by Ilakkiah Chandran

Graphic design by Brendan Lazar

The 2023 Fraser Institute report revealed that wait times from general practitioner referral to receipt of treatment has increased by 198% between 1993 and 2023.¹ Aside from the general increase in wait times across the country, this report also identified that the province of care and specialty are factors for wait times and, inadvertently, negatively impacting the care and patient’s quality of life. Wait times were significantly high for surgery across all specialties, with patients waiting an average of 10 months for neurosurgery since receiving a referral from their general practitioner.¹ Notably, patients in New Brunswick waited 46 times longer than those in Quebec for neurosurgery.¹ This report raises an interesting question regarding additional factors that impact one’s care and treatment in Canada. If a patient’s geographic location can affect their care, how do social determinants of health (SDOH) such as one’s socioeconomic status, gender, or race factor into patient wait times and overall care? 

SDOH has been studied in the past, including understanding how education impacts health promotion, the racial disparities in health access and the role of housing on healthcare access. There’s an overwhelming amount of research that explores how SDOH impacts people’s healthcare and surgical experiences. This viewpoint shows how two fictional characters, Alisha and Aiden, may navigate their surgical experience from diagnosis to recovery. 

Alisha is a 45-year-old African Canadian woman. She is a single mother with 2 young boys, and also of low-income status. She lives with her older sister in an apartment building in Scarborough and works at a local grocery store. After a workplace injury, Alisha requires knee surgery.  

Aiden is a 23-year-old White man. He is a single man who recently moved from British Columbia after completing his undergraduate degree and lives alone in downtown Toronto. He works a 9-5 PM job at a well-established marketing firm and is of middle-high income. Due to tears in Anterior Cruciate Ligament (ACL), Aiden is also looking to get knee surgery. 

Preparing for Surgery

As the Fraser Institute report reveals, having access to timely surgery remains a challenge for all. However, there is a notable challenge in accessing healthcare among individuals of different SDOH statuses. A recent study conducted in 2020 revealed that despite the accessibility of hospitals in major metropolitan cities across Canada, the suburbs around these cities experienced the lowest accessibility.² Similarly, financial challenges such as the inability to take time off from work, the lack of paid time off, and temporary employment make it challenging for individuals to prioritize their health and wellbeing.³ Aside from these factors, it’s also important to consider the roles individuals play in others’ lives. Caregivers are more likely to prioritize the person they are caring for over their own health.⁴ Given these two factors, Alisha was more likely to experience challenges getting to her appointments, given the challenges with accessibility and the lack of flexibility in her job and her responsibilities as a caregiver. Now even after finally making it to their general practitioner, the nature of both their procedures would’ve required them to wait 24-29 weeks to receive treatment.¹

Surgery

Now, after finally being scheduled for surgery, there are additional barriers one may experience while undergoing the procedure. Experiences of racism and sexism have been described as impacting the quality of life and the health outcomes experienced. Research in obstetrics reveals that black women have experienced manifestations of racism, including instances of discrimination, loss of agency, being objectified and being mistreated in Canada.⁵ Similarly, a recent study identified that surgeons were reimbursed at significantly lower rates in 8 Canadian provinces when performing surgeries on female patients.⁶ This may impact their willingness to take on female patients and inadvertently impact the care female patients receive. These factors impact the care Alisha will receive during her surgery compared to what Aiden may experience. 

Post-Surgery

Patients are often discharged from the hospital after being monitored for a few days to weeks.⁷ Previous research identifies that having social support plays a significant role in the postoperative recovery of patients who have undergone surgery and can significantly impact their mental and functional health outcomes.^8,9 Between Alisha and Aiden, although being single may impact their recovery and health outcomes, Alisha’s access to her sister may warrant greater social support. However, Aiden may be able to hire in-home support if necessary. In contrast, Alisha’s sister may have to work to support their day-to-day expenses. Another key factor that impacts surgical recovery is an individual’s socioeconomic status, which includes access to time off work and prioritized health. For example, previous research identifies that absences after surgery are often associated with lower household income.¹⁰ Another study recognizes that the lack of financial resources and lower social connectivity can reduce successful surgeries and influence readmission in some surgeries.¹¹ In this case, we can anticipate that Alisha may have more difficulty staying on course with her recovery, given her job and her lower income status. Similarly, it’s less likely that Alisha is part of a union at her job, and being in a more precarious role may require her to be ready to work earlier than she is healed.  

Conclusion

The various factors point to Alisha facing additional barriers and challenges when navigating her surgery experience. But what does this mean? Despite wait times being a challenge experienced by the two of them, SDOH have a significant role on the overall health status of patients and their recovery. This reveals the dire need to ensure systems are equipped with adequate tools to improve accessibility, care and health outcomes as part of the interest in improving wait times is necessary. 

References: 

1. Moir, M., Barua, B. & Wannamaker, H. Waiting your Turn 2023: Wait Times for Health Care  in Canada, 2023 Report. (2023).

2. Boisjoly, G. et al. Measuring accessibility to hospitals by public transport: An assessment of eight Canadian metropolitan regions. J Transp Health 18, 100916 (2020).

3. DeRigne, L., Stoddard-Dare, P. & Quinn, L. Workers Without Paid Sick Leave Less Likely To Take Time Off For Illness Or Injury Compared To Those With Paid Sick Leave. Health Aff 35, 520–527 (2016).

4. Acton, G. J. Health-Promoting Self-Care in Family Caregivers. West J Nurs Res 24, 73–86 (2002).

5. Boakye, P. N. et al. Obstetric racism and perceived quality of maternity care in Canada: Voices of Black women. Women’s Health 19, (2023).

6. Chaikof, M. et al. Surgical sexism in Canada: structural bias in reimbursement of surgical care for women. Canadian Journal of Surgery 66, E341–E347 (2023).

7. Canadian Association of General Surgeons. After your Surgery. (2023).

8. Orlas, C. P. et al. Perceived social support is strongly associated with recovery after injury. Journal of Trauma and Acute Care Surgery 91, 552–558 (2021).

9. Kulik, J. A. & Mahler, H. I. Social support and recovery from surgery. Health Psychol 8, 221–38 (1989).

10. Gbolahan, O. O., Fasola, A. O., Ayantunde, A. A. & Olaopa, O. I. Evaluation of causes and predictors of non-attendance at review appointments following treatment of Maxillofacial injuries. Niger Dent J 23, 181–189 (2020).

11. Holbert, S. E. et al. Social Determinants of Health Influence Early Outcomes Following Lumbar Spine Surgery. Ochsner Journal 22, 299–306 (2022).