural areas smoke at a higher rate compared to adults that live in urban areas. This relates back to a lack of education and low incomes (Australian Government, n.d.). In these communities, smoking is more common and socially acceptable. Creating communities that promote smoking cessation will help deter individuals from smoking.
Societal/Policy level:
The introduction of policies that deter smoking can increase smoking cessation rates. A common recommended policy is increasing taxes on tobacco products (Pierce & Kealey, 2021). Additionally, Pierce & Kealey (2021) recommend increasing insurance coverage for medical treatments such as pharmaceutical treatments and behavioral coaching. Changes in policies that promote smoking cessation can lead to creating a society that is tobacco free.
Future Directions:
Prior to the pandemic, in 2018–2019, clinicians conducted only 8% of their clinical visits virtually but during the pandemic this percentage increased to approximately 60% in Canada (Mohammed et al, 2021). The use of digital health services has significantly increased. Digital health encompasses telehealth, centralized electronic health records, wearable sensors, cloud technology, machine learning, and artificial intelligence (Hamoni et al, 2021). The pandemic made advancements in technologies related to health more widely accepted in society.
The use of telehealth specifically has drastically increased. Telehealth is an alternative to in-person consultations with healthcare professionals. Telehealth services are conducted through electronic communications such as audio or video calls, text messages and emails (Hamoni et al, 2021). Telehealth has been noted to have higher patient satisfaction, better access to care, decrease in costs and increased access to specialist care (Mohammed et al, 2021). However, some challenges are digital competency among both healthcare providers and patients, affordability and accessibility of technology required and internet access (Mohammed et al, 2021).
Ambrosino, N., Vagheggini, G., Mazzoleni, S., & Vitacca, M. (2016). Telemedicine in chronic obstructive pulmonary disease. Breathe (Sheffield, England), 12(4), 350–356. https://doi.org/10.1183/20734735.014616
In terms of COPD and smoking cessation, I believe telehealth can potentially play a significant role in patients. Education on smoking cessation, medication use and technique, and COPD self management can be delivered through telehealth. This would provide patients with all the resources and tools they would need in the comfort of their homes. Additionally, telehealth eliminates the distant travel required for some patients (Hamoni et al, 2021). It has been noted that telehealth saw a reduction in out-patient visits, early detection and proactive intervention in the patients before the occurrence an acute COPD exacerbation (Ambrosino et al, 2016). A telehealth program currently in Ontario has shown great promise in smoking cessation. The program uses Interactive Voice Recognition System (IVR) to provide smoking cessation in smokers. Patients that are struggling are contacted by nurses and offered one-on-one support and access to additional resources in the community (Government of Ontario, n.d.). Participants were noted to have a high satisfaction with this program and currently has a 50% success rate in smoking cessation for patients at six months (Government of Ontario, n.d.).
My time in this course has really changed my perspective on health. I have learned the importance of SDoH, multilevel health approaches, chronic diseases, vulnerable populations and the future of health. Through the readings and engagement with fellow classmates, my professional identity has further developed and blossomed. I have developed various skills to promote and advocate for patients and health care. As a RT, I was able to apply COPD in context with our learning objectives for this course. In doing so I was able to develop critical thinking tools that will enable me to continue advocating and championing on their behave. As I continue on in other courses in this program, I will feel at ease as i have built a strong foundation thanks to this class.
References:
Ambrosino, N., Vagheggini, G., Mazzoleni, S., & Vitacca, M. (2016). Telemedicine in chronic obstructive pulmonary disease. Breathe (Sheffield, England), 12(4), 350–356. https://doi.org/10.1183/20734735.014616
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