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Presentation Fam Med Masters Seminar Apr 25 07brief

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Dr. Gary Bloch's Presentation to University of Toronto Masters in Family Medicine

Dr. Gary Bloch's Presentation to University of Toronto Masters in Family Medicine


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  • 1. Questions to Answer
    • What are this person’s health concerns?
    • Which “social determinants of health” have the most impact on this person’s situation?
    • How would you prioritize these issues and determinants of health (on the same list)?
    • Propose some approaches you can take to the top two issues on your list. Today? In the future?
  • 2. Bringing Health to Poverty: A Call to Action for Health Providers Gary Bloch MD CCFP St. Michael’s Hospital, Seaton House Shelter Health Providers Against Poverty ( Masters Candidate, M.H.Sc.) April 25, 2007
  • 3. Objectives
    • To examine, in the context of the available evidence, the impact of poverty on health
    • To identify and discuss specific strategies health providers can use to alleviate the impact of poverty on their clients’ health, at the individual, practice, and community levels.
  • 4. Outline
    • Case Discussion (15 mins)
    • Presentation: Background on Poverty and Health (25 minutes)
    • Discussion: What Can Health Providers Do to Address Poverty? (35 mins.)
  • 5. Poverty and Health Background
    • Poverty in Canada
    • Population Health Indicators
    • Chronic Disease
    • Children’s Health
    • The Social Policy Context
  • 6. What is Poverty?
    • Absolute: Income falls below an objectively defined minimum level (e.g. Market Basket)
    • Relative: Income is a certain amount less than others in society (e.g. % of median income)
    • Subjective: Income is less than an individual feels she needs
    • Other considerations: depth of poverty, longitudinal data
    • Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Literature,” CIHI , June 2003.
  • 7. Figure 3.2: Percentage of Canadians Living in Poverty, 2004 Source: Statistics Canada (2006). Persons in Low Income Before Tax, 2004, CANSIM Tables. Courtesy of: Dennis Raphael
  • 8. Figure 3.7: Percentage of Canadians, Children, and Individuals in Female Lone-Parent Families Living in Poverty by Province, 2004 Source: Statistics Canada (2006). Persons in Low Income Before Tax, CANSIM Tables. Courtesy of: Dennis Raphael
  • 9.
    • Courtesy of Dennis Raphael
  • 10. Selected Major Canadian Reports Mentioning Health and Poverty
    • Health Council of Canada. Health Care Renewal in Canada Feb. 2006 & Feb. 2007
    • Ontario Health Quality Council. Yearly Reports 2006 & 2007.
    • Canadian Institute for Health Information and Statistics Canada. Health Care in Canada 2006
    • Canadian Population Health Initiative: What Have We Learned Studying Income Inequality and Population Health. Dec. 2004
    • Health Disparities task Group, Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security. Dec. 2004
    • Toronto Public Health: Weekly Cost of the Nutritious Food basket in Toronto 2005, 2006, 2007.
  • 11. Isn’t it Just that Poor Health Causes Poverty?
    • Review by Phipps (CIHI, 2003): “all [the studies reviewed] conclude that reverse causation is not a serious problem and … the main direction of influence is from poverty to poor(er) health.”
  • 12. Population Level Indicators
  • 13. Life Expectancy
    • Poorest vs. richest areas:
      • 5 years shorter for men
      • 1.7 years shorter for women
      • R. Wilkins, et. al., “Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996,” Health Reports (Stats Can), 2002: 13(Supplement).
  • 14. Adler, N. (2001). A Consideration of Multiple Pathways from Socioeconomic Status to Health. In J. Auerbach and B. Krimgold (eds.). Income, Socioeconomic Status, and Health. Washington DC: National Policy Association, Data from NCHS, 1998. Courtesy of Dennis Raphael
  • 15. Infant Mortality and LBW
    • Poorest vs. richest areas:
      • Infant Mortality: 61% higher
      • Low Birth Weight: 43% higher
      • Wilkins, et. al., 2002.
  • 16.  
  • 17. Odd of Reporting Fair or Poor Self-Rated Health: Ontario, 1996 Source: Xi et al. (2005). “Income inequality and health in Ontario”, CJPH, 96, 206-211 Adapted from: Dennis Raphael
  • 18. Person Years of Life Lost , 1996
    • Source: Wilkins, et. al., 2002.
    • Adapted from: Dennis Raphael
    %
  • 19. Chronic Disease
  • 20. [i] Adapted from Wilkins, et. al., 2002, 14-15. 47% Females 56% Males Diabetes 30% Both sexes Mental Disorders 241% Both sexes Infectious Diseases 56% Males Lung Cancer 50% Females Uterine Cancer -5% Females 150% Males Cirrhosis 25% Females 31% Males Ischemic Heart Disease 32% Both sexes All causes Increase in Mortality in lowest vs. highest income quintile neighbourhoods Cause of Death
  • 21. Adler, N. (2001). A Consideration of Multiple Pathways from Socioeconomic Status to Health. In J. Auerbach and B. Krimgold (eds.). Income, Socioeconomic Status, and Health. Washington DC: National Policy Association, Data from NCHS, 1998. Courtesy of Dennis Raphael
  • 22. Diabetes
    • Increase in prevalence among low income vs. high income:
      • Men 40%
      • Women 280%
    • For low vs. high physical activity:
      • Men 40%
      • Women 50%
      • Douglas G. Manuel & Susan Schulz, “Chapter 4 Diabetes Health Status and Risk Factors,” in J. Hux, G. Booth & A. Laupacis, eds., The ICES Practice Atlas: Diabetes in Ontario, 2002, Institute for Clinical and Evaluative Sciences.
  • 23. Increased Risk of Diabetes in Ontario Among Low Income Residents, 1997/97
    • Courtesy of Dennis Raphael
  • 24. Cardiovascular Disease
    • Low income responsible for 25-30% of CVD mortality
      • On par with smoking and hypertension
    • $10 000 increase in neighbourhood median income = 10% decrease in CVD mortality
    • Peter Tanuseputro, et. al., “Risk Factors for Cardiovascular Disease in Canada,” Can J Cardiol 2003; 19(11):1249-1259.
    • D. Raphael, “From increasing poverty to societal disintegration: how economic inequality affects the health of individuals and communities,” in Armstrong, et. al., (eds), Unhealthy Times: The Political Economy of Health and Care in Canada. 2 001, Toronto, Canada, Oxford Press
  • 25. Courtesy of Dennis Raphael
  • 26. Mental Health
    • Depression: Overall prevalence 9.17%; among low income 14.52% (10.79% men, 17.09% women) ¹
    • Food insecure individuals 3X more likely to have MDE or significant distress (NPHS 1999)
    • Lowest third income 2.6 times more likely to have lower sense of control over their lives
    • ¹ Katherine L W Smith, et. al., “ Gender, Income and Immigration Differences in Depression in Canadian Urban Centres,” CJPH, Mar/Apr 2007; 98(2): 149 .
  • 27. Children’s Health
  • 28. Annual Family Income and Percentage of Children with “Lower Functional Health” Functional Health includes testing for vision, hearing, speech, mobility, dexterity, cognition, emotion, pain and discomfort Prepared by the Canadian Council on Social Development using the National Longitudinal Survey of Children and Youth, 1994-1995 Adapted from Dennis Raphael
  • 29. Income and Children’s Problems Source: National Longitudinal Survey of Children and Youth Courtesy of Dennis Raphael
  • 30. Cumulative Effects
    • Children living in poverty suffer cumulative health effects throughout their lifespans, regardless of later socioeconomic status
    • Specifically increased risk for CVD
    • G. Davey-Smith & D. Gordon, “Poverty across the life course and health,” in Pantazis, C. and Gordon, D. (Eds), Tackling Inequalities: Where Are We Now and What Can Be Done? , 2000, Bristol, U.K., Policy Press.
  • 31. How Does Poverty Cause Poor Health
    • Absolute income: unable to attend to basic needs (e.g. nutrition, health care, environmental hazards) below a certain income level
    • Relative position: Ongoing stress of being lower on the income scale results in poor health
    • Neo-materialist: income inequality part of larger process including other inequalities (e.g. medical, transportation, housing, education)
    • Shelley Phipps, “The Impact of Poverty on Health: A Scan of the Research Literature,” CIHI , June 2003.
  • 32.  
  • 33. The Policy Environment
    • Where does Canada rank internationally on health and social spending???
  • 34. Courtesy of Dennis Raphael
  • 35. Source: OECD (2004). Social Expenditure Database www.oecd.org/els/social/expenditure Courtesy of Dennis Raphael
  • 36. Courtesy of Dennis Raphael
  • 37. Source: Organization for Economic Cooperation and Development. (2005). Society at a Glance: OECD Social Indicators 2005 Edition. Paris, France. Figure SS6.1, p.45. Courtesy of Dennis Raphael
  • 38. Source: Daily Bread Food Bank (2006). 2005 profile of hunger in the GTA. Toronto: DBFB.
  • 39. What Can We Do About It?
    • An Example: The Special Diet Campaign and Health Providers Against Poverty
  • 40. Background to the Campaign
    • Social assistance in Ontario:
      • Recipients’ income 34-58% of poverty line
      • 22% rate cut 1995, 40% total decrease in real $ now
      • Single person on welfare in Toronto earns $569/month, needs an extra $390/month to meet basic needs
        • Single parent earns $1653, needs an extra $223/month
    • The Special Diet Supplement: Up to $250/month extra per individual recipient
  • 41. The Campaign
    • Mass assessment clinics
    • Advocacy: government, health organizations, media
    • Alliances with antipoverty, health orgs, communities
    • Education and outreach to health providers
  • 42.  
  • 43. The Results
    • 6000+ forms signed … millions of dollars to people living in poverty
    • Awareness raised: government, health providers, health organizations, media/public
    • Mobilization of health providers and new voice in the antipoverty movement
    • Mobilization of low income people
    • Government Action, ?policy changes
  • 44. What can health providers do about poverty and health???
    • Brainstorm
  • 45. What Can We Do About It???
    • Individual Patient-Provider Interventions
    • Practice Interventions
    • Community Interventions
  • 46. Individual Patient-Provider
    • See situation from client’s perspective … alter priorities
    • Limitations poverty places on patient’s ability to adhere to care: time, priorities, hopelessness, demands of social services
    • Assess eligibility for income supplements, ODSP, exclusion from forced work/education programs
  • 47. Practice Level Interventions
    • information on income support programs and supplements
    • contact information for welfare and housing offices, social workers, legal aid clinics, and antipoverty/advocacy organizations
    • form letters, e.g. to support access to affordable housing, and to appeal rejected income supplement applications
    • Information on the health effects of poverty
  • 48. Changes to Initial Assessments What is the highest level of education you have achieved? If you are from another country, is your education recognized here? Education What supports do you currently have, from family, friends, or your community, in this city and elsewhere? Social Supports What is your current living situation? Have you ever been homeless? Do you feel your housing is stable and permanent? Housing If you are on social assistance, have you applied for additional income through supplemental allowances or disability support programs? Social Assistance What is your current income level? What are your current sources of income? Who does this income support? If you are working, do you feel your job is secure and do you have room for advancement? Income Intake Questions Social Determinant of Health
  • 49. Additional Interventions for Periodic Health Exam Consider poverty a risk factor for chronic and acute disease, and assess consider earlier screening for high prevalence conditions: e.g. cardiovascular, respiratory, liver disease; cancer; mental illness; addictions; ( etc. ) Referral to social worker, employment counselor, antipoverty advocates Support of application for disability supports Assessment of eligibility for social assistance supplements
  • 50. Community Level Interventions
    • Direct Health Services for underserved groups
    • Use privileged voice to speak publicly about poverty and health
    • Educate people living in poverty about health risks to improve their ability to advocate for selves
    • Participate in public events around decreasing poverty
    • Meet with elected representatives
    • Tell your clients’ stories
    • Conduct and support research into health and poverty