Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature.

BACKGROUND: It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it. PURPOSE OF STUDY: This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation. METHODS: Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes. RESULTS: Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs. CONCLUSION: Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.

Housing and Healthy Child Development: Known and Potential Impacts of Interventions.

Housing is often described as an important determinant of health, but less commonly of child health. Despite acknowledgment of the importance of housing to health, however, there are relatively few studies of the effects of housing interventions on health, and again even fewer on child health. This article argues that a broad focus on healthy child development-as opposed to just physical health-coupled with a conceptual framework outlining specific attributes of housing with the potential to influence child health, should be adopted to guide a comprehensive approach to public health policy for healthy child development. Most housing interventions address direct pathways linking in-home hazard exposures to child health outcomes, with promising but mixed results. But few housing interventions address the broader aspects of healthy child development. This review addresses potential housing interventions that could impact the broader determinants of healthy child development and accompanying methodological challenges.

Residential moves, neighbourhood walkability, and physical activity: a longitudinal pilot study in Ontario Canada.

BACKGROUND: Numerous cross-sectional studies have consistently demonstrated an association between attributes of urban form or 'walkability' and individual- and population-level physical activity (PA) patterns. However, in the absence of longitudinal research, the self-selection problem undermines the claim that a walkable built form produces more physically active people. Through a longitudinal pilot study of 'imminent movers' in Ontario using a quasi-experimental approach, we sought to examine the feasibility of longitudinal methods that would produce stronger evidence for a causal relationship between the built environment and PA levels. METHODS: Participants were recruited using publicly available real estate listings. Successful recruits were sent a PA diary to track their activity for a week, and were also scheduled for a 45-min phone interview that collected demographic details, neighbourhood perceptions and self-efficacy for walking, and verified the PA diary. Following their move, participants were given the same tasks and then sorted into groups based on changes in their neighbourhood walkability (measured with Walk Score) from baseline to follow-up. RESULTS: There were challenges in recruiting a sufficient number of participants and counter-factuals to examine the relationship between changes in walkability and PA. Our limited sample showed a substantial decrease in Walk Score over the entire sample, from an average of 45.8 to 30.6, with most participants moving to less walkable areas. From baseline to follow-up, the largest declines in reported self-efficacy for walking were to grocery stores, banks, and for entertainment. For the entire sample, utilitarian PA decreased, while recreational and job-related PA increased. CONCLUSIONS: This pilot study highlighted the methodological challenges involved in collecting quasi-experimental evidence on the effect of walkable environments on PA. Additionally, the low sample size and the tendency for most participants to move to less walkable areas meant there were insufficient counter-factuals for study of the effect of walkability on PA. Despite these challenges, we saw important changes in self-efficacy for walking that were commensurate with changes to the built environment. In sum, while longitudinal research on health and the built environment is urgently needed, recruiting an adequate sample size for a quasi-experimental study such as this is extremely challenging.

Enabling the participation of marginalized populations: case studies from a health service organization in Ontario, Canada.

We examined efforts to engage marginalized populations in Ontario Community Health Centers (CHCs), which are primary health care organizations serving 74 high-risk communities. Qualitative case studies of community participation in four Ontario CHCs were carried out through key informant interviews with CHC staff to identify: (i) the approaches, strategies and methods used in participation initiatives aimed specifically at engaging marginalized populations in the planning of and decision making for health services; and (ii) the challenges and enablers for engaging these populations. The marginalized populations involved in the community participation initiatives studied included Low-German Speaking Mennonites in a rural town, newcomer immigrants and refugees in an urban downtown city, immigrant and francophone seniors in an inner city and refugee women in an inner city. Our analysis revealed that enabling the participation of marginalized populations requires CHCs to attend to the barriers experienced by marginalized populations that constrain their participation. Key informants outlined the features of a 'community development approach' that they rely on to address the barriers to marginalized peoples' involvement by strengthening their skills, abilities and leadership in capacity-building activities. The community development approach also shaped the participation methods that were used in the engagement process of CHCs. However, key informants also described the challenges of applying this approach, influenced by the cultural values of some groups, which shaped their willingness and motivation to participate. This study provides further insight into the approach, strategies and methods used in the engagement process to enable the participation of marginalized populations, which may be transferable to other health services settings.

Establishing stability: exploring the meaning of 'home' for women who have experienced intimate partner violence.

There is evidence that involuntary housing instability may undermine health and well-being. For women who have experienced intimate partner violence (IPV), achieving stability is likely as important for other groups, but can be challenging. Through our analysis of 41 interviews with women who have experienced low income and IPV, we argue that definitions of housing stability are multifaceted and for many centred on a shared understanding of the importance of creating an environment of "home". We found that obtaining housing that satisfied material needs was important to women. However, in asking women to define what housing stability meant to them, we found that other factors related to ontological security and the home, such as safety, community, and comfort, contributed to women's experiences of stability. Through our discussion of the importance these women placed on establishing stable homes, we argue that future research on women's experiences with housing stability and IPV should include definitions of stability that capture both material security and women's experiences with building emotionally stable homes.

Absolute and relative densities of fast-food versus other restaurants in relation to weight status: Does restaurant mix matter?

BACKGROUND: Given the continuing epidemic of obesity, policymakers are increasingly looking for levers within the local retail food environment as a means of promoting healthy weights. PURPOSE: To examine the independent and joint associations of absolute and relative densities of restaurants near home with weight status in a large, urban, population-based sample of adults. METHODS: We studied 10,199 adults living in one of four cities in southern Ontario, Canada, who participated in the Canadian Community Health Survey (cycles 2005, 2007/08, 2009/10). Multivariate models assessed the association of weight status (obesity and body mass index) with absolute densities (numbers) of fast-food, full-service and other restaurants, and the relative density (proportion) of fast-food restaurants (FFR) relative to all restaurants within ~10-minute walk of residential areas. RESULTS: Higher numbers of restaurants of any type were inversely related to excess weight, even in models adjusting for a range of individual covariates and area deprivation. However, these associations were no longer significant after accounting for higher walkability of areas with high volumes of restaurants. In contrast, there was a direct relationship between the proportion of FFR relative to all restaurants and excess weight, particularly in areas with high volumes of FFR (e.g., odds ratio for obesity=2.55 in areas with 5+ FFR, 95% confidence interval: 1.55-4.17, across the interquartile range). CONCLUSIONS: Policies aiming to promote healthy weights that target the volume of certain retail food outlets in residential settings may be more effective if they also consider the relative share of outlets serving more and less healthful foods.

Housing Instability and Policy Considerations for Equitable Aging in Place in Canada.

BACKGROUND: In this article, we apply a gender-based analysis plus framework to research the housing experiences of older, low-income adults living and aging in Hamilton. Low-income older adults with intersectional identities are at risk of not aging in place due to marginalization and housing instability. OBJECTIVE: Policy currently homogenizes the experience of aging by sidelining intersectional factors that have a bearing on aging well in place. The research aims to develop policy recommendations to address this gap. METHODS: Several methods captured the housing experiences of low-income older adults, including interviews, participant observation, and arts-based techniques. FINDINGS: Findings illustrate how gender and intersectional factors shape both housing trajectories and agentive practices low-income adults utilize to try to age well and in place. These strategies encompass practicing cultural citizenship, which is a claim for inclusion when excluded from mainstream ideals of aging in place. DISCUSSION: We provide policy recommendations informed by participants' lived experiences aimed at promoting equitable aging in place as fundamental to full citizenship.

The effect of cash transfers on health in high-income countries: A scoping review.

High-income countries use cash transfer programs to mitigate poverty, in part to improve the health of low-income populations and potentially reduce their use of public health care. This review synthesizes evidence from studies that employed experimental or quasi-experimental designs to evaluate the effect of cash transfer interventions on health outcomes or health care utilization in high-income countries. We excluded interventions if they required prior contributions for eligibility, substituted cash transfers for in-kind services, or were contingent on specific health behaviours, and excluded studies published before 1970. We searched 14 academic databases on May 13, 2022 and April 18, 2023, identifying 20,978 unique records. After screening, 164 studies were included. These studies covered interventions in 14 countries, with the largest share from the United States. The most common health outcomes examined were fertility, birth weight, self-rated health, tobacco use, and depression. We classified studies into seven intervention categories and eight health outcome domains, and identified where systematic reviews may be possible. We found relatively few studies examining health care utilization as an outcome and identify this as a knowledge gap. We categorized effects as beneficial or harmful, except for fertility and health care utilization where effects were categorized as increase or decrease. With insufficient consistency of outcomes for meta-analysis, we employed a vote count and sign test to assess the presence of any effect. Across the six relevant health domains, 98 of 130 studies (.75; 95% CI: .67, .82) reported a beneficial median effect, significantly different from the null value of 50% (p = .000). Of 37 studies examining fertility, 23 showed increases (.62; 95% CI: .46, .76) in fertility, which did not clear our threshold for statistical significance using conservative assumptions (p = .094). However, a larger share of studies reported increased fertility for child/family benefits (.69, n = 26) than for employment-related cash transfers (.44, n = 9). Results for health care utilization were evenly distributed (5 increase, 4 inconsistent, 6 decrease), but these are difficult to interpret as outcomes include both preventive and acute care. Our study provides replicable methods to enable future meta-analyses.

State-level association between income inequality and mortality in the USA, 1989-2019: ecological study.

BACKGROUND: Prior studies have shown a positive relationship between income inequality and population-level mortality. This study investigates whether the relationship between US state-level income inequality and all-cause mortality persisted from 1989 to 2019 and whether changes in income inequality were correlated with changes in mortality rates. METHODS: We perform repeated cross-sectional regressions of mortality on state-level inequality measures (Gini coefficients) at 10-year intervals. We also estimate the correlation between within-state changes in income inequality and changes in mortality rates using two time-series models, one with state- and year-fixed effects and one with a lagged dependent variable. Our primary regressions control for median income and are weighted by population. MAIN OUTCOME MEASURES: The two primary outcomes are male and female age-adjusted mortality rates for the working-age (25-64) population in each state. The secondary outcome is all-age mortality. RESULTS: There is a strong positive correlation between Gini and mortality in 1989. A 0.01 increase in Gini is associated with more deaths: 9.6/100 000 (95% CI 5.7, 13.5, p<0.01) for working-age females and 29.1 (21.2, 36.9, p<0.01) for working-age males. This correlation disappears or reverses by 2019 when a 0.01 increase in Gini is associated with fewer deaths: -6.7 (-12.2, -1.2, p<0.05) for working-age females and -6.2 (-15.5, 3.1, p>0.1) for working-age males. The correlation between the change in Gini and change in mortality is also negative for all outcomes using either time-series method. These results are generally robust for a range of income inequality measures. CONCLUSION: The absence or reversal of correlation after 1989 and the presence of an inverse correlation between change in inequality and change in all-cause mortality represents a significant reversal from the findings of a number of other studies. It also raises questions about the conditions under which income inequality may be an important policy target for improving population health.

Does receipt of social housing impact mental health? Results of a quasi-experimental study in the Greater Toronto Area.

Affordable housing is commonly described as an important determinant of health, but there are relatively few intervention studies of the effects of housing on health. In this paper, we describe the results of a quasi-experimental, longitudinal study investigating the impacts of receiving social housing among a cohort of 502 people on waitlists for social housing in the Greater Toronto Area, Canada. Specifically, we sought to determine if adults who received housing were more likely than a control group to show improvements in depression, psychological distress, and self-rated mental health 6, 12 and 18 months after moving to housing. Amongst the participants, 137 received social housing and completed at least one follow-up interview; 304 participants did not receive housing and completed at least one follow-up interview and were treated as a control group (47 people provided data to both groups). The difference-in-differences technique was used to estimate the effect of receiving housing by comparing changes in the outcomes over time in the housed (intervention) group and the group that remained on the waitlist for social housing (control group). Adjusted mixed effects linear models showed that receiving housing resulted in significant decreases in psychological distress and self-rated mental health between the groups. Improvements in self-rated mental health between the groups were observed 6, 12 and 18 months after receiving housing (6 months, +2.9, p < 0.05; 12 months, +2.6, p < 0.05; 18 months, +3.0, p < 0.05). Reductions in psychological distress (-1.4, p < 0.05) were observed 12 months after receiving housing. Overall findings suggest that receiving subsidized housing improves mental health over a 6-to-18-month time horizon. This has policy and funding implications suggesting a need to reduce wait times and expand access to subsidized housing.

Short-term impact of a neighbourhood-based intervention on mental health and self-rated health in Hamilton, Ontario, Canada.

The Hamilton Neighbourhoods Study aimed to measure the short-term impact of a neighbourhood-based intervention known as the City of Hamilton's Neighbourhood Action Strategy on health and neighbourhood outcomes. A quasi-experimental study with 881 intervention participants across six targeted neighbourhoods and 173 control participants was conducted to investigate changes in self-rated health and mental health from baseline to follow-up. There was evidence of small improvements in mental health in two neighbourhoods, but there was no change in self-rated health. Place-based interventions aimed at high poverty neighbourhoods may have only modest impacts on health in the short-term.

Friendly Visiting Programs for Older People Experiencing Social Isolation: A Realist Review of what Works, for whom, and under what Conditions.

Many social interventions have been developed with the hopes of reducing and preventing social isolation among older people (e.g., recreation, arts-based programs and social prescription). Friendly visiting programs, also known as befriending schemes, have been a mainstay in this area for decades and are largely thought to be effective at reconnecting older people (≥ 60 years of age) experiencing isolation. Research and evaluations have yet to determine, however, how and why these programs may be most successful, and under what conditions. This article presents the findings of a realist synthesis aimed at identifying the critical mechanisms and contextual factors that lead to successful outcomes in friendly visiting programs. Seven studies are synthesized to inform a friendly visiting program theory accounting for key mechanisms (e.g., provision of informal support) and underlying contexts (e.g., training of volunteers) that can be used to inform future programs. Recommendations for future research are also presented.

The association between housing cost burden and avoidable mortality in wealthy countries: cross-national analysis of social and housing policies, 2000-2017.

BACKGROUND: It has been shown that the high cost of housing can be detrimental to individual health. However, it is unknown (1) whether high housing costs pose a threat to population health and (2) whether and how social policies moderate the link between housing cost burden and mortality. This study aims to reduce these knowledge gaps. METHODS: Country-level panel data from Organisation for Economic Co-operation and Development (OECD) countries are used. Housing cost to income ratio and age-standardised mortality were obtained from the OECD database. Fixed effects models were conducted to estimate the extent to which the housing cost to income ratio was associated with preventable mortality, treatable mortality, and suicides. In order to assess the moderating effects of social and housing policies, different types of social spending per capita as well as housing policies were taken into account. RESULTS: Housing cost to income ratio was significantly associated with preventable mortality, treatable mortality, and suicide during the post-global financial crisis (2009-2017) but not during the pre-global financial crisis (2000-2008). Social spending on pensions and unemployment benefits decreased the levels of mortality rate associated with housing cost burden. In countries with higher levels of social housing stock, the link between housing cost burden and mortality was attenuated. Similar patterns were examined for countries with rent control. CONCLUSION: Our findings suggest that housing cost burden can be related to population health. Future studies should examine the role of protective measures that alleviate health problems caused by housing cost burden.

How do housing asset and income relate to mortality? A population-based cohort study of 881220 older adults in Canada.

OBJECTIVE: A growing body of research has documented a well-established link between socioeconomic conditions and mortality among older adults. This study aims to understand (a) whether housing assets and income are associated with mortality and (b) if the value of housing assets affects the relationship between income and mortality; both questions are studied among older adults aged 65 or over in Canada. METHODS: Using the population-based linked dataset (2011 Canadian Census Health and Environment Cohorts) of 881,220 older adults over six years of follow-up (2011-2017), this study uses survival analysis to estimate the link between housing assets, income level and mortality. We also assess the potential moderating effect of housing asset levels on the association between income and mortality by categorizing individuals along two dimensions: whether they are income-poor and whether they are housing assets-poor. RESULTS: The mortality rate was higher among both the lowest asset (HR = 1.346) and the lowest income group (HR = 1.203). The association is pronounced for older adults aged 65 to 74. Assets did not significantly moderate the link between income and mortality. Income-related inequalities in mortality are observed among each group of housing asset level. Compared to those who are neither income-poor nor housing assets-poor, individuals who were income poor but not housing assets-poor were more likely to die (HR = 1.067) over seven years of follow-up, and people who were housing assets-poor only were more likely to die (HR = 1.210). Being housing-assets poor and income-poor yielded a higher hazard ratio (HR = 1.291). CONCLUSIONS: Housing assets and income are associated with mortality of older adults. It is important to identify people who are assets poor and/or income poor who are at higher risks of mortality. Social policies aimed at reducing income insecurity and housing insecurity can reduce mortality inequalities.

Income inequality and population health: a political-economic research agenda.

There is more than 30 years of research on relationships between income inequality and population health. In this article, we propose a research agenda with five recommendations for future research to refine existing knowledge and examine new questions. First, we recommend that future research prioritise analyses with broader time horizons, exploring multiple temporal aspects of the relationship. Second, we recommend expanding research on the effect of public expenditures on the inequality-health relationship. Third, we introduce a new area of inquiry focused on interactions between social mobility, income inequality and population health. Fourth, we argue the need to examine new perspectives on 21st century capitalism, specifically the population health impacts of inequality in income from capital (especially housing), in contrast to inequality in income from labour. Finally, we propose that this research broaden beyond all-cause mortality, to cause-specific mortality, avoidable mortality and subcategories thereof. We believe that such a research agenda is important for policy to respond to the changes following the COVID-19 pandemic.

Health and social outcomes in the Housing First model: Testing the theory of change.

Background: Homelessness continues to grow globally. The Housing First (HF) model offers immediate access to housing and support services without preconditions and has a growing body of evidence documenting its effectiveness at ending homelessness. HF has a robust theory of change that hypothesizes how unique program components (i.e., immediate access to housing, separation of services from housing, client choice, etc.) drive positive social and health changes over time. We advance the understanding of how HF causes client improvement by empirically testing this program's theory of change. Methods: Using a unique longitudinal quantitative data from the large Canadian At Home/Chez Soi Housing First trial we used path analysis to test the theory of change for Quality of Life, Crisis related events or service utilization, and Recovery.  Program pathways and health and social outcomes were measured at enrolment, 6-, 12- and 24-months post-enrolment. Findings: Most hypothesized pathways were confirmed with path analysis.  Confirmed pathways for two outcomes- Quality of Life (QOL) and Recovery - were similar. Health and social consultations at enrolment, health status at 6- and 12-months post enrolment, and social connectedness at 12-months were important predictors of the 24-month outcomes of Quality of Life and Recovery, but not for Crisis related events or service utilization. Interpretation: This analysis directly responds to recent calls for more empirical evidence about intervention mechanisms. Ensuring linkages to health and social service consultations for clients, supporting clients' engagement with family and community, and enabling clients to improve or maintain good health will drive better longer term client outcomes within Housing First. Funding: Funding Mental Health Commission of Canada.

Influence of neighborhood deprivation, gender and ethno-racial origin on smoking behavior of Canadian youth.

OBJECTIVE: Deprived neighborhoods play an important role in adult smoking behavior, but little research exists about youth on this topic. This study explored the relationship between deprivation and youth smoking to examine whether this association differs by gender and ethno-racial origin. METHODS: Individual-level data from the Canadian Community Health Survey (2000-2005) were combined with neighborhood-level data from the 2001 Canada Census to assess smoking among youth aged 12-18 (n = 15,615). RESULTS: Youth who were female (OR = 1.27, 95%CI:1.16-1.38), White (OR = 1.95, 95%CI:1.71-2.21) and living in deprived neighborhoods (OR = 1.22, 95%CI:1.16-1.28) were more likely to smoke. In multilevel models, White females were more likely to smoke relative to non-White females and males (OR = 1.42, 95%CI:1.06-1.89). Youth with a strong sense of community belonging and living in deprived neighborhoods were at increased risk of smoking (OR = 1.18, 95%CI:1.06-1.32). The individual-level risk factor, household smoker, contributed substantially to youth smoking reducing the bivariate association between material deprivation and smoking by 33%. CONCLUSION: White females, youth cohabiting with other smokers and youth living in poor neighborhoods with a strong sense of community belonging, are at an increased risk of smoking. Future anti-smoking efforts might have greater impact if they target at-risk youth as well as household members who cohabit with youth.

Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program.

Supportive housing, defined as subsidized housing in conjunction with site-based social services, may help improve the health and residential stability of highly disadvantaged individuals. This study examined changes in health status, quality of life, substance use, health care utilization, and residential stability among 112 homeless and vulnerably housed individuals who applied to a supportive housing program in Toronto, Canada, from December 2005 to June 2007. Follow-up interviews were conducted every 6 months for 18 months. Comparisons were made between individuals who were accepted into the program (intervention) and those who were wait-listed (usual care) using repeated-measures analyses. Individuals who were accepted into the housing program experienced significantly greater improvements in satisfaction with living situation compared with individuals in the usual care group (time, F(3,3,261) = 47.68, p < 0.01; group × time, F(3,3,261) = 14.60, p < 0.01). There were no significant differences in other quality of life measures, health status, health care utilization, or substance use between the two groups over time. Significant improvement in residential stability occurred over time, independent of assigned housing group (time, F(3,3,261) = 9.96, p < 0.01; group × time, F(3,3,261) = 1.74, p = 0.17). The ability to examine the effects of supportive housing on homeless individuals was limited by the small number of participants who were literally homeless at baseline and by the large number of participants who gained stable housing during the study period regardless of their assigned housing status. Nonetheless, this study shows that highly disadvantaged individuals with a high prevalence of poor physical and mental health and substance use can achieve stable housing.