Transcript But Doctor I Can`t Buy Fruits and Vegetables

BUT DOCTOR I CAN’T
BUY FRUITS AND
VEGETABLES AT THE
DOLLAR STORE….
Addressing social determinants of health in
clinical practice
Physicians for Global Survival
Ottawa Mar.27th, 2010
Dr. Lee MacKay
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
DISCLOSURES
I have not received any money from the
poverty corporations…
But much of my work relies on its effects…
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)

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
“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.
"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
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

“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)
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 selfinterest.
 The rational choice model doesn’t ask why some
people’s choices are limited and others’ are not.

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.
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.
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.

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…
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

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):115-120
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 23 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;12:91110.
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.
PULMONARY FUNCTION (PF) AND
SES
Numerous studies involving approx. 125 000
adults and 19 000 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.

Chest 2007;132:1608-1614
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

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.

Diabetes in Ontario: An ICES
Practice Atlas 2003
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.

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?
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
1.
2.
3.
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
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

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?
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:
2009.
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…)
PROVIDING PATIENT CENTRED
CARE
Patient priorities
Shelter
 Food
 Income
 Sexual orientation
 Gender identity

Physician priorities
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.
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

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)

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

OTHER SUGGESTIONS?
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
“the physician is
the natural
advocate for the
poor."
-Rudolf Ludwig Karl Virchow
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;291:9498
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;291:9498
JAMA. 2004;291:94-98
POWER TO CHANGE
SOCIAL
ADVOCACY MODEL
P articipate
O rganize
W rite
E ducate
R espond
To change the world
“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
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

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
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.
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
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

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 2009.
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.
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 email (s) on your
draft and as a group look up the
address of your consultant and
email the letters out for
everyone to sign if they want
and send in.
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

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
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. http://depts.washington.edu/eqhlth/
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

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

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.

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
QUESTIONS?
REFERENCES







Chin, N; Monroe, A; and K Fiscella. Social Determinants of (Un)Healthy
Behaviors. Education for Health. 2000.13(3): 317–328.
Vozoris, N. and V. Tarasuk. The Health of Canadians on Welfare.
Canadian Journal of Public Health. 2004. 93(2): 115-120.
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;132:1608-1614.
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.
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. 2008. 32-37.
The Ontario Physicians Poverty Work Group. Identifying poverty in your
practice and community. Ontario Medical Review. 2008. 39-43.
The Ontario Physicians Poverty Work Group. Strategies for physicians to
mitigate the health effects of poverty. Ontario Medical Review. 2008. 4549.
Wilkinson, R and M. Marmot. The Social Determinants of Health: Solid
Facts. 2nd Edition. WHO Europe. 2003.
Population Health Forum website. http://depts.washington.edu/eqhlth/
accessed. October 8th, 2009.
American Academy of Family Physicians website.
http://capwiz.com/aafp/home/ accessed October 7th, 2009.