Objective: To assess the feasibility of implementing a clinical decision aid called the CLEAR Toolkit that helps front-line health workers ask their patients about social determinants of health, refer to local support resources, and advocate for wider social change.
Design: A mixed-methods study using quantitative (online self-completed questionnaires) and qualitative (in-depth interviews, focus groups, and key informant interviews) methods.
Setting: A large, university-affiliated family medicine teaching centre in Montreal, Que, serving one of the most ethnically diverse populations in Canada.
Participants: Fifty family doctors and allied health workers responded to the online survey (response rate of 50.0%), 15 completed in-depth interviews, 14 joined 1 of 2 focus groups, and 3 senior administrators participated in key informant interviews.
Methods: Our multimethod approach included an online survey of front-line health workers to assess current practices and collect feedback on the tool kit; in-depth interviews to understand why they consider certain patients to be more vulnerable and how to help such patients; focus groups to explore barriers to asking about social determinants of health; and key informant interviews with high-level administrators to identify organizational levers for changing practice.
Main findings: Senior administrators consider asking about social determinants to be part of the mandate of health workers. However, barriers perceived by front-line clinicians include insufficient training in social history taking, uncertainty about how to address these issues in clinical practice, and a lack of knowledge of local referral resources. Health workers with specific ways of asking patients about their social challenges were more likely to report having helped their patients as compared with those who did not know how to ask (93.8% vs 52.9%; P = .003).
Conclusion: While health workers recognize the importance of social determinants, many are unsure how to ask about these often sensitive issues or where to refer patients. The CLEAR Toolkit can be easily adapted to local contexts to help front-line health workers initiate dialogue around social challenges and better support patients in clinical practice.
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