Social Ecological Model of Health and Respiratory Disease in Nova Scotia Compared with Ontario
Over 3 million Canadians of all ages have a serious respiratory disease such as asthma, COPD, Lung Cancer, Cystic fibrosis, TB and Respiratory Distress syndrome. Currently Respiratory Diseases are the third highest cause of hospitalizations and deaths in Canada. Smoking is the main preventative cause of chronic respiratory diseases. However, the proportion of smokers has dropped in Canada over the last decade and despite there remains an increase in chronic respiratory disease. As a report by Health Canada (2007) explains, "since many of these diseases affect adults over the age of 65, the number of people with respiratory diseases will increase as the population ages. The corresponding increase in demand for services will pose a significant challenge for the health care system.”
Facts about Respiratory Disease in Nova Scotia the report, “Mortality due to Respiratory Disease” published by the CONFERENCE Board of Canada (2015):
Nova Scotia has one of the highest provincial mortality rates due to respiratory diseases.
6.3% of Nova Scotian’s are living with COPD
In a report by the Canadian Lung Association (2015), the four Atlantic provinces received poor and failing grades in COPD Care
Risk factors for respiratory disease include tobacco consumption and exposure to second-hand smoke, poor living conditions, and poor diet.
Smoking rates in the Atlantic Provinces are considerably higher than the Canadian average of 14.9 per cent between 2011 and 2013. In fact, on average, more than 17 per cent of the population aged 12 and over smoked daily between 2011 and 2013.
Residents of these four provinces are more exposed to second-hand smoke.5
Living conditions are also likely worse for a greater share of the population in these provinces
The population aged 18 to 64 earning low incomes in Newfoundland and Labrador, Nova Scotia, and New Brunswick is greater than the Canadian average of 14.4 per cent.
Facts about Respiratory Disease in Ontario from a “COPD in Ontario: Health, Care and Costs” by the Canadian Foundation for Healthcare Improvement (2015):
Approximately 4.3% to 12% of Ontarians are living with COPD and 1 in 4 over the age of 35 will develop the disease
According to Statistics Canada, the 5th leading cause of death in Ontario is COPD
While 18.9% of Ontarians are smokers, 80-90% of COPD cases are associated with smoking as an underlying cause
It is estimated in Ontario that the cost of acute inpatient COPD admissions is $191.4 million per year
In Ontario, 13% of physicians admit to discriminating against smokers in terms of quality of care and 14% of patients report that their quality of healthcare diminished because they are, or were, smokers
Recognizing the burden respiratory disease will have on resources and costs to the health care systems of both provinces, it may be beneficial to examine the issue through a different health model. The Social Ecological Model (SEM) is one that is used for prevention and health promotion. It is a method of using upstream thinking to improve health of a population. It is based on five influences and how each overlap in continuing circles; Individual, Interpersonal, Community, Organizational, and Policy. It is a multilevel system that demonstrates how each level has a role and that at any given point one level can influence what is happening at a different level. It is a good method for identifying gaps that exist between policy making and primary care. The Figure below demonstrates what each level/circle represents and how they overlap with each other.
The table below lists the 5 influences of the SEM model and some of the factors that determine how each level is represented in Nova Scotia.
SEM Level
Individual
Nova Scotia
- Knowledge
- Attitudes
- Behaviors
- High % of smoking
- High proportion of low income population
- Rural living
- Aging population
- Lack of knowledge of early recognition diagnosis and flare ups
- Food security
- Lack of affordable housing
- High obesity rates
- Sedentary lifestyles due to physical limitations
- Increased depression, anxiety and fatigue
Ontario
- Moderate % of smoking
- Aging population
- Rural and urban living
- Industrial and agricultural employers
- Lack of affordable housing
- Lack of knowledge for proper medication administration, early exacerbations
- Low obesity rates (compared to other provinces)
Interpersonal
Nova Scotia
- Formal and informal social networks
- Support systems
- Family support not always available for aging population
- Limited access to family MD/primary care, public health clinics, home support workers, (emphasizes need for collaborative clinics)
- Lack of communication between health professions (MD, RN, RT, SW, PT, OT)
Ontario
- Often have to reduce hours at work (or stop working) which results in smaller social networks
- Limited number of family MD/primary care
- Lack of provincial charting system to share and communicate between institutions, physicians and health professions
- Lack of sufficient outpatient support programs (especially in the northern regions of the province and the highly dense areas around Toronto and Ottawa)
Community
Nova Scotia
- Relationships among organizations
- Community Programs such as active lifestyle clubs
- Employer support programs
- Regional Programs including Home support, home oxygen, supplies support
- Research programs
- Home Oxygen Program
- Media
- Transportation available in rural communities, accessible communities
- Affordable food in small communities
Ontario
- COPD Action Plans
- Fitness for Breath programs
- BreathWorks (Lung Association)
- Employer support programs
- Home Oxygen program
- Ventilator Equipment Pool (shared equipment resources)
- Assistive Devices Program (ADP)
- Community Care Access Centers
- WheelTrans in urban areas
Organizational
Nova Scotia
- Organizations with rules and regulations
- Public Health Plan (MSI)
- Private Health Insurance
- Pharmaceutical Drug Plan (Pharmacare)
- NSHA,
- Community Health Boards,
- Nova Scotia Lung Association,
- INSPIRE Program,
- NSCRT,
- Collaborative Health Clinics,
- Public Health Programs such as the provincial health eating strategy
- No official provincial programs targeting Respiratory Disease,
- Other provincial supports such as Home Oxygen Program, Pulmonary Rehabilitation Program
Ontario
- Ontario Health Insurance Plan (OHIP)
- Private health insurance
- Ontario drug programs
- Ontario Lung Association
- Adaptation of INSPIRE at select locations
- Smoking cessation programs
- Public Health programs
Policy/Enabling Environment
Nova Scotia
- Local, provincial, national, global laws and policies
- Nova Scotia Government
- Department Health and Wellness
- GOLD COPD Standards
- WHO Recommendations
- Health Authorities Act
- Provincial Smoking free Places Act
- National Prevention Strategies
- Canadian Thoracic Society, Canadian Lung Association
- Nova Scotia Public Health Profile
- DHW Accountability Report
- Canadian Foundation for Health Improvement (CHFI)
Ontario
- Ontario Government
- Air Quality Health Index
- Smoke-Free Ontario Act
- QBP for COPD (Health Quality Ontario)
- GOLD COPD Standards
- WHO Recommendations
- Regulated Health Professions Act
- National Prevention Strategies
- Canadian Thoracic Society, Canadian Lung Association
- Canadian Foundation for Health Improvement
Overall, using this model identifies that there are gaps in care for the management of COPD and for addressing that the prevalence continues to incline. There are provincial programs in both Nova Scotia and Ontario that focus on cardiovascular disease, Diabetes Care and Renal disease to name a few. However, there is no program at a provincial level in either province that is dedicated to researching and addressing COPD. Health Quality Ontario (an agency that advises the Ontario government) put forth recommendations for a provincial COPD strategy in Ontario in March 2012. The response from the Ministry of Health in Ontario did endorse these recommendations and increased access to some existing programs but there is not yet a provincial-wide strategy (HQC, 2012).
Without overarching programs many of the influences listed above are working separately in both provinces instead of together cohesively. There are many great initiatives that are in place such as the, “Implementing a Novel and Supportive Program of Individualized Care for Patients and Families Living with Respiratory Disease (INSPIRE)” in Nova Scotia (INSPIRE is a national program that recently finished its pilot implementation and evaluation phase in Nova Scotia) and the “Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease” in Ontario from Health Quality Ontario.
Using the SEM model, these programs are analyzed in the table below:
SEM Level
INSPIRE Initiative
Individual
- Knowledge, Attitudes, Behavior
Self-Management Education, Individualized action plans, Home Education on lungs, disease management, medications, inhaler use, home oxygen
COPD QBP
- Care decisions (invasive vs. non-invasive ventilation, DNR status)
- Patient-centered education/health literacy
- Action Plans
Interpersonal
INSPIRE Initiative
- Formal and informal social networks
- Support systems
Psychosocial Support, Spiritual; Support, Advanced Planning Support, Fatigue and Anxiety Support for patient and families
COPD QBP
- Advanced care planning
Community
INSPIRE Initiative
- Relationships among organizations
Smoking Cessation Support groups, Local transportation support for physical restrictions, Community Health Sessions on disease Management, Healthy Nutrition Group, Supervised Physical Activity,
COPD QBP
- End-of-Life care
- Vaccinations
- Smoking cessation programs (ex. CAMH STOP program)
- Medication reconciliation with primary care MD upon discharge from acute care
- Community-based multi-disciplinary functional support
- Nutrition, weight and lifestyle management
Organizational
INSPIRE Initiative
- Organizations with rules and regulations
Better Access to Primary Care Services, Pulmonary Rehabilitation Program support, Telephone Hotlines, Social Work Support, RT care, Physio/OT support, Dietician Support, Pharmacist Support, Appointment Reminders
COPD QBP
- Standardizing diagnosis requirements
- Standardizing exacerbation definitions
- Standardizing routine medical care in acute care facilities
- Management of co-morbidities
- Early ambulation
- Pulmonary rehabilitation
- Pharmacotherapy
- End-of-Life care
- Discharge planning
Policy/Enabling Environment
INSPIRE Initiative
- Local, provincial, national, global laws and policies
Accessible transport and Communities, Canadian Foundation for Healthcare Improvement Initiative and Funding
COPD QBP
- GOLD COPD Guidelines
- NICE COPD Guidelines
- COPD QBP Guidelines (recommends establishment of a COPD network)
Five Years of the INSPIRE Program in Nova Scotia according to CFHI Final Report (2016) would prevent:
2000 ED visits
1300 Hospitalizations
Save 19 million in hospital costs
Save 2.3 million in ED costs
INSPIRED Bottom Line is $1 in Nova Scotia prevents $21 in Health Care Costs
The INSPIRE program address’s COPD management from multiple levels and recognizes that while each level is independent they also influence the other levels. A proven program like INPSIRE is precisely what Nova Scotia needs to change the rates and health of those living with COPD. It is also proof that more programs addressing chronic disease that look at them on multiple levels is required to improve and sustain health in Nova Scotia. This article from the Chronicle Herald from 2016 puts a face to the disease and the impact programs like INPIRE can have. The Ontario COPD QBP is a recommendation to enhance the care pathway of COPD in the province. As is demonstrated in the table above, the QBP focus is mainly on the acute phase of the disease and care pathways within acute care facilities. While it does mention ideal scenarios for the continuation of care before and after an acute care discharge it is not specific enough to operationalize. This QBP is a recommendation and is adopted by each acute care facility differently and with various degrees of enforcement. From this SEM framework analysis we can see that much work is still needed to arrive at a provincial COPD strategy in Ontario.
References
Atlantic Canada Backgrounder: Supporting COPD Patients at home saves hospital resources and health care dollars. (2015). Canadian Foundation of Health Care Improvement. Retrieved from: http://www.cfhi-fcass.ca/sf-docs/default-source/documents/inspired/inspired-backgrounder-atlantic-e.pdf?sfvrsn=3ed3d244_2
Canadian Foundation for Healthcare Improvement (May 2015). COPD in Ontario: Health, Care and Costs. Retrieved on February 25th, 2018 from: http://www.cfhi-fcass.ca/sf-docs/default-source/newsevents/inspired-roundtable-resources/ontario-copd-fact-sheet.pdf
Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The Social Determinants of Chronic Disease. American Journal of Preventive Medicine, 52(1 Suppl 1), S5–S12. http://doi.org/10.1016/j.amepre.2016.09.010
Dechman, G. (2010). Clinician’s Commentary. Physiotherapy Canada, 62(4), 374–377. http://doi.org/10.3138/physio.62.4.374
Health Quality Ontario (2015). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease (Acute and Post Acute). Health Quality Ontario and Ministry of Health and Long Term Care. Retrieved on February 26th, 2018 from: http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_copd.pdf
Modelling the INSPIRED COPD Outreach Program. National and Provincial Analysis. Final Report (2016) Canadian Foundation of Health Care Improvement. Retrieved from: http://www.cfhi-fcass.ca/sf-docs/default-source/documents/inspired/inspired-riskanalytica-e.pdf?sfvrsn=4fded244_2
Mortality due to Respiratory Disease” published by the CONFERENCE Board of Canada (2015): http://www.conferenceboard.ca/hcp/provincial/health/resp.aspx?AspxAutoDetectCookieSupport=1
Ontario Lung Association (2017). Lung Disease. Retrieved on February 26th, 2018 from: http://lungontario.ca/lung-disease/
Public Health Agency of Canada, Life and Breath: Respiratory Disease in Canada, (Ottawa: PHAC, 2007), vii.
Statistics Canada, National Household Survey, 2011.