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The Role of Physicians in Recognizing and Supporting Treatment of Gambling Addiction (Update 2005)

https://policybase.cma.ca/en/permalink/policy1934
Last Reviewed
2017-03-04
Date
2005-12-03
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2005-12-03
Replaces
Statement on the role of physicians in recognizing and supporting treatment of gambling addiction (2003)
Topics
Population health/ health equity/ public health
Text
The Role of Physicians in Recognizing and Supporting Treatment of Gambling Addiction (Update November 2005) Gambling is a common activity in our society. For a small percentage, this behaviour can become pathological, affecting the well-being of gamblers as well as their families and workplaces. This disorder has been described in the "Diagnostic and Statistical Manual of Mental Disorders" Fourth Edition, (DSM IV) and is recognized as an illness by physicians. Physicians have a role in identifying pathological gambling behaviour and being aware of the resources that exist to treat and support addicted individuals and their families. To assist them in performing this role, the CMA makes the following recommendations: * The CMA supports the development of core curricula in gambling disorders to be offered at undergraduate and post-graduate levels and through CME programs. These could include inter-professional or interdisciplinary curricula developed in partnership with other health professionals. * The CMA supports the development and dissemination of resources to help practising physicians screen patients to identify those with gambling addiction and to provide appropriate treatment. * Governments should ensure the timely availability of quality treatment services appropriate to the age, culture and background of client groups. * The CMA encourages research into gambling addiction, which could include: ­ identifying the biological basis for gambling; ­ identifying best-practice interventions to reduce the prevalence of problem gambling; ­ measuring the social and economic impacts of gambling on individuals and communities; and ­ dispelling the myths surrounding gambling addiction. * Governments and others should work together to implement educational and policy strategies to reduce the prevalence of problem gambling. These could include: ­ elementary school programs to help prevent pathological gambling disorders; ­ limiting the number of gambling establishments, particularly video lottery terminals (VLTs) and casinos; ­ placing age limits on accessibility to VLTs so that children and adolescents are restricted from their use; and ­ promoting lower risk gambling approaches for primary prevention and harm reduction such as gambling only with a predetermined loss limit and not gambling alone.
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Climate Change and Human Health

https://policybase.cma.ca/en/permalink/policy9809
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
Text
Climate Change and Human Health Background Climate change is increasingly recognized as a significant threat facing society and has the potential to be one of the greatest threats to human health in the 21st Century1. While the damage is being done now, many of the health effects may arise only decades in the future2. Possible impacts could include some or all of the following: * Increased mortality, disease and injuries from heat waves and other extreme weather events; * Continued change in the range of some infectious disease vectors (i.e. 260-320 million more cases of malaria predicted by 2080, with six billion more at risk for dengue fever); * Effects on food yields- increased malnutrition; * Increased flooding in some areas and increased droughts in others, along with other impacts on freshwater supply; * Increases in foodborne and waterborne illnesses; * Warming and rising sea levels adding to displacement and also impacting water supply through salination; * Impaired functioning of ecosystems; * Negative effects on air quality associated with ground level ozone, including increases in cardio-respiratory morbidity and mortality, asthma, and allergens; * Displacement of vulnerable populations (especially in coastal areas)1; and * Loss of livelihoods3. Most of the impacts of climate change will result from amplifying the existing health hazards found in populations4. How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities (i.e. disease burden, resources etc.) as well as their adaptive capacity5. The World Health Organization has projected that countries that have, and will likely continue to suffer the greatest effects, are those who have contributed the smallest amount to the causes of climate change.6 While the vast majority of climate change deaths will occur in developing countries with systemic vulnerabilities, a recent Health Canada report has noted that Canada is likely to experience higher rates of warming in this century than most other countries in the world. Climate change scenarios predict an increased risk of extreme weather and other climate events for all regions of Canada, with the exception of extreme cold7. Canadians most vulnerable to climate change include seniors, children and infants, socially disadvantaged individuals, and those with pre-existing medical conditions such as cardiovascular disease8. Those living in cities could be especially vulnerable due to the impact of the heat island effect. However, given their greater access to emergency, health, social, and financial resources, they might also have the greatest adaptive capacity9. The health consequences of climate change have the potential to be more severe in far northern regions. Populations in Canada's north including aboriginals have already begun to see differences in their hunting practices as a result of changing ice patterns10, and the melting of permanent snowpacks11. Changes in ice patterns have also led to increased injuries12. In some places in the North, climate changes have led to greater risks from avalanches, landslides and other hazards13. Further problems are related to the infrastructure in Northern Canada, with some communities already noticing degradation of structures due to the thawing of the permafrost14. Given that much of the Northern infrastructure is already in disrepair, this represents a considerable problem. Geographic isolation, and a lack of resources may further exacerbate the situation15. What CMA has done? Physicians have a critical role to play in advancing public understanding of the potential impact of climate change on health and promoting health protecting responses. The CMA has been working on the issue of climate change and human health for a number of years. CMA was supportive of Canada's ratification of the Kyoto Protocol, and urged the Government of Canada to commit to choosing a climate change strategy that satisfied Canada's international commitments while also maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2007, a number of resolutions were passed at General Council calling on government to properly plan for the health impacts of climate change and put in place measures to mitigate the impact of climate change on vulnerable populations in Canada's north. In that same year, CMA and the Canadian Nurses Association updated a joint position statement first entered into in 1994 calling for environmentally responsible activity in the health-care sector. Most recently, the CMA has been an integral part of the drafting of the World Medical Association (WMA) policies on health and climate change. The WMA Declaration of Delhi on Health and Climate Change was adopted at its annual General Assembly in New Delhi, India in October 2009, The declaration calls for action in five main areas; advocacy to combat global warming; leadership-help people be healthy enough to adapt to climate change; education and capacity building; surveillance and research; and collaboration to prepare for climate emergencies. This policy is written to complement the WMA declaration. What needs to be done? Climate change may lead to significant impacts on human health. While it is unlikely that these outcomes can be avoided, there are some strategies that can be employed to help limit the negative consequences. Education and Capacity Building There is a need for greater public and health professional awareness and education about climate change in order to gain understanding of the health consequences and support for strategies to reduce green house gases and mitigate climate change effects. CMA recommends: 1. A national public awareness program on the importance of the environment and global climate change to personal health; 2. Encouraging health sciences schools to enhance their provision of educational programs on environmental health; and fostering the development of continuing education modules on environmental health and environmental health practices. Surveillance and Research There are important gaps in our knowledge on the health impacts of climate change as well as the effectiveness of various mitigation and adaptation strategies. Surveillance and reporting functions need to be strengthened to allow for greater accuracy in modeling of future impacts. CMA recommends: 3. That the federal government must address the gaps in research regarding climate change and health by undertaking studies to - quantify and model the burden of disease that will be caused by global climate change - identify the most vulnerable populations, the particular health impacts of climate change on vulnerable populations, and possible new protections for such populations; - increase the collection and accuracy of health data, particularly for vulnerable and underserved populations; - report diseases that emerge in conjunction with global climate change, and participate in field investigations, as with outbreaks of infectious diseases; and - develop and expand surveillance systems to include diseases caused by global climate change. Reducing the Burden of Disease to Mitigate Climate Change Impacts How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities. Therefore, work needs to be done to reduce the burden of diseases and improve upon the social determinants of health for vulnerable populations in Canada and globally. CMA recommends: 4. That the federal and provincial/territorial governments work together to improve the ability of the public to adapt to climate change and catastrophic weather events by - Encouraging behaviours that improve overall health, - Creating targeted programs designed to address specific exposures, - Providing health promotion information and education on self-management of the symptoms of climate-associated illness, - Ensuring physical infrastructure that allows for adaptation; 5. That the federal government develop concrete actions to reduce the health impact of climate-related emissions, in particular those initiatives which will also improve the general health of the population; 6. That the federal government support the Millennium Development Goals and support the principles outlined in the WHO Commission on the Social Determinants of Health report; and Preparing for Climate Emergencies To deal with the future burden of climate change related health issues there is a need to ensure adequate health capacity and infrastructure. Rebuilding of public health capacity globally is seen as the most important, cost-effective, and urgently needed response to climate change16. Domestically, there is a need to ensure adequate surge capacity within the health care system to be prepared for an increase in illness related to climate change effects. There is also a need to strengthen not only the health systems, but the infrastructure (i.e. housing) for vulnerable populations including Aboriginals and those in the North. CMA recommends that the federal and provincial /territorial governments work together to: 7. Strengthen the public health system both domestically and internationally in order to improve the capacity of communities to adapt to climate change; 8. Ensure adequate surge capacity within Canada's health system to handle the increase in climate change related illness; 9. Ensure the health of vulnerable populations is adequate to handle climate change related situations; 10. Develop knowledge about the best ways to adapt to and mitigate the health effects of climate change; 11. Integrate health professionals into the emergency preparedness plans of government and public health authorities so that front-line providers are adequately informed and prepared to properly manage any health emergencies. Advocacy to Combat Climate Change Finally, there is a need to take action to reduce the damaging effects of climate change. The global community needs to come together to reduce the levels of green house gases being released in the atmosphere, and focus on safer more environmentally friendly energy sources. Investments in cuts to greenhouse gas emissions would greatly outweigh their costs, and could help to reduce the future burden of climate change related illness17. CMA recommends: 12. That the government of Canada become a global leader in promoting equitable, carbon neutral economic, industrial, and social policies, and practices that fight global warming and adopt specific green house gas reduction targets as determined by the evolving science of climate change. 13. That health care professionals act within their professional settings to reduce the environmental impact of medical activities and to develop environmentally sustainable professional settings; 14. That all Canadians act to minimize individual impacts on the environment, and encourage others to do so, as well. Conclusions The CMA believes that Canada must prepare now for the potential health threat that climate change poses to its population. While many of these effects will take decades to materialize, certain populations, such as those in Canada's north, or those in low lying coastal areas, are already starting to experience the impact of climate change. A focus on education and health promotion, as well as advocacy for improved public policy and primary health care resources will be a good start in dealing with this issue. Additionally, further research and data collection is necessary to improve our understanding of climate change and the effectiveness of adaptation and mitigation strategies. Finally, the global community needs to act together to address the health and environmental impacts of climate change. By working together, in an international response, strategies can be implemented to mitigate any negative health effects of climate change. Canada's physicians believe that: What is good for the environment is also good for human health. It is past time for those of us in the health sector in Canada to engage fully in the debate and discussions within our own house, as well as in the broader body politic to ensure that protecting human health is the bottom line of environmental and climate change strategies. Bibliography 1 Currently a third of the world's population lives within 60 miles of the shoreline and 13 of 20 biggest world cities located on the coast- more than a billion people could be displaced (Costello et.al., 2009) 1 Costello, Anthony et.al. "Managing the health effects of climate change.' The Lancet Volume 373 May 16, 2009. pp.1693-1733. 2 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 3 Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf ; Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.; Friel, Sharon; Marmot, Michael; McMichael, Anthony J.; Kjellstrom, Tord & Denny Vagero. "Global health equity and climate stabilization: a common agenda." The Lancet Volume 372 November 8, 2008. pp.1677-1683. 4Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf; World Health Organization (2009) Protecting Health From Climate Change: Global research priorities. Available at: http://whqlibdoc.who.int/publications/2009/9789241598187_eng.pdf 5 Health Canada (2001) Climate Change and Health & Well-being: A Policy Primer Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/policy_primer-abecedaire_en_matiere/index-eng.php 6 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237 7 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 8 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 9 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 10 Ibid 11 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 12 Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005. 13 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 14 Field, Christopher B. et.al. (2007) North America. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter14.pdf 15 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 16 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 17 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
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Lessons from the frontlines: A collaborative report on Pandemic H1N1

https://policybase.cma.ca/en/permalink/policy9840
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
Text
Lessons from the frontlines: A report on Pandemic H1N1 from Canadian Medical Association, The College of Family Physicians of Canada, National Specialty Society for Community Medicine One year ago, a novel influenza virus claimed its first victim in Mexico, and soon the world was plunged into its first influenza pandemic in 40 years. Although pandemic H1N1 (pH1N1) swept across the globe, we were fortunate this time as the virus was far less virulent than first feared. Now that pH1N1 has peaked and faded, it is time to look at what we learned and how it will help us plan for the next national public health emergency. The College of Family Physicians of Canada, the National Specialty Society for Community Medicine and the Canadian Medical Association have joined together to present a picture of lessons learned from the front lines of the pandemic. Together we represent over 80,000 physicians, of whom almost 50,000 are family physicians, engaged in all aspects of Canada's health care and public health systems. Canada's experience with SARS in 2003 was a "wake-up call"; much changed in its aftermath. The creation of the Public Health Agency of Canada led by a chief public health officer and the Pan-Canadian Public Health Network increased Canada's ability to respond to a public health emergency like pH1N1. The Canadian Pandemic Influenza Plan for the Health Sector, as well as complementary provincial and territorial plans, provides a framework and approach to responding to a pandemic. In many ways, this planning paid off. Canada mobilized quickly in response to the pH1N1 threat. Morbidity and mortality were lower than feared, and 45% of the population was vaccinated. But this response can also be seen as a "dress rehearsal" for a more severe influenza pandemic or some other national public health emergency: a test of our plans and an opportunity to learn from experience, with the time to incorporate these lessons into our strategic planning. Those on the front lines of response understand how health emergencies test our entire system - public health, acute and primary care and the community-based family physician. The success of our response depends on planning and practice, the effectiveness of public health and clinical countermeasures, our health human resources, the surge capacity within our health care and public health systems and our ability to reach the public. One of our greatest challenges in Canada is also to establish a coherent national and provincial/territorial strategy that can be implemented at a local level. Although we believe that Canada's overall response to pH1N1 produced many success stories, there were circumstances that challenged us as health professionals. Both health care and public health need further strengthening, and their separate infrastructures and the interdependence between these structures need attention and bolstering. The following comments focus on two overarching areas that influenced our ability to respond to the pandemic: communications and health system integration. Communications Communication was a consistent source of concern. Channels of communication among the various levels of public health providers were stronger than those for primary care providers, especially family physicians. On 9 Aug. 2009, following the first wave of pH1N1, our leaders wrote to chief public health officer of Canada Dr. David Butler-Jones on behalf of our members to share their thoughts and recommendations on how to improve communications with physicians. Family physicians in particular, but also other front-line health care providers, needed communication that was tailored to the practice setting, resources that were easy to access, and clear messages written in a manner that allowed rapid implementation into clinical practice during health emergencies because the timing of clinical response was critical. We recommended that front-line clinical practitioners be involved in the development of guidelines and the strategies for their dissemination, so that the content could be linked directly to the clinical setting. Family physicians are part of our first line of defence during infectious disease outbreaks. To ensure optimum patient care, they need clinical guidance quickly. Many physicians felt that the urgent need to provide consistent, clinically relevant information was not well recognized by the Public Health Agency of Canada (PHAC), the Public Health Network and, in some cases, provincial, territorial, regional or local levels. It took three months after recognition of the emerging pandemic to publish Interim Guidance for Ambulatory Care of Influenza-like Illness in the Context of H1N1. The current Public Health Network process of federal/provincial/territorial (FPT) consultation and consensus building seemed ill-suited to the acute national need for clinical information on issues such as the use and prescription of anti-viral medications. As provincial authorities and professional medical organizations moved to fill the void, different approaches and recommendations arose independent from one another. Better integration of primary care response by a national organization such as PHAC and the provincial/territorial health ministries could address the needs of clinical practitioners in concert with public health responses. This would also ensure that care directives are translated into user-friendly formats appropriate to clinical settings. We were pleased to be able to work with PHAC in fall 2009 to produce Pandemic H1N1: Fast Facts for Front-line Clinicians. This resource was highly valued by many of our members, and the collaboration demonstrated how health organizations can work effectively with government to contribute their expertise to the development and distribution of appropriate, clinically relevant information. Nevertheless, our critics declared that it was too little, too late. In situations where scientific evidence is rapidly changing, the processes used to distribute information to both front-line public health and clinical professionals must be designed to avoid confusion. Coordinated, unified communication strategies are needed at the national, provincial/territorial and local levels. Regardless of the official source, the information must be consistent. During the pandemic, many physicians and public health workers complained that multiple levels of government provided similar, but not the same advice. The differences led to skepticism, and the inundation of messages led to overload. The bottom line is that clinically relevant and trustworthy information should be provided on a timely basis, even if levels of certainty are fluctuating. Jurisdictions with effective communication to the primary care sector were characterized by cooperation and consultation between the medical community and the provincial, territorial and regional health authorities, both before and during the crisis. We recommend: 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. Surveillance and electronic communications The national response to infectious disease would have been greatly facilitated if system-wide communicable disease surveillance had been in place to support the sharing of data between public health and the rest of the health care system, particularly at the regional and local levels of pandemic response. Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. Real-time data were not available to most physicians and when data did become available, they were already several weeks old. Delayed clinical guidelines were not a suitable substitute for timely surveillance information. Expansion of the use of electronic medical records (EMRs) in primary care, with bi-directional links to public health electronic health records (EHRs), could have facilitated surveillance and communications. Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments and collect the required data for public health. The varied levels of success of public pH1N1 vaccination clinics were further proof of the need to move to standard use of EMRs and EHRs in the health system. Communications can be enhanced through the sharing of data between the public health and primary care systems. EMRs may help resolve the challenge of collecting data from primary care sites. Collaboration among the PHAC, the Canadian Medical Association and the Information Technology Association of Canada's Health Division led to development of a pilot project to demonstrate the use of primary care EMRs as real-time sentinel surveillance tools for public health action to supplement existing surveillance mechanisms. In addition, after a successful two-year pilot project, the College of Family Physicians of Canada is working with the PHAC, in association with the Canadian Institute for Health Information, to conduct surveillance for five chronic diseases using EMRs, local networks across Canada and a national central repository for standardized data. These studies represent the increasingly important role of electronic information in surveillance and the value of collaboration between public health and primary care. We recommend: 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. System issues FPT responsibilities The division of responsibility between federal and provincial/territorial authorities for health care and emergency response influences how we respond to public health emergencies. Provincial/territorial governments have a primary role to play in regulating health matters within their boundaries. At the same time, the federal government has responsibilities related to national public safety and health protection. There can be no disputing the legitimacy of federal involvement in public health matters of an interprovincial/territorial nature. Under International Health Regulations, the federal government also has a responsibility to report and monitor public health emergencies of potential harm to other countries. Since Canada's SARS experience, there has been much progress in building FPT cooperation and increasing consultation on public health matters. However, the division of responsibility has led us to a situation where public health and clinical guidance in each province and territory was similar, yet different. Although the Pandemic Influenza Committee and the Special FPT Advisory Committee on H1N1 Influenza strove for consensus at the national level, individual provinces and territories were under no obligation to implement the guidance agreed to at the FPT level. Consultative and collaborative processes at the FPT level created delays in decision-making and directly interfered with the capacity of front-line professionals to respond to the urgent health needs of their patients. This led to a sense of confusion in the media and a loss of trust among the public and health professionals regarding Canada's capacity to respond to pH1N1. System capacity Canada's health system lacks surge capacity and can be sorely tested during a public health emergency, such as the recent experience with pH1N1. The underdeveloped public health infrastructure also means that it is a challenge to handle more than one national crisis at a time. To mount a response to pH1N1, public health units pulled human resources from other programs and many critical ones were delayed, suspended or cancelled altogether. During the first wave of pH1N1, Manitoba experienced a severe outbreak that stretched the resources of its critical care infrastructure to its limits. Front-line health care providers were inundated with telephone calls from the worried well and an increase in visits from those with flu symptoms. If pH1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees. In 2008, the Canadian Coalition for Public Health in the 21st Century noted that Canada remains vulnerable to the risks presented by epidemics and pandemics. This vulnerability remains today, and a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority if we are to be prepared for the next emergency. We recommend: 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. Public health/primary care partnership Family physicians, in particular, understand that primary health care happens at the local level. In fact, so does all public health. During times of public health crisis, it is crucial for public health and primary care to work together, each respecting, supporting and bolstering the efforts of the other. Strengthening local public health and primary care structures and the interface between them would have resulted in improved, shared understanding of each sector's roles and responsibilities during the pH1N1 epidemic, better communications, improved data sharing and, most important, better served populations. Public health measures are directed toward the mitigation of disease through surveillance, research and outbreak management activities, while physicians provide information, education and clinical treatment to their patients. A commitment from both sectors at the local and provincial levels - and the professionals within each sector - to work together in the inter-pandemic period to build on processes that allow sharing of perspectives and information is essential. It is crucial that local public health authorities receive financial resources to increase their ability to collaborate effectively with family physicians, specialist physicians and other front-line providers. A number of the challenges faced by front-line public health workers and front-line physicians during the pH1N1 outbreak could have been lessened if there had been stronger links within the health system. We recommend: 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. Vaccination A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. Canada was one of the first countries with sufficient vaccine for the population and, with one domestic vaccine supplier, Canada avoided the confusion of multiple formulations as seen in the United States. The outcome was positive, but many public health units were stretched as expectations exceeded the pre-existing constrained resources. Although we recognize that the provinces and territories have quite different approaches to the delivery of their routine immunization programs, there is agreement that the pandemic immunization process did not adequately engage physicians in planning and delivery. A number of difficulties, such as the impact of bulk packaging, manufacturing delays that affected the agreed "sequencing" of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians. These could have been avoided with strengthened interdependence and mutual understanding before this crisis. The great variation in mass vaccination programs between provinces/territories, and even between local public health units, led to public confusion. Recognition of the diversity of primary care settings in which physicians work and bilateral planning in advance of the event is essential, because it is simply not feasible to tailor responses to myriad settings in the heat of the moment. Television broadcasts of long lines of people waiting to be vaccinated contributed to a loss of confidence in the system at a time when public confidence was sorely needed to encourage vaccination. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crisis eroded the public's confidence in the federal, provincial and territorial response. Ensuring future consistency in clinical approaches will require examination of ethical principles for the allocation of resources, such as anti-virals, vaccines and hospital treatment. Public engagement in the discussion of ethical principles is essential and, as much as possible, the consultative process should be transparent and undertaken in advance. We recommend: 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis. Conclusion In 2003, in its submission to the National Advisory Committee on SARS, the Canadian Medical Association noted that the uptake of new information is influenced by many qualitative factors, and that research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Communication processes should be based on sound research and build on existing communication networks and relationships. The College of Family Physicians of Canada has recommended that information networks be strengthened to promote the sharing of the most relevant information among family physicians, other primary care providers and public health at the local level. We believe that PHAC is well positioned to undertake research on how health professionals can best receive information and to catalogue existing communication networks to build them into a well-coordinated national emergency response communication system. We must work together to translate pandemic information into practical messages relevant to front-line providers and employ trusted channels to deliver key messages to our patients and the public. Broad consensus is developing that our experience with the pH1N1 outbreak has shown that one of our greatest needs in preparing for the next public health emergency is for a national communications strategy that involves all levels of government, targets all sectors of our health system and uses the channels with which these targets are most familiar. An effective response to infectious disease outbreaks depends on effective surveillance, data collection and sharing and tracking of clinical interventions. The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the [Public Health] Agency [of Canada] should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." In 2010, Canada still does not have a comprehensive national surveillance and epidemiological system. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration. Greater adoption of the EMR in primary care and better public health EHRs with the ability to link systems will augment existing surveillance capacity and should be considered essential to a pan-Canadian system. Many of the challenges front-line health practitioners faced during the pH1N1 were also challenges during the SARS outbreak in 2003. The Naylor report proposed a number of measures to improve Canada's readiness and strengthen public health. Although a great deal of work and effort has gone into building links with and between provinces/territories and the federal government within the public health and the health emergency management system, little has trickled down to the front lines. This is not to devalue the much-improved spirit of FPT cooperation and the important achievements that have been made. Rather it is to suggest that, as the roof is no longer leaking, it is time to focus attention on the foundation - the response at the local level. Embedding primary care expertise in public health planning within the PHAC and at provincial/territorial and local levels will help circumvent problems and improve the effectiveness of our health system to respond to public health emergencies. A dialogue between primary care and the emergency management structures will help the response team understand and value the capabilities within primary care and build them into their planning and response systems. At the end of the day, we need to nurture collaborative relations between public health and primary care. Our shared objective is protecting the health of Canadians, recognizing that, in reality, neither system can be successful in isolation. It is essential that we trust each other's professionalism and expertise and work together to ensure that a strong foundation is in place to protect Canadians from future health threats. We have the will and expertise. We need the resources and a firm commitment to move forward. We have had two "wake-up calls" - SARS and pH1N1. Let's not wait for a third to find that we are not yet prepared. Recommendations 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis.
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Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession

https://policybase.cma.ca/en/permalink/policy11062
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians. Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1 There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care. Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care. There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars. Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include: (see pdf for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care. On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. Introduction: In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians. Equitable Access to Health Care in Canada: Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4 Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6 Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7 Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11 There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15 Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21 It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23 Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25 Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2 Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30 Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33 However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42 Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43 There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45 Areas for Action: As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access. (See PDF for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers Patient based actions for improving equitable access: Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported. Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health. Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored. There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay. Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58 Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness. Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures. 2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally. 3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. 4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care. 5. Governments explore options to provide funding for long-term care services for all Canadians. 6. Governments ensure that necessary interpretation and translation services are provided at all points of care. Physicians in Practice The CMA recommends that 7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers. 8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live. System based actions for improving equitable access: On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. 1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need. Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60 Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients. More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62 Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63 Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64 One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65 Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66 Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care. The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67 Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70 Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74 Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75 Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions. 2. Better care coordination and greater access to necessary medical services along the continuum of care. Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79 Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care. Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care. 3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate. Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83 The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84 Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians. 4. Health system planning and assessment which prioritizes equitable access to care Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations. Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88 One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90 To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91 Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 9. Governments continue efforts to ensure that all Canadians have access to a family physician. 10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians. 11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care. 12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines. 13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care. Health System Planners The CMA recommends that: 14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians. 15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems. 16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate. Physicians in Practice The CMA recommends that: 17. Physicians be supported in efforts to offer timely access in primary care settings. 18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses. 19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease. 20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health. Conclusion: Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians. References: 1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf 2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014. 1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14). 3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658. 6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 7 Kirby M, Goldbloom D, Bradley L. 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Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6). 25 Bowen, S. Access to Health Services for Underserved Populations in Canada. In Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada: A collection of papers and reports prepared for Health Canada. Ottawa (ON) Health Canada; 2000. Available: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-certain-equit-acces/2001-certain-equit-acces-eng.pdf (accessed 2013 Feb 6). 26 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. Ottawa, ON; 2013. Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.pdf (accessed 2013 Sep 18). 27 Kirby M, Goldbloom D, Bradley L. 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Hamilton (ON) Social and Economic Dimensions of an Aging Population Research Program; 2007. Available: http://catalogue.iugm.qc.ca/GEIDEFile/23002.PDF?Archive=102297992047&File=23002_PDF (accessed 2013 Feb 14). 42 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 43 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. Ottawa(ON); 2012. Available: https://secure.cihi.ca/free_products/PHC_Experiences_AiB2012_E.pdf (accessed 2013 Feb 14). 44 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13) 45 Canadian Institute for Health Information. 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Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 59 Indigenous Physicians of Canada and the Association of Faculties of Medicine Canada, "First Nations, Inuit, Métis Health, Core Competencies: A Curriculum Framework for Undergraduate Medical Education" Updated April 2009, online: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf (accessed October 20, 2010). 60 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2012.Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter13-AchievingHealthEquityinOntario.pdf (accessed 2013 Feb 6). 61 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... ;Bowen, S. Access to Health Services for Underserved Populations..... 62 Williams, R. 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Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 69 Ibid 70 Access Improvement Measures. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCI/RelatedPrograms/AIM/Pages/default.aspx (accessed 2013 Mar 12). 71 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 72 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences... 73 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 74 About Primary Care Networks. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCNs/Pages/default.aspx (accessed 2013 Mar 12). 75 Glazier RH. Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare. Healthcare Papers 2007; 8(Sp):35-45. 76 General Practice Services Committee. Learning Modules-Practice Management. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: http://www.gpscbc.ca/psp/learning/practice-management (accessed 2013 Mar 12). 77 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 78 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 79 Improving Care for High-Needs Patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Toronto (ON) Ontario Ministry of Health and Long-Term Care; December 6, 2012. Available: http://news.ontario.ca/mohltc/en/2012/12/improving-care-for-high-needs-patients.html (accessed 2012 Dec 10). 80 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence... 81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12). 82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18). 83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 84 Ibid. 85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12). 86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6). 87 Bowen, S. Access to Health Services for Underserved Populations... 88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6). 89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30). 90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems... 91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
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The built environment and health

https://policybase.cma.ca/en/permalink/policy11063
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
Text
The Built Environment is part of the overall ecosystem of our earth. It encompasses all the buildings, spaces and products that are created, or at least significantly modified by people. It includes our homes, schools and workplaces, parks, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains and across the country in the form of highways (Health Canada, 1997)." The built environment affects every one of us every day, and mounting evidence suggests that it can play a significant role in our state of health and well-being. This policy statement provides the perspective of the Canadian Medical Association on how the built environment can influence health, and what all sectors in society might do to ensure that community design and development takes the health of residents into consideration. Background In the 19th century, the industrial revolution attracted hordes of people into cities. Congestion, squalid living conditions, and lack of clean water, clean air, and proper sewage systems led to outbreaks of diseases such as cholera and tuberculosis. These events, coupled with the development of the germ theory, served as a catalyst for public and professional awareness of how the built environment has direct health impacts; clean water, fresh air, uncongested living conditions, and proper housing were all recognized as constituents of good health. During the past three decades, the 'Healthy Cities' movement has brought a renewed interest to the health implications of the built environment by focusing on disease prevention through community design. Over the years this idea has proliferated, and a body of literature has grown revealing the large scope of health risk factors that may be influenced by the built environment. The literature indicates that the following connections between the built environment and public health are possible: o Decreased physical activity o Increased prevalence of obesity o Increased prevalence of asthma and other respiratory diseases o Injuries and unintended fatalities o Heat exposure. (Frank , Kavage S, & Devlin A, 2012) (Franks, Kavage & Devlin, 2012; Health Canada 2013) There is also mounting evidence that these factors may be compounded for vulnerable populations such as children, the elderly, and those living in poverty. Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organizations may differ slightly in their view of what smart growth means, its general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. The 'Smart Growth' movement contains tenets that research supports in creating healthy built environments such as mixed land uses, providing transportation alternatives like walking and bicycle infrastructure and public transit, and creating walkable neighbourhoods. (Smart Growth BC, 2012)(See definitions) What the Research Is Telling Us Physical Activity Canada's physical activity guidelines recommend that children from 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week. (Canadian Society of Exercise Physiology, 2011). Participation in regular physical activity bestows substantial health benefits; it can lengthen and improve quality of life and reduce the risk for many physical and mental health conditions. Physical activity can improve overall fitness, lower risk for heart disease, stroke, and high blood pressure, lower risk for non-insulin dependent diabetes and the risk of overweight. (Dannenberg, Frumkin, & Jackson, 2011) Physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. One of the most important determinants of physical activity is a person's neighbourhood. (Jackson & Kochtotzky) Research shows that urban sprawl, access to parks and recreation/fitness facilities, and neighbourhood walkability all may have an impact on physical activity levels (Cutts, Darby, Boone, & Brewis, 2009; Ewing, Schmid, Killingsworth, Zlot, & Raudenbush, 2003). Individuals living in walkable neighbourhood with a mix of land uses and interconnected street networks were found to be 2-4 times more likely to achieve 30 minutes moderate physical activity a day. Urban design characteristics associated with higher physical activity rates include pedestrian-oriented street and site design, parks, trails, playgrounds and other recreational facilities within walking distance and sidewalks. (Frank , Kavage S, & Devlin A, 2012) A barrier to physical activity can be the perception of the lack of a safe place to be active. Safety concerns keep 1 in 5 Canadians from walking or bicycling. Urban design that encourages walking and cycling can improve perceived neighbourhood safety. (Heart and Stroke Foundation of Canada, 2011) There are unique barriers to active modes of transportation in rural communities. Rural environments often lack pedestrian facilities and bike lanes; stores, schools, jobs, and services are sometimes located far apart from homes; and parks and recreation facilities are rare. Understanding these barriers is the first step towards finding opportunities to remove them. (Active Living Research and the Public Health Institute, 2013) CMA' policy on Active Transportation recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation and physical activity. Increased prevalence of obesity Obesity has almost doubled in the past 3 decades; in 1978 the measured obesity rate was 13.8% and in 2008 the measured obesity rate was 25.4% (PHAC/CIHI, 2011). Obesity is associated with high blood pressure, stroke, and heart disease, which are among the leading causes of disability and death (Statistics Canada, 2008). Mental health conditions, type II diabetes, several types of cancer, among many other diseases, are also linked to obesity (Guh, Zhang, Bansback, Amarsi, Birmingham, & Anis, 2009). The combined cost of obesity and these related conditions was estimated to be $4.3 billion dollars in 2005 (Public Health Agency of Canada, 2012). There are many factors involved in this increase, but a causal indicator is the decline in physical activity among Canadians: In 2005, 47% of Canadians were reported as being 'inactive' (Human Resource and Skills Development Canada, 2006). Urban design that encourages sedentary living habits such as work, home, school and shopping separated by distances that discourage walking, parking lots built as close as possible to final destinations not only discourage walking but encourage automobile usage. (Jackson, Kochtitzky, CDC) Less walkable, auto dependent built environments have been correlated with higher body weights and obesity. (Frank , Kavage S, & Devlin A, 2012) Furthermore, research indicates that the food environment that we live in, and the amount of healthy food choices we have access to, can affect the chance of becoming obese as well. For example, neighbourhoods with a high density of fast food restaurants or neighbourhoods with poor access to grocery stores (food deserts) have both been correlated with obesity (Larsen & Gilliland, 2008; Cummins & Macintyre, 2006; Frank L. D., 2009). Increased prevalence of asthma and other respiratory diseases In August 2008, the CMA released a report estimating that the effects of air pollution would result in 11,000 hospital admissions and 21,000 deaths Canada wide, totaling a financial cost of close to $8.1 billion dollar (Canadian Medical Association, 2008). Carbon monoxide, sulfur and nitrogen oxides, volatile organic compounds, ozone, and lead, among other toxins, are emitted into the air every day from industrial processes and car exhaust. These air-borne chemicals are associated with heart disease, cancer, acute respiratory illness, and the aggravation of other respiratory illnesses such as asthma (Frank L. D., 2009). While the built environment does not directly produce these chemicals, it has a role to play in where those chemicals are emitted, where they are concentrated, and, in the case of vehicles, how much of them are produced. Urban sprawl has been tied to longer commute times and higher total vehicle miles traveled per person. Neighbourhood design and walkability have been identified as factors that can affect number of vehicle trips taken and transportation mode choice, and increased mixed land use has been identified as a factor that could further decrease emission rates (Newman & Kenworthy, 1989; Frank, Sallis, Conway, Chapman, Saelens, & Bachman, 2006). Injuries and unintentional fatalities Transport-related injuries accounted for a total of $3.7 billion dollars in healthcare costs in Canada in 2009 (SmartRisk, 2009). The majority of this financial burden was related to motor vehicle, pedestrian, and cycling accidents. Death and injuries from these types of incidents typically happen at a younger age which both increases the years of life lost due to death or disability and the financial burden of continuing care (SmartRisk, 2009). The built environment perhaps has the most identifiable and direct correlation to this category of impacts. Designs of auto-oriented environments that promote high traffic volume, high traffic speed, and low accessibility for pedestrians and cyclists lead to increased incidence of injuries and fatalities (Surface Transportation Policy Partnership, 2002). Increased prevalence of illness and death related to heat exposure The 'urban heat island effect' is a phenomenon correlated with urban environments that are primarily asphalt and concrete and lack vegetation and green space. Such environments have been estimated to have anywhere from 1oC to 12oC higher surface level temperatures in comparison to rural areas (United States Environmental Protection Agency, 2012). This can be especially dangerous for elderly individuals in the summertime and studies have demonstrated increased mortality amongst these populations during hot summers (Centers for Disease Control and Prevention, 2009). This is not only an issue of building materials and the balance of green space but has to do with isolation as well: If elderly residents have poor access to public transportation they may not be able to reach air-conditioned facilities. Noise Exposure Noise - be it from transport, industry, neighbours, or construction - is a prominent feature of the urban environment. Prolonged exposure to environmental noise has been directly linked to physical and psychosocial health outcomes, including hypertension, high blood pressure and heart disease, hearing impairment, stress levels, and sleep. There is some evidence linking noise to reduced ability to concentrate and more aggressive behavior. (Stansfeld SA, 2003) In general, denser neighbourhoods have higher levels of ambient noise through the concentration of more people, traffic, and activities. However, as with air pollution, noise exposure is extremely site-specific and not necessarily exclusive to walkable or auto-oriented neighbourhoods. (Frank , Kavage S, & Devlin A, 2012) Canadian noise mapping data would assist researchers in assessing how environmental noise affects health and assist communities to proactively manage noise pollution. Vulnerable populations The research shows that certain built environment characteristics may affect specific populations such as children, the elderly, low-income populations. Children: Overweight and obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 to 2004 there was a 70% increase in overweight and obese children aged 12-17 (Statistics Canada, 2006). Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopedic complications (Statistics Canada, 2006). Furthermore obesity in childhood has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease (Statistics Canada, 2006). With this in mind, environments that promote physical activity are especially important for this segment of the population. Living in mixed use communities with walkable destinations, parks and recreational facilities is related to greater physical activity. (Dannenburg, Frumkin & Jackson, 2011) Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging (Vogel, Brechat, Lepetre, Kaltenbach, Berthel, & Lonsdorfer, 2009). Being physically active however, requires accessible and safe streets that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population. CMA's policy on Health and Health Care Principles for an Aging Population recommends that communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems or other aspects of the built environment. Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks (Centre for Chronic Disease Prevention and Control. , 2002; Statistics Canada, 1996-97). They are also more likely to smoke, be overweight or obese, and are less likely to be physically active (Creatore, Gozdyra, Booth, & Glazier, 2007). Many of these factors may be due to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options. Recommendations Planning and public health combined efforts in the 19th century to improve living conditions. Today there is a need for health care practitioners, particularly those in the public health field, and community planners to work together, to share their expertise and efforts, to improve the health and well-being of Canadians. By designing communities that encourage and support healthy living - physical activity, healthy weights, access to healthy foods - we can address some of the risk factors for many chronic diseases and create supportive, active communities. Health Care Associations can: o Advocate for health supportive environments by increasing the public and policy makers' understanding of the impact of the built environment on health. o Advocate for the contribution that public health professionals can make to urban planning and development to ensure that population health impacts are recognized and mitigated. o Provide community planners with strong public health arguments and health data to support healthy communities. Health Care Professionals can: o Incorporate an awareness of a patient's built environment (such as housing, access to transportation and healthy foods) into treatment programs and health counseling. o Encourage your community to adopt policies and design principles that build healthy supportive environments. Federal, Provincial and Local Governments can: o Integrate concepts of population health into urban planning. o Promote multidisciplinary planning teams, including professionals in medicine, public health and community design to ensure that all stakeholders take health impacts into account. o Incorporate health impact assessments into community planning and development initiatives in the public sector. o Encourage the private sector to provide infrastructure and amenities in developments that promote healthy living. The Public can: o Learn more about the connection between the built environment and health and advocate for positive change. o Become involved in public consultations regarding local community planning and development. Further Research o Develop research projects at the Federal level on the impact of the built environment on health to inform and help coordinate programs and initiatives at the provincial and local levels. o Focus on creating a standardized set of health indicators that can be uniformly applied to assess the status of a community's built environment. o Research into the effectiveness of policy options on various communities (urban, suburban, rural). Conclusion It is important that we acknowledge how our surroundings can affect our lives and health, and work together to create positive change. The CMA is willing to work with other people and organizations to ensure that the influence of the built environment on health receives the attention that it warrants with the ultimate goal of building or re-inventing healthy communities for all Canadians. Definitions In order of appearance Inactive: "Respondents are classified as active, moderately active or inactive based on an index of average daily physical activity over the past 3 months. For each leisure time physical activity engaged in by the respondent, an average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour) of the activity. The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are classified as follows: 3.0 kcal/kg/day or more = physically active; 1.5 to 2.9 kcal/kg/day = moderately active; less than 1.5 kcal/kg/day = inactive". (Human Resource and Skills Development Canada, 2006). Urban Sprawl: "A particular type of suburban development characterized by very low-density settlements, both residential and non-residential; dominance of movement by use of private automobiles, unlimited outward expansion of new subdivisions and leap-frog developments of these subdivisions; and segregation of land uses by activity." (United States Department of Housing and Urban Development, 1999) Walkability: Walkability refers to the ease with which pedestrians can move within and between environments. The literature gives varied definitions but the main variable to consider are the following: mixed land use (defined below), proximity to destinations (accessibility and convenience), pedestrian facilities (sidewalks, urban furniture etc...), street connectivity (short block lengths, availability of multiple alternate routes etc...), aesthetics (landscape, vegetation, architecture), presences of public spaces (parks, plazas, etc...), presence of traffic calming measures (lower speed limits, street narrowing, speed bumps etc...), and access to transit. (Shay, Spoon, & Khattak, 2003) Transportation Mode Choice: Transportation mode choice refers to an individuals decision regarding how to get from one destination to another. The theory behind mode choice is complex and involves characteristics of the built environment, socio-demographic and socioeconomic variables, benefit-cost analysis, and personal preference. (Cervero, Built Environments and Mode Choice: Toward a Normative Framework, 2002) Mixed Land Use: "Land use mix is the composition of uses within a given geographic area." (Cervero, Land Use Mixing and Suburban Mobility, 1998) The uses referred to can be restaurants, offices, studios, shops, or any variety of business, institution, natural space, or recreation site. In the literature there are various indices and equations used to measure the degree of 'mixed land use' in an area. Urban Heat Island Effect: The urban heat island effect occurs when the sun significantly heats urban surfaces (concrete, asphalt, etc...) to significantly higher temperatures than the surroundings air (can be upwards of 27-50oC). Comparatively shaded or more moist regions (such as rural areas with lots of vegetation) stay much closer to the surrounding air temperature. This heat imbalance between urban surfaces and surrounding air causes heat to transfer from those surfaces to the air, elevated the temperature above what it normally would be. This happens both at a surface and an atmospheric level. (United States Environmental Protection Agency, 2012) Smart Growth: Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organization's may differ slightly in their view of what smart growth means, it's general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. Some of the principles of this movement are as follows: 1). Incorporate mixed land uses into community designs 2). Build compact, accessible neighbourhoods close to jobs and amenities 3). Provide alternative modes of public transportation 4). Diversify housing to meet the needs of people from all socioeconomic classes 5). Maintain and protect natural open spaces 6). Build within existing communities instead of developing beyond community boundaries 7). Preserve agricultural land 8). Use new, sustainable technology in infrastructure and buildings 9). Develop community identity 10). Encourage active citizens to remain engaged in their communities (Smart Growth BC, 2012) Bibliography Human Resource and Skills Development Canada. (2006). Retrieved July 15, 2012, from Indicators of Well-Being in Canada: Physical Activity: http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=8 Active Living Research and the Public Health Institute. (2013). Where the Rubber Meets the Road: Promoting Active Transportation in Rural Areas.. Retrieved September 2013, from Active Living Research : http://activelivingresearch.org/where-rubber-meets-road-promoting-active-transportation-rural-areas Canadian Medical Association. (2008). No Breathing Room: National Illness Cost of Air Pollution. Ottawa: CMA. Canadian Society of Exercise Physiology. (2011). 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Mortality, Summary List of Causes. Health Statistics Division . Ottawa: Statistics Canada. Surface Transportation Policy Partnership. (2002). Mean Streets 2002. Washington, DC: STPP. United States Department of Housing and Urban Development. (1999). The State of the cities 1999: Third Annual Report. Washington, DC: USHUD. United States Environmental Protection Agency. (2012, July 13). Heat Island Effect. Retrieved July 29, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/ United States Environmental Protection Agency. (2012, June 21). Heat Island Effect: Basic Information. Retrieved July 15, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/resources/pdf/BasicsCompendium.pdf Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.
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