Exploring social determinants of health in a Saudi Arabian primary health care setting: the need for a multidisciplinary approach.

BACKGROUND: Action on social determinants of health (SDH) in primary health care settings is constrained by practitioners, organizational, and contextual factors. The aim of this study is to identify barriers and enablers for addressing SDH in clinical settings in Saudi Arabia, taking into consideration the influence of local cultural and social norms, to improve care and support for marginalized and underserved patients. METHODS: We conducted a qualitative study involving individual in-depth interviews with a sample of 17 primary health care physicians purposefully selected based on the inclusion criteria, as well as a focus group with four social workers, all recruited from King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. All interviews were audio-recorded, translated from Arabic to English, transcribed verbatim, and analyzed using thematic analysis following a deductive-inductive approach. RESULTS: According to study participants, financial burdens, challenges in familial dynamics, mental health issues and aging population difficulties were common social problems in Saudi primary health care. Action on SDH in primary care was hindered by 1) lack of physician knowledge or training; 2) organizational barriers including time constraints, patient referral/follow up; 3) patient cultural norms and 4) lack of awareness of physician's role in managing SDH. Enablers to more socially accountable care suggested by participants includes: 1) more education and training on addressing SDH in clinical care; 2) organizational innovations to streamline identification of SDH during patient encounters (e.g. case finding questionnaire completed in waiting room); 3) better interprofessional coordination and clarification of roles (e.g. when to refer to social work, what support is provided by physicians); 4) identifying opportunities for broader advocacy to improve living conditions for marginalized groups. CONCLUSION: Enabling more socially accountable care requires a multipronged approach including leadership from the Ministry of Health, hospital administrations and medical schools. In particular, there is a need for: 1) training physicians to help patients in navigating social challenges; 2) improving clinical/administrative interprofessional teams, 3) mobilizing local communities in addressing social challenges; and 4) advocating for intersectoral action to prevent health inequities before they become more complex issues presenting to clinical care.

Challenges and opportunities in addressing social determinants of child health in Cambodia: perspectives and experience of frontline providers in two health districts.

OBJECTIVES: Other forces related to socio-economic and cultural factors, besides biomedical and behavioural fields, also influence health but receive little attention in health research. This study aims to illuminate social determinants of health and to identify challenges and opportunities in addressing social determinants of child health (SDCH) in rural Cambodia. METHODS: This is a qualitative study based on interviews of frontline primary health care providers, health officials, local authorities and community volunteers in two health districts in Cambodia. The data were supplemented by secondary data on different aspects of the districts and Cambodia. RESULTS: Poverty, lack of basic commodities and adverse social conditions remained problems for population health. While access to health services was considered adequate, households and communities had several major risk exposures. Challenges in addressing SDCH were the high prevalence of social and household adverse conditions, and the lack of training of providers, of information about social services, of effective coordination and of trust in public services. Opportunities were present, including social services being existent albeit poor functioning, the traditional practice of social inquiry, existing frontline providers being open to further information and training, existing subnational coordination bodies at district and provincial levels, and use of evidence in planning and resource allocation. CONCLUSION: Addressing SDCH requires broad and coordinated efforts of stakeholders from multiple sectors. Among the prerequisites are to leverage the existing structures and mechanisms, training primary health care providers and providing them with adequate information about local resources and available supports. Improving social care services and infrastructures requires strong coordination, planning and adequate resource allocation.

RéSUMé: OBJECTIFS: D'autres forces liées aux facteurs socio-économiques et culturels, en plus des domaines biomédicaux et comportementaux, influencent également la santé mais reçoivent peu d'attention dans la recherche en santé. Cette étude vise à éclairer les déterminants sociaux de la santé et à identifier les défis et les opportunités pour aborder les déterminants sociaux de la santé infantile (SDCH) dans les régions rurales du Cambodge. MéTHODES: Il s'agit d'une étude qualitative basée sur des entretiens avec des prestataires de soins de santé primaire de première ligne, des responsables de la santé, des autorités locales et des volontaires communautaires dans deux districts de santé au Cambodge. Les données ont été complétées par des données secondaires sur différents aspects des districts et du Cambodge. RéSULTATS: La pauvreté, le manque de produits de base et les conditions sociales défavorables restent des problèmes pour la santé de la population. Bienque l'accès aux services de santé est considéré suffisant, les ménages et les communautés sont exposés à plusieurs risques majeurs. Les défis liés à la lutte contre la SDCH étaient la prévalence élevée de conditions sociales et domestiques défavorables, ainsi que le manque de formation des prestataires, d'informations sur les services sociaux, de coordination efficace et de confiance dans les services publics. Des opportunités étaient présentes, y compris des services sociaux existants bienque fonctionnant mal, la pratique traditionnelle de l'enquête sociale, les prestataires de première ligne existants étant disposés à encore d'informations et de formation, les organes de coordination sous-nationaux existants au niveau des districts et des provinces, et l'utilisation des preuves dans la planification et l'allocation des ressources. CONCLUSION: Aborder la SDCH nécessite des efforts larges et coordonnés des parties prenantes de plusieurs secteurs. Parmi les conditions préalables, il faut tirer parti des structures et mécanismes existants, former les prestataires de soins de santé primaire et leur fournir des informations adéquates sur les ressources locales et soutiens disponibles. L'amélioration des services et des infrastructures de protection sociale nécessite une coordination, une planification et une allocation adéquate des ressources.

Evidence-informed interventions and best practices for supporting women experiencing or at risk of homelessness: a scoping review with gender and equity analysis. / Interventions fondées sur des données probantes et pratiques exemplaires en matière de soutien apporté aux femmes en situation ou à risque d'itinérance : examen de la portée avec analyse fondée sur le sexe et l'équité.

INTRODUCTION: While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada's homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness. METHODS: We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations. RESULTS: Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being. CONCLUSION: Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women.

Creating an Environmentally Sustainable Health System Demands a Socially Accountable Approach in a Post-COVID World.

The impacts of climate change can already be seen among many of the patients in our clinics and emergency rooms, and as with all disasters, the most impoverished and marginalized members of society are the hardest hit. The health system has a social accountability role to anticipate and respond to the evolving health needs of our society. We are the stewards of this planet, steering the course through current and future challenges. What we do now will determine what the world will be like for our children and grandchildren. At times like this, more than ever before, health workers around the world must unite and engage in contributing to shaping future policy directions and monitoring progress to create a post-COVID world where social accountability and sustainable development go hand in hand.

Caring for patients with lived experience of homelessness.

OBJECTIVE: To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION: The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE: Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION: Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.

Soigner les patients ayant connu l'itinérance.

OBJECTIF: Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l'itinérance. SOURCES D'INFORMATION: L'approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l'opinion des personnes avec une expérience vécue de l'itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. MESSAGE PRINCIPAL: Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l'accès au logement, à l'aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s'associer aux organisations communautaires locales et aux personnes ayant vécu l'itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. CONCLUSION: Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d'approche et d'intégration qui aident les personnes avec une expérience vécue de l'itinérance à accéder aux centres de médecine de famille et peuvent militer pour l'adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l'itinérance.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review.

BACKGROUND: Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. METHODS AND FINDINGS: We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. CONCLUSIONS: Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study.

BACKGROUND: Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. METHODS: We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. FINDINGS: Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. INTERPRETATION: The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.

The impact of interventions for youth experiencing homelessness on housing, mental health, substance use, and family cohesion: a systematic review.

BACKGROUND: Youth often experience unique pathways into homelessness, such as family conflict, child abuse and neglect. Most research has focused on adult homeless populations, yet youth have specific needs that require adapted interventions. This review aims to synthesize evidence on interventions for youth and assess their impacts on health, social, and equity outcomes. METHODS: We systematically searched Medline, Embase, PsycINFO, and other databases from inception until February 9, 2018 for systematic reviews and randomized controlled trials on youth interventions conducted in high income countries. We screened title and abstract and full text for inclusion, and data extraction were completed in duplicate, following the PRISMA-E (equity) review approach. RESULTS: Our search identified 11,936 records. Four systematic reviews and 18 articles on randomized controlled trials met the inclusion criteria. Many studies reported on interventions including individual and family therapies, skill-building, case management, and structural interventions. Cognitive behavioural therapy led to improvements in depression and substance use, and studies of three family-based therapies reported decreases in substance use. Housing first, a structural intervention, led to improvements in housing stability. Many interventions showed inconsistent results compared to services as usual or other interventions, but often led to improvements over time in both the intervention and comparison group. The equity analysis showed that equity variables were inconsistently measured, but there was data to suggest differential outcomes based upon gender and ethnicity. CONCLUSIONS: This review identified a variety of interventions for youth experiencing homelessness. Promising interventions include cognitive behavioural therapy for addressing depression, family-based therapy for substance use outcomes, and housing programs for housing stability. Youth pathways are often unique and thus prevention and treatment may benefit from a tailored and flexible approach.

Physician experiences and barriers to addressing the social determinants of health in the Eastern Mediterranean Region: a qualitative research study.

BACKGROUND: While it is increasingly recognized that social determinants influence the health of patients and populations, little is known about how doctors in the Eastern Mediterranean Region can help their patients with these issues. Our study aimed to identify common social challenges faced by patients in Eastern Mediterranean countries, to assess what doctors are already doing to address these challenges, and to identify barriers and facilitators for addressing the social causes of poor health in Eastern Mediterranean countries with shedding some light on how does this compare to a developed country like Canada. METHODS: We conducted a qualitative research study employing qualitative descriptive methodology. A purposeful sample as well as snowballing technique were used to recruit 18 physicians who were trained in Eastern Mediterranean countries but have since moved to Canada. Recruitment continued until data saturation was reached. A content analysis was carried out after transcribing the interviews. RESULTS: The main social challenges identified in clinical care in Eastern Mediterranean Regions include poverty, illiteracy, domestic violence, and food insecurity. Doctors attempted to help their patients by providing free medical services and free medications, establishing a donation box, and referring to social workers and support services, where available. Cultural constraints, lack of time, and unavailability of referral resources were often cited as important barriers. Our participants stated that Canada is generally better in dealing with the social challenges than their countries of origin. CONCLUSIONS: Most study participants expressed their willingness to help patients in dealing with social challenges, and shared their experiences of tackling such issues, though there were also important barriers reported that would need to be overcome. Participants suggested that better addressing social challenges in clinical care would require educating both health care providers and patients about the importance of discussing the patient's social environment as part of the health care encounter, as well as advocating for broader policy approaches by governments to address the underlying social problems.

Screening for social determinants of health in clinical care: moving from the margins to the mainstream.

BACKGROUND: Screening for the social determinants of health in clinical practice is still widely debated. METHODS: A scoping review was used to (1) explore the various screening tools that are available to identify social risk, (2) examine the impact that screening for social determinants has on health and social outcomes, and (3) identify factors that promote the uptake of screening in routine clinical care. RESULTS: Over the last two decades, a growing number of screening tools have been developed to help frontline health workers ask about the social determinants of health in clinical care. In addition to clinical practice guidelines that recommend screening for specific areas of social risk (e.g., violence in pregnancy), there is also a growing body of evidence exploring the use of screening or case finding for identifying multiple domains of social risk (e.g., poverty, food insecurity, violence, unemployment, and housing problems). CONCLUSION: There is increasing traction within the medical field for improving social history taking and integrating more formal screening for social determinants of health within clinical practice. There is also a growing number of high-quality evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels.

Blood and hair mercury concentrations among Cree First Nations of Eeyou Istchee (Quebec, Canada): time trends, prenatal exposure and links to local fish consumption.

To describe exposure to methylmercury among Cree, focusing on women of childbearing age, we used data from 2 studies. Multiple regression was employed to examine associations between blood and hair mercury concentrations and consumption of locally harvested fish. Approximately 9.9% of non-pregnant women aged 15-44 y and 3.9% of pregnant women required follow-up according to Health Canada's blood mercury guidance value of 40 nmol/L. 8% of hair mercury observations in the non-pregnant women and 2.5% among pregnant women exceeded the equivalent threshold of 10 nmol/g. The geometric mean blood mercury concentration was 12.7 nmol/L in 1,429 persons aged 8 and over, and 17.7 nmol/L in adults aged 18 and older. The proportion of hair mercury concentrations greater than 12.5 nmol/g decreased in all age-sex groups when comparing the 2002-2009 data to published values for 1993-1994. Among women of childbearing age, local fish consumption was associated with increased blood and hair mercury concentrations. While over 90% of women of childbearing age in this population have acceptable levels of mercury, ongoing intake of mercury suggests that their consumption of fish with known high mercury content be minimised. Reducing consumption of fish known to be high in mercury content needs to be balanced with promoting ongoing connection to Cree culture and land-based activities that are also important determinants of health.

Evidence for Health II: Overcoming barriers to using evidence in policy and practice.

Even the highest quality evidence will have little impact unless it is incorporated into decision-making for health. It is therefore critical to overcome the many barriers to using evidence in decision-making, including (1) missing the window of opportunity, (2) knowledge gaps and uncertainty, (3) controversy, irrelevant and conflicting evidence, as well as (4) vested interests and conflicts of interest. While this is certainly not a comprehensive list, it covers a number of main themes discussed in the knowledge translation literature on this topic, and better understanding these barriers can help readers of the evidence to be more savvy knowledge users and help researchers overcome challenges to getting their evidence into practice. Thus, the first step in being able to use research evidence for improving population health is ensuring that the evidence is available at the right time and in the right format and language so that knowledge users can take the evidence into consideration alongside a multitude of other factors that also influence decision-making. The sheer volume of scientific publications makes it difficult to find the evidence that can actually help inform decisions for health. Policymakers, especially in low- and middle-income countries, require context-specific evidence to ensure local relevance. Knowledge synthesis and dissemination of policy-relevant local evidence is important, but it is still not enough. There are times when the interpretation of the evidence leads to various controversies and disagreements, which act as barriers to the uptake of evidence. Research evidence can also be influenced and misused for various aims and agendas. It is therefore important to ensure that any new evidence comes from reliable sources and is interpreted in light of the overall body of scientific literature. It is not enough to simply produce evidence, nor even to synthesize and package evidence into a more user-friendly format. Particularly at the policy level, political savvy is also needed to ensure that vested interests do not undermine decisions that can impact the health of individuals and populations.

Evidence for Health I: Producing evidence for improving health and reducing inequities.

In an ideal world, researchers and decision-makers would be involved from the outset in co-producing evidence, with local health needs assessments informing the research agenda and research evidence informing the actions taken to improve health. The first step in improving the health of individuals and populations is therefore gaining a better understanding of what the main health problems are, and of these, which are the most urgent priorities by using both quantitative data to develop a health portrait and qualitative data to better understand why the local population thinks that addressing certain health challenges should be prioritized in their context. Understanding the causes of these health problems often involves analytical research, such as case-control and cohort studies, or qualitative studies to better understand how more complex exposures lead to specific health problems (e.g. by interviewing local teenagers discovering that watching teachers smoke in the school yard, peer pressure, and media influence smoking initiation among youth). Such research helps to develop a logic model to better map out the proximal and distal causes of poor health and to determine potential pathways for intervening and impacting health outcomes. Rarely is there a single 'cure' or stand-alone intervention, but rather, a continuum of strategies are needed from diagnosis and treatment of patients already affected, to disease prevention, health promotion and addressing the upstream social determinants of health. Research for developing and testing more upstream interventions must often go beyond randomized controlled trials, which are expensive, less amenable to more complex interventions, and can be associated with certain ethical challenges. Indeed, a much neglected area of the research cycle is implementation and evaluation research, which often involves quasi-experimental research study designs as well as qualitative research, to better understand how to derive the greatest benefit from existing interventions and ways of maximizing health improvements in specific local contexts. There is therefore a need to alter current incentive structures within the research enterprise to place greater emphasis on implementation and evaluation research conducted in collaboration with knowledge users who are in a position to use the findings in practice to improve health.