Category Archives: Social Determinants of Health

The factors that influence and impact health including social/cultural structures.

Trauma Informed Care

Reading Assignment

Matchinger, E, et al. From Treatment to Healing: Inquiry and Response to Recent and Past Trauma in Adult Health Care.  Women’s Health Issues, 29 (2)  2019

https://www.whijournal.com/article/S1049-3867(18)30550-4/fulltext

Context: This brief article by Matchinger et al describes a trauma-informed approach to inquiring about and responding to patients’ recent and past trauma.  It also provides an overview of the other principles of trauma-informed care.

GoalIdentify components of trauma-informed care and how they apply to inquiring and responding to patients’ previous traumatic experiences within the clinical encounter.  Compare and contrast universal screening, targeted screening, universal education, and universal trauma precautions.

Reflect: How have you seen inquiries about and responses to patients’ experiences of trauma approached in your clinical settings?  What has worked well?  What pitfalls have you seen?  Have you ever been screened for current or past trauma within a clinical encounter?  How have your personal experiences affected the way you approach these encounters with your own patients?

Online Module

Complete Aquifer Trauma-Informed Care: Module 06: Trauma-Informed Care: Practice Patient-Centered Communication and Care

https://owhtic-re.meduapp.com/document_sets/7778

Instructions: Access or set up an Aquifer account using your uw.edu email address.  Complete cases 1-4 of Module 06 of Trauma-Informed Care Course.  At the completion of each case, download the case summary PDF, which will summarize the key points of the case and provide you a document to upload as completion of the assignment in Canvas.  Credit for completion will be given when all 4 documents have been uploaded.

Context: Experiences of trauma can affect how patients engage with healthcare providers and how patients are affected by the healthcare encounter. These cases explore concepts of traumatic stress, universal trauma precautions, and other trauma-informed care principles.

Goal: Apply principles of trauma-informed care to the clinical encounter through exploring these four online cases.

Further learning: The entire Aquifer Trauma-Informed Care course is free to students, and contains excellent, clinically relevant information and skills.

Optional reading:

  • This AAFP article is a nice overview of trauma-informed care principles, particularly universal trauma-informed precautions for the physical exam. Article: American Family Physician Curbside Consultation: Providing Trauma-Informed Care.  Ravi A and Little V.  Am Fam Physician 2017 May 15;95(10):655-657 
  • Book: The Body Keeps The Score, Bessel Van Der Kolk MD.  The Body Keeps the Score” is a seminal work by one of the preeminent pioneers in trauma research and treatment. This essential book unites the evolving neuroscience of trauma research with an emergent wave of body-oriented therapies and traditional mind/body practices.”  
  •  Website and TED talk: The Trauma Stewardship Institute, Laara van Dernoot Lipsky. Offers “practical tools for cultivating the deep self-knowledge and systemic insights that are at the core of trauma stewardship.” Addresses self-care for those who care for others experiencing trauma.   Her 20 min TED talk “Beyond The Cliff” is a good introduction.
  • Article: “Violence Is a Public Health Problem”, American Public Health Association Policy Statement Nov 2018 . This 2018 policy statement looks at the rationale for viewing violence as a public health problem. Risk factors for and differential impacts of violence are reviewed. Successful public-health based intervention programs are discussed, and recommendations for physician practice, collaboration and advocacy are made. 
  • Book Chapter: Medical Management of Vulnerable and Underserved Patients: Principles, Practice and Populations, 2e.  Talmage and Wheeler.  “Chap 36: Trauma and Trauma-Informed Care”, Kimberg.
  • Database of Articles: Reducing Firearm Related Injuries and Deaths In the US: Annals of Internal Medicine database:
  • Website: King County Violence Prevention Resources:  Hosted by King County Public Health, this website has excellent general information on prevention of and resources for domestic violence, gun violence, trafficking and suicide.  Most resources are general or national, although some are King County specific. 

Resources:

  1. PEARR tool”

Dignity Health tool outlining trauma-informed approach to identifying and responding to survivors of interpersonal trauma.   https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool

  1. Excellent Safety Planning worksheets in multiple languages.

Some of the worksheets include California specific resources, but all include general resources as well.    https://www.leapsf.org/html/safety_plan.shtml

  1. Futures without Violence training videos on implementing universal education using wallet cards  https://www.futureswithoutviolence.org/health-training-vignettes/  and downloads (free) for wallet cards for many different populations https://secure3.convio.net/fvpf/site/Ecommerce/15587835?FOLDER=0&store_id=1241 (Note, in order to download, “add to cart” the pdfs you want, then “checkout” and you will be able to download for free)
  2. MyPlanApp: web or phone based app for patients to assess the safety of their relationship make plans to become safer, and to access resources:  https://www.myplanapp.org/home 
  3. State-by-State reporting requirements for violence towards adults  https://drive.google.com/open?id=1GGGhtc93exi1KuBS42A0acMef5PlUVAN
  4. Gun safe storage “Lock It Up” resources for physicians

https://www.kingcounty.gov/depts/health/violence-injury-prevention/violence-prevention/gun-violence/LOCK-IT-UP/providers.aspx 

7. National hotlines

  • National Domestic Violence Hotline
  • https://www.thehotline.org/ 1800-799-(SAFE) 7233 has online chat
  • National Human Trafficking Hotline
  • 1 (888) 373-7888 SMS: 233733 (Text “HELP” or “INFO”)
  • 200 languages available
  • Website: org
  • National Sexual Assault Hotlineof the Rape Abuse and Incest National Network
  • Call 1-800-656-4673
  • rainn.orgonline chat

Gender and Health

In this session, we will consider how the relationship between gender and health by examining the historical and present-day influences of sexism and cissexism on disparities in health status and care. Gender, like race, is considered a “master status” in US society: one of the first things we notice about someone is their gender and gender is central to our perceptions of self and our attribution of characteristics and qualities to others. Medicine is not immune to these social influences and in many ways, has perpetuated inequities based on gender. To gain an understanding of the relationship between gender and health, please complete the following before class. It is recommended that you read/watch and take notes as you complete the following three activities.

(1) WATCH: Toxic Masculinity In Boys Is Fueling An Epidemic Of Loneliness (6 min 44 sec)

  • Content Warning: homophobic language is used in this video as a descriptive
  • Goal: Introduce students to the concept of “Toxic Masculinity” and how it affects men’s health

As you watch the video, CONSIDER…

  1. How might this impact diagnosis and treatment of depression or other mental illness in adults and older adolescents in the primary care setting?
  2. Think about what you have learned in other EHM talks, and in your physiology courses.  How might this also impact the development of other illnesses such as cardiovascular disease?
  3. Suggested: Consider the research on social isolation among baby boomers. As adolescent and young men age, what might this mean for health status and care throughout the life course?

(2) READ: The XX & XY Lie: Our Social Construction of a Sex and Gender Binary (15 min)

  • Goal: Introduce students to the sex and gender binary, the concept of intersex, and definitions of trans/non-binary identities

As you read the article, CONSIDER…

  1. What is your gender identity? How do you know this about yourself? What does this identity mean to you?
  2. Imagine not being able to see your anatomy or chromosomal makeup. Pause and reflect on how this does and/or does not impact your identity?

(3) READ: I Was Pregnant and in Crisis. All the Doctors and Nurses Saw Was an Incompetent Black Woman (5 minutes)

  • Goal: Introduce students to biases experienced by women in clinical settings and allude to the idea of intersectionality (racism and sexism; “misogynoir”)

As you read the article, CONSIDER…

  1. Intersectionality is defined by sociologist and legal scholar Kimberlé Crenshaw as, “the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.” Recalling your sessions on race, how is intersectionality at play in this essay?

Part 2: Introduction to Social Determinants of Health

In this session, we will continue learning about the social determinants of health with a focus on social class and neighborhood effects. Students were introduced to social class/classism as a fundamental cause of health inequity in Week 1. This week, we expand on the SES-health relationship by describing what it is about social class that effects health both in relative and absolute terms. We also cover key aspects of environments and theories of how environmental conditions affect health. We close by offering anecdotes from faculty and community members on risk factors, protective factors, resilience, and prevention.

Optional activity:

Intimate Partner Violence

Recognize structural factors that contribute to IPV and IPV disparities, using this example of IPV among Indigenous women. 

There will be an in-class discussion of this reading.  Amnesty International “Maze of Injustice” Chapters 1, 2 and 8 (pp 1-18, 75-82)

Here is a brief (2min) frame of IPV and the importance to health & healthcare 

IPV introductory video:

 

Optional reference for students to have as they travel throughout WWAMI, to understand their responsibilities/requirements if they encounter a disclosure: 

Information on rules/requirements for mandatory reporting by state

Optional reference for students to have as they travel throughout WWAMI, to direct patients to appropriate resources ;

Information on state-specific DV/IPV/assault resources: state by state numbers and resources 2018

Optional printable reference for students who wish to use/give out the cards and/or lose the hard copy they were given:

“Is Your Relationship Affecting Your Health” safety card

Optional reading for students who wish to learn more about dating violence among teens/tweens:

Fact sheet on dating violence among adolescents

Intersectionality and Structural Competency

These three readings explore the complexities of identity and power in the clinical setting from the patient and physician perspectives.

  1. Manning, Kimberly D. “The nod.” JAMA 312.2 (2014): 133-134.
  2. Gridley, Samantha. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Third Place Gauze and Guns.” Academic Medicine 90.10 (2015): 1356-1357.
  3. Lynch, Katrina. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Second Place The Doctor Will See You Now.” Academic Medicine 90.11 (2015): 1530-1531.

Optional readings for students who want to explore more:

Introduction to Social Determinants of Health / What is Health?

Read What is Health by Fiona Godlee (2011), BMJ. The goal for this activity is to introduce students to two definitions of health. Students should take notes and reflect on the reading. Students can also research definitions of health.

Additional Optional resources – Review websites

Community Visit

Complete the readings

Watch: Entering and Exiting Communities

  • Whether you’re working with a partner, conducting a site visit, doing research, or getting to know folks in a community, it helps to think through the before, during, and after to create a comfortable, safe, and reciprocal experience

READ: Collins, Janet, and Jeffrey P. Koplan. “Health impact assessment: a step toward health in all policies.” Jama 302.3 (2009): 315-317.

  • Instructions: Review social and structural determinants of health and how they apply to communities and health outcomes.

Review Community Visit Materials on Canvas

Supplemental readings and resources (not required)

The Medical Safety Net with Health Policy

1. READ: The “Executive Summary” for Community Health Centers: Recent Growth and the Role of the ACA

  • NOTE: the longer “Issue Brief” contains additional details but is NOT required reading
  • GOAL: Provide additional data regarding community health centers, populations served, and funding received.
  • INSTRUCTIONS: Read the following summary for basic introductory information regarding community health centers. Pay particular attention to the mechanisms for funding and access.

 

Optional Video

 

Optional additional references

Adverse childhood experiences and trauma informed care

Activities:

  1. Watch Nadine Burke Harris’s TED talk that introduces key concepts about Adverse Childhood Experiences and how they impact health.
    • Goal: Define the scope and frequency of adverse childhood experiences (ACE) and toxic stress, the connection to illness across the lifespan, and opportunities for clinician intervention
    • Context and Instructions: Dr. Nadine Burke Harris explains how incorporating an understanding of the frequency and effects of adverse childhood experiences (ACES) can impact medical practice.

2. Then READ EITHER:

OR

Optional readings:

  1. NYT article on WA state resilient community success story
    • Goal: compare and contrast effective community interventions to promote resilience in our region
  1. Original ACEs study: Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;14(4):245–258. doi:10.1016/s0749-3797(98)00017-8. 
    • Goal: For students who want to read the Kaiser study that introduced the idea of ACES and the impact on health.  A caveat that some language in this original paper (“family dysfunction”) would not be used in the trauma informed care environment that this work ultimately produced.

Additional Resources:

Social Determinants of Health in US Populations

Required:

  • Link and Phelan. 1995. “Social Conditions as Fundamental Causes of Disease” Journal of Health and Social Behavior pp.80-94
    • In this foundational article, social epidemiologists Bruce Link and Jo Phelan argue three main points:
      1.  social conditions (e.g., SES, inequality, racism, segregation) have a causal effect on health and well-being,
      2. to understand patterns of disease prevalence and incidence, we need to contextualize risk factors and understand what conditions put people “at risks of risks” (i.e., people in poor neighborhoods have an elevated risk of exposure to crime which increases the risk of stress accumulation), and
      3. researchers need to acknowledge that social conditions are not just distal causes of disease, they are FUNDAMENTAL causes, meaning that the relationship between the social conditions (e.g., SES) and health is robust and will remain present even as the risk factors for disease and the leading causes of disease/death change.
    • This is because high SES individuals are afforded flexible resources that they can use to avoid risks and minimize the consequences of disease.
  • Frieda, Misha. 2016. “For Native Americans, Health Care Is a Long, Hard Road Away”.
    • NPR : https://www.npr.org/2016/04/13/473264076/for-native-americans-health-care-is-a-long-hard-road-away
  • Social Determinants of Health PPT