Concepts of Health and Its Determinants

Introduction to Population Health for MCCQE1

For Canadian medical students and international medical graduates preparing for the MCCQE1, understanding the concepts of health and its determinants is fundamental. The Medical Council of Canada (MCC) emphasizes a Population Health approach, which moves beyond the biomedical model of treating disease to understanding the underlying factors that influence health outcomes.

This guide covers the PHELO (Population Health, Ethical, Legal, and Organizational aspects of Medicine) objectives required for the exam, focusing on the Public Health Agency of Canada (PHAC) guidelines and the CanMEDS Health Advocate role.

Defining Health and Disease

To answer MCCQE1 questions effectively, you must distinguish between related but distinct concepts:

• Disease: A pathological process, often physical (e.g., fracture, viral infection).
• Illness: The patient’s subjective experience of ill health.
• Sickness: The social role assumed by an individual who is ill (e.g., taking sick leave).

The WHO Definition

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” — World Health Organization (1948)

The Canadian “Population Health” Definition

The Canadian approach broadens this to include the capacity of people to adapt to, respond to, or control life’s challenges and changes.

Social Determinants of Health (SDOH)

The Social Determinants of Health are the specific conditions in which people are born, grow, live, work, and age. Evidence suggests that SDOH are more significant predictors of health status than genetics or access to healthcare services.

Key Canadian Determinants

The Public Health Agency of Canada identifies 12 key determinants:

Additional Determinants Specific to Canada

• Culture: Cultural practices and the marginalization of specific cultures.
• Gender: Socially constructed roles affecting health behaviors and access.
• Indigenous Status: A distinct determinant due to the legacy of colonization, residential schools, and systemic racism.

Health Equity vs. Health Equality

Understanding the difference between equity and equality is crucial for the Health Advocate CanMEDS role.

Levels of Prevention

The MCCQE1 frequently tests your ability to classify medical interventions into the correct level of prevention.

The Ottawa Charter for Health Promotion

Adopted in 1986, this is a cornerstone of Canadian public health policy. You should memorize the 5 Action Areas.

Vulnerable Populations in Canada

For MCCQE1 preparation, pay special attention to the following groups:

1. Indigenous Peoples (First Nations, Inuit, Métis)

• Health Status: Generally poorer health outcomes compared to non-Indigenous Canadians (higher rates of diabetes, suicide, tuberculosis).
• Key Concepts:
  • Cultural Safety: Analyzing power imbalances and institutional discrimination.
  • Jordan’s Principle: Ensures First Nations children can access public services on the same terms as other children (resolves jurisdictional disputes between federal/provincial governments).
  • Truth and Reconciliation Commission (TRC): Specifically Calls to Action 18-24 regarding health.

2. Immigrants and Refugees

• Healthy Immigrant Effect: New immigrants often have better health than Canadian-born residents upon arrival, but this declines over time (usually within 5-10 years) to match the general population.
• Barriers: Language, lack of health insurance (during waiting periods), lack of culturally competent care.

Key Points to Remember for MCCQE1

• Income is the strongest predictor of health in Canada.
• Health Literacy is the ability to access, understand, and use information to make health decisions. Low health literacy is common and linked to poor outcomes.
• CanMEDS Health Advocate: This role requires you to use your expertise and influence to advance the health and well-being of individual patients, communities, and populations.
• Epidemiology: Understand that chronic diseases (Cardiovascular, Cancer) are the leading causes of death in Canada, but accidents/injuries are the leading cause of death in young people.

// Mnemonic for Levels of Prevention
const prevention = {
  Primordial: "Prevent Risk Factors",
  Primary: "Prevent Disease",
  Secondary: "Screening",
  Tertiary: "Treatment/Rehab",
  Quaternary: "Quit Unnecessary Care"
}

Sample Question

Question

A 28-year-old female presents to her family physician with a 3-month history of worsening asthma symptoms. She requires her rescue inhaler daily and has woken up at night coughing three times in the past week. She is a single mother of two children and recently moved into a basement apartment to save money. She mentions that the apartment smells musty and she has seen black spots on the bathroom ceiling. Physical examination reveals end-expiratory wheezes bilaterally. Spirometry confirms reversible airflow obstruction.

Which one of the following interventions is the most appropriate next step in the management of this patient, incorporating the principles of the social determinants of health?

• A. Prescribe a high-dose inhaled corticosteroid and long-acting beta-agonist combination.
• B. Advise the patient to purchase a high-efficiency particulate air (HEPA) filter for the apartment.
• C. Write a letter to the landlord or housing authority advocating for mold remediation in the apartment.
• D. Refer the patient to a respirologist for biologic therapy assessment.
• E. Schedule a follow-up appointment in 6 months to monitor symptoms.

Explanation

The correct answer is:

• C. Write a letter to the landlord or housing authority advocating for mold remediation in the apartment.

Detailed Explanation

This question tests the Health Advocate CanMEDS role and the application of Social Determinants of Health (specifically Physical Environment/Housing) to clinical management.

• Option C is correct. While medical management is necessary, the root cause (“upstream” factor) of her worsening asthma is likely the mold exposure in her housing. As a Health Advocate, the physician should assist the patient in addressing the environmental trigger. Without addressing the housing conditions, medical therapy will likely be insufficient or require unnecessarily high doses.
• Option A is incorrect. While escalating therapy might be indicated based on asthma guidelines (GINA), doing so without addressing the environmental trigger is not the most appropriate holistic management. It treats the symptom, not the cause.
• Option B is incorrect. While a HEPA filter might help, it places the financial burden on a patient who has already indicated financial strain (“moved… to save money”).
• Option D is incorrect. Biologic therapy is reserved for severe, refractory asthma after environmental triggers and maximal inhaler therapy have been addressed.
• Option E is incorrect. This patient has uncontrolled asthma and requires immediate intervention and closer follow-up.

Canadian Guidelines & Resources

1. Public Health Agency of Canada (PHAC): Social Determinants of Health.
2. CanMEDS Framework: Royal College of Physicians and Surgeons of Canada.
3. Truth and Reconciliation Commission of Canada: Calls to Action (Health).

References

1. Public Health Agency of Canada. (2020). Social determinants of health and health inequalities. Government of Canada. Link 
2. World Health Organization. (1986). The Ottawa Charter for Health Promotion.
3. Frank, J., & Abel-Smith, B. (2020). Public Health and Preventive Medicine. In: MCCQE1 Objectives. Medical Council of Canada.
4. Royal College of Physicians and Surgeons of Canada. (2015). CanMEDS 2015 Physician Competency Framework.
5. National Collaborating Centre for Aboriginal Health. (2013). An Overview of Aboriginal Health in Canada.