Prepared for by Dane Wanniarachige

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Social and economic factors play a big role in the health of Canadians

Policy makers have known for some time now that social and economic factors have a big influence on our health and on disparities in health across different groups in society. These factors, known as the “social determinants of health,” include the following, but are not limited to: income, social status, education, our social/physical environment, gender and race.

Health providers are broadening their role to recognize and address the social determinants of health

As our understanding of the links between social and economic factors and health outcomes has grown, health professionals, health organizations and policymakers have increasingly begun to talk about how to address them.

Traditionally, responsibility for preventing disease and promoting health has rested with our public health system, while our healthcare system has focused on treating people once they are sick.  Doctors and other health providers, however, are now being encouraged to gather socio-economic and behavioural data from patients that can also help inform diagnoses and guide treatment choices.

These less traditional data sources can also potentially be used to inform larger choices with respect to health policy and the design of our healthcare services, as well as to drive innovation to improve healthcare outcomes and reduce healthcare costs.

Should health providers be doing more?

Close to five million Canadians, or one in seven, live in poverty. An overwhelming body of evidence shows that poverty puts patients at a higher risk of cardiovascular diseases, diabetes, cancer and depression. Children in low-income families are particularly affected as poverty places them at a higher risk of low birth weight, mental health problems, asthma, malnutrition, injuries and hospitalization.

Recognizing the urgency of this situation, Dr. Kathy Lawrence, President of the College of Family Physicians of Canada (CFPC), at a 2014 roundtable discussion with the Canadian Minister of Health, spoke in favour of physicians more actively recognizing and responding to the social determinants of health.  In her own words:

The CFPC is dedicated to supporting the role of the socially accountable family physician…Family medicine training helps to prepare family physicians to identify and address the health and social determinants of health impacts stemming from family violence and child maltreatment.

The CFPC is particularly interested in addressing the impact of poverty on domestic abuse and subsequent harm to children, as the rate of spousal abuse is 16 per cent for Canadians in low-income households compared to four per cent in households with incomes of $75,000 or more.

Recognizing the need for “upstream” solutions, the CFPC called on the federal government to implement a national anti-poverty program.

Asking the right questions

Healthcare providers routinely screen patients and intervene for poor diet, lack of exercise, substance abuse and high-risk sexual behaviour. While it is clear that poverty is an equally important risk factor requiring screening and intervention, few health organizations and providers routinely collect socio-demographic information and fewer still have that data in individual patient files.

There are a number of reasons for this. When it comes to collecting socio-demographic data, there is not yet a consensus on what questions to ask, how these questions should be worded and how to best survey patients. Doctors are also concerned that patients may misunderstand the purpose for collecting this information and that this could disrupt the doctor-patient relationship.

However, a Toronto pilot study of about 400 patients found that asking questions about socio-demographic characteristics using a tablet was both feasible and acceptable to patients. Patients were willing to answer questions about sensitive subjects including: sexual orientation, gender, housing, religion, race or ethnicity. The highest rate of no response, however, was for questions about income. The study nonetheless suggests that directly linking detailed socio-demographic data to electronic medical records could be used to identify inequalities in real time, develop tailored interventions and more easily evaluate the impact of these interventions on health outcomes.

The Institute of Medicine recommends that doctors collect a mix of core social and behavioural measures and include them in all patient electronic health records. In addition to four measures that are already being collected (race/ethnicity, tobacco use, alcohol use and residential address), it recommends eight more measures. One of these is “financial resource strain.”

In other words, instead of asking patients to reveal their income, the first step to recognizing and treating poverty could be as simple as a health provider asking each patient – Do you ever have difficulty making ends meet at the end of the month? 

Building on this, the Centre for Effective Practice has updated and enhanced an original ‘poverty tool’ developed by Dr. Gary Bloch, with support from the Ontario College of Family Physicians.  It outlines a plan for primary care providers to screen for poverty, consider the risks and intervene on behalf of their patients.

How health providers are learning to screen their patients for poverty, consider the risks and intervene

The Ontario College of Family Physicians has taken a leadership role by developing and offering an award winning workshop that teaches healthcare providers about the social determinants of health and how they can respond by following the 3-step process outlined by Dr. Bloch and team in their ‘poverty tool’, which calls for screening for poverty, considering the risk for associated health problems and providing education and resources.

According to the ‘poverty tool,’ the first step is for a health provider to ask the question above, about difficulty making ends meet. A positive response would alert the provider to a higher likelihood of certain health problems where poverty is a known risk factor. These include diabetes, cancer, cardiovascular disease and mental illness.

The second step is to verify if the patient belongs to any other high risk groups – e.g., new immigrants, women, Aboriginal peoples and the LGBTQ community. Given an elevated risk level, the provider might then consider medical tests to screen for likely health problems. For example, if an otherwise healthy patient without risk factors for diabetes lives in poverty, a physician could consider ordering a screening test for diabetes. Similarly, if an otherwise low-risk patient presents with chest pain and is also found to live in poverty, this could trigger a more aggressive investigation than might otherwise be ordered.

The third and final step recommended is for the health provider or another health team member to intervene by educating and connecting patients and families to benefits, resources and social services. This could be as simple as asking the patient if they have filed their annual tax return and, if they have not, referring them to a local tax clinic.

In Canada, tax filing is the primary delivery channel for a range of income-boosting benefits that, when accessed, can substantially alleviate financial stress. For example, tax filing can unlock up to $8,000 per year in additional income for a low-income single parent, and at least $1,200 per month for a senior living in poverty.  This is why there is a movement afoot amongst health practitioners across the country to encourage patients to file their taxes and seek the social and economic benefits to which they are entitled.

As knowledge of recognizing and treating social determinants of health emerges, health practitioners are moving forward on finding ways to address the issues.  By collecting sociodemographic data and applying this information to intervene early and connect patients with resources, health practitioners in Canada are spearheading the treatment of the social determinants of health.


Experts available for interview

Gary Bloch, MD, BA (Hons)
University of Toronto
Poverty and Health, Health of the Homeless
416-864-3011 (clinic) |

Noralou Roos, CM, PhD
University of Manitoba
Poverty and Well Being
204-789-3319 |

Further reading:

Poverty: A Clinical Tool for Primary Care Providers from the Centre for Effective Practice
Recommendations for a Provincial Poverty Reduction Strategy from Upstream
Resources for Health Care Providers from Health Care Providers Against Poverty
A New Way to Talk About the Social Determinants of Health from the Robert Wood Johnson Foundation 

Related Backgrounders:

Backgrounder: The impact of poverty on health

Our commentaries on poverty

The Canadian doctor who prescribes income to treat poverty
Child poverty a Canadian problem // La pauvreté infantile, un problème canadien
Why our governments need to address poverty now // Pourquoi nos gouvernements doivent s’attaquer dès maintenant à la pauvreté
Elimination of poverty requires more than a growing economy — it requires a dedicated plan
Poverty costs Canada billions of dollars every year
This doctor treats poverty like a disease
Another kind of poverty // Une autre sorte de pauvreté
Poverty linked to multiple health problems in new mothers // Étude sur les liens entre pauvreté et problèmes de santé multiples chez les nouvelles mères
Another kind of poverty // Une autre sorte de pauvreté
Poverty linked to multiple health problems in new mothers // Étude sur les liens entre pauvreté et problèmes de santé multiples chez les nouvelles mères
How doctors can tackle the poverty of their patients without leaving the doctor’s office How an inadequate minimum wage is linked to poorer health outcomes — for everyone // Un salaire minimum insuffisant conduit à de piètres résultats en matière de santé : un constat universel Why a doctor prescribes tax returns // Un médecin prescrit des déclarations de revenus Social assistance reform can lead to better health for all // La réforme de l’aide sociale peut améliorer la santé de tous

Our videos on poverty

The latest public health crisis? Canadian kids going hungry, with Dr. Elizabeth Lee Ford Jones (5 min)

Why Canadian doctors should be on the front lines of the anti-poverty struggle

Ending Homelessness in Canada is Possible

Our podcasts on poverty

Why Canadian doctors should be on the front lines of the anti-poverty struggle: interview with Dr. Paul Goering, Dr. Ryan Meili, Dr. John Millar and Dr. Gary Bloch

Implementing a basic income in Canada to improve health and reduce poverty: interview with Dr. Danielle Martin and Evelyn Forget

For more information, see also:

Get Your Benefits | Demandez Vos Prestations or visit


This work is licensed under a Creative Commons Attribution 4.0 International License.