Have you heard of a virus named COVID-19? I bet that as soon as you read that statement your eyes rolled and a subtle sigh was released. Since the end of 2019 we have been inundated with headlines, data and healthcare driven guidance on how to manage our response to, and our permitted actions to minimize the risk of exposure to, COVID-19. In Ontario, and across the globe, the COVID-19 pandemic has led to fundamental changes in our lives and many have experienced tragic consequences, including the loss of loved ones, lost jobs, livelihoods, and reduced social connections and isolations. (Tam, 2020) As Director of Laboratory, Diagnostic Imaging & Quality, COVID-19 has created an approximate additional eight hours of meetings to my weekly work schedule, not including the additional work and process changes required to support our organizations on-going pandemic response. As a father, COVID-19 has resulted in interruptions to my children’s hockey season, intermittently removed their access to playing with their friends in person and led us to choose to have them complete their schooling virtually. As COVID-19 has spread, it has also made its presence known within our local communities. However, the consequences of this virus have not been distributed equally throughout our population (Figure 1) (Tam, 2020). Tam has noted that although the pandemic crosses many spheres of life, from health and well-being to employment and income, we did not all have access to the same resources, leading to different health, social and economic impacts. (Tam, 2020) How can we explain and address this complex health issue in a way that considers many different factors that contribute to an individual and/or communities health and well-being? This post is intended to expand on our discussion of health and review how a multilevel model of health can be applied to address the impact COVID-19 has had on our health and well-being.
Figure 1. National COVID-19 Case Distribution by Health Region. (Tam, 2020)
In 1948 the World Health Organization established the definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (WHO n.d.) We have learned that health is influenced by a wide range of factors, including social determinants of health that affect the conditions in which individuals and communities live, learn, work, and play. (Population and Public Health Division, 2018) Health equity has been defined as “addressing differences in health that are avoidable, unfair and unjust”. (Haldimand Norfolk Health Unit, n.d.) For my community, the Haldimand-Norfolk Health Unit (HNHU) identifies some of the social conditions that impact health equity as: race, gender, income level or sexual orientation. (Haldimand Norfolk Health Unit, n.d.) HNHU also recognizes some of the economic / environmental conditions that impact health as: housing, income, transportation, access to affordable healthy food and employment. (Haldimand Norfolk Health Unit, n.d.) Public Health Ontario (PHO) has stated that the data assessing the impacts of COVID-19 is “painting a grim picture that highlights how this pandemic and its response are exacerbating existing systemic health inequities.” (Public Health Ontario, 2020a)
In May of 2020, relatively early in in our pandemic response, PHO identified three key points related to the COVID-19 impact on our social determinants of health: (Public Health Ontario, 2020b)
Early findings demonstrate an unequal social and economic burden of COVID-19 internationally, with emerging evidence of this relationship from Ontario and Quebec.
Social determinants of health, such as gender, socioeconomic position, race/ethnicity, occupation, Indigeneity, homelessness, and incarceration, play an important role in risk of COVID-19 infection, particularly when they limit ability to maintain physical distancing.
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.
In December of 2020, PHO released an environmental scan document with a focus on addressing health inequities within the COVID- 19 public health response that identified these key findings: (Public Health Ontario, 2020a)
There is wide variation in how health equity action is applied to COVID-19 efforts. This includes the scope of work (e.g. surveillance, testing, recovery), areas of focus (e.g. race, ethnicity, non-specific equity), and responsibility for implementing the work (e.g. led by government, community partnership, task force).
Within government-led and government-supported work, there is no standard approach or framework to embedding equity in COVID-19 efforts.
There are a variety of multilevel models of health that can improve our understanding of complex issues such as the impact COVID-19 has had on our health by explaining the influence of the determinants on the well-being of individuals, communities and populations. (Health, 2015) The Canadian Council on Social Determinants of Health (CCSDH) completed a review of thirty seven frameworks, some of which included: the First Nations Holistic Policy and Planning Model; A Conceptual Framework for the Planning of a Healthy Community; and the Mandala of Health. (Health, 2015) One of the most widely known and used models on the determinants of health that CCSDH reviewed was the Wider Determinants of Health Model (Fig. 2) proposed by Dalhgren & Whitehead in 1991. (Health, 2015) This model illustrates the influence of various factors on individual health including socio-economic, cultural, environmental conditions and lifestyle factors. (Health, 2015) Moreover, this model includes the determinants of health that my local health unit identified, as well as those that PHO has utilized to assess the impact COVID-19 has had on our population. (Public Health Ontario, 2020b)
Figure 2: Wider Determinants of Health Model. (Health, 2015)
Individuals, communities, and populations will experience each of the factors of the Wider Determinants of Health Model differently, putting some at a disadvantage and greater susceptibility to poor health outcomes.” (Population and Public Health Division, 2018) Kirst et al. identified in their study that almost all respondents (98%) felt that everyone in Ontario should have the same opportunity for a long and healthy life, however less than half of the respondents (47%) felt that everyone does have the same opportunity. (Kirst et al., 2017) In considering COVID-19, Wang & Tang have identified that “apart from the immediate health effects for the vulnerable populations, the epidemic will inevitably have long-term socioeconomic impacts on both the people infected and the communities in which they live.” (Wang & Tang, 2020)
Addressing a pandemic cannot be completed by considering the individual, social and community networks, or general socio-economic, cultural and environmental conditions separately. To develop a plan to ensure the health and well-being of all members of our communities and beyond, a multilevel approach is required. Dr. Teresa Tam has summarized the direct and indirect impacts of COVID-19 on Canadians using a conceptual framework based on existing health equity models (Figure 3).(Tam, 2020) As you can see in Figure 3, ensuring the health and well-being of all our friends and families is no small task. The use of a multilevel model of health does assist in identifying and conceptualizing the interrelation of the many determinants of health that impact our health and well-being
Figure 3: Direct and Indirect Consequences of COVID-19. (Tam, 2020)
References Cited:
Halidmand Norfolk Health Unit. (n.d.) Health Equity. Retrieved February 10, 2021 from
Canadian Council on Social Determinants of Health. (2015). A Review of Frameworks on the
Kirst, M., Shankardass, K., Singhal, S., Lofters, A., Muntaner, C., & Quiñonez, C. (2017).
Addressing health inequities in Ontario, Canada: what solutions do the public
support? BMC Public Health, 17(1), 1–9. https://doi.org/10.1186/s12889-016-
3932-x
Population and Public Health Division, M. of H. and L.T. C. (2018). Health Equity Guideline,
2018. Toronto, ON: Queen’s Printer for Ontario., 20.
http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/
docs/protocols_guidelines/Health_Equity_Guideline_2018_en.pdf
Public Health Ontario. (2020a). Addressing health inequities within the COVID-19 public
health response.
https://www.publichealthontario.ca/-/media/documents/ncov/he/2020/
12/covid-19-environmental-scan-addressing-health-inequities.pdf?la=en
Public Health Ontario. (2020b). COVID-19 – What we know so far about … social
determinants of health.
https://www.publichealthontario.ca/-/media/documents/ncov/covid-
wwksf/2020/05/what-we-know-social-determinants-health.pdf?la=en
Tam, D. T. (2020). From Risk to Resilience : AN EQUITY APPROACH. In Public Health
Agency of Canada. https://www.canada.ca/en/public-
health/corporate/publications/chief-public-health-officer-reports-state-public-health-
canada/from-risk-resilience-equity-approach-covid-19.html#shr-pg0
Wang, Z., & Tang, K. (2020). Combating COVID-19: health equity matters. Nature Medicine,
26(4), 458. https://doi.org/10.1038/s41591-020-0823-6
World Health Organization. (n.d.). Frequently asked questions. Retrieved February 5, 2021
NOTE - blog opening image obtained from Tam 2020
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