In 2016, 44% of Canadian adults (20+) had at least one chronic condition (Government of Canada, 2019). Increasingly, Canadians report multimorbidity, with this statistic expected to rise with population age (Roberts et al., 2015; Wang & Wang, 2021). These conditions account for increasingly high levels of health care spending and preventable death (Government of Canada, 2019, Mirolla, 2004; Wang & Wang, 2021). In the wake of technology that allows Canadians to live longer while managing multiple chronic conditions (Branchard et al., 2018), and as both incidence of and spending on chronic disease continues to increase year-over-year (Wang & Wang, 2021), it is evident that a significant shift in approach to prevention and management is required.
In the following blog I reflect on concepts and lessons learned this semester as they relate to chronic disease prevention and management and the improvement of health and health care in Canada.
Determinants of chronic disease:
In Canada and globally, an adherence to a biomedical understanding of and approach to health tends to perpetuate the blame for chronic conditions on the individual; citing lifestyle factors, health risk behaviours, and the need for personal modification (Allen et al., 2020; Egger & Dixon,2014). This however ignores the role of less and unmodifiable factors that influence health acutely and over time. These social determinants of health (SDoH), the non-medical factors including “the conditions in which people are born, grow, work, live, and age…” (World Health Organization [WHO], n.d.) can heavily impact the experience of chronic disease for the country’s most vulnerable. As result of these numerous, often compounding factors (including race, indigeneity, income, education, housing, employment/job security) vulnerable groups regularly experience barriers to care and the inability to effectively prevent and manage health challenges. Some examples as they relate to chronic disease include an inability to afford recommended medications and proper nutrition, lesser health literacy and insight into one’s condition(s), the inability to attend necessary appointments due to part-time or precarious work, and failure to seek supportive or preventative care due to systemic, structural, and epistemic racism which promotes othering of certain groups and degrades actual or perceived quality of care available.
The importance of multilevel models of health:
Moving forward, to mitigate the impact of chronic disease, we must heed the call for expanded interventions and reformed approaches to care. Beyond acute care and individual behaviour modification, it is time to address SDoH, take action within and beyond the health system to collaboratively address multiple levels of influence on individual, community, and population wellbeing, and invest in prevention to ensure the sustainability of the health system and improve individual mortality over time (Government of Canada, n.d.; Hutchinson & Lauckner, 2020; Mirolla, 2004; Wang & Wang, 2021). A critical (and daunting) first step will be to create a systems shift towards an understanding of, appreciation for, and implementation of multilevel models of health (Hutchinson & Lauckner, 2020). Multilevel models aim to understand and address the layered factors impacting the achievement of optimal health. These models exact change within and across levels of influence simultaneously, rather than singularly in one area [read: individual behaviour]. Multilevel models leverage the resources and action of individuals, communities, organizations, institutions, government and other influential sectors in effort to create awareness, shared responsibility, and sustained system change.
In recognition of the continued disadvantage faced by vulnerable groups, especially as it relates to the experience of chronic disease, the Canadian government has taken the positive step of publicly endorsing the need for a multileveled approach; releasing a framework for health promotion, which aims to facilitate individual and community empowerment towards greater (feelings of) control over factors affecting health (Barr et al., 2003; Government of Canada, n.d.).
Utilizing the tenets of health promotion in its design, one example of a multilevel model, the Expanded Chronic Care Mode (ECCM), will be useful in the continued effort to address chronic disease.
The Expanded Chronic Care Model (ECCM):
The ECCM, seeks to improve the quality of life of those with chronic conditions through strengthening relationships between patient, health providers, and broader community systems of support; building capacity of these to more fluidly collaborate, participate, and advocate towards the shared goal of health optimization (Ahmed et al., 2015; Hutchinson & Lauckner, 2020). The ECCM recognizes that consistent connection to supports fosters feelings of inclusion and patient purpose and can result in a greater likelihood of (behaviour) change that is sustained over time (Hutchinson & Lauckner, 2020; Roberts et al., 2015). Health, rather than illness, underpins work (Barr et al., 2003) . The ECCM recognizes that chronic disease prevention and management requires more than individual behaviour modification and suggests improvements across seven (7) key areas to transform the health system, improve access to services, and foster social connection, while simultaneously addressing the persistent inequities that impact health outcomes (Barr et al., 2003; Hutchinson & Lauckner, 2020).
Components of the ECCM and suggested action to be taken towards improved chronic disease management and prevention can be seen in the table below:
Success of the ECCM as it relates to improved management and prevention of chronic disease will rely on the involvement of and collaboration between influential actors from multiple sectors to ensure interventions and opportunities for proper management and prevention are accessible, consistent, (culturally) appropriate, and in keeping with best practices (Hutchinson & Lauckner, 2020). Health, education, government and media (among others) all have important roles to play in reframing chronic disease as a population-level crisis rather than individual health concern (Hutchinson & Lauckner, 2020), and reshaping attitudes and behaviours of individuals and communities in ways that are health promoting, socially inclusive, and future-focused. An exploration of the roles and responsibilities of each of these sectors is sadly beyond the word count of this post but will remain top of mind as I move forward in my education and leadership journey.
Indigenous considerations in chronic disease prevention and management:
In Canada, it is important to note that Indigenous populations have and continue to be disproportionately affected by chronic disease due to colonial structures put in place through the Indian Act. These structures continue to shape the modern treatment of Indigenous health (Earle, 2011; Richmond & Cook, 2016). Notably, approaches to care continue to demonstrate notions of Western superiority, as well as influences of structural discrimination (Richmond & Cook, 2016; Taylor et al., 2020; Truth and Reconciliation Commission of Canada [TRC], 2015). Western approaches tend to ignore the importance of holistic views of health that are important to Indigenous ways of knowing and being, as well as the impact of intergenerational trauma, importance of intergenerational knowledge transmission, role of elders and knowledge keepers, and importance of the institutions of family and community (Allen et al., 2020; Earle, 2011).
To improve approach to and outcomes of chronic disease prevention and management in Indigenous populations practitioners and system leaders must look to the TRC Calls to Action (2015) specifically as they relate to health and the needs of the system to do better. Of note, the TRC calls on those who can effect change in the health system to recognize and promote the value of Aboriginal healing practices and use these in the treatment of Aboriginal patients (Taylor et al., 2020; TRC, 2015). More importantly, the government and health system need to increase the number of Indigenous professionals in health fields, and work in collaboration with these persons to provide consistent, holistic, and culturally safe care (Allen et al., 2020; Earle, 2011; TRC, 2015). In achieving this, cultural competence training for all health professionals will be invaluable, including the consistent inclusion of approaches to Aboriginal health as a necessary component in health education (Allen et al., 2020; TRC, 2015). Colonial health practitioners should commit to regular self-reflection and examination of personal bias and engage in practice from a lens of cultural humility (Allen et al., 2020).
Finally, where possible, priority should be given to Indigenous designed and led health partnerships to address chronic disease. These partnerships are grounded in Indigenous knowledge with the view that “culture is cure” (Allen et al., 2020, p.209). Such partnerships address the bias and rigid systems of power present in Western medicine, and improve access to and sustained use of care, thereby improving chronic disease outcomes and the likelihood of prevention (Allen et al., 2020; Earle, 2011; Taylor et al., 2020). Where initiatives are not Indigenous led, it is important that practitioners and the health system as a whole value equally Indigenous perspectives on multidisciplinary teams (Taylor et al., 2020).
Importance of interprofessional collaboration:
In redefining approach to chronic disease prevention and management, an element that cannot be overlooked is the importance of interprofessional collaboration (IPC). IPC, the integrated practice of two or more (health) disciplines, seeks to improve patient experience and health outcomes through its use of consistency, shared goals, and ability to simultaneously investigate and address the interaction and impact of multiple health determinants (Green & Johnson, 2015; Grymonpre et al., 2021; WHO, 2010). IPC evokes patient-centeredness in practice in turn increasing acceptance of care for chronic conditions and adherence to interventions, including condition self-management (WHO, 2010). Through the involvement of multiple professions, there exist opportunity for the development of innovative solutions to complex problems, as well as opportunity to creatively address health human resource challenges without compromising consistency of patient care (Green & Johnson, 2015).
The profession of social work can play a particularly important role as it relates to IPC and its use in chronic disease prevention and management. The skills of interviewing and counselling, innate to the social work profession, are of great importance when examining and determining needs of individual patients and investigating barriers to care (Ahmed et al., 2015). Additionally, social workers are by nature case managers, important in the establishment of links to and coordination of services, evaluation of progress and evolving needs, and provision of ongoing self-management support (Ahmed et al., 2015).
To date, Canada has been a leader in IPC, but there exists much still to be done to embrace its benefits most fully as they relate to improved prevention and management of chronic disease (Grymonpre et al., 2021). Reorientation to IPC will ultimately require a restructuring of the health system and rethinking of chronic disease as a population health issue rather than current individual focus and treatment of conditions case-by-case (Ahmed et al., 2015; Wang & Wang, 2021).
Conclusions:
As a health professional and aspiring leader it has been with great interest that I have learned and reflected this semester on the many benefits and challenges present in our health systems, and more specifically, how little change in these has been seen over time. As a social work professional, I gravitate towards a social approach to care, and so to me, solutions seem obvious. However, moving rhetoric to action will take much more than one student’s awareness. In the prevention and management of chronic disease the time is now (if not yesterday) to advocate for a cultural shift towards collaborative, intersectoral, interprofessional, and health promoting care that acknowledges the impact of social determinants on individual and population outcomes and views chronic disease (and health more broadly) as beyond individual control (Ahmed et al., 2015). Through increased accountability at all levels (individual, community, institution, and government) we risk only to create a system in which health is viewed as both a resource and capacity, responsibility for health outcomes is shared, and barriers to access are reduced and eliminated.
“Thriving people result in healthy communities and a better society” (Ontario Association of Social Workers, 2020).
References
Allen, L., Hatala, A., Ijaz, S., Courchene, E., & Bushie, E. (2020). Indigenous-led health care partnerships in Canada. Canadian Medical Association Journal, 192(9), E208–E216. https://doi.org/10.1503/cmaj.190728
Barr, V., Robinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., & Salivaras, S. (2003). The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Healthcare Quarterly, 7(1), 73–82. https://doi.org/10.12927/hcq.2003.16763
Branchard, B., Deb-Rinker, P., Dubois, A., Lapointe, P., O'Donnell, S., Pelletier, L., & Williams, G. (2018). At-a-glance - how healthy are Canadians? A brief update. Health Promotion and Chronic Disease Prevention in Canada, 38(10), 385–390. https://doi.org/10.24095/hpcdp.38.10.05
Earle, L. (2011). Understanding chronic disease and the role for traditional approaches in Aboriginal communities. National Collaborating Centre for Aboriginal Health. https://www.nccih.ca/495/Understanding_chronic_disease_and_the_role_for_traditional_approaches_in_Aboriginal_communities_.nccih?id=45
Egger, G., & Dixon, J. (2014). Beyond obesity and lifestyle: A review of 21st century chronic disease determinants. BioMed Research International, 2014, 1–12. https://doi.org/10.1155/2014/731685
Government of Canada. (n.d.). Achieving health for all: A framework for health promotion. https://www.canada.ca/en/health-canada/services/health-care-system/reports- publications/health-care-system/achieving-health-framework-health-promotion.html
Government of Canada. (2019). Prevalence of chronic disease among Canadian adults [Infographic]. https://www.canada.ca/en/public-health/services/chronic- diseases/prevalence-canadian-adults-infographic-2019.html
Government of Ontario (CCO and Public Health Ontario), (2019, July). The burden of chronic diseases in Ontario: Key estimates to support efforts in prevention [Report]. https://www.publichealthontario.ca/-/media/Documents/C/2019/cdburden-report.pdf? sc_lang=en
Green, B. N., & Johnson, C. D. (2015). Interprofessional collaboration in research, education, and clinical practice: Working together for a better future. Journal of Chiropractic Education, 29(1), 1–10. https://doi.org/10.7899/jce-14-36
Grymonpre, R. E., Bainbridge, L., Nasmith, L., & Baker, C. (2021). Development of accreditation standards for interprofessional education: A Canadian case study. Human Resources for Health, 19(1). https://doi.org/10.1186/s12960-020-00551-2
Hutchinson, S. L., & Lauckner, H. (2020). Recreation and collaboration within the expanded chronic care model: Working towards social transformation. Health Promotion International, 35(6), 1531–1542. https://doi.org/10.1093/heapro/daz134
Mirolla, M. (2004). The cost of chronic disease in Canada [Report]. The Chronic Disease Prevention Alliance of Canada. http://gpiatlantic.org/pdf/health/chroniccanada
Ontario Association of Social Workers (2020, April). OASW submission on Ontario’s new poverty reduction strategy. https://www.oasw.org/Public/Collective_Action/Consultations___Statements/Public/Advocacy_and_Research/Consultations___Statements.aspx?hkey=87b719c6-0252-4507-a762-171f9d7f5b97&msclkid=379ef4c7b04911eca41ee6c3beb9fdd5
Richmond, C. M., & Cook, C. (2016). Creating conditions for Canadian Aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(1). https://doi.org/10.1186/s40985-016-0016-5
Roberts, K. C., Rao, D. P., Bennett, T. L., Loukine, L., & Jayaraman, G. C. (2015). Prevalence and patterns of chronic disease multimorbidity and associated determinants in canada. Health Promotion and Chronic Disease Prevention in Canada, 35(6), 87–94. https://doi.org/10.24095/hpcdp.35.6.01
Truth and Reconciliation Commission of Canada (2015). Truth and Reconciliation Commission of Canada: Calls to action. National Centre for Truth and Reconciliation. http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf
Wang, F., & Wang, J.-D. (2021). Investing preventive care and economic development in ageing societies: Empirical evidences from OECD countries. Health Economics Review, 11(1). https://doi.org/10.1186/s13561-021-00321-3
World Health Organization (2010). Framework for action on interprofessional education & collaborative practice. https://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf?sequence=1&msclkid=a12c6250ab8611eca239aed3bfbe9e16
World Health Organization (n.d.). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
Kommentare