Introduction to Marginalized Communities

Natalie Lovesey, MD, CCFP

Family PhysicianAssociate Director, Local/Marginalized CommunitiesThe Office of Global Health, SSMDwww.delicious.com/nlovesey

Global Health Selective 2012

April 13, 2012

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.

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.

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?

Source: UNESCO Background Paper for the Education For All Global Monitoring Report 2010 – Reaching the Marginalized – Educational Marginalization in National Education Plans.

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.”

Definition Can be various “causes” or “groups”,

depending on the society or region “Vulnerable populations”,

“disadvantaged groups” are similar terms; may have different meanings

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

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?

Unequal distribution of poverty

1998 Statistics. In: Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder: Thinking about Marginalization: What, Who and Why?

How does being a member of a Marginalized Community impact on health?

Social Determinants of Health WHO: “The conditions in which people

are born, grow, live, work and age, including the health system.”

Social Determinants of Health Socio-economic status

and income Personal/family

income Income distribution in

the population Social Support

Networks Education & Literacy Employment/Working

Conditions

Social Environments Housing/Physical

Environments Health Services Gender Social Exclusion Disability Aboriginal Status Race

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

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

Film excerpt

Profiles government-assisted refugees in Vancouver, BC

Many similarities with refugee patients seen here in London, ON

Film discussion

What is the biggest health care gap the refugees profiled identify?

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?

Break: 5 minutes

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.

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?

Clinical Tool: Searching the ODB formulary https://www.healthinfo.moh.gov.on.ca/formulary/index.jsp

Google “ODB formulary search”

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.?

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.?

Ontario Poverty Tool

www.healthprovidersagainstpoverty.ca

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

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.

Final questions?

Reminder: UWO Global Health Conference, April 27-29

Will you be a UWO Family Med resident? Consider the Marginalized Communities Elective.

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/