Collecting social needs data in primary care for better health outcomes

June 20, 2024

A new network of health practitioners in Canada is improving the routine collection of data to address social determinants of health at the individual, clinic, and policy levels.

Data on social needs – the conditions that affect a person’s ability to maintain health like income, housing or access to healthy food – can identify actions to improve health outcomes but are rarely collected in healthcare settings. Documenting social needs data also varies between providers and health records.

Here is a common scenario: Mr. Smith is in the emergency department with severe headache and hand numbness. He has been managing diabetes with the help of his primary care team, but what they don’t know is that Mr. Smith recently lost his job. He has struggled to afford healthy food and started rationing his medication. If he had been screened for precarious employment, he could have been referred to a health and social support program.

Healthcare settings need a standardized system for collecting social needs data and a network of practitioners to support implementation efforts. In Mr. Smith’s case, the ideal system would have recorded his poor work conditions with other health information, referred him to support programs, and identified patients in a similar situation. Mr. Smith, and many patients like him, could have prevented diseases that not only burden individuals but also healthcare systems.

“Data on key social factors and determinants – ideally self-reported by patients – is essential to building a foundation for upstream action. It helps providers respond to individual needs, direct or link people to local services, but it also helps organizations identify inequities and ultimately can hold health systems accountable,” said Dr. Andrew Pinto, current and founding director of Upstream Lab and a public health specialist and family physician at St. Michael’s Hospital.

Tool for routine and systematic data collection

The Upstream Lab has developed the SPARK Tool to collect social needs data in healthcare settings. Patients can share information on their language preference, religion, education, finances, food security, medication access, housing and additional non-medical factors that impact health.

Creating the SPARK Tool is part of a national research project funded by the Canadian Institutes of Health Research that stemmed from the lack of social determinants of health data in Canada.

Over 2,000 patients and healthcare providers across Canada tested the SPARK Tool and found it useful, supporting its potential to drive actions to improve health equity in primary care. However, as with new approaches in healthcare settings, sites identified challenges with implementation that call for additional support to scale up the tool’s use.

Health practitioners’ network improving data collection

The work of Upstream Lab and the SPARK team initiated the launch of Primary Health Care at the Deep End Canada / Soins Primaires en milieux défavorisés Canada. It is a network of health practitioners that aims to improve the collection and use of social data to address social determinants of health at the individual, clinic, and policy levels.



The Deep End Project started in Scotland and has grown into an international coalition. “It’s great to welcome Canada to the Deep End movement – our 17th project, 9th country and 4th continent – all different in terms of situations and opportunities but united in their values, commitment to inclusive health care and determination to improve health and lives where it matters most,” said Dr. Graham Watt, former Scottish Deep End Project lead and emeritus professor at the University of Glasgow.

With funding from the Canadian Primary Care Research Network (CPCRN), over 20 primary care sites involved in Deep End Canada will implement the SPARK Tool for three years. They will interpret data, develop local solutions to address the identified needs, and share strategies, working together to advocate for health equity in primary care.

“We can’t solve the primary care crisis by doing more of the same. We need to tackle the root causes of illness. Across Canada, there are pockets of innovative upstream services addressing inequities and meeting social needs like food security, housing, and social isolation. Scaling up these efforts is essential for resilient, effective, and fair healthcare,” said Dr. Mélanie Ann Smithman, co-founder of Deep End Canada and postdoctoral fellow at Upstream Lab.

“Deep End Canada is uniting innovative primary care teams and patients experiencing socioeconomic disadvantage to collect data, share knowledge, and advocate together to lay the foundation for this critical work,” she added.

To learn more or explore potential collaborations, visit the Deep End Canada website or contact 


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