Addressing individual income as a social
determinant of health in clinical settings:
A realist systematic review
CPHA
May 28, 2014
Danyaal Raza1, Andrew D. Pinto2,3
1. Harvard School of Public Health, Harvard University
2. Department of Family and Community Medicine, St. Michael’s Hospital
3. Centre for Research on Inner City Health, St. Michael’s Hospital
No specific financial conflict of interest.
My research is funded by CIHR and the Ontario Ministry of
Health and Long-Term Care.
The premise of this discussion is working towards social
justice and hence, a more healthy society. This is my
objective as a physician, activist and public scholar.
I bring a privileged world-view and set of experiences to this
work. I do not bring the lived experience of being a member of a
marginalized population.
ROLE OF PRIMARY HEALTH CARE IN
ADDRESSING HEALTH INEQUITY
Social Determinants of Health
• #SDOH
• “the conditions in which people are born,
grow, live, work and age. These circumstances
are shaped by the distribution of money,
power and resources at global, national and
local levels”
http://www.who.int/social_determinants/en/
Canadian Medical Association, 2013
http://healthcaretransformation.ca/infographic-social-determinants-of-health/
WHO 2008. Final Report of the Commission on the Social Determinants of Health. p.43.
How do SDOH “get under our
skin”? How do they work?
WHO. World Health Report 2008. p. 43
http://www.who.int/whr/2008/08_chap3_en.pdf
Opportunity for change as we move toward “people-centred” model
WHO. World Health Report 2008. p. 43
http://www.who.int/whr/2008/08_chap3_en.pdf
Features of PHC that are key to addressing
health equity
•
•
•
•
•
•
•
First contact
Accessible
Longitudinal
Person-focused
Coordination and navigation
Comprehensive
BOTH preventive (future needs) and curative
(immediate needs)
• Existing and potential connections to other systems
• Political/media focus
• Highly resources
Adapted from De Maeseneer et al. WHO 2007.
http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf
St. Michael’s Hospital
• Established a SDOH Committee within the
DFCM
• Ongoing projects:
– Socio-demographic data collection
– Income security health promotion
– Medical-legal partnership
– Childhood literacy (future)
EVIDENCE: SYSTEMATIC REVIEW
AND REALIST SYNTHESIS
Search Strategy
• Published in English
• Search terms used included “income intervention”,
“poverty intervention*,” “welfare advice,” “income
supplement,” “social assistance,” “disability benefit,”
“citizen* advice,” “counsel*” and “outreach”
• With the assistance of an information specialist, nine
databases were chosen: Applied Social Sciences Index
and Abstracts, CINAHL, FRANCIS, International
Bibliography of the Social Sciences, MEDLINE, PAIS
International
• January 1, 1990 to June 13, 2013
Inclusion/Exclusion
Inclusion/Exclusion
Potentially relevant articles identifies though
electronic databases search
968 articles
Independent title & abstract review with
inclusion/exclusion criteria applied
933 articles excluded
35 articles included
Independent full text review with
inclusion/exclusion criteria applied
4 articles excluded
29 articles included
Key Findings
• Vast majority of studies from the UK (27 of 29)
• Most focused on implementation of “Citizen
Advice Bureau” workers within GP practices
• Almost all interventions were focused on
improving access to state benefits
• Range of sample sizes (n=62-2484), but most
around 200-300
• Vast majority were observational studies; one
RCT (Mackintosh. BMC Public Health 2006)
• Most reported income change outcomes, and
very few reported health outcomes
Key Findings
• On average, approximately 25% of participants
had an increase in benefits, typically on the order
of £100-200/month
• Most studies followed participants for 12 months
• Typically took 3-6 months for benefit change to
be implemented
• Health outcomes focused on QOL measures.
Found little difference before/after or between
those who received benefits and those who did
not.
Key Findings
• Interviews with those who received benefits:
– Improved mental health
– Less stress around bills, rent
– Able to afford better food
– Able to participate in social life
Health care team universally supportive of benefits
advice. Seen as saving money and time, and
improving care for patients.
Practical Tips
• Requires support from health care team and
significant education of providers
• Many patients did not initially understand why
referred to benefits advisor
• Small % of participants were very complex and
required a great deal of support and follow-up
• Main groups that benefited were:
– Elderly, particularly home-bound
– New immigrants
– People with mental illness
Enabling characteristics
Underlying mechanisms of income
security intervention
Context [economic, political, historical]
Context [family, community,
society]
Health care setting
Patient identification: in clinical encounter OR survey
OR chart audit
Patient
Income Security
Intervention
Increase Income
Benefits/
grants
Engage
other
advocates
Information
& advice
Admin
support/as
sist with
forms
Direct
advocacy
for
patient
Increase
investm
ents
Reduce expenses
Employ
ment
Cheaper
housing
Help job
search &
apply
Improve financial
literacy
Support
action to
improve
wages
Retraining/Edu
cation/Rehab
Reduce
other
expenses
Obtain
free
goods/s
ervices
Work
accommodatio
n for disability
Improved Income Security
Reduce debt
&
restructure
debt
Increase
savings
Set up
bank
account
Budgeting
Change
spending
habits
Post-synthesis framework
Context [family, community, society]
Context [economic, political, historical]
Patient
Health care setting
Patient identification: in clinical encounter OR survey OR chart audit
Mechanisms
Enabling
Characteristics
Patient
Health
Promoter
Colocation
Accessible
Decreased
stigma
Health Setting
Embedment
Income Security Intervention
Provider
Benefits
counsellorhealth care
team
relationship
Trust
Improved
Income
Security
Pro-active
advice
High
Impact
Expert
benefits
advice
Patienthealth
provider
relationship
Income Security Health Promotion
Interventions:
1. Increasing income
•
•
•
•
Benefits/grants
Taxes
Employment
Retraining
2. Reducing expenses
3. Improving financial literacy
Phase I: Multi-institutional
support
Phase II: Data and
triangulation
Phase III: Meeting individual
needs
Phase IV: Community
collaboration
Phase V: Community
leadership
Thank You
andrew.pinto@utoronto.ca
@AndrewDPinto