A Brief Tool to Screen Patients for Precarious Employment: A Validation Study.

PURPOSE: Precarious employment, defined by temporary contracts, unstable employment, or job insecurity, is increasingly common and is associated with inconsistent access to benefits, lower income, and greater exposure to physical and psycholosocial hazards. Clinicians can benefit from a simple approach to screen for precarious employment to improve their understanding of a patient's social context, help with diagnoses, and inform treatment plans and intersectional interventions. Our objective was to validate a screening tool for precarious employment. METHODS: We used a 3-item screening tool that covered key aspects of precarious employment: non-standard employment, variable income, and violations of occupational health and safety rights and protections. Answers were compared with classification using the Poverty and Employment Precarity in Southern Ontario Employment Index. Participants were aged 18 years and older, fluent in English, and employed. They were recruited in 7 primary care clinic waiting rooms in Toronto, Canada over 12 months. RESULTS: A total of 204 people aged 18-72 years (mean 38 [SD 11.3]) participated, of which 93 (45.6%) identified as men and 119 (58.3%) self-reported as White. Participants who reported 2 or more of the 3 items as positive were almost 4 times more likely to be precariously employed (positive likelihood ratio = 3.84 [95% CI, 2.15-6.80]). CONCLUSIONS: A 3-item screening tool can help identify precarious employment. Our tool is useful for starting a conversation about employment precarity and work conditions in clinical settings. Implementation of this screening tool in health settings could enable better targeting of resources for managing care and connecting patients to legal and employment support services.

An evaluation of an employment assistance program focused on people living with HIV in Toronto, Canada.

Unemployment is more common among people living with HIV (PLWH) compared to the general population. PLWH who are employed have better physical and mental health outcomes compared to unemployed PLWH. The main objective of this mixed-methods study was to conduct a program evaluation of Employment Action (EACT), a community-based program that assists PLWH in Toronto, Ontario, Canada to maintain meaningful employment. We extracted quantitative data from two HIV services databases used by EACT, and collected qualitative data from 12 individuals who had been placed into paid employment through EACT. From 131 clients included in the analysis, 38.1% (n = 50) maintained their job for at least 6 weeks within the first year of enrollment in the EACT program. Gender, ethnicity, age, and first language did not predict employment maintenance. Our interviews highlighted the barriers and facilitators to effective service delivery. Key recommendations include implementing skills training, embedding PLWH as EACT staff, and following up with clients once they gain employment. Investment in social programs such as EACT are essential for strengthening their data collection capacity, active outreach to service users, and sufficient planning for the evaluation phase prior to program implementation.

Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents.

BACKGROUND: The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews. METHODS: We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method. RESULTS: Thirty-eight community residents participated in either adaptation (n = 14, 64% female; average age 54 y) or evaluation (n = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals. CONCLUSIONS: Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention. TRIAL REGISTRATION: #NCT03052959, 10/02/2017.

Collection and Use of Social Determinants of Health Data in Inpatient General Internal Medicine Wards: A Scoping Review.

BACKGROUND: There is growing interest in incorporating social determinants of health (SDoH) data collection in inpatient hospital settings to inform patient care. However, there is limited information on this data collection and its use in inpatient general internal medicine (GIM). This scoping review sought to describe the current state of the literature on SDoH data collection and its application to patient care in inpatient GIM settings. METHODS: English-language searches on MedLine, Embase, Web of Science, CINAHL, Cochrane, and PsycINFO were conducted from 2000 to April 2021. Studies reporting systematic data collection or use of at least three SDoH, sociodemographic, or social needs variables in inpatient hospital GIM settings were included. Four independent reviewers screened abstracts, and two reviewers screened full-text articles. RESULTS: A total of 8190 articles underwent abstract screening and eight were included. A range of SDoH tools were used, such as THRIVE, PRAPARE, WHO-Quality of Life, Measuring Health Equity, and a biopsychosocial framework. The most common SDoH were food security or malnutrition (n=7), followed by housing, transportation, employment, education, income, functional status and disability, and social support (n=5 each). Four of the eight studies applied the data to inform patient care, and three provided community resource referrals. DISCUSSION: There is limited evidence to guide the collection and use of SDoH data in inpatient GIM settings. This review highlights the need for integrated care, the role of the electronic health record, and social history taking, all of which may benefit from more robust SDoH data collection. Future research should examine the feasibility and acceptability of SDoH integration in inpatient GIM settings.

Addressing health inequity during the COVID-19 pandemic through primary health care and public health collaboration: a multiple case study analysis in eight high-income countries.

BACKGROUND: The COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions. METHODS: We analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021. RESULTS: Four themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries. CONCLUSIONS: This study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Best Practices for COVID-19 Mass Vaccination Clinics.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global public health crisis. Mass vaccination is the safest and fastest pandemic exit strategy. Mass vaccination clinics are a particularly important tool in quickly achieving herd immunity. Primary care physicians have played a crucial role in organizing and running vaccination clinics. In this special report, we synthesize existing guidelines and peer-reviewed studies to provide physicians with practical guidance on planning and implementing COVID-19 mass vaccination clinics. METHODS: PubMed, Ovid MEDLINE and Embase were used to search for relevant literature using search terms that included COVID-19, mass vaccination, and best practice. We also identified and analyzed national and international guidelines. RESULTS: Forty-six relevant articles, reports, and guidelines were identified and synthesized. Articles included mass vaccination clinic guidelines and studies before and during the COVID-19 pandemic. Key considerations for COVID-19 mass vaccination clinics include leadership and role designation, site selection, clinic layout and workflow, day-to-day operations, infection prevention, and communication strategies. CONCLUSIONS: Planning and implementing a successful COVID-19 mass vaccination clinic requires several key considerations. Primary care plays an important role in organizing clinics and ensuring populations made vulnerable by social and economic policies are being reached. Ongoing data collection is required to evaluate and continuously improve COVID-19 mass vaccination efforts. As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine rollout occurs in various countries, research will be required to identify the main factors for success to inform future pandemic responses.VISUAL ABSTRACT.

The COVID-19 pandemic: Adverse effects on the social determinants of health in children and families.

OBJECTIVE: To describe the impact of social determinants on the experience of the coronavirus disease 2019 (COVID-19) pandemic within the pediatric population, how this impact may influence the long-term health and security of children, and what measures can be taken to ameliorate this impact moving forward. DATA SOURCES: Nonsystematic review of relevant literature and news sources. STUDY SELECTIONS: Relevant literature and news sources. RESULTS: There have been increases in housing insecurity and food insecurity during the pandemic, including global increases in poverty. Public policies such as school closures have had a disproportionate impact on those facing adverse social determinants. There has been a dramatic increase in reports of abuse-related injuries and other injuries indicative of child abuse during the pandemic. In addition, there are disproportionate impacts of COVID-19 based on race and ethnicity within the United States. It is clear that children are facing more adverse determinants as a result of this pandemic and that there are both short-term and long-term implications associated. For those living in poverty or with other adverse social determinants of health, the pandemic has made a bad situation worse. Ongoing studies are required to measure the impact of COVID-19 on those with adverse social determinants, in particular among children. CONCLUSION: Social determinants of health must be part of pandemic research priorities, public health and vaccination goals, and economic policy implementation. The impact of the COVID-19 pandemic has further served to shed a light on the broad disparities that exist within our society and their direct and indirect impacts on health outcomes.

Examining COVID-19 vaccine uptake and attitudes among 2SLGBTQ+ youth experiencing homelessness.

OBJECTIVES: The COVID-19 pandemic has disproportionately impacted 2SLGBTQ+ youth experiencing homelessness. Little is known about vaccine attitudes and uptake among this population. To address this, the objectives of this study were to explore this group's COVID-19 vaccine attitudes, and facilitators and barriers impacting vaccine uptake. METHODS: 2SLGBTQ+ youth experiencing homelessness in the Greater Toronto Area were recruited to participate in online surveys assessing demographic characteristics, mental health, health service use, and COVID-19 vaccine attitudes. Descriptive statistics and statistical tests were used to analyze survey data to explore variables associated with vaccine confidence. Additionally, a select group of youth and frontline workers from youth serving organizations were invited to participate in online one-on-one interviews. An iterative thematic content approach was used to analyze interview data. Quantitative and qualitative data were merged for interpretation by use of a convergent parallel analytical design. RESULTS: Ninety-two youth completed surveys and 32 youth and 15 key informants participated in one-on-one interviews. Quantitative and qualitative data showed that the majority of 2SLGBTQ+ youth experiencing homelessness were confident in the COVID-19 vaccine; however, numerous youth were non-vaccine confident due to mistrust in the healthcare system, lack of targeted vaccine-related public health information, concerns about safety and side effects, and accessibility issues. Solutions to increase vaccine confidence were provided, including fostering trust, targeted public health messaging, and addressing accessibility needs. CONCLUSION: Our study highlights the need for the vaccine strategy and rollouts to prioritize 2SLGBTQ+ youth experiencing homelessness and to address the pervasive health disparities that have been exacerbated by the pandemic.

Building integrated, adaptive and responsive healthcare systems - lessons from paramedicine in Ontario, Canada.

BACKGROUND: Being responsive and adaptive to local population needs is a key principle of integrated care, and traditional top-down approaches to health system governance are considered to be ineffective. There is need for more guidance on taking flexible, complexity-aware approaches to governance that foster integration and adaptability in the health system. Over the past two decades, paramedics in Ontario, Canada have been filling gaps in health and social services beyond their traditional mandate of emergency transport. Studying these grassroots, local programs can provide insight into how health systems can be more integrated, adaptive and responsive. METHODS: Semi-structured interviews were conducted with people involved in new, integrated models of paramedic care in Ontario. Audio recordings of interviews were transcribed and coded inductively for participants' experiences, including drivers, enablers and barriers to implementation. Thematic analysis was done to ascertain key concepts from across the dataset. RESULTS: Twenty-six participants from across Ontario's five administrative health regions participated in the study. Participants described a range of programs that included acute, urgent and preventative care driven by local relationship networks of paramedics, hospitals, primary care, social services and home care. Three themes were developed that represent participants' experiences implementing these programs in the Ontario context. The first theme, adapting and being nimble in tension with system structures, related to distributed versus central control of programs, a desire to be nimble and skepticism towards prohibitive legal and regulatory systems. The second theme, evolving and flexible professional role identity, highlighted the value and challenges of a functionally flexible workforce and interest in new roles amongst the paramedic profession. The third theme, unpredictable influences on program implementation, identified events such as the COVID-19 pandemic and changing government priorities as accelerating, redirecting or inhibiting local program development. CONCLUSIONS: The findings of this study add to the discourse on governing health systems towards being more integrated, adaptive and responsive to population needs. Governance strategies include: supporting networks of local organizational relationships; considering the role of a functionally flexible health workforce; promoting a shared vision and framework for collaboration; and enabling distributed, local control and experimentation.

Collecting occupation and hazards information in primary care using O*NET.

OBJECTIVE: The objective of this study was to determine the feasibility of collecting occupation and occupational hazard data in a primary care setting, using the Occupational Information Network (O*NET) database to assist with classification. METHODS: We collected data from 204 employed adult primary care patients in Toronto, Canada, on their occupation and exposure to occupational hazards, and mapped their job titles to the O*NET database. We compared their self-reported occupational hazard exposures with the likelihood of exposure on O*NET. RESULTS: Exposure to repetitive arm movement was reported by 78%, to vapors/gas/dust/fumes by 30%, to noise by 30%, and to heavy loads by 31%. Significant differences in exposure to vapors/gas/dust/fumes were associated with work precarity. We matched the majority of job titles (89%) to O*NET categories. CONCLUSIONS: Collecting employment information in primary care setting was feasible, with the majority of job titles mapping onto O*NET classifications.

Is primary health care ready for artificial intelligence? What do primary health care stakeholders say?

BACKGROUND: Effective deployment of AI tools in primary health care requires the engagement of practitioners in the development and testing of these tools, and a match between the resulting AI tools and clinical/system needs in primary health care. To set the stage for these developments, we must gain a more in-depth understanding of the views of practitioners and decision-makers about the use of AI in primary health care. The objective of this study was to identify key issues regarding the use of AI tools in primary health care by exploring the views of primary health care and digital health stakeholders. METHODS: This study utilized a descriptive qualitative approach, including thematic data analysis. Fourteen in-depth interviews were conducted with primary health care and digital health stakeholders in Ontario. NVivo software was utilized in the coding of the interviews. RESULTS: Five main interconnected themes emerged: (1) Mismatch Between Envisioned Uses and Current Reality-denoting the importance of potential applications of AI in primary health care practice, with a recognition of the current reality characterized by a lack of available tools; (2) Mechanics of AI Don't Matter: Just Another Tool in the Toolbox- reflecting an interest in what value AI tools could bring to practice, rather than concern with the mechanics of the AI tools themselves; (3) AI in Practice: A Double-Edged Sword-the possible benefits of AI use in primary health care contrasted with fundamental concern about the possible threats posed by AI in terms of clinical skills and capacity, mistakes, and loss of control; (4) The Non-Starters: A Guarded Stance Regarding AI Adoption in Primary Health Care-broader concerns centred on the ethical, legal, and social implications of AI use in primary health care; and (5) Necessary Elements: Facilitators of AI in Primary Health Care-elements required to support the uptake of AI tools, including co-creation, availability and use of high quality data, and the need for evaluation. CONCLUSION: The use of AI in primary health care may have a positive impact, but many factors need to be considered regarding its implementation. This study may help to inform the development and deployment of AI tools in primary health care.

Early Impacts of the COVID-19 Pandemic on Public Health Systems and Practice in 3 Canadian Provinces From the Perspective of Public Health Leaders: A Qualitative Study.

CONTEXT: The COVID-19 pandemic has impacted health systems worldwide. Studies to date have largely focused on the health care system with less attention to the impact on public health systems and practice. OBJECTIVE: To describe the early impacts of COVID-19 on public health systems and practice in 3 Canadian provinces from the perspective of public health system leaders and synthesize lessons learned. DESIGN: A qualitative study using semistructured virtual interviews with public health leaders between October 2020 and April 2021. The World Health Organization's essential public health operations framework guided data collection and analysis. SETTING: This study involved the Canadian provinces of Alberta, Ontario, and Québec. These provinces were chosen for their large populations, relatively high COVID-19 burden, and variation in public health systems. PARTICIPANTS: Public health leaders from Alberta (n = 21), Ontario (n = 18), and Québec (n = 19) in organizations with a primary mandate of stewardship and/or administration of essential public health operations (total n = 58). RESULTS: We found that the COVID-19 pandemic led to intensified collaboration in public health systems and a change in workforce capacity to respond to the pandemic. This came with opportunities but also challenges of burnout and disruption of non-COVID-19 services. Information systems and digital technologies were increasingly used and there was greater proximity between public health leaders and other health system leaders. A renewed recognition for public health work was also highlighted. CONCLUSIONS: The COVID-19 pandemic impacted several aspects of public health systems in the provinces studied. Our findings can help public health leaders and policy makers identify areas for further investment (eg, intersectoral collaboration, information systems) and develop plans to address challenges (eg, disrupted services, workforce burnout) that have surfaced.

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial.

BACKGROUND: Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted. METHODS AND FINDINGS: We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports. CONCLUSIONS: In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT02744963.

A qualitative study of barriers to employment experienced by people living with HIV in Toronto and Ottawa.

BACKGROUND: Effective treatment has extended the life expectancy and reduced disability in people living with HIV (PLWH). However, previous research has found 45-65% of working-age PLWH were unemployed compared to 5-10% in the general public of North America and Europe. We examined the barriers to gaining employment among PLWH. METHODS: Thirty-five in-depth interviews were conducted in person or over the phone with PLWH living in Toronto or Ottawa. This included PLWH who were unemployed but actively seeking employment, as well as PLWH who had successfully gained employment through an agency that specifically supported PLWH funded by the AIDS Committee of Toronto. Interviews were conducted between February 2019 and March 2020. All interviews were audio-recorded, transcribed and analyzed using thematic analysis. RESULTS: The majority of participants were between the ages of 40-55 and identified as male. Participants shared many common barriers when describing their attempts to attain or maintain employment. Although varying in employment status at the time of the study, consistent barriers included experiencing HIV stigma in workplaces, challenges overcoming mental health illnesses, and difficulties in navigating social assistance and unemployment insurance programs when pursuing a return to work. CONCLUSIONS: PLWH face significant barriers when attempting to engage with employment opportunities. Health providers and organizations can do more to support campaigns to end HIV stigma, to support individuals in pursuing employment, and to advocate for policy change that supports reentry into the workforce for PLHA.

Exploring different methods to evaluate the impact of basic income interventions: a systematic review.

BACKGROUND: Persistent income inequality, the increase in precarious employment, the inadequacy of many welfare systems, and economic impact of the COVID-19 pandemic have increased interest in Basic Income (BI) interventions. Ensuring that social interventions, such as BI, are evaluated appropriately is key to ensuring their overall effectiveness. This systematic review therefore aims to report on available methods and domains of assessment, which have been used to evaluate BI interventions. These findings will assist in informing future program and research development and implementation. METHODS: Studies were identified through systematic searches of the indexed and grey literature (Databases included: Scopus, Embase, Medline, CINAHL, Web of Science, ProQuest databases, EBSCOhost Research Databases, and PsycINFO), hand-searching reference lists of included studies, and recommendations from experts. Citations were independently reviewed by two study team members. We included studies that reported on methods used to evaluate the impact of BI, incorporated primary data from an observational or experimental study, or were a protocol for a future BI study. We extracted information on the BI intervention, context and evaluation method. RESULTS: 86 eligible articles reported on 10 distinct BI interventions from the last six decades. Workforce participation was the most common outcome of interest among BI evaluations in the 1960-1980 era. During the 2000s, studies of BI expanded to include outcomes related to health, educational attainment, housing and other key facets of life impacted by individuals' income. Many BI interventions were tested in randomized controlled trials with data collected through surveys at multiple time points. CONCLUSIONS: Over the last two decades, the assessment of the impact of BI interventions has evolved to include a wide array of outcomes. This shift in evaluation outcomes reflects the current hypothesis that investing in BI can result in lower spending on health and social care. Methods of evaluation ranged but emphasized the use of randomization, surveys, and existing data sources (i.e., administrative data). Our findings can inform future BI intervention studies and interventions by providing an overview of how previous BI interventions have been evaluated and commenting on the effectiveness of these methods. REGISTRATION: This systematic review was registered with PROSPERO (CRD 42016051218).

Implementation of targeted screening for poverty in a large primary care team in Toronto, Canada: a feasibility study.

BACKGROUND: Poverty has a significant influence on health. Efforts to optimize income and reduce poverty could make a difference to the lives of patients and their families. Routine screening for poverty in primary care is an important first step but rarely occurs in Canada. We aimed to implement a targeted screening and referral process in a large, distributed primary care team in Toronto, Ontario, Canada. The main outcome was the proportion of targeted patients screened. METHODS: This implementation evaluation was conducted with a large community-based primary care team in north Toronto. The primary care team serves relatively wealthy neighborhoods with pockets of poverty. Physicians were invited to participate. We implemented targeted screening by combining census information on neighborhood-level deprivation with postal codes in patient records. For physicians agreeing to participate, we added prompts to screen for poverty to the charts of adult patients living in the most deprived areas. Standardized electronic medical record templates recommended a referral to a team case worker for income optimization, for those patients screening positive. We recorded the number and percentages of participants at each stage, from screening to receiving advice on income optimization. RESULTS: 128 targeted patients with at least one visit (25%) were screened. The primary care team included 86 physicians distributed across 19 clinical locations. Thirty-four physicians (39%) participated. Their practices provided care for 27,290 patients aged 18 or older; 852 patients (3%) were found to be living in the most deprived neighborhoods. 509 (60%) had at least one office visit over the 6 months of follow up. 25 patients (20%) screened positive for poverty, and 13 (52%) were referred. Eight patients (62% of those referred) were ultimately seen by a caseworker for income optimization. CONCLUSIONS: We implemented a targeted poverty screening program combined with resources to optimize income for patients in a large, distributed community-based primary care team. Screening was feasible; however, only a small number of patients were linked to the intervention Further efforts to scale and spread screening and mitigation of poverty are warranted; these should include broadening the targeted population beyond those living in the most deprived areas.

Addressing financial strain through a peer-to-peer intervention in primary care.

BACKGROUND: Financial strain is a key social determinant of health. As primary care organizations begin to explore ways to address social determinants, peer-to-peer interventions hold promise. OBJECTIVE: Our objective was to evaluate a peer-to-peer intervention focussed on financial empowerment delivered in primary care, in partnership with a social enterprise. METHODS: This intervention was hosted by a large primary care organization in Toronto, Canada. Participants were recruited within the organization and from local services. We organized three separate groups who met over 10 weekly in-person, facilitated sessions: millennials (age 19-29) no longer in school, precariously employed adults (age 30-55) and older adults near retirement (age 55-64). We applied principles of adult education and peer-to-peer learning. We administered surveys at intake, at exit and at 3 months after the intervention, and conducted three focus groups. RESULTS: Fifty-nine people took part. At 3 months, participants had sustained higher rates of optimism about their financial situation (54% improved from baseline), their degree of control (55% improved) and stress around finances (50% improved). In focus groups, participants reported greater understanding of their finances, that they were not alone in struggling with finances, and that it was useful to meet with others. One group continued to meet for several months after the intervention. CONCLUSIONS: In this study, a peer-to-peer intervention helped address a key social determinant of health, likely through reducing stigma, providing group support and creating a space to discuss solutions. Primary care can host these interventions and help engage potential participants.

Routine collection of sexual orientation and gender identity data: a mixed-methods study.

BACKGROUND: Sexual orientation and gender identity are key social determinants of health, but data on these characteristics are rarely routinely collected. We examined patients' reactions to being asked routinely about their sexual orientation and gender identity, and compared answers to the gender identity question against other data in the medical chart on gender identity. METHODS: We analyzed data on any patient who answered at least 1 question on a routinely administered sociodemographic survey between Dec. 1, 2013, and Mar. 31, 2016. We also conducted semistructured interviews with 27 patients after survey completion. RESULTS: The survey was offered to 15 221 patients and 14 247 (93.6%) responded to at least 1 of the sociodemographic survey questions. Most respondents answered the sexual orientation (90.6%) and gender identity (96.1%) questions. Many patients who had been classified as transgender or gender diverse in their medical chart did not self-identify as transgender, but rather selected female (22.9%) or male (15.4%). In the semistructured interviews, many patients expressed appreciation at the variety of options available, although some did not see their identities reflected in the options and some felt uncomfortable answering the questions. INTERPRETATION: We found a high response rate to questions about sexual orientation and gender identity. Fitting with other research, we suggest using a 2-part question to explore gender identity. Future research should evaluate the acceptability and feasibility of administering these questions in a variety of care settings. These data can help organizations identify health inequities related to sexual orientation and gender identity.

Exploratory study of "real world" implementation of a clinical poverty tool in diverse family medicine and pediatric care settings.

BACKGROUND: Poverty is associated with increased morbidity related to multiple child and adult health conditions and increased risk of premature death. Despite robust evidence linking income and health, and some recommendations for universal screening, poverty screening is not routinely conducted in clinical care. METHODS: We conducted an exploratory study of implementing universal poverty screening and intervention in family medicine and a range of pediatric care settings (primary through tertiary). After attending a training session, health care providers (HCPs) were instructed to perform universal screening using a clinical poverty tool with the question "Do you ever have difficulty making ends meet at the end of the month?" for the three-month implementation period. HCPs tracked the number of patients screened and a convenience sample of their patients were surveyed regarding the acceptability of being screened for poverty in a healthcare setting. HCPs participated in semi-structured focus groups to explore barriers to and facilitators of universal implementation of the tool. RESULTS: Twenty-two HCPs (10 pediatricians, 9 family physicians, 3 nurse practitioners) participated and 150 patients completed surveys. Eighteen HCPs participated in focus groups. Despite the self-described motivation of the HCPs, screening rates were low (9% according to self-reported numbers). The majority of patients either supported (72%) or were neutral (22%) about the appropriateness of HCPs screening for and intervening on poverty. HCPs viewed poverty as relevant to clinical care but identified time constraints, physician discomfort, lack of expertise and habitual factors as barriers to implementation of universal screening. CONCLUSIONS: Poverty screening is important and acceptable to clinicians and patients. However, multiple barriers need to be addressed to allow for successful implementation of poverty screening and intervention in health care settings.

Screening for poverty and intervening in a primary care setting: an acceptability and feasibility study.

BACKGROUND: A movement is emerging to encourage health providers and health organizations to take action on the social determinants of health. However, few evidence-based interventions exist. Digital tools have not been examined in depth. OBJECTIVE: To assess the acceptability and feasibility of integrating, within routine primary care, screening for poverty and an online tool that helps identify financial benefits. METHODS: The setting was a Community Health Centre serving a large number of low-income individuals in Toronto, Canada. Physicians were encouraged to use the tool at every possible encounter during a 1-month period. A link to the tool was easily accessible, and reminder emails were circulated regularly. This mixed-methods study used a combination of pre-intervention and post-intervention surveys, focus groups and interviews. RESULTS: Thirteen physicians participated (81.25% of all) and represented a range of genders and years in practice. Physicians reported a strong awareness of the importance of identifying poverty as a health concern, but low confidence in their ability to address poverty. The tool was used with 63 patients over a 1-month period. Although screening and intervening on poverty is logistically challenging in regular workflows, online tools could assist patients and health providers identify financial benefits quickly. Future interventions should include more robust follow-up. CONCLUSIONS: Our study contributes to the evidence based on addressing the social determinants of health in clinical settings. Future approaches could involve routine screening, engaging other members of the team in intervening and following up, and better integration with the electronic health record.