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

Modernizing the Canada Health Act

Why changes need to be made for the Canada Health Act to reflect the current climate of health care needs in Canada

The Saskatchewan Hospitalization Act of 1946 (SHA) was the original universal health care legislative act that the Canadian Health Act of 1984 was built upon. The SHA established and required that all hospital and diagnostic services are provided free of charge to residents of the province (Flood and Thomas, 2016, p.400). This policy led to the creation of the Hospital Insurance and Diagnostic Services Act (HIDSA) of 1957 which was essentially the first iteration of the Canadian Health Act. The HIDSA was created in the hopes to incentivize other provinces to follow Saskatchewan’s lead of offering free hospital care and diagnostic services. The federal government’s legislative act offered 50/50 cost-sharing to all provinces with similar health care models as Saskatchewan (Flood and Thomas, 2016, p.400).

Over the 1960s and 1970s, other revisions and acts were established to further develop and shape heath care in Canada. In 1984, the CHA was developed and remains the current iteration of what health care in Canada encompasses. The Canadian government however have failed to modernize the CHA and its limitations. The CHA limits coverage to “medically necessary” hospitalizations and physician services. The CHA does not include universal drug care, dental care, long-term care and mental health services (Flood and Thomas, 2016, p.398). As a result, the CHA fails to allow for the changing health care climate, specifically for the aging population and chronic disease management (Flood and Thomas, 2016, p.399).

As a Respiratory Therapist (RT), many patients are regularly admitted into the emergency room for Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) exacerbations. These patients often suffer these health incidents due to the gaps in coverage outlined in the CHA (Flood and Thomas, 2016, p.402). The lack of a universal drug coverage under the CHA often leaves many patients struggling to obtain the drugs prescribed to them. As a result, these patients often end up in hospital requiring treatment and putting a financial burden on the health care system. In 2000, Canada chronic diseases accounted for $99.1 billion with $31.6 billion being associated in direct costs (BC Ministry of Healthy Living and Sport, 2010, p.4-5). These numbers have only risen and it is estimated that chronic diseases account for $190 billion annually with $68 billion of it being a direct cost (Chronic Disease Prevention Alliance of Canada, 2018, p.1). Most of the direct costs are due to chronic diseases that can be prevented and mitigated.

In Fraser Health, we are fortunate enough to have Community Respiratory Services. This program employs community RTs who specifically provide chronic disease management, education and support to people living with COPD (Fraser Health, 2021). The RTs help patients quit smoking, optimize the use of medications and other therapies to reduce symptoms, help educate patients to recognize COPD flare-ups and how to initiate self-management for COPD flare-ups. Additionally, they help determine when patients should seek medical attention (Fraser Health, 2021). This program provides patients in the community the support they need with the hope of reducing frequent hospitalizations. Community RTs also provide support to patients in the community living with a tracheostomy. The RTs will provide assistance with making sure the trach stoma is healthy and patent, provide further education. Programs like these aim at reducing the direct cost placed on our health care system by chronic diseases. Consequently, programs like these tend to have strict guidelines and are heavily underfunded. For community respiratory services, you must be diagnosed by a physician with COPD and referred by either a physician, nurse practitioner or any other health professional to the program (Fraser Health, 2021). From my personal experience, many patients that would benefit from these kinds of programs get missed. Some patients do not fit the requirements, others refuse to participate and sometimes health care practitioners do not refer potential candidates.

Society is always evolving and changing. Ideologies that worked in the past do not always continue to work in the future. In the 1980’s and 1990’s, the ideology of “medical necessity” set forth under the CHA may have worked but with an aging population now in the 2000’s, reform around what is considered “medical necessity” is needed. In British Columbia alone, over half of the population has at least one chronic condition and in the province chronic diseases are responsible for the majority of deaths (BCCDC, 2018, p.3). The CHA needs to amended the definition of “medical necessity” to be more reflective of the current climate in heath care. Having access and coverage for prescription drugs is a “medical necessity” in the eyes of people living with chronic diseases. The lack of universal drug coverage causes many low-income Canadians to avoid or delay seeking care because of the fear of costly prescriptions (Flood and Thomas, 2016, p. 403). Ultimately, these patients arrive in the emergency room of hospitals requiring medical attention that costs the heath care system more. Yet politicians are more concerned with driving down the cost of drugs before they would even consider a publicly funded drug coverage (Flood and Thomas, 2016, p. 409).

Modernizing the CHA will require frequent reviews and updating that keeps up with the emerging needs in Canadians. A good starting point is expanding the CHA’s coverage to include prescription drugs, diagnostics, mental health (psychology), home care and dental care (Flood and Thomas, 2016, p. 409). Additionally, CHA needs a taskforce that consistently reviews the needs of Canadians and determines what services are needed or no longer needed under the CHA (Flood and Thomas, 2016, p. 409). Health is not stagnant and our CHA shouldn’t be either.

References:

BC Centre for Disease Control. (2018). The Economic Burden of Risk Factors in British Columbia, 2015. BC Centre for Disease Control. Retrieved January 23, 2022 from http://www.bccdc.ca/pop-public-health/Documents/economic_burden_five_risk_factors_BC_2015.pdf

BC Ministry of Healthy Living and Sport. (2010). Model Core Program Paper: Chronic Disease. BC Ministry of Healthy Living and Sport. Retrieved January 23, 2022 from https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/public-health/healthy-living-and-healthy-communities/chronic_disease-model_core_program_paper.pdf

Chronic Disease Prevention Alliance of Canada (2018). 2018 pre-budget submission to the House of Commons Standing Committee on Finance. Chronic Disease Prevention Alliance of Canada. Retrieved January 23, 2022 from https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR9073636/br-external/ChronicDiseasePreventionAllianceOfCanada-e.pdf

Flood, C.M, & Thomas, B. (2016). Modernizing the Canada Health Act. Dalhousie Law Journal, 39(2), 398-411. http://charon.athabascau.ca/cnhsgrad/mhst601_w2018/unit2.htm

Fraser Health Authority. (2021). Community Respiratory Services. Fraser Health. Retrieved January 23, 2022 from https://www.fraserhealth.ca/Service-Directory/Services/home-and-community-care/community-respiratory-services