Addressing individual income as a social determinant of health in clinical settings:

A realist systematic review

CPHAMay 28, 2014

Danyaal Raza1, Andrew D. Pinto2,3

1. Harvard School of Public Health, Harvard University2. 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, 2013http://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. 43http://www.who.int/whr/2008/08_chap3_en.pdf

WHO. World Health Report 2008. p. 43http://www.who.int/whr/2008/08_chap3_en.pdf

Opportunity for change as we move toward “people-centred” model

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

35 articles included

933 articles excluded

Independent full text review with inclusion/exclusion criteria applied

29 articles included

4 articles excluded

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 [family, community, society]

Patient

Context [economic, political, historical]

Health care setting

Income Security Intervention

Patient identification: in clinical encounter OR survey OR chart audit

Information & advice

Admin support/as

sist with forms

Employment

Improve financial literacy

Retraining/Education/

Rehab

Reduce expensesIncrease Income

Benefits/ grants

Help job search &

apply

Support action to improve wages

Cheaper housing

Direct advocacy

for patient

Engage other

advocatesReduce other

expenses

Reduce debt &

restructure debt

Set up bank

accountBudgeting

Change spending

habits

Increase savings

Improved Income Security

Obtain free

goods/services

Increase investm

ents

Work accommodation for disability

Context [family, community, society]

Patient

Context [economic, political, historical]

Health care setting

Income Security Intervention

Patient identification: in clinical encounter OR survey OR chart audit

Patient-health

provider relationship

AccessibleColocation Benefits counsellor-health care

team relationship

Pro-active advice

Expert benefits advice

Decreased stigma

TrustHigh

ImpactHealth Setting Embedment

Enab

ling

Char

acte

ristic

sM

echa

nism

s

Health Promoter

Patient

Provider

Improved Income Security

Post-synthesis framework

Income Security Health Promotion

Interventions:1. Increasing income• Benefits/grants• Taxes• Employment• Retraining

2. Reducing expenses3. 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

andrew.pinto@utoronto.ca@AndrewDPinto

Thank You