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Vulnerable Populations in Canada

Question:

Discuss about the Impacts of the Social Determinants of Health on Cardiovascular Disease in Older Adults.

Nearly six percent of Canadians were living with cardiovascular disease (CVD) in 2015; a disease which has a mortality rate of 194.7 deaths per 100,000 (Public Health Agency of Canada, 2017b). Older adults are one of many vulnerable populations in Canada and there are a variety of factors that make them more vulnerable. This paper will explore how social determinants of health (SDOH), specifically socioeconomic status, affects Canadian and international multicultural older adult populations with (CVD), include a SDOH model, followed by public health implications that arise as a result of this issue. We will examine why these socioeconomic status may affect this vulnerable population and explore information about CVD.

For the purposes of this research, older adults are defined as individuals between the ages of 55 and 79. According to Raphael (2016), there are many factors that make senior populations more vulnerable or susceptible to higher mortality rates; those including, but are not limited to SDOH such as personal health practices/coping, education, socioeconomic status (SES), gender, and social support systems. When examining the rates of CVD in older adults a comparison will be made between those of low and high SES. SES will be measured using household income and level of education. The writers of this paper believe that older adults that have a lower level of education will have a higher rate of CVD disease due to diminished access or knowledge to support and foundations to live or obtain a better quality of lifestyle. The writers also believe that along with a lower level of education would contribute to a lower level of income, thus putting older adults in a position to not obtain a healthier lifestyle and higher quality of living.

Cardiovascular diseases affect the heart and blood vessels and includes coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism (World Health Organization, 2017). CVD is a rampant problem for developing nations and is the number one cause of death worldwide (World Health Organization, 2017). According to the Canadian Chronic Disease Surveillance System (CCDSS) incident rates of heart attacks in the Canadian population for age groups, 50 - 64 and 65-79 are 2.38% and 5.55%, respectively (Public Health Agency of Canada, 2017c). This is much higher than age groups 35 - 49, who were 0.61% of the population that experience heart attacks (Public Health Agency of Canada, 2017c). In the United States, 69.1% of men and 67.9% of women aged 60 - 79 suffer from some form of CVD (American Heart Association, 2016). Diseases of the heart are the lead cause of death for American women over 65 years old (American Heart Association, 2016). 

Cardiovascular Diseases


CVD is commonly diagnosed by a physician in regular or emergency room visits. Data is then collected through a variety of sampling methods. Specifically, the CCDSS collects data based on health insurance registry databases that are linked to physician billing and hospital databases (Public Health Agency of Canada, 2017a). Through this collection technique, errors from self-reporting are avoided. Another common information data base is the Canadian Community Health Survey (CCHS). A survey is provided to a cross-section of the country who then are responsible for self-reporting (Statistics Canada, 2016). When self-reporting is used for collecting information there is always a chance that respondents will be intentionally dishonest or misunderstand a question and provide the wrong answer.

SES and education are SDOH that are the strongest predictors to affect CVD (Joffres et al., 2013; Winkleby et al., 1992). SES reflects spending ability, housing, diet, and medical care based on income, whereas education reflects skills for social, psychological, and economic resources (Winkleby et al., 1992). 

A healthy diet is essential for the prevention of CVD yet income can be a stumbling block as much of heart disease medication costs are not covered under Medicare (Gucciardi et al., 2009). Those with low income tend to lack insurance coverage that covers expensive medications such as those for CVD, which are among the most expensive within Canada (Booth et al., 2012; Campbell et al., 2012). Booth et al. (2012) found an increase in diabetes related mortality rates between those of high and low SES especially in those over the age of 65. Woodward et al. (2015) revealed that CVD is associated with lower SES. A community-based study from Turkey revealed that unhealthy diet was associated with lower SES (OR = 3.31) and lower education (OR=4.48) (Simsek et al., 2013).

A lack of education can have profound effects in those with CVD. In developing countries, there is often a gap in hypertension treatment for seniors due to lack of knowledge of what hypertension is and preventative signs (Maurer & Ramos, 2015). Maurer & Ramos (2015) reveal that low-cost treatment options for hypertension exist and could increase awareness in seniors. Seniors of higher SES are associated with higher physical activity, greater nutritional habits and lower risk of smoking compared to those of lower SES (Campbell et al., 2012). This means that those of low SES are associated with increased use of healthcare services that have little impact on poorer health outcomes and mortality (Campbell et al., 2012).

Social Determinants of Health and Cardiovascular Diseases

It's important to assess how determinants are measured. The studies referenced in this paper directly evaluated income, education and CVD data utilizing census reports, self-reporting data and medical records.

SES was measured using household income and level of education, any additional information on education, income, and occupation was ascertained through questionnaires. For example, one study measured income using the "median household income level of an individual’s neighborhood of residence on 1, April, 2002 from the 2001 Canadian Census. Neighborhoods were defined using small geographic units (dissemination areas) from Statistics Canada" (Booth et al., 2012).

Woodward et al. (2015) measured education by using self-reported data, falling into one of three groups. Group one had no completed education or completed only primary school. Group two composed of people who completed secondary school; and lastly group three completed tertiary education (university or college).

Booth et al. (2012) recorded "baseline CVD, acute myocardial infarction, and stroke, based on relevant diagnostic codes from hospital discharge records. Co-morbidity was captured using diagnostic codes listed in hospital records and physicians’ service claims from the year prior to baseline to create distinct case-mix categories based on the Johns Hopkins Adjusted Clinical Groups case-mix system."

If blood pressure and cholesterol levels were used to determine CVD risk, they were obtained using standard protocols as in Woodward et al. (2015) and Winkleby et al., (1992).

The CCHS is a cross-sectional study in Canada that measures rates of different health outcomes in the country. The most recent complete survey data is from 2014. Based on the survey design, the most efficient way to access the rates of CVD was by studying those who self-reported having heart disease. Data was collected for those with heart disease and was then compared to level of education and to person income. Only the data for those aged 55 to 79 was analyzed.

When studying the rates of heart disease in both older adult males and females it was noted that the highest rates were in those that had completed post-secondary education followed secondly by those who had not completed secondary education (Statistics Canada, 2016). It is likely that there are confounding factors that create the high rates of heart disease in those with the highest education level. In males, 26.7% of heart disease occurs in those with less than secondary education, 18.2% in those who had completed secondary education, and only 2.7% of those who had completed some post-secondary education (Statistics Canada, 2016). Similarly for females, 31.8% of heart disease occurs in those with less than secondary education, 22.2% in those who had completed secondary education, and only 3.0% of those who had completed some post-secondary education (Statistics Canada, 2016). This data shows that to a certain extent, an increase in education is correlated with a decrease in heart disease.

Impact of Socioeconomic Status on Older Adults with Cardiovascular Diseases

When comparing rates of heart disease to income levels it is found that those with income rates less than $20,000 to $39,999 had significantly greater rates of heart disease (Statistics Canada, 2016). For males, 23.2% of all heart disease occurs in those with less than $20,000 income and 33.6% occurs among those with $20,000 to $39,000 income (Statistics Canada, 2016). In females, 46% of all heart disease occurs in those with less than $20,000 income and 35.4% occurs among those with $20,000 to $39,000 income (Statistics Canada, 2016). In both male and female populations the rates continue to drop as income rises with rates in the final category, income greater than $80,000, at 12.3% for males and 2.8% for females (Statistics Canada, 2016). A very clear correlation can be noted between that of low income and heart disease.

The social determinants of health (SDOH) model (WHO, 2010) is the conceptual model (refer to Appendix A) used to show how political, social and economic mechanisms strongly influence an individual's’ socioeconomic position.  In addition, there are three major factors which influence an individual’s health, which are: material, psychosocial and biological and behavioral factors (WHO, 2010).  Material factors are things like housing, community environment, and place of employment (WHO. 2010).  Psychosocial factors are one’s family, friends and social networks (WHO, 2010).  Lastly, biological and behavioral factors are things like lifestyle choices, genetics, nutrition, and personal health habits (WHO, 2010).  All of these factors affect an older adult’s ability to access health care and as a result influence their risk of developing cardiovascular disease (CVD).

The SDOH model (WHO, 2010) specifically addresses the two determinants of health: income and education which are related to an increase in CVD in older adults.  Both income and education fall under the category “material factors” because they are specifically related to financial gain and the attainment of skill/s (WHO, 2010).  Income is a major determinant of health because it most directly measures material resources and also has a cumulative effect over an individual’s life course as it’s the one socioeconomic indicator that can change the most quickly, as income varies often (Havranek et al., 2015).  Studies have shown that after controlling other sociodemographic factors, there was a 40-50% decrease in mortality from CVD with increasing family income (Havranek et al., 2015).  The SDOH model discusses how several factors result in low income increasing one’s risk of CVD and other illnesses, for example: income inequality causes stress for those who make less money, resulting in poorer health; income inequality results in fewer economic resources for poorer individuals resulting in less treatment options; income inequality results in less money to invest in better social and economic conditions leading to living in poorer neighborhoods and attending schools that are of lesser quality resulting in poorer health outcomes (WHO, 2010).

Assessing Social Determinants of Health and Cardiovascular Diseases in Canada

Education is the second determinant of health that is linked with an increased risk of CVD in older adults and the SDOH model addresses this as well (WHO, 2010).  In Canada, studies have shown a strong correlation between CVD and one’s level of education, CVD morbidity and mortality rates have an increased risk when an individual has a lower level of education (Kreatsoulas, 2010).  Education is a life course determinant as it begins in early childhood (influenced by one’s parents) and develops along the lifespan (WHO, 2010).  The knowledge and skills attained through education makes it easier to understand health messages and make informed choices regarding health and well-being throughout one’s lifespan (Kreatsoulas, 2010).

Overall, the SDOH model (Hosseini et al., 2017)) is able to show how the material factors of both income and education are present as social determinants of health.  When income and education levels are reduced the risk of developing CVD is increased; on the contrary, when income and education levels are higher, an older adult has a lifetime decreased risk of developing CVD (Havranek et al., 2015).

Public Health interventions that target material factors (socioeconomic status and education) from the Social Determinant of Health Model will help to decrease CVD in older adults. Interventions that address socioeconomic status (SES) will uncover greater reasoning for gaps in policies which will help to address physical activity, nutritional habits and smoking habits (Campbell et al., 2012; Booth et al., 2012). Booth et al. (2012) suggests that interventions that address SES will uncover that older adults with lower income are unable to pay for expensive medications, especially due to lack of an insurance plans, thus policies need to address this. Canadians with lower SES tend to use more healthcare services that have little impact on CVD due to lack of income to obtain healthier lifestyle changes (Campbell et al., 2012).


Research suggests that there are gaps in awareness of pre-CVD symptoms and treatment (Joffres, 2013), especially within third world countries and low- middle income households (Maurer & Ramos, 2015). Low-cost treatments exist for CVD management, but many older adults are unaware of them (Maurer & Ramos, 2015). Many older adults are also unaware that they are manifesting symptoms for CVD and interventions need to increase educational efforts especially within small rural communities (Maurer & Ramos, 2015). Interventions that address the lack of education to include incentives for healthcare professionals to screen older adults for hypertension yearly will not only increase awareness but will also help to change unhealthy behaviour (Maurer & Ramos, 2015; Campbell, 2012; Bloetzer et al., 2015). Research indicates that plans for interventions have been made to increase CVD awareness in numerous countries, but there seems to lack implementation and evaluation of programs (Maurer & Ramos, 2015; Joffres et al., 2013).

SDOH Model for Cardiovascular Diseases in Older Adults

England is leading in public health interventions by using government organizations to promote and educate the public on the risk of salt and implementing a bonus payment initiative to general practitioners to achieve targets for hypertension care (Joffres et al., 2013). The Public Health Agency of Canada (PHAC) suggests that education efforts need to extend to hard to reach populations such as Indigenous communities and healthcare professionals need to be conscience of individuals who may not seem to be at risk (Campbell et al., 2012). The PHAC aso suggests that policies need to be transparent and take an upstream approach through cabinet level committees to include incentives for collaboration (Campbell et al., 2012).

Finland has implemented a sodium reduction strategy in 2010 that was very effective in treating and controlling hypertension, reducing medical costs and preventing CVD disease earlier in patients (Campbell et al., 2012). Policies that create supportive environments make healthy choices easier by include reducing sodium in processed foods like Finland, restricting processed trans fats, allowing low income households to afford healthy food and creating pricing policies to restrict energy-dense foods (Campbell et al., 2012). Healthy interventions need to reflect community needs (Campbell et al., 2012). Canada has implemented healthy food procurement policies in public schools to remove soft drinks and junk food, but this could be taken a step further to implement this policy in health care facilities, workplaces, correctional institutions and military bases (Campbell et al., 2012). The United Kingdom has implemented a total ban on junk food ads during children’s programs and adult programs at peak watching times, which could also be implemented in Canada to help prevent CVD earlier than in senior age (Campbell et al., 2012).

Alternative programs not already discussed include community-linkage systems and environmental approaches to prevent CVD. (Greenlund et al., 2012)

Greenlund et al., 2012, describe successful community programs such as the, Sickness Prevention Achieved Through Regional Collaboration (SPARC) which coordinate with community partners to deliver screening and preventative healthcare such as a set of recommended immunization, cancer, and CVD screening services to older adults in places where they can be easily accessed. 

Environmental approaches include promoting healthy choices, availability, accessibility to information, and resources for the entire population, not just high risk groups. For example the Center for Disease Control (CDC) is working with restaurants and food manufactures to reduce the amount of sodium in processed and restaurant foods. (Greenlund et al., 2012).

Public Health Implications


Historically these initiatives have been successful. In the past, government agencies and the food industry have worked together to “address nutritional problems by fortifying foods with minerals and vitamins (e.g., vitamin D fortification of milk to prevent rickets, niacin fortification of flour to prevent pellagra, and folic acid fortification of flour to prevent neural tube defects).” (Greenlund et al., 2012).

Unfortunately these type of changes take time, lifestyle changes, and significant resources and may require government subsidies to bring about change. The 2010 Healthy Hunger-Free Kids Act costing approximately $10 billion annually (Healthy, Hunger-Free Kids Act of 2010, n.d) is an example of a government initiative to reduce childhood obesity, a preventative strategy against obesity, CVD, diabetes and various health related problems. The act has both pros and cons and has been all but eliminated by the Trump administration. Successes of the program include, “increased nutritional value, iron, calcium, vitamin A, vitamin C, and protein nutrition” and decreased caloric intake, which benefited children with obesity (Cornish et al., 2016). However the program also had its critics. Students complained about poor portion sizes, bland food and a study published by the Harvard School of Public Health “discovered that about 60 percent of vegetables and roughly 40 percent of fresh fruit are thrown away due to no interest.” (Healthy, Hunger-Free Kids Act of 2010, n.d)

Public health interventions are clearly beneficial for the reduced risk of CVD. It is imperative that investments are made towards health education with a focus towards individuals from lower income and socioeconomic households.

Conclusion

Income and social determinants have generally determined the CVD prevalence in Canada. It has been shown the CVD’s prevalence in high -income economies. Also, Canadians with lower SES tend to use more healthcare services that have little impact on CVD due to lack of income to obtain healthier lifestyle change. In Canada, it is expected that CVD will still be the leading cause of death even by 2030. The CVD is a major issue in Canada since it accounts for higher number of deaths than any other illness in the country. Because of the higher magnitude of CVD in Canada, the studies are being directed towards the social determinants of health (SDH). These are the risk factors “causes of causes”). Thus Canada wants to control the impacts of social environment on people sharing a community as mechanism to reduce CVD prevalence. The implications of this study is that Public Health interventions that target material factors (socioeconomic status and education) from the Social Determinant of Health Model will help decrease CVD in older adults. The future study should focus on interventions that address socioeconomic status (SES) to uncover greater reasoning for gaps in policies. This will help address physical activity, nutritional habits and smoking habits.

References

American Heart Association. (2016). Statistical Fact Sheet 2016 Update: Older Americans & Cardiovascular Diseases. Retrieved from https://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_483970.pdf

Havranek, E. P., Mujahid, M. S., Barr, D. A., Blair, I. V., Cohen, M. S., Cruz-Flores, S., & ..Yancy, C. W. (2015). Social Determinants of Risk and Outcomes for Cardiovascular      Disease. Circulation, 132(9), 873-898. doi:10.1161/CIR.0000000000000228

Hosseini, S., Arab, M., Emamgholipour, S., Rashidian, A., Monterzari A., & Zaboli, R. (2017).

Conceptual Models of Social Determinants of Health: A Narrative Review. Iranian 

Journal of Public Health, 46(4), 435–446.

Kreatsoulas, C., & Anand, S. S. (2010). The impact of social determinants on cardiovascular        

disease. The Canadian Journal of Cardiology, 26(Suppl C), 8C–13C.

Public Health Agency of Canada. (2017a). Canadian chronic disease surveillance system methods report abridged version for v2015 and v2016 (Dementia, Including Alzheimer’s Disease). Retrieved from https://infobase.phac-aspc.gc.ca/ccdss-scsmc/data-tool/Methods

Public Health Agency of Canada. (2017b). The 2017 Canadian chronic disease indicators. Health Promotion and Chronic Disease Prevention in Canada Research, Policy and Practice, 37(8), 248-251. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-37-no-8-2017/ar-03-eng.pdf

Public Health Agency of Canada. (2017c). Public health infobase: Canadian Chronic Disease Surveillance System (CCDSS). Retrieved from https://infobase.phac-aspc.gc.ca/CCDSS-SCSMC/data-tool/?l=eng&HRs=00&DDLV=CDSAMI&DDLM=ASIR&1=M&2=F&DDLFrm=1999&DDLTo=2012&=10&VIEW=2

Raphael, D. (2016). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars Press Inc.

Statistics Canada. (2016). Canadian Community Health Survey – Annual Component (CCHS). Retrieved from https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226

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Social determinants of health. Retrieved from:https://www.who.int/social_determinants/corner/SDHDP2.pdf page 9

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 Table 1, 2 Statistics Canada. (2016). Canadian Community Health Survey, 2014: Annual component [public-use microdata file]. Ottawa, Ontario: Statistics Canada. Health Statistics Division, Data Liberation Initiative [producer and distributor]. Retrieved From https://odesi1.scholarsportal.info.ezproxy.lakeheadu.ca/webview/index.jsp?object=http%3A%2F%2F142.150.190.11%3A80%2Fobj%2FfStudy%2Fcchs-82M0013-E-2014-Annual-component&headers=http%3A%2F%2F142.150.190.11%3A80%2Fobj%2FfVariable%2Fcchs-82M0013-E-2014-Annual-component_V100

Table 3, 4 Statistics Canada. (2016). Canadian Community Health Survey, 2014: Annual component [public-use microdata file]. Ottawa, Ontario: Statistics Canada. Health Statistics Division, Data Liberation Initiative [producer and distributor]. Retrieved From https://odesi1.scholarsportal.info.ezproxy.lakeheadu.ca/webview/index.jsp?object=http%3A%2F%2F142.150.190.11%3A80%2Fobj%2FfStudy%2Fcchs-82M0013-E-2014-Annual-component&headers=http%3A%2F%2F142.150.190.11%3A80%2Fobj%2FfVariable%2Fcchs-82M0013-E-2014-Annual-component_V100

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