Taking action on the social determinants of health in clinical practice: a framework for health professionals

CMAJ. 2016 Dec 6 – Anne Andermann, MD DPhil

[Excerpts] There is strong evidence from around the globe that people who are poor and less educated have more health problems and die earlier than those who are richer and more educated,  and these disparities exist even in wealthy countries like Canada. To make an impact on improving health equity and providing more patient-centred care,it is necessary to better understand and address the underlying causes of poor health. Yet physicians often feel helpless and frustrated when faced with the complex and intertwined health and social challenges of their patients. Many avoid asking about social issues, preferring to focus on medical treatment and lifestyle counseling.

It is increasingly recognized that to improve population health, health equity needs to become a priority in the health sector, and measures to reduce disparities must be integrated into health programs and services.6 Training physicians, nurses and other allied health workers to address the social determinants of health is considered one of the key principles for promoting more equitable health outcomes for patients, families and communities.7 Indeed, health professional schools are socially accountable to contribute to meeting the needs of the local community. However, what exactly should health workers do to make a positive impact? In this review, we identify the concrete actions that clinicians can use to help address the social determinants of health as part of their routine clinical practice 

What are the social determinants of health?

The World Health Organization (WHO) defines social determinants of health as follows:

“the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”

The social determinants of health include factors such as income, social support, early childhood development, education, employment, housing and gender. Many of these can result from even more upstream and insidious structural forces at play. For instance, in the case of First Nations, Inuit and Metis peoples, ongoing challenges from the impacts of colonization, intergenerational trauma from residential schools, systemic racism, jurisdictional ambiguity and lack of self-determination exert a further influence on health and its determinants.

How are social determinants linked to health outcomes?

Certain subgroups of the population, particularly those who are less empowered and who have lower socioeconomic status, tend to live and work in more degraded environments and have a higher exposure to risk factors for disease, as well as physiologic impacts from chronic stress. Consequently, they have worse health and shorter lives.

How can health care workers influence social determinants?

There are many ways that physicians and other allied health workers can take action on the social determinants of health at the patient, practice and community levels.

What can be done at the patient level?

Asking patients about social challenges in a sensitive and caring way 

The first step in addressing often hidden social issues is asking patients about potential social challenges in a sensitive and culturally acceptable way. There are a growing number of clinical tools to help frontline practitioners ask about problems such as lack of employment, food insecurity and discrimination; generally taboo topics such as physical and sexual abuse, and history of psychological trauma; or factors that can further complicate care such as low literacy, legal or immigration status issues, fears regarding health care or barriers to making appointments. 3 For example, a simple screening question such as “do you ever have difficulty making ends meet at the end of the month?” is 98% sensitive and 64% specific for identifying patients living below the poverty line.3

Referring patients and helping them access benefits and support services 

Once a “social diagnosis” has been made, “social prescribing” involves connecting patients with various support resources within and beyond the health system, such as local women’s groups, housing advocacy organizations or employment agencies. A randomized controlled trial conducted in the United Kingdom involving 161 patients identified in primary care as having psychosocial problems found that referral to community-based support groups reduced patient anxiety and improved perception of overall health compared with usual general practitioner care. In one pilot study, 35 out of 131 patients initially referred were still using these support services 4 weeks later.

How are social determinants linked to health outcomes?

Certain subgroups of the population, particularly those who are less empowered and who have lower socioeconomic status, tend to live and work in more degraded environments and have a higher exposure to risk factors for disease, as well as physiologic impacts from chronic stress. Consequently, they have worse health and shorter lives. 

Taking action on the social determinants of health in clinical practice: a framework for health professionals
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