Vulnerable populations in the Canadian health care system

Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of social, economic or environmental factors (“Care of Vulnerable Populations,” 2006; Health Equity Institute, 2014). Social characteristics include age, race, gender, ethnicity, sexual orientation, spirituality, disability, and immigration status (“Care of Vulnerable Populations,” 2006; Health Equity Institute, 2014). Social characteristics can unfairly create unequal opportunities that lead to differences in socio-economic status and environment conditions (Health Equity Institute, 2014). For example, differences in educational opportunities lead to differences in income, and lower income groups often live in poorer neighbourhoods. These neighbourhoods are more likely to have environmental hazards, higher crime rates and less access to healthy foods (Health Equity Institute, 2014). This concept is described in the following video by the Health Equity Institute (2014).

In my previous blog post I discussed the levels of influence on health and health outcomes. The individual-level factors discussed align with the social characteristics that can make a population vulnerable. Many of these factors are interrelated, and certain populations are disadvantaged on many or all levels of health influence. For example, the proportion of working adults who struggle to make ends meet (known as the working poor) is 2.2 times higher among Black Canadians than White Canadians (Public Health Agency of Canada, 2018). The working poor are more likely to have lower education, fewer benefits such as drug plans and disability insurance, and greater health problems (Public Health Agency of Canada, 2018).

Indigenous populations are some of the most vulnerable in Canada, with higher rates of diabetes, smoking, obesity, infant mortality, and death by suicide than non-Indigenous Canadians, as shown in Table 1 (and these are only a few examples) (Public Health Agency of Canada, 2018).

Table 1. Comparison of health inequities between Indigenous and non-Indigenous Canadians.

Disparities in health and health care are a result of a complex and interconnected set of individual, provider, health system, societal, and environmental factors (Artiga et al., 2020). Figure 1 displays one depiction of the social determinants of health that contribute to health outcomes (Artiga et al., 2020).

Education

Statistics Canada reported that in 2015, 28.9% of Aboriginal adults aged 25-54 had less than a high school education compared to 12.1% of the non-Aboriginal population, a difference of 17% (Statistics Canada, 2018).

Income

The average full-time employment income of Aboriginals in Canada was $36,152 in 2001, compared to $43,486 for Non-Aboriginals. In the population of Canadians with low household income, Aboriginals living off-reserve reported significantly higher “fair or poor health” (34%) compared to Non-Aboriginals earning the same income (25%) (Reading & Wein, 2009).

Health Care System

Aboriginal populations face barriers to health services in Canada as they are subject to an inadequate federal system of health care delivery, compared to other Canadians who fall under provincial systems (Reading & Wein, 2009). Both physical and social challenges exist for Aboriginal populations accessing health care (Reading & Wein, 2009). In 2002-03, 18.5% First Nations adults living on-reserve reported doctors or nurses were not available in their area, 13.7% reported they could not afford transportation costs to seek medical care, and 13.5% reported that the service was not culturally appropriate (Reading & Wein, 2009).

The health inequities experienced by Indigenous populations are a result of forced relocation, loss of lands, creation of the reserve system, banning of Indigenous lands and cultural practices, and the creation of the residential school system (Public Health Agency of Canada, 2018; Rahim et al., 2018). Systemic racism, discrimination, and social exclusion are also factors that contribute to health inequities (Reading & Wein, 2009). In 2002, 37.9% of First Nations adults living on reserve reported experiencing instances of racism in the previous 12 months (Reading & Wein, 2009). Of these individuals, 35.7% reported that these instances had some to a very strong effect on their self-esteem (Reading & Wein, 2009). Self-determination is the ability to make choices and have control over your own life. It is one of the most important determinants of health among Aboriginal peoples as it influences all other determinants including education, housing, and safety (Reading & Wein, 2009). Colonial policies and practices have striped the rights of Aboriginal peoples resulting in unequal access to and control over land, economic assets and health services (Reading & Wein, 2009).

Steps for improvement

The causes of the health disparities faced by Aboriginal peoples in Canada are historic and complex, and it would be naïve of me to think that I have all the solutions after a couple weeks of research. That being said, I have provided a few ways in which the Aboriginal population could be better served in the health care system.

As I discussed in my previous blog post, public health interventions that consider multiple levels of influence and target upstream levels such as media advocacy and policy change are more successful than interventions that focus on individual-level factors (Stellefson, 2019). Therefore, interventions aimed to improve health care and decrease health disparities should consider and address the “whole picture”.

In order to better understand and correct the current health inequities, I believe that Aboriginal representation in positions of power is extremely important. This may involve programs that encourage and support Aboriginal youth to pursue careers in politics and medicine. This would improve the availability of culturally appropriate care. Additionally, the fundamental causes and issues of the current system would be best addressed by Aboriginal peoples.

Finally, zero tolerance for racism at all levels (individual and institutional) needs to be enforced. Mandatory education sessions in hospitals could be used to address and prevent racism, discrimination, and stereotyping. Aboriginal patient advocates could encourage conversation and learning with health care providers to speak about their experiences and educate health care providers on their cultural values, norms and traditions.

It is undeniable that vulnerable populations exist in the Canadian health care system, and most would agree that this is unacceptable. This is a large and complex issue, and as individuals the best place to start is by educating yourself. Please see my references for further reading.

References

Artiga, S., Orgera, K., & Pham, O. (2020). Disparities in Health and Health Care: Five Key Questions and Answers. Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/

Care of vulnerable populations. (2006). Journal of Hospital Medicine, 1(1), 62–62. https://doi.org/10.1002/jhm.42

Health Equity Institute. (2014). What is Health Equity? https://www.youtube.com/watch?v=ZPVwgnp3dAc

Public Health Agency of Canada. (2018). Key Health Inequalities in Canada: A National Portrait. Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/publications/science-research-data/inequalities-working-poor-canadians-infographic.html

Rahim, S., Mahida, S., King, J., & Kwok, M. (2018). Indigenous health in Canada. Demystifying Medicine. https://healthsci.mcmaster.ca/learningtechlab/news/2018/04/02/indigenous-health-in-canada

Reading, C. L., & Wein, F. (2009). Health Inequalities and Social Determinants of Aboriginal Peoples’ Health. National Collaborating Centre for Aboriginal Health. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjp_evQ1pntAhWEmuAKHYwUB8MQFjABegQIBBAC&url=https%3A%2F%2Fwww.ccnsa-nccah.ca%2Fdocs%2Fdeterminants%2FRPT-HealthInequalities-Reading-Wien-EN.pdf&usg=AOvVaw1LD9o-ZQfm4xm

Statistics Canada. (2018). The educational attainment of Aboriginal peoples in Canada. https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_3-eng.cfm

Stellefson, M. (2019). Social Ecological Model. [Video]. Youtube. https://www.youtube.com/watch?v=1fJfZI5wlt0