As my first master’s level course – MHST601: Critical Foundations in Health Disciplines – comes to an end, it is time to reflect on the important concepts realized over the last 13 weeks. MHST601 has been an excellent introduction to understanding health and health systems in Canada. Via my personal research curation and the invaluable insights shared by my peers, I was able to explore the determinants of health and multilevel health models, examining how they tie into chronic diseases, especially within our must vulnerable populations, such as Canada’s Indigenous Peoples. In this final blog post, I will work through each of the topics covered during the course, reflect on my personal learning, and apply it to a specific health related issue: osteoarthritis. Osteoarthritis (OA) is the most common form of arthritis in Canada, affecting 3.9 million (14%) Canadians aged 20 and older in 2016-2017, with 219,000 newly diagnosed during that time (PHAC, 2020). As the most common cause of disability in older adults, OA is a very important issue to address (O’Brien et al., 2020). By examining OA through each of the course concepts, I hope to show where the gaps in Canada’s current health system lie, and why there is an urgent need for change.
Unit 1: Inter Professional Connectedness
We started the course by self-auditing our digital presence, learning about content curation tools, creating our ePortfolio space and discussing the importance of maintaining a professional online presence. In a previous blogpost, I discussed how health professionals often find it very difficult to balance free speech with professional online standards. That said, the ongoing plague of online misinformation campaigns makes it more important than ever that their knowledgeable voices are heard. Their voices can be used to combat the spread of false health claims, such as those assigned to alternative health products. For example, a dietary supplement, Synovia, was marketed with unsupported claims for treating arthritis and joint pain and despite the company being fined, the product continues to be sold with claims such as “support healthy joints and connective tissue!” (FTC Stops Marketers from Making False Arthritis Treatment Claims, 2019; Synovia, n.d.). Health professionals must use their online platforms in an effective manner, ensuring that the information they share is trustworthy and evidence based.
Unit 2: Federal and Provincial Health Systems in Canada
Each provincial and territorial government is responsible for managing their own health care system for which they receive federal funding, provided they meet the 5 criteria and 2 conditions set out by the Canada Health Act, as described below (Government of Canada, 2020):
Unfortunately, this has led to a patchwork of independent health care systems offering little or no consistency in health care delivery (Flood & Thomas, 2016). Canada’s health system is not suited to meet the current or future health needs of an aging Canadian population. In addition, the lack of a national pharmacare program means that an estimated 20% of Canadians do not have the means to access necessary medications (Health Canada, 2020). Patients who live with chronic diseases, such as OA, require medication to manage their disease (Nelson et al., 2014). Without coverage for the cost of pharmaceuticals, the 20% are left to needlessly suffer.
Unit 3: Understanding Health and Determinants of Health
As I discussed in a previous blogpost, the definition of health set out by the WHO in 1948 is generally seen as outdated and in need of an update (Huber, 2011). The main criticisms stem from the fact that the WHO definition is not inclusive and does not account for the fact that it is possible to be healthy while living with a chronic disease – such as OA. The second part of this unit focused on the determinants of health, which are factors beyond the individual or health care system that have the ability to influence our health. They are often routed in government policy rather than individual choices. When it comes to OA, the key determinants of health include income and social status, employment and working conditions, education and literacy, social supports and coping skills, healthy behaviours, gender, and race (Vennu et al., 2020).
Unit 4: Multilevel Approaches to Understanding Health
Multilevel health models allow us to conceptualize the complex interactions at play between a person or population’s health, the determinants of health and the varying levels of influence within society. They enable us to take an upstream approach, examining the bigger picture and incorporating the factors that lead to health related issues. I discussed multi-level health models, and specifically the population health promotion (PHP) model, in a previous blog post (Hamilton & Bhatti, 1996). The PHP model requires us to answer 3 questions when creating action strategies:
When fully completed, the model looks like this:
Here is a brief example of the model in action:
THE ISSUE: Self-management is a key factor in effectively living with OA (Gustafsson et al., 2020). Let’s apply the PHP model to create an action strategy to improve patient access to OA self-management programs.
WHAT?: We need to ensure that OA self-management programs are accessible and inclusive of all populations (Health Services).
HOW? By implementing public health policy that supports and promotes more inclusive and accessible programs (Build Healthy Public Policy) and having appropriate systems in place to ensure that all affected patients are aware of and offered access to these programs (Reorient Health Services).
WHOM? Via government policy (Society) providing support and funding for these programs and hospitals/health centers/physicians (Sector/System) prioritizing and refocusing these health services.
EVIDENCE BASED? This action strategy is supported by research which shows that those who need these programs most – those in lower socio-economic classes – are the least likely to be referred to or belong to OA self-management groups (Reyes & Katz, 2021).
Unit 5: Chronic Disease Prevention and Management
Chronic disease (CD) is a major and ever-growing burden on our healthcare systems. The infographic below highlights CD prevalence and shows that OA affects 14% of adult Canadians (PHAC, 2018):
Due to the structure of Canada’s health care system, management and prevention of chronic disease varies between cities and even health zones. In Alberta, the Auditor General found that CD management and care is fragmented and inconsistent, with no party assigned responsibility and no defined care expectations for physicians to follow (Auditor General of Alberta, 2014). A 2020 follow up report shows that the majority of the 2014 recommendations have yet to be implemented (Auditor General of Alberta, 2020).
OA management and prevention includes patient education, exercise programs and weight-loss programs (Bannuru et al., 2019). Although there is considerable educational information online – both for physicians and patients – there is no data to indicate whether patients with OA are being appropriately cared for. Albertans are left with no way of knowing how well the system is performing, and no benchmarks for future improvements.
Unit 6: Vulnerable Populations
Vulnerable populations are groups at an increased risk of poor health outcomes due to factors outside their control, including socioeconomic disadvantages and lack of resources (NCCDH, n.d.). Canada’s Indigenous Peoples have poorer health outcomes as a direct result of colonization and the inherently racist policies enacted by the Canadian government (Truth and Reconciliation Commission of Canada, 2015). Research shows that they are disproportionately affected by chronic diseases – including OA (O’Brien et al., 2020). In Alberta, the prevalence of OA in First Nations people is double that of other Canadians (Barnabe et al., 2015). People in lower socioeconomic groups are at a higher risk of developing OA, and our Indigenous communities face many barriers in this regard in comparison to the rest of Canada including lower income and inadequate housing (Richmond & Cook, 2016). These groups are less likely to receive OA management education from their physician or join self-education programs and receive less exercise/physical therapy (Reyes & Katz, 2021). In addition, they are less likely to be referred to OA self-management programs (Gustafsson et al., 2020). This clearly illustrates that essential services and programs are not reaching our most vulnerable members of society.
If we want to improve Indigenous health outcomes in OA, physicians must be taught to respect and recognize cultural aspects that are important to our Indigenous Peoples (Arthritis Care in Indigenous Communities, 2017). We need to involve Indigenous communities in their care and work towards community-led initiatives rather than imposing Western medical practices on them (Richmond & Cook, 2016).
Unit 7: Future Health Directions
In a TEDx Talk, Dr. Luigi Boccuto (2017) explains how personalized medicine must look at groups of genetic factors that may lead to disease in the context of environmental factors.
I believe that if precision medicine is to have a major impact on the future of healthcare, it needs to follow the concept the CDC has labeled ‘precision health’. This concept looks at an individual’s “genes, behaviour (such as exercise and eating habits), and environment” to tailor treatments to the individual (CDC, n.d.). In this way, the genomic component of precision medicine is incorporated into a broader health movement which addresses the factors affecting the patient as an individual – their determinants of health.
OA does not present itself in the same way in all patients, therefore, precision medicine is being explored as a path forward (Karsdal et al., 2014). By defining subsets of patients with OA, physicians would be able to consider the specifics of the individual patient – including their unique determinants of health – to create personalized treatment options (Grässel & Muschter, 2020).
CONCLUDING THOUGHTS
OA prevalence is increasing which makes it a major concern for Canadians and our health care system (Sayre et al., 2020). Working through each of the course topics through the lens of OA truly sheds a light on the urgent need for change. If our goal is to improve health and health outcomes, our health care system needs to focus on disease prevention by addressing upstream health determinants and the socioeconomic inequities adversely affecting the health of Canadians – especially our vulnerable populations. MHST601 has provided me with an excellent foundation in Canadian health and a new set of skills which will allow me to successfully continue in my professional growth and my future studies in health care.
References Cited:
Auditor General of Alberta. (2014, September). Health—Report on Chronic Disease Management. https://www.oag.ab.ca/reports/oag-health-report-chronic-disease-management-sept-2014/
Auditor General of Alberta. (2020, December 9). Alberta Health. Office of the Auditor General, Alberta. https://www.oag.ab.ca/reports/oag-health-fs-nov-2020-2/
Arthritis care in Indigenous Communities. (2017, March 1). News. https://www.ucalgary.ca/news/arthritis-care-indigenous-communities
Barnabe, C., Hemmelgarn, B., Jones, C. A., Peschken, C. A., Voaklander, D., Joseph, L., Bernatsky, S., Esdaile, J. M., & Marshall, D. A. (2015). Imbalance of Prevalence and Specialty Care for Osteoarthritis for First Nations People in Alberta, Canada. The Journal of Rheumatology, 42(2), 323–328. https://doi.org/10.3899/jrheum.140551
Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., Kraus, V. B., Lohmander, L. S., Abbott, J. H., Bhandari, M., Blanco, F. J., Espinosa, R., Haugen, I. K., Lin, J., Mandl, L. A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T.,... McAlindon, T. E. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578–1589. https://doi.org/10.1016/j.joca.2019.06.011
CDC. (n.d.). Precision health: Improving health for each of us and all of us. Center for Disease Control and Prevention. Retrieved April 2, 2021, from https://www.cdc.gov/genomics/about/precision_med.htm
Flood, C. M., & Thomas, B. (2016). Modernizing the Canada Health Act (SSRN Scholarly Paper ID 2907029). Social Science Research Network. https://papers.ssrn.com/abstract=2907029
FTC Stops Marketers from Making False Arthritis Treatment Claims. (2019, December 5). Federal Trade Commission. https://www.ftc.gov/news-events/press-releases/2019/12/ftc-stops-marketers-making-false-arthritis-treatment-claims
Government of Canada. (2020). Canada Health Act.
Grässel, S., & Muschter, D. (2020). Recent advances in the treatment of osteoarthritis. F1000Research, 9. https://doi.org/10.12688/f1000research.22115.1
Gustafsson, K., Kvist, J., Eriksson, M., Dahlberg, L. E., & Rolfson, O. (2020). Socioeconomic status of patients in a Swedish national self-management program for osteoarthritis compared with the general population—A descriptive observational study. BMC Musculoskeletal Disorders, 21(1), 10. https://doi.org/10.1186/s12891-019-3016-z
Hamilton, N., & Bhatti, T. (1996, February). Population Health Promotion: An Integrated Model of Population Health and Health Promotion. Retrieved from: https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-promotion-integrated-model-population-health-health-promotion.html
Health Canada. (2020, July 20). A Prescription for Canada: Achieving Pharmacare for All - Final Report of the Advisory Council on the Implementation of National Pharmacare. https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/implementation-national-pharmacare/final-report.html#9
Huber, M. (2011). HEALTH: HOW SHOULD WE DEFINE IT? BMJ: British Medical Journal, 343(7817), 235–237. https://www.jstor.org/stable/23051314
Karsdal, M. A., Christiansen, C., Ladel, C., Henriksen, K., Kraus, V. B., & Bay-Jensen, A. C. (2014). Osteoarthritis--a case for personalized health care? Osteoarthritis and Cartilage, 22(1), 7–16. https://doi.org/10.1016/j.joca.2013.10.018
NCCDH. (n.d.). Vulnerable populations. National Collaborating Center for Determinants of Health. Retrieved April 5, 2021, from https://nccdh.ca/glossary/entry/vulnerable-populations#:%7E:text=Vulnerable%20populations%20are%20groups%20and,due%20to%20illness%20or%20disability
Nelson, A. E., Allen, K. D., Golightly, Y. M., Goode, A. P., & Jordan, J. M. (2014). A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Seminars in Arthritis and Rheumatism, 43(6), 701–712. https://doi.org/10.1016/j.semarthrit.2013.11.012
O’Brien, P., Bunzli, S., Lin, I., Gunatillake, T., Bessarab, D., Coffin, J., Garvey, G., Dowsey, M., & Choong, P. (2020). Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities—A Call to Action. Journal of Clinical Medicine, 9(8), 2393. https://doi.org/10.3390/jcm9082393
PHAC. (2018). Prevalence of chronic diseases among Canadian adults. Public Health Agency of Canada. http://publications.gc.ca/collections/collection_2018/aspc-phac/HP35-107-2018-eng.pdf
PHAC. (2020, September). Osteoarthritis in Canada. Public Health Agency of Canada. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/osteoarthritis/osteoarthritis-factsheet.pdf
Reyes, A. M., & Katz, J. N. (2021). Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management. Rheumatic Disease Clinics of North America, 47(1), 21–40. https://doi.org/10.1016/j.rdc.2020.09.006
Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian aboriginal health equity: the promise of healthy public policy. Public Health Reviews, 37(1), 2. https://doi.org/10.1186/s40985-016-0016-5
Sayre, E. C., Esdaile, J. M., Kopec, J. A., Singer, J., Wong, H., Thorne, A., Guermazi, A., Nicolaou, S., & Cibere, J. (2020). Specific manifestations of knee osteoarthritis predict depression and anxiety years in the future: Vancouver Longitudinal Study of Early Knee Osteoarthritis. BMC Musculoskeletal Disorders, 21(1), 467. https://doi.org/10.1186/s12891-020-03496-8
Synovia. (n.d.). AS Research. Retrieved April 3, 2021, from https://asresearchlabs.com/products/synovia
TEDx Talks. (2017, June 8). Personalized Medicine: A New Approach | Luigi Boccuto | TEDxGreenville. https://www.youtube.com/watch?v=J2ITkfzp0SY
Truth and Reconciliation Commission of Canada. (2015). Truth and Reconciliation Commission of Canada: Calls to Action. http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf
Vennu, V., Abdulrahman, T. A., Alenazi, A. M., & Bindawas, S. M. (2020). Associations between social determinants and the presence of chronic diseases: data from the osteoarthritis Initiative. BMC Public Health, 20(1), 1323. https://doi.org/10.1186/s12889-020-09451-5
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