A few weeks ago, I wrote that I’ve been taking a course on the social determinants of health (SDoH). This offering(1) is a collaboration between the BMJ (formerly the British Medical Journal) and the Institute of Health Equity, the latter of course being home to Sir Michael Marmot.
One of the best learning tools of this online course, to me, is its discussion forum; each participant can post short (1200-character maximum) comments and reply to others’ comments. These comments are moderated, with the professors often joining the online conversations.
With a truly global reach, this course has provided an opportunity to interact with patient-concerned individuals from Africa, Asia, Australia, Europe, New Zealand, and elsewhere ‘-) If you follow this blog, you’ll know that I’ve been active on Twitter since 2012 – primarily for the opportunities to form connections with others around the world the course forum was similar in nature.
The forum was also a fantastic learning tool, because participants were asked to post their responses to each assigned exercise (limited to 1200 characters, again); to share with the entire course cohort. This allowed each of us to learn about differences in jurisdictions and approaches, as well as particular challenges faced in specific areas of the world.
All of this worldwide interaction brought home the point that we have an opportunity – particularly those of us working in bioethics, or biomedical ethics if you prefer – to raise awareness of the impact and importance of individuals’ social determinants of health on their long-term health outcomes.
I’ve always believed that the best way to ‘treat’ diseases is to prevent them whenever possible, and measures to improve SDoH may allow us to do just that. An excellent example (which I posted to the course forum as part of an assignment!) is diabetes prevention, for which a systematic review was published last December – covering fifteen years of real-world prevention:
programs that have high uptake — both in terms of good coverage of invitees and their willingness to accept the invitation — can still have considerable impact in lowering diabetes risk in a population, even with a low intensity intervention that only leads to low or moderate weight loss.
Aziz, Absetz, Oldroyd, Pronk & Oldenburg; BMC Implementation Sci, 15 Dec 2015
From a public health perspective, this is an important finding, especially for resource constrained settings”(2)
In that spirit of global interaction among people interested in healthcare, I’d like to share with you a few of the highlights of this SDoH course. These were my own personal ‘take-home messages’ or ‘take-away points’.
The first is that socioeconomic and/or political contexts significantly impact SDoH, often by limiting the choices that individuals are able to make. We’re all familiar with this type of situation, so I’ll mention only one issue which was raised in a discussion on the course forum. In many countries, working within the field of healthcare – or the sciences in generals – can result in being viewed with suspicion by religious government leaders.
Living in Canada, that wasn’t something that immediately sprang to my mind. It’s important to me to point this out, because it goes to show the level of disparity which exists even among healthcare professionals. In some countries, you might be imprisoned for research or statements that run counter to government-sanctioned viewpoints based on religious tenets.
Another take-away for me was the confirmation that healthcare systems themselves can contribute to “health and social disparities”.(1) For the assignments and discussions on this topic, I described two instances based on local cases.
One is the seemingly innocuous measure of parking fees at hospitals, medical clinics, and other healthcare establishments. These fees are often justified by a need for maintenance, e.g. snow removal here in Montreal is an expensive recurring cost for any parking area and our government-funded hospitals are loathe to use operating funds to cover this.
But for a person of limited income who has a car – as do many in my region due to a lack of adequate bus service – these fees may be prohibitively expensive. It’s easy to say, “Well, just take the bus that runs past the hospital”, but what if the (potential) patient can’t afford bus tickets? What then?
I’ve driven many people to or from our local hospital on my way back and forth from work, neighbours and also friends of my mother, because they simply couldn’t afford either the parking fees or the two bus tickets.
One little boy and his mother have hospital appointments at least once a week for his blood disorder. Even if the parking is ‘only’ $10 a day, that would cut well over $500 from the family’s annual budget – and his mother has already had to give up her job because of all the work absences required for her son’s medical appointments and sick days from school.
Another pervasive issue is that most family medicine practices in my area are open only during business hours. This requires a patient to take time off work to visit their physician, usually with Canada’s interminable wait times even in family practice. For many (potential) patients, these lost wages can mean the difference between eating or not.
Another major take-away point from this course was the individual healthcare professionals can help improve the SDoH of individual patients, which can have long-term positive effects on entire families – and on future children.
For this point, the first example that I imagined for an assignment involved non-medical means; a family physician counselling the sedentary parents of a young girl to encourage her to try physical activities. Knowledge of local low-cost or free activities for kids, perhaps even having brochures or flyers available as handouts, could permit a family physician to have a long-term positive impact on that child’s health by providing an avenue into sports and active life habits.
If that child were to take up physical activities, there could be a positive impact on her parents; they might be subconsciously encouraged to get more exercise so that they could keep up with her, go for walks together, and more.
Further down the line, if she were to late have children, they would in turn be much more likely to be encouraged to take part in organized sports or other physical activities… a snowball effect (the reason for which I opted for a winter photo for this post; I snapped this one of my husband while we were snowshoeing to the summit of Hurricane Mountain in norther New York State a few weeks ago).
The second situation I came up with was that of asking physicians, nurse practitioners, and other healthcare professionals to consider the ability and means of a particular patient, parent, or guardian to comply with their recommendations. I opted to mention that no-cost physical therapy is provided in my province only within hospital environments, and generally only for immediate post-surgical or post-trauma care.
Many patients require longer-term occupational and physical therapy, which isn’t covered. For this reason, we have a proliferation of private ‘physio’ clinics. In the range of $70 per hour, this type of treatment is out of the question for anyone with limited means.
So while a child from an affluent family would be likely to receive a series of additional paid physiotherapy sessions, following hospital discharge with a fractured femur, another child would not. That second child could end up with a permanent limp, chronic pain, and a lifelong reduction in their physical abilities because they hadn’t had access to the additional (out of pocket) but medically-suggested therapy.
That negative outcome could be prevented, if the child’s family physician were able to follow up every few weeks to ensure that the child was doing the strengthening exercises prescribed by the hospital physiotherapist. If, of course, there were no parking fees required and the parent(s) didn’t have to lose wages to visit the physician…
Another interesting aspect of this course was the emphasis of the role of advocacy. Not advocacy by those who are at risk of negative social determinants of health, but by physicians. One of the surprises of this course was the fact that Canada was cited as an example of how physician advocacy can improve SDoH at a societal level:
Advocacy can take the form of writing directly to ministers of health.
This is what a group of Canadian Physicians did. They wrote a letter to Minister of Health and Long-Term Care, Hon. Dr. Eric Hoskins advocating for a basic income guarantee.”(1)
I’ve been following these developments within Canada with interest, but hadn’t realized that this was such a novel approach by healthcare professionals that it merited a place in this SDoH course! This reflects my own good luck, in having been born into a country with (albeit far from perfect) public health insurance systems:
“We, the undersigned, are 194 physicians providing clinical and public health services in Ontario.
Berger & Simon, On behalf of the 194 physician signatories; Open letter, 17 Aug 2015
We are seeking your leadership in advancing consideration by the Ontario government for introducing a basic income guarantee (BIG) for the people of Ontario…
The link between health and income is solid and consistent—almost every major health condition, including heart disease, cancer, diabetes, and mental illness, occurs more often and has worse outcomes among people who live at lower income.
As people improve their income, their health improves.
It follows that improving my patients’ income should improve their health.”(3)
This group of physicians in one province envisioned, however, a much larger impact for their advocacy. Their eventual goal was for improvements at a national level, to set the stage for other developed countries to follow suit:
We recognize that, optimally, the federal government would be involved in establishing a BIG for all in Canada, in cooperation with the provinces and territories.
Berger & Simon, On behalf of the 194 physician signatories; Open letter, 17 Aug 2015
While we are hopeful that a future federal government will demonstrate leadership for a BIG, we believe that Ontario could act on its own… at the very least moving forward with a focused, well-designed and evaluated trial program or demonstration project.”(3)
Those were my principle take-away points from this excellent course, along with the reminder that each of us can make a difference in the lives of others. And that, as with so many of you, is why I chose the field of bioethics!
Wherever you live, whatever your role in healthcare, I hope this post has raised some good discussion points for you. Like me, I hope you’ll now be actively looking for ways in which to improve the health outcomes of patients, by challenging the status quo in relation to social determinants of health.
As always, thanks so much for stopping by!
References
(1) BMJ Learning, and the Institute of Health Equity (IHE) at University College London (UCL). Social Determinants of Health: What Is Your Role? FutureLearn. 2016. Online course. Web:
https://www.futurelearn.com/courses/social-determinants-of-health
(2) Aziz, Z., Absetz, P., Oldroyd, J. et al. A systematic review of real-world diabetes prevention programs: learnings from the last 15 years. Implementation Sci 10, 172 (2015). Online 15 Dec 2015. https://doi.org/10.1186/s13012-015-0354-6. Web:
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0354-6
(3) Philip B. Berger & Lisa Simon, On behalf of the 194 physician signatories. Open Letter to the Minister of Health and Long-Term Care, the Honourable Dr. Eric Hoskins, calling for a basic income guarantee pilot program. 17 Aug 2015. Web (PDF):
https://healthprovidersagainstpoverty.files.wordpress.com/2015/08/ontario-physicians-letter-aug-17-2015.pdf