Athabasca University's Foundations of Health Systems in Canada is a graduate course that offers an introductory exploration of Canada's healthcare system and its complex, influential factors. For the past thirteen weeks, new learning consisted of curating weekly readings and synthesizing articles while participating with other students through various social media platforms, forum discussions and blog posts. By understanding health and its determinants, I was able to synthesize and integrate the many complexities that make different populations more vulnerable to substance use, human trafficking, and HIV. This blog post will synthesize this course's learning components regarding HIV (Human Immunodeficiency Virus) and some factors that make people more vulnerable to HIV transmission risk and barriers within the care cascade of prevention and management.
Unit 1 – Inter-professional Connectedness
Before exploring health issues within Canada's healthcare system, my classmates and I had an opportunity to meet each other online to share our professional backgrounds and connect via different inter-professional learning networks (Athabasca University, 2018, -1a). This unit's objective was to discover our professional identity and evaluate how we would like to exist in the digital world. As a registered nurse, I must abide by professional standards set out by the College of Nurses of Ontario (CNO). By taking a moment to pause with the advice of the Registered Nurses Association of Ontario (RNAO), "when in doubt, don't post" (n.d., para. 3), I can professionally represent and connect, promote and share accurate, credible and reliable information while engaging in healthy and meaningful discussions. We also had an opportunity to develop a digital presence by creating an electronic portfolio to display professional accomplishments, credentials, ongoing research, and curate scholarly citations. I used the reference manager software program Zotero (2016) to curate, cite and share.
Video 1
Reflect Before you Post
(CNO, 2013)
Unit 2 – Federal and Provincial Health Systems in Canada
In this unit, I reflected upon my nursing profession and belongingness within my local organization and expanded into the healthcare system's broader provincial and federal levels. As a registered nurse, the Regulated Health Professions Act 1991 and the Nursing Act 1991 determine Ontario's nursing profession within Canada's Health Act (CNO, 2020). Through various readings, I learned that Canada's Health Act has only minimally progressed throughout the years despite the ever-changing population and needs. Only the "medically necessary" hospital and physician services and "medically required" physician services are universally covered, while some services such as medications, dental care, long-term care and mental health services are not (Flood & Thomas, 2016, p. 403). For our healthcare system to be truly universal, the first step would be to reexamine modern-day times and address the gaps to determine reasonable and necessary care to improve our changing population's health and well-being.
Unit 3 – Health of Canadians – Understanding Health and Determinants of Health
Amid the foundation of Canada's healthcare system, we explored the traditional definition of health and analyzed a more contemporary approach to understanding health (Athabasca University, 2018, -b). In 1948, the World Health Organization (WHO) defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (2021, para. 1). Huber argues this definition was over-ambitious at the time and notably criticizes that this notion of health is nearly impossible to achieve, leaving many of us with the status of being unhealthy (2013). I believe a reconsideration of the definition of health would be to replace perfection with progress. Only then can we relate to more people across different times in their lives, allowing space for those managing an illness because health is not static and can be fluid depending on circumstance.
After understanding health, we sought to identify health determinants, the intricate factors influencing one's current and future state of health. These are the conditions in which people are born, grow, work, live, and age (WHO, n.d.) and are not medical treatments or lifestyle choices (Raphael et al., 2020). In many of my readings, income, although not a single factor, is one of the most critical socioeconomic factors with positive or negative health impacts. Various research on socioeconomic status and HIV suggests that the disease is entrenched in social and economic inequity. Polliwski et al. (2013) argue the effects of lower socioeconomic status and impoverished neighborhoods are at disproportionately high rates, affecting both local HIV prevalence and individual risk behaviors.
Infographic 1
Ontario's Population: Determinants of Health
(Public Health Ontario, [PHO], 2015)
Unit 4 – Multilevel Approaches to Understanding Health – Beyond the Individual
Continuation of health determinants, unit 4 presented us with a learning goal to choose a multilevel health model and apply it to a population relevant to our practice. I applied the socio-ecological model (SEM) to understand further the circumstances leading to substance use and strategize supportive and effective interventions to effectively minimize risk and harm when problematic use occurs to prevent dependence. The SEM (see Figure 1) adds to the concept that health is not influenced by one's personal health choices but by the more extensive societal system and experiences within that system (Golden & Earp, 2012).
Figure 1
The Socio-Ecological Model: A Framework for Prevention
(Center for Disease Control & Prevention, [CDC], 2021)
When looking at any health issue, it is essential to recognize that changing one's behavior is not merely as easy as informing one of their risks. It takes a deeper understanding of the intricate layers that intertwine amongst relational, communal, and upstream societal context that helps shape individual lives to develop comprehensive and supportive strategies. For instance, poverty increases susceptibility to HIV infection often through lack of access to preventative health care and education, inability to afford safer sex supplies and perceptions of risk are overshadowed by survival needs (Larkin, 2000, as cited in Duncan et al., 2011). Furthermore, the social and economic conditions in a person's life can affect their overall wellness by unhealthy means of coping, such as substance abuse (Raphael et al., 2020). The CDC provides a linkage with increased susceptibility for HIV acquisition and transmission as substance use alters judgment, leading to risky sexual behaviors and noncompliance to HIV treatment (2020). More vigorous government policy changes at a local, national and global level are needed to address the socioeconomic factors that influence downstream health outcomes (see Table 1).
Table 1
SEM: Examining Broader Societal Level Change & Impact on Individual Behavioral Change for HIV Prevention & Management
Date created: April 2021
Unit 5 – Chronic Disease Prevention and Management
Chronic diseases often progress slowly, have a long duration, impact one's quality of life and require ongoing medical care (PHO, 2019). Although chronic diseases are one of the leading causes of death in Ontario, most are preventable. In unit 5, I explored the primary determinants of HIV and its progression from an endemic to a chronic disease that continues to be a significant public health issue. In Canada, 2018 estimates indicate that over 62 000 people are living with HIV and the stigma associated with this infection (Haddad et al., 2021; Public Health Agency of Canada, [PHAC], 2018; The Ontario Advisory Committee on HIV/AIDS, [OACHA], 2016). Vulnerable populations that account for disproportionate numbers include gay, bisexual, and other men who have sex with men, women, and indigenous people (see Infographic 2).
Infographic 2
People living with HIV in Canada
(PHAC, 2018)
Earlier models for infectious disease prevention predominantly focused on individual-level behavioral interventions that seek to influence knowledge, attitudes, and behaviors (Dean & Fenton, 2010). As a nurse working within a Sexual Health and Harm Reduction Program that ensures access to healthcare without barriers, I work with marginalized populations to create messaging to reduce stigma and provide current health education. When taking a harm reduction approach, it is essential to meet the individual to where they are at for change and provide supportive guidance to reduce harm to themselves and others. Although some individual-focused interventions have shown a reduction in risk behaviors, their success is improved when HIV prevention addresses the broader structural factors that shape or constrain individual behavior, such as poverty, policy, and power (Dean & Fenton, 2010). Ontario's approach to HIV prevention and a cascade of care for management includes focusing energy and resources on vulnerable populations most affected by HIV (OACHA, 2016). Despite efforts, new infection still occurs, and most people living with or at risk of HIV are coping with a combination of health, social and structural factors.
Unit 6 – Vulnerable Populations
In unit 6, we brought particular interest to vulnerable population groups within our discipline and shared invaluable personal testimonies. Often at increased risk for harm and health problems while facing significant barriers to accessing health care services are indigenous populations. To address the prevention and management of HIV, we must understand the variety of factors and determinants of health that make individuals more vulnerable to transmission risk, particularly the profound effects of racism and multigenerational colonialism. The history of colonization amongst indigenous people and their health is complicated and intertwined, often resulting in adverse social determinants of health and negative health outcomes (Raphael et al., 2020). Through colonialism and systemic racism, indigenous people have been denied access to necessary resources to maximize economic and social opportunities, often leading to migration to urban centers, a site of increased HIV infection (Waldrem et al., 1995, as cited in Duncan et al., 2011). According to national HIV estimates, 2018 statistics show that 6,180 Indigenous people live with HIV, representing 10% of all people with HIV in Canada (Canada's Source for HIV and Hepatitis C Information, [CATIE], 2021). With disproportionate rates of HIV transmission through injection drug use and unprotected sexual intercourse (Duncan et al., 2011). Furthermore, indigenous women are among the poorest subgroups in Canada, which has the additional risk of sexual exploitation and involvement in the sex trade industry, which generates a greater risk of acquiring HIV (Larkin, 2000, as cited in Duncan et al., 2011). Often, with limited economic opportunities, riskier sexual practices occur in exchange for the necessities for survival.
Although various communities and organizations have made significant progress within the past decade, new infection rates remain the highest amongst indigenous people. Collective and continued efforts are needed to serve our vulnerable populations better to prevent and manage HIV, including providing safe, supportive, and accessible healing spaces that are culturally sensitive to indigenous people's unique needs and distinct challenges.
Picture 1
HIV/AIDS is Quiet at Times in Native Communities
(The Visual Aids Blog, 2014)
Unit 7 – Future Directions
This unit allowed us to look at future healthcare trends, including the exciting and proven efficacy of rapid point-of-care testing for early detection and the use of treatment to prevent transmission. These trends have been recognized federally and globally with the Joint United Nations Program on HIV and AIDS (UNAIDS) in their established goals for countries trying to achieve progress in preventing and treating HIV infection and are summarized by 90-90-90 (PHAC, 2018; PHAC, 2020, -b.).
The overall goal of testing is to identify as many people who have acquired HIV as early as possible and link them to prevention, care and treatment services (see Factsheet 1). Challacombe & Arkell (2019) state engagement is also essential for HIV prevention of people who test negative but are at ongoing risk of acquisition. Recently introduced in Canada is HIV rapid self-testing and is recommended as an additional approach to HIV testing services (WHO, 2016). HIV self-testing will contribute to global 90-90-90 targets (see Infographic 2) by reaching first-time testers or those with ongoing risk who require frequent testing (WHO, 2016). It will increase access for people who face other barriers because it ensures confidentiality and allows them to test privately (CATIE, 2020).
Factsheet 1
Approach to HIV Screening
(PHAC, 2020, -a.)
Access to earlier antiretroviral therapy (ART) initiation reduces infectivity for those living and managing their HIV (Cohen et al., 2011., as cited in Cáceres et al., 2015) and is a treatment used as prevention. The ultimate goal of therapy is to achieve and maintain an undetectable viral load (PHAC, 2020, -c.), allowing a person to live a long, healthy life and unlikely to pass the virus onto others when compliant with their treatment. Another form of treatment as prevention is pre-exposure prophylaxis (PrEP), which can be taken orally by an HIV-negative person to reduce their risk of getting HIV by up to 99% (Arkell & Herrigan, 2019). By implementing rapid HIV point-of-care testing, including self- HIV testing for early detection and treatment prevention, we have changed the healthcare approach from reactive to proactive. We must continue to explore innovative ways to address biological factors that promote and impede infectiousness and susceptibility amongst our vulnerable populations. We need to continue to create awareness of emerging trends, such as testing opportunities available for all people at risk and overcome barriers of equitable accessibility to allow early HIV detection and close the gaps to the cascade of care for HIV prevention and management.
Video 2
Daniel's HIV Story
(Healthy Canadians, 2019)
Conclusion
This final blog post has provided me with synthesis and integration of Canada's health systems disciplines and has set a firm foundation for future courses. Simplistically, we know the complex layers that determine health, from individual factors to broad societal and structural ones and must close the gap on disparities and strive for health equity. By understanding my role and other healthcare professionals within the healthcare system, I appreciate the importance of advocacy for Canada's most vulnerable populations to influence further and support continuing progress toward better, healthier lives.
References
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