Multi-Level Model: Addressing Health Inequity

Individuals who access and receive healthcare services are diverse and representative of all socio-economic classes. As part of this course work, I discovered low-income Manitobans carry an increased risk of chronic disease and premature death compared to the highest income earners (Martens, Brownell and Au, 2010). I propose this information to be true for the majority of low-income earners across the nation. There are a number of modifiable and non-modifiable factors which precipitate the onset of diabetes, hypertension, hyperlipidemia and coronary heart disease. It should come as no surprise the Canada identifies “income” as the first determinant of health. Access to healthy food, food security, affordable housing, employment and education highlight the health imbalance between low-income and high-income Canadians (Government of Canada, 2020). COVID-19 has exacerbated this health disparity to a greater extent. Public Health Ontario (2020) identified marginalized areas having 4x greater likelihood of requiring hospitalization and 2x risk of death, with a call to action to curb this trend. It seems plausible to use this data as a comparison for the rest of the country. The majority of provinces have some proportion of residents who are homeless, identify as a visible minority, identify as low-income, access food banks and or are receiving some form of government financial assistance.

The World Health Organization (2018) defines health inequities as “differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age.” Quantifying Canadians health based solely on socio-economic status (SES) provides one dataset. Others exist and may be better able to describe local, regional, provincial and national datapoints to determine an individual or community’s health risk. In 2016, the Canadian Index of Multiple Deprivation (CIMD) was developed evaluating “residential instability, economic dependency, ethno-cultural composition and situational vulnerability” (Statistics Canada, 2019). Similar terminology has been used by other provinces and or countries including material, social and neighborhood deprivation. Since 2001, Public Health Ontario (PHO, 2017) has been using the Marginalization Index (ON-Marg) to differentiate deprivation in local and regional areas across “four dimensions” as noted in Figure 1 Residential instability describes “high rates of family or housing instability” (PHO, 2017). Material deprivation refers to the inability to access basic requirements, dependency speaks to individuals who are not employed, and ethnic concentration refers to recent immigrants or individuals who identify as a visible minority (PHO, 2017).

Figure 1 – Retrieved from: http://www.torontohealthprofiles.ca/onmarg/userguide_data/ON-Marg_user_guide_1.0_FINAL_MAY2012.pdf

With a robust collection of datapoints, scores for individual dimensions are available for each geographical/dissemination area in Ontario. Individuals or communities in a higher quintile are at greater risk of developing chronic disease, while those in the lower quintiles are considered less deprived. Figure 2 describes residents living in an East Toronto area (PHO, 2017). A large proportion of residents in this geographical area experience a greater degree of uncertainty and risk related to their health and well-being.

Figure 2 – Retrieved from: https://www.publichealthontario.ca/-/media/documents/O/2017/on-marg-user-2011.pdf?la=en

Given this information, how do individuals, communities, provincial and federal governments institute the required measures to improve health for low-income earners? White (2015) describes the social-ecological model (SEM) model “as a way of appreciating how people relate through family and community relationships to society as a whole.” I will utilize a five level model (Figure 3) to discuss the promotion of health and health equity including individual, interpersonal, organizational, community and policy.

Figure 3 – Retrieved from: http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/cancer/nbccedp/sem.htm

The individual level focuses on one’s knowledge. Efforts to alter health behaviors related to nutrition, physical activity and substance misuse are considered important factors related to health and well-being. These have been a staple of education and government policy. Raphael (2003) argues this “downstream behavioural approach remains dominant in Canada, despite limited evidence of its effectiveness and increasing evidence of the importance of societal determinants of health.” The North York Heart Health Network (2001) highlighted “income” as having a greater impact for developing cardiovascular heart disease (CHD) compared to lifestyle changes. Other research has tried to build upon the resiliency of low-income earners while advocating for social reform for this disadvantaged group. Taylor and Distelberg (2016) studied individual resilience for low-income families, they identified “self-esteem, internal locus of control, education, spirituality and hope” as key factors which positively impact overall health and substance use. What is clear among researchers, government and non-profit organizations is that graduation from high school provides greater opportunity to earn a higher income, improving health and life expectancy. Zahondone et al. (2018) links education with income and “social connections.”

The hallmark of the interpersonal level is an individual’s connection with family, friends and peers. Smith and Anderson (2017) identified that positive social networks increased low-income individual’s resiliency, bolstering their health outlook. Individuals who share similar values, such as positive health behaviors related to food, drugs, education are less likely to engage in harmful behaviors (Smith and Anderson, 2017). Another at risk group is Canada’s aging population (65+), which encompass 17.5% of the population and may reach 25% by 2040 (Government of Canada, 2020). We’re familiar with age related changes and disease processes which affect cognition, vision, hearing and spatial awareness. Without friends, family or peers, this population is at risk for malnutrition, with self-reports ranging from 29 - 37% (GoC, 2020). Keller et al (2008) identified low-income seniors required assistance with transportation and dependence on others for food provision. Participants commented “companionship” during meals were valued and appreciated, indicating that community resources are accessed for food and socialization (Keller et al., 2008).

The organizational level links individuals with structured settings, such as schools, stores and workplace. As mentioned previously, educational attainment can improve health and well-being. High-school graduation is one of the key factors in health promotion. Graduation rates have remained relatively stable across most provinces since 2014 (Statistics Canada, 2021), except for remote and rural areas which have not achieved this steady state and continue to show a decline. According to the Composite Learning Index (2010), “the proportion of Aboriginal people aged 20 to 24 who had not completed high school was almost three times higher than that of non-Aboriginal Canadians.” Factors leading to this unfortunate statistic is multifactoral, and includes a history of “racism, colonization and discrimination” (GoC, 2020). Previous trauma experienced as a result of colonization, slavery and or residential schools continues to have a generational impact on the health and well-being of Indigenous Peoples and Black Canadians (GoC, 2020). Individuals may have felt disconnected from their culture, forced to assimilate as a result of the 1970’s “scoop,” experienced neglect or abuse leading to chronic disease and mental health issues, including substance misuse. These factors can lead to distrust regarding institutions, government agencies and the workplace. In order to address these concerns, extra resources and support must be provided for children from low socioeconomic households throughout primary, middle and secondary settings (Martens, Brownell and Au 2010), noting “children who enter school already behind their peers tend to fall further behind, and being behind in school can lead to discouragement and disengagement.”

The community level involves relationships with community services and agencies, the built environment and non-profit organizations. In 1994, the U.S. department of housing and urban development sponsored a housing mobility study. Low-income families (4,600) living in the most disadvantaged urban areas were randomly assigned to one of three groups. The 2011 report outlined that families moving from a high-poverty neighborhood to a subsidized private-market house or traditional housing voucher expressed “feeling safer and more satisfied with their housing,” experienced “lower prevalence of severe obesity and diabetes” compared to the control group (Kling 2008, Orr 2011). In particular, female youths experienced “less psychological distress, were less likely to use drugs or be arrested for property crime” (Kling, 2008). Horowitz and Lawlor (2008) suggest a multi-disciplinary team composed of community members, medical staff, public health, government policy and research to “make clinical care more responsive to vulnerable populations and to make clinical interventions more effective in improving their health,” citing “significant health benefits” to common chronic diseases from such measures.

Policy is the final level, implementing local, regional, provincial and federal initiatives to improve health equity. Martens, Brownell and Au (2010) suggest targeted interventions for those experiencing the most deprivation, whilst calling for implementation strategies across all domains of SEM; akin to proportionate universalism. Tonelli, Tang and Forest (2020) advocate for “Health in All Policies” (HiAP) which institutes policy change across all sectors of government citing, “many of the drivers for health outcomes are beyond the reach of the health sector, and because initiatives that increase health and health equity often pay for themselves through better productivity and higher tax revenues.” The study identifies two initiatives which have already proven to be beneficial. The first is a reduction in disability and mortality related to traffic accidents through prevention of impaired driving strategies, and a lower prevalence of tobacco use as a result of taxes and or duties. Given the success of these strategies, they contend that an Indigenous-led national strategy following the truth and reconciliation commissions recommendations would produce “substantial health gains for Indigenous Peoples” (Tonelli, Tang, Forest, 2020). Finally, Crombie et al. and the World Health Organization’s (2005) seminal work on health equity and inequality outlined that effective policies exist to address the needs of those most disadvantaged, advocating for attainment.

References

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