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

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 the 4 cases 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.

Pre-class Required Reflection (bring written answers and a description of case to the small group discussionno submission is required) :

90% of adults have been exposed to trauma in their lives.  A history of trauma can affect how a patient engages with and/or experiences health and healthcare.

Please consider a case you have been involved in where you know or suspect that the patient may have been affected by past trauma, and consider:

  1. How did/may have trauma affect this patient’s health and wellbeing? Consider physical and emotional health, socioeconomic status including employment, relationships, outlook, health “behaviors”, etc.
  2. How did trauma affect this patient’s engagement in the healthcare system?  Consider access to care, followup, participation in care, communication style, behavior in the clinic, etc.
  3. How did trauma affect this patient’s experience of the healthcare encounter? Consider signs or symptoms of trauma that were apparent.
  4. What components of traumainformed care were implemented in the care of this patient? What worked well?  What didn’t work well?
  5. What components of trauma-informed care would have helped this patient or encounter?  What would have been different?
  6. What barriers did you or the team experience that interfered with implementing those aspects of trauma-informed care?  What additional skills or support do you feel you need in order to provide excellent traumainformed care?
  7. If relevant, how has your own personal experience of trauma, or personal experiences of team members, affected the way you engage with patients experiencing the effects of trauma? (Personal experiences will not be shared in class.)  
  8. How can implementation of trauma-informed care provide a safer, more responsive environment for providers as well as patients?

Optional reading:

  • 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:

Violence

1) Pre-class reading

  • Raja, S.  Trauma Informed Care In Medicine: Current Knowledge and Future Research Directions.  Family and Community Health 38(3):216-26. July 2015
    • Context: Exposure to trauma is nearly universal, and yet differential incidence and impact of trauma are a large source of health disparities.  Trauma informed care uses an understanding of the prevalence and impact of trauma to provide care that is responsive, safe and empowering for providers and survivors.  Through universal and trauma specific practices, this approach serves to reduce health disparities.
    • Goal: Describe the components of a trauma informed clinical practice.
    • Reflect: Which of these practices have you seen implemented in your primary care practicum?  Have you participated in patient encounters that, in retrospect, may have benefitted from this approach?  How do you think implementation of trauma informed practices benefits providers?

2) Pre-class Module

  • Aquifer Trauma-Informed Care Course, Module 1: Understand the Nature and Prevalence of Trauma: Understand how simple and complex trauma may present in a diverse patient population, Cases 1-4  https://owhtic-re.meduapp.com
    • Instructions: Students will create an account using their UW email address.  After completing each case, click on “case summary download.”  This will provide you with a pdf of the instructional content.  Keep these completed pdfs for your own use and reference.
    • Context: These four clinical cases demonstrate a range of ways in which trauma may affect health and the clinical encounter.  Through the cases the concepts of trauma, the epidemiology of IPV and child abuse, and screening are reviewed.  Trauma informed care is introduced including universal trauma precautions and trauma specific interventions.  
    • Goal: Appreciate the prevalence and impact of trauma on patients’ health and interaction with the healthcare system.  Acquire skills for applying trauma informed care principles to the clinical encounter.
    • Reflect: Which patients from PCP do these cases remind you of?  What is one patient you might approach differently after working through these cases?
    • Further reading: interested students may complete other modules from this Aquifer course.

Optional Reading

  • Amnesty International Maze of Injustice: Sexual Violence Against Indigenous Women in the USA.(chapters 1,2,4)
    • 4 in 5 American Indian and Alaska Native women have experienced violence.  1 in 2 have experienced sexual violence.  Alaska Native women have 10 x risk of IPV compared to the general US population.  On some reservations indigenous women are murdered at more than 10x national average, many by non-indigenous men.  This report explores the complex etiologies and impact of this violence.
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively?
  • 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.
    • This statement by the American Public Health Association reviews the epidemiology of violence, the differential impact on traditionally marginalized communities, the similarities to other types of epidemics and chronic health problems, the evidence available for physicians’ role in primary and secondary prevention and a call for further action in approaching violence through a public health lens.
    • Goal: Describe the scope of interpersonal violence and its impact on health.     Recognize structural factors that contribute to disparities in frequency and impact of violence in different populations.  Describe the potential role of physicians in responding to and preventing violence.  Understand the role of interprofessional and community partnerships in preventing and responding to violence.
    • Reflect:  What factors contribute to the resistance of the political and medical community to viewing violence through a public health lens?  What is one idea from this reading that you hope to take with you into your clinical work as a medical student?
  • Seattle: 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.

Optional Videos

  • Futures without Violence video resource library: universal screening, education and referral
    • https://www.futureswithoutviolence.org/health-training-vignettes/
  • Violence Against American Indian and Alaska Native Women and Men, National Indigenous Women’s Resource Center.
    • http://www.niwrc.org/resource-topic/videos
    • This video describes the findings of a National Institute of Justice (NIJ) supported study on the prevalence of violence against American Indian and Alaska Native women and men, and briefly examines the impact of violence int that community.
    • Interested students can read about the some of the complex factors involved in the optional reading below, “Maze of Injustice, an Amnesty International report.”
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively

Additional Resources

  1. PEARR tool: Dignity Health Tool universal education and screening approach https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool
  2. Excellent Education and 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
  3. Futures without Violence training videos on implementing universal education using wallet cards –  https://www.futureswithoutviolence.org/health-training-vignettes/
  4. Futures without violence wallet card pdfs (link to wordpress IPV site resource)“Is Your Relationship Affecting Your Health” safety card
  5. Link to MyPlanApp website https://www.myplanapp.org/home
  6. State-by-State reporting requirements for violence towards adults Information on rules/requirements for mandatory reporting by state
  7. Hotlines: If it is safe for you to do so, consider programming these hotlines into your own phone.

Structural Competency Cases

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?

These three articles give a basic introduction to social determinants of health.

This article summarizes social determinants of health (SDOH) and steps on how to get involved  AMA Addressing Social Determinants of Health

The CDC Ten Essential Public Health Services show examples of public health services available and how they address SDOH.

The AAFP SDOH Guide to Social Needs Screening Tool and Resources discusses practical screening of patients to assess SDOH

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 biology of stress

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.

Dr. Nadine Burke Harris explains how incorporating an understanding of the frequency and effects of adverse childhood experiences (ACES) can impact medical practice.

Reflect: How can a physician’s understanding of ACEs impact their clinical practice and outcomes?

 

2. READ: 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: Define and provide examples of Adverse Childhood Experiences.  Review the relationship between various forms of trauma/violence/ACEs and health status or health care outcomes throughout the life course.

This massive prospective study is the original research that described the prevalence of certain “adverse childhood events” in a managed care population and provided evidence for the strong correlation with morbidity and mortality later in life. Please note: 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.

REFLECT: How does this information change the way you think about chronic diseases such as diabetes?  In what way does the study population (white, employed, insured, middle class) affect your reading of this article?

OPTIONAL PRE-CLASS READING

1. READ (OPTIONAL): NYT article on WA state resilient community success story

GOAL: Apply concepts of resilience to responding to and preventing ACEs.

WA state was a leader in community level interventions to reduce ACEs and mitigate their outcomes.  Ready about some of these projects and outcomes.

REFLECT: How might physicians be involved in such projects?

2. READ (OPTIONAL): The Lifelong Effects of Early Childhood Adversity and Toxic Stress, Shonkoff et al, Pediatrics Jan 2012, 129 (1) , focusing on pages e235-238, and figure 2 on page e23

GOAL: Describe the proposed pathophysiologic mechanisms of toxic stress’ effect on health across the lifespan and the mediating effect of known resilience factors.

In this Pediatrics article, Shonkoff et al, delve into the science of toxic stress on the developing brain and the moderating effect of resilience factors.  Based on this science, they propose an “ecobiodevelopmental framework” from which the clinicians of the future should approach primary care.

REFLECT: What potential roles can clinicians take in responding to and preventing toxic stress?

3. READ (OPTIONAL): American Family Physician Curbside Consultation: Providing Trauma-Informed Care, Ravi A, Little, V.  May 2017https://www.aafp.org/afp/2017/0515/p655.html

GOAL: With deepened understanding of the prevalence and effects of childhood trauma, describe universal concrete actions that can be taken during the interview and exam to maximize emotional safety for patients.

This article was also provided in Immersion; it is provided here for clinical correlation.  Ravi and Little discuss trauma-informed care as a “…universal precaution to optimally address patient’s health care needs while decreasing the risk of traumatization.”

REFLECT: Have you seen these precautions taken in your clinical settings?

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