The Social Determinants of Following Public Health Advice

This story is part of a series about the Social Determinants of Health and COVID-19. If you missed the first one about chronic conditions and unequal disease burden, you can read it here.

Not everyone is able to access or implement Provincial Health Officer Dr. Bonnie Henry’s public health advice, and those who face the greatest social and economic barriers to adherence are the same people being disproportionately affected by measures intended to control the spread of the virus.

Throughout the pandemic, the provincial government and regional health authorities have worked to ensure that information reaches different communities. They provide COVID-19 information in more than 130 languages, Video Relay Services or Teletypewriter for people with hearing loss, and work with partners to develop culturally appropriate messages. Despite this, barriers to individuals’ ability to receive or use information about COVID-19 remain.

Dr. Brenda Poon, an Assistant Professor within UBC’s School of Population and Public Health (SPPH) and Research Division Lead at the Wavefront Centre for Communication Accessibility, studies ways that community structures and systems affect health inequities, including through access information, screening, testing, and care. “We have to ask, ‘Do all families know about that service? Is it easy to get to that service? Do they have access to transportation? Do the offered times work for all socioeconomic backgrounds? For example, if services are offered during typical working hours, that might not work well for everyone,” explains Dr. Poon.

Although many people are accessing information online or receiving care virtually, engaging with the health care system that way is not always an option. “Much like the rest of the province, country, and even the world, we’ve been using virtual technology to deliver care,” explains Dr. Raina Fumerton, a Clinical Assistant Professor at SPPH and the Northwest Medical Health Officer at Northern Health. She notes, however, “Some of our remote communities don’t have the bandwidth, cell coverage, or Wi-Fi capacity to actually use the technology.”

In addition to language and technology, cultural context is a crucial piece of health literacy, explains Dr. Patricia Spittal, a Professor at SPPH and the Principal Investigator of The Cedar Project, a Canadian Institutes of Health Research (CIHR)-funded initiative that is looking to understand the sexual and drug-related vulnerabilities of Indigenous youth who use drugs.

Dr. Spittal adds that the province’s dark history with pandemics is critical to understanding the hesitancy of some to follow public health advice. “Indigenous peoples in B.C. have experienced the brunt of pandemics over centuries – from smallpox to tuberculosis – and pandemics become a part of intergenerational trauma.” In the 1800’s, smallpox devastated Indigenous communities in B.C., and led to the seizure of land. Additionally, there is the legacy of how residential schools and Indian Hospitals affected the spread of tuberculosis. “If you think about the role of racism and pandemic history in the colonial process, you start to understand the skepticism, concern, and distrust Indigenous peoples may have around the pandemic response.”

Differing from historic pandemic responses, the province has worked in partnership with the First Nations Health Authority, and has emphasized respect for Indigenous leadership and their role in developing COVID-19 strategies for their own communities. Still, there are concerns about how the historic context may affect the current pandemic. “What we can’t fix immediately is the systemic racism that exists currently in the system,” adds Dr. Spittal. “Indigenous peoples face racism on a daily basis, often related to policing and health care interactions, contributing to hesitancy to access those same systems.”

Many organizations that serve marginalized populations have closed their doors due to fear of transmission and inability to follow COVID-19 guidelines within their current resources. This also contributes to distrust, argues Dr. Spittal. “When one tries to access health care and is refused, that contributes to PTSD experiences.” In addition, she adds, “These closures have led to a lack of safe drinking water for those who are unstably housed, other personal indignities related to a lack of sanitation and showering ability, and a lack of washroom facilities.”

For the Cedar Project, closing was never an option. They made the decision to pivot from research to community outreach at the start of the pandemic to fill unmet needs. In a matter of months they have distributed harm reduction supplies and more than 5,000 bottles of clean drinking water.  They are also working to ensure that those who need to isolate aren’t left without support through their collaboration with SPPH Associate Member Dr. Richard Lester, founder of mobile health company WelTel. Supported by grants from the Canadian Institutes of Health Research (CIHR), Dr. Lester and Dr. Spittal are providing participants of the Cedar Project with mobile devices, through which they can communicate with staff, have their symptoms monitored, and receive emotional support.

“Asking people to self-isolate when they have been infected or are at higher risk of getting infected or transmitting COVID-19 can cause anxiety and be very difficult, especially those who already have vulnerable access to health services,” explains Dr. Lester. “Mobile health efficiently provides the monitoring and support that people need to ensure they are safe and have their needs met by connecting them to their own healthcare providers or public health.” Dr. Spittal and Dr. Lester note these phones also provide a culturally appropriate ‘lifeline’ for vulnerable individuals in need of extra support.

Dr. Mark Tyndall, a Clinical Professor at SPPH who works on issues of safe drug supply in Vancouver’s Downtown Eastside, explains that COVID-19 closures are also contributing to the number of drug overdoses. “For people who use drugs, suddenly there is nowhere to go: overdose prevention services have been cut back, more people are alone, and the drug supply is more toxic.” There is the added complication, notes Dr. Spittal, that overdose prevention practices are in strong tension with COVID-19 prevention. “People are told not to use alone but to keep their safe distance – the advice is completely opposite.”

Throughout the province, inequities affecting marginalized communities have been amplified by COVID-19 both directly and through unintended consequences like service closures. These affects extend to their ability to follow public health advice, agrees Dr. Fumerton. “For people who face vulnerabilities in terms of those struggling with addition, mental health issues, who are precariously housed or precariously employed, adhering is a real challenge.”

Dr. Michael Brauer, a Professor at SPPH who studies linkages between the built environment and human health, recently published a study on global access to hand washing. He notes that its findings are especially alarming in the context of disease transmission. “Hand-washing is one of the key measures recommended to prevent COVID transmission, yet it is distressing that access is unavailable, especially in many countries with limited health care capacity.” He adds, “in the Canadian context access is limited in many Indigenous communities and for some occupational sectors, such as construction.

The risks associated with workplace transmission – and the importance of supporting workers in adhering to public health advice – have been evident since the early days of the pandemic. British Columbia’s strategy of housing thousands of newly arrived Temporary Foreign Workers (TFWs) for a two-week isolation period reduced the spread of COVID-19 on farms, especially compared to jurisdictions that were slower to act. In care homes, the province’s policy decision to support workers who had previously been working at multiple sites to remain at a single site was key to limiting outbreaks between facilities. Still, there are many workers who face challenges taking time off work if they were to contract or be exposed to COVID-19, risking broader community spread.

Occupational health risks are frequently driven by socioeconomic factors. Research from SPPH’s Partnership for Work, Health and Safety (PWHS) found that those who are unable to work from home – and are thus at elevated risk of contracting COVID-19 – are also more likely to be in the lowest income group and precarious employment, and are the least likely to have paid sick leave. Additionally, immigrant workers reported higher levels of financial distress and greater concern of job loss due to COVID-19, compared to Canadian-born counterparts. When these individuals are asked to isolate due to exposure to COVID-19, missing their next paycheck can mean being unable to feed their family, pay rent, or legitimate fear of job loss.

Medical Health Officer for Fraser Health and Clinical Assistant Professor at SPPH Dr. Ingrid Tyler has observed this trend throughout the Fraser health region. “We are seeing significant COVID-19 transmission in large, multigenerational households, and which often have underemployed individuals or those doing low wage work with often little or no benefits to support them.”

Dr. Tyler explains that while specific settings have been identified as high risk for transmission, the root causes of many of these vulnerable settings are socioeconomic. “The drivers of transmission seem to be structural factors around employment, income, and possibly access barriers related to language and culture.” She adds that one of the greatest challenges is ensuring that close contacts to someone who tests positive are physically and financially able to isolate. “We come across individuals who are precariously housed, precariously employed, and who cannot live without a regular paycheck. For these people it is very, very challenging to comply with public health advice.”

Dr. Fumerton agrees that the key to preventing further spread of COVID-19 is not taking an enforcement approach but rather taking a supportive approach. “When someone tests positive, we help support them and their close contacts by connecting them to services and making sure they have access to food, are safely sheltered, and that their other needs are met in terms of mental health and addictions issues.” She adds, “It will take an intensive wrap-around effort by a local team of people they trust. These people are not unwilling to adhere to advice, but rather they are simply unable. We have to make it possible for them to overcome the challenges they face so they can mitigate the risk as much as possible.”

The complexity of these issues and an understanding of the difficult decisions facing those on the margins underpin Provincial Health Officer and SPPH Clinical Associate Professor Dr. Bonnie Henry’s now-famous motto, “be kind, be calm, and be safe.” The sentiment was echoed by Premier John Horgan, reminding British Columbians who might observe behaviour they believe to be contrary to health guidelines that “we don’t know the circumstances of people when we come upon them.”

Dr. Fumerton argues that addressing inequity within our society is the key to improved health for all. “It is about understanding the systemic factors that result in significant inequities that have been highlighted by COVID-19, making sure there is an all of society recognition to it and approach to addressing it.” While the scale of the task may seem daunting, the work being done by SPPH faculty shows that one person can make a tremendous impact on the health – and lives – of many.

By Elizabeth Samuels

Read more about COVID-19 research at SPPH here. To contribute to this important work, consider donating to the Future of Public Health Fund.