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CPHA May 28, 2014 Danyaal Raza 1 , Andrew D. Pinto 2,3

Addressing individual income as a social determinant of health in clinical settings: A realist systematic review . CPHA May 28, 2014 Danyaal Raza 1 , Andrew D. Pinto 2,3 1. Harvard School of Public Health, Harvard University

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CPHA May 28, 2014 Danyaal Raza 1 , Andrew D. Pinto 2,3

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  1. Addressing individual income as a social determinant of health in clinical settings: A realist systematic review CPHA May 28, 2014 Danyaal Raza1, Andrew D. Pinto2,3 1. Harvard School of Public Health, Harvard University 2. Department of Family and Community Medicine, St. Michael’s Hospital 3. Centre for Research on Inner City Health, St. Michael’s Hospital

  2. No specific financialconflict of interest. My research is funded by CIHR and the Ontario Ministry of Health and Long-Term Care. The premise of this discussionisworking towards social justice and hence, a more healthysociety. This ismy 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.

  3. Role of Primary health care in addressing health inequity

  4. 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/

  5. Canadian Medical Association, 2013 http://healthcaretransformation.ca/infographic-social-determinants-of-health/

  6. WHO 2008. Final Report of the Commission on the Social Determinants of Health. p.43.

  7. How do SDOH “get under our skin”? How do they work?

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

  9. Opportunity for change as we move toward “people-centred” model WHO. World Health Report 2008. p. 43 http://www.who.int/whr/2008/08_chap3_en.pdf

  10. 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

  11. 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)

  12. Evidence: Systematic review and realist synthesis

  13. 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

  14. Inclusion/Exclusion

  15. Inclusion/Exclusion

  16. Potentially relevant articles identifies though electronic databases search 968 articles Independent title & abstract review with inclusion/exclusion criteria applied 933 articles excluded 35 articles included Independent full text review with inclusion/exclusion criteria applied 4 articles excluded 29 articles included

  17. 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

  18. 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.

  19. 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.

  20. 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

  21. Enabling characteristics

  22. Underlying mechanisms of income security intervention

  23. Context [economic, political, historical] Context [family, community, society] Health care setting Patient identification: in clinical encounter OR survey ORchart audit Patient Income Security Intervention Improve financial literacy Increase Income Increase investments Reduce expenses Benefits/ grants Employment Reduce debt & restructure debt Engage other advocates Increase savings Cheaper housing Reduce other expenses Support action to improve wages Set up bank account Help job search & apply Information & advice Budgeting Obtain free goods/services Change spending habits Retraining/Education/Rehab Admin support/assist with forms Direct advocacy for patient Work accommodation for disability Improved Income Security

  24. Post-synthesis framework Context [economic, political, historical] Context [family, community, society] Patient Health care setting Patient identification: in clinical encounter OR survey ORchart audit Patient Health Promoter Income Security Intervention Provider Enabling Characteristics Patient-health provider relationship Benefits counsellor-health care team relationship Expert benefits advice Colocation Pro-active advice Accessible Decreased stigma High Impact Health Setting Embedment Mechanisms Trust Improved Income Security

  25. Income Security Health Promotion Interventions: • Increasing income • Benefits/grants • Taxes • Employment • Retraining • Reducing expenses • Improving financial literacy

  26. Thank You andrew.pinto@utoronto.ca @AndrewDPinto

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