HIN's Key Speaker for our annual general meeting 2014, Dr. Andrew Pinto, presents his research findings on how data collection is used to address the social determinants of health.

1. Collec&ng
Data
to
address
the
Social
Determinants
of
Health
Healthcare
Interpreta&on
Network
October
22,
2014
Andrew
Pinto
MD
CCFP
FRCPC
MSc
Department
of
Family
and
Community
Medicine,
St.
Michael’s
Hospital
Department
of
Family
and
Community
Medicine,
Faculty
of
Medicine,
University
of
Toronto
Centre
for
Research
on
Inner
City
Health,
St.
Michael’s
Hospital

2. No
specific
financial
conflict
of
interest.
Salary
support:
• Department
of
Family
&
Community
Medicine,
St.
Michael’s
Hospital
• Department
of
Family
&
Community
Medicine,
Faculty
of
Medicine,
University
of
Toronto
Research
funding:
• Ontario
Ministry
of
Health
and
Long-­‐Term
Care
• TD
Financial
Literacy
Grant
Fund
• PSI
Founda&on
• Legal
Aid
Ontario
The
premise
of
this
discussion
is
working
towards
social
jus*ce
and
hence,
a
more
healthy
society.
This
is
my
objec&ve
as
a
physician,
ac&vist
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
popula&on.

3. Acknowledgements
SDOH
Commi=ee
Gary
Bloch
(physician,
Chair)
Daniel
Bois
(nurse)
Jacqueline
Chen
(clinical
manager)
Ka&e
Dorman
(resident
physician)
Laura
Easty
(resident
physician)
Melinda
Glassford
(die&cian)
Laurie
Green
(physician)
Sue
Hranilovic
(nurse
prac&&oner)
Laurie
Malone
(execu&ve
director)
Anthony
Mohamed
(senior
specialist
equity
&
community
engagement)
Nav
Persaud
(physician)
Danyaal
Raza
(physician)
Katherine
Rouleau
(physician)
Courtney
Ruddy
(clerical)
Mannie
Sarao
(resident
physician)
Celia
Schwartz
(social
worker)
Karen
Tomlinson
(income
security
health
promoter)
OCFP
Poverty
Commi`ee
Health
Providers
Against
Poverty
IGNITE
Study
Team
Ahmed
Bayoumi
Gary
Bloch
Muhammad
Mamdani
Nav
Persaud
Linda
Rozmovits
Kevin
Thorpe
EMBER
Study
Team
Ri&ka
Goel
Yogendra
Shakya
Gary
Bloch
Deena
Ladd
Anthony
Mohamed

4. Outline
1. Our
role
in
addressing
SDOH
2. Developing
a
SDOH
Commi`ee
3. Collec&ng
socio-­‐demographic
data
4. Ques&ons
and
feedback

5. Part
1
OUR
ROLE
IN
ADDRESSING
SDOH

6. Social
Determinants
of
Health
“the
condi&ons
in
which
people
are
born,
grow,
live,
work
and
age.
These
circumstances
are
shaped
by
the
distribu&on
of
money,
power
and
resources
at
global,
na&onal
and
local
levels”
h`p://www.who.int/social_determinants/en/
Commission on Social Determinants of Health FINAL REPORT
Closing
the gap
in a
generation
Health equity through action on
the social determinants of health

7. Canadian
Medical
Associa&on,
2013
h`p://healthcaretransforma&on.ca/infographic-­‐social-­‐determinants-­‐of-­‐health/

8. Life Expectancy at Birth
Figure 2a: Life Expectancy at Birth, by Income1,
Males, Toronto, 2001, 2003 & 2004
Combined2
Figure 2b: Life Expectancy at Birth, by Income1,
Females, Toronto, 2001, 2003 & 2004
Combined2
85
80
75
0
Lowest Q2 Q3 Q4 Highest
Income
Years
Lowest Q2 Q3 Q4 Highest
Income
1 Income is the population quintile by proportion of the population below the LICO in census tracts.
2 Mortality data are used from 2001, 2003 and 2004 as these years contain the most current and
complete data for postal code. Three years of data are required for this type of analysis.
Error bars (I) denote 95% confidence intervals.
Source: Ontario Mortality Data 2003-2004, Provincial Health Planning Database (PHPDB) Ver.
18.01, Ontario MOHLTC. Ontario Mortality Data 2001, Statistics Canada, June 2008.
85
80
75
0
Years
Toronto
Public
Health.
2008.
Unequal
City
Report.
Life expectancy at birth represents the average number of years a group born at a specific time will live and is

9. Teen Pregnancy
Figure 7: Teen Pregnancy1 Rate2, by Income3, Toronto, 2004-2006
50
40
30
20
10
0
Lowest Q2 Q3 Q4 Highest
Income
Rate per 1,000
1 Teen pregnancy includes hospital deliveries (live and still born) plus therapeutic abortions.
2 Rate is per 1,000 women aged 15 to 19 years per year.
3 Income is the population quintile by proportion of the population below the LICO in census
tracts.
Error bars (I) denote 95% confidence intervals.
Source: Teen deliveries (live and stillbirth) Hospital In-Patient Data, and Therapeutic abortions
Hospital In-Patient Data, Ambulatory Visits, Day Procedures, 2004-2006, Provincial Health
Planning Database (PHPDB) Ver. 18.01, Health Planning Branch, Ontario MOHLTC.
Toronto
Public
Health.
2008.
Unequal
City
Report.

10. Hulchanski.
Ci&es
Centre,
U
of
T.
2010

11. Diabetes

12. inequity. By recognizing the nature and scale of both non-communicable
determinants of health.
Figure 4.1 Commission on Social Determinants of Health conceptual framework.
Policy
(Macroeconomic,
Social, Health)
Source: Amended from Solar & Irwin, 2007
Income
Gender
Ethnicity / Race
COMMISSION ON SOCIAL DETERMINANTS OF HEALTH | FINAL REPORT
Socioeconomic
& political context
Social position
Education
Occupation
Health-Care System
SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES
Governance
Cultural and
societal norms
and values
Material circumstances
Social cohesion
Psychosocial factors
Behaviours
Biological factors
Distribution of health
and well-being
WHO.
Final
Report
of
the
Commission
on
Social
Determinants
of
Health.
2008.

13. Professional Activities
Social Determinants of Health –
What Doctors Can Do
October 2011
“Doctors
can
help
by
intervening
with
individual
pa*ents,
contacts,
using
clinical
tools
including
social
prescribing
and
brief
interven&ons.
They
can
work
within
example,
by
commissioning
measures
including
health
promo&on
and
ill-­‐health
preven&on
that
will
affect
changes
to
the
social
determinants
and
are
effec&ve
in
the
whole
community
including
those
who
are
tradi&onally
hard
to
reach.
Doctors
can
use
their
families
and
communi*es,
evidence
and
for
influence
to
have
a
posi&ve
impact
on
health
inequali&es.
Doctors
can
use
their
posi&on
and
their
exper&se
to
advocate
for
change…”
h`p://bma.org.uk/-­‐/media/files/pdfs/working%20for%20change/improving%20health/socialdeterminantshealth.pdf

14. • Development/refinement
of
health
equity/social
determinants
of
health
assessment
tool
• Development/modifica&on
of
clinical
prac&ce
guidelines
to
integrate
social
and
economic
factors
into
medical
care
• Development
of
resources
for
physicians
on
programs
and
services
for
pa*ents
• Development
of
resources
for
physicians
on
accessing
provincial/territorial
and
federal
programs
including
forms
and
referral
pathways,
etc.
• Development/consolida&on
and
dissemina&on
of
plain
language
resources
for
pa&ents
on
chronic
disease
management
h`p://healthcaretransforma&on.ca/wp-­‐content/uploads/2013/03/Health-­‐Equity-­‐Opportuni&es-­‐in-­‐Prac&ce-­‐Final-­‐E.pdf

15. Health care in Canada
WHAT MAKES US SICK?
Canadian Medical Association Town Hall Report | July 2013
Recommenda&ons:
1. Poverty
Reduc&on
Strategies
2. Guaranteed
annual
income
3. Affordable
housing
4. Housing
First
5. Na&onal
food
security
6. Early
child
development
7. Pharmacare
8. Recognize
SDOH
9. Require
HIA
10.
Local
health
and
social
databases
11.
Investments
in
Aboriginal
health
12.
Educa&on
on
Aboriginal
health
h`ps://www.cma.ca/Assets/assets-­‐library/document/fr/advocacy/What-­‐makes-­‐us-­‐sick_en.pdf
report, July 2013
Recommendation 7: That governments, in consultation with
and health insurance industry and the public, estab-lish
program of comprehensive prescription drug coverage
administered through reimbursement of provincial–
and private prescription drug plans to ensure that all
Canadians have access to medically necessary drug therapies.
Recommendation 8: That the federal government recognize
Recommendation 10: That local databases of community
services and programs (health and social) be developed and
provided to health care professionals, and where possible, tar-geted
guides be developed for the health care sector.
Recommendation 11: That the federal government put in
place a comprehensive strategy and associated investments
for improving the health of Aboriginal people that involves a

16. Why
address
SDOH
in
health
care?
• First
contact
• Accessible
• Longitudinal
• Person-­‐focused
• Coordina&on
and
naviga&on
• Comprehensive
• BOTH
preven&ve
(future
needs)
and
cura&ve
(immediate
needs)
• Exis&ng
and
poten&al
connec&ons
to
other
systems
• Poli&cal/media
focus
• Highly
resources
Adapted
from
De
Maeseneer
et
al.
WHO
2007.
h`p://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf

17. Part
2
ST.
MICHAEL’S
HOSPITAL
DFCM
SDOH
COMMITTEE

18. St.
Michael’s
Hospital
• Established
a
SDOH
Commi`ee
within
the
DFCM
• Projects:
1. Socio-­‐demographic
data
collec&on
(ongoing)
2. Income
security
health
promo&on
(ongoing)
3. Medical-­‐Legal
Partnership
(to
launch)
4. Reach
Out
and
Read
(future)
5. Employment
and
Be`er
Employment
(future)

19. Medical-­‐Legal
Partnership
Commi`ee
led
by
Nav
Persaud
(SMH)
and
Yedida
Zalik
(ARCH
Disability
Law
Centre).
Funding
from
Legal
Aid
Ontario.
Es&mated
demand
based
on
cases
seen
by
social
work:
– 55%
of
pa&ents
seen
by
SW
have
a
legal
need
– Of
3600
yearly
referrals,
1980
pa&ents/year
expected
to
have
a
legal
need
Legal
needs:
– Most
common
issues:
• family
law
issues
(19%)
• employment
issues
(17%)
• tenant
rights
(10%)
• social
benefits
(9%)
Needs
assessment
conducted
by
Dr.
Rami
Shoucri

21. Reach
Out
and
Read
@
SMH
Commi`ee
led
by
Laurie
Green
(staff
physician)
and
Ka&e
Dorman
(PGY-­‐2).
Currently
applying
for
funding.
GOAL:
enhance
childhood
development
and
improve
health
equity
among
low-­‐income
families
receiving
primary
care
from
the
St.
Michael’s
Hospital
Family
Health
Team.
We
propose
to
implement
the
following
components
1. Literacy-­‐rich
wai&ng
room
2. Informa&on
sheets
on
(i)
importance
of
reading
aloud,
(ii)
informa&on
on
accessing
local
libraries,
and
(iii)
loca&ons
of
Early
Years
Centres
and
Parent
Literacy
Centres
3. An&cipatory
guidance
on
benefits
of
reading
aloud
4.
Book
distribu*on
at
child
visits
(birthdays
-­‐
1,
2,
3,
4,
5)

22. Income
Security
Health
Promo&on
Poverty Interventions
May 2012 for Family Physicians
Developed
by
Gary
Bloch
POVERTY:
A clinical tool
for primary care
in Ontario
“There is strong and growing evidence
that higher social and economic status is
associated with better health. In fact,
these two factors seem to be the most
important determinants of health.”1
- Public Health Agency of Canada
Poverty requires intervention
like other major health risks:
The evidence shows poverty
to be a risk to health equivalent
to hypertension, high
cholesterol, and smoking. We
devote significant energy and
resources to treating these
health issues. Should we treat
poverty like any equivalent
health condition?
Of course .
Poverty accounts for 24% of person years of life lost in Canada
(second only to 30% for neoplasms).2
Income is a factor in the health of all but our richest patients.
Three
Steps
To
Addressing
Poverty
in
Primary
Care
1. Screen
2. Adjust Risk
3. Intervene
h`p://www.healthprovidersagainstpoverty.ca/

23. Income
Security
Health
Promoter
at
SMH
DFCM
Interven&ons
include
assis&ng
with:
1. Increasing
income
• Benefits/grants
• Comple&ng
taxes
• Employment/retraining
2. Reducing
expenses
• Housing
&
rent
• Free
services
3. Improving
financial
literacy
• Fraud
preven&on
• Budge&ng
• Avoiding
cheque
cashing

24. IGNITE
(addressInG
iNcome
securITy
in
primary
carE)
Study
Builds
on
findings
of
systema&c
review
and
detailed
retrospec&ve
review
of
1
year
of
cases,
and
qualita&ve
interviews
with
12-­‐15
pa&ents
Design:
pragma&c
RCT
Funding:
TD
Financial
Literacy
Grant
Fund,
AFP
Innova&on
Fund,
PSI
Founda&on
What
is
the
impact
on
income,
health
status
and
health
service
u;liza;on
of
pa;ents
living
in
poverty
of
engaging
with
an
income-­‐focused
health
promoter,
based
in
a
primary
care
seAng?

25. EMployment
and
Be=er
Employment
through
Rela*onships
(EMBER)
Project
• Being
employed
AND
the
condi&ons
of
employment
are
key
SDOH
• Growing
awareness
that
decent
work
is
rare
1. Develop
a
network
in
SE
Toronto
of
primary
health
care
organiza&ons
(e.g.
SMH,
ICHA,
Access
Alliance),
social
service
organiza&ons
and
advocacy
organiza&ons
(e.g.
Workers’
Ac&on
Centre)
2. Environmental
scan
&
survey
of
organiza&ons
who
succeed
in
helping
clients
gain
decent
work
3. Pilot
test
an
interven&on
with
30-­‐40
unemployed
pa&ents

26. Client is identified
by any
organization
Case discussion and consultation:
Primary health care representative
• Readiness assessment
Social service representative
Follow-up
• Interview skills
&
Discharge
• CV writing
support
• Job search
Advocacy organization representative
• Advice on workplace accommodation
• Explore how client wants to be involved in systemic change
Intake
by EMBER
Project Coordinator/
Employment Advocate
With
Yogendra
Shakya
(Access
Alliance),
Ri&ka
Goel
(ICHA
FHT),
Deena
Ladd
(Workers’
Ac&on
Centre)
and
others.

27. Part
3
COLLECTING
SOCIO-­‐DEMOGRAPHIC
DATA

28. WE ASK BECAUSE
Socio-­‐demographic
data
collec&on
SUMMARY REPORT
JUNE 2013
WE CARE.
201306278
We ask because we care
The Tri-Hospital + TPH Health Equity Data Collection Research Project Report
Will you please provide us with information about yourself?
This information will increase access to services
and improve the quality of care.
What language do you
feel most comfortable
speaking in with your
health-care provider?
Which of the
following
best describes
your racial or
ethnic group?
Do you have
any of the
following
disabilities?
With funding and support from the Toronto Central LHIN.
Language
Immigra&on
Race/ethnicity
Disabili&es
Gender
iden&ty
Sexual
orienta&on
Income
Housing
h`p://www.stmichaelshospital.com/quality-­‐new/data-­‐collec&on-­‐research-­‐project.php

29. Language
as
a
SDOH
• Recent
immigrants
with
prolonged
limited
English
language
proficiency
are
more
likely
to
experience
a
downwards
trend
in
self-­‐reported
health
and
higher
rates
of
unmet
health
needs.
• Ontarians
who
are
non-­‐English
speaking
are
more
likely
to
report
poor
health.
• Limited
English
proficiency
in
Canada
has
been
associated
with
reduced
treatment
comprehension
and
compliance,
increased
risk
of
adverse
drug
reac&ons,
and
increased
likelihood
of
inadequate
management
for
chronic
disease.
• Non-­‐English
speaking
pa&ents
are
less
likely
to
be
sa&sfied
with
the
care
received
when
not
speaking
the
same
language
as
their
provider.
Bierman
et
al.
POWER
Study.
ICES
2012.
Raphael
D.
SDOH:
Canadian
Perspec&ves.
Scholars’
Press
2008
CSDOH.
WHO:
2008
Wu
Z
et
al.
CJPH
2005;
96:
369-­‐73
Bowen
S.
Health
Canada
2001.
Dastjerdi
M
et
al.
Int
J
Equity
Health
2012;
11:55.

30. Appendix B
8 Final Core Questions
1. What language would you feel most comfortable speaking in with your healthcare provider? CHECK ONE ONLY.
 Amharic  Hindi  Somali
 Arabic  Hungarian  Spanish
 ASL  Italian  Tagalog
 Bengali  Karen  Tamil
 Chinese (Cantonese)  Korean  Tigrinya
 Chinese (Mandarin)  Nepali  Turkish
 Czech  Polish  Twi
 Dari  Portuguese  Ukrainian
 English  Punjabi  Urdu
 Farsi  Russian  Vietnamese
 French  Serbian  Prefer not to answer
 Greek  Slovak  Do not know
 Other (Please specify) _______________________________________________
2. Were you born in Canada?
 Yes  No  Prefer not to answer  Do not know
 If no, what year did you arrive in Canada? ________________________________________

31. Most
comfortable
language
(at
least
1
person
responding)
12
5
2
3
4
367
3
1
2
1
1
1
1
1
3
1
1
2
1
1
400
350
300
250
200
150
100
50
0

33. h`p://www.theglobeandmail.com/life/health-­‐and-­‐fitness/health/concerns-­‐raised-­‐at-­‐over-­‐demographic-­‐data-­‐collec&on-­‐at-­‐canadian-­‐hospitals/ar&cle20487997/

34. Final
Thoughts
• SDOH
is
not
only
a
public
health
challenge,
but
something
that
we
can
address
in
health
care
organiza&ons
• Recognizing
the
limits
of
this
work
(income
security,
legal
advice,
child
literacy,
employment)
we
must
incorporate
a
system
of
advocacy
that
looks
across
cases
• All
work
is
based
on
rela&onships
and
collabora&on

35. Ques&ons?
andrew.pinto@utoronto.ca
@AndrewDPinto