Presented to 4th year medical students on April 13, 2012 at the Schulich School of Medicine & Dentistry.

1. Introduction to
Marginalized
Communities
Natalie Lovesey, MD, CCFP
Family Physician
Associate Director,
Local/Marginalized Communities
The Office of Global Health, SSMD
www.delicious.com/nlovesey
Global Health
Selective 2012
April 13, 2012

2. Learning Objectives
 1. To define marginalization and outline the
social determinants of health.
 2. To provide an overview of marginalized
populations globally and locally and the
health issues they face.
 3. To demonstrate educational and clinical
tools and resources that can assist in working
with marginalized populations.

3. Session Outline
 Introduction and lecture on Marginalized
Communities – 30 mins.
 Film excerpt: “Safe and Sound” – 15 mins.
 Break – 5 mins.
 Small group activity: Case-based
questions – 20 mins.
 Feedback to group – 10 mins.
 Wrap-up & final questions – 10 mins.

4. Questions:
 What is a “marginalized community”?
 What challenges do marginalized
communities face when accessing health
care?
 What aspects of health care policy are
relevant to marginalized communities?
 What challenges have you had when
dealing with marginalized communities?

5. Source: UNESCO Background Paper for the Education For All Global Monitoring Report 2010 –
Reaching the Marginalized – Educational Marginalization in National Education Plans.

6. Marginalized communities:
definition
 No one agreed-upon definition of
marginalization
 International Consultative Forum on
Education for All (EFA Forum), UNESCO, Status
and Trends, 2000 - definition:
“Marginalization occurs when people are
systematically excluded from meaningful
participation in economic, social, political,
cultural and other forms of human activity in
their communities and thus are denied the
opportunity to fulfill themselves as human
beings.”

7. Definition
 Can be various “causes” or “groups”,
depending on the society or region
 “Vulnerable populations”,
“disadvantaged groups” are similar terms;
may have different meanings

8. Marginalized Communities
 Broadly, can look at:
 Gender-related, sexuality-related
 Culture-related incl. ethnic groups, First
Nations, religious groups, language groups
 Location-related – conflict areas, rural
areas
 Poverty-related
 Special groups – Persons with disabilities or
special needs, HIV-AIDS

9. Further issues
 The concept of marginalization is complex
 Different views of causes leads to different
approaches to reducing it
Source: Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder:
Thinking about Marginalization: What, Who and Why?

10. Unequal distribution of poverty

1998 Statistics. In: Jenson Jane. Canadian Policy Research Networks Inc.
(CPRN). Backgrounder: Thinking about Marginalization: What, Who and
Why?

11. How does being a member
of a Marginalized
Community impact on
health?

12. Social Determinants of Health
 WHO: “The conditions in which people are
born, grow, live, work and age, including
the health system.”

13. Social Determinants of Health
 Socio-economic
status and income
 Personal/family
income
 Income distribution
in the population
 Social Support
Networks
 Education & Literacy
 Employment/Workin
g Conditions
 Social Environments
 Housing/Physical
Environments
 Health Services
 Gender
 Social Exclusion
 Disability
 Aboriginal Status
 Race

16. Questions:
 What is a “marginalized community”?
 What challenges do marginalized
communities face when accessing health
care?
 What aspects of health care policy are
relevant to marginalized communities?
 What challenges have you had when
dealing with marginalized communities?
 Discuss examples with the group

17. Health Issues Faced by Marg.
Comm.: Locally
 Social determinants of health
 Reduced access to health services – mainly lack
of primary health care ie. Family physician, nurse
practitioner.
 Reduced ability to pay for non-insured health care
eg. Prescription drugs, dental care, physiotherapy,
etc.
 Challenges with transportation
 Challenges navigating the complex health care
system
 Literacy &/or English limitations – ex.: written
colonoscopy instructions mailed to patients

18. Film excerpt
 Profiles
government-
assisted refugees in
Vancouver, BC
 Many similarities
with refugee
patients seen here
in London, ON

19. Film discussion
 What is the biggest
health care gap
the refugees
profiled identify?

20. Questions:
 What is a “marginalized community”?
 What challenges do marginalized
communities face when accessing health
care?
 What aspects of health care policy are
relevant to marginalized communities?
 What challenges have you had when
dealing with marginalized communities?

21. Break: 5 minutes

22. Case Discussion
 You are a PGY1 seeing a patient in the
Emergency Dept.
 52 yo man with uncontrolled diabetes.
Random bg is 24. HbA1C is 11%.
 PMH – DM II, HTN, obesity
 Meds – Metformin 500 mg bid
 Sitagliptin 100 mg od (started by WIC),
Amlodipine 5 mg od
 Hasn’t taken his meds in about 3 months.

23. Questions
 What factors might impact his adherence
to his prescribed medications?
 What key social history features do you
want to know?
 What would you include in your discharge
plan from the Emergency Dept.?
 What community resources could you
refer him to?

24. Clinical Tool: Searching the
ODB formulary
 https://www.healthinfo.moh.gov.on.ca/fo
rmulary/index.jsp
 Google “ODB formulary search”

30. Taking a Social History “Plus”
 Occupation
 Level of education (may be very different than
current occupation, especially in immigrants)
 Literacy in English and/or in mother tongue.
 Language(s) spoken (write it on the chart in the
hospital).
 Living arrangement – who is at home - asking if
married, children, etc. does not tell you who is at
home; may have extended family or friends. Is
spouse/partner present, or does he/she work in
another province, country, etc.?
 What type of home – apartment, house, townhouse,
etc.?

31. Social History “Plus”
 Level of English proficiency – can ask re:
ESL Level if taking classes.
 Social Networks – friends or family nearby?
Social isolation?
 Lifestyle habits – any particular diet?
Foods avoided or emphasized for
religious, cultural or personal reasons?
 Smoking, alcohol, drugs, tobacco, etc.?

32. Ontario Poverty Tool
www.healthprovidersagainstpoverty.ca

33. Recap
 Marginalization = exclusion from full
participation in society, for one or more
reasons
 Social determinants of health are key
 Add some “extra” social questions to your
history
 Utilize clinical tools and community
resources to assist your patients

34. Parting Thoughts
 Keep asking “why?” – to your patients’
social situations, and also to yourself.
 Educate yourself; take courses, read
articles, stay informed. Learn about the
region/group’s issues and politics.

35. Final questions?
 Reminder: UWO Global Health
Conference, April 27-29
 Will you be a UWO Family Med resident?
Consider the Marginalized Communities
Elective.

36. References
 Hospital for Sick Children – Cultural Competence e-Modules. Module: Social
Determinants of Health. Available online at
http://www.sickkids.ca/culturalcompetence/elearning-modules/eLearning-
modules.html. Includes document “Key Social Determinants of Health –
January 2011”.
 Jenson Jane. Canadian Policy Research Networks Inc. (CPRN). Backgrounder:
Thinking about Marginalization: What, Who and Why? Web version –
November 2000. Available online at
http://www.cprn.org/doc.cfm?l=en&doc=181
 Mikkonen J and Raphael D. Social Determinants of Health: The Canadian
Facts. Toronto: York University School of Health Policy and Management, 2010.
Available online at http://www.thecanadianfacts.org/
 Safe and Sound? Documentary. Website www.safeandsoundfilm.com.
 UNESCO – International Institute for Educational Planning. Background paper
prepared for the Education for All Global Monitoring Report 2010 - Reaching
the Marginalized. Educational Marginalization in National Education Plans.
UNESCO 2009. Available online at http://unesdoc.unesco.org/images
0018/001866/186608e.pdf
 World Health Organization – Definition of Social Determinants of Health.
Available online at http://www.who.int/social_determinants/en/