Social Determinants Of Health

Social conditions, such as income, employment, education, housing status, gender, race, and early childhood experience have a greater impact on health than genetics or access to health services.

In 2013 the St. Michael’s Hospital Family Health Team created a committee to address these factors. The goal is to improve the health of patients and our community. The Social Determinants of Health (SDOH) committee includes physicians, nurse practitioners, social workers, patient advisors, and other members of the health care team.

Our team has built an approach to social risks to health and social inequities into our clinical programs, education, research, and quality improvement. The story of the unique development of our team is told in the booklet below:

About

On March 11, 2020, the World Health Organization declared a global pandemic related to COVID-19.

COVID-19 has disproportionately impacted individuals and groups on the basis of social determinants of health (SDOH). Vulnerable populations include the elderly, people with disabilities, people with precarious work or low income, people who are homeless, people who are incarcerated, 2SLGBTQI+, people with lower literacy, people with significant mental illness and addictions, and racialized or Indigenous persons who are already subject to systemic racism and structural inequities.

In March 2020, the COVID-19 pandemic necessitated a rapid shift in models of care in Canada, to promote physical distancing and enhance health care capacity for treating COVID-19 cases. Our department underwent significant changes to clinic operations, with several staff being re-deployed. Early on it was apparent that a specific focus on equity and vulnerable populations would be required and a SDOH Committee-COVID-19 Working Group was created.

Purpose

The SDOH-COVID Working Group aims to support the SMH DFCM and AFHT during and after the COVID-19 pandemic by:

  • Applying a health equity lens to clinical operations, teaching, research, and quality improvement
  • Coordinating SDOH-related activities
  • Engaging with the community in advocacy

Structure

Interdisciplinary team including social workers, psychologist, nurses, health promoters, community engagement specialist, lawyer, nurse practitioners, physicians, and clerical support.

Priorities

The SDOH Committee identified several priority populations based on the socioeconomic and medical risk that COVID-19 and pandemic related measures impose:

  • Elderly
  • People with disabilities
  • People with severe mental illness
  • People who use substances
  • People who are homeless
  • People with low income and/or food insecurity
  • Indigenous people
  • Racialized people
  • 2SLGBTQI+ people

To improve equity and mitigate risk among our patients and the community, our group has undertaken or supported a number of activities:

Wellness checks Telephone calls from a trained team to check in with patients – > 1800 calls between March and June 2020
Equity-focused operations review Involvement in clinical service planning, creation of specific care pathways for vulnerable patients, application of a Health Equity Impact Assessment (HEIA) tool
Resource dissemination Creation of a Marginalized Populations COVID Resource Google Drive; creation of patient educational materials, communications to staff and patients
Addressing patient needs Projects to meet needs and fill gaps for patients – tablets, cell phone, grocery gift cards, cloth masks
Advocacy Collaboration with community partners, campaign sharing, and systemic advocacy

Provider resources

Education

In partnership with the Ontario College of Family Physicians, our staff have developed an intensive training workshop, called Treating Poverty. The workshop allows participants to develop advanced knowledge and skills in social interventions in primary care.

Clinical tools

Poverty: A Clinical Tool For Primary Care Providers
Simple tool to guide primary care providers in screening for and intervening in poverty
Developed by Gary Bloch, in collaboration with the Centre for Effective Practice, St. Michael’s Hospital, and the Ontario College of Family Physicians.

IFITHELPS tool
A comprehensive guide to taking a social history, developed by Dr. Ritika Goel.

Our Family Health Team has also partnered with Prosper Canada to develop an online tool that screens individuals for low income and helps them access benefits they might not be receiving.

Literature

Canadian Family Physician series on Social Accountability, at the MicroMeso, and Macro Levels (2016)
Co-authored by Dr. Ritika Goel

Ontario Medical Review Series: Income and Health (2013)
Co-authored by several SDOH committee members

Community engagement, which involves building relationships and partnering with community-based organizations, service providers, other health organizations and community residents, is an important part of our work.

This allows us to better promote wellness among our patients and to reach individuals or groups in our catchment who may face some forms of marginalization and barriers to accessing health services.

Sociodemographic factors such as income, education, ethnicity, language, and gender impact one’s health, in part, by influencing access to and experience within health services.

In 2012, the St. Michael’s Hospital Academic Family Health Team started collecting sociodemographic data from patients through self-administered surveys that in the clinic waiting rooms. Our goal is to be able to identify and address health inequities within among the patient populations we serve.

This work is part of a larger initiative, through the Toronto Central Local Integration Network. For more information, visit http://torontohealthequity.ca.

Publications

Lofters AK, Schuler M, Baxter NN, Persaud N, Pinto AD, Kucharski E, Davie S, Nisenbaum R, Kiran T. Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges. BMC Family Practice 2017; 18:31.

Pinto A, Glattstein-Young G, Mohamed A, Bloch G, Leung F-H, Glazier R. Building a foundation to reduce health inequities: routine collection of sociodemographic data in primary care. J Am Board Fam Med 2016; 29(3): 348-355.

The St. Michael’s Academic Family Health Team’s Advocacy Committee has developed an advocacy toolkit and departmental framework to support advocacy by members of the department.

The SMHAFHT has a department-wide advocacy campaign, initiated in 2019, called “Healing our roots: A health equity approach to reconciliation”

Many staff and physicians are already working to shape policy on social determinants of health through community-based advocacy and participation in government consultations at the municipal, provincial and federal levels.

Examples

Exploring and addressing how racism affects health is a new area of specific focus for the St. Michael’s Hospital Academic Family Health Team. This focus on racism directly aligns with the strategic priorities of St. Michael’s Hospital and the Truth and Reconciliation Commission. It also complements the ground-breaking work on addressing racism through Indigenous cultural safety training.

Since the Racism and Health committee was formed in 2017, foundational work on how the department can develop and implement anti-racial discriminatory practices and approaches at the learning and clinical levels has been funded. The Racism and Health committee aims to position the team as a primary care leader that embeds a lens of anti-racism and anti-racial discrimination in how it provides access to care, health outcomes and its learning and clinical environment. This work on addressing racism is led by a powerful group made up primarily of racialized women.

One of the main objectives of this new focus is to identify strategies to address racism in the learning and clinical environment. In 2019, the team conducted a scoping review that identified and synthesizes existing antiracism interventions in health care settings. It is also supporting the capacity development of leadership, staff and learners in adopting an anti-racism lens to understand and transform views, practices and interactions with patients and staff. Another key objective is to assist with embedding racism as a determinant of health in the department’s understanding of patient experience and in the development of primary care interventions.

With a focus on the piloting and implementation of tools to assess all programs and services through a health equity lens, the first step was to gather information on the specific tools and approaches that can be used to inform equity-focused decision-making in a health care setting. What stood out in the literature on health equity impact assessment was the need for good data, which requires the team to dig deeper into patients’ experiences and better identify the gaps in their care that result from their socio-economic circumstances.

Specific tools can be used to assess how a program and service is meeting the needs of populations that experience disadvantage. They have been used in other parts of the health system, including the Government of Ontario’s Health Equity Impact Assessment. The working group reviewed the literature and others’ experiences, and developed a team-specific assessment tool, which was piloted with the team’s diabetes program. They then trained a wide range of health team members at a full-day workshop, and are now supervising its rollout throughout the health team.

The team is committed to mainstreaming the use of equity-oriented assessment tools and outcome evaluations throughout its programs and services, and is currently developing an infrastructure to embed this approach into day-to-day operations.

Faculty members within the department are leaders in research on the social determinants of health.

Our department has a robust health equity and social determinants-focused research program.

DFCM researchers are leading work in the following areas:

Dr. Andrew Pinto

  • Income security, decent work, and healthy equity (see the Upstream Lab website)

Dr. Tony Antoniou

  • HIV outcomes among immigrant groups
  • Barriers for people with HIV after incarceration

Dr. Rick Glazier

  • Healthy equity in primary care

Dr. Tara Kiran

  • Health equity in primary care (see the project website)
  • Income-related disparities in cancer screening (see the project website)

Dr. Aisha Lofters

  • Immigrant health and health equity
  • Income-related disparities in cancer screening (see the project website)

Dr. Nav Persaud

  • Access to essential medicines (see the CLEAN Meds study website)

Dr. Janet Smylie

Our department has a strong commitment to providing education on the social determinants of health to medical, nursing, and allied health professionals during their training and through continuing education during their careers.

Our faculty members have been involved in designing and teaching curriculum on the social determinants of health for medical students, residents, practicing family physicians, nurse practitioners, and other health care providers.

Highlights include:

  • Our staff physicians developed and lead a workshop on Treating Poverty for family physicians
  • Our staff physicians developed two workshops on social interventions that are part of the core 3rd and 4th year curriculum for University of Toronto medical students
  • Medical students develop an advocacy project focused on the social needs of patients who are adversely affected by social inequities
  • Our medical students engage in a mandatory clinical experience in a homeless service setting
  • We offer extremely popular medical student and resident elective experiences in inner city health and homelessness and health
  • Members provide dozens of presentations every year to medical, academic and other audiences on our work on health equity and the social determinants of health

Last updated July 09, 2021