Can't Catch your Breath?
For many years, how best to define health has been explored and debated. Many definitions have been suggested as the population changes over time. The World Health Organization (WHO) definition still remains the widely accepted definition globally. WHO (1948) defines health as,”a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In keeping with this definition, the biomedical model of illness has been the primary model applied when health care decisions are being explored. The biomedical model focuses on the physical illness and the treatment of disease. When this model was evaluated by Wade and Halligan (2004), they found there to be three assumptions made by this model which are, “ to all illness has a single underlying cause, disease (pathology) is always the single cause, and removal or attenuation of the disease will result in a return to health.” Research has shown that these assumptions are incorrect and emphasizes the need for a multilevel model especially pertaining to the burden of chronic diseases. In an editorial by Early (2016), she states, “Decades of research have shown us that the health challenges people face largely influenced by a wide range of factors which are social, cultural, environmental, economic and political.” These have been defined as the social determinants of health and there is evidence showing that these need to be viewed at multiple levels that are overlapping as described by many multilevel models. Why then is health care and treatment of illness still the main focus of many health care systems when addressing chronic disease?
One example of a multilevel model developed by McLeroy et al. (1988), is the Social Ecological Model (SEM). This multilevel model is focused on health promotion and prevention and is based on two main concepts. One being that there are multiple levels of influence that affect behaviors and secondly that the reciprocal causation between these levels (Wade & Halligan, 2004). There are five nested, hierarchical levels of influence of the SEM: Individual, interpersonal, community, organizational, and policy/enabling environment as shown below in Figure 1.
Figure 1. SEM Model: Adapted from the Centers for Disease Control and Prevention (CDC), The Social Ecological Model: A Framework for Prevention. Retrieved from: http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html (retrieved April 21, 2014).
Looking at the sphere of influence in Figure 1, the importance of how each level/ circle interplays with one another and how health must be addressed on a broader level is displayed. Each of the social determinants of health is recognized in the model and their importance is apparent at each level. Using a resource from Unicef (2014), “SEM is a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviors, and for identifying behavioral and organizational leverage points and intermediaries for health promotion within organizations.” A decision at one level of influence can directly impact the result of another level. Table 1 below describes each of these levels in the SEM model.
A description of each of the SEM levels (UNICEF, 2014)
SEM Level
Individual:
Characteristics of an individual that influence behavior change, including knowledge, attitudes, behavior, self-efficacy, developmental history, gender, age, religious identity, racial/ethnic identity, sexual orientation, economic status, financial resources, values, goals, expectations, literacy, stigma, and others.
Interpersonal:
Formal (and informal) social networks and social support systems that can influence individual behaviors, including family, friends, peers, co-workers, religious networks, customs or traditions.
Community:
Relationships among organizations, institutions, and informational networks within defined boundaries, including the built environment (e.g., parks), village associations, community leaders, businesses, and transportation.
Organizational:
Organizations or social institutions with rules and regulations for operations that affect how, or how well, for example, MNCH services are provided to an individual or group.
Policy/Enabling Environment:
Local, state, national and global laws and policies, including policies regarding the allocation of resources for maternal, newborn, and child health and access to healthcare services, restrictive policies (e.g., high fees or taxes for health services), or lack of policies that require childhood immunizations.
By applying the SEM Model described above to Chronic Obstructive Pulmonary Disease (COPD) in Nova Scotia (NS), it helps gain a better understanding of how the model differs from the biomedical model and how the multiple levels influence each other. It has been well established that chronic diseases are a leading cause of death and disability in NS and have a substantial impact on economic growth. According to the report, “Mortality due to Respiratory Disease” published by the Conference Board of Canada (2015), the province has one of the highest provincial mortality rates due to respiratory diseases and 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. The table below demonstrates the influences on COPD at each level of the SEM model. 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.” By applying the SEM model to how to best address COPD it can be shown how there are many influences and that addressing just one social determinant has not improved the health of those living with the disease.
SEM Levels applied to COPD in Nova Scotia
Individual:
High % of smoking compared to other provinces, exposure to second hand smoke, High proportion of low income population compared to Canadian average, 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
Interpersonal:
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)
Community:
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/Social Media , Transportation available in rural communities, accessible communities, Affordable healthy food in small communities
Organizational:
Public Health Plan (MSI) , Private Health Insurance, Pharmaceutical Drug Plan (Pharmacare), Nova Scotia Health Authority (NSHA), Community Health Boards, Nova Scotia Lung Association, INSPIRE Program, Nova Scotia College of Respiratory Therapists (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
Policy/Enabling Environment:
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)
Referring to the above, at each level there are multiple determinants of health that are present in each section. Currently, there are programs and legislation in place in Nova Scotia that address the issue of COPD however, there are obvious gaps in care and prevention.
There are provincial programs in place that focus on cardiovascular disease, diabetes care and renal disease to name a few. There is no program at a provincial level dedicated to researching and addressing COPD and quality of life for those living with the disease. Without an overarching program many of the influences listed above are working separately in NS instead of together. With these departments working individually, it makes it difficult to measure the impact each influence is having on the overall goal of improving COPD health. As well, if one influence is having a negative impact on another influence it may go unnoticed because the accountability to an overall system is not present.
There are initiatives that are taking place in Nova Scotia such as the, “Implementing a Novel and Supportive Program of Individualized Care for Patients and Families Living with Respiratory Disease (INSPIRE).” This is a national program that recently finished its pilot implementation and evaluation phase in Nova Scotia. This program is at the organizational level of the health authorities in Nova Scotia and can be broken down by the SEM model itself as shown in below.
SEM levels applied to the INSPIRE program
Individual
Self-Management Education, Individualized action plans, Home Education on lungs, disease management, medications, inhaler use, home oxygen
Interpersonal:
Psychosocial Support, Spiritual; Support, Advanced Planning Support, Fatigue and Anxiety Support for patient and families,
Community:
Smoking Cessation Support groups, Local transportation support for physical restrictions, Community Health Sessions on disease Management, Healthy Nutrition Group, Supervised Physical Activity,
Organizational:
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,
Policy/Enabling Environment:
Accessible transport and Communities, Canadian Foundation for Healthcare Improvement Initiative and Funding, Adoption of GOLD standards
The INSPIRE program does address COPD management from multiple levels and recognizes that each level is independent but has influences at each level that can affect outcomes. Five years of the INSPIRE Program in Nova Scotia according to CFHI Final Report (2016) would prevent 2000 Emergency department visits, 1300 Hospitalizations and save 19 million in hospital costs. 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 diseases on multiple levels is required to improve and sustain the health care system in Nova Scotia.
This program however is not the only answer to managing chronic disease from a prevention standpoint. The program remains focused on self-management of COPD and the costs associated with treatment of exacerbations and does not directly offer support to address areas such as lack of affordable and appropriate housing. Examining smoking rates in NS can explain this further. Smoking is the main preventative cause of chronic respiratory diseases and has been the focus of many public health campaigns over the past few decades. Smoking rates in the Atlantic Provinces are considerably higher than the Canadian average of 14.9 per cent between 2011 and 2013 and residents of these four provinces are more exposed to second-hand smoke. (Canadian Lung Association, 2015). Despite the education on the harms of smoking at an individual level the rates in Nova Scotia are not significantly lower. Smoking has also been addressed at the policy level in NS with the, Smoke Free Places Act.” It may be at the other levels and addressing other social determinants of health that may have greater impact on smoking rates. This would include addressing the stress associated with food insecurity or poor housing that often leads induvial to partake in adverse behaviors like smoking and the community culture around the acceptance of smoking. It will require a root cause analysis of what factors have the most influence on an individual’s choice to smoke or not smoke.
Overall, using this model identifies that there are gaps in care for the management of COPD and addressing the continued incline in COPD prevalence. The question remains how to best manage each of the determinants of health when applying it to a broad goal such as improving population health and the burden of chronic diseases. It will take a new framework like SEM and a change in thinking and in practice. It is time for different departments of the government to stop working in silos and start collaborating. Our health is what will benefit.
This video gives an overview of the model:
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 of Health Care Improvement (2016). Modelling the INSPIRED COPD Outreach Program. National and Provincial Analysis. Final Report. Retrieved from: http://www.cfhi-fcass.ca/sf-docs/default-source/documents/inspired/inspired-riskanalytica- e.pdf?sfvrsn=4fded244_2
Centers for Disease Control and Prevention (CDC), The Social Ecological Model: A Framework for Prevention, http://www.cdc.gov/violenceprevention/overview/social- ecologicalmodel.html
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