Social Determinants of Health in Elderly Chronic Disease Management

Introduction

While the health of Canada's population compares favorably to many other developed economies, the prevention and management of chronic diseases among the elderly present the greatest challenge to the country's healthcare system. Today, seniors tend to live longer, as they are healthier and economically better off compared to previous generations. However, as they age, studies reveal that the elderly suffer increasingly from chronic diseases that place extra burdens on the healthcare system. Canada's elderly population is highly prone to poverty and has the greatest demands for community, home, and acute care services (Belanger, Gosselin, Valois, & Abdous, 2014). The lack of government support and the shortage of home care nurses mean that most seniors are confronting the health challenges of aging largely on their own. As a result, the only healthcare alternatives for many are emergency ambulance transport and hospital admission (Belanger, Gosselin, Valois, & Abdous, 2014).

Little is known about the distinct impact of social determinants of health on chronic disease management for the elderly in Canada. However, it is evident that the spiritual, emotional, and physical dimensions of chronic disease management among this population are influenced by a variety of social determinants. This literature review focuses on three major social determinants: access to health services, physical environment, and income and social status. These factors influence the management of chronic diseases among the elderly along a continuum from excellent to poor health. As Cott, Gignac, and Badley (1999) observed, "illness-related variables were associated with poor health, with smaller but significant contributions from demographic and lifestyle factors" (p. 731).

Access to health services, physical environment, and income and social status all influence the health vulnerability and chronic disease management of the elderly. This population is not only a burden on the national healthcare system but is often restricted from access to resources that could ameliorate their problems. The three determinants not only influence the diverse health outcomes of seniors but also trigger health complications that reflect and reinforce subsequent health determinants (Mery, Wodchis, & Laporte, 2015). For example, living in low-income households is associated with high levels of illness and disability, which in turn diminishes opportunities for gainful employment, thereby aggravating poverty and chronic disease among the elderly.

Researchers in this area have reached tentative agreement regarding these three determinants of health as they relate to chronic disease management of the elderly in Canada (Belanger, Gosselin, Valois, & Abdous, 2014). The contexts and mechanisms through which these determinants influence the health of this group have been articulated clearly, and for decades researchers have been mapping the complex interconnections among them, demonstrating these linkages in empirical formats (Belanger, Gosselin, Valois, & Abdous, 2014).

Access to Health Services

Penman-Aguilar, Talih, Huang, Moonesinghe, Bouye, and Beckles (2016) examined health inequities and social determinants of health in support of advancing health equity. They report that Canadians must have social, physical, and political access to healthcare services in order to experience the benefits of the country's advanced system. However, this is often not the case for Canadian seniors suffering from chronic diseases. The nation's system of healthcare delivery for seniors with chronic diseases reflects a program characterized by fragmented delivery, limited accountability, and jurisdictional ambiguity. Salzman, Collins, and Hajjar (2012) added that present healthcare services for chronic diseases among the elderly remain focused on communicable illnesses, even as morbidity and mortality among the elderly are increasingly attributable to chronic illness. Similarly, social access to healthcare is limited for the elderly because the system accounts for neither the age nor the social position of seniors when determining their healthcare needs (Salzman, Collins, & Hajjar, 2012).

Compared to other populations, elderly people living in rural areas face particular challenges in accessing healthcare services for their chronic illnesses, including long waiting lists, services not covered by the Non-Insured Health Benefit (NIHB) Plan, and the absence of nurses or doctors in their communities (Salzman, Collins, & Hajjar, 2012). Researchers have also cited frequent cases of inadequate or culturally inappropriate health provision. Because many Canadian seniors live in isolated and rural communities, geographic distance presents a significant obstacle to accessing needed healthcare services (Cott, Gignac, & Badley, 1999).

For the roughly 50% of Canada's seniors living in remote and rural areas, lack of transport, low population density, long waits, and inadequate human resources constitute significant obstacles to healthcare access. Low population density and large distances imply greater per capita delivery costs, which in turn translate into fewer health professionals and reduced access to health services for seniors living with chronic illness (Penman-Aguilar et al., 2016).

This geographic remoteness is particularly pronounced in Northern Canada, a region characterized by remote and rural communities. Belanger, Gosselin, Valois, and Abdous (2014) focused on individual and contextual determinants of home care usage and found that, of the Inuit Nunaat communities that hold the majority of Canada's Inuit population, only a few have hospitals and none have year-round road access. In such communities, healthcare is typically provided through health facilities staffed by nurses rather than physicians. Seniors with chronic diseases are less likely to access specialized healthcare experts such as family physicians, dentists, and other medical specialists, largely because these experts are non-residents who are flown into communities only for short periods. The isolation and remoteness of such communities also lead to low retention rates among health professionals (Cott, Gignac, & Badley, 1999).

Most Canadian seniors battling chronic illness live in rural communities characterized by a critical shortage of medical personnel. Canada's nursing sector is under strain, and from a proportional perspective the number of doctors serving this population is said to be "under half of that serving the cities" (Mery, Wodchis, & Laporte, 2015). Low retention rates combined with the absence of permanent health professionals leads to less continuity of care, which lowers the effectiveness of health services for chronic disease management among the elderly. For instance, patients must navigate lengthy paperwork procedures that can take days or months before they obtain a drug exemption for a medication not listed on the NIHB program's drug benefit list. For the elderly, this process is especially burdensome because patients must depend on visiting health experts who are available for appointments only once a month (Mery, Wodchis, & Laporte, 2015).

According to Penman-Aguilar et al. (2016), lack of access to healthcare services for the management of chronic diseases among the elderly has had numerous implications. These patients are often forced to leave their communities to access specialized care, typically being transferred to cities for medical appointments, emergencies, hospitalizations, and diagnosis and treatment. This means they leave behind their support networks and communities. For instance, 10% of seniors with chronic disease in Inuit Nunaat report having been temporarily away from their communities for months due to illness. The absence of interpreters can add further stress to patients who do not speak the dominant language and cannot understand the nature of their disease or their treatment prescriptions. Penman-Aguilar et al. (2016) concluded that "although much is understood about the role of social determinants of health in shaping the health of populations, researchers should continue to advance understanding of the pathways through which they operate on particular health outcomes" (p. S33).

Not only must Canadian elderly people have physical access to healthcare services, but the quality, nature, and appropriateness of those services must also be considered. Salzman, Collins, and Hajjar (2012) point out that healthcare delivery models designed for urban locales are not effective in remote and rural settings. The quality and nature of services are also affected by the timeliness of care. The most notable impact of systemic obstacles to healthcare access — such as the lack of health specialists and long wait times — is the inhibition of early diagnosis of chronic illness (Bradley-Springer, 2012). When the elderly feel they cannot access care regularly or trust their medical specialists, they are less likely to seek help when they experience symptoms. Belanger, Gosselin, Valois, and Abdous (2014) agreed that chronic diseases in the elderly often cannot be detected early, and treatable conditions are discovered only when complete recovery is no longer possible. Researchers have also found that Canada's elderly with chronic disease tend to be diagnosed at later stages, leading to higher mortality rates — a pattern attributed to restricted access to treatment and screening services, coupled with a lack of knowledge about early detection and prevention (Penman-Aguilar et al., 2016).

Conclusion

Previous studies on health in Canada confirm that access to healthcare, income and social status, and physical environment are all essential to positive outcomes in chronic disease management among the elderly. This literature review has surveyed existing published information about social determinants of health as they relate to chronic disease management of the elderly in Canada. While seeking to improve the health of seniors living with chronic disease, intervention approaches must be tailored to their socio-demographic factors and existing knowledge. Strategies adopted must also factor in the socioeconomic circumstances of the elderly in order to encourage positive health behaviors based on theoretically grounded interventions. Drawing on socioeconomic models, such strategies may help change the attitudes of both communities and individuals toward health (Mery, Wodchis, & Laporte, 2015).

Health research institutes, the Ministry of Health, and healthcare organizations should allocate funds to conduct research on chronic disease among the elderly in order to help reduce the prevalence of these diseases. Future researchers should concentrate on qualitative studies examining obstacles to screening, including ways to overcome individual, psychological, and structural barriers. The determinants highlighted in this review have been used to explain and predict individual health outcomes in relation to chronic disease. It is through understanding these three determinants that more affirmative action and appropriate interventions can be devised to change the health status of Canadian seniors living with chronic disease.