Final Thoughts
- Nina Arboine
- Dec 8, 2020
- 16 min read
Happy final blogging!!! Congratulations, we are almost at the finish line!! Cue the music from Chariots of fires. Over the last three months, I have been growing as a student in this course learning to understand how to conceptualize, study and analyze factors influencing the health of Canadians within the context of the Canadian health care system. In this final blog, I will provide an overall summary briefly discussing each core concept based on the weekly learning. As outline in the course curriculum, I will be summarizing the following core concepts (Athabasca University MHST, 2019):
Establishing a professional identity and the use of social media;
Federal and Provincial health systems in Canada;
Understanding health and the social determinants of health;
Health outcome from a multilevel approach;
Chronic diseases and management;
Vulnerable populations; and
Future directions.
Professional Identity and Social Media
Social media is quickly becoming one of the most important aspects in the digital world, which provides incredible benefits that help reach millions of people worldwide. Social medial presences is a good way for engaging and providing interactive communication with real people in real time. It allows for openness and transparency of dialogue amongst targeted users. Having goals to create a strong social media present is crucial. A strategic marketing approach focuses on creating and distributing valuable, relevant and consistent content to attract and retain a clearly-defined audience (Tutelman, Dol, Tougas & Chambers, 2018). As a member of a regulated health profession, nurses also need to consider all of the implications of social media for their profession, including their accountabilities to the CNO. It is essential for all nurses employed in Ontario to consider the possible impact of their online lives and their social media communications for the workplace and their profession, as well as, personal representation of social media usage (RNAO, n.d). According to Bjerke & Renger (2017) the S.M.A.R.T goal framework is all about creating relevant and achievable goals that help support your overall objectives when creating a social media presence.
S (specific): What will be accomplished? What actions will you take?
M (measurable): What data will measure the goal(s)?
A(achievable): Do yo have the necessary skills and resources?
R(realistic): How does the goal align with broader goals?
T(timely): What is the time frame for accomplishing the goals.
Furthermore, as mentioned in Dutta (2010) article, effective social media presence is paramount and when done correctly could make a significant impact. As listed below, one should consider the following to assist in composing a profound social media platform.
1) Branding consistency: easily recognizable, clear agenda, cohesion
2) Building targeted audience and expanding followers
3) Actively engaging with audience: participating in conversation, sharing relevant information, sharing user-generated content, posting and answering questions and showing appreciation towards the attending audience.
4) Monitoring progression
5) Maintaining a consistent presence and observing peak times to engage with audience
6) Maintaining a credibility and reputable social media presence
7) Maintaining a level of professionalism in the content: A major risk associated with the use of social media is the unprofessional content that can reflect unfavourably on healthcare professionals and affiliated institutions.
8) Cross-Channel Marketing to reach target audience.
Online professionalism is important in order to safeguard both careers and reputations. As eloquently elaborated in (Basevi, Reid & Godbold, p.76, 2014) article, “Whilst some organizations have been effective in creating and implementing guidelines, many remain without policy, leaving the institution and working healthcare professionals unaware of and unable to navigate the risks surrounding them in a social medial world.” I think with social media presence, there is an expectation of professional ethical standards and having social media etiquettes. Modern day technologies continues to challenge our profession to think critically about professional/personal boundaries, self-disclosure, dual and multiple relationships, privacy and conflicts of interest within an ethical framework. The Registered Nurses’ Association of Ontario (RNAO) and the Canadian Nurses Association (CNA) has provided its’ nurses with a guideline for electronic communication interaction. The guideline encourage nurses to become familiar with its standards and codes of ethics set out by their regulating college to ensure compliance. In addition to, the College of Nurse of Ontario has issues a position statement on the expectations for nurses with social media. The purpose of their position statement is to inform nurses about emerging issues nursing. However, it is not one of the College’s Standards of practice.
Federal and Provincial health systems in Canada
Federal and provincial governments have been jointly involved in the provision of universal publicly insured and administered health care to Canadians for decades. In the early post-war, federal and provincial governments agreed on the use of conditional intergovernmental grants as the means to build the Canada-wide set of health care arrangements that exist today. What was done in the 1950s through to the 1970s was a considerable achievement both in policy and fiscal terms and from the viewpoint of cooperative intergovernmental relations (Hutchison, Levesque, Strumpf & Coyle, 2011).. Today, however, there are a number of disconnects between the federal government's approach to the financing of health care and to intergovernmental care relations, on the one hand, and its policy role in promoting a Canada-wide system of health care for Canadians. These disconnects are contributing to provincial difficulties in reforming their health care systems and they are serious irritants in intergovernmental relations (Hutchison, Levesque, Strumpf & Coyle, 2011).
The Constitution Act 1867, reflected nineteenth century conceptions about the appropriate role of government. The health and social needs of Canadians were ween then as a matter for the individual, the family, the church and charitable institutions, with the state's role largely confined to rudimentary forms of poverty relief administered through local agencies. When the social role of the state began to expand in the twentieth century, Canada had to resolve the division of responsibility in new domains of state of action. During the war years, the federal government developed ambitious proposals for a postwar system of social insurance, including public health insurance.
Canada has thirteen provincial and territorial health care systems that operate within a national legislative framework, the Canada Health Act. The act defines the following standards to which provincial health insurance programs must conform in exchange for federal funding: universality, portability, comprehensiveness, public administration and accessibility.
Universality: Provincial health insurance programs must insure Canadians for all medically necessary hospital and physician care. This also means Canadians do not have to pay an insurance premium in order to be covered through provincial health insurance.
Portability: Canadians are covered by a provincial insurance plan during short absences from that province.
Comprehensiveness: Provincial health insurance programs must include all medically necessary services for the purpose of maintaining health, preventing disease pr diagnosing or treating an injury, illness or disability.
Public administration: Provincial insurance programs must be publicly accountable for the funds they spend. Provincial governments determine the extent and amount of coverage of insured services. Management of provincial health insurance plans must be carried out by a non-for-profit authority, which can be part of government or an arm's length agency.
Accessibility: Canadians must have reasonable access to insured services without charge or paying user fees.
As part of Canada's health care system, the federal government has several responsibilities for our Canadians with includes :
setting and administering national principles for the system under the Canada Health Act;
financial support to the provinces and territories;
funding and/or delivery of primary and supplementary services to certain populated groups including - First Nations living on the reserves, Canadian Armed Forces, eligible veterans, inmates in federal penitentiaries and refugee claimants;
responsible for health protection and regulation;
consumer safety;
disease surveillance and prevention;
support for health promotion and health research;
health-related tax measures, including tax credit for medical expenses, disability, caregivers and infirm dependants;
tax rebates to public institutions for health services; and
deductions for private health insurance premiums for the self-employed.
When examining the roles of the provincial and territorial governments in health care, those include:
administration of their health insurance plans;
planing and funding of care in hospitals and other health facilities;
services provided by doctors and other health professionals;
planning and implementation of health promotion and public health initiatives; and
negotiation of fee schedules with health professionals.
Understanding health and the social determinants of health
Health can be viewed as the presence or absence of disease or medically measured risk factors in an individual. However, more broadly, health is 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Jakab, 2011).' Health reflects the complex interactions of a person's genetics, lifestyle and environment. Generally, a person's depends on two things: determinants (factors that influence health) and interventions (actions taken to improve health, and the resources requires for those interventions) (Mikkonen & Raphael, 2010). Health is fundamental to an individual's wellbeing. It reflects a person's relative ability to effectively engage with society- improve health outcomes support better economic, educational and social outcomes and conditions (Mikkonen & Raphael, 2010). Health determinants are the many risk and protective factors that influence an individual's health. Figure 1 divides determinants into 4 groups, where the main direction of influence is from contextual factors through to more direct influences.
Health outcomes affect and are affected by the social determinants of health, a term that encompasses not only social but economic, political, culture and environmental determinants. Essentially, these are the conditions into which people are born, grow, live, work and age. All of these social determinants interact with the physical and psychological make-up of individuals. Additionally, the factors within each box in Figure 1 can interact and are closely related to each other.
Figure 1: Framework for determinants of health
Socio-economic position is one of the most crucial determinants of health inequities within societies. Health inequities are differences in health between specific population groups that are systematic, avoidable, unfair and unjust. Health inequities systematically place individuals who are already socially disadvantaged, in terms of income, gender, race and/or ethnicity, at further disadvantage related to health (Raphael, 2003). Globally, there is momentum to investigate and act upon health inequities by strengthening the social determinants of health, including early childhood development, adequate income, fair income distribution, high educational attainment, non-precarious employment, safe working conditions, food security and affordable housing. Power of government at all jurisdictional level (example local, provincial, national) to enact policies that facilitate structural improvements to the social determinants of health, strengthening political will or motivation to act, is a critical concern for addressing health inequities (Raphael, 2003). In Canada’s most populous province of Ontario, while there has been some recent action in creating more equitable access to healthcare system, there has been little action to address other social determinants of health. Such policy inaction could be due to a numerous of factors, including competing political and social agendas or the status of economic development, however, may also be due to a lack of political will to tackle health inequities (Gore & Kothan, 2012). Research has shown that in democratic countries, public opinion can influence political buy-in and public policy outcomes especially in the areas of social welfare and poverty policy; the more salient an issue is to the public, the stronger the relationship to the formulation of the policy agenda. In the Canadian context, and more specifically Ontarian’s, a study of public opinion about health equity policy interventions that address the social determinants of health, in additional engaging a debate in the equity literature that considers whether policy interventions to reduce health inequities should be universal or targeted to the socially disadvantaged (Gore & Kothan, 2012). As part of these analysis, to examine the relationship between how the public attribute health inequities and support for targeted vs. broader health equity interventions (Turnbull, 2017). The survey asked a series of questions related to three thematic areas: 1) awareness of health inequities; 2) explanations or attributions of health inequities; and 3) opinions about possible solutions to health inequities. Ontarian participants where asked to respond to the following questions: “ 1) the importance of addressing health inequities in Ontario; 2) fairness in health status in Ontario; 3) possible intervention approaches to address health inequities in the province; and 4) support for specific intervention types (Turnbull, 2017).”
The results concluded (Turnbull, 2017):
64% agreed that people need to take self responsibility for their own health and not expect the government to address this;
98% agreed Ontarian’s should have the same opportunity to live a ling and healthy life;
47% agreed that Ontarian’s actually have this opportunity;
58% Ontario society needs major changes in order to make things more equitable among people;
48% agreed that the government should address health inequities by increasing taxes;
65% agreed that the government should address health inequities through redistributive processes, whereby resources are shifted away from the wealthy to support lower income.
Multilevel approach and health
There are different theories strategies, and model that can be used to inform health promotion and disease prevention programs. Communities can use these theories, strategies, and models to develop and implement programs that empower and motivate people to improve and better manage their health. The theories and strategies can be implemented during program planning to ensure the integration of health promotion and disease prevention approaches to improve population health.
The health belief model helps explain why individual patients may accept or reject preventative health services or adopt to healthy behaviours. Social psychologist originally developed the health belief model to predict the likelihood of a person taking recommended preventative health action and to understand a person's motivation and decision-making about seeking health services (Jones et al, 2014). The health belief model proposes that people will respond best to messages about health promotion or disease prevention when the following four condition for change exist (Jones et al, 2014):
The person believed that they are at risk of developing a specific condition.
The person believes that the risk is serious and the consequences of developing the condition are undesirable.
The person believes that the risk will be reduced by a specific behaviour change.
The person believes that barrier to the behaviour change can be overcome and managed.
Knowing what aspect of the health belief model patients accept or reject can help design appropriate interventions. As such, if a patient is unaware of their own risk factors for one or more diseases, you can direct teaching toward informing the patient about personal risk factors. It the patient is aware of the risk, but feels that the behaviour change is overwhelming or unachievable, you can focus your teaching efforts on helping the patient overcome the perceived barriers (Jones et al, 2014).
The social ecological model recognize individuals as embedded within larger social systems and describe the interactive characteristics of individuals and environments that underlie health outcomes. Building on the work of Urie Brofenbrener, who had previously articulated a multilevel framework, McLeroy, Bibeau, Steckler and Glanz offered five levels of influence specific to health behaviour: intra-personal factors, inter-personal processes and primary groups, institutional factors, community factors an public policy (Kilanoski, 2017). In addition to articulating level-specific influences on health behaviours, intervention strategies at each level of influence. Ecological models assume not only that multiple levels of reinforcing (Kilanoski, 2017). Kilanoski (2017) argues that social, physical and cultural aspects of an environment have a cumulative effect on health. She further contends that the environment itself is multilayered, since institutions and neighbourhoods are embedded in larger social and economic structures, and that the environmental context may influence the health of people of individual people differently, depending on their unique beliefs and practices. Creating sustainable health improvements, therefore, is most effective when all of these factors are targeted simultaneously.
The ecological model looks at the following as represented in Figure 2:
Intrapersonal/individual factors: which influence behaviour such as knowledge, attitudes, beliefs and personality;
Interpersonal factors: such as interactions with other people, which can provide social support or create barriers to interpersonal growth that promotes healthy behaviours;
Institutional and organizational factors: including the rules, regulations, policies, and informal structures that constrain or promote healthy behaviours;
Community factors: such as formal or informal social norms that exist among individuals, group or organizations, can limit or enhance healthy behaviours;
Public policy factors: including local, state and federal policies and laws that regulate or support actions and practices for disease prevention including early detection, control and management (Newes-Adeyi, Helitzer, Caulfield & Bronner, 2000).
The social cognitive theory model (SCT) describes the influence of individual experiences, the actions of others, and environmental factors on individual health behaviours. SCT provides opportunities for social support through instilling expectations, self-efficacy, and using observational learning and other reinforcements to achieve behaviour change (Luszcynska & Schwarzer, 2005). Key components of the SCT related to individual behaviour change includes (Luszcynska & Schwarzer, 2005):
Self-efficacy: The belief that an individual has control over and is able to execute a behaviour.
Behavioural capability: Understanding and having the skill to perform a behaviour.
Expectations: Determining the outcomes of behaviour change.
Expectancies: Assigning a value to the outcomes of behaviour change.
Self-control: Regulating and monitoring individual behaviour.
Observational learning: Watching and observing outcomes of others performing or modelling the desired behviour.
Reinforcements: Promoting incentives and rewards that encourage behaviour change.
Transtheoretical model (TTM) of change was developed by Prochaska and DiClemente to describe the process of behaviour change. The TTM, reproduced in Figure 3, illustrates behavioural change as a progression through a series of stages. The process of change is non-linear and is unique for each individual. The model helps practitioners assess and identify the stage that a particular individual is at with respect to change, enabling stage-appropriate engagement and intervention strategies (Prochaska & Velicer, 1997).
Figure 3: Transtheoretical Mode of change

Chronic Disease and Management
Chronic diseases are long duration and generally slow progression. As per the World Health Organization (WHO) (2020), the four main type of chronic diseases are cardiovascular disease, cancer, chronic respiratory disease and diabetes. Chronic diseases are by far the leading cause of death in the world, representing over 60% of all annual deaths. Of the 57 million deaths that occurred globally in 2008, 36 million were due to chronic diseases comprising mainly from the four main types (Grover & Joshi, 2015). Approximately, 80% of all chronic disease death occurred in low and middle income countries, populations and communities and is projected to increase substantially over the next two decades (Grover & Joshi, 2015). In Ontario, Canada, chronic diseases contribute to about three-quarters of deaths and the direct healthcare cost was an estimated to be $10.5 billion a year (CCO & Public Health Ontario, 2015).
Risk factors is any trait, characteristic or exposure of an individual that increases their likelihood of suffering from a disease. These can be non-modifiable or modifiable such as (CCO & Public Health Ontario, 2015):
Non-modifiable Risk Factors Modifiable Risk Factors
Age Tobacco use
Gender Alchohol consumption
Family history Excess body weight
Ethnicity Physical activity
Healthy eating
Addressing increased incidence of chronic diseases is one of the most important challenges for the healthcare system. In contrast to the traditional medical model management of acute conditions, management of chronic disease requires that patients take a more active role in the day-to-day decisions about the management of their illness. This new disease paradigm requires that there be a working patient-provider partnership that involves effective treatment within an integrated system of collaborative care. The essential ingredient of effective chronic care management is the partnership between the patient and health professionals because it offers the opportunity to empower patients to become more active in managing their health. When patients are more informed, involved and empowered, they interact more effectively with healthcare providers and strive to take action that will promote healthier outcomes .
Chronic disease prevention and programs is an integrated approach aimed to reduce premature mortality and morbidity of chronic noncommunicable disease, but also the need to integrate primary, secondary and tertiary prevention, health promotion and related programs across sectors and different disciplines (Grover & Joshi, 2015). The objectives are:
strengthen prevention and control of chronic communicable diseases by tackling major risk factors;
reduce premature mortality and morbidity;
improve quality of life;
raise awareness;
promote development and implementation of national policy and strategies, programs, community-based demonstration projects for prevention and control of chronic diseases with a special focus on developing countries;
to link regional networks and international partnership; and
stimulate training and capacity building (WHO, 2020).
Rather than adhering to a specific list of diseases and a specified time period,we need to advocate for similar approaches. There are many diseases, conditions and syndromes that do not make the "list of chronic diseases" but when taken into consideration, they affect a large number of individuals which can be quite costly to manage and can be justified as emotionally and physically taxing for patients and their caregivers. We need to bring more diseases and conditions under the umbrella, with the hope of increasing awareness, sharing knowledge and creating a larger community of individuals working toward improving the health of those who suffer from chronic health problems. The following video presents a women with an illness that does not meet the WHOs definition of chronic diseases. Should her illness not matter too.
Vulnerable Populations
Vulnerable populations are groups and communities at a higher risk for poor health as a result of the barriers they experience to social, economic, political and environmental resources, as well as limitations due to illness or disability. Vulnerable populations include the economically disadvantaged, the elderly, racial and ethnic minorities, the unemployed, uninsured and under-insured, children of low-income families, LGCTQ and non-conforming, people with HIV, people withe severe mental and behavioural health disorders, the homeless, refugees and many others. These groups are especially susceptible to poor health, chronic disease, disability, and earl mortality. Often, standard health care delivery cannot meet the needs of these vulnerable populations and new modalities need to be discovered to address these growing and preventable concerns (Shi et al, 2008). Effectively addressing the social determinants requires multistakeholder and multisectoral action across government and society. This includes strengthening capacity to govern for better health across sectors and implementing multistakeholder policies, service and systems. These need to engage citizens, service providers, civil society, the media,planner, policy-makers and politicians (Shi et al, 2008).
What I have learnt about vulnerable populations is that, social exclusion is the process of marginalizing individuals or groups of a particular society and denying them from full participation in social, economic and political activities. Social vulnerability is the inability of these individual or communities to oppose negative situations or impacts. Hence, social exclusion leads certain individuals to social vulnerability. Through there are differences in perspectives, there is consensus that social exclusion is multi-dimensional, dynamic and relational. Social exclusion, characterized by unequal access to resources, capabilities and rights, is a multi-dimensional process driven by unequal power relationships across four dimensions - economic, political, social and culture, which operates at individual, household, community and global levels. The relational processes, operating as macro and micro levels, deliberately exclude particular groups of people from engaging fully in things such as affordable education, equal employment opportunities, affordable housing, and sustaining the basic needs for life. Evidence has shown through research that unmet needs contribute to poorer outcomes and poorer health in vulnerable populated groups.
The consequences of social exclusion are enormous, often making excluded groups voiceless and invisible in the society in which they life in (Shi et al, 2008).
Future Direction
The rapid upscaling of virtual care capacity and the mainstreaming of telehealth have given rise to new digital health tools. Self-triaging and contact tracing for COVID-19 infection detection are among the new breed of digital health applications that startups to big firms alike were looking at to seize the emerging opportunities (Green, 2020). Virtual care is the future of healthcare delivery in Canada. Many Canadians had likely never heard the term 'virtual care' before the COVID-19 pandemic. Now it's part of our lexicon, right up there with terms like 'physical distancing' and 'flattening the curve'. Virtual care connecting with a health care provider by email, phone or video call has become a necessity during the pandemic because in-person appointments at clinics and doctor's office are not safe or feasible (Green, 2020). Health care providers across the country have been offering virtual options for all but urgent or ongoing care. Tracking by Canada Health Infoway [sic] shows that, by the end of April 2020, the proportion of visits that happened virtually rather than in-person had increased to 60%. This is a drastic jump from less than 20% prior to COVID-19. The most common way to connect with patients was by phone at 40%, followed by video visits at 11% and emails/online chats at 5% (Baumgart,2020). Many health systems that permitted the use of consumer technologies such as Zoom and Skype in the interest of expediency during the pandemic are carefully reviewing their platform choice (Green, 2020).
Conclusion
Through this course, I have learned that it is imperative to understand each section individually to have a foundation, but they all have a interactive roll together. For example in order to produce effective health policies in achieving good health in the vulnerable population, we need to look at the issues that exit in the vulnerable populated groups, how the social determinants of health impact the vulnerable population, and what is health according to a person as this differs for everyone.
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