Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces.

The extent to which power, resources, and responsibilities for public health are centralized or decentralized within a jurisdiction and how public health functions are integrated or coordinated with health care services may shape pandemic responses. However, little is known about the impacts of centralization and integration on public health system responses to the COVID-19 pandemic. We examine how public health leaders perceive centralization and integration facilitated and impeded effective COVID-19 responses in three Canadian provinces. We conducted a comparative case study involving semi-structured interviews with 58 public health system leaders in three Canadian provinces with varying degrees of centralization and integration. Greater public health system centralization and integration was seen by public health leaders to facilitate more rapidly initiated and well-coordinated provincial COVID-19 responses. Decentralization may have enabled locally tailored responses in the context of limited provincial leadership. Opacity in provincial decision-making processes, jurisdictional ambiguity impacting Indigenous communities, and ineffectual public health investments were impediments across jurisdictions and thus appear to be less impacted by centralization and integration. Our study generates novel insights about potential structural facilitators and impediments of effective COVID-19 pandemic responses during the second year of the pandemic. Findings highlight key areas for future research to inform system design that support leaders to manage large-scale public health emergencies.

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.

“We cobble together a storyline of system performance using a diversity of things”: a qualitative study of perspectives on public health performance measurement in Canada

There have been longstanding calls for public health systems transformations in many countries, including Canada. Core to these calls has been strengthening performance measurement. While advancements have been made in performance measurement for certain sectors of the health care system (primarily focused on acute and primary health care), effective use of indicators for measuring public health systems performance are lacking. This study describes the current state, anticipated challenges, and future directions in the development and implementation of a public health performance measurement system for Canada. We conducted a qualitative study using semi-structured interviews with public health leaders (n = 9) between July and August 2021. Public health leaders included researchers, government staff, and former medical officers of health who were purposively selected due to their expertise and experience with performance measurement with relevance to public health systems in Canada. Thematic analysis included both a deductive approach for themes consistent with the conceptual framework and an inductive approach to allow new themes to emerge from the data. Conceptual, methodological, contextual, and infrastructure challenges were highlighted by participants in designing a performance measurement system for public health. Specifically, six major themes evolved that encompass 1) the mission and purpose of public health systems, including challenges inherent in measuring the functions and services of public health;2) the macro context, including the impacts of chronic underinvestment and one-time funding injections on the ability to sustain a measurement system;3) the organizational structure/governance of public health systems including multiple forms across Canada and underdevelopment of information technology systems;4) accountability approaches to performance measurement and management;and 5) timing and unobservability in public health indicators. These challenges require dedicated investment, strong leadership, and political will from the federal and provincial/territorial governments. Unprecedented attention on public health due to the coronavirus disease 2019 pandemic has highlighted opportunities for system improvements, such as addressing the lack of a performance measurement system. This study provides actionable knowledge on conceptual, methodological, contextual, and infrastructure challenges needed to design and build a pan-Canadian performance measurement system for public health.

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.

A comparison of the COVID-19 response for urban underserved patients experiencing healthcare transitions in three Canadian cities.

OBJECTIVES: The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises. METHODS: Using Walt & Gilson's Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response. RESULTS: Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration. CONCLUSION: The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.

RéSUMé: OBJECTIFS: La pandémie et la riposte au COVID-19 ont mis en évidence les forces existantes au sein du système de soins pour les populations urbaines mal desservies, mais aussi de nombreuses faillites, en particulier lors des transitions de soins. Les objectifs de cette étude étaient de décrire les politiques de réponse au COVID-19 pour les populations urbaines mal desservies dans trois villes canadiennes; examiner l'impact de ces politiques sur la continuité des soins pour les populations urbaines mal desservies; déterminer si et comment les membres de la communauté urbaine mal desservie ont été impliqués dans les processus politiques; et développer des recommandations politiques et opérationnelles pour optimiser la continuité des soins pour les populations urbaines mal desservies pendant les crises de santé publique. MéTHODES: Utilisant le cadre Policy Triangle de Walt et Gilson comme guide conceptuel, 237 documents politiques et des médias ont été récupérés. Cinq séances d'entrevues de groupe virtuelles complémentaires ont été organisées avec 22 informateurs clés de première ligne et d'expérience vécue pour saisir des réponses et des expériences politiques moins bien documentées. Les documents et les transcriptions des entrevues ont été analysés de manière inductive pour le contenu politique, le contexte, les acteurs et les processus impliqués dans la riposte à la pandémie. RéSULTATS: Les documents disponibles suggèrent que l'accent est peu mis sur la continuité des soins pour les populations urbaines mal desservies pendant la pandémie, malgré les mesures de santé publique ayant des impacts négatifs disproportionnés sur leurs soins. Les réponses politiques étaient en grande partie réactives et temporaires, et les membres de la communauté étaient rarement impliqués. Cependant, un certain nombre d'initiatives communautaires ont été élaborées en réponse aux lacunes des politiques. Des pratiques prometteuses ont émergé, y compris des exemples de nouvelles collaborations multiniveaux et multisectorielles. CONCLUSION: La réponse à la pandémie a révélé des inégalités pour les populations urbaines mal desservies qui subissent des transitions de soins, mais elle a également exposé les forces du système et les possibilités d'amélioration pour éclairer l'orientation future des politiques.

Precarious work among personal support workers in the Greater Toronto Area: a respondent-driven sampling study.

BACKGROUND: The COVID-19 pandemic has highlighted the role of personal support workers (PSWs) in health care, as well as their work conditions. Our study aimed to understand the characteristics of the PSW workforce, their work conditions and their job security, as well as to explore the health of PSWs and the impact of precarious employment on their health. METHODS: Our community-based participatory action research focused on PSWs in the Greater Toronto Area. We administered an online, cross-sectional survey between June and December 2020 using respondent-driven sampling. Data on sociodemographics, employment precarity, worker empowerment and health status were collected. We assessed the association between precarious employment and health using multivariable logistic regression models. RESULTS: We contacted 739 PSWs, and 664 consented to participate. Overall, 658 (99.1%) completed at least part of the survey. Using data adjusted for our sampling approach, the participants were predominantly Black (76.5%, 95% confidence interval [CI] 68.2%-84.9%), women (90.1%, 95% CI 85.1%-95.1%) and born outside of Canada (97.4%, 95% CI 94.9%-99.9%). Most worked in home care (43.9%, 95% CI 35.2%-52.5%) or long-term care (34.5%, 95% CI 27.4%-42.0%). Although most participants had at least some postsecondary education (unadjusted proportion = 83.4%, n = 529), more than half were considered low income (55.1%, 95% CI 46.3%-63.9%). Most participants were precariously employed (86.5%, 95% CI 80.7%-92.4%) and lacked paid sick days (89.5%, 95% CI 85.8%-93.3%) or extended health benefits (74.1%, 95% CI 66.8%-81.4%). Nearly half of the participants described their health as less than very good (46.7%, 95% CI 37.9%-55.5%). Employment precarity was significantly associated with higher risk of depression (odds ratio 1.02, 95% CI 1.01-1.03). INTERPRETATION: Despite being key members of health care teams, most PSWs were precariously employed with low wages that keep them in poverty; the poor work conditions they faced could be detrimental to their physical and mental health. Equitable strategies are needed to provide decent work conditions for PSWs and to improve their health.

The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study.

OBJECTIVE: During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare 'heroes' as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs. METHODS: This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs. RESULTS: We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19-related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges. CONCLUSION: Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

RéSUMé: OBJECTIF: Au plus fort de la pandémie de COVID-19, les préposés aux bénéficiaires (PAB) étaient salués comme les « héros ¼ des soins de santé, car beaucoup s'occupaient de populations vulnérables et âgées à risque élevé et travaillaient dans le milieu des soins de longue durée, qui était aux prises avec un grand nombre d'éclosions de COVID-19 et de décès. Malgré l'importance névralgique des PAB dans la main-d'œuvre des soins de santé, leurs conditions de travail durant la pandémie sont peu connues. Nous avons cherché à examiner les conditions de travail (sécurité d'emploi, régimes de travail et expériences personnelles) des PAB dans la région du Grand Toronto durant la pandémie de COVID-19 selon la perspective de ces PAB. MéTHODE: Nous avons utilisé un plan d'étude à méthodes mixtes. De juin à décembre 2020, nous avons sondé 634 PAB pour connaître leurs conditions de travail durant la pandémie de COVID-19. Des entretiens semi-directifs ont été menés auprès de 31 répondants et répondantes entre les mois de février et de mai 2021 pour approfondir notre compréhension de l'impact des conditions de travail des PAB sur leur bien-être. RéSULTATS: Nous avons constaté que les PAB ont connu de nombreuses difficultés en lien avec la COVID-19, dont l'anxiété à l'idée de transmettre la COVID-19, les heures de travail réduites, la prise de congés, les craintes pour leur sécurité d'emploi et la perte de services de garde. Bien que la pandémie de COVID-19 ait braqué les projecteurs sur les PAB et leur importance pour le système de soins de santé (surtout dans le système de soins de longue durée), leurs mauvaises conditions de travail préexistantes ­ des emplois précaires sans congés de maladie payés ni avantages sociaux ­ ont exacerbé les problèmes posés par la COVID-19. Malgré ces épreuves, les PAB ont pu compter sur leur résilience mentale et leur passion pour la profession pour faire face aux difficultés. CONCLUSION: D'importants changements doivent être apportés pour améliorer les conditions de travail des PAB. De meilleurs salaires, une plus grande sécurité d'emploi, une charge de travail allégée et des mesures d'appui à la santé mentale sont nécessaires.

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.

Implementing High-Quality Primary Care Through a Health Equity Lens.

The COVID-19 pandemic highlighted the importance of centering health equity in future health system and primary care reforms. Strengthening primary care will be needed to correct the longstanding history of mistreatment of First Nations/Indigenous and racialized people, exclusion of health care workers of color, and health care access and outcome inequities further magnified by the COVID-19 pandemic. The National Academies of Sciences, Engineering, and Medicine (NASEM) released a report on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, that provided a framework for defining high-quality primary care and proposed 5 recommendations for implementing that definition. Using the report's framework, we identified health equity challenges and opportunities with examples from primary care systems in the United States and Canada. We are poised to reinvigorate primary care because the recent pandemic and the attention to continued racialized police violence sparked renewed conversations and collaborations around equity, diversity, inclusion, and health equity that have been long overdue. The time to transition those conversations to actionable items to improve the health of patients, families, and communities is now.Appeared as Annals "Online First" article.

Reducing Inequities During the COVID-19 Pandemic: A Rapid Review and Synthesis of Public Health Recommendations.

Objectives: Efforts to contain the COVID-19 pandemic should take into account worsening health inequities. While many public health experts have commented on inequities, no analysis has yet synthesized recommendations into a guideline for practitioners. The objective of this rapid review was to identify the areas of greatest concern and synthesize recommendations. Methods: We conducted a rapid systematic review (PROSPERO: CRD42020178131). We searched Ovid MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials databases from December 1, 2019 to April 27, 2020. We included English language peer-reviewed commentaries, editorials, and opinion pieces that addressed the social determinants of health in the context of COVID-19. Results: 338 articles met our criteria. Authors represented 81 countries. Income, housing, mental health, age and occupation were the most discussed social determinants of health. We categorized recommendations into primordial, primary, secondary and tertiary prevention that spoke to the social determinants of COVID-19 and equity. Conclusion: These recommendations can assist efforts to contain COVID-19 and reduce health inequities during the pandemic. Using these recommendations, public health practitioners could support a more equitable pandemic response. Systematic Review Registration: PROSPERO, CRD42020178131.

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.

Cash transfer during the COVID-19 pandemic: a multicentre, randomised controlled trial.

OBJECTIVE: To evaluate the effect of a one-time cash transfer of $C1000 in people who are unable to physically distance due to insufficient income. DESIGN: Open-label, multi-centre, randomised superiority trial. SETTING: Seven primary care sites in Ontario, Canada; six urban sites associated with St. Michael's Hospital in Toronto and one in Manitoulin Island. PARTICIPANTS: 392 individuals who reported trouble affording basic necessities due to disruptions related to COVID-19. INTERVENTION: After random allocation, participants either received the cash transfer of $C1000 (n=196) or physical distancing guidelines alone (n=196). MAIN OUTCOME MEASURES: The primary outcome was the maximum number of symptoms consistent with COVID-19 over 14 days. Secondary outcomes were meeting clinical criteria for COVID-19, SARS-CoV-2 presence, number of close contacts, general health and ability to afford basic necessities. RESULTS: The primary outcome of number of symptoms reported by participants did not differ between groups after 2 weeks (cash transfer, mean 1.6 vs 1.9, ratio of means 0.83; 95% CI 0.56 to 1.24). There were no statistically significant effects on secondary outcomes of the meeting COVID-19 clinical criteria (7.9% vs 12.8%; risk difference -0.05; 95% CI -0.11 to 0.01), SARS-CoV-2 presence (0.5% vs 0.6%; risk difference 0.00 95% CI -0.02 to 0.02), mean number of close contacts (3.5 vs 3.7; rate ratio 1.10; 95% CI 0.83 to 1.46), general health very good or excellent (60% vs 63%; risk difference -0.03 95% CI -0.14 to 0.08) and ability to make ends meet (52% vs 51%; risk difference 0.01 95% CI -0.10 to 0.12). CONCLUSIONS: A single cash transfer did not reduce the COVID-19 symptoms or improve the ability to afford necessities. Further studies are needed to determine whether some groups may benefit from financial supports and to determine if a higher level of support is beneficial. TRIAL REGISTRATION NUMBER: NCT04359264.

Recommendations for equitable COVID-19 pandemic recovery in Canada: CMAJ

Persaud et al discuss the recommendations for equitable COVID1-19 pandemic recovery in Canada. Health inequities-or avoidable differences in health status between populations -that were exposed and exacerbated during the COVID-19 pandemic can be addressed through interventions and policy changes that were studied before SARS-CoV-2 spread across Canada. Racialized people, women, people with a low income, people experiencing homelessness, people who use substances and people who are incarcerated were disproportionately affected during the pandemic. Inequities that were exposed and exacerbated by COVID-19 will continue to threaten health after the pandemic. Specific interventions and changes that relate to income, housing, safety from intimate partner violence, childcare, access to health care and antiracism are known to be beneficial.

Cash transfer during the COVID-19 pandemic: a multicentre, randomised controlled trial

Objective To evaluate the effect of a one-time cash transfer of $C1000 in people who are unable to physically distance due to insufficient income. Design Open-label, multi-centre, randomised superiority trial. Setting Seven primary care sites in Ontario, Canada;six urban sites associated with St. Michael’s Hospital in Toronto and one in Manitoulin Island. Participants 392 individuals who reported trouble affording basic necessities due to disruptions related to COVID-19. Intervention After random allocation, participants either received the cash transfer of $C1000 (n=196) or physical distancing guidelines alone (n=196). Main outcome measures The primary outcome was the maximum number of symptoms consistent with COVID-19 over 14 days. Secondary outcomes were meeting clinical criteria for COVID-19, SARS-CoV-2 presence, number of close contacts, general health and ability to afford basic necessities. Results The primary outcome of number of symptoms reported by participants did not differ between groups after 2 weeks (cash transfer, mean 1.6 vs 1.9, ratio of means 0.83;95% CI 0.56 to 1.24). There were no statistically significant effects on secondary outcomes of the meeting COVID-19 clinical criteria (7.9% vs 12.8%;risk difference −0.05;95% CI −0.11 to 0.01), SARS-CoV-2 presence (0.5% vs 0.6%;risk difference 0.00 95% CI −0.02 to 0.02), mean number of close contacts (3.5 vs 3.7;rate ratio 1.10;95% CI 0.83 to 1.46), general health very good or excellent (60% vs 63%;risk difference −0.03 95% CI −0.14 to 0.08) and ability to make ends meet (52% vs 51%;risk difference 0.01 95% CI −0.10 to 0.12). Conclusions A single cash transfer did not reduce the COVID-19 symptoms or improve the ability to afford necessities. Further studies are needed to determine whether some groups may benefit from financial supports and to determine if a higher level of support is beneficial. Trial registration number NCT04359264.

Association between new-onset anosmia and positive SARS-CoV-2 tests among people accessing outpatient testing in Toronto, Ontario: a retrospective cross-sectional study.

BACKGROUND: Reports have suggested that anosmia is strongly associated with SARS-CoV-2 infection, but patients were often asked about this symptom after their diagnosis. This study assessed associations between prospectively reported anosmia and other symptoms related to SARS-CoV-2 infection, and SARS-CoV-2 positivity in community testing centres in Toronto, Ontario. METHODS: We conducted a retrospective cross-sectional study in which data were collected from 2 COVID-19 assessment centres affiliated with 2 hospitals in Toronto, Ontario, from Apr. 5 to Sept. 30, 2020. We included symptomatic profiles of all people who underwent a SARS-CoV-2 test at either clinic within the study period. We used generalized estimating equations to account for repeat visits and to assess associations between anosmia and other symptoms and SARS-CoV-2 positivity. RESULTS: A total of 83 443 SARS-CoV-2 tests were conducted across the 2 sites for 72 692 participants during the study period. Of all tests, 1640 (2.0%) were positive; 837 (51.0%) of people who tested positive were asymptomatic. The adjusted odds ratio for the association between anosmia and test positivity was 5.29 (95% confidence interval [CI] 4.50-6.22), with sensitivity of 0.138 (95% CI 0.121-0.154), specificity of 0.980 (95% CI 0.979-0.981), a positive predictive value of 0.120 (95% CI 0.106-0.135) and a negative predictive value of 0.983 (95% CI 0.982-0.984). INTERPRETATION: Anosmia had high specificity and a positive predictive value of 12% for SARS-CoV-2 infection in this community population with low prevalence of SARS-CoV-2 positivity. The presence of anosmia should increase clinical suspicion of SARS-CoV-2 infection, and our findings suggest that people presenting with this symptom should be tested.

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.