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

What is Health?

Is the World Health Organization's 1948 definition of health still valid in 2022?

In 1948, the World Health Organization (WHO) released their answer to the question what is health. They stated that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, n.d). As society has aged and changed through the years, this statement has remained the same and has become irrelevant. Some even consider the statement to be counterproductive due to aging populations and changes in the patterns of illnesses (Huber, 2011, p.236). In the current climate the prevalence of chronic diseases has risen in our aging population. Consequently, the WHO’s use of the word “complete” results in a majority of people being considered unhealthy. The word “complete” and with chronic diseases becoming the norm, many researchers criticize the use of the WHO’s definition of health (Huber, 2011, p.235-236). As a result, many researchers have developed their own definition of health.

The WHO’s definition of health at the time was considered ground-breaking as it defined health as more than just the absence of disease and included physical, mental and social aspects (Huber, 2011, p.235). However, many criticize the word “complete” as it confines health to an absolute and makes measuring health extremely difficult (Oleribe et al, 2018). This completeness that is needed to be considered healthy could unintentionally contribute to the medicalization of society (Huber, 2011, p.236). Aiming for complete health as defined by WHO would result in more medical dependency in individuals. With the advancements of medicine, individuals who are declared healthy today may be considered diseased tomorrow. We are consistently seeing more advanced methods for investigating and these advancements might find signs of a disease that was not diagnosable earlier (Sartorius, 2006). Additionally, issues arise over whether it is even possible for a person to be without any physical, mental or social challenges (Oleribe et al, 2018). This requires an individual at any time to be free of any challenges in all three areas. With this in mind, any individual that has ever broken a bone is considered unhealthy or an individual who is mentally stressed before an exam or job interview is considered unhealthy. This prerequisite for completeness would make the majority of the population unhealthy (Oleribe et al, 2018).

In 1948 acute diseases plagued the population and chronic diseases led to an early death (Huber, 2011, p.236). Presently in today’s population the reverse is true. The number of people living with chronic diseases is significantly higher. A 2018 study found that 129 million adults in the United States were diagnosed and living with at least one chronic disease (Boersma et al, 2020). Using the current definition set out by the WHO, these 129 million individuals are considered indefinitely unhealthy. Huber (2011) suggests this minimizes the role of humans’ ability to cope with life's ever changing physical, emotional, and social challenges. As a result, individuals managing their chronic disease or multiple diseases are disregarded. One is considered unhealthy even if they feel they have their disease under control and feel healthy. Chronic diseases account for most of the expenditures in healthcare and aging with chronic diseases has become the norm (Huber, 2011, p.236). The current definition of heath by the WHO is not reflective of the current state of heath. With a majority of the population living with some form of a chronic disease a new definition of what is considered healthy is need.

All the criticisms and critiquing of the WHO’s definition of health has led to many researchers promoting their own definitions. Huber (2011) defines health as the ability to adapt and to self manage. This definition allows for individuals living with a chronic disease to be considered healthy. By successfully adapting to an illness, individuals who are able to manage and cope with their disease can still feel healthy despite their limitations (Huber, 2011, p.236). A similar definition of health proposed by The Ottawa Charter for Health Promotion states an individual or group must be able to identify, realize aspirations, satisfy needs, and to change or cope with the environment (Government of Canada, 2008). Both these definitions focus on the ability for an individual to cope and manage their health. Another definition proposed by Brooks (2017) emphasizes the expansion of the WHO’s definition to include acceptance and tolerance. Brook argues individuals can only be completely healthy if they are accepting and without hate. A French physician named Georges Canguilhem saw health as the ability to adapt to one's environment (The Lancet, 2009). He believed an individual’s circumstances shapes and defines one's health. Additionally, he believed health is determined by the individual, based on his or her functional needs and not a doctor (The Lancet, 2009).

Health is ever changing and the definition should be as well. Society, the population and current state of health should dictate the definition of health at different points in time.

References:

Boersma, P, Black, L.I., & Ward, B.W. (2020). Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Research Brief, 17. https://www.cdc.gov/pcd/issues/2020/20_0130.htm#:~:text=05.-,Results,2%20chronic%20conditions%20(Table)

Brook. R. H. (2017). Should the definition of health include a measure of tolerance? JAMA, 317 (6), 585-586. https://0-jamanetwork-com.aupac.lib.athabascau.ca/journals/jama/fullarticle/2601506

Government of Canada. (2008). What is health? Government of Canada. Retrieved February 7, 2022, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-approach/what-is-health.html

Huber, M. (2011). Health: How should we define it? British Medical Journal, 343, (7817), 235-237. Retrieved February 6, 2022 from http://www.jstor.org/stable/23051314

The Lancet (2009). What is health? The ability to adapt. Lancet. 373 (9666), 781. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2809%2960456-6

Oleribe, O. O., Ukwedeh, O., Burstow, N. J., Gomaa, A. I., Sonderup, M. W., Cook, N., Waked, I., Spearman, W., & Taylor-Robinson, S. D. (2018). Health: redefined. Pan African Medical Journal, 30(292). https://panafrican-med-journal.com/content/article/30/292/full/

Sartorius N. (2006). The meanings of health and its promotion. Croatian medical journal, 47(4), 662–664. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080455/

World Health Organization. (n.d.) Constitution. World Health Organization. Retrieved February 6, 2022, from https://www.who.int/about/governance/constitution

World Health Organization. (2018). What does your health mean to you? World Health Organization. Retrieved March 31, 2022 from https://www.youtube.com/watch?v=0wjzQVuDej4