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

• Published in: Canadian Medical Association journal (CMAJ) Vol. 188; no. 17-18; pp. E474 - E483
• Main Author: Andermann, Anne
• Format: Journal Article
• Language: English
• Published: Canada Elsevier Inc 06.12.2016; Joule Inc; CMA Impact, Inc
• Subjects: Canada; Clinical medicine; Collaboration; Community; Community-Institutional Relations; Cooperative Behavior; Domestic violence; Employment; Families & family life; Health care access; Health Personnel; Health Planning; Health Services Accessibility; Health Services Needs and Demand; Health Status Disparities; Humans; Low income groups; Medical personnel; Mental health care; Mortality; Patient-Centered Care; Patients; Physicians; Quality of Health Care; Referral and Consultation; Review; Social aspects; Social Change; Social Determinants of Health; Social Support; Socioeconomic factors; Vulnerable Populations; Workers; Canada
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.160177

Although there has been a lot of focus on supportive environments for physical activity and nutrition, the family environment in childhood is particularly important and can have farreaching consequences on physical and mental health, as well as mortality.18 Children who experience multiple forms of abuse, witness domestic violence and grow up in a household where family members are mentally ill, substance abusers or sent to prison, are "12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs" by the time they reach adulthood.19 On the positive side, developing a relationship of support with an "alternative support figure" (e.g., grandparent, elder, friend or health worker) can serve as "a corrective emotional experience [that] allows the subject to work through his/her negative childhood experiences and acquire modalities of interaction that enable him/her to function more effectively in the world."20 This forms part of a continuum of strategies from victim identification and care to multisectoral structural interventions that better support parents and children, promote nurturing relationships, empower women and change social norms to ideally prevent violence in the first place.21 Although clinical practice guidelines in this domain lack evidence to recommend universal screening of asymptomatic patients,23,24 failure to identify hidden social challenges can lead to "misdiagnosis and a path of inappropriate investigations" (e.g., failing to ask about exposure to violence in the work-up of pelvic pain)25 or inappropriate care plans (e.g., prescribing medicines that patients cannot afford).26 In a study involving a survey of patient perceptions on care integration between mainstream health care services and community-based services that address the social determinants, more than 40% of patients reported that their family doctor was unaware of their struggles (e.g., obtaining enough to feed themselves, arranging transportation to clinic visits or paying for medicines).27 Even when women presented with bruises and broken bones, only 14% had been asked about violence as a potential cause by their primary care provider,28 although over 170 000 women in Canada are victims of violence each year according to police-reported data and over 1 600 000 according to self-reported data.29 Therefore, recent clinical guidance has encouraged physicians to have a heightened awareness of clinical flags and patient cues, using "selective enquiry based on clinical considerations" to work social history questions into the patient encounter in a more seamless way.30 Physicians who know how to ask about social challenges are more likely to report helping their patients work through these issues.31 Indeed, all patients may struggle with social challenges and require support in various spheres at different stages in their lives, and challenges such as discrimination, social isolation or exposure to violence can occur regardless of socioeconomic status.32 Community-oriented primary care is the "integration of public health practice with the delivery of primary care services" with the aim of improving the health of a defined population.67 Communityoriented primary care is a form of "community diagnosis" and "community treatment" blended with clinical patient care that has a long history68 and continues to inspire innovative approaches to support disadvantaged patient groups.69 In a study involving a cohort of over 1000 disadvantaged patients in San Antonio, Texas, a community-oriented primary care approach using health promoters acting as cultural brokers between patients and physicians, as well as helping to map out, mobilize and connect patients with resources in the local community, resulted in a 24% decrease in admissions to hospital and a cost savings of over US$250 000 per year."70