There is compelling evidence globally indicating that individuals with lower socioeconomic status and education levels experience more health issues and have shorter lifespans compared to those who are wealthier and more educated.1 These disparities persist even in affluent nations like Canada.2 To genuinely impact health equity and deliver more patient-centered care,3 a deeper understanding and address of the root causes of poor health is essential. However, healthcare professionals often feel overwhelmed and helpless when confronting the complex and intertwined health and social challenges of their patients.4 Many avoid inquiring about social issues,5 preferring to concentrate on medical treatments and lifestyle counseling. This article explores a practicum guide for social workers: an integrated approach epub, offering insights into how social workers can effectively address these challenges.
The healthcare sector increasingly recognizes that prioritizing health equity and integrating measures to reduce disparities into health programs and services are vital for improving population health.6 Training healthcare professionals, including physicians, nurses, and allied health workers, to address the social determinants of health is considered a fundamental principle for promoting more equitable health outcomes for patients, families, and communities.7 Health professional schools are socially accountable and need to contribute to meeting the needs of the local community. But what specific actions can healthcare workers take to make a positive impact? This review identifies concrete steps clinicians can implement to address the social determinants of health as part of their routine clinical practice (Box 1; Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.160177/-/DC1).
Understanding the Social Determinants of Health
The World Health Organization (WHO) defines social determinants of health as:
“the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”8
These determinants encompass factors like income, social support, early childhood development, education, employment, housing, and gender.9 For instance, Indigenous peoples face ongoing challenges stemming from colonization, intergenerational trauma from residential schools, systemic racism, jurisdictional ambiguity, and a lack of self-determination, all of which significantly influence health and its determinants.10
The Link Between Social Determinants and Health Outcomes
Vulnerable populations, characterized by disempowerment and lower socioeconomic status, often live and work in degraded environments with higher exposure to disease risk factors and the physiologic impacts of chronic stress.11 This results in poorer health and shorter lifespans.12
Traditional medical approaches often focus on behavioral modification for high-risk groups, like smoking cessation and dietary changes.13 However, this approach is often ineffective.14 Individuals often lack control over the factors that make them sick and respond unconsciously to environmental cues.15 Supportive environments that make healthy choices easy are crucial for reducing unhealthy behaviors.16 For instance, neighborhood socioeconomic disadvantage and a high concentration of convenience stores are linked to tobacco use, while limited access to fresh produce, combined with fast-food outlets and scarce recreational opportunities, can lead to suboptimal nutrition and less physical activity.17 Broader interventions like urban planning to create parks and community gardens are needed in addition to individual counseling.
The family environment in childhood is particularly important, with profound consequences for physical and mental health, as well as mortality.18 Children who experience abuse, witness domestic violence, or grow up in households with mental illness or substance abuse are significantly more likely to experience negative outcomes in adulthood.19 A supportive relationship with an alternative figure can be a corrective emotional experience, enabling individuals to work through negative childhood experiences.20 This requires a continuum of strategies from victim identification and care to structural interventions that support families, promote nurturing relationships, empower women, and prevent violence.21
Healthcare workers can engage in clinical preventive practices, intervening early to prevent disease and promote health. Addressing social determinants entails starting earlier and broadening the scope of interventions to include families and communities.
How Healthcare Workers Can Influence Social Determinants
Physicians and allied health workers can take action on social determinants at patient, practice, and community levels.
Patient-Level Interventions
The types of disadvantage clinicians encounter vary and aren’t always obvious. In urban settings, these may include single mothers, isolated older adults, Indigenous youth who have left their communities, the hidden homeless, non-status refugees, and people with mental health or addiction issues. Clinicians can better support these patients by asking about their social history, providing advice, referring them to local support services, facilitating access to these services, and acting as a reliable resource.22
Failing to identify hidden social challenges can lead to misdiagnosis or inappropriate care plans.25,26 Studies show that many patients feel their doctors are unaware of their struggles with basic needs.27 Even in cases of violence, few women are asked about it by their primary care providers.28,29 Clinical guidance encourages heightened awareness of clinical flags and patient cues, using selective inquiry based on clinical considerations.30 Physicians who ask about social challenges are more likely to report helping patients.31 Challenges like discrimination, social isolation, and violence can affect anyone, regardless of socioeconomic status.32
Sensitive Inquiry About Social Challenges
The first step is asking patients about potential challenges in a sensitive and culturally acceptable way. Tools exist to help practitioners inquire about employment, food insecurity, discrimination, abuse, and other complicating factors.33,34,35 A simple screening question like “do you ever have difficulty making ends meet at the end of the month?” can be highly effective.36
Asking about these issues in a caring way is important, as compassion and empathy improve diagnoses and care.37 Integrating information on social challenges into the medical record ensures the entire care team considers these factors.
Referral and Access to Support
“Social prescribing” connects patients with support resources like women’s groups, housing organizations, and employment agencies. Studies show that referrals to community-based support groups reduce patient anxiety and improve overall health perception.38
Healthcare workers can advocate for patients and help them access benefits and programs, like tax credits, home visitation programs, and nutrition support.40,41 Systematic screening for basic needs and providing a list of local community resources can lead to increased provider referrals, family enrollment in support services, maternal employment, and reduced use of homeless shelters.42
Practice-Level Interventions
Practice-level interventions and broader systems changes promote equity-oriented primary healthcare. Key dimensions include inequity-responsive care, trauma- and violence-informed care, contextually tailored care, and culturally competent care.44 Organizational-level changes and senior management support reinforce social accountability and help marginalized individuals access and navigate health and social services more easily.46
Improving Access and Quality of Care
Practices can reduce barriers to care by providing bus fare, childcare, interpreter services, extended hours, convenient locations, a welcoming environment, financial incentives for meeting benchmarks, and healthcare services beyond the clinic walls.47
Patient experience surveys and patient councils provide input for redesigning practices to be more accessible and responsive.48 Isolated patients may require assertive outreach, patient tracking, and individual case managers.49 Health systems can provide financial support for the care of vulnerable patients.50
Integrating Patient Social Support Navigators
Hiring patient navigators helps patients access support services more easily. Primary care settings can provide a safe space for identifying unemployed patients with multiple barriers to finding a job.51 Employment consultants can lead to full-time employment, improved perceived health, and reduced visits to primary care.51
Alternate models exist, such as task shifting and sharing, or using trained volunteers to assist patients in navigating support pathways.52,53
Community-Level Interventions
Physicians can serve as effective health advocates and valuable community resources.54
Partnerships with Community Groups
Improving health requires partnerships and intersectoral action involving education, justice, and employment sectors.55 Clinical–community relationships create collaborative initiatives with far-reaching effects, such as low-cost daycare, violence prevention programs, parks, green spaces, and farmer’s markets.56,57 Engaging local leaders and partners early is crucial.58 Public health partners can facilitate this through community-based interventions for health equity.59
Advocacy for Social Change
Physicians and other healthcare professionals can speak about the health impacts of social challenges to encourage policy responses.62 They can engage in activism by supporting social movements and political parties that advocate for basic income, affordable childcare, and progressive taxation.63 Locally relevant research and social determinants data can be used to intervene and generate evidence for advocacy.64 They can create organizations to defend humanitarian causes and ensure the health system is part of the solution.65,66
Community Needs Assessment and Health Planning
Community-oriented primary care integrates public health practice with primary care services to improve the health of a defined population.67 This approach has a long history and inspires innovative ways to support disadvantaged patient groups.68,69 Community-oriented primary care, using health promoters acting as cultural brokers, resulted in a decrease in hospital admissions and cost savings.70
Community Engagement
Engagement and empowerment are needed to tackle deeply rooted challenges. Physicians and allied health workers can catalyze community-level shifts by initiating dialogue and identifying local solutions.72,73 Even the clinical setting can be influenced by broader social prejudices.75 Self-reflexivity about biases is a core skill in developing culturally safe relationships.76
Cultural competency training should be provided for all health workers.[77](#b77-188e474],78 Health workers can empower communities to deal with pressing issues, leading to improved health and more cohesive communities.79,80
Overcoming Barriers to Action
Multiple barriers exist to adopting a social determinants of health approach in clinical practice, including low perceived self-efficacy, lack of training, and the absence of communities of practice.81
Reminders and Participatory Approaches
Western medical culture often focuses on disease management rather than a biopsychosocial approach.82 Chart reminder systems can flag patients at risk. Participatory approaches can create a culture of reflection and shift work practice upstream.83
Treating Patients with Dignity
Being open to different cultural backgrounds and avoiding stereotyping is crucial for developing trust and helping patients disclose social challenges.84
Time Per Consultation
Increasing consultation time by even a few minutes can improve care, decrease stress, and improve patient enablement.85
Local Referral Resources
Access to a well-maintained, locally relevant internet directory of community resources is a major enabler.86,87
Resources and Support of Health Workers
Emphasis on social accountability is increasing in medical schools.88,89 Training programs are improving attitudes, skills, and competencies in addressing social determinants.90,[91](#b91-188e474],[92](#b92-188e474] Clinical practice tools and training are important facilitators for widespread culture change.95
Clinical Tools for Addressing Social Determinants
Clinical practice tools can help physicians and allied health workers improve performance in identifying and addressing the root causes of poor health. The CLEAR toolkit helps healthcare workers assess patient vulnerability and identify key referral resources.97 The poverty toolkit helps physicians screen for low income and assist patients in accessing benefits.98
The increasing number of publications shows how training and clinical practice tools are changing knowledge, attitudes, and skills. Local adaptation and rigorous implementation and evaluation research are key to determining the impact on patient outcomes.99
Conclusion
Addressing social determinants of health requires collaboration across multiple sectors and levels of government.100 Healthcare workers are important catalysts for change, supporting patients, raising awareness, and advocating for better living conditions.101 A social determinants and population health approach is needed to reduce healthcare demand and contribute to health system sustainability.102 Physicians are encouraged to implement creative solutions, measure the impact, and share successes.
Key points
- Physicians often recognize the influence of social determinants but are unsure how to intervene.
- Guidance exists on concrete actions clinicians can take to address social determinants.
- At the patient level: be alert to clinical flags, ask sensitively, and help access benefits.
- At the practice level: offer culturally safe services, use patient navigators, and ensure accessibility.
- At the community level: partner with organizations, get involved in planning, and advocate for supportive environments.
- Clinical decision aids and practice guidelines are available to help healthcare workers address social determinants.
Acknowledgements
The author thanks Grand Challenges Canada, Canadian Institutes for Health Research, Fonds de la recherche du Québec-Santé, Fédération des médecins spécialistes du Québec and St. Mary’s Research Centre, Montréal, for funding this work. The author also acknowledges Ali Okhowat, Gilbert Velasquez and Sonali Srivastava for contributing to the literature search, data extraction and preliminary thematic analysis. The author dedicates this article to the first-year medical students whom she teaches in their first month of medical school during a course called “Improving Health: From Molecules to Global Health.” Finally, the author is grateful to the members of the Community Links Evidence to Action Research (CLEAR) collaboration for their ongoing support of this program of research (www.mcgill.ca/clear/about).
Footnotes
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/160177-rev
Competing interests: None declared.
This article has been peer reviewed.
Funding: The project is supported by Grand Challenges Canada, Canadian Institutes for Health Research, Fonds de recherche du Québec – Santé, Fédération des médecins spécialistes du Québec and St. Mary’s Research Centre, Montréal, Que.
References
(References remain the same as the original article)
