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Intro to Marginalized Communities for Medical Students

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Presented to 4th year medical students on April 13, 2012 at the Schulich School of Medicine & Dentistry.

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Intro to Marginalized Communities for Medical Students

  1. 1. Introduction to Marginalized Communities Natalie Lovesey, MD, CCFP Family Physician Associate Director, Local/Marginalized Communities The Office of Global Health, SSMD www.delicious.com/nlovesey Global Health Selective 2012 April 13, 2012
  2. 2. Learning Objectives  1. To define marginalization and outline the social determinants of health.  2. To provide an overview of marginalized populations globally and locally and the health issues they face.  3. To demonstrate educational and clinical tools and resources that can assist in working with marginalized populations.
  3. 3. Session Outline  Introduction and lecture on Marginalized Communities – 30 mins.  Film excerpt: “Safe and Sound” – 15 mins.  Break – 5 mins.  Small group activity: Case-based questions – 20 mins.  Feedback to group – 10 mins.  Wrap-up & final questions – 10 mins.
  4. 4. Questions:  What is a “marginalized community”?  What challenges do marginalized communities face when accessing health care?  What aspects of health care policy are relevant to marginalized communities?  What challenges have you had when dealing with marginalized communities?
  5. 5. Source: UNESCO Background Paper for the Education For All Global Monitoring Report 2010 – Reaching the Marginalized – Educational Marginalization in National Education Plans.
  6. 6. Marginalized communities: definition  No one agreed-upon definition of marginalization  International Consultative Forum on Education for All (EFA Forum), UNESCO, Status and Trends, 2000 - definition: “Marginalization occurs when people are systematically excluded from meaningful participation in economic, social, political, cultural and other forms of human activity in their communities and thus are denied the opportunity to fulfill themselves as human beings.”
  7. 7. Definition  Can be various “causes” or “groups”, depending on the society or region  “Vulnerable populations”, “disadvantaged groups” are similar terms; may have different meanings
  8. 8. Marginalized Communities  Broadly, can look at:  Gender-related, sexuality-related  Culture-related incl. ethnic groups, First Nations, religious groups, language groups  Location-related – conflict areas, rural areas  Poverty-related  Special groups – Persons with disabilities or special needs, HIV-AIDS
  9. 9. Further issues  The concept of marginalization is complex  Different views of causes leads to different approaches to reducing it Source: Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder: Thinking about Marginalization: What, Who and Why?
  10. 10. Unequal distribution of poverty  1998 Statistics. In: Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder: Thinking about Marginalization: What, Who and Why?
  11. 11. How does being a member of a Marginalized Community impact on health?
  12. 12. Social Determinants of Health  WHO: “The conditions in which people are born, grow, live, work and age, including the health system.”
  13. 13. Social Determinants of Health  Socio-economic status and income  Personal/family income  Income distribution in the population  Social Support Networks  Education & Literacy  Employment/Workin g Conditions  Social Environments  Housing/Physical Environments  Health Services  Gender  Social Exclusion  Disability  Aboriginal Status  Race
  14. 14. Questions:  What is a “marginalized community”?  What challenges do marginalized communities face when accessing health care?  What aspects of health care policy are relevant to marginalized communities?  What challenges have you had when dealing with marginalized communities?  Discuss examples with the group
  15. 15. Health Issues Faced by Marg. Comm.: Locally  Social determinants of health  Reduced access to health services – mainly lack of primary health care ie. Family physician, nurse practitioner.  Reduced ability to pay for non-insured health care eg. Prescription drugs, dental care, physiotherapy, etc.  Challenges with transportation  Challenges navigating the complex health care system  Literacy &/or English limitations – ex.: written colonoscopy instructions mailed to patients
  16. 16. Film excerpt  Profiles government- assisted refugees in Vancouver, BC  Many similarities with refugee patients seen here in London, ON
  17. 17. Film discussion  What is the biggest health care gap the refugees profiled identify?
  18. 18. Questions:  What is a “marginalized community”?  What challenges do marginalized communities face when accessing health care?  What aspects of health care policy are relevant to marginalized communities?  What challenges have you had when dealing with marginalized communities?
  19. 19. Break: 5 minutes
  20. 20. Case Discussion  You are a PGY1 seeing a patient in the Emergency Dept.  52 yo man with uncontrolled diabetes. Random bg is 24. HbA1C is 11%.  PMH – DM II, HTN, obesity  Meds – Metformin 500 mg bid  Sitagliptin 100 mg od (started by WIC), Amlodipine 5 mg od  Hasn’t taken his meds in about 3 months.
  21. 21. Questions  What factors might impact his adherence to his prescribed medications?  What key social history features do you want to know?  What would you include in your discharge plan from the Emergency Dept.?  What community resources could you refer him to?
  22. 22. Clinical Tool: Searching the ODB formulary  https://www.healthinfo.moh.gov.on.ca/fo rmulary/index.jsp  Google “ODB formulary search”
  23. 23. Taking a Social History “Plus”  Occupation  Level of education (may be very different than current occupation, especially in immigrants)  Literacy in English and/or in mother tongue.  Language(s) spoken (write it on the chart in the hospital).  Living arrangement – who is at home - asking if married, children, etc. does not tell you who is at home; may have extended family or friends. Is spouse/partner present, or does he/she work in another province, country, etc.?  What type of home – apartment, house, townhouse, etc.?
  24. 24. Social History “Plus”  Level of English proficiency – can ask re: ESL Level if taking classes.  Social Networks – friends or family nearby? Social isolation?  Lifestyle habits – any particular diet? Foods avoided or emphasized for religious, cultural or personal reasons?  Smoking, alcohol, drugs, tobacco, etc.?
  25. 25. Ontario Poverty Tool www.healthprovidersagainstpoverty.ca
  26. 26. Recap  Marginalization = exclusion from full participation in society, for one or more reasons  Social determinants of health are key  Add some “extra” social questions to your history  Utilize clinical tools and community resources to assist your patients
  27. 27. Parting Thoughts  Keep asking “why?” – to your patients’ social situations, and also to yourself.  Educate yourself; take courses, read articles, stay informed. Learn about the region/group’s issues and politics.
  28. 28. Final questions?  Reminder: UWO Global Health Conference, April 27-29  Will you be a UWO Family Med resident? Consider the Marginalized Communities Elective.
  29. 29. References  Hospital for Sick Children – Cultural Competence e-Modules. Module: Social Determinants of Health. Available online at http://www.sickkids.ca/culturalcompetence/elearning-modules/eLearning- modules.html. Includes document “Key Social Determinants of Health – January 2011”.  Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder: Thinking about Marginalization: What, Who and Why? Web version – November 2000. Available online at http://www.cprn.org/doc.cfm?l=en&doc=181  Mikkonen J and Raphael D. Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management, 2010. Available online at http://www.thecanadianfacts.org/  Safe and Sound? Documentary. Website www.safeandsoundfilm.com.  UNESCO – International Institute for Educational Planning. Background paper prepared for the Education for All Global Monitoring Report 2010 - Reaching the Marginalized. Educational Marginalization in National Education Plans. UNESCO 2009. Available online at http://unesdoc.unesco.org/images 0018/001866/186608e.pdf  World Health Organization – Definition of Social Determinants of Health. Available online at http://www.who.int/social_determinants/en/

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