Paramedic attitudes and experiences working as a community paramedic: a qualitative survey.

BACKGROUND: Community paramedicine (CP) is an extension of the traditional paramedic role, where paramedics provide non-acute care to patients in non-emergent conditions. Due to its success in reducing burden on hospital systems and improving patient outcomes, this type of paramedic role is being increasingly implemented within communities and health systems across Ontario. Previous literature has focused on the patient experience with CP programs, but there is lack of research on the paramedic perspective in this role. This paper aims to understand the perspectives and experiences, both positive and negative, of paramedics working in a CP program towards the community paramedic role. METHODS: An online survey was distributed through multiple communication channels (e.g. professional organizations, paramedic services, social media) and convenience sampling was used. Five open-ended questions asked paramedics about their perceptions and experiences with the CP role; the survey also collected demographic data. While the full survey was open to all paramedics, only those who had experience in a CP role were included in the current study. The data was qualitatively analyzed using a comparative thematic analysis. RESULTS: Data was collected from 79 respondents who had worked in a CP program. Three overarching themes, with multiple sub-themes, were identified. The first theme was that CP programs fill important gaps in the healthcare system. The second was that they provide paramedics with an opportunity for lateral career movement in a role where they can have deeper patient connections. The third was that CP has created a paradigm shift within paramedicine, extending the traditional scope of the practice. While paramedics largely reported positive experiences, there were some negative perceptions regarding the slower pace of work and the "soft skills" required in the role that vary from the traditional paramedic identity. CONCLUSIONS: CP programs utilize paramedic skills to fill a gap in the healthcare system, can improve paramedic mental health, and also provide a new pathway for paramedic careers. As a new role, there are some challenges that CP program planners should take into consideration, such as additional training needs and the varying perceptions of CP.

Cardiometabolic risk factors in social housing residents: A multi-site cross-sectional survey in older adults from Ontario, Canada.

OBJECTIVE: This study describes cardiometabolic diseases and related risk factors in vulnerable older adults residing in social housing, aiming to inform primary care initiatives to reduce health inequities. Associations between sociodemographic variables, modifiable risk factors (clinical and behavioural), health-related quality of life and self-reported cardiometabolic diseases were investigated. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study with an interviewer-administered questionnaire. Data was collected from residents aged 55 years and older residing in 30 social housing apartment buildings in five regions in Ontario, Canada. OUTCOME MEASURES: The proportion of cardiometabolic diseases and modifiable risk factors (e.g., clinical, behavioural, health status) in this population was calculated. RESULTS: Questionnaires were completed with 1065 residents: mean age 72.4 years (SD = 8.87), 77.3% were female, 87.2% were white; 48.2% had less than high school education; 22.70% self-reported cardiovascular disease (CVD), 10.54% diabetes, 59.12% hypertension, 43.59% high cholesterol. These proportions were higher than the general population. Greater age was associated with overweight, high cholesterol, high blood pressure and CVD. Poor health-related quality of life was associated with self-reported CVD and diabetes. CONCLUSIONS: Older adults residing in social housing in Ontario have higher proportion of cardiovascular disease and modifiable risk factors compared to the general population. This vulnerable population should be considered at high risk of cardiometabolic disease. Primary care interventions appropriate for this population should be implemented to reduce individual and societal burdens of cardiometabolic disease.

Effect of a Legal Clinic Program Within an Urban Primary Health Care Center on Social Determinants of Health: A Program Evaluation.

BACKGROUND: Individuals living in poverty often visit primary healthcare clinics for health problems stemming from unmet legal needs. We examined the impact of a medical-legal partnership on improving the social determinants of health (SDoH), health-related quality of life, and perceived health status of attendees of a Legal Clinic Program (LCP). METHODS: This was a pre-post program evaluation of a weekly LCP established within an urban primary healthcare clinic to provide free legal consultation. Patients aged 18 years or older were either approached or referred to complete a screening tool to identify potential legal needs. Those identified with potential legal needs were offered an appointment with LCP lawyers who provided legal counsel, referrals, and services. For those who attended the LCP, changes in SDoH and health indicators were collected via a self-reported survey 6 months after they attended the LCP and compared to their baseline scores using paired t-tests, McNemar's test for paired proportions, and the Wilcoxon Signed Rank Test for related samples. RESULTS: During the 6-month evaluation period, 31 participants attended the LCP and completed both the baseline and 6-month surveys; 67.8% were female, 64.5% were white, 90.3% were not working full-time, and 61.3% had a household income of $700 to 1800 per month. At follow-up, 25.8% were receiving at least 1 new benefit and there was a statistically significant reduction in food insecurity (35.5% vs 9.7%, P < .05). Also, perceived health status using the visual analog scale (ranges from 0 to 100) significantly improved from 42.5 points (SD = 25.3) at baseline to 56.6 points (SD = 19.6) after 6 months (P < .05). CONCLUSIONS: The LCP has the potential to improve the health and wellbeing of patients in primary healthcare clinics by addressing unmet legal needs and SDoH.

The Community Paramedicine at Clinic Program: Improving Participant Health while Preserving Healthcare System Resources.

Vulnerable populations such as low-income older adults in social housing suffer from poor quality of life and are impacted by chronic diseases. These populations are also high users of emergency services, which contribute to high healthcare costs. Community-based, patient-centred interventions, such as community paramedicine (CP) programs, can address the healthcare gaps for these underserved populations. Community Paramedicine at Clinic (CP@clinic) is an innovative, evidence-based, chronic disease prevention/management program that improves patient health and quality of life, connects them with health and community services, preserves healthcare resources and yields cost savings for the emergency care system. The program also works with other community organizations, facilitating interprofessional engagement and supporting other disciplines in providing care. Known barriers to implementing CP programs highlight the importance of standard practices and training as exemplified by the CP@clinic program.

Development of indicators for avoidable emergency medical service calls by mapping paramedic clinical impression codes to ambulatory care sensitive conditions and mental health conditions in the UK and Canada.

OBJECTIVE: Paramedic assessment data have not been used for research on avoidable calls. Paramedic impression codes are designated by paramedics on responding to a 911/999 medical emergency after an assessment of the presenting condition. Ambulatory care sensitive conditions (ACSCs) are non-acute health conditions not needing hospital admission when properly managed. This study aimed to map the paramedic impression codes to ACSCs and mental health conditions for use in future research on avoidable 911/999 calls. DESIGN: Mapping paramedic impression codes to existing definitions of ACSCs and mental health conditions. SETTING: East Midlands Region, UK and Southern Ontario, Canada. PARTICIPANTS: Expert panel from the UK-Canada Emergency Calls Data analysis and GEospatial mapping (EDGE) Consortium. RESULTS: Mapping was iterative first identifying the common ACSCs shared between the two countries then identifying the respective clinical impression codes for each country that mapped to those shared ACSCs as well as to mental health conditions. Experts from the UK-Canada EDGE Consortium contributed to both phases and were able to independently match the codes and then compare results. Clinical impression codes for paramedics in the UK were more extensive than those in Ontario. The mapping revealed some interesting inconsistencies between paramedic impression codes but also demonstrated that it was possible. CONCLUSION: This is an important first step in determining the number of ASCSs and mental health conditions that paramedics attend to, and in examining the clinical pathways of these individuals across the health system. This work lays the foundation for international comparative health services research on integrated pathways in primary care and emergency medical services.

Perceived value and benefits of the Community Paramedicine at Clinic (CP@clinic) programme: a descriptive qualitative study.

OBJECTIVES: Community Paramedicine (CP) is increasingly being used to provide chronic disease management for vulnerable populations in the community. CP@clinic took place in social housing buildings to support cardiovascular health and diabetes management for older adults. The purpose of this study was to examine participant perceptions of their experience with CP@clinic as well as potential ongoing programme benefits. DESIGN: This descriptive qualitative study used focus groups to understand resident experiences of the CP@clinic programme. Groups were facilitated by experienced moderators using a semistructured guide. An inductive coding approach was used with at least two researchers taking part in each step of the analysis process. SETTING: Community-based social housing buildings in Ontario, Canada. PARTICIPANTS: Forty-one participants from four CP@clinic sites took part in a focus group. Convenience sampling was used with anyone having taken part in a CP@clinic session being eligible to attend the focus group. RESULTS: Analysis yielded six themes across two broad areas: timely access to health information and services, support to achieve personal health goals, better understanding of healthcare system (Personal Benefits); and sense of community, comfortable and familiar place to talk about health, facilitated communication between healthcare professionals (Programme Structure). Participants experienced discernible health changes that motivated their participation. CP@clinic was viewed as a programme that created connections within the building and outside of it. Participants were enthusiastic for the continuation of the programme and appreciated the consistent support to meet their health goals. CONCLUSIONS: CP@clinic was successful in creating a supportive and friendly environment to facilitate health behavioural changes. Ongoing implementation of CP@clinic would allow residents to continue to build their chronic disease management knowledge and skills. TRIAL REGISTRATION NUMBER: Trial registration number: NCT02152891, Clinicaltrials.gov.

Challenges in recruiting frequent users of ambulance services for a community paramedic home visit program.

BACKGROUND: The Community Paramedicine at Home (CP@home) program is a health promotion program where community paramedics conduct risk assessments with frequent 9-1-1 callers in their homes, with a goal of reducing the frequency of 9-1-1 calls in this vulnerable population. The effectiveness of the CP@home program was investigated through a community-based RCT conducted in four regions in Ontario, Canada. The purpose of this current recruitment study is to examine the challenges met when recruiting for a community randomized control trial on high frequency 9-1-1 callers. METHODS: Eligible participants were recruited from one of four regions participating in the CP@home program and were randomly assigned to an intervention group (n = 1142) or control group (n = 1142). Data were collected during the recruitment process from the administrative database of the four paramedic services. Whether they live alone, their parental ethnicity, age, reason for calling 9-1-1, reason for not participating, contact method, and whether they were successfully contacted were recorded. Statistical significance was calculated using the Chi-Squared Test and Fisher's Exact Test to evaluate the effectiveness of the recruitment methods used to enroll eligible participants in the CP@home Program. RESULTS: Of the people who were contacted, 48.0% answered their phone when called and 53.9% answered their door when a home visit was attempted. In Total, 110 (33.1%) of people where a contact attempt was successful participated in the CP@home program. Most participants were over the age of 65, even though people as young as 18 were contacted. Older adults who called 9-1-1 for a lift assist were more likely to participate, compared to any other individual reason recorded, and were most often recruited through a home visit. CONCLUSIONS: This recruitment analysis successfully describes the challenges experienced by researchers when recruiting frequent 9-1-1 callers, which are considered a hard-to-reach population. The differences in age, contact method, and reason for calling 9-1-1 amongst people contacted and participants should be considered when recruiting this population for future research.

Adapting the Community Paramedicine at Clinic (CP@clinic) program to a remote northern first nation community: a qualitative study of community members' and local health care providers' views.

The views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada on their health care landscape and adapting the Community Paramedicine at Clinic (CP@clinic) Program to their community are presented. Key informant interviews took place between September 2020 and March 2021, and were thematically analysed using the Framework Hierarchical Analysis. There were seven themes that emerged with many subthemes: available services in the community, health care access, health challenges in community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic program considerations for adaptation. CP@clinic program considerations for adaptation included defining the role of CP, refining referral processes to capture the target population, advertising and promoting, ensuring community awareness, determining clinic setting and composition, focusing on advocacy and timely continuity, adding to the program through time, managing resistance, engaging community and partners, deploying cultural training and language accommodations, leveraging community assets, and ensuring sustainability. Focusing on continuity, engagement, and leveraging available resources may support the success of the CP@clinic program implementation. Findings from this study may be useful to other underserved communities in Canada seeking health programming.

Do school characteristics, based on the Comprehensive School Health Framework, contribute to youth meeting national physical activity recommendations over time? / Est-ce que certaines caractéristiques des écoles, classées selon l'Approche globale de la santé en milieu scolaire, aident les adolescents à mettre en pratique les recommandations nationales en matière d'activité physique au fil du temps?

INTRODUCTION: Canadian youth are insufficiently active, and schools may play a role in promoting student physical activity (PA). Based on the Comprehensive School Health (CSH) framework, this study examined whether school characteristics are associated with secondary school students meeting national PA recommendations over time. METHODS: We used COMPASS survey data from 78 schools in Ontario and Alberta and 9870 Grade 9 and 10 students attending those schools. Students who provided two years of linked PA data (2013/14 and 2015/16) and gender were included. Multilevel analysis was conducted by gender, evaluating the relationship of school-level characteristics (guided by CSH) with students achieving all three PA recommendations after two years (≥ 60 min/day of moderate-to-vigorous PA, vigorous PA ≥ 3 days/week, strengthening activities ≥ 3 days/week). RESULTS: More than half (56.9%) of students achieving the PA recommendations at baseline were no longer achieving them after two years, and just a quarter (25.6%) of students not achieving the recommendations at baseline achieved them after two years. School-level factors were significantly associated with students achieving the recommendations, but these factors differed by student strata (i.e. by gender and baseline PA status). Generally, student access to equipment, public health partnerships and staff time for health were associated with increased odds of achieving the PA recommendations for certain students. CONCLUSION: Modifications to school characteristics within CSH may play a role in supporting students in achieving or continuing to achieve the PA recommendations after two years. Further research is needed to better understand the underlying dynamics of the observed relationships.

Health knowledge and self-efficacy to make health behaviour changes: a survey of older adults living in Ontario social housing.

BACKGROUND: Older adults living in social housing are a vulnerable population facing unique challenges with health literacy and chronic disease self-management. We investigated this population's knowledge of cardiovascular disease and diabetes mellitus, and self-efficacy to make health behaviour changes (for example, physical activity). This study characterized the relationship between knowledge of health risk factors and self-efficacy to improve health behaviours, in order to determine the potential for future interventions to improve these traits. METHODS: A cross-sectional study (health behaviour survey) with adults ages 55+ (n = 599) from 16 social housing buildings across five Ontario communities. Descriptive analyses conducted for demographics, cardiovascular disease and diabetes knowledge, and self-efficacy. Subgroup analyses for high-risk groups were performed. Multivariate logistic regressions models were used to evaluate associations of self-efficacy outcomes with multiple factors. RESULTS: Majority were female (75.6%), white (89.4%), and completed high school or less (68.7%). Some chronic disease subgroups had higher knowledge for those conditions. Significant (p < 0.05) associations were observed between self-efficacy to increase physical activity and knowledge, intent to change, and being currently active; self-efficacy to increase fruit/vegetable intake and younger age, knowledge, and intent to change; self-efficacy to reduce alcohol and older age; self-efficacy to reduce smoking and intent to change, ability to handle crises, lower average number of cigarettes smoked daily, and less frequent problems with usual activities; self-efficacy to reduce stress and ability to handle crises. CONCLUSIONS: Those with chronic diseases had greater knowledge about chronic disease. Those with greater ability to handle personal crises and intention to make change had greater self-efficacy to change health behaviours. Development of stress management skills may improve self-efficacy, and proactive health education may foster knowledge before chronic disease develops.

Integrating community paramedicine with primary health care: a qualitative study of community paramedic views.

BACKGROUND: Community paramedicine (CP) is an emerging model of care that addresses local health needs through programs led by community paramedics; however, CP remains poorly defined and appears to lack systematic integration with the broader health system, specifically primary care, within which it is seated. The purpose of the study was to elucidate the views of community paramedics and their stakeholders in Ontario, Canada, on the topic of integrating CP with the broader health system. METHODS: This was a retrospective qualitative analysis of a public recording of a CP provincial forum held in Ontario, Canada, in 2017. Forum attendees (paramedics and stakeholders) were invited by email if they had attended a similar provincial forum in the past (no exclusion criteria for attendance). In small- and large-group discussions, attendees discussed their views on how CP could fit into primary care and what medical oversight and acceptance for the profession could involve. A recording of the large-group discussion, which is publicly available, was transcribed and thematically analyzed. RESULTS: The 89 participants varied in professional affiliation (66% from a paramedic service, n = 59). Among those from paramedic services, 33% were community paramedics (n = 14). Five major themes emerged: defining the role of community paramedics, how CP may integrate with other services, how to garner support for CP, where standardization is needed and possible oversight structures. INTERPRETATION: Community paramedics and their stakeholders have insights into barriers and facilitators for integration with the health system. These study findings could help inform the integration of health and social services in Ontario with a consideration for the unique position and potential of community paramedics.

A Comprehensive School Health Approach to Student Physical Activity: A Multilevel Analysis Examining the Association between School-Level Factors and Student Physical Activity Behaviors.

BACKGROUND: The comprehensive school health (CSH) framework has four components: social and physical environment; partnerships and services; teaching and learning; and policy. This study examines associations between CSH and student physical activity (PA). METHODS: Using 2015/2016 COMPASS study survey data of 37,397 students (grades 9-12) from 80 secondary schools in Ontario and Alberta, Canada, associations between school-level factors within CSH and student PA outcomes (weekly moderate-to-vigorous PA [MVPA] minutes and achieving the national PA recommendations of ≥60 min of MVPA daily, vigorous PA ≥3 days/week, strengthening activities ≥3 days/week) were analyzed using multilevel regression models stratified by gender and grade. RESULTS: Factors within all four CSH components were associated with student PA. Four student subgroups were more likely to achieve the recommendations if their school had youth organization partnerships (Range of AORs:1.15-1.33, p <.05) and female students were less likely if their school had low prioritization of PA (AOR = 0.77, 95% CI: [0.65-0.92]). Grade 9 students had higher MVPA when provided non-competitive PA opportunities (ß = 100.4, 95%CI: [30.0-170.9]). All student subgroups had better PA outcomes when schools provided access to equipment during non-instructional time. CONCLUSION: There is opportunity to improve student PA through CSH-guided interventions, but different strategies may be more effective for each gender/grade.

School-Level Factors within Comprehensive School Health Associated with the Trajectory of Moderate-to-Vigorous Physical Activity over Time: A Longitudinal, Multilevel Analysis in a Large Sample of Grade 9 and 10 Students in Canada.

(1) The majority of Canadian youth are insufficiently active, and moderate-to-vigorous physical activity (MVPA) decreases substantially during secondary school. School factors within the comprehensive school health (CSH) framework may help attenuate this decline. This study aimed to examine how youth MVPA changes over a three-year period and evaluate the school characteristics associated with preventing the decline in MVPA over time, guided by the CSH framework. (2) This study uses COMPASS survey data from 78 secondary schools in Ontario and Alberta that participated in Year 2 (2013/14), Year 3 (2014/15), and Year 4 (2015/16), and 17,661 students attending these schools. Multilevel (linear mixed effects) models were used to determine the association between school-level factors and student MVPA (weekly minutes) over time, stratified by gender. (3) Both male and female students had a significant decline in MVPA across the 3 years, with a greater decrease observed among female students. Within the CSH framework, the school's social environment, partnerships, and policies were associated with student MVPA over time, however the specific school factors and directions of associations varied by gender. (4) School-based interventions (e.g., public health partnerships) may help avoid the decline in MVPA observed in this critical period and support student health.

Subjective social isolation or loneliness in older adults residing in social housing in Ontario: a cross-sectional study.

BACKGROUND: Older adults face greater risk of social isolation, but the extent of social isolation among low-income older adults living in social housing is unknown. This study aims to explore the rate of, and risk factors contributing to, subjective social isolation or loneliness among older adults in social housing. METHODS: We conducted a cross-sectional study of data collected from a community program held in the common rooms of 55 social housing buildings in 14 communities across Ontario, Canada, from May 2018 to April 2019. Participants were program attendees aged 55 years and older who resided in the buildings. Program implementers assessed social isolation using the 3-Item Loneliness Scale from the University of California, Los Angeles and risk factors using common primary care screening tools. We extracted data for this study from the program database. We compared the rate of social isolation to Canadian Community Health Survey data using a 1-sample χ2 test, and evaluated associations between risk factors and social isolation using univariate and multivariate logistic regressions. RESULTS: We included 806 residents in 30 buildings for older adults and 25 mixed-tenant buildings. Based on the 3-Item UCLA Loneliness Scale, 161 (20.0%) of the 806 participants were socially isolated. For those aged 65 and older, the rate of social isolation was nearly twice that observed in the same age group of the general population (36.1% v. 19.6%; p < 0.001). Risk factors were age (65-84 yr v. 55-64 yr adjusted odds ratio [OR] 1.99, 95% confidence interval [CI] 1.01-3.93), alcohol consumption (adjusted OR 2.45, 95% CI 1.09-5.54), anxiety or depression (adjusted OR 6.05, 95% CI 3.65-10.03) and income insecurity (adjusted OR 2.10, 95% CI 1.24-3.53). Protective factors were having at least 1 chronic cardiometabolic disease (adjusted OR 0.44, 95% CI 0.24-0.80), being physically active (adjusted OR 0.47, 95% CI 0.30-0.73) and having good to excellent general health (adjusted OR 0.60, 95% CI 0.39-0.90). INTERPRETATION: The high rate of social isolation in low-income older adults living in social housing compared with the general population is concerning. Structural barriers could prevent engagement in social activities or maintenance of social support, especially for older adults with income insecurity and anxiety or depression; interventions are needed to reduce subjective social isolation in this population.

Older adults living in social housing in Canada: the next COVID-19 hotspot?

Older adults in social housing have high rates of chronic diseases and live in clustered housing, creating the ideal situation for a tragic outbreak in this vulnerable population, which has been largely unrecognized in the public health discourse. It is estimated that two thirds of this population have cardiometabolic conditions that put them at higher risk of poor outcomes from COVID-19. In addition, their social isolation, low mobility, low health literacy, and limited internet access are barriers to accessing basic needs, health information, and health care in a Canadian context where many services have moved to virtual platforms. Since older adults in social housing tend to be clustered in apartment buildings with shared facilities, there is an increased risk of exposure through common spaces (e.g., elevator, laundry room) and high-touch surfaces. Compared to long-term care homes, there is substantial movement in and out of social housing buildings as residents are required to go out to meet their basic needs and individuals providing support enter the buildings without screening (e.g., personal support workers, volunteers delivering groceries). Without a targeted public health strategy to support this vulnerable population, we surmise that social housing will be the next COVID-19 hotspot.

RéSUMé: Les adultes âgés en logement social présentent des taux élevés de maladies chroniques et vivent dans des logements regroupés, une situation propice à une éclosion tragique dans cette population vulnérable largement laissée pour compte dans le discours de la santé publique. Il est estimé que les deux tiers de ces adultes ont des troubles cardiométaboliques qui les exposent davantage aux résultats défavorables de la COVID-19. En outre, leur isolement social, leur faible mobilité, leur faible littératie en santé et leur accès limité à l'Internet font obstacle à la satisfaction de leurs besoins fondamentaux et à leur accès aux renseignements médicaux et aux soins de santé dans un contexte canadien où de nombreux services ne sont maintenant offerts que sur des plateformes virtuelles. Comme les adultes âgés en logement social tendent à être regroupés dans des immeubles d'appartements avec des installations communes, les espaces communs (ascenseur, salle de lavage) et les surfaces souvent touchées leur font courir un risque d'exposition accru. Comparativement aux maisons de soins de longue durée, il y a de nombreux va-et-vient dans les immeubles de logements sociaux, car les résidents doivent sortir pour satisfaire leurs besoins fondamentaux, et les personnes qui les aident (préposés aux services de soutien à la personne, bénévoles qui livrent des produits d'épicerie) entrent dans l'immeuble sans être assujetties à un contrôle. En l'absence d'une stratégie de santé publique pour appuyer cette population vulnérable, nous présumons que les logements sociaux seront le prochain « point chaud ¼ de la COVID-19.

Type 2 Diabetes Risk in Older Adults Living in Social Housing: A Cross-Sectional Study.

OBJECTIVES: This study aimed to describe the risk of developing diabetes and the probable prevalence of diabetes and prediabetes in residents of subsidized or social housing who were 55 years of age or older. METHODS: We conducted a cross-sectional study using data collected from an ongoing community health program in social housing buildings-the Community Paramedicine at Clinic (CP@clinic) program. Community paramedics staffing the CP@clinic program conducted lifestyle-related modifiable risk factor assessments of participating social housing residents who were 55 years of age or older. The Canadian Diabetes risk assessment (CANRISK) tool was administered to all participants, and those with moderate-to-high risk of developing diabetes were asked to return for a fasting capillary blood glucose (CBG) measurement. Data were collected from program participants who attended the sessions between December 2014 and May 2018. RESULTS: There were 728 participants. Most were women (80.5%), aged 65 to 84 (68.1%), white (85.4%) and educated to the high school level or less (69.2%). At baseline, 71.3% were identified as having overweight or obesity, and 12.5% were diagnosed with diabetes. Of participants not diagnosed with diabetes (N=632), 66.6% were at high risk of developing diabetes, and 30.1% were categorized as moderate risk. The CBG assessments showed that 37.7% (N=158) of those with high risk and 22.0% (N=42) of those with moderate risk had blood glucose readings indicating impaired fasting glucose or probable diabetes. CONCLUSIONS: This study shows that 96.7% of low-income older adults in social housing buildings had moderate-to-high risk of developing diabetes and that the probable prevalence of undiagnosed prediabetes and diabetes was 32.0%.

Legal needs of patients attending an urban family practice in Hamilton, Ontario, Canada: an observational study of a legal health clinic.

BACKGROUND: Individuals living in poverty often visit their primary care physician for health problems resulting from unmet legal needs. Providing legal services for those in need may therefore improve health outcomes. Poverty is a social determinant of health. Impoverished areas tend to have poor health outcomes, with higher rates of mental illness, chronic disease, and comorbidity. This study reports on a medical-legal collaboration delivered in a healthcare setting between health professionals and lawyers as a novel way to approach the inaccessibility of legal services for those in need. METHODS: In this observational study, patients aged 18 or older were either approached or referred to complete a screening tool to identify areas of concern. Patients deemed to have a legal problem were offered an appointment at the Legal Health Clinic, where lawyers provided legal advice, referrals, and services for patients of the physicians. Fisher's exact test was used to compare populations. Binary logistic regression was used to determine the factors predicting booking an appointment with the clinic. RESULTS: Eighty-four percent (n = 648) of the 770 patients screened had unmet legal needs and could benefit from the intervention, with an average of 3.44 (SD = 3.42) legal needs per patient screened. Patients with legal needs had significantly higher odds of attending the Legal Health Clinic if they were an ethnicity that was not white (OR = 2.48; 95% CI 1.14-5.39), did not have Canadian citizenship (OR = 4.40; 95% CI 1.48-13.07), had housing insecurity (OR = 3.33; 95% CI 1.53-7.24), and had difficulty performing their usual activities (OR = 2.83; 95% CI 1.08-7.43). As a result of the clinic consultations, 58.0% (n = 40) were referred to either Legal Aid Ontario or Hamilton Community Legal Clinic, 21.74% (n = 15) were referred to a private lawyer; one case was taken on by the clinic lawyer. CONCLUSION: The Legal Health Clinic was found to fulfill unmet legal needs which were abundant in this urban family practice. This has important implications for the future health of patients and clinical practice. Utilizing a Legal Health Clinic could translate into improved health outcomes for patients by helping overcome barriers in accessing legal services and addressing social causes of adverse health outcomes.

Cost-effectiveness analysis of a community paramedicine programme for low-income seniors living in subsidised housing: the community paramedicine at clinic programme (CP@clinic).

OBJECTIVES: To evaluate the cost-effectiveness of the Community Paramedicine at Clinic (CP@clinic) programme compared with usual care in seniors residing in subsidised housing. DESIGN: A cost-utility analysis was conducted within a large pragmatic cluster randomised controlled trial (RCT). Subsidised housing buildings were matched by sociodemographics and location (rural/urban), and allocated to intervention (CP@clinic for 1 year) or control (usual care) via computer-assisted paired randomisation. SETTING: Thirty-two subsidised seniors' housing buildings in Ontario. PARTICIPANTS: Building residents 55 years and older. INTERVENTION: CP@clinic is a weekly community paramedic-led, chronic disease prevention and health promotion programme in the building common areas. CP@clinic is free to residents and includes risk assessments, referrals to resources, and reports back to family physicians. OUTCOME MEASURES: Quality-adjusted life years (QALYs) gained, measured with EQ-5D-3L. QALYs were estimated using area-under-the curve over the 1-year intervention, controlling for preintervention utility scores and building pairings. Programme cost data were collected before and during implementation. Costs associated with emergency medical services (EMS) use were estimated. An incremental cost effectiveness ratio (ICER) based on incremental costs and health outcomes between groups was calculated. Probabilistic sensitivity analysis using bootstrapping was performed. RESULTS: The RCT included 1461 residents; 146 and 125 seniors completed the EQ-5D-3L in intervention and control buildings, respectively. There was a significant adjusted mean QALY gain of 0.03 (95% CI 0.01 to 0.05) for the intervention group. Total programme cost for implementing in five communities was $C128 462 and the reduction in EMS calls avoided an estimated $C256 583. The ICER was $C2933/QALY (bootstrapped mean ICER with Fieller's 95% CI was $4850 ($2246 to $12 396)) but could be even more cost effective after accounting for the EMS call reduction. CONCLUSION: The CP@clinic ICER was well below the commonly used Canadian cost-utility threshold of $C50 000. CP@clinic scale-up across subsidised housing is feasible and could result in better health-related quality-of-life and reduced EMS use in low-income seniors. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, NCT02152891.

Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population.

BACKGROUND: The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population. METHODS: This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed. RESULTS: There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease. CONCLUSION: Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.