Precarious work on the rise.

Precarious employment (PE) is non-standard employment with uncertain and unstable contract duration, low wages, and limited labour protections and rights. Research has associated PE with workers' poor mental health and well-being; however, this association has been studied primarily using quantitative methods. This qualitative study seeks to examine the mechanisms between PE and mental health in the context of the COVID-19 pandemic in Ontario, Canada. Specifically, it aims to address: (Benach J, Muntaner C. Precarious employment and health: developing a research agenda. J Epidemiol Community Health. 2007;61(4):276.) How do PE and working conditions impact the mental well-being of workers and members of their close families or households?; and (Kreshpaj B, Orellana C, Burström B, Davis L, Hemmingsson T, Johansson G, et al. What is precarious employment? A systematic review of definitions and operationalizations from quantitative and qualitative studies. Scand J Work Environ Health. 2020;46(3):235-47.) How has the COVID-19 pandemic shaped these relationships? Semi-structured interviews were conducted with a sample of 40 individuals aged 25-55 engaged in PE during the first wave of the COVID-19 pandemic or whose employment was terminated due to the pandemic. Results showed that PE amplified mental health symptoms and illnesses for workers and their families. These experiences were described as chronic, where impacts were exerted on precariously employed workers through systemic discrimination and racism, colonialism, workplace hierarchies, and gendered ideologies. PE negatively impacted mental health through emotional stress about employment and income instability, insecurity, and loss; added pressure for households where both partners are engaged in PE; impacted ability to maintain or improve overall health and well-being; and barriers to social connectedness. Overall, this study characterizes multiple dimensions of PE and the consequences they have on the mental health of workers and their families.

Design and Development of a Suite of Intimate Partner Violence Screening and Safety Planning Web Apps: User-Centered Approach.

BACKGROUND: The popularity of mobile health (mHealth) technology has resulted in the development of numerous apps for almost every condition and disease management. mHealth and eHealth solutions for increasing awareness about, and safety around, intimate partner violence are no exception. These apps allow women to control access to these resources and provide unlimited, and with the right design features, safe access when these resources are needed. Few apps, however, have been designed in close collaboration with intended users to ensure relevance and effectiveness. OBJECTIVE: The objective of this paper is to discuss the design of a suite of evidence-based mHealth and eHealth apps to facilitate early identification of unsafe relationship behaviors and tailored safety planning to reduce harm from violence including the methods by which we collaborated with and sought input from a population of intended users. METHODS: A user-centered approach with aspects of human-centered design was followed to design a suite of 3 app-based safety planning interventions. RESULTS: This review of the design suite of app-based interventions revealed challenges faced and lessons learned that may inform future efforts to design evidence-based mHealth and eHealth interventions. CONCLUSIONS: Following a user-centered approach can be helpful in designing mHealth and eHealth interventions for marginalized and vulnerable populations, and led to novel insights that improved the design of our interventions.

Helping women transition out of sex work: study protocol of a mixed-methods process and outcome evaluation of a sex work exiting program.

BACKGROUND: For women who want to, exiting sex work can be challenging. Numerous programs strive to help women wanting to exit sex work and secure alternative sources of income by providing targeted support at key moments during the transition, yet few of those initiatives are rigorously evaluated. In 2017 "Exit Doors Here", a 9-month sex work exiting program based on the critical time intervention (CTI) approach, was developed to provide wrap-around support services (e.g., health, addiction, housing, education, and employment supports) to women wishing to transition towards exiting sex work. METHODS: We present the design of an evaluation study of Exit Doors Here which combines quantitative and qualitative methods to assess participant recruitment and retention into the program, program fidelity, and relationships with service providers (process evaluation), as well as progress made by participants in terms of strengthening their social support networks and moving closer to achieving their housing, pre-employment (i.e., educational, training and volunteering), and income-related goals, as well as their involvement in sex work (outcome evaluation). Each year for 4 years, between 25 and 30 Exit Doors Here clients will be invited to complete an interviewer-administered questionnaire at the beginning and after completing the program, and to share data from their CTI charts and related documentation. Once a year, program staff and peer workers will be interviewed, and service providers will be surveyed. DISCUSSION: Conducting a formative (process) evaluation will allow us to inform program implementation and improve program delivery early on for maximum benefit. The summative (outcome) evaluation will provide much needed evidence on the effectiveness of CTI in supporting a traditionally underserved population to achieve the housing, pre-employment and income-related goals they value, and their progress towards reducing their involvement in, and eventually exiting, sex work.

Supporting Women Exit Sex Work: A Contribution Analysis of the Exit Doors Here Integrated Care Program in Toronto, Canada.

Introduction: Exiting sex work is a complex process which can be facilitated by integrated action on health and its social determinants such as housing and employment. Few programs offer such coordinated support, and even fewer have been evaluated. We assessed if and how Exit Doors Here, a program anchored in the Critical Time Intervention (CTI) model, facilitated women's progress towards their goals, and exit from sex work. Description: We performed a contribution analysis by combining pre-post questionnaire and administrative data from 55 women enrolled in the program (2018-2021), yearly interviews with program staff and peer mentors, and literature reviews to assess program outcomes and mechanisms as described in the theory of change. Discussion: We found evidence that the program contributed to participants progressing on their pre-employment, housing, income, and sex work exiting goals. We identified four "key ingredients" facilitating success: trust building, collaborative goal setting, connecting with community supports and weekly drop-in sessions. Conclusion: This rigorous theory-based evaluation provides much needed evidence on the process and effectiveness of an integrated sex work exiting program. Findings regarding key program ingredients can inform other interventions serving similarly marginalized populations.

Working Conditions, Worker Rights, and Managerial Domination During the COVID-19 Pandemic: Assessing Their Toll on Precariously Employed Workers and Family Well-Being.

Precarious Employment (PE) is characterized by job, income, and benefit insecurities. Studies surrounding PE and well-being have been predominantly quantitative, leaving a gap in rich descriptions of employment experiences. We recruited a sample of 40 adults aged 25-55 who were involved in PE during the beginning of the COVID-19 pandemic or lost employment due to the pandemic. Semi-structured interviews were administered. Employment and income insecurities were common and had negative impacts on the well-being of participants and their families. Uncertainty about future employment prospects and job and income loss resulted in chronic distress. Other insecurities-access to benefits, violation of worker rights, worker safety-was also reported as impacting well-being. The COVID-19 pandemic deepened insecurities, hardships, and distress among workers with PE conditions. Given the myriad insecurities experienced by those engaged in PE, the focus of precarious work research should also include working conditions, violation of worker rights, and managerial domination.

Asking the Right Questions: Screening Men for Partner Violence.

With lifetime intimate partner violence (IPV) victimization rates for self-identified men between 14% and 20%, and an expanding understanding of gender as a nonbinary construct, practitioners in some clinical environments have expressed interest in screening all patients for IPV. Yet, few IPV screening instruments have been validated for use in nonfemale populations. This research tests the appropriateness and acceptability of a screening instrument developed for use with women.A literature review was completed to determine the current state of research into IPV screening practices tailored to men. Next, cognitive interviews were conducted to test a 9-question IPV screening instrument with men considered at average and elevated risk for experiencing partner violence. Participants were read the questions aloud and asked about item comprehension and question appropriateness and acceptability.The literature review uncovered no published reports describing routine clinic based IPV screening of men, and only two screening instruments had been validated with men. Twenty men participated in cognitive interviews from a variety of settings in a large urban center. All participants accurately described the intended meaning of each question and verified the appropriateness of asking the questions.This work addresses the gap in research on routine IPV screening with men, building on efforts to screen individuals and support improved health and response to violence to those across the gender spectrum.

Assessing program fidelity to critically reflect on the suitability of Critical Time Intervention to facilitate exiting sex work.

An emerging approach to facilitating exiting sex work is through applying the Critical Time Intervention [CTI] model. CTI represents a time-limited approach that supports marginalized individuals during periods of transition. We performed a fidelity assessment as part of a process evaluation of Exit Doors Here [EDH], a program supporting women who wish to exit sex work. We reflect on the appropriateness of the CTI model for supporting these women, and highlight contextual and population specificities which might need to be considered for effective scaling up of similar programs. First, we applied an existing fidelity assessment tool to the EDH program. Program staff highlighted areas for adaptation. We then adapted the tool based on this feedback and assessed program fidelity by analyzing data from eight participants' CTI charts. Fidelity ratings were computed and interpreted according to established guidelines. Consultations with program staff resulted in adaptations to seven of the 12 fidelity assessment tool items. The majority of adaptations surrounded the time-limited nature of CTI and unique needs of the program participants such as their experiences with violence and substance use. The fidelity assessment of the adapted tool demonstrated that even after adaptations were made, certain items were still not appropriate for this study population. Difficulties in implementing selected program components with high fidelity can be attributed to contextual and population specificities of the study population. This study reiterates the importance of considering such factors when developing and implementing programs aimed at improving the health and livelihoods of marginalized women such as those who engage in sex work.

Limited research exists that speaks to the appropriateness of the Critical Time Intervention [CTI] model for women who attempt to exit sex work. We found that many components of the CTI model [e.g., time limited nature] were not appropriate for providing care to women who engage with sex work due to their complex and intersecting needs/realities. Considering population specificities is key to providing effective health and social care to these groups. These findings contribute to existing gaps in the implementation science literature and program development which aims to assist women exit sex work and other similarly marginalized groups.

Double Jeopardy: Maintaining Livelihoods or Preserving Health? The Tough Choices Sex Workers Faced during the COVID-19 Pandemic.

The COVID-19 pandemic and associated public health preventive measures such as lockdown and home confinement have posed unique challenges to female sex workers (FSW) globally, including in Canada where the sex trade is not formally recognized. In this commentary, we discuss the unintended consequences the pandemic has had on various social determinants of health among FSW. We draw on a review of scholarly and grey literature, complemented by our experience with the Exit Doors Here program, a sex work exiting program implemented in Toronto, Canada. Due to COVID-19, many FSW suddenly lost their main source of income, work conditions became riskier, and sheltering-in-place presented challenges for women with no safe housing. The slowdown of social and health care services also meant FSW were not receiving the required attention. We make recommendations for intersectoral mitigation strategies to limit the short- and long-term impacts of COVID-19 on FSW health and livelihoods. Recommendations focus on addressing women's marginalizing circumstances and speak to a gender transformative approach to the COVID-19 recovery. Our recommendations are relevant to FSW and other marginalized groups, in the current context and in the context of future health, social, and economic crises.

Using implementation science to build intimate partner violence screening and referral capacity in a fracture clinic.

RATIONALE, AIMS, AND OBJECTIVES: Over the past two decades, research informing good clinical practices related to intimate partner violence (IPV) has been plentiful, yet partner violence screening remains challenging to translate into action. In spite of the documented efficacy of routine screening for women of reproductive age and the availability of validated screening instruments, many IPV screening programmes lack the components necessary for success. In Toronto, a multidisciplinary team of researchers and clinicians is using the tools of implementation science to scale up an evidence-based IPV screening and response programme in an urban orthopaedic clinic where prior screening attempts have been ineffective. METHODS: Using the Active Implementation Framework as a guide, researchers collected data across multiple sources to inform the first stage of implementation. Analysis focused on identifying the characteristics of the clinic that support or hinder implementation of new processes, evidence-based screening practices that fit with the clinic, and characteristics of a strong implementation team. RESULTS: Through this process, researchers and clinicians uncovered organizational strengths and weaknesses related to IPV screening that may not have been identified previously. The need to incorporate technology into our screening processes became apparent, as did the importance of shared communication and colearning between clinicians and researchers. CONCLUSIONS: The benefits of investing in the preparatory phases of implementation are discussed. Without undertaking the process of gathering and analysing data, examining the factors that support effective and sustainable implementation, and investing in the creation of a strong implementation team, it is likely that decisions about our screening approaches would have resulted in a less-effective and sustainable process.