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

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

Implementing experiential learning logs addressing social accountability into undergraduate medical clerkship education.

Medical schools have a responsibility to ensure students meet and advocate for the needs of the community. However, addressing the social determinants of health is not always emphasized in clinical learning objectives. Learning logs are useful tools that can engage students to reflect on clinical encounters and direct students in their learning to target the development of highlighted skills. Despite their efficacy, the use of learning logs in medical education is largely applied towards biomedical knowledge and procedural skills. Thus, students may lack competence to address the psychosocial challenges involved in comprehensive medical care. Social accountability experiential logs were developed for third year medical students at the University of Ottawa to address and intervene on the social determinants of health. Students completed quality improvement surveys and results demonstrated this initiative to be beneficial to their learning and contributed to greater clinical confidence. Experiential logs in clinical training can be adapted across other medical schools and tailored to fit the needs and priorities of each institution's local communities.

Les facultés de médecine ont la responsabilité de s'assurer que les étudiants répondent aux besoins de la collectivité et militent pour leurs intérêts. Or, les objectifs d'apprentissage clinique ne sont pas toujours axes sur les déterminants sociaux de la santé. L'utilité des carnets d'apprentissage est d'inciter les étudiants à réfléchir sur les rencontres cliniques et de les orienter dans leur apprentissage vers le développement des compétences ciblées. Malgré leur efficacité, les carnets d'apprentissage sont surtout appliqués aux connaissances biomédicales et aux compétences procédurales. Par conséquent, les étudiants pourraient ne pas disposer des compétences nécessaires pour relever les enjeux psychosociaux, qui sont à considérer aux fins d'une prise en charge médicale globale. Des carnets d'apprentissage expérientiel portant sur la responsabilité sociale ont été élaborés pour les étudiants en médecine de troisième année de l'Université d'Ottawa afin d'aborder et d'intervenir sur les déterminants sociaux de la santé. Les étudiants ont participé à des sondages sur l'amélioration de la qualité et les résultats de ceux-ci ont montré que cette initiative était bénéfique pour leur apprentissage et qu'elle contribuait à améliorer leur confiance en eux en tant que cliniciens. Les carnets expérientiels en formation clinique peuvent être adaptés par les diverses facultés de médecine pour qu'ils correspondent aux besoins et aux priorités des collectivités locales qu'elles desservent.

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

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

Meeting Farmers Where They Are - Rural Clinicians' Views on Farmers' Mental Health.

Objective: To explore rural clinicians' understanding of farmers' mental health and well-being, current health services, and potential responses.Methods: Qualitative design, with semi-structured, taped interviews of five family physicians and four mental health nurses-counselors practicing in rural Grey-Bruce counties, Ontario. Transcripts analyzed with N-Vivo through iterative coding of emergent themes and mapping of relationships among themes.Results: Participating rural clinicians all expressed admiration for farmers. They shared insights around three main themes: 1) farming as a unique subculture; 2) farming involved both benefits and challenges for health; and 3) farmers rarely seek care. Clinicians need to take advantage of contact opportunities to ask about mental health. Several suggested ways to meet farmers where they are, e.g., through better funding for house-farm calls and community events.Conclusion: Clinician responses to farmers' mental health challenges include recognizing farmers' distinct context. Complementary health promotion in conjunction with farm organizations is needed to reach farmers.

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

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

The potential of an online educational platform to contribute to achieving sustainable development goals: a mixed-methods evaluation of the Peoples-uni online platform.

BACKGROUND: This paper reports on an online platform, People's Open Access Education Initiative (Peoples-uni), as a means of enhancing access to master's level public health education for health professionals. Peoples-uni seeks to improve population health in low- and middle-income countries by building public health capacity through e-learning at very low cost. We report here an evaluation of the Peoples-uni programme, conducted within the context of Sustainable Development Goal 4, which seeks to "ensure inclusive and quality education for all and promote lifelong learning" by 2030. The evaluation seeks to address the following three questions: (1) Did Peoples-uni meet its intended goals? (2) What were the different types of impacts that students experienced? (3) What suggestions for future changes in Peoples-uni did students recommend? METHODS: A mixed methods evaluation consisted of two parts, namely an online survey and a telephone interview. A total of 119 master's level graduates were invited to participate; responses were obtained from 71 of those invited, giving a response rate of 60%. Respondents were spread across 31 countries. Interviews were conducted with 18 respondents. RESULTS: There was strong evidence that Peoples-uni had achieved its stated goals. Potential impacts on students included knowledge to enhance practice and appreciation of context, enhanced research capacity through knowledge of public health, critical thinking and evidence-based programming, and empowerment of students about the potential of education as a means of improving their lives. Accreditation through future partnerships with local universities was recommended by students. CONCLUSIONS: Peoples-uni has been able to deliver a credible public health master's level educational programme, with positive impacts on the students who graduated. Challenges are to find a way to accredit the programme to ensure its sustainability and to see how to take full advantage of the current, and future, graduates to turn this from an education programme into a capacity-building programme with real impact.