INTRODUCTION
“Best care, every person, every time” – these words are not just my organization’s vision statement, but they represent why I want to work in health care (HWMH, 2021). I am pursuing the Master of Health Studies to improve my knowledge of health to support my ability to meet this vision everyday. COVID-19 is a virus that has presented challenges that have impacted us as individuals, as families, as communities and as a country. As Director of Laboratory, Diagnostic Imaging and Quality, it is my role, even during a pandemic, to provide an environment that is safe, inclusive and supports the needs of our patients, their families, and our clinical partners, regardless of their background or status within our community. This final blog post will use COVID-19 to summarize my learnings from MHST601.
WHAT IS HEALTH
I believe that each of us possess a unique perspective on what health is. We learned that the World Health Organization definition of health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO n.d.). A definition of health that resonates with me states that “health is an environment of mental, emotional, physical and spiritual balance that leads to a life with positive energy, peacefulness and harmony with the community, nature and oneself and is achieved through good nutrition, sharing, self-will and faith” (Bautista-Valarezo et al., 2020). Being able to run and play with my kids brings joy and happiness to my life at both a physical and emotional level. When I hear my family or friends laugh during a virtual game night, I am filled with a warmth that I would describe as emotional and spiritual health. In Ontario, and across the globe, the COVID-19 pandemic has led to fundamental changes in our health and many have experienced tragic consequences, including the loss of loved ones, lost jobs, livelihoods, and reduced social connections and isolations (Tam, 2020).
UNDERSTANDING HEALTH AND DETERMINANTS OF HEALTH
Building on the definition of health, we identified that everyone does not have equal access to health services. Kirst el al. identified that health inequities are differences in health between specific population groups that are systematic, avoidable, unfair and unjust (Kirst et al., 2017). Some of the key elements that impact the health of Canadians, as described by Raphael et al., are not medical treatments or lifestyle choices but rather the living and working conditions they experience, also known as social determinants of health (SDOH) (Raphael et al., 2020). My local health unit has identified some of the SDOH as: race, gender, income level, sexual orientation, housing and access to affordable healthy food (Haldimand Norfolk Health Unit, n.d.). Considering COVID-19, it is not impacting Canadians equally as we did not all have access to the same resources and choices during the pandemic, leading to different health, social and economic impacts (Tam, 2020). SDOH have played an important role in risk of COVID-19 infection, particularly when they limit ability to maintain physical distancing (Public Health Ontario, 2020b). Existing social inequities in health increase risk of severe COVID-19 outcomes through increased prevalence of underlying medical conditions and/or decreased access to health care (Public Health Ontario, 2020b). A health equity model was utilized Dr. Teresa Tam to identify the direct and indirect impacts of COVID-19 on Canadians, which is an excellent visual of the need to consider the SDOH when planning a response to a healthcare issue (Figure 1) (Tam, 2020). As a healthcare leader, building a better understanding of SDOH will ensure health inequities are considered when planning and improving the services we provide.
Figure 1: Direct and Indirect Consequences of COVID-19 (Tam, 2020).
MULTILEVEL APPROACHES TO UNDERSTANDING HEALTH – BEYOND THE INDIVIDUAL
Multilevel approaches to understanding health are the most effective preventive methods to control the spread of diseases and conditions when compared to models that focus solely on individual level characteristics (Nyambe et al., 2016). Reviewing the Wider Determinants of Health Model (Figure 2) I learned that individuals, communities, and populations will experience each of the factors differently, putting some at a disadvantage and greater susceptibility to poor health outcomes (Figure 2) (Population and Public Health Division, 2018). Vaccination and screening testing are examples of measures to support individual and general levels of health that are recommended for controlling the spread of diseases and conditions (Nyambe et al., 2016). At the individual level, 98% of hospitalized patients who died in hospital had one or more underlying medical condition (Tam, 2020). At the community level, Ontario neighbourhoods with the highest ‘ethnic diversity’ rates had higher hospitalization rates (4x higher), higher intensive care unit admission rates (4x higher), and higher death rates (2x higher) (Public Health Ontario, 2020a). At the general socio-economic level, our work environment puts us at different levels of risk for exposure to COVID-19. In Canada, approximately 19% of cases of COVID-19 are healthcare workers and healthcare workers represent at least 27 known deaths (Tam, 2020). To ensure we do our best to minimize the health inequities during the remainder of our COVID-19 response, Tam has also prepared a multilevel framework for our path moving forward (Figure 3) (Tam, 2020). As Rangel et al. have stated, it is reassuring that governments are embracing a ‘whole-of-society, whole-of-government’ approach to address a complex problem such as COVID-19 (Rangel et al., 2020).
Figure 2: Wider Determinants of Health Model (Health, 2015).
Figure 3: A Health Equity Approach to COVID-19 (Tam, 2020).
CHRONIC DISEASE PREVENTION AND MANAGEMENT
We reviewed chronic disease prevention and management and identified that Canada, like other developed and developing countries, is facing an epidemic of chronic disease (Health Canada, 2007). Public Health Ontario states that chronic diseases are the leading cause of death and disability in Ontario (PHO, 2021). Interprovincial comparisons identified that chronic disease prevention and management are emphasized to different degrees within provincial / territorial health systems (Health Canada, 2007). The three chronic diseases that my teams support through the provision of diagnostic results, are COPD, cancer and diabetes. The primary determinants of chronic disease in my community include leisure-time physical activity; smoking status; vegetable and fruit consumption and intentional self-harm (HNHU, n.d.). Figure 4 identifies how these primary determinants contribute to disease (PHO, 2012). Due to service interruptions and redeployment of personnel to support urgent care for COVID-19 patients, a negative outcome of the pandemic response has been inadequate ongoing care for chronic conditions (Kendzerska et al., 2021). Moreover, 86% of hospitalized COVID-19 cases had at least one underlying health condition, such as vascular illness including hypertension (64%), cardiac illness (32%), and diabetes (30%) (Tam, 2020).
Figure 4: Social Determinants of Health (PHO, 2012).
VULNERABLE POPULATIONS
Vulnerable populations were discussed through an interprovincial comparison, that for me focused on those living with mental health and addictions issues. More than one million Ontarians experience a mental health or addiction issue every year, with 500,000 Canadians per week calling in sick because of mental health and addictions issues (Ministry of Health, 2020). Mental health and addictions have a burden in Ontario that is more than 1.5 times that of all cancers and more than seven times that of all infectious diseases (Ratnasingham et. al, 2012). The COVID-19 pandemic has not improved the health conditions for those living with mental health and addictions issues (CMHA, 2021):
36 per cent of Ontarians say they’re experiencing very high or high stress (up from 30 per cent in the summer)
35 per cent are feeling very high or high anxiety (up from 30 per cent in the summer)
More than one quarter of Ontarians (27 per cent) are using more substances to cope (up from 21 per cent in the summer)
Nearly eight in ten Ontarians (79 per cent) can see how COVID-19 is negatively impacting the mental health of others
Although I was aware of vulnerable populations, I have realized I have more to learn about the difficulties these patients and their families have when trying to navigate our healthcare system. I will learn more about the barriers that our vulnerable populations deal with on a daily basis, so that I can improve our processes to support them better.
FUTURE DIRECTIONS
As healthcare leaders, we need to appreciate that the services we provide today, may not be adequate for tomorrow. One future direction that I see emerging is the use of virtual care and telemental health. As Madigan et al. have identified COVID-19 and its associated physical-distancing requirements have served as a catalyst for the rapid uptake and implementation of telemental health (Madigan et al., 2020). Virtual care visits increased from approximately 350 per month to almost 3,000, an increase of over 850%, from March to April 2020 at the Centre for Addictions and Mental Health (Gratzer et al., 2021). Some of the benefits of this approach include increased reach and accessibility for those in rural areas and cost savings due to reduced travel (Madigan et al., 2020). We do need to be aware of the downfalls of virtual care as it can discriminate against those without accessibility to the Internet and capability to navigate online platforms (Madigan et al., 2020).
CONCLUSION
Since the start of the COVID-19 pandemic my role as Director of Laboratory, Diagnostic Imaging and Quality has been an exciting and exhausting roller coaster ride. Between the frequent provincial guidance changes, subsequent operational changes, and the persistent fear that a team member or their family will be impacted by COVID-19, I have taken on many tasks and responsibilities I would have never imagined. Initiating my pursuit of a Master of Health Studies during a pandemic has been a difficult yet rewarding experience. Completing the learnings and discussions has widened my perspective on what health and health care truly is. It is not just the completion of a laboratory result or x-ray report but the provision of an environment and services that are available for all our community members (patients, their families and designated care partners) when they need us. I look forward to my educational and leadership journey ahead as I continue to build upon the foundation that has been established in MHST601.
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