Canada, our great multicultural land. A country that prides itself on cultural diversity and peace so much that according to a 2020 Ipsos poll for Global News, a shocking “40 percent of Canadians hold the view that Racism is an American issue” (Bricker, 2020). Unfortunately, this belief is not reality. Amha (2020) further expands on this topic stating that “the truth is: Canada and the United States share centuries-old twin histories of Indigenous genocide, mass displacement, and chattel slavery,” and “it’s a history that extends to the internment of the Japanese, the creation of laws specifically designed to ban Black immigration, and the discriminatory practice of redlining.” But how does this relate to health? When thinking of racial discrimination and health inequities in Canada, most people automatically think of our Indigenous populations, but our Black Canadians are just as susceptible, if not in some cases, more susceptible. According to the Government of Canada website (2020), “Black Canadians experience health and social inequities linked to processes of discrimination at multiple levels of society, including individual, interpersonal, institutional, and societal discrimination.” Hypertension is one of the leading chronic conditions affecting Black people in Canada and this blog will aim to explore how the Population Health Promotion Model applies to and explains the correlation between hypertension and socioeconomic status as it relates to racial identity. From a multiple levels of influence perspective, the Population Health Promotion model will be used to answer the questions of What, How, Who, and Why, in the context of social determinants of health contributing to the outcome of hypertension among our fellow Black Canadians.
The Population Health Promotion Model
The Population Health Promotion Model was created by Hamilton and Bhatti (1996) with a goal of integrating two major approaches to health: health promotion and population health. The model aims to explore four major questions: What, How, Who, and Why as it relates to these two concepts. More specifically, the basis of this model was formed around two very important and influential documents: Strategies for Population Health (1994), which provides a list of health determinants (the WHAT), and The Ottawa Charter for Health Promotion (1986), which lists five key action strategies to enhance health (the HOW). Reutter and Kushner (2009) further explain this model stating that “to enhance population health, action must be taken on a variety of levels” (the WHO), and that the model is a great example of how “evidence-informed decision making is a foundation to ensure that policies and programs focus on the right issues, take effective action, and produce successful results” (the WHY) (p. 11). I chose this model to explore the correlation between hypertension and socioeconomic status among Black Canadians because it is very comprehensive and applicable when exploring multiple levels of health influence. Now let’s dive in.
What?
Sadly, there are many inequalities in health and the determinants of health prevalent within Black communities across Canada. In the context of hypertension, “Canadians who are Aboriginal, of South Asian and Black ethnicity, or individuals with low socioeconomic status are at greater risk for developing hypertension” (Hypertension Canada, 2016). Furthermore, research suggests that there is a strong correlation between racial identity, gender, income and hypertension (Gagne & Veenstra, 2017). Gagne & Veenstra (2017) even conclude that poor Black Canadian women are most at risk for developing hypertension possibly because “they are more likely than poor White Canadians and poor Black men to be single parents, have long commutes to work, work at menial jobs, or lack access to quality health care,” all factors that could lead to increased/chronic stress – a significant risk factor for hypertension.
How?
A strategic approach for hypertension prevention and control in Canada was developed in 2015 by Hypertension Canada which incorporated all five action strategies outlined in the “How” section of the Population Health Promotion Model: 1) Strengthen Community Action; 2) Build Healthy Public Policy; 3) Create Supportive Environments; 4) Develop Personal Skills; and 5) Reorient Health Services. 2). These recommendations aimed to reduce the individual and societal burden that hypertension posed then and still poses now. The following were some of the recommendations presented in this document that should be applied directly to the female Black Canadian population for the purposes of the prevention and control of hypertension.
1. Strengthen Community Action
a) Prioritize community programs (self-help programs, universal screenings, healthy lifestyle coaching) in
areas where populations perceived to be disadvantaged live, work, and play (Black Canadian communities).
i) Some modifiable risk factors of hypertension include excess body fat, physical inactivity, and high
alcohol intake.
2. Build Healthy Public Policy
a) Subsidize healthy food products and tax unhealthy food products simultaneously.
i) Hypertension is associated with an unhealthy diet, particularly high dietary sodium.
3. Create Support Environments
a) Partner on advocacy with Black communities, having an understanding of the cultural and
environmental changes that have contributed to reduced physical activity levels and to poor nutrition in
those communities.
4. Develop Personal Skills
a) Facilitate access to medical care for individuals without a primary care provider through workplace-
based blood pressure screening and targeted outreach to disadvantaged populations.
5. Reorient Health Services
a) Prevent costly misdiagnosis by funding and promoting the use of ambulatory and home-based blood
pressure monitors as well as training for their optimum use.
Who?
In order to successfully enhance the health of Black Canadians through the prevention and control of hypertension, actions must be taken at all levels of the Population Health Promotion Model: 1) Individual; 2) Family; 3) Community; 4) Sector/system; and 5) Society. Action can be taken at the individual level by helping Black Canadians access resources and supports related to the prevention and management of hypertension in an inpatient and community setting. When possible, family members should also be involved in this process to help build stronger support systems for the individual. However, there must be an understanding by the health care professional that certain populations do not always have supportive family environments and other measures may be required. At the community level, healthy school lunch programs, free recreational activities, government funded community kitchens, and hypertension support groups should be provided in areas populated by disadvantaged Black Canadians. From a sector/system perspective, health care professionals can lobby local and provincial governments to implement healthy public policies related to affordable housing, job creation, childcare, and accessible health services. Lastly, nurses can raise awareness about the negative effects of stress, unaffordable housing, low-income, physical inactivity, and poor access to health care services on health (blood pressure) and well-being.
Why?
Evidence informed decision making can be attributed back to the 1850s, during the era of Florence Nightingale. It is said that Nightingale “noted a connection between poor sanitary conditions in the hospital and rising death rates among wounded soldiers” and “her subsequent efforts to sanitize hospitals led to dramatic drops in patient mortality” (CNA, 2021). It is Nightingale’s methods of evidence-based practice that have informed how we deliver nursing care today. Black Canadians should not be an exception to this rule, and it is imperative that society does more and does better to help this vulnerable population. Effective action on eliminating the health inequities that Black Canadians face today will not only help the individual, but it will inevitably release some of the burden of healthcare associated costs that our country is facing and will be facing today and in future and that is why we must act now.
My focus as an inpatient nurse has primarily been on assessment and the alleviation of risk factors for the disease processes that my patients present with. It is through continued education and work experience that I am starting to realize that health promotion goes far beyond the bedside and that it is both multi-sectoral and political. The Canadian Public Health Association (1996) confirms this thought by adding that health promotion should always be guided by seven strategic principles: 1) Addressing health issues in context; 2) Adapting a holistic approach; 3) Requiring a long-term perspective; 4) Supporting a balance between centralized and decentralized decision-making on policies; 5) Following a multi-sectoral approach; 6) Drawing on knowledge from a variety of sources (social, economic, political, medical, environmental, etc.); and 7) Emphasizing public accountability. It is this type of forward thinking that will be required if we ever want to effectively address the structural and systemic inequities that our Black Canadian brothers and sisters face daily.
Source: YouTube (Youngsterdam Dynamo Account)
References
Amha, M. (2020). What Americans tend to get wrong about racism in Canada. Retrieved from
Bricker, D. (2020). Majority (60%) see racism as a serious problem in Canada today, up 13 points since last
year. Retrieved from https://www.ipsos.com/en-ca/majority-60-see-racism-serious-problem-canada-
Canadian Nurses Association. (2021). Evidence-based practice. Retrieved from https://cna-aiic.ca/en/nursing-
Canadian Public Health Association. (1996). Action statement for health promotion in Canada. Retrieved from
https://www.cpha.ca/action-statement-health-promotion-canada
Gagne, T., & Veenstra, G. (2017). Inequalities in hypertension and diabetes in Canada: intersections between
racial identity, gender, and income. Ethnicity & Disease, 27(4), p. 371-378. doi:10.18865/ed.27.4.371
Government of Canada. (2020). Social determinants and inequities in health for Black Canadians: a snapshot.
Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and
health promotion. Ottawa, ON: Health Promotion Development Division, Health Canada.
HSFC/CIHR Chair in Hypertension Prevention and Control, & Hypertension Canada. (2016). Hypertension in
Canada fact sheet. Retrieved from https://hypertension.ca/wp-content/uploads/2018/12/HTN-Fact-
Hypertension Canada. (2015). Hypertension prevention and control in Canada: a strategic approach to save
lives, improve quality of life and reduce health care costs. Retrieved from https://hypertension.ca/wp-
content/uploads/2017/11/Hypertension-Framework-Update-2015_Oct_26.pdf
Reutter, L., & Kushner, K. E. (2009). Health and Wellness. In J. C. Ross-Kerr, & M. J. Wood (Eds.), Canadian
fundamentals of nursing (p. 11). Location: Elsevier Canada.
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