Telehealth: Will it stay or will it fade?

Telehealth Services is revolutionizing the way we access health care.

2020 will forever be considered a year full of exponential change. COVID-19 and all its mutations redefined the world we lived in. Office jobs turned into work from home. Personal protective equipment (PPE) went from recommended to mandatory. Being sick required self-isolating instead of powering through a shift at work. Propaganda questioning the science behind vaccines were amplified through the use of the internet and social media. The world drastically changed and so did health.

2020 and 2021 saw a drastic increase in digital health. Digital health encompasses telehealth, centralized electronic health records, wearable sensors, cloud technology, machine learning, and artificial intelligence (Hamoni et al, 2021). Interest and the use of telehealth services specifically grew within Canadians due to COVID-19 lockdowns and stay-at-home orders (Hamoni et al, 2021). Prior to the pandemic, in 2018–2019, clinicians conducted only 8% of their clinical visits virtually (Mohammed et al, 2021).

Majority of the use of telehealth was used to aide in the disparity of access to healthcare in northern rural parts of Canada. These individuals benefited from telehealth services as it created opportunities for cost-effective and accessible care closer to home. Telehealth provided timely care, reduced the cost of health care and increased accessibility as individuals in rural areas didn’t need to travel to larger urban settings (Jong et al, 2018).

Some services that are being provided by telehealth in rural Canada are (Jong et al, 2018):

•Preoperative assessments and postoperative care for surgery

•Management of fractures and dislocations

•Assistance with procedures and surgeries via more experienced colleagues

•Daily remote hemodialysis rounds

•Tele-oncology

•Point of care ultrasound with the aid of an untrained person and led remotely via video by an experienced health provider

•Speech pathology

•Dietary consult

•Physiotherapy consult

•Professional development

•Supervising learners in remote communities

However in 2020, with the COVID-19 pandemic, this percentage increased to approximately 60% in Canada (Mohammed et al, 2021). And in this current climate of health care and the uncertainty of the pandemic, telehealth is here to stay and is the future of health care delivery.

Telehealth services or telemedicine 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 allows patients to meet with healthcare providers from the comfort of their own homes. Additionally, telehealth allows for patients to meet with health care professionals that whom would normally require distant travel to meet with for an appointment (Hamoni et al, 2021).

Benefits (Mohammed et al, 2021):

• Higher patient satisfaction

• Better access to care

• Overall cost savings

• Access to specialist care

Challenges (Mohammed et al, 2021):

• Digital competency among both healthcare providers and patients

• Affordability and accessibility of technology required

• Internet access

Since the pandemic, the healthcare system has endorsed several different virtual modes to increase clinical interactions with patients (Mohammed et al, 2021). The drastic implementation of telehealth services has resulted in many beneficial outcomes. It 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, telehealth still has plenty of limitations. Limitations are often seen around digital competency in both health care providers and patients (Mohammed et al, 2021). Individuals’ familiarity with the vast range of technologies within telehealth can be vastly different. Some individuals are highly literate in telehealth while others are very illiterate. Education in telehealth is strongly need to support the growth of telehealth services. Additionally, affordability and accessibility of telehealth technology is required (Mohammed et al, 2021). Mohammed et al (2021) states that this is often seen as a huge barrier within individuals with poor income. These individuals do not have the means to access and buy equipment necessary to participate in telehealth services (Mohammed et al, 2021). Additionally, limitations around internet access is an issue for individuals (Mohammed et al, 2021). Depending on the individual, connectivity issues regarding internet access may be due to their geographical location (Jong et al, 2019). Conversely, an individual’s internet access may be due to their income. Patients with low income may prioritize food and shelter over obtaining internet access (Jong et al, 2019). Thus limiting their access to telehealth services.

Telehealth should not replace traditional methods of delivering health care however, it does have its own place within health care in Canada. I believe telehealth has a place in rural areas where travel is an issue, for simple routine check ups, prescription refills, obtaining requisitions for bloodwork/x-rays, referrals for specialist etc. I still believe that in some instances physical assessments are still warranted and are unavoidable. Telehealth should be used as an aide to support the delivery of health care. Replacing some aspects with telehealth will help ease accessibility in our health care system. It will help replace wait times, increase convince for patients, reduce travel time, decrease emergency room hospitalizations and overall cost burdened by our health care system in Canada.

References:

Bloomberg Markets and Finance. (2020). Telehealth Is Booming During Covid Pandemic. Is it Here to Stay? Bloomberg. Retrieved April 1, 2022 from https://www.youtube.com/watch?v=j6htr4SxA08

Hamoni, R., Matthews, M., and Watson, M. (2021). Digital Transformation: The Next Big Leap in Healthcare. Information and Communications Technology Council (ICTC). Retrieved March 28, 2022 from https://www.ictc-ctic.ca/wp-content/uploads/2021/08/ICTC_Report_DigitalTransformation_August-12.pdf

Jong, M., Mendez, I., & Jong, R. (2019). Enhancing access to care in northern rural communities via telehealth. International journal of circumpolar health, 78(2), 1554174. https://doi.org/10.1080/22423982.2018.1554174

Mohammed, H. T., Hyseni, L., Bui, V., Gerritsen, B., Fuller, K., Sung, J., & Alarakhia, M. (2021). Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use. PloS one, 16(6), e0253665. https://doi.org/10.1371/journal.pone.0253665

Eliminating Influential Factors in Smoking with the use of SEM

How use of the Socio-Ecological Model of health can diminish smoking prevalence.

Socio-Ecological Model (SEM) of health is the multilevel model of health that has been built upon and expanded upon Urie Brofenbrenner’s 1977 multilevel framework of social ecology (Earp and Golden, 2012). This model recognizes the broader interplay of influencing factors and how they interact with one another (Early, 2017). It breaks down these influencing factors into the individual, interpersonal (relationships), organizational, community, and societal/policy factors (Early, 2017). The SEM of health clearly demonstrates how an individual’s health is not determined by just disease and genetics but is also determined by societal factors. Recently many have even included the internet as a new influencing factor after societal/policy factors. The internet and digital content are classified as the virtual system (Greiner, 2021). The influence of the internet in today’s age is significant as many people obtain information through the internet. Additionally, the reach of the internet is global and ideas from around the globe can potentially influence individuals and systems (Greiner, 2021).

The SEM of health recognizes individuals are entrenched within larger social systems and the interactions of an individual’s characteristics and environment result in health outcomes (Earp and Golden, 2012). As a result, when examining the SEM of health, we must consider the Social Determinants of Health (SDoH). The World Health Organization (WHO) identifies SDoH as the non-medical factors that influence health outcomes (WHO, n.d.). While the government of Canada elaborates and expands the WHO's definition 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. All these factors make up an individual’s health status and creates health inequalities among individuals (Government of Canada, n.d.). Due to all these social and other influencing factors in an individual’s life, a multilevel approach is needed to tackle change and change at all levels is required. At the individual and interpersonal level, interventions that are aimed at knowledge, beliefs and skills are required. Additionally, at the interpersonal-level and organizational-level, interventions need to be designed to create change in social relationships and organizational environments. For changes in the community level, partnerships with agencies, churches, neighborhoods are needed with the aim of community-focused interventions. Finally, implementing public policies with regards to health need the backing of politicians and public outcry for these interventions to work (Earp and Golden, 2012).

As a Respiratory Therapist, the SEM of health can be applied to patients suffering from chronic obstructive pulmonary disease (COPD). Majority of the individuals suffering from COPD can contribute their disease to years of smoking. Over 80% of current lung cancer and respiratory diseases such as COPD are caused by excessive tobacco smoking or exposure (Pierce and Kealey, 2021). On average, 20% of the population smokes, thus making 20% of patients admitted to hospital potentially smokers (Government of Ontario, n.d.). From a glance, this statistic seems like a relatively small number. However, when applied to the total population of Canada, this still accounts for millions of individuals. As of 2017 it still accounted for 4.6 million Canadian who smoke (University of Waterloo, n.d.). This clearly demonstrates that a large proportion of Canadians still smoke.

Using the SEM of health, Pierce and Kealey (2021) came up with a lot of potential interventions to help with smoking cessation. At the individual level they recommend additional tobacco education and tobacco free schools. Pierce and Kealey (2021) state that targeting the age group which smoking initially occurs will have the best results. Most smokers first start between the ages of 12 to 25 years old (Pierce and Kealey, 2021). They also state that education alone will not work and that creating an environment that promotes anti-tobacco beliefs and behaviors will have the best success (Pierce and Kealey, 2021). British Columbia (BC) has taken steps to increase education at the individual level. BC has developed lots of smoking cessation and educational resources that can be find on their website and have links to smoking cessation websites like “QuitNow.ca”. Furthermore, majority of the resources are translated into various languages for individuals (British Columbia govt, n.d.). To tackle interpersonal and organizational influences they recommend interventions like smoke-free workplaces and the use of the internet to promote smoke-free homes (Pierce and Kealey, 2021). In BC, smoking is completely prohibited in workplaces (British Columbia govt, n.d.). For the community level, the recommendation for stricter enforcement of “No sales to minors” laws were proposed (Pierce and Kealey, 2021). This would require buy in from shop owners in the community. There are fines in place for selling to minors but are not enforced enough to deter shop owners. Finally, Pierce and Kealey (2021) on a societal/policy level recommend implementing an increase in tobacco taxes. They believe that increasing the cost of a cigarette will deter people from smoking. However, a study by Huisman et al (2011) found that money was not as big as a deterrence as education was for smoking cessation. Additionally, on a societal and policy level, Pierce and Kealey (2021) recommend increasing insurance coverage for medical treatments such as pharmaceutical treatments and behavioral coaching to increase smoking cessation. This method has already been implemented in BC. The BC government offers residents of the province 100 percent coverage for the cost of nicotine replacement therapy (NRT) and cover some of the cost for specific smoking cessation prescription drugs (British Columbia govt, n.d.).

In Ontario, the Ottawa Model Smoking Cessation Network implemented a smoking cessation program that currently has a 50% success rate for patients at six months (Government of Ontario, n.d.). Within 6 months 50% of individuals are smoke-free. This program targets smokers by establishing a provincial wide protocol that requires health care providers to ask every individual admitted into hospital their smoking status regardless of the reason for their visit. Once smoking status is identified and documented, the appropriate treatment is provided (Government of Ontario, n.d.). If the individual is a smoker, the protocol requires that a nurse visit the patient and offer smoking cessation assistance, including cessation medications (Government of Ontario, n.d.). Patient follow-up is managed by nurses who monitor the Interactive Voice Recognition System (IVR). The IVR consists of yes or no questions, and questions that use a numerical scale for its answers. The answers are automatically recorded in an excel spreadsheet and highlights any patients that are struggling (Government of Ontario, n.d.). 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.). The success of the program has prompted the launch of ten similar pilot programs in BC and New Brunswick (Government of Ontario, n.d.). Looking at this from the SEM of health perspective, this program does a great job of tackling the influencing factors. From an individual factor, the province wide protocol identifies individuals who smoke and give them the appropriate education. Additionally, the province wide protocol tackles organizational influences as all the hospitals in Ontario are required to ask smoking status. The program provides additional smoking cessation in the community for patients. This helps combat negative community influencing factors that may be present in the patient’s community. The introduction of this program in different provinces and the backing from the Canadian government to establish this program nation wide will help alter societal opinions on smoking. Additionally, the successful implementation of this program nation wide will usher in new political views and policies. With all this information and other various smoking cessation education available on the internet the program can reach more people.

As a Respiratory Therapist and like most health care professionals, I believe smoking is very detrimental to one’s health. As a bedside therapist, I always try to promote smoking cessation in patients who are currently smoking and provide educational resources if they are open to reading them. Smoking is an extremely difficult habit to break and it takes multiple failed attempts before an individual will kick the habit (Pierce and Kealey, 2021). I believe using a SEM of health approach to tackle smoking is extremely important. I believe that the interventions recommended by Pierce and Kealey (2021) need to be implemented everywhere and programs like the IVR system in Ontario need to be established nation wide. Additionally, all the recommended interventions need to implemented together to target all the different influencing factors in an individual’s life. Earp and Golden (2012) found that implementations of interventions that only target one or two levels have no significant impact in causing change. Without targeting all levels, we will never accomplish any real change.

References:

British Columbia Government. (n,d). BC Smoking Cessation Program. British Columbia. Retrieved February 22, 2022 from https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/what-we-cover/bc-smoking-cessation-program

British Columbia Government. (n,d). Tobacco and Vapour Free Places. British Columbia. Retrieved February 22, 2022 from https://www2.gov.bc.ca/gov/content/health/keeping-bc-healthy-safe/tobacco-vapour/requirements-under-tobacco-vapour-product-control-act-regulation/tobacco-vapour-free-places#:~:text=The%20Tobacco%20and%20Vapour%20Products%20Control%20Regulation%20sets%20a%20six,can%20stand%20and%20use%20tobacco

Communities for Healthy Living. (2017). Ecological Model. Communities for Healthy living. Retrieved February 21, 2022 from https://www.youtube.com/watch?v=e9UyplfevyQ&feature=emb_imp_woyt

Early, J. (2016). Health is More than Healthcare: It’s Time for a Social Ecological Approach. Journal of Nursing and Health Studies, 1, 1-2. https://www.imedpub.com/articles/health-is-more-than-healthcare-its-time-for-a-social-ecological-approach.php?aid=17440

Greiner, K. P. (2021, April 19). Concept 3: Spheres of influence (SEM 2.0). The Social Change Cookbook. Retrieved February 22, 2022 from https://medium.com/the-social-change-cookbook/concept-3-spheres-of-influence-44bd5bd940ac

Golden, S. D., & Earp, J. L. (2012). Social ecological approaches to individuals and their contexts. Health Education & Behavior, 39(3), 364–372. https://doi.org/10.1177/1090198111418634

Government of Canada. (n.d.) Social determinants of health and health inequalities. Government of Canada. Retrieved February 28, 2022 from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Government of Ontario. (n.d.). The Ottawa Model for Smoking Cessation, The Network’s Success: Simply Smoke Free. Government of Ontario. Retrieved February 28, 2022 from https://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/ottawa.pdf

Huisman, M., Van Lenthe. F.J., Giskes, K., Carlijn, K., Kamphuis, B.M., Brug, J. & Mackenbach, J.P. (2012). Explaining socio-economic inequalities in daily smoking: a social–ecological approach. European Journal of Public Health, 22(2), 238–243. https://doi.org/10.1093/eurpub/ckr039

Pierce, J. P., & Kealey, S. (2021). Socio-ecological model and health promotion in the healthy people initiative.

Public Health Agency of Canada. (2019). Health Inequalities in Canada. Public Health Agency o Canada. Retrieved March 31, 2022 https://www.youtube.com/watch?v=RMkBUXJLW9g

University of Waterloo. (n.d). Current smoking prevalence. Tobacco Use in Canada. Retrieved February 28, 2022 from https://uwaterloo.ca/tobacco-use-canada/adult-tobacco-use/smoking-canada/current-smoking-prevalence#:~:text=In%202017%2C%20the%20overall%20prevalence,the%202015%20estimate%20of%2013.0%25.&text=Approximately%2010.8%25%20of%20Canadians%20(3.3,daily%20smokers%20(Figure%201.2)

World Health Organization. (n.d.) Social determinants of health. World Health Organization. Retrieved February 28, 2022, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

Social Determinants of Heath

A look at the current climate of Social Determinants of Health specifically in Canada.

The World Health Organization (WHO) identifies social determinants of health (SDoH) as the non-medical factors that influence health outcomes (WHO, n.d). 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). Thus, creating large disparities between countries. Life expectancy is 18 years longer in high-income countries compared to low-income countries (WHO, n.d.). Generally, individuals born in areas of lower socioeconomic positions have poor health and this disparity is seen in all countries regardless of income (WHO, n.d.) Even a well-developed country like Canada is unable to escape the social gradient of health and illness. The poor are more prone to experiencing worse health. The population of Canada is plagued with health inequity.

The government of Canada defines 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.). All this is used to establish an individual’s place in society. As a result, Canadians have different experiences with health and health care. These differences are referred to as health inequalities and result in the health inequity present in Canada. A prime example of this is in Canadians that live in remote or northern regions with limited access to nutritional foods compared to other Canadians (Government of Canada, n.d). Canada recognizes these health inequalities and has pledged to take action to create a country with health equity. The government of Canada is tackling health inequalities by strengthening the use of evidence base knowledge to make informed decisions, engaging beyond the health sector and by sharing knowledge of action across Canada (Government of Canada, n.d). Canada has been recognized and continues to be at the forefront of research into the SDoH (Donkin et al, 2017). Consequently, provincial governments have taken notice and started to take action as well.

In British Columbia (BC), the government established the B.C. Social Determinants of Health Standards (Standards) with the goal to provide consistency and guidance for SDoH data collection within British Columbia’s health care community (Government of British Columbia, n.d). The Standards sets out to standardize the definitions and terminology surrounding SDoH, improve culturally safer care and health equity in communities experiencing health inequity, bring SDoH data into the mainstream and improve information practices. Essentially, the Standards is meant to help identify, capture, maintain, understand SDoH and highlight negative impacts of health inequalities on individuals and the population (Government of British Columbia, n.d). However, very limited information is available on what they have accomplished. As of right now the Standards is currently working on cultural identity and Indigenous identity (Government of British Columbia, n.d).

Furthermore, it should also be noted that British Columbians are generally healthy people and tend to live longer than the average Canadian. This statement however creates the illusion that British Columbia has health equity. However, variations in socio-economic status, social support and other factors have created considerable health disparities between British Columbians (BCNU, 2011). Majority of these disparities are due to the distribution of wealth, access to basic necessities and unjust government policies. In BC, the top 20% make 10 times more than the bottom top 20% (BCNU, 2011). As a result, the poor have difficulty obtaining adequate housing and access to food. A large portion of people experiencing poverty are First Nations, new immigrants, single mothers, those with disabilities and the elderly. The BCNU stresses eliminating poverty will create more health equity among British Columbians. They propose eliminating poverty through similar policies established in Newfoundland and Labrador that focus on poverty reduction and supporting low-income families (BCNU, 2011). Additionally, other provinces have also acknowledged the importance of SDoH. Alberta for instance established a province-wide SDoH and health equity approach. The Alberta Health Services (AHS) are improving people’s health and wellness by targeting 3 different levels. They are targeting individuals, the community and through policy reform (AHS, n.d). Through this, the AHS hopes to eliminate health equalities. A similar trend in creating health equity can be seen across the Canadian provinces and territory.

Social factors determine about 75% of our health (BCCDC Foundation for Public Health, n.d). SDoH play an important role in an individual’s health and health status. Numerous studies suggest that SDoH account for between 30-55% of health outcomes in individuals (WHO, n.d). This demonstrates that an individual’s social factors and environment can either positively or negatively impact one’s health. All across world there has been significant progress made in the recognition and adoption of SDoH and health equity (Marmot & Allen, 2014). However, significant work is still required and this is clearly evident in Canada. Although, Canada has been progressive on this front both federally and provincially. Federally, Canada is taking steps to promote and advocate for health equity. While provincially, provinces like British Columbia and Alberta have taken steps in creating policies and establishing committees to tackle SDoH and health inequalities.

References:

Alberta Health Services (n.d). What Determines Health? Alberta Healthy Communities. Retrieved February 14, 2022 from https://albertahealthycommunities.healthiertogether.ca/about/what-determines-health/

BCCDC Foundation for Public Health. (n.d.). Social Determinants of Health 101: Decoding Public Health. Retrieved February 14, 2022 from https://bccdcfoundation.org/social-determinants-of-health-101-decoding-public-health/

BMJ. (2016). Social Determinants of Health. British Medical Journal. Retrieved from https://www.youtube.com/watch?v=_X2tdLTx_1Y

British Columbia Nurses’ Union. (2011). Position Statement: Social Determinants of Health. BCNU. Retrieved February 14, 2022 from https://www.bcnu.org/AboutBcnu/Documents/position-statement-social-determinants-of-health.pdf

Donkin, A, Goldblatt, P, Allen, J, Nathanson, V & Marmot, M. (2017). Global Action on the Social Determinants of Health. BMJ Glob Health, 3. https://gh.bmj.com/content/bmjgh/3/Suppl_1/e000603.full.pdf

Government of British Columbia. (n.d.). B.C. Social Determinants of Health Standards. Government of British Columbia. Retrieved February 14, 2022 from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/health-information-standards/standards-catalogue/bc-social-determinants-of-health-standards

Government of Canada. (n.d.) Social determinants of health and health inequalities. Government of Canada. Retrieved February 14, 2022 from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Marmot, M, & Allen, J. (2014). Social Determinants of Health Equity. American Journal of Public Health, 104. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2014.302200

Public Health Agency of Canada. (2019). Health Inequalities in Canada. Public Health Agency of Canada. Retrieved February 14, 2022 from https://www.youtube.com/watch?v=RMkBUXJLW9g

UBC Medicine. (2017). The Social Determinants of Health. University of British Columbia. Retrieved from https://www.youtube.com/watch?v=nTqknri15fQ

World Health Organization. (n.d.) Social determinants of health. World Health Organization. Retrieved February 14, 2022, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1