Eliminating Health Care Disparities
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Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: https://www.tandfonline.com/loi/wshc20
Making the Invisible Visible: Are Health Social Workers Addressing the Social Determinants of Health?
Shelley L. Craig PhD LCSW , Raluca Bejan MSW & Barbara Muskat PhD RSW
To cite this article: Shelley L. Craig PhD LCSW , Raluca Bejan MSW & Barbara Muskat PhD RSW (2013) Making the Invisible Visible: Are Health Social Workers Addressing the Social Determinants of Health?, Social Work in Health Care, 52:4, 311-331, DOI: 10.1080/00981389.2013.764379
To link to this article: https://doi.org/10.1080/00981389.2013.764379
Published online: 14 Apr 2013.
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Social Work in Health Care, 52:311–331, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2013.764379
Making the Invisible Visible: Are Health Social Workers Addressing the Social
Determinants of Health?
SHELLEY L. CRAIG, PhD, LCSW and RALUCA BEJAN, MSW Factor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, Ontario, Canada
BARBARA MUSKAT, PhD, RSW The Hospital for Sick Children, Toronto, Ontario, Canada
This study explored the ways in which health social workers (HSW) address the social determinants of health (SDH) within their social work practice. Social workers ( n = 54) employed at major hospitals across Toronto had many years of practice in health care ( M = 11 years; SD = 10.32) and indicated that SDH were a top priority in their daily work; with 98% intentionally intervening with at least one and 91% attending to three or more. Health care services were most often addressed (92%), followed by housing (72%), disability (79%), income (72%), and employment security (70%). Few HSW were tackling racism, Aboriginal status, gender, or social exclusion in their daily practice.
KEYWORDS hospital social work, social work, social determi- nants of health, medical social work, health and social care
Received June 19, 2012; accepted January 1, 2013. We are grateful to the inspired social workers from Toronto Western Hospital, The
Hospital for Sick Children, St. Michaels Hospital, Centre for Addiction and Mental Health, University Health Network, and the Ontario Association of Social Workers for sharing their time and insight with us.
Address correspondence to Shelley L. Craig, PhD, LCSW, Assistant Professor, University of Toronto, Factor-Inwentash Faculty of Social Work, 246 Bloor Street W., Toronto, Ontario, M5S 1A1, Canada. E-mail: shelley.craig@utoronto.ca
311
312 S. L. Craig et al.
INTRODUCTION
The social determinants of health (SDH) have been defined as the “causes of the causes” (Marmot, 2007, p. 1153), the environmental, social, politi- cal, cultural, and economic factors (Baum, Begin, Houweling, & Taylor, 2009), adverse social conditions (Fisher & Baum, 2010), or social inequalities (Daniels, Kennedy, & Kawachi, 1999) that influence individuals’ health status (Kosny, 1999). These SDH mirror fundamental social hierarchical structures (Marmot, 2007), and affect the degree of health and illness experienced by members of various socioeconomic groups (Halfon, Larson, & Russ, 2010; Raphael et al., 2006). Social determinants, rather than a genetic predispo- sition or personal health choices (Marmot & Wilkinson, 2003), have been found to be the primary correlates of health (Commission on the Social Determinants of Health [CDSH], 2008). Although all societies are stratified along social axis of differentiation, such as ethnicity, race, gender or occupa- tion, health disparities mainly result from the unequal distribution of power, privilege, and resources among various groups (Marmot, 2007). A signifi- cant body of multidisciplinary and international literature has determined that many health and mental health issues are rooted in preventable social inequalities such as poverty, inadequate housing, food insecurity, and social exclusion (Berkman & Kawachi, 2000; Raphael, 2008a; Rosenberg, 2008), themes familiar to social workers.
The social causes of ill health have been recognized since the 1980s, fol- lowing the public release of the Black Report and the Health Divide (Raphael, 2004). Starting points for future research studies, these reports explored the relation between social class and health. The Black Report was the first to link material deprivation with health differences, as particularly defined by mortality and morbidity rates (Fein, 1995; Raphael, 2004; Smith, Bartley, & Blane, 1990). The materialist-structuralist perspective approach highlighted in the report (Marmot, 2001; Marmot, Kogevinas, & Elston, 1987), identified societal structures’ impact on health (Fein, 1995; Feinstein, 1993; Smith et al., 1990) and proposed long-term policy recommendations to better address health inequalities (Marmot, 2001). Later research studies constructed fur- ther knowledge regarding the social causes of health disparities (Fein, 1995; Phillimore, Beattie, & Townsend, 1994), mainly framed in terms of mate- rial resources (Feinstein, 1993), as distal causes of disease (Link & Phelan, 1995). By 1995, the link between socioeconomic status (SES) and health out- comes has been well established (Dahl, 1994; Feinstein, 1993). Ten years after the Black Report, the awareness of health inequalities (Whitehead, Evandrou, Haglund, & Diderichsen, 1997) and mortality differences across class divisions has increased (Smith et al., 1990).
The SDH paradigm is grounded in values of social justice, human rights, and equality (Bywaters, McLeod, & Napier, 2010). It goes well beyond the bio-medical and behavioral approaches (Watt, 2007), traditionally ingrained
Applying SDH to Social Work Practice 313
within the public health discourse (Cameron, Mathers, & Parry, 2006) and entails a holistic view of praxis (Nayar, 2007), as a foundational basis of health (Buijs & Olson, 2001). It further defines the social, cultural, and polit- ical contextual circumstances (Hankivsky & Christoffersen, 2008; Heinonen, Metteri, & Leach, 2009; Irwin & Scali, 2007) as proxies for opportunities and resources influencing health outcomes (Frohlich, Ross, & Richmond, 2006) and suggests that physical as well as mental health and well being, are con- ditions embedded in social experiences (Heinonen et al., 2009). Thus, the SDH framework provides a mechanism to understand multilevel policy and practice interventions designed to improve health (Raphael, 2008a).
Health Social Work and the Social Determinants of Health
A SDH perspective fits well with social work’s fundamental values of social justice and also with the ecological model emphasizing a broad context of individual functioning (Kasperski, Power, & VanderBent, 2005). The International Federation of Social Work (IFSW) has stated that health is both a human rights and social justice issue (Karban, 2010), yet most of the exis- tent literature is focused on policy directives and fails to adequately address the relevance for social workers in direct practice. HSWs bring a holistic perspective to health care, by incorporating a full range of psychological, social, and emotional factors (Rachman, 1995) and by focusing on the social effects of illness rather than on the illness in itself (Volland, 1996). They are educated to consider the social context more so than any other profession (Lymbery, 2006), with a particular focus on the on the ecological perspective, which suggests that individuals function within larger systems (Claiborne & Vandenburgh, 2001), and a biopsychosocial approach, which emphasizes the person in the environment (Berkman, 1996; Cowles & Lefcowitz, 1992). Therefore, HSWs are considered to be closer to service users (Herod & Lymbery, 2008), provide a continuum of care coordination and support for their clients (Keefe, Geron, & Enguidanos, 2009), and identify many more patient psychosocial problems than professionals from other disci- plines (Mizrahi & Abramson, 2000). Their presence in health care settings has been associated with fewer emergency visits, less hospital admissions, and reduced lengths of patient stay (Keefe et al., 2009). It has been suggested that other health care professionals would not be able to adequately address these issues, if HSWs were to be withdrawn from medical multidisciplinary teams (Herod & Lymbery, 2008). Although scholarly work has emphasized the need for research related to SDH for many years (Baum et al., 2009; Raphael, 2008) and the need for HSWs to concentrate on social inequalities (Rosenberg, 2008), there has been a lack of practice-based research about how HSWs are addressing these issues. This pilot study aims to understand the relevance of this conceptual framework to social work by exploring those SDH currently attended to by HSWs within their daily work.
314 S. L. Craig et al.
The Social Determinants of Health
SDH definitions have been inconsistently reported in the literature (Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006), as they dually refer to the social factors determining health, but also to the processes and mechanisms contributing to their unequal distribution (Graham, 2004). Without a SDH universal typology in place, scholarly work has inconsis- tently been reporting on a variety of health influences (Buijs & Olson, 2001; Courtwright, 2008) including: SES (income, education, employment, working conditions), personal health practices, coping skills, healthy child develop- ment, physical environments, social support networks (Buijs & Olson, 2001), Aboriginal status, geographical locations (Frohlich et al., 2006), chronic stres- sors, racism, or the medicalized stigmatization of disease (Courtwright, 2008). Using Public Health Agency of Canada’s categorization of SDH (PHAC, 2004), this article reports on those SDH most frequently cited within the litera- ture and loosely organizes them into several domains of social stratification: (1) SES: income and its distribution; unemployment and employment secu- rity; education, employment, and working conditions; early life; (2) social supports: housing, social safety net, food security; (3) diversity and equity: gender, racism, Aboriginal status, disability status, social exclusion; and (4) health care services. Although this article is not intended to provide an exhaustive review of the SDH (see Rosenberg, 2008 for a comprehensive review), each of these categories is briefly described below to contextualize the pilot study.
SOCIOECONOMIC STATUS
Although social SES, as defined by social SES empirical measures, such as occupation, income and education (Fein, 1995), has often been at the center of analyses on health disparities (Marmot et al., 1987), the SDH approach also includes the hierarchized dynamics of social positions (Bartley, Blane, & Smith, 1998). A social gradient (Marmot, 2003), as a rel- ative position in social hierarchy (Marmot, 2001; Marmot et al., 1987) was deemed to affect health (Marmot, 2003) and to translate into differential health outcomes (Marmot, 2001, 2003; Marmot et al., 1991). Social gradi- ent’s effect on health (Daniels et al., 1999; MacDonald, 2006) has been explained via a cultural behavioral model (Irwin & Scali, 2007) that iden- tifies chronic stress (Bywaters et al., 2010), links stressors to their contexts (Schulz et al., 2002), and associates the differential distribution of health behaviors and living standards (Graham, 2004) with hierarchical social posi- tions (Frohlich et al., 2006; Irwin & Scali, 2007). Although intersectional SDH perspectives (Hankivsky & Christoffersen, 2008) do not presume the importance of ethnicity, gender, and other singular categorical positionali- ties (Graham, 2004; Hankivsky & Christoffersen, 2008), health disparities are
Applying SDH to Social Work Practice 315
related to the inequitable distribution of social and cultural capital among economically variant groups (Frohlich et al., 2006). Overall, SES factors are markers for position in society (Marmot, 2003). Those in a lower economic strata are more likely to experience adverse health outcomes (Rahkonen, Laaksonen, Martikainen, Roos, & Lahelma, 2006; Marmot, 2007; Wilson, 2009), higher rates of mortality and morbidity (Auger, Zang, & Daniel, 2009; Isaacs & Schroeder, 2004), and frequent use of health care services (Barnett, Coyle, & Kearns, 2000); yet individuals’ health depends on context specific stressors: physiological, psychological, or behavioral (Fiscella & Williams, 2004; Schulz et al., 2002).
Income inequality at the neighborhood level and socially differentiated material resources have been found to unequally influence the distribution of health outcomes (Irwin & Scali, 2007; Watt, 2007; Whiteside, 2004) and health care (Kilbourne et al., 2006) at the societal, environmental, behavioral, and disease levels (Graham, 2004).
Unemployment and employment insecurity have been associated with poor physical health and well-being (Bambra & Eikemo, 2009; Kalil, Ziol- Guest, Hawkley, & Cacioppo, 2010), chronic disease (Safaei, 2008), psycho- logical distress (D’Souza et al., 2005; Puig-Barrachina, Malmusi, Martenez, & Benach, 2011; Virtanen, Vahtera, Kivimaki, Pentti, & Ferrie, 2002), poor self- reported health (Bambra & Eikemo, 2009; Burgard, Brand, & House, 2009), higher rates of medical visits (D’Souza et al., 2005), and decreased medical coverage (Kendall, Rose, & Kim, 2009).
Lower educational levels have also been linked to adverse health out- comes in later life (Albert & Davia, 2011; Goldman & Smith, 2002; Stafford, Nazroo, Popay, & Whitehead, 2008), including shorter life expectancies, even after controlling for SES and economic resources (Baker, Leon, Smith Greenaway, Collins, & Movit, 2011). The link between education and health (Marmot, 2003) may be mediated through health behaviors (Daniels et al., 1999), literacy levels (Reading & Wien, 2009), income (Fiscella & Williams, 2004), and labor participation (Fiscella & Williams, 2004).
Poor working conditions (Daniels et al., 1999; Kaikkonen, Rahkonen, Lallukka, & Lahelma, 2009), such as precarious or temporary, employment (Burgard et al., 2009; Kim, Kim, Park, & Kawachi, 2008), occupational sta- tus (Clougherty, Souza, & Cullen, 2010), work-related stress (Holmgren, Dahlin-Ivanoff, Bjorkelund, & Hensing, 2009; Vanroelen, Levecque, Moors, & Louckx, 2010), longer working hours (Artazcoz, Cortes, Escriba-Aguir, Cascant, & Villegas, 2009), high level of work–life conflicts (McNamara, Bohle, & Quinlan, 2011), and a lack of job control (Rahkonen et al., 2006), have been associated with adverse health outcomes (Clougherty et al., 2010), including poor self-rated physical (Holmgren et al., 2009; Kim et al., 2008) and mental health (Artazcoz et al., 2009).
From a life course epidemiological perspective (Kuh, Ben-Shlomo, Lynch, Hallqvist, & Power, 2003), children’s development is dependent on
316 S. L. Craig et al.
their environments (Daniels et al., 1999; Marmot, 2007). The exposure to risk factors during early life (Johnson & Schoeni, 2007) has been found to impact health (McGowan & Szyf, 2010; Melchior, Moffitt, Milne, Poulton, & Caspi, 2007; O’Rand & Hamil-Luker, 2005), throughout all life stages (Marmot, 2007; Reading & Wien, 2009).
SOCIAL SUPPORTS
Social supports such as housing, food security, and a social safety net have been shown to be health predictors. Poor housing, defined as unaffordable (Pollack, Griffin, & Lynch, 2010) or unstable (Kushel, Gupta, Gee, & Haas, 2006) is related to poor self-rated health, higher rates of acute health care use (Kushel et al., 2006), chronic health conditions (Pollack et al., 2010), and non-adherence to health care regimes (Pollack et al., 2010). In turn, improvements in housing conditions have been linked to better self reported levels of physical and mental health, along with lower rates of health services use (Thomson, Petticrew, & Morrison, 2001).
Food insecurity, which generally refers to one’s inability to afford suffi- cient food for an active and healthy life (Seligman, Laraia, & Kushel, 2010), has been associated with high rates of acute health services utilization and low rates of access to care (Kushel et al., 2006), as well as adverse physical (Seligman et al., 2010) and mental health outcomes (Stuff et al., 2004).
Social safety networks, as the universal social protection benefits and programs intended to support health, including welfare and unemployment insurance, various social services or health care (Iatridis, 2000) are associated with better population health (Malmberg-Heimonem, 2010; Marmot et al., 2008).
DIVERSITY AND EQUITY
Social exclusion further entrenches inequalities in health (Gray, 2003) and can include aspects of diversity such as disability, gender, and racial discrim- ination. The association between social marginalization and poor health has been related to levels of chronic stress factors (Fiscella & Williams, 2004). Fair or poor health (Havercamp, Scandlin, & Roth, 2004) has been more commonly reported by those with disabilities and developmental disabili- ties compared to non-disabled adults. Gender differences are also found. For example, adult women are more likely to be hospitalized for depres- sive disorder and men are more likely to report bipolar disorder (Savoie, Morettin, Green, & Kazanjian, 2004). Racial discrimination has also been associated with poor or fair self-rated health, lower physical functioning, and higher rates of cardiovascular disease (Harris et al., 2006; Keefe, 2010),
Applying SDH to Social Work Practice 317
and lifetime illness (Kwate, Valdimarsdottir, Guevarra, & Bovbjerg, 2003). Finally, a number of chronic physical (Larson, Gillies, Howard, & Coffin, 2007) and mental health (Reading & Wien, 2009) conditions are more preva- lent among Aboriginal individuals than the general population (Anand et al., 2001; Reading & Wien, 2009).
HEALTH CARE SERVICES
The health care system has been considered a social determinant in itself, given it mediates access to all other social determinants (Marmot et al., 2008). Availability and access to health services has been found to significantly reduce people’s mortality (Bloom, 2001). A systematic review on the associ- ation between health insurance and health status documented poorer general health and higher mortality rates for medically uninsured U.S. residents, in comparison with those insured (Hadley, 2003). Uninsured individuals have also been found to report many more unmet health needs (Ayanian, Weissman, Schneider, Ginsburg, & Zaslavsky, 2000), use fewer preventive services (Sudano & Baker, 2002), and experience cost barriers in seeing a physician (Ayanian et al., 2000), resulting in increased use of emergency rooms for primary care (CIHI, 2012).
METHODS
Sample
Toronto, the largest city in Canada, was chosen for this study, as it con- tains multiple major hospitals employing many HSWs. A self-report survey collected information from hospital-based social workers about the nature of their daily work. Participants (N = 65) were recruited through contact with social work practice leaders in hospitals who distributed an informa- tional flyer to social workers in seven settings. These included hospitals serving adults, children, patients with medical and mental health issues, and encompassed staff who work with a broad variety of medical conditions. Study participants represented a range of professional and demographic backgrounds. Their average age was 43.07 (SD = 14.02) and ranged from 22 to 65 years. Participants identified as female (87%) or male (13%), and as heterosexual (91%) or sexual minority (9%). Race and ethnicity included Caucasian (75%); Asian (12%); mixed (9%); Aboriginal (2%); African (2%), and the highest level of education indicated as MSW (83%) followed by BSW (13%) and PhD/DSW (2%). Table 1 presents the demographics of the sample.
Participants reported being engaged in many years of social work prac- tice (M = 14 years; SD = 12.7), specifically in health care settings (M = 11 years; SD = 10.32), ranging, on both dimensions, from less than 1 year
318 S. L. Craig et al.
TABLE 1 Summary of Participants’ Demographic Characteristics
Number Percent
Age group (n = 52) 15–24 3 5.8 25–44 27 51.9 45–64 18 34.6 65–74 4 7.7
Gender (n = 54) Female 47 87 Male 7 13
Race/Ethnicity (n = 51) Caucasian/White European 36 70.6 South Asian 6 11.8 Mixed Background 4 7.8 East Asian 3 5.9 Aboriginal 1 2.0 African American 1 2.0
Sexual orientation (n = 54) Heterosexual 50 92.6 Queer 2 3.7 Gay 1 1.9 Other 1 1.9
Education (n = 54) MSW 45 83.3 BSW 7 13.0 PhD/DSW 1 1.9 Other 1 1.9
Years as a social worker (n = 54) Less than 1 year 4 7.4 1–5 years 15 27.8 6–10 years 7 13.0 11–20 years 12 22.2 Over 20 years 16 29.6
Years in health care settings (n = 53) Less than 1 year 6 11.3 1–5 years 18 34.0 6–10 years 8 15.1 11–20 years 10 18.9 Over 20 years 11 20.8
Not every participant answered each question and therefore, the actual number (n) is reported for clarification purposes.
to over 20 years of experience. Their job titles included social worker (66%), professional practice leader (10%), advanced practice clinician (9%), coun- selor (9%), and case manager (6%). Chronic care, rehabilitation, emergency care, outpatient counseling, oncology, and heart units were the participants’ reported workplace settings. In terms of job duties, they conducted assess- ments (61%), advocacy work (42%), counseling (35%), case management (33%), and research (9%).
Applying SDH to Social Work Practice 319
Measures
Participants provided basic demographic information (age, race, gender identity, sexual orientation, educational degree), job details (number of years in social work practice, number of years in a health care setting), job title, job duties and overall job satisfaction, ranging from very dissatisfied to very sat- isfied. Public Health Agency of Canada’s explanation of the SDH (PHAC, 2004) was used to capture the key constructs. The final list was gener- ated in collaboration with two HSWs. The 12-item measure included health care services, housing, income and its distribution, social exclusion, gen- der, unemployment and employment security, aboriginal status, early life, disability status, education, employment and working conditions, and food security. Participants were asked to identify whether or not they addressed each of the SDH through their daily hospital work practice (yes/no). The term addressing was operationalized to include HSWs role specific efforts in reducing the impact of social factors and underlying social processes associ- ated with health disparities on their clients, during the assessment, planning, intervention, or referral stages. Data was collected by a two-person team, one who is a member of a social work faculty and the other who is a social work leader in a hospital. Respondents were instructed to complete the sur- vey anonymously. The study was approved by the research ethics board at the principal investigator’s university. Using SPSS 19.0, quantitative analy- sis of the data, including descriptive statistics, correlations, and Chi-square analyses, was conducted.
RESULTS
Findings indicate that SDH were a priority for the participants, with 98% intervening with at least one and 91% attending to three or more of the SDH. HSWs defined intervention activities as the provision of assistance by directly acquiring services for patients, educating them about resources or advocating with the medical team for consideration of the relevant SDH in their care. On average, HSWs in health care settings have been addressing 7 out of the 14 SDH surveyed. Table 2 illustrates the range and frequencies of social work involvement with SDH in their daily practice. Health care services were reported to receive the greatest attention, (92%), followed by housing (72%), disability status (79%), income and its distribution (72%) and unem- ployment and employment security (70%). A further 60% of medical HSWs were addressing factors related to the social safety net, 57% were attending to those related to employment and working conditions, while others were addressing food security (47%) and education (47%). On the lower end, many participants did not report attending to several SDH, including early life (79%), Aboriginal status (68%), racism (68%) gender (66%), and social
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Applying SDH to Social Work Practice 321
exclusion (53%). To understand whether job factors were associated with particular SDH, chi-square analyses were conducted between the number of years in social work practice, job satisfaction and respectively, each singular and the total number of addressed SDH. For all determinants, no statistically significant differences occurred with respect to participants’ experience or job satisfaction.
As seen in Table 2, chi square analyses were conducted to examine the relationships between those SDH addressed by participants in their daily practice. Statistically significant correlations (p < .1) were observed between income inequality and unemployment and employment insecurity, early life and education, and early life and working conditions. In contrast, signifi- cantly higher percentages were reported within the social supports category. Those participants addressing housing were also more likely to address food security and social safety net factors. However, within the diversity and equity domain, with the exception of disability status, statistically significant associations (p < .1) were observed among all other determinants, including gender, racism, social exclusion, and Aboriginal status.
DISCUSSION
This study provided valuable information about the work of HSWs, partic- ularly regarding: (1) the relationship of employment and social supports constructs to the SDH and (2) the most influential SDH addressed in their daily practice. The lack of significant correlations between SDH and participants’ employment measures indicated that, regardless of their job sat- isfaction or professional experience, social workers are dealing with many SDH frequently and concurrently. Although many SDH are addressed by hos- pital HSWs in their daily practice, efforts solely directed toward disparities related to diversity and equity, such as racism, Aboriginal status, gender, and social exclusion, do not take the majority of their time. Further, participants’ self-reported inability to intervene with each one of these determinants was significantly associated with the lack of action on those within the same domain. For instance, if racism was not addressed, the other equity and diversity issues such as Aboriginal status, gender, and social exclusion were also not likely to be a focus.
There are several explanations for why HSWs report the least amount of attention to diversity and equity related SDH. First, it is plausible that, the very same medical settings per se, had contributed to HSWs choice of attended SDH. Since prior research findings (Craig & Muskatt, 2013) sug- gested that HSWs roles within urban hospitals often resembled the figurative work aspects of firefighter, broker, and glue, it is likely that they are focused on proximal concerns, such as health care utilization, rather than on distal and more complex issues such as racism and gender. These findings might
322 S. L. Craig et al.
also suggest that HSWs are focused on meeting immediate micro-level needs, with less available time to take on added macro issues.
Second, the medical model’s dominance within the health care settings (Baum et al., 2009; Niederdeppe, Bu, Borah, Kindig, & Robert, 2008), which is often criticized for failing to consider the impact of wider environments on individual health outcomes (Raphael, Curry-Stevens, & Bryant, 2008), could potentially impact practitioners’ focus on individual treatments over inter- ventions addressing macro social determinants of health. The perspective that an individual bears sole responsibility for health (Kosny, 1999), which links adverse health outcomes with biomedical markers, erroneous personal choice, and risky behaviors (Raphael et al., 2008). In such cases, health promotion efforts become targeted toward changing such unsafe individual behaviors (Baum et al., 2009) and less attention is ultimately paid to the societal context and its influence on health inequities. It is hard to know if a study’s participants have been attending to the health service utilization as the main determinant of health, simply because they are employed in health care settings or merely because they share the general public belief that “medical care is the primary determinant of health” (Niederdeppe et al., 2008, p. 492). Practitioners’ responses could also be reflective of the overall “pub- lic health gaze” (Raphael, 2008, p. 15), which has not adequately developed concrete social policies to address the numerous forms of marginalization impeding on individuals’ health (Baum et al., 2009; Raphael, 2008) and to shape the quality of SDHs (Raphael, 2006). HSWs’ direct practice occurs in settings shaped by complex political environments and social work funding often requires direct services such as discharge, mental health, or behavioral challenges, hence efforts related to the distal SDH may be further challenging in these environments.
IMPLICATIONS FOR SOCIAL WORK PRACTICE
By increasing the visibility of singular and relational SDH aspects that are attended to by HSWs in their daily work, this study aims to assist them in efforts to better understand and address the socially created inequalities in health (Bywaters et al., 2010), both at the population and individual lev- els (Graham, 2004). At a policy level, medical HSWs could strengthen their advocacy efforts (Bywaters et al., 2010) and augment the public health dis- course focused on health outcomes (Graham, 2004), through the support of employment, fiscal, or housing policies and programs, aimed at reducing dis- parities that impact health (Graham, 2004). Further, this study identifies that the mutually reinforced (Frohlich et al., 2006) and intersecting (Hankivsky & Christoffersen, 2008) SDH, at both, micro and macro levels of practice are important areas for HSW to address.
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At the direct level of practice, HSWs are trained to attend to the diversity of circumstances influencing individuals’ physical and mental health and well-being (Heinonen, Metteri, & Leach, 2009). Therefore, although most health promotion workers tend to address SDH symptoms rather than the determinants in themselves (Whiteside, 2004), HSWs have the potential to go beyond such efforts to better facilitate the development and implemen- tation of interventions addressing the social factors and social processes producing health disparities. HSWs can use the SDH framework to address health disparities outside their institutional sphere (Courtwright, 2008) and promote the SDH paradigm within their vast range of assessment, planning and intervention related activities. At a practice level, this could translate in directly supporting clients’ health by facilitating their access to health knowl- edge and education resources (Frohlich et al., 2006), providing them with tangible SDH information, connecting them with appropriate referral ser- vices, countering disease stigmatization (Courtwright, 2008), intervening in discrimination within health care, addressing biases related to race and lan- guage differences (Nguyen, Ho, & Williams, 2011), promoting social support (Schulz et al., 2002), and developing programs and interventions that could diminish the impact of contextual stressors on health and reduce subsequent health disparities.
This study’s limitations must be considered when interpreting the results. Our sample was relatively small and homogenous, with the majority of par- ticipants identifying as Caucasian and therefore, it might not be entirely representative of all HSWs or hospital environments. It is important for future SDH research to investigate how the concepts of race, gender, and other social categories operate as social processes within research settings, even more so than participants’ independent variables (Cole, 2008). Moreover, data is based on participant self-report, which may contribute to reporting biases. Despite such limitations, this study adds to the existent scholarly knowledge as it relates to hospital HSWs’ practice of addressing the vast range of SDH within their daily work.
Further research should create a more complex measure of SDH and detail the specific types of interventions used to address each SDH, have a larger and more diverse sample that compares the impact on SDH across other disciplines, and include participants’ feedback about how SDH informs their practice in health care settings. Finally, HSWs should consider the ways in which they impact the SDH in their daily practice, as professional expectations continue to focus on service efficiency and best practices, and strive to demonstrate their efforts as effective and positive influences on vul- nerable patients’ outcomes (Judd & Sheffield, 2010). Partnerships between community and university based researchers using a practice-based research approach, such as those employed in this study, can assist HSWs to identify their roles, functions, and overall value to the health system.
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CONCLUSION
In sum, participants did address many SDH in their health care prac- tice; however, they focused more on proximal SDH, such as access to health care services and housing and less on the complex distal ones, such as social exclusion. This approach may be suitable for the types of roles they are hired to fill. It has been advanced that health services are both causes and solutions to health disparities (Kilbourne et al., 2006). Improving population health requires a vision of social justice (Krieger, 2001) and therefore there is potential for social work to work toward equal- ity in health care (Whiteside, 2004). Health inequalities are located at the heart of social work (Bywaters et al., 2010), and this article hopes to add to a critical knowledge base by discussing how social work practitioners are addressing the SDH. It will be difficult for social workers to achieve goals for a just society until consideration of SDH implications becomes a priority.
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