Multilevel Approaches to Health

Despite overwhelming evidence of the impact health inequalities and determinants of health have on the health and well-being of Canadians, Canada’s publicly funded healthcare system continues to apply biomedical metrics to measure health outcomes – a gap that has been worsened by the COVID-19 pandemic. The current health human resource crisis has forced frontline health practitioners into providing a downstream approach to care out of necessity. This type of “Band-Aid” healthcare most often results in a negative care experience for patients and families, and a negative caring experience for healthcare workers.

The consequence: Public outcry against a failing health system, exacerbated by an exodus of overworked and unfulfilled healthcare workers. The solution: Rebuilding a health system that supports a comprehensive and integrated approach to health. A system in which health equity, spheres of influence, and social determinants of health (SDOH) are not only amalgamated into health policy, but also reflected in performance metrics and funding allocations.

The three (3) frameworks highlighted below outline multi-level upstream approaches which incorporate 3 key factors: health equity, spheres of influence, and SDOH’s, which have not only been evidenced to improve health outcomes for health care consumers, but theoretically would also serve to restore our valued healthcare workers with the sense of pride achieved when they are able to leave work feeling confident that they have provided patients with the best possible care - and knowing that they truly helped to make a difference.

In their 2021 research paper titled The Health Equity Framework: A Science- and Justice-Based Model for Public Health Researchers and Practitioners. Peterson et al. share a Health Equity Framework (HEF) that illustrates how health outcomes are influenced by complex interactions between people and their environments. Building on existing models, the HEF centers on three foundational concepts: equity at the core of health outcomes; multiple, interacting spheres of influence (systems of power, relationships and networks, individual factors, and physiological factors); and a historical and life-course perspective.

The Government of Canada aims to provide an integrated and operational framework, built on previous work in health promotion, population health, public health, and community health, integrating these concepts with the Population Health Framework, and the Ottawa Charter on Health Promotion to create the Population Health Promotion Model (PHP) illustrated below.

The Social-Ecological Model of Health Integration (SE Model) highlighted in the 2015 article Primary Health Care and Public Health: Foundations of Universal Health Systems (White, 2015), illustrates the elements of an organized health system which addresses overlap between primary care and public health. The SE Model “depicts interplay between individual, relationship, community, societal, and global influences... An approach that incorporates complementary interventions at several levels is more likely to achieve success over time than a single intervention.” (White, 2015).

Healthcare reform is inevitable as Canada struggles to addresses post-pandemic health system recovery under a universal healthcare model. There is tremendous opportunity to advance integrated care through a focus on multi-level and multimodal models. In sum, population health initiatives must address the full range of foundational health determinants, but must also be supported by comprehensive action strategies that aim to influence the underlying influences, factors and conditions that determine health.