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Review
CMAJ
Taking action on the social determinants of health
in clinical practice: a framework for health professionals
Anne Andermann MD DPhil; for the CLEAR Collaboration
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/160177-rev
Competing interests: None
declared.
This article has been peer
reviewed.
Correspondence to:
Anne Andermann, anne.
[email protected]
CMAJ 2016. DOI:10.1503
/cmaj.160177
T
here 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,1 and these disparities exist even in wealthy
countries like Canada.2 To make an impact on
improving health equity and providing more
patient-centred care,3 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.4 Many
avoid asking about social issues,5 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
Key points
•
Although physicians generally recognize that social determinants (e.g.,
income, education and social status) influence the health of their
patients, many are unsure how they can intervene.
•
An increasing body of evidence provides guidance on a number of
concrete actions that clinicians can use to address social determinants in
their clinical practice to improve patient health and reduce inequities.
•
At the patient level, physicians can be alert to clinical flags, ask patients
about social challenges in a sensitive and caring way, and help them
access benefits and support services.
•
At the practice level, physicians can offer culturally safe services, use
patient navigators where possible, and ensure that care is accessible to
those most in need.
•
At the community level, physicians can also partner with local
organizations and public health, get involved in health planning and
advocate for more supportive environments for health.
•
Growing numbers of clinical decision aids, practice guidelines and other
tools are now available to help physicians and allied health workers
address the social determinants in their day-to-day practice.
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CMAJ, December 6, 2016, 188(17–18)
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 (Box 1; Appendix 1, available at www.cmaj.
ca/lookup/suppl/doi:10.1503/cmaj.160177/-/DC1).
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.”8
The social determinants of health include factors such as income, social support, early childhood development, education, employment,
housing and gender.9 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.10
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.11 Consequently, they have worse
health and shorter lives.12
© 2016 Joule Inc. or its licensors
Review
The field of medicine continues to operate
under a “risk factor” paradigm focused on
behavioural modification for high-risk groups as
the main strategy for preventing disease (e.g.,
smoking cessation, decreasing salt and fat intake
and reducing sedentary lifestyle).13 However,
this approach has not proven to be effective,14
largely because individuals are often not in control of the factors that make them sick and
respond unconsciously to environmental cues.15
Therefore, reducing unhealthy behaviours
requires creating more supportive environments
that make the healthy choices the easy choices.16
For example, neighbourhood socioeconomic
disadvantage and higher concentration of convenience stores have been linked to tobacco use.
Similarly, lower availability of fresh produce,
which — combined with concentrated fast food
outlets and few recreational opportunities —
can lead to suboptimal nutrition and less physical activity.17 Therefore, in addition to individual counselling, broader interventons are
needed, such as urban planning to create parks
and bicycle paths to promote active transport
and community gardens and mobile markets to
increase access to healthy foods.
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
Physicians and other allied health workers
already engage in a wide range of clinical preventive practices, intervening early with the
aim of preventing disease and promoting
health. Addressing the social determinants is an
important and emerging area of practice that
entails starting earlier and broadening the scope
of interventions, thus making entire families
and communities healthier.
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?
Depending on where clinicians are practicing,
the types of disadvantage that they will encounter will vary and will not always be obvious just
from looking at the patient. For instance, in a
Canadian urban context, one might encounter
single mothers, isolated older people, Indigenous youth who left their community to seek
employment opportunities or escape violence,
hidden homeless (e.g., couch surfers), nonstatus
refugees, Indigenous youth and people with
mental health or addiction problems. Physicians
can better support patients faced with social
challenges by asking about their social history,
providing them with advice, referring them to
local support services, facilitating access to
these services and acting as a reliable resource
person throughout the process.22
Box 1: Evidence used in this review
A realist review methodology was used that is outlined in full in Appendix 1
(available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.160177/-/DC1). Broadly,
multiple databases (e.g., Medline, Cumulative Index to Nursing and Allied Health
Literature [CINAHL], Embase, ISI Web of Knowledge) were searched using the
following search terms: Social near determinant* AND health OR Health near/2
*equit* OR disparit*, Health* worker* OR Health* professional* OR Health*
provider* OR primary health care OR community health worker* and training* or
education* or capacity strengthening OR capacity building. Additional searches of
selected relevant websites were conducted, including those of the Canadian Task
Force on Preventive Health Care, US Preventive Services Task Force, UK National
Institute for Health and Care Excellence, National Guideline Clearinghouse
and the Guide to Community Preventive Services. Grey literature was identified
by Google searches, scanning reference lists, key informant discussions and
postings on Internet listserves relating to health equity. This search identified
almost 500 documents that were scanned for relevance, and a total of 71
documents were retained. Because this is a relatively new area of scientific
inquiry that examines a variety of complex interventions impacting multiple health
and social outcomes, a qualitative synthesis of the findings is presented that can
be used as a framework for action on social determinants in clinical practice.
With the exception of some clinical practice guidelines, most of the evidence on
the effectiveness of physician intervention in social determinants is from smallerscale observational studies and a few randomized controlled studies, as well as a
growing number of qualitative and mixed-methods studies that are able to better
assess the complexity involved and the role of context in influencing outcomes.
Most publications pertain to low-resource settings within high-income country
contexts, such as inner city neighbourhoods with high rates of poverty.
CMAJ, December 6, 2016, 188(17–18)
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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
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;33 generally taboo topics such as physical and sexual abuse, and history of psychological trauma;34 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.35 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.36
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CMAJ, December 6, 2016, 188(17–18)
Asking about these issues in a caring way is
important in its own right, because there is evidence that compassion and empathy “makes
patients more forthcoming about their symptoms
and concerns, yielding more accurate diagnoses
and better care … and leads to therapeutic interactions that directly affect patient recovery.”37
Integrating information on social challenges into
the medical record is also helpful in ensuring
that the entire care team can take these considerations into account during care planning.
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.38 In one pilot study, 35 out
of 131 patients initially referred were still using
these support services 4 weeks later.39
Beyond referral, physicians and allied health
workers can advocate for individual patients
(e.g., by writing letters on the patient’s behalf
to housing agencies, educational institutions or
the courts).40 They can also help their patients
to access benefits or programs to which patients
are entitled (e.g., tax credits, child and family
benefits, home visitation programs, low-cost
day care, parenting classes, school readiness
programs or nutrition support programs).41 A
recent cluster randomized trial involving eight
community health care centres in Boston, Massachusetts, showed that systematic screening
for locally relevant basic needs during wellchild visits (i.e., child care, food security,
household heat, housing, parent education and
employment) and giving physicians a one-page
list of local community resources led to
increased provider referrals, family enrollment
in support services, maternal employment,
numbers of children accessing child care; and
there was also a reduction in the use of homeless shelters at one year follow-up compared
with standard clinical care (i.e., opportunistic
screening and access to basic social work services).42 Thus showing the importance of asking about social challenges and referring to
local support resources, as well as building
upon patient strengths and resilience.43
Review
What can be done at the practice level?
Beyond the provider–patient interaction, practicelevel interventions and broader systems changes
are also important in promoting equity-oriented primary health care services. A mixed-methods ethnographic study identified four key organizationallevel dimensions: inequity-responsive care,
trauma- and violence-informed care, contextually
tailored care and culturally competent care.44 A
multiple case study design is currently being used
in an ongoing evaluation of the impact on patient
outcomes and experiences of care that results from
implementing these strategies as a multicomponent
intervention in four primary health care clinics in
Ontario and British Columbia.45 Changes at the
organizational level and senior management support can reinforce the social accountability mandate
of physicians46 and help marginalized individuals to
have better access to health and social services, and
navigate the system more easily.
Improving access and quality of care for
hard-to-reach patient groups
Clinical practices that want to reduce barriers to
accessing care for underserved groups can use a
range of approaches. These include: providing
patients with bus fare and child care services to
make it easier for them to attend appointments;
documenting language preferences of patients,
identifying language skills of practitioners and providing interpreter services; extending clinic hours
and locating clinics close to where people live and
work; offering a welcoming and culturally safe
practice environment; providing health care workers with targets and financial incentives for meeting benchmarks and improving outcomes; and creating opportunities to provide health care services
beyond the clinic walls, such as outreach to local
schools or by partnering with community groups
and religious organizations.47
Patient experience surveys or setting up a
patient council may also provide useful input
toward redesigning clinical practices to be more
accessible and responsive to patient needs.48 Particularly isolated and hard-to-reach patients may
require even more integrated and proactive
approaches (i.e., assertive outreach, patient tracking and individual case managers).49 Such actions
can be further supported by health systems: for
example, the Quebec Health Insurance Plan pays
primary care physicians a small financial stipend
for the care of vulnerable patients to promote quality care and compensate for the heavier case mix.50
Integrating patient social support
navigators into the primary care team
Several clinical practices have published evaluations of the effectiveness of hiring dedicated
facilitators or patient navigators to help patients
access support services more easily. For example, a pilot project (COMPASS) commissioned
by the National Health Service Greater
Glasgow and Clyde (Scotland) showed how the
primary care setting provided a “safe space” for
identifying chronically unemployed patients
who had multiple barriers to finding a job. 51
Having an employment consultant who worked
with patients at their own pace and “spoke their
language” resulted in full-time paid employment for 57 of 117 patients, a 53.6% improvement in perceived health and a 25% reduction
in repeat visits to primary care and in medication requirements for depression and addictions.
Although hiring patient navigators has cost
implications, alternate models exist, such as
task shifting and sharing among existing members of the care team, or the Health Leads
model in the United States52 and the Basics for
Health Society model in Canada, 53 which
instead rely on trained volunteers who are
located in clinic waiting rooms to assist patients
in “filling social prescriptions” and navigating
often complex and fractured support pathways.
What can be done at the community
level?
Physicians need not confine their activities to
the clinic or hospital but can also serve as effective health advocates and valuable resources for
the community.54
Partnerships with community groups,
public health and local leaders
Improving individual and population health
requires partnerships and intersectoral action to
engage other sectors (e.g., education, justice and
employment) in creating healthier environments.55 There is a growing interest in “clinical–
community relationships” to create multistakeholder, community-wide collaborative initiatives
that can have far-reaching effects (e.g., offering
low-cost daycare and early childhood education
opportunities, introducing violence prevention
programs in schools, increasing the number of
parks and green spaces, banning soda-vending
machines, creating bicycle lanes or introducing
farmer’s markets to combat food deserts).56,57
The earlier and more substantively that physicians engage local leaders and other partners, the
more pronounced the impact.58 This can often be
facilitated with the help of partners in public
health who are already actively engaged in
addressing social determinants through a growing number of community-based interventions
for promoting health equity,59 as well as community groups who are aware of what is happening
CMAJ, December 6, 2016, 188(17–18)
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locally. Developing a common language and a
shared understanding is important for establishing such collaborations.60
Using clinical experience and research
evidence to advocate for social change
Physicians, as well as medical students61 and
other allied health professionals, have a powerful voice and can speak about the health
impacts of social challenges to encourage
broader policy responses and influence what
gets onto local agendas. 62 Physicians can
engage in activism by supporting social movements and political parties that advocate for
basic income, affordable child care, progressive
taxation and other measures to reduce health
disparities.63 They can conduct locally relevant
research and use social determinants data to
better intervene in their own context and generate evidence as a lever for advocacy.64 They can
create their own organizations to defend
humanitarian causes ranging from refugee care
to climate change,65 and they can ensure that
the health system is “part of the solution,” for
instance, by purchasing surgical instruments
that are not produced using child labour or by
challenging patent laws that restrict access to
life-saving medicines for the world’s poor.66
Getting involved in community needs
assessment and health planning
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
Community engagement, empowerment
and changing social norms
Engagement and empowerment of the local
community is needed to tackle deeply rooted
challenges that become engrained in the social
norm. For instance, violence against women
can often be quite widespread and can become
the “new normal” in some contexts, particularly
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CMAJ, December 6, 2016, 188(17–18)
when the perpetrators themselves were abused
and lack power in various domains of their life,
which creates a cycle of harm.71 However, physicians and allied health workers can serve as
important catalysts for change to spark community-level shifts in ways of thinking and acting
by initiating a dialogue and helping identify
local solutions.72,73 Community engagement is
an ongoing process to “create opportunities for
community voice and action to affect social and
structural conditions that are known to have
wide-ranging health effects on communities.”74
Even the clinical setting can become infiltrated
by broader social prejudices, such as structural
racism against Indigenous peoples.75 Yet, selfreflexivity about one’s own biases and stereotypes is a core skill that can be learned and an
important starting point in the development of
culturally safe relationships.76
According to the recently released calls to
action by the Truth and Reconciliation Commission in Canada,77 cultural competency training
should be provided for all health workers.78 Physicians need to combine introspection with strategic
thinking to move the health agenda forward.
McKnight, in his seminal article on politicizing
health care in 1978, wrote about health workers
empowering communities to deal one by one with
their pressing issues, from rounding up stray dogs,
to lobbying local politicians to get better traffic
controls and building greenhouses to grow fresh
vegetables.79 Today, such activities lead not only
to improved health for marginalized and underserved groups but also to more cohesive and
healthier communities.80
What are the barriers to action
and how can these be overcome?
Although physicians and allied health workers
can take action at various levels, this review also
identified multiple barriers to adopting a social
determinants of health approach in clinical practice (Table 1). They include low perceived selfefficacy of health care workers, lack of training
and role modelling, and the absence of communities of practice to bring together like-minded
health professionals who can share their experiences and find support in helping disadvantaged
patients with their challenges.81 Nonetheless,
many of these barriers can be overcome.
Reminders and participatory approaches
to go beyond the medical-model bias
Western medical culture is traditionally focused
on disease management and “quick fixes” that
“medicalise society’s problems” rather than
Review
adopting a more biopsychosocial approach. 82
Chart reminder and recall systems to flag
patients at risk can be useful in triggering more
holistic care. Participatory approaches that
engage primary health care providers have also
been helpful in creating a culture of reflection
and “shifting work practice more upstream.”83
Treating patients with dignity and respect
and creating safe spaces for disclosure
Being open to different cultural backgrounds
and avoiding stereotyping by understanding
that the individual variation within groups is
often more pronounced than the variation
between groups84 is important for developing
the relationship of trust required to help
patients disclose often sensitive and personal
social challenges and to work with them in
finding solutions.
A little extra time per consultation to
address complex health and social needs
Although physicians are often overstretched
and short on time, and fear the “Pandora’s box
effect” of delving into social challenges,
increasing the consultation time by even two or
three minutes when dealing with complex cases
can improve anticipatory and coordinated care,
decrease the stress of health care workers and
improve patient enablement.85
Knowing about local referral resources
for specific social challenges
Physicians often lack sufficient knowledge of
problem-specific referral resources in their local
community to address issues such as income
insecurity, housing problems or domestic violence.86 Access to a “well-maintained, locally
relevant, and user friendly internet directory of
community resources for use by practitioners”
is considered a major enabling factor in helping
frontline health care workers to better support
their patients.87
Resources, training and ongoing support
of health care workers
Increasingly, there is a growing emphasis on the
social accountability of medical schools and other
institutions responsible for training health professionals to better serve disadvantaged patients.88,89
There are a growing number of examples of training programs that have improved attitudes, skills
and competencies in addressing social determinants:90–92 a community tour for medical students
to better understand the population they serve,93 a
video curriculum to increase screening and referral for domestic violence by pediatric residents94
and a practicum with underserved patient
groups.95 In the absence of such training, health
care workers can get by using experiential learning,96 but clinical practice tools and training are
important facilitators, particularly if the intention
is to create a widespread culture change in the
way health care workers practise.
Which clinical tools help with
social determinants in practice?
Box 2 provides links to some clinical practice
tools that can help physicians and allied health
care workers improve their performance in identifying and taking action on the root causes of
poor health. For example, the CLEAR (Community Links Evidence to Action Research) toolkit
was developed by an international collaboration
of researchers and policy-makers to help health
care workers assess different aspects of patient
vulnerability in a contextually appropriate and
caring way, and easily identify key referral
resources in their local area.97 The poverty toolkit, originally developed by Dr. Gary Bloch and
colleagues (St. Michael’s Hospital, Toronto,
Ont.) helps physicians to screen for low income
and to assist patients in accessing various social
benefits and tax transfers to which they are entitled in their province.98
Table 1: Overcoming barriers to adopting a social determinants of health approach in clinical practice
Barrier
Facilitator
Medical model bias and the treatment imperative in health care
Health care provider reminder and recall systems to adopt a
more holistic and biopsychosocial approach
Patients who experienced prior stereotyping and discrimination
in clinical care
Treating patients with dignity and respect and creating “safe
spaces” for disclosure
Physicians feeling overwhelmed, overworked and lacking time
Taking a few extra minutes per consultation to address complex
health and social needs
Physicians not knowing what resources exist in the local
community
Providing a mapping of benefits and local referral resources for
specific social challenges
Physicians unsure of what concrete actions to take to address
social determinants
Resources, training and ongoing support of physicians and
allied health care workers
CMAJ, December 6, 2016, 188(17–18)
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The increasing number of publications in
this area shows how training and clinical practice tools are changing physician knowledge,
attitudes and skills to support patients better,
engage communities and advocate for social
change. A key element is the local adaptation
process, whereby educators of health professionals map out local resources and decide
upon the best strategies for soliciting information and supporting patients to provide physicians with locally relevant guidance to address
social challenges. Another important element is
Box 2: Physician resources
Clinical decision aid to help physicians adopt a social determinants of health approach in everyday practice:
•
The CLEAR toolkit: helping health workers address the social causes of poor health
(www.mcgill.ca/clear/download)
Clinical practice guidelines and tools relating to specific populations:
•
People from diverse backgrounds: Culturally effective care toolkit (https://www.aap.org/en-us/professional
-resources/practice-support/Patient-Management/pages/Culturally-Effective-Care-Toolkit.aspx)
•
Indigenous persons: Health professionals working with First Nations, Inuit, and Métis consensus
guideline (http://sogc.org/wp-content/uploads/2013/06/gui293CPG1306E.pdf)
•
Immigrants and refugees: Evidence-based clinical guidelines for immigrants and refugees
(www.cmaj.ca/content/183/12/E824)
•
Gay, lesbian, bisexual or transgender (GLBT) youth: Practice parameter on GLBT children and
adolescents (www.jaacap.com/article/S0890-8567(12)00500-X/pdf)
•
Adolescents who are pregnant: Adolescent pregnancy guidelines
(http://sogc.org/wp-content/uploads/2015/08/gui327CPG1508E.pdf)
•
People with developmental disabilities: Primary care of adults with developmental disabilities
(www.cfp.ca/content/57/5/541.full.pdf and http://www.cfp.ca/content/57/5/541.full.html)
Clinical practice guidelines and tools relating to specific areas of action on social determinants:
•
Poverty: Poverty: a clinical tool for primary care (http://ocfp.on.ca/cpd/povertytool [Ontario], http://
cqmf.qc.ca/wp-content/uploads/2016/04/CQMF-Outil-LaPauvrete_Final.pdf [Quebec],
