Applying the Social-Ecological Framework to Long-Term Care: A Holistic Approach to COVID-19 Response

The recent COVID-19 pandemic has exposed the extent of previously underappreciated health disparities in Ontario’s Long-Term Care (LTC) Sector. Have these cracks in the foundation of a system designed to protect and care for seniors requiring complex care been fractured beyond repair? Ontario’s not-for-profit and for-profit LTC residents suffered tremendously during the many waves of the global pandemic.

The social-ecological framework developed by Brofenbrenner in 1979 (Social Ecological Model, 2023) has been described as a 5 stage model for which healthy public policy and interventions can be designed, implemented, monitored, and evaluated. The model considers the individual, their affiliation with people and groups, and their communities (White, 2015).

By applying this framework to analyze the effects of COVID-19 on residents in LTC in Ontario, we can review how the residents interact with their environment and the greater health system.

Figure 1 will allow demonstration of the spheres of influence of COVID-19 on LTC.

Figure 1. Social Ecological Model applied to COVID-19 in LTC in Ontario.

Provincial and regional structures (Ontario Health and Regions) are responsible for developing operational oversight across the health system. Although attempts were made to coordinate responses and support resource sharing across the health system, there were limited resources to support this effort at the regional or local level. Public Policy is required for the prevention of the spread of infectious disease that may lead to pandemics. The limited amount of information available on the novel COVID-19 virus prevented the ability of these governing bodies to respond with appropriate interventions safely and efficiently. Mansourian (2020) identifies the effectiveness of prevention, control, and interventions when they are based on a model that considers all determinants.

As the Community level resides in the portfolio of the provincial government, local Public Health agencies were not able to support residents in LTC. Nevertheless, local agencies did prioritize vaccinations for residents in LTC once they were available.

At the Organizational level, LTC homes, both for-profit and not, struggled to manage the care of the residents while mitigating the risk to their employees due to the lack of available personal protective equipment. In addition to this, the number of staff members infected with the virus presented ongoing challenges with staffing and day-to-day operations such as meal delivery and laundry services.

The largest impact on the residents came at the Interpersonal level. Many LTC homes in Ontario completely shut down any visitation during the height of the pandemic, adding additional stress when residents were denied interaction with family and friends including some caregivers that were often their daily source of companionship.

Upon examination of the residents in LTC at the Individual level, it is important to note their life circumstances have already placed them in a congregate living setting with complex needs requiring specialized care. The public health measures may have resulted in a lack of understanding of current events and a struggle to comprehend the severity or the need for such strict measures added to individual isolation. Some of the Infection Prevention and control measures were overly conservative and restrictive, adding to social isolation.

As the pandemic in Ontario progressed, all stakeholders began to work together to address and support the health and well-being of residents in LTC. Information was more readily available to all residents and presented in a way they could understand. Many LTC facilities set up virtual visiting options to ensure residents maintained a connection to their loved ones while maintaining a ‘no in-person’ visiting policy. LTC organizations were partnering with acute care hospitals and other system-level players to enable rescue transfers for patients at risk of deterioration. Municipal health regions were setting up mobile response teams deployed to LTC homes in crisis. All these interventions, working together, have strengthened the healthcare system through an increased understanding, transparency, and knowledge among different sectors within the provincial healthcare system in Ontario.

In collaboration with Kethra Stewart, a fellow MHST 601 student, we are applying the Social-Ecological framework to the COVID-19 pandemic in LTC. While the COVID-19 pandemic affected all of Canada, specific populations saw a far greater impact such as seniors, essential workers, and those living with disabilities due to the inequities that already existed across this group well before the global pandemic hit.

In the Chief Public Health Officer’s Report on the state of Public Health in Canada (2020), the first COVID-19 pandemic in LTC was declared on March 7, 2020, in British Columbia (BC) while the largest outbreak in a congregate living setting was seen about a month later in Ontario with 164 cases (Chief Public Health Officer, 2020).

Upon focusing on the Community level within the framework, one can examine how Ontario LTC residents can be affected by a pandemic since Provincial Public Health agencies in Ontario have no accountability or oversight for long-term care. The role of Public Health in the Ontario LTC system can be broken down into three categories – guidance, outbreak management and vaccinations.

Public Health agencies in Ontario developed and enforced local mandates when it came to testing, isolation requirements, visiting guidelines, outbreak management strategies and distribution of vaccines once available for delivery. This meant that in Ontario, two cities located geographically close to one another may have entirely different mandated regulations when it came to protecting the public during the Covid-19 pandemic.

In BC, there are five different regional districts, and each section is managed by different health authorities governing health (Government of B.C, 2021). The Regional Health Authorities include Fraser Health, Interior Health, Island Health, Northern Health, and Vancouver Coastal Health (Government of B.C, 2021).

In the Interior Health Authority where Kethra works, there are a total of 20 hospitals (tertiary, regional and community) and 24 clinics (primary and community) (Interior Health Data and Analytics Services, 2021/22)where patients can walk in without an appointment. The pharmacies at most stores have a walk-in policy for vaccinations for flu and Covid-19 (British Columbia Pharmacy Association, 2023). Each community follows the health authority in accordance with the public health policies as directed by the Health Minister of BC.

Three factors made long-term care facilities in BC particularly vulnerable, not unlike Ontario: “the staffing model, ageing facilities, and a frail dependent client population” (Chung, 2020). These factors can be likened to the levels in the Social-Ecological framework. At the Public Policy level, like in Ontario, the response to COVID-19 in LTC in BC has been focused on protecting vulnerable residents and staff as well as controlling the spread of the virus within facilities. Initially, BC Health Authorities limited visitors to long-term care facilities and implemented enhanced screening protocols for staff and visitors. LTC homes were required to have a COVID-19 safety plan in place. At the Organizational level, staff were also educated and trained in infection prevention and control measures (BC Government News, 2020). Reflections on the Community level can be observed in how the Province of BC implemented outbreak management strategies in LTC facilities including additional funding for cleaning and access to personal protective equipment for staff. In December 2020, the province began rolling out COVID-19 vaccinations for residents and staff in LTC facilities to address both the Interpersonal and Individual levels by strengthening the public policy and personal protective supporting in-person interactions amongst residents and their loved ones. As of March 2023, over 95% of eligible residents have received at least one dose of the vaccine, and over 90% have received two doses (Government of Canada, 2023). Face masks are still currently mandated in all clinical and healthcare settings (Interior Health, 2023). To ensure communication, each organization in the community has a website that has information on Covid-19 regarding facilities, employment opportunities, prevention and self-care, vaccination and booster information regarding Covid19 and other commonly asked questions.

In conclusion, the Social-Ecological framework is a conceptual framework that helps to understand the interplay between human behaviour, social systems, and the physical environment. This framework is based on several concepts and theories, such as ecological systems theory, social determinants of health, social capital, and community-based research (ER Services, 2023). The COVID-19 pandemic highlighted the extent of previously underappreciated health disparities in Ontario's Long-Term Care sector and applying the Social-Ecological framework can help to analyze the effects of COVID-19 on residents in long-term care in Ontario. The framework recognizes that individual behaviour is influenced by the social and physical environment in which people live and highlights the importance of addressing social determinants of health, building social capital, and promoting community participation and empowerment to improve health outcomes. As the COVID-19 cases continue and in the event of future pandemics, it is imperative we take note of the “lessons learned” and ensure all levels of influence work together to address and support the health and well-being of residents in LTC. The interventions working together have strengthened the healthcare system and have resulted in increased understanding, transparency, and knowledge amongst different sectors within the provincial healthcare system in Ontario. The pandemic brought attention to the gaps created by the existing siloed structures but as a result, there was a silver lining in that out of necessity health system providers broke down those silos to address and correct disparities amongst our most vulnerable population.

Works Cited

BC Government News. (2020, September 9). Retrieved from Investment brings new support to those most vulnerable to COVID-19 and communities where they live: https://news.gov.bc.ca/releases/2020PREM0050-001694

British Columbia Pharmacy Association. (2023). 2022 Flu Vaccines in B.C. Pharmacies. https://www.bcpharmacy.ca/flu

Chief Public Health Officer. (2020). From Risk to Resilience: An Equity Approach to COVID 19. Ottawa: Public Health Agency of Canada. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19/cpho-covid-report-eng.pdf

Chung, A. (2020). COVID-19 and Long-Term Care. BC Medical Journal, 206.

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https://www2.gov.bc.ca/gov/content/health/about-bc-s-health-care-system/partners/health-authorities/regional-health-authorities

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