1. BUT DOCTOR I CAN’T BUY FRUITS AND VEGETABLES AT THE DOLLAR STORE….
5168
Addressing social determinants of health in clinical practice
Physicians for Global Survival
Ottawa Mar.27th, 2010
Dr. Lee MacKay

2. PRESENTERS/DEVELOPERS
Lee MacKay
B.Sc. Biology
University of Victoria
MD UBC
PGY2 Family Medicine
Dalhousie, Halifax
Mandi Irwin
B.A. International Development Studies
Dalhousie
MD Dalhousie
PGY1 Family Medicine Dalhousie, Halifax
Mandi sends her regrets for not being able to attend today

3. DISCLOSURES
I have not received any money from the poverty corporations…
But much of my work relies on its effects…

4. OBJECTIVES
To facilitate connections between health professionals interested in social medicine/justice
Review the social determinants of health and their impact on patients’ health
Explore recent research on social determinants of health and common medical issues
Provide attendees with a practical approach to addressing the SDH with their patients
Actively participate in a campaign to address the SDH in Canada
Discuss a broad approach to social advocacy (targeted for physicians)

5. AGENDA Introduction Review key concepts
Analyze recent literature and epidemiologic data
Explore a patient centred approach to collaboratively addressing social determinant of health issues effecting your patients’ health
Small group practical social advocacy exercise
POWER to change, strategies to put social advocacy into action
Case examples
Networking (throughout…)
Transition from workshop to the real world

6. “REDUCING HEALTH INEQUALITIES IS AN ETHICAL IMPERATIVE, SOCIAL INJUSTICE IS KILLING PEOPLE ON A GRAND SCALE.”
Commission on Social Determinants of Health (CSDH), Geneva 2008.

7. "Social determinants of health are the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole. Social determinants of health are the primary determinants of whether individuals stay healthy or become ill. Social determinants of health also determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment. Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members." - Dennis Raphael, 2008

8. LISTS ELEVEN DETERMINANTS OF HEALTH
income and social status
social support networks
education and literacy
employment and working conditions
physical and social environments
biology and genetic endowment
personal health practices and coping skills
healthy child development
health services
gender
culture 

9. “There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health.”
Public Health Agency of Canada, Social Determinants of Health (2004)

10. SOCIAL CLASS AND BEHAVIOURAL RISK FACTORS
Traditional medical training teaches a rationale choice model of human behaviour and this lens is used in approaching and addressing patient risk factors.
The rational choice assumes that people are rational, aware, self-creating agents of their own health who can behave in the pursuit of self- interest.
The rational choice model doesn’t ask why some people’s choices are limited and others’ are not.

11. SOCIAL CLASS AND BEHAVIOURAL RISK FACTORS
If lifestyle and behavioural risk factors are not influenced by societal factors and are just due to rationale choice, then these factors should be randomly distributed throughout the population without regard to social class.
They are not.
National surveys conducted
in the US and Europe have
demonstrated striking
gradients in smoking, diet,
and physical activity by
social class.

12. SOCIAL DETERMINANTS OF (UN)HEALTHY BEHAVIORS
Among a representative US sample, Lantz et al. (1998) reported statistically significantly higher rates of behavioral risk factors among those with less than a high school education than those with college education:
smoking 42% vs. 20%
excessive alcohol intake 4.4% vs. 3.7%,
physical inactivity 37% vs. 14%,
obesity 28% vs. 11%.
Similarly, lower social class is associated with higher rates of drug dependence, earlier age of first coitus, and non-use of seat belts.

13. A NEW APPROACH TO PATIENT HEALTH
This suggests the traditional individualistic, rational choice model for behavioural risk factors we are taught in medical school is incomplete.
An educational approach that integrates sociocultural factors into a patient-centered approach to health care, resulting in a true biopsychosocial model of care is needed.

14. There is burgeoning research on the health impacts of the social determinants of health from all areas of medicine from cardiology to infectious disease all over the globe.
We will just cover a few relevant to all areas of medicine to give you a sense of the impact…

15. POVERTY AND ILL HEALTH – THE CONNECTION
Life expectancy in the poorest quintile neighbourhoods in urban Canada is 5 years shorter for men and 1.6 years shorter for women than those in the highest quintile neighborhoods.
Infant mortality rates are 61 percent higher and low birthweight rates are 43 percent higher in the poorest areas.
24 percent of all potential years of life lost in Canada in 1996 were attributable directly to poverty compared to:
31 percent for cancer
18 percent for cardiovascular disease

16. THE HEALTH OF CANADIANS ON WELFARE
In 2001 an estimated 1,910,900 or 6.4% of Canadians relied on welfare
These individuals are:
3.1 times more likely to report their health as poor or fair
2.9 times more likely to have poor functional health
2.1 times more likely to have poor social supports
2.7 times more likely to have depression
1.6 times more likely to have heart disease
1.2 times more likely to have diabetes
1.2 times more likely to be obese
Canadian Journal of Public Health. 2004; 95(2):

17. SOCIOECONOMIC STATUS AND BLOOD PRESSURE: AN OVERVIEW ANALYSIS
Lower SES associated with higher mean BPs in almost all studies in developed countries.
Inverse gradient stronger and more consistent in women.
The magnitude of the association varied with age adjusted mean systolic BP differences of about 2- 3 mm Hg between the highest and lowest SES groups.
Little evidence that adverse psycho-social factors associated with low SES cause chronic elevations in BP.
Journal of Human Hypertension.1998;12:

18. The pathways of socioeconomic status (SES) influence are not yet clear
The pathways of socioeconomic status (SES) influence are not yet clear. SES may limit access to high-quality health care, including high-cost medications; influence awareness, knowledge, and health beliefs about blood pressure and its treatment; affect communications with providers and adherence to treatment regimens; and affect environmental living conditions that can facilitate or impede life opportunities and lifestyle.

19. PULMONARY FUNCTION (PF) AND SES
Numerous studies involving approx adults and children since the mid-1980s have examined the relationship between SES and PF in both developed and developing countries.
Positive correlation between higher SES and PF, even after correcting for anthropometric features, age, race, sex, smoking and respiratory illness.
The magnitude of the effect of SES on PF is variable, but measurable and significant.
There remains an effect of childhood SES on adult PF, again after correcting for confounders.
MANDI - One study of subjects showed the effect of SES was larger than poor air quality (1.9% to 2.3%) but smaller than smoking (5.2% to 6.4%) .
Chest 2007;132:

20. WHY DOES SES AFFECT LUNG FUNCTION?
Still unclear to researchers!
Some factors associated with lower SES that affect lung function include:
prenatal exposure and IUGR
Childhood respiratory tract infections
Housing conditions
Heating or cooking with biomass fuels
Tobacco smoke exposure
Poor nutrition
Occupational exposures
Air pollution
MANDI- Diets low in anti-oxidants and fresh fruit are associated with reduced lung function.

21. DIABETES AND SES
The link between low SES and type 2 diabetes has long been established across cultures, ages and even neighbourhoods.
Low-income Ontario women are 4 times more likely to suffer from diabetes than high-income women.
Low SES is associated with increased risk of hospitalizations from acute diabetes complications, even in the context of a universal health care model.
MANDI - The least affluent are admitted to hospital 43% more often than the wealthiest.
Diabetes in Ontario: An ICES Practice Atlas 2003

22. HEART ATTACKS AND THE SDH
Hypertension, abnormal lipid levels, smoking, diabetes, abdominal obesity, psychosocial factors, inadequate consumption of fruits and vegetables, excessive alcohol, and lack of regular physical activity collectively account for 90% of the population attributable risks in men and 94% in women at all ages of myocardial infarction worldwide.
These have all been closely linked to the social determinants of health.

24. Okay so its clear the social determinants of health effect the encounters we have with our patients every day.
But these are social issues what can we do to deal with these with our patients?

25. APPROACHES TO SDH IN CLINICAL PRACTICE
The Ontario Physicians Poverty Work Group discusses three important steps in assisting patients suffering health effects from the social determinants of health
Provide patient centred care
Incorporate poverty as a clinical risk factor
Assist patients in accessing community resources
We will discuss these three strategies and specific ways to employ each with patients in your practice
MANDI

26. INCORPORATING POVERTY AS A CLINICAL RISK FACTOR
The most important step in managing the social determinants of health is identifying that they are an issue for your patients (remember this is one of the most significant risk factors for almost any medical condition)
There are many ways to do this and the true effects of poverty vary widely depending on other factors
Easy places to start:
Ask the patient every time you write a prescription if financial concerns will be an issue in filling it
Ensure you know the educational level obtained by everyone of your patients and if they can read
Include social demographic information on the intake form for all new patients
MANDI

28. Sample Routine History Questions Assessing Income as a Determinant of Health
Are you currently working? On a scale of 1 to 10 how concerned are you about losing you job?
If you are not working are you on social assistance? If so have you applied additional income through supplemental allowances or disability programs?
Have you been denied social assistance? Have appealed this decision? Did you have physician input into your appeal?
Do you have a place to live? On a scale of 1 to 10 how concerned are you about losing your home?
Do you ever have difficulty making ends meet at the end of the month? Does this result in not enough food for your family?

29. VALIDATED SCREENING QUESTION
“Do you ever have difficulty making ends meet at the end of the month?”
(Sensitivity 98%, Specificity 64% for living below the poverty line)
Brcic, Vanessa and Caroline Eberdt, “Developing a tool to identify poverty in a family practice setting,” Unpublished. Vancouver, BC:

30. PROVIDING PATIENT CENTRED CARE
“Patient centred care respects the individuality, ethnicity, dignity, privacy and information needs of each patient and the patient’s family. That respect should pervade the health system. Patients should be in control of their own care. Accountability to patients and their families should be high.”
This translates into attempting to appreciate and approach each patient’s situation from their perspective and incorporating the patient’s values not our own in health decision making
(yes, this may mean abandoning our well ingrained guidelines…)

31. PROVIDING PATIENT CENTRED CARE
Patient priorities
Physician priorities
Shelter
Food
Income
Sexual orientation
Gender identity
Lower blood pressure
Tight glycemic control
Smoking cessation
Safe sex
VTE prevention
Next time you want to use the word compliance in regards to a patient ask yourself what else might be going on and if you have screened for issues that may be influencing a patients action.

32. PROVIDING PATIENT CENTRED CARE
The challenge of dealing with issues that bear significant stigma for patients
Ways of reframing behavioral change:
Motivational interviewing - a little Colombo goes a long way
Patient and physician versus society – support your patients in overcoming the institutional systems that effect their health
Harm reduction – start small and let your patient gather esteem and momentum

33. ASSISTING PATIENTS TO ACCESS COMMUNITY RESOURCES
There are many practical and direct ways a physician can help increase a patients income, especially those on social assistance, or access to costly medical treatments
Encourage patients to apply for supplements to welfare that require approval by a physician such as special dietary requirements, transportation to health appointments and extra medical supplies
Direct patients to programs to assist them with their health care costs (low income dental programs, Trillium drug program) and avoid samples as they only worsen the situation in the long run
Provide patients with counselling on potential tax benefits (child tax benefit, medical cost deduction)
MANDI

34. COMMUNITY RESOURCES – HOW TO LEARN THE LANDSCAPE
To know how to help your patient access community resources you must know what they are yourself.
Arrange a briefing with a social worker in your community on available supports
Know what drugs your provincial pharmacare plan covers
Research the requirements for supplemental social assistance programs
Consider adding a part time social worker to your health care team
MANDI

35. OTHER SUGGESTIONS?
MANDI

36. LOOKING UP STREAM
As in managing the medical complications of any preexisting risk factor dealing only with the result of the social determinants of health can at times be frustrating and feel unfulfilling
The effective antidote to this frustration is getting involved in correcting the root cause
Hence, SOCIAL ADVOCACY
MANDI

37. “the physician is the natural advocate for the poor."
MANDI
-Rudolf Ludwig Karl Virchow

39. PHYSICIAN-CITIZENS—PUBLIC ROLES AND PROFESSIONAL OBLIGATIONS
Although leaders and other commentators have called for the medical profession's greater engagement in improving systems of care and population health, neither medical education nor the practice environment has fostered such engagement.
A clear definition of physicians' public roles, reasonable limits to what can be expected, and familiarity with tasks that are compatible with busy medical practices is needed.
JAMA. 2004;291:94-98

40. PHYSICIAN-CITIZENS—PUBLIC ROLES AND PROFESSIONAL OBLIGATIONS
Clear and visible leadership in the interests of the public’s health is regarded by many as the best way for the medical profession to regain and retain the public trust that has diminished in recent decades.
Answering calls for greater public engagement, physicians may face unfamiliar challenges, such as broadening their focus to include communities of patients, addressing illness prevention, as well as its treatment, and accepting responsibilities outside regular practice settings
JAMA. 2004;291:94- 98

41. JAMA. 2004;291:94-98

42. POWER TO CHANGE SOCIAL ADVOCACY MODEL
articipate
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
- Margaret Mead
rganize
rite
ducate
espond
To change the world

43. PARTICIPATE in change
There are innumerable passionate, dedicated and active community groups working to address the social determinants of health in your community and in Canada as a whole who would be thrilled to have even just the voiced support of a physician
Many of these groups struggle to find grants and funding for the projects they are ready to put into action and even just some simple editing and the addition of your name and title on a grant proposal could mean the difference between a project living or dying
Fewer physicians are now in parliament today than the very first Canadian parliament

44. PHYSICIAN-CITIZENS PUBLIC ROLES AND PROFESSIONAL OBLIGATIONS - CONCLUSIONS
Public-interest advocacy projects are often coordinated by other groups, and physicians can fulfill their public responsibilities by providing support.
Successful collaborations with consumer groups and public organizations have resulted in improvement of coordination between agencies, provision of care for disadvantaged populations, attention given to public health issues, success of health promotion initiatives, and the political impact of community-voiced concerns
JAMA. 2004;291:94-98

45. ORGANIZE for change
The coming together of a group of physicians to address a social issue is something that is taken notice of by the media and the government
Examples:
International Physicians for the Prevention of Nuclear War
awarded The Nobel Peace Prize in 1985 for their work in preventing nuclear war.

46. ORGANIZE for change
“I’ve had the opportunity, over the past quarter century, to see the effects of ill health and pandemic diseases tear apart societies in poor countries. The work that Physicians for Peace is doing around the world not only represents the best of what we stand for, but goes right to the core challenges of our time, really the life and death issues, in the most creative and positive way.”
- Jeffery Sachs, Special Advisor to UN Secretary-General Ban Ki-moon

47. WRITE letters for change
The respect and added weight of the two letters at the end of your name are something recognized by the public, politicians, companies and the media as having power. Do not squander it.
Exercise this power as often as you can.
Most physicians dictate letters every day and one extra letter can take only a matter of a few minutes
If done on a computer it is easy to circulate your letter to colleagues or others so they can edit and sign it themselves

48. Example from American Academy of Family Physicians website:
As a family physician and constituent, I stand with 450,000 doctors who want health care reform in I urge you to take bold action and pass legislation that provides coverage and high-quality, affordable health care for my patients. We need these reforms because the current system is not working. I believe that a US health care system that is based on primary care will be of higher quality, increase access and will lower cost. We need health care reform so that doctors can once again do the job they signed up for in the first place: provide the best care for their patients. Please fight for the health of all of your constituents.

49. One more dictation ~ a practical exercise in social advocacy ~
We will now try a quick exercise in putting advocacy into action and make it as similar to what we are familiar with as possible
Introduce yourself to your neighbours and get into groups of two or three
Letter format:
Come up with a chief complaint (CC)
Write a brief history of presenting injustice (HPI)
Suggest a management plan (Plan)
Decide on who this needs to be referred to (consultant)
Provide your (s) on your draft and as a group look up the address of your consultant and the letters out for everyone to sign if they want and send in.

50. EDUCATE about the need to change
Teaching the next generation of physicians, from medical students to residents, a different approach to addressing the social determinants of health is essential in achieving system change
Inform your patients about the link between these factors and their health so they can organize support groups and community resources of their own
Give presentations about the effect of the social determinants of health in schools or to community groups whenever possible

51. CASE EXAMPLE – Dr. Stephen Bezruchka
Stephen Bezruchka has worked as an Emergency Physician in Seattle,  Washington.
His personal and professional work led him to an interest in the  connection between income disparities and health outcomes
He has translated this into research on effective methods of  disseminating determinants of population health to the general population so they  work to change societal structures to improve America's health
With a group of Public Health students at the University of Washington he started an educational initiative that sent undergrad and grad  students into classrooms to teach students about the connection between income disparities and poor population health outcomes

52. Population Health Forum Advocating for Action Toward a Healthier Society
OUR GREATEST HEALTH HAZARD is the economic "gap" between the rich and the poor. With greater economic inequality comes worse health — lower life expectancy and higher mortality rates. The U.S. spends the most money on health care, but ties for 30th place in life expectancy.
All of the countries that rank higher in the Health Olympics have a smaller gap in income distribution between their richest and poorest citizens.
Population Health Forum website.

53. RESPOND to what you see
When you identify an issue in your practice and community take steps to correct it
This can mean negotiating with local politicians, business groups, your provincial medical association or other community leaders
Past examples of successful physician initiatives include seat belts, bike helmets, and speed bumps
MANDI

54. CASE EXAMPLE - Dr. Andrew Lynk
Andrew Lynk is a full scope pediatrician in Sidney, NS with a busy paediatric practice with a one in three call rotation for the Cape Breton Regional Hospital Paediatric Department and Neonatal ICU
He noticed a pattern in his daily walk to the NICU which took him by the smoking area of Cape Breton Regional Hospital
He found that often he would see the parents of the neonates he was walking to see in the NICU smoking outside in the designated smoking area on his daily trip
He realized this wasn’t a coincidence and decided to do something about this clear risk factor

55. CASE EXAMPLE
Dr. Lynk gathered a group of local physicians and lobbied for the successful passage of the Cape Breton Regional Municipality's (CBRM) Tobacco By-Law, which led to the complete prohibition of smoking in all public buildings.
This was the first jurisdiction in Canada to do so with similar by-laws following in municipalities across the country.

56. SUMMARY The SDH are major risk factors that deserve our attention
The current view of the rationale choice model is flawed
There are tangible things that can be done in clinical practice to manage the SDH
The public and leaders throughout medicine are demanding physician involvement in social issues
There are many examples of active full scope physicians that have made significant impacts on social issues
Social advocacy education is essential for the future of medicine
Your passion to ‘help people’ is still possible
You are not alone

57. QUESTIONS?

58. REFERENCES
Chin, N; Monroe, A; and K Fiscella. Social Determinants of (Un)Healthy Behaviors. Education for Health (3): 317–328.
Vozoris, N. and V. Tarasuk. The Health of Canadians on Welfare. Canadian Journal of Public Health (2):
Minor D, Wofford M, Wyatt SB. Does socioeconomic status affect blood pressure goral achievement? Curr Hypertens Rep. 2008;10(5):390-7.
Colhoun, H., Hemingway, H., & N. Poulter. Socioeconomic status and blood pressure: An overview analysis. Journal of Hum Hypertens.1998;12:91–110
Hegewald MJ and Crapo RO. Socioeconomic Status and Lung Function. Chest. 2007;132:
Rabi D et al. Association of socio-economic status with diabetes prevalence and utilization of diabetes care services. BMC Health Services Research 2006, 6:124.
Hux J, Booth G, Slaughter P, & A. Laupacis. Editors. Diabetes in Ontario: An ICES Practice Atlas. Toronto, ON: Institute for Clinical Evaluative Sciences in Ontario; 2003.

59. REFERENCES CONT’D
Gruen, R.; Pearson, S. and T Brennan. Physician-Citizens—Public Roles and Professional Obligations. JAMA. 2004;291:94-98
The Ontario Physicians Poverty Work Group. Why poverty makes us sick. Ontario Medical Review
The Ontario Physicians Poverty Work Group. Identifying poverty in your practice and community. Ontario Medical Review
The Ontario Physicians Poverty Work Group. Strategies for physicians to mitigate the health effects of poverty. Ontario Medical Review
Wilkinson, R and M. Marmot. The Social Determinants of Health: Solid Facts. 2nd Edition. WHO Europe
Population Health Forum website. accessed. October 8th, 2009.
American Academy of Family Physicians website. accessed October 7th, 2009.