Heart Health… Or Lack Thereof!
A Multilevel Approach to Heart Health in NL

​

     There are many factors that play a part in the health and wellbeing of an individual. Being a registered nurse, my main goal is to help prevent disease and promote health to keep the population healthy and optimize health. Stemming from my study of the determinates of health, I realize there are many factors that work together to influence health. There are also different health models that can be used to both explain the factors that interact to affect health as well as assist in developing interventions to promote health. The health model which I chose to explore in this post is the Social-ecological model (SEM). This model reinforces the concept that in order to improve the health of the public, health interventions must look at all the influences of health in a multilevel approach (ER Services, 2012). Whether we like it or not, our families, communities, culture, and other factors all affect how we act. So, changing people’s influences can often change their behavior and in turn affect their health (Golden & Earp, 2012). 

​

     White (2015) describes the 5 levels of the social ecological model. These include individual, interpersonal, organizational, community and policy factors. White goes on to say that the social ecological model is more likely to achieve success in improving health as it looks at influences and interventions in a multilevel lens. 

​

​

​

​

​

​

​

​

​

​

​

     

 

 

 

This particular model (SEM) can be applied when attempting to understand heart disease in Newfoundland and Labrador (NL). Heart disease is any condition that affects the structure or function of the heart (Heart and Stroke, 2020). Heart disease results from an interaction of genetic factors, health behaviours, and environmental factors (The Newfoundland and Labrador Centre for Health Information, 2015). Heart disease is very prominent in the province of NL and has a very close personal impact to my life. The leading causes of death in Newfoundland and Labrador are diseases of the circulatory system, such as heart disease and stroke (Government of NL, 2011). 

​

​

​

​

​

​

​

​

​

​

​

​

 

 

 

 

Individual Factors-
These are factors which influence behavior such as genetics, knowledge, attitudes, beliefs, and socio-economic status.

   

     In NL genetics play a key role in the prevalence of disease. A study by Kosseim, Pullman, Perrot-Daley, Hodgkinson, Street, Rahman (2012) found that a number of common genetic conditions are more prevalent in Newfoundland and Labrador including cardiac diseases. Early detection and preventative measures can be used to assist in this area. An interesting finding in this study was that arrhythmogenic right ventricular cardiomyopathy (ARVC) is a particularly lethal genetic condition very common in Newfoundland. Fifty per cent of affected men are dead by the age of 40, and 80% by age 50. Research in Newfoundland has identified the gene responsible for this condition and testing is now available. Although the condition is medically untreatable, implantable defibrillators are a means of prophylactic intervention for affected individuals.

   

    NL has the highest rate of poverty in the country, this in turn correlates with the highest rate of cardiac disease and death in the country (Government of NL, 2003). Having a stable income allows an individual to purchase healthier food options that promote heart health. There is a strong correlation with low socioeconomic status and unhealthy eating (Aboueid, Pouliot, Nurr, Bourgeault, & Giroux, 2019). 

​

Interpersonal Factors-
These are factors such as interactions with other people, which can provide social support or create barriers to interpersonal growth that promotes healthy behavior.

 

     A person's closest social circle, peers, partners and family members-influence their behavior and contributes to their range of experience (Children’s Advocacy Center, 2021). In NL there is a strong family culture as well as a tendency to choose not so healthy food. The strong family and social network create a foundation of somewhat unhealthy eating. Newfoundland and Labrador residents (12 years and older, except where noted) 73% do not eat enough fruits and vegetables and 23% have high blood pressure (Government of NL, 2011) Personally, my entire childhood for as long as I can remember, my family would gather at my grandparents’ house on Sundays to have the Newfoundland staple, “Jiggs Dinner”, which was packed with salt and cooked with salt beef. As mentioned above, a unhealthy diet has direct correlation to poor heart health. 

 

 

 

 

 

 

 

 

 

 

 

Institutional Factors-
These are factors, including the rules, regulations, policies, and informal structures that constrain or promote healthy behaviors.

 

     It is a well-known fact that a higher education leads to a healthier lifestyle (Raphael, D. et. Al, 2020). In Newfoundland, vital statistics found that 26% of males and 25.4% of females aged 25-64 years had an education level of less than high school (Statistics Canada, 2006). A sedentary lifestyle is one of the 5 major risk factors (along with high blood pressure, abnormal values for blood lipids, smoking, and obesity) for cardiovascular disease (Myers, 2003). Having a higher level of education allows an individual to have access to a higher income and in turn healthier food and options for exercise. 53% of Newfoundlanders are not physically active according to the Chronic Disease Policy Framework of NL (Government of NL, 2011). Higher education also allows an individual to be more aware of health promotion and instill this in the youth of society. “Newfoundland and Labrador leads the way for overweight kids — aged 12 to 17 years old — compared with the rest of the country, and that doesn't come as a shock to one expert in childhood obesity” CBC (2018). Implementing healthier food options in NL schools and educating the public regarding healthy exercise options will directly affect overall heart health. 

​

Community Factors-
Include factors such as social and physical environment. 

 

     Physical environment and proximity to a health care facility/provider have major implications on heart health. NL is known for its rugged terrain and dispersed population. In fact, in 2016, 41.9 percent of Newfoundland and Labrador's population lived in rural areas. In a study by Kettle, Roebothan, and West (2005), the authors found that the prevalence of heart disease in NL is found more so in the rural areas. The authors described many reasons which contribute to this including diet and lack of access to fresh fruit and vegetables, socioeconomic status and distance from a health care institution. 
“Residents of rural communities have been characterized as having lower incomes, higher unemployment rates and lower educational levels compared with urban residents. There is also speculation that rural residents differ from their urban counterparts with regard to their ability to access health services, adequate food supplies and health knowledge” (Kettle et al. 2005). 

 

Policy Factors-
Including local, state, and federal policies and laws that regulate or support health actions and practices for disease prevention including early detection, control, and management.

 

     Another lifestyle habit which negatively impacts heart health is smoking. 20% of

the NL population are current smokers. Chemicals in cigarette smoke cause the

cells that line blood vessels to become swollen and inflamed. This can narrow the

blood vessels and can lead to many cardiovascular conditions (CDC, 2014). The NL

government has taken initiative on this front and implemented many resources to

assist with smoking cessation such as increased taxes and cost on cigarettes and

vaping as well as publicly funded smoker’s cessation program. 
     

     In terms of early detection for heart health I believe that NL is behind the rest of

the country. In NL, it is estimated that 90,000 individuals do not have access to a

family physician (Newfoundland and Labrador Medical Association, 2021). Family

physicians are important in early detection of disease and can pick up on a health

care issue prior to it being a major event, such as a heart attack. Limited access to

healthcare services has many challenges as early intervention and a consistent

physician play a vital role in positive heart health and overall health outcomes.

​

Prevention/Intervention

     The NL government is focused on increasing awareness and engaging individuals to encourage healthy living. They realize that deducing the incidence of chronic disease begins with keeping people healthy. Some focus areas that the government highlights in their Chronic Disease Action Plan (2019)
include ensuring access to affordable and nutritious food, providing opportunities for physical activity, improving detection and screening for diseases, and creating health-supportive environments. An example would include the government implemented a service called " Dial a Dietician", this 24/7 services allows an individual of NL to call and get advice on healthy eating. By having this information individuals living with chronic diseases, such heart disease, will benefit from dietary advice as evidence shows that healthy eating can improve disease management (Government of NL, 2019). In order to improve detection and screening of chronic diseases such as cardiovascular health, the NL government implemented the BETTER program, which is an evidence-based approach to chronic disease prevention and screening, focusing on cancer, diabetes, cardiovascular disease and their associated lifestyle factors (The BETTER program, 2021). Under the BETTER program individuals are supported to address lifestyle behaviors associated with chronic disease including diet, exercise, smoking, and alcohol use. Program participants will benefit from improved health outcomes and the ability to more proactively manage their health and the health of their family (Government of NL, 2019). 

​

 “The most chronic heart disease is caused by having greediness in your heart. Go for check ups regularly and learn how to swallow those lumpy pills of generosity. Be kind and be healthy”
― Israelmore Ayivor

Aboueid, S., Pouliot, C., Nurr, T., Bourgeault, I., & Giroux, I. (2019). Dietitians’ perspectives on patient                  barriers and enablers to weight management: An application of the social-ecological model.                      Nutrition & Dietetics. 76, 353–362. 

 

CBC (2018). Expert weighs in as N.L. tops country for most overweight kids. Retrieved from                              https://www.cbc.ca/news/canada/newfoundland-labrador/study-finds-nl-kids-most-

       overweight-1.4813732. 

​

CDC. (2014). Smoking and Cardiovascular Disease. Retrieved from                                                                          https://www.cdc.gov/tobacco/data_statistics/sgr/50thanniversary/pdfs/fs_smoking_CV

        D_508.pdf

​

Children’s Advocacy Center. (2021). The Social-Ecological Model: A Framework for Prevention. 

       Retrieved from: https://www.cachc.org/child-abuse/. 

ER Services (2012). Models and Mechanisms of Public Health: Social Ecological Model. 

       Retrieved from: https://courses.lumenlearning.com/suny-buffalo-

       environmentalhealth/chapter/multilevel-interventions-are-for-behavior-change/

 

Golden, S. and J.A., Earp (2012). Social Ecological Approaches to Individuals and Their Contexts: 

      Twenty Years of Health Education & Behavior Health Promotion Interventions. Health 

      Education & Behavior. 39(3) 364–372.

 

Government of Newfoundland and Labrador. (2003). Reducing Poverty in Newfoundland and

      Labrador: Working towards a solution. Retrieved from                   

      https://www.gov.nl.ca/publicat/povertydiscussion-final.pdf

 

Government of NL. (2011). Chronic Disease Policy Framework. Retrieved from: 

      https://www.gov.nl.ca/hcs/files/chronicdisease-improving-health-together.pdf.

 

Government of NL. (2019). Chronic Disease Action Plan. Retrieved from:                                                             https://www.gov.nl.ca/hcs/files/chronicdisease-pdf-chronic-illness.pdf. 

​

Kettle, S., Roebothan, B., West. R. (2005). Prevalence of specific cardiovascular disease risk factors in             young Newfoundland and Labrador adults living in urban and rural 

       communities. Canadian Journal of Rural Medicine. 10(2). 

 

Kosseim,P., Pullman, D., Perrot-Daley, A., Hodgkinson, K., Street, C., Rahman, P. (2012) Privacy protection         and public goods: building a genetic database for health research in 

 

Newfoundland and Labrador. Journal of the American Medical Informatics Association. 20, 38–43. 

 

Myers, J. (2003). Exercise and Cardiovascular Health. Circulation, 107(2), 2-5. 

 

Newfoundland and Labrador Medical Association. (2021). NLMA calls on leadership candidates

      to help the 90,000 people in NL without a family doctor. Retrieved from:                     

      https://www.nlma.nl.ca/News-And-Events/NLMA-News/Page/0/Article/371. 

 

Public Health Agency of Canada (2016). Chronic Disease and Injury Indicator Framework. Edition 2016,          using data from the Canadian Community Health Survey 2014. 

 

Public Health Agency of Canada. (2018). Report from the Canadian Chronic Disease Surveillance                    System: Heart Disease in Canada, 2018. Retrieved from: 

      https://www.canada.ca/en/public-health/services/publications/diseases-

      conditions/report-heart-disease-Canada-2018.html. 

 

Raphael, D., Bryant, T., Mikkonen, J. and Raphael, A. (2020). Social determinants of health: The 

      Canadian facts (2nd edition). Ontario Tech University Faculty of Health Sciences and 

      York University School of Health Policy and Management.

 

Statistics Canada. (2006). Visual census: Education, Newfoundland and Labrador. Retrieved

      https://www12.statcan.gc.ca/census-recensement/2006/dp-pd/fs-fi/index.

 

The Better Program. (2021). Improving Chronic Disease Prevention and Screening Across Canada.                 Retrieved from: https://better-program.ca/. 

​

The Newfoundland and Labrador Centre for Health Information. (2015). Cardiovascular Disease: 

      Fast Facts. Retrieved from: 

      https://www.nlchi.nl.ca/images/PDFs/Fast%20Facts_CVD_February%202015%20NMEDI

      T_ng.p.df. 

 

White, F. (2015). Primary Health Care and Public Health: Foundations of Universal Health 

      Systems. Medical Principles and Practice, 24(2), 1-14.