Background
Diabetes is a complex disease that lowers life expectancy, is the leading cause for blindness and increases risk for cardiovascular disease, depression, kidney disease and amputation (Diabetes Canada, 2021a). The prevalence of diabetes in Newfoundland and Labrador currently sits at 35% and is expected to rise by 21% over the next 10 years (Diabetes Canada, 2021b). By 2031, over an estimated 200,000 individuals in the province will be living with diabetes or pre-diabetes, which will continue to put a large burden on the provincial healthcare system as direct costs are estimated to reach approximately $80 million (Diabetes Canada, 2021b).
A comparison of the prevalence of diabetes and some of its risk factors between Newfoundland and Labrador (NL) and the rest of Canada revealed that not only is the prevalence of diabetes higher in NL, but several modifiable risk factors, such as smoking, obesity and inactivity are also significantly more prominent in the province than in the rest of the country (Table 1).
These statistics are what lead me down this path of investigating the prevalence of diabetes in NL. The focus for this blog will be the social-ecological model of health, how it applies to patients living with diabetes, and how it affects adherence to treatment and management of disease.
The Social-Ecological Model of Health
The social-ecological model (SEM) of health was first introduced in 1977 by Bronfenbrenner and explains health issues as complex interactions between and interdependency of an individual and their physical and social environment (National Cancer Institute [NCI], 2005). It explains that not only is an individual's behaviour both shaped and affected by various levels of influence but that the behaviour also both affects and shapes their relationships and social environment (Golden & Earp, 2012; NCI, 2005). The SEM is broken down into several levels of influence: intrapersonal, interpersonal, community, institutional and public policy (Golden & Earp, 2012). Each of these levels, as pointed out in the MCH Training Program (2017) video below, can influence an individual's behaviour and their behaviour can, in turn, influence the level.
This model can be applied to a wide range of health issues to identify and assess the factors that impact health outcomes and to then target health promotion and prevention interventions at those very factors.
Intrapersonal
The intrapersonal level focuses on individual factors (Rural Health Information Hub[RHIH], 2002-2021) such as age, gender, beliefs and values, habits, education, income and genetics. At this level the focus is on the individual's own qualities, characteristics and personality and how those traits affect their behaviour. For example, a person with a genetic pre-disposition to diabetes (ie., a family history), dyslipidemia, obesity, and/or an individual who leads a more inactive lifestyle is at higher risk of developing diabetes and may have more difficulty in managing their disease (Mayo Clinic, 1998-2021). Likewise individual factors such as illness, stress, lack of sleep, menstrual periods, inactivity, too much activity, alcohol consumption and pain can all affect blood glucose levels to varying degrees (Knutson, 2007; Good to Know, 2018). This makes managing diabetes a complicated task for an individual as there can be such variability day-to-day.
In addition, education and income also play a role in adopting healthy behaviours and managing diabetes. Understanding the complexities of diabetes, the dietary plans, and the intricacies of insulin and medication regimens requires a certain level of health literacy. Kino and Kawachi (2020) pointed out that "education predicts health because it is connected to health literacy and the adoption of preventive health behaviors". It can be overwhelming for an individual with low health literacy to suddenly have to learn how to carb count, check blood glucose levels, understand what the numbers mean, and give self-injections of insulin. These individuals may then opt to complete these task only sometimes or even not at all. Similarly, individuals with low incomes may not be able to afford the medications and supplies needed to treat and monitor their disease and therefore may only take their medications or check their blood glucose levels periodically.
Interpersonal
The interpersonal level refers to individuals' relationships with others. Deng and Liu (2020) showed that regular social interactions, such as group leisure and fitness activities, had a positive benefit on individuals with diabetes as it kept them physically active. The positive influence of an individual's close contacts can influence the adoption and maintenance of healthy behaviours. In contrast, having peers or family who do not support healthier lifestyle or dietary choices can make it difficult for an individual to continue to adopt those healthy behaviours needed to maintain control of their diabetes. Therefore, the relationship between social interaction and health is significant in that close social contacts can have both positive and negative influence on an individual's health (Deng & Liu, 2020).
Institutional Factors
Institutional factors include organizations, institutions, and regulations and policies that can promote or inhibit healthy behaviours (NCI, 2005; MCH Training Program, 2017) such as workplace, health insurance and school policies, as well as access to healthcare, diabetes clinics and diabetes support groups. For example, workplace policies that allow for regular breaks would give individuals with diabetes the opportunity to check their blood glucose levels, administer insulin, or have a snack. In addition, workplace health benefits that provide fee-reimbursement for fitness and physical activity programs also help to promote and encourage the adoption of healthy behaviours by removing the cost to the individual and making exercise more appealing. In contrast, health insurance policies that do not offer coverage for diabetic supplies can negatively impact self-monitoring of their diabetes as individuals may not be able to afford to do regular blood-glucose testing. Similarly, prescription drug policies that have small drug formularies or stringent criteria for drug coverage, can significantly impact an individual's ability to afford and obtain the necessary medications to control their disease.
Community Factors
Community factors include the social networks where people live, work and play, cultural and societal norms, and interactions between organizations (RHIH, 2002-2021; MCH Training Program, 2017). These environments can have great influence on an individual's success in managing and adhering to diabetic treatment regimens. Individuals living in communities where the societal norm is to maintain and promote healthy living by, for example, attending farmer's markets to buy fresh foods and making use of outdoor community spaces to exercise, would likely have a greater success in attaining their goals for staying active, maintaining a healthy weight, and managing diabetes. By comparison, societal norms and access to affordable food and fitness facilities in more rural parts of NL do not always align with health prevention and promotion initiatives. Individuals with diabetes living in these communities may therefore face more obstacles in trying to become more active, make healthier food choices, and prevent and manage diabetes.
Public Policy Level
Finally, public policy refers to the broader factors that influence health outcomes (RHIH, 2002-2021) and have an impact on a large number of people. For diabetes management these would include government assistance programs, health and education promotion programs and policies, and government allocation and funding of services. The province of NL has established a health task force, known as Health Accord NL, with the objective of creating a 10-year plan to improve the health its residents (Health Accord NL, 2021). Part of their plan is to address the social, environmental, and economic factors that influence health (Health Accord NL, 2021). As an example, the province recently announced that a 'sugar-sweetened beverage tax' would be imposed in the coming year. This tax is part of their "Promoting a Healthier Newfoundland and Labrador" initiative to encourage healthier choices and behaviours and to lessen the burden on the provincial healthcare system (Government of Newfoundland and Labrador, 2021). And while this new tax will impact a large number of people, may discourage some individuals from buying sugar-sweetened beverages, and may help lower the risk of developing diabetes, I wonder if it will actually have its intended impact. Or will it make a somewhat affordable form of hydration, albeit not the healthiest choice of beverage, slightly less affordable for those who already cannot afford it. However, since this tax has not yet been enacted only time will tell if it has more positive or negative health outcomes.
Conclusion
With rising healthcare costs and an older, more obese and more rural population than most of the rest of Canada, Newfoundland and Labrador will face unique challenges in the future management of not only diabetes, but chronic diseases in general. Improving health outcomes of individuals with diabetes and other chronic conditions requires accessibility of health resources and services in both rural and urban communities in addition to an individual's adoption of positive health and lifestyle choices (Deng, & Liu, 2020). Numerous research and health promotion and prevention interventions have been focused on the individual and, while focus in that area is necessary, in order to have a more long-lasting impact on health outcomes, healthcare providers, educators and researchers may be better concentrating efforts on improving understanding of the structural levels of the social ecological influence on behaviour (Golden & Earp, 2012). As Golden and Earp (2012) noted, all levels of the social-ecological model can influence the health of individuals differently, therefore targeting all of the structural factors at once may be a more effective way to create enduring and sustainable health improvements.
References
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