13 However, this approach has not proven to be effective, 14 largely because individuals are often not in control of the factors that make them sick and respond unconsciously to environmental cues. The field of medicine continues to operate under a “risk factor” paradigm focused on behavioural modification for high-risk groups as the main strategy for preventing disease (e.g., smoking cessation, decreasing salt and fat intake and reducing sedentary lifestyle). 11 Consequently, they have worse health and shorter lives. How are social determinants linked to health outcomes?Ĭertain subgroups of the population, particularly those who are less empowered and who have lower socioeconomic status, tend to live and work in more degraded environments and have a higher exposure to risk factors for disease, as well as physiologic impacts from chronic stress. Most publications pertain to low-resource settings within high-income country contexts, such as inner city neighbourhoods with high rates of poverty. With the exception of some clinical practice guidelines, most of the evidence on the effectiveness of physician intervention in social determinants is from smaller-scale observational studies and a few randomized controlled studies, as well as a growing number of qualitative and mixed-methods studies that are able to better assess the complexity involved and the role of context in influencing outcomes. Because this is a relatively new area of scientific inquiry that examines a variety of complex interventions impacting multiple health and social outcomes, a qualitative synthesis of the findings is presented that can be used as a framework for action on social determinants in clinical practice. This search identified almost 500 documents that were scanned for relevance, and a total of 71 documents were retained.
Grey literature was identified by Google searches, scanning reference lists, key informant discussions and postings on Internet listserves relating to health equity. Additional searches of selected relevant websites were conducted, including those of the Canadian Task Force on Preventive Health Care, US Preventive Services Task Force, UK National Institute for Health and Care Excellence, National Guideline Clearinghouse and the Guide to Community Preventive Services.
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However, what exactly should health workers do to make a positive impact? In this review, we identify the concrete actions that clinicians can use to help address the social determinants of health as part of their routine clinical practice ( Box 1 Appendix 1, available at Evidence used in this reviewĪ realist review methodology was used that is outlined in full in Appendix 1 (available at Broadly, multiple databases (e.g., Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, ISI Web of Knowledge) were searched using the following search terms: Social near determinant* AND health OR Health near/2 *equit* OR disparit*, Health* worker* OR Health* professional* OR Health* provider* OR primary health care OR community health worker* and training* or education* or capacity strengthening OR capacity building.
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7 Indeed, health professional schools are socially accountable to contribute to meeting the needs of the local community. 6 Training physicians, nurses and other allied health workers to address the social determinants of health is considered one of the key principles for promoting more equitable health outcomes for patients, families and communities. It is increasingly recognized that to improve population health, health equity needs to become a priority in the health sector, and measures to reduce disparities must be integrated into health programs and services. 4 Many avoid asking about social issues, 5 preferring to focus on medical treatment and lifestyle counseling. Yet physicians often feel helpless and frustrated when faced with the complex and intertwined health and social challenges of their patients. 2 To make an impact on improving health equity and providing more patient-centred care, 3 it is necessary to better understand and address the underlying causes of poor health. There is strong evidence from around the globe that people who are poor and less educated have more health problems and die earlier than those who are richer and more educated, 1 and these disparities exist even in wealthy countries like Canada.
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