The Canadian Chronic Disease Surveillance System reports that heart disease is the leading cause of death globally with a death toll of 8.9 million people, which is 45% of all non-communicable deaths worldwide (Public Health Agency of Canada, 2018). In Canada alone, heart disease accounts for 20% of all deaths and is the second leading cause of death after cancer (Public Health Agency of Canada, 2018). Heart disease does not discriminate. 1 in 12 Canadians aged 20 years and older are diagnosed with ischemic heart disease, and the prevalence of heart disease in Canadian adults from 2000-2013 increased from 251,000 to 578,000 (Public Health Agency of Canada, 2018). Heart disease is a type of chronic disease. Chronic diseases are characterized as long-term diseases that develop slowly over time often progressing in severity and though can often be controlled, they can rarely be cured (Ministry of Health and Long Term Care, 2007). Chronic diseases are becoming a financial burden to the Canadian healthcare system with 80% of those over the age of 45 living with a chronic condition such as diabetes (9%) and high blood pressure (30%) (MOHLTC, 2007).
But what is heart disease? The Public Health Agency’s report: Canadian Chronic Disease Surveillance System defines heart disease as a condition in which the heart muscle is damaged or does not function properly. This can be contributed to the development of plaque on the inner walls of the coronary arteries and over time hardens and/or ruptures. When plaque narrows or ruptures, blood flow to the heart tissue is obstructed causing a heart attack (also known as an acute myocardial infarction). Repeated myocardial infarctions can lead to heart failure (inability of the heart to effectively pump blood to the body), cardiac arrhythmias (abnormal heart rhythms that can lead to instant death) or strokes (2018).
Figure adapted from Jessup M. et al and Dzau VJ et al.
Now that we’ve discussed what heart disease is, lets define the contributing factors. Preventable, behavioural risk factors such as poor diet; physical inactivity; smoking and alcohol use all contribute to an individuals risk of developing heart disease later in life (Government of Canada, 2018). Chronic health conditions that can contribute to heart disease include hypertension; diabetes; high cholesterol; obesity and mental health factors such as depression and anxiety (Government of Canada, 2018 & Valtora N, Kanaan M, Gilbody S, Ronzi S and Hanratty, B., 2016).
The final component of contributing factors includes socioeconomic status (SES). Socioeconomic status is an influential determinant of health and includes: where an individual lives; education and employment status; income; race or culture (Winter et al. (7th Eds). pp 176-204). Those with poor SES have demonstrated higher rates of obesity; smoking; higher alcohol consumption; higher stress; and a high fat diet (Winter et al. (7th Eds). pp 176-204). Poorer SES is attributed to increased rates of depression and anxiety, oftentimes leading to unhealthy coping mechanisms( like alcohol and poor dietary choices) in addition to decreased education (Valtora et al, 2016).
So, up to this point we’ve reviewed the statistics and the pathophysiology of heart disease, as well as the causative and influencing factors separately. Now, lets examine these factors contributing to heart disease all together using the Social Ecological Model (SEM) pictured below. The SEM examines the policy; community; organizational and interpersonal factors that affect an individual’s health.
POLICY
By recognizing the modifiable risk factors of heart disease (smoking, alcohol use, healthy diet, and exercise) the Ontario Ministry of Health and Long Term Care (MOHLTC) operates Programs for Health Promotion and Disease Prevention. This program aims to develop community-based programs among Public Health Units across Ontario in collaboration with health service providers; health and community organizations; schools; businesses and volunteers (Ministry of Health and Long Term Care, 2012). These programs include the FOCUS Community Program that focuses on alcohol and substance abuse prevention. FOCUS also includes ACTION: The Alcohol, Cannabis and Tobacco Health Promotion Project for Youth; ODAP: The Ontario Drug Awareness Partnership; FYI: The Family and Youth Information Program; CODA: Preventive Education Programs and Information Services at the Council on Drug Abuse; and APN: The Alcohol Policy Network (MOHLTC, 2012).
The MOHLTC also operates The Heart Health Program, a $17 million, 5-year investment movement in preventing cardiovascular disease. This is largest program of its kind delivered in North America and is provided through public health units and their local partners across Ontario. The goal of this program is to raise public awareness and encourage health promoting factors such as smoking cessation and avoiding tobacco use, eating a healthy low- fat diet and staying active throughout life (MOHLTC, 2012). The Heart Health Program also operates the Heart Health Network, a provincial network of health professionals working in the field of cardiovascular disease prevention (MOHLTC, 2012). The MOHLTC also takes into account the SES of individuals by operating the Best Start program that target the health of women and families before, during and after pregnancy and includes smoking cessation, alcohol-abuse prevention, and healthy nutritional habits. They also drive Better Beginnings, Better Futures as well as Healthy Babies/Healthy Children. These programs focus on children in high-risk neighbourhoods to develop healthy habits early in life as a way to prevent chronic health issues (like cardiovascular disease) into adulthood (2012).
COMMUNITY
The Heart and Stroke Foundation is an example of a community resource according to the SEM. The Heart and Stroke foundation provides evaluated peer-reviewed studies for health practitioners, as well as research programs and funding to support researchers in heart disease. The Heart and Stroke foundation also address and provides research into health disparities. These include social, cultural, environmental and population health research. When examining health disparities, the Heart and Stroke foundation identifies two priority focuses: (1) Women’s health (2) Indigenous Health (2018). According to the Rural and Northern Health Care Report released by MOHLTC, access to quality health care in rural, remote and northern communities is a long-standing issue in Ontario and includes many health disparities (2011). The report determined:
1) Statistically higher proportions of rural residents reported having a fair/poor health status compared with urban Canadians
2) Significantly greater proportions of rural Canadians aged 20 to 64 years reported being overweight than urban Canadians
Challenges that led to health disparities included:
Access across the continuum of care
Decreased availability of health care services across local communities due to health resources infrastructure or other factors (lack of community services, primary care/family health teams, emergency medical services and public health programs)
Limited availability of cultural and linguistically appropriate services
Scarcity of resources
Lack of transportation and travel distance
Limited sharing of health records and information across health professionals (2011).
Local Health Integration Networks (LHINs) are assigned the accountability to coordinate health care services that meet the needs of the local community (Rural and Northern Health Care Report, 2011). Research demonstrates that individuals who participated in a congestive heart failure program that coordinated care and provided education for them and their families had over 60% fewer re-admissions to hospital (Preventing and Managing Chronic Disease, 2007).
ORGANIZATIONAL
Organizational factors take cues from the community and policy resources. An example of organization factors for cardiovascular disease include the Consumer Health Information Service and the Public Health Districts that are operated by the Public Health Agency of Canada. SES greatly affects the organizational level as well. Depending on an individual’s education and employment status, health insurance plans and their coverage is variable. As a general rule, wealthy people tend to be healthier than those of poorer financial means (Winter et al. (7th Eds). pp 176-204). Low socioeconomic status affected by education, occupation or income has been associated with increased rates of hypertension in both men and women (Winter et al. (7th Eds). pp 176-204). Access to multidisciplinary healthcare professionals including physicians; nurse practitioners; nurses; pharmacists; occupational therapists; dieticians, etc. can be integral in the difference between positive and negative health outcomes. Social disparities due to lack of resources and funding from a policy and community level may also affect the organizational level as well.
Public Health Ontario organizations are widespread across Ontario and run many programs aimed at evidence based research; resources; scientific and technical advice; and responds to needs as identified by the public (Public Health Ontario, n.d). Public Health of Ontario provides many peer reviewed journals in relation to cardiovascular disease and provides external links to the World Health Organization; Public Health Agency of Canada; and Centers for Disease Control and Prevention.
INTERPERSONAL
The policy, community and organizational levels set out by the SEM are demonstrated at the interpersonal level. The Canadian Chronic Disease Indicators measured a rate of 84.6% of the population aged 12 and older reports having a regular health care provider. This same report indicated that 61.1% of the Canadian population aged 12 and above rates their physical health as “very good or excellent” and 70.3% their mental health as “very good or excellent” (2019). These numbers demonstrate that health disparities are affecting 20% to 40% of the population that deem their health as less than very good and do not have access to, or are not receiving regular medical care through a provider.
These results are concerning as rates of newly diagnosed myocardial infarction cases were 222.2 per 100,000 people and newly diagnosed heart failure cases were 535.6 per 100,000 people in the 2016-2017 year (The Canadian Chronic Disease Indicator, 2019). Having regular access to a healthcare provider is a mainstay according to the SEM. This is an example of one health disparity that was previously mentioned in the community section. In addition, this is when we see poor SES affect an individual's health. Deficiencies in social relationships are associated with a higher risk of developing cardiac disease. Among this population, we also see higher rates of smoking; obesity; and alcohol consumption as a a coping mechanism (Valtorata et al. 2016).
Improving health outcomes goes beyond the individual. Regardless of the SES, all Canadians require access to health practitioners; programs; well-funded centres with treatment options; health education and provincial funding as demonstrated by the SEM. Despite the advancements made in healthcare funding, research and provisions; we still see health disparities and an increase in chronic disease. As a country we are utilizing and recognizing the importance of the SEM and becoming more connected in the care of an individual. As we utilize this knowledge, healthcare transformation will continue to evolve and hopefully provide an end to cardiovascular disease.
References
Heart and Stroke Foundation (2018). Retrieved from https://www.heartandstroke.ca/research/strategy/funding-excellence
Ministry of Health and Long Term Care: Ontario Programs for Health Promotion and Disease Prevention. (2012). Retrieved from http://www.health.gov.on.ca/en/public/publications/hpromo/hpromo.aspx
Ministry of Health and Long Term Care. Preventing and Managing Chronic Disease: Ontario’s Framework. (May 2007). Retrieved from http://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf
Ministry of Health and Long Term Care. Rural and Northern Health Care Report. (2011). Retrieved from http://www.health.gov.on.ca/en/public/programs/ruralnorthern/report.aspx
Public Health Agency of Canada, 2018. Report from the Canadian Chronic Disease Surveillance System: Heart Disease in Canada. (2018). Retrieved from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/report-heart-disease-Canada-2018.html#s2-3
Public Health Ontario. Health Promotion, Chronic Disease and Injury Prevention. (n.d.) Retrieved from https://www.publichealthontario.ca/en/about/our-organization/departments/hpcdip
Valtorta NK, Kanaan M, Gilbody S, et al
Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies Heart 2016;102:1009-1016.
Varin M, Baker M, Palladino E, & Lary T. (2019). Canadian Chronic Disease Indicators, 2019- Updating the data and taking into account mental health. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-39-no-10-2019/EN_2_Varin.pdf
Winters-Miner, L. Bolding, P. S. Hilbe, J.M. Goldstein, M. Hill, T. Nisbet, R. Walton, N. Miner, G. D. (2015) Practical Predictive Analytics and Decisioning Systems for Medicine. (7th Eds.) Personalized Medicine (pp 176-204). Academic Press
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