Social Determinants of Paramedicine Care
What are Social Determinants of Health?
These are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. For paramedics, understanding these factors is crucial because they directly influence who calls for an ambulance, why they call, and what barriers they face in accessing care.
Key Determinants Include:
- Socioeconomic Position: Income, social protection, and financial security.
- Education & Health Literacy: The ability to understand and use health information. In 2006, 59% of Australians had less than adequate health literacy.
- Employment: Job security and working conditions.
- Housing and Environment: The physical conditions of a person's home and community.
- Social Inclusion & Non-discrimination: The impact of factors like race, gender, and disability on access and equity.
- Access to Health Services: Availability and affordability of care beyond the emergency response.
- Early Childhood Development: Experiences in the "first 1000 days" have lifelong health impacts.
Patient Decision-Making in Emergencies
Who Calls an Ambulance and Who Delays?
Research by Morgans et al. (2008) and Toloo et al. (2013) shows that patient decisions are driven more by psychosocial factors and feelings than by clinical knowledge. This explains why traditional health education campaigns often have limited success.
| Factors Associated with Calling an Ambulance | Reasons for Delaying or Not Calling |
|---|---|
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Key Takeaways for Paramedics
- Recognize that patients who call are more likely to be impacted by adverse SDH.
- Your interaction can significantly influence a patient's future willingness to access healthcare. A negative experience can become a barrier to future care.
- Patient delay is not a sign of ignorance but is often a complex coping response. Avoid judgment and focus on building trust.
Cultural Competence and Safety
Defining Key Terms
- Culture: A combination of knowledge, beliefs, and behaviors specific to ethnic, racial, religious, geographic, or social groups.
- Cultural Competence: A lifelong process of learning. It is a paramedic's ability to tailor healthcare to be ethical and equitable while meeting the clinical and cultural needs of the patient.
- Cultural Safety: This is determined by the patient. It is an outcome of competent practice where the patient feels respected and safe within the healthcare encounter, free from racism or discrimination.
A Model for Developing Cultural Competence
This is a continuous process involving five key constructs:
- Cultural Awareness: Self-reflection on your own cultural and professional background to dissolve assumptions, biases, and prejudices.
- Cultural Knowledge: Actively educating yourself about diverse cultures.
- Cultural Skill: Collecting relevant data and performing a cultural assessment to determine a patient's specific needs.
- Cultural Encounters: Engaging in cross-cultural interactions to refine your beliefs and challenge stereotypes.
- Cultural Desire: Having a genuine motivation and care to engage with all patients, not just to fulfill an organizational requirement.
Diversity in Paramedic Education
The study by Lam et al. (2022) highlights a significant gap in paramedic education in Australia and New Zealand. While cultural competence is taught in theory, there is a lack of culturally diverse training equipment (e.g., manikins of colour, religious props) in simulation labs. This is a missed opportunity to:
- Visually prompt students to consider cultural aspects during practical training.
- Practice assessing clinical signs (like cyanosis or pallor) on different skin tones.
- Promote feelings of inclusiveness for students from diverse backgrounds.
- Translate theoretical knowledge into practical, culturally safe skills.
Core Concepts for Reflective Practice
Intersectionality
Coined by Kimberlé Crenshaw, intersectionality is a framework for understanding how multiple forms of inequality or disadvantage (e.g., race, gender, class, disability) can compound and create unique obstacles for an individual. For paramedics, this means recognizing that a patient is more than a single label. Focusing only on one aspect of their identity (e.g., their ethnicity) can cause you to miss other crucial factors (e.g., their socioeconomic status or disability) that impact their health and needs.
Othering
This is the process of labeling and defining a person as belonging to a subordinate social group, creating an "Us versus Them" mentality. In paramedicine, this can manifest through depersonalizing language (e.g., "the psych patient," "a frequent flyer"). Othering dismisses the individual, leads to bias, and can result in discriminatory care.
Bias in Decision-Making
Biases, both conscious and unconscious, can significantly impact clinical decision-making, especially in time-pressured environments.
- Anchoring Bias: The tendency to rely too heavily on the first piece of information offered.
- Affinity Bias: The tendency to warm up to people who are like ourselves.
Paramedics must engage in continuous self-reflection to identify and challenge their own biases. The tutorial triage scenario (83yo female vs. 5yo male vs. 21yo male driver vs. 28yo female) is a classic example designed to expose these biases. Ethical frameworks like utilitarianism (doing the most good for the most people) guide triage, but unconscious bias can influence who we perceive as "most worthy" of that care.