"Access to healthcare is a human right": a constructivist study exploring the impact and potential of a hospital-community partnered COVID-19 community response team for Toronto homeless services and congregate living settings.

BACKGROUND: Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity, and premature mortality. COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. In March 2020, the COVID-19 Community Response Team formed at Women's College Hospital, to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model of onsite mobile testing and infection prevention. From this, the Women's College COVID-19 vaccine program emerged, where 14 shelters were identified to co-design and support the administration of vaccine clinics within each shelter. This research seeks to evaluate the impact of this partnership model and its future potential in community-centered integrated care through three areas of inquiry: (1) vaccine program evaluation and lessons learned; (2) perceptions on hospital/community partnership; (3) opportunities to advance hospital-community partnerships. METHODS: Constructivist grounded theory was used to explore perceptions and experiences of this partnership from the voices of shelter administrators. Semi-structured interviews were conducted with administrators from 10 shelters using maximum variation purposive sampling. A constructivist-interpretive paradigm was used to determine coding and formation of themes: initial, focused, and theoretical. RESULTS: Data analysis revealed five main categories, 16 subcategories, and one core category. The core category "access to healthcare is a human right; understand our communities" emphasizes access to healthcare is a consistent barrier for the homeless population. The main categories revealed during a time of confusion, the hospital was seen as credible and trustworthy. However, the primary focus of many shelters lies in housing, and attention is often not placed on health resourcing, solidifying partnerships, accountability, and governance structures therein. Health advocacy, information sharing tables, formalized partnerships and educating health professionals were identified by shelter administrators as avenues to advance intersectoral relationship building. CONCLUSION: Hospital-community programs can alleviate some of the ongoing health concerns faced by shelters - during a time of COVID-19 or not. In preparation for future pandemics, access to care and cohesion within the health system requires the continuous engagement in relationship-building between hospitals and communities to support co-creation of innovative models of care, to promote health for all.

Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study.

BACKGROUND: Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS: The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS: The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION: The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.

Spirituality as a core concept in the theoretical literature of nursing: A comparative overview between Watson & Lovering's perspectives.

Nurse theorists have addressed the primacy of the phenomenon of caring, aiming at providing a framework that captures the complex nature of caring. Several theorists emphasized the mechanical facet of care while others emphasized the holistic aspect of care. Spirituality as a central concept in caring theories was targeted in this manuscript; as it a fundamental aspect of holistic care. Watson's Human Caring Science Theory and Lovering's Crescent of Care Nursing Model represent two distinctive approaches to caring in the dimension of spirituality. A compare/contrast approach is used to depict the similarities and differences between both works, focusing on spirituality as a common concept. The outcome of the comparison showed that spirituality is a multidimensional metaphysical concept that both theorists had identified as an indispensable core aspect of holistic nursing and is context-bound in terms of its dimensions, applications, and meaningfulness.

Prevalence of SARS-CoV-2 infection among people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic.

OBJECTIVES: People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristics and prevalence rates. METHODS: The study included individuals who were staying at shelters, encampments, COVID-19 physical distancing sites, and drop-in and respite sites and completed outreach-based testing for SARS-CoV-2 during the period April 17 to July 31, 2020. We examined test positivity rates over time and compared them to rates in the general population of Toronto. Negative binomial regression was used to examine the relationship between each shelter-level characteristic and SARS-CoV-2 positivity rates. We also compared the rates across 3 time periods (T1: April 17-April 25; T2: April 26-May 23; T3: May 24-June 25). RESULTS: The overall prevalence of SARS-CoV-2 infection was 8.5% (394/4657). Site-specific rates showed great heterogeneity with infection rates ranging from 0% to 70.6%. Compared to T1, positivity rates were 0.21 times lower (95% CI: 0.06-0.75) during T2 and 0.14 times lower (95% CI: 0.04-0.44) during T3. Most cases were detected during outbreak testing (384/394 [97.5%]) rather than active case finding. CONCLUSION: During the first wave of the pandemic, rates of SARS-CoV-2 infection at sites for people experiencing homelessness in Toronto varied significantly over time. The observation of lower rates at certain sites may be attributable to overall time trends, expansion of outreach-based testing to include sites without known outbreaks, and/or individual site characteristics.

RéSUMé: OBJECTIFS: Les personnes en situation d'itinérance courent un risque accru de contracter une infection par le SRAS-CoV-2. Notre étude rend compte de la prévalence ponctuelle des infections par le SRAS-CoV-2 au cours de tests de dépistage menés dans des lieux de services aux personnes en situation d'itinérance de Toronto au cours de la première vague de la pandémie de COVID-19. Nous avons aussi exploré l'association entre les caractéristiques de ces lieux et les taux de prévalence. MéTHODE: L'étude a inclus les personnes séjournant dans des refuges, des campements, des lieux de distanciation physique et des centres d'accueil et de répit et ayant subi un test de dépistage de proximité du SRAS-CoV-2 entre le 17 avril et le 31 juillet 2020. Nous avons examiné les taux de positivité des tests au fil du temps et nous les avons comparés aux taux dans la population générale de Toronto. Des analyses de régression binomiales négatives ont été effectuées pour étudier la relation entre chaque caractéristique au niveau des refuges et les taux de positivité au SRAS-CoV-2. Nous avons aussi comparé les taux de trois intervalles (I1: 17 au 25 avril; I2: 26 avril au 23 mai; I3: 24 mai au 25 juin). RéSULTATS: La prévalence globale des infections par le SRAS-CoV-2 était de 8,5 % (394/4 657). Les taux d'infection spécifiques aux lieux de services ont présenté une grande hétérogénéité, soit de 0 % à 70,6 %. Comparés au 1er intervalle (I1), les taux de positivité ont été 0,21 fois plus faibles (IC de 95% : 0,06 ­ 0,75) durant l'I2 et 0,14 fois plus faibles (IC de 95% : 0,04 ­ 0,44) durant l'I3. La plupart des cas ont été détectés lors d'un dépistage en cours d'éclosion (384/394 [97,5%]) et non lors d'une recherche active de cas. CONCLUSION: Au cours de la première vague de la pandémie, les taux d'infection par le SRAS-CoV-2 dans les lieux de services aux personnes en situation d'itinérance de Toronto ont varié de façon significative au fil du temps. L'observation de taux plus faibles dans certains lieux pourrait s'expliquer par les tendances temporelles globales, par l'expansion des activités de dépistage de proximité pour inclure les lieux sans éclosion connue et/ou par les caractéristiques individuelles des lieux.

Concordance of self-reported varicella history and serology among adolescent and adult refugee patients at a primary care clinic in Toronto, Canada.

BACKGROUND: Previous studies have found higher rates of varicella susceptibility among migrants from tropical regions. This study seeks to estimate the prevalence of varicella susceptibility in a cohort of newly arrived refugees and refugee claimants at a primary care clinic in Toronto and to compare patients' self-reported history of varicella infection with serologic test results. METHODS: We conducted a retrospective chart review of 1888 refugee patients aged 13 years and older rostered at a specialized primary care clinic in Toronto from December 2011 to October 2017. Basic sociodemographic variables, self-reported varicella history, and varicella serologic results were examined. RESULTS: Based on serologic testing, 8.5% of individuals were varicella non-immune, with highest rates of varicella susceptibility among adolescents aged 13-19 years (13.5%). All adults over age 60 were varicella immune on serology (n = 56). A positive self-reported history of varicella infection was strongly predictive of varicella immunity on serology (PPV 96.8%; 95% CI: 95.2-97.9). A self-reported history of no prior varicella infection did not correlate reliably with serologic test results (NPV 15.8%; 95% CI: 13.3-18.0). A substantial proportion of patients (34.1%) were unsure of their varicella history. CONCLUSION: Identification and immunization of varicella susceptible refugee newcomers remains a health care priority. Self-reported history of varicella infection had mixed reliability as a predictor of varicella immunity.

Caring for refugees and newcomers in the post-COVID-19 era: Evidence review and guidance for FPs and health providers.

OBJECTIVE: To guide clinicians working in a range of primary care clinical settings on how to provide effective care and support for refugees and newcomers during and after the coronavirus disease 2019 (COVID-19) pandemic. SOURCES OF INFORMATION: The described approach integrates recommendations from evidence-based clinical guidelines on refugee health and COVID-19, practical lessons learned from Canadian Refugee Health Network clinicians working in a variety of primary care settings, and contributions from persons with lived experience of forced migration. MAIN MESSAGE: The COVID-19 pandemic has amplified health and social inequities for refugees, asylum seekers, undocumented migrants, transient migrant workers, and other newcomers. Refugees and newcomers face front-line exposure risks, difficulties accessing COVID-19 testing, exacerbation of mental health concerns, and challenges accessing health care, social, and settlement supports. Existing guidelines for clinical care of refugees are useful, but creative case-by-case strategies must be employed to overcome additional barriers in the context of COVID-19 and new care environments, such as the need for virtual interpretation and digital literacy skills. Clinicians can address inequities and advocate for improved services in collaboration with community partners. CONCLUSION: The COVID-19 pandemic is amplifying structural inequities. Refugees and newcomers require and deserve effective health care and support during this challenging time. This article outlines practical approaches and advocacy priorities for providing care in the COVID-19 context.

Soigner les réfugiés et les nouveaux arrivants à l'ère post-COVID-19: Revue des données probantes et conseils pour les MF et les professionnels de la santé.

OBJECTIF: Guider les cliniciens qui travaillent dans divers milieux cliniques de soins primaires quant aux façons de prodiguer des soins et du soutien efficaces aux réfugiés et aux nouveaux arrivants, durant et après la pandémie de la maladie à coronavirus 2019 (COVID-19). SOURCES D'INFORMATION: L'approche décrite intègre les recommandations tirées de guides de pratique clinique fondés sur des données probantes portant sur la santé des réfugiés et la COVID-19, de leçons concrètes apprises de cliniciens du Réseau canadien sur la santé des réfugiés (Canadian Refugee Health Network) qui travaillent dans divers milieux de soins primaires, ainsi que de contributions de personnes ayant vécu l'expérience d'une migration forcée. MESSAGE PRINCIPAL: La pandémie de la COVID-19 a amplifié les iniquités sociales et de santé pour les réfugiés, les demandeurs d'asile, les migrants sans papiers, les travailleurs transitoires de l'étranger et d'autres nouveaux arrivants. Les réfugiés et les nouveaux arrivants sont confrontés à des risques d'exposition en première ligne, à des problèmes d'accès aux tests de dépistage de la COVID-19, à l'exacerbation des préoccupations liées à la santé mentale, et aux difficultés d'accéder aux soins de santé et aux services sociaux et d'établissement. Les lignes directrices existantes sur les soins cliniques aux réfugiés sont utiles, mais des stratégies créatives au cas par cas doivent être utilisées pour surmonter les obstacles additionnels dans le contexte de la COVID-19 et des nouveaux environnements de soins, comme la nécessité d'une traduction simultanée virtuelle et d'habiletés en littératie numérique. Les cliniciens peuvent lutter contre les iniquités et plaider en faveur de meilleurs services en collaboration avec des partenaires communautaires. CONCLUSION: La pandémie de la COVID-19 amplifie les iniquités structurelles. Les réfugiés et les nouveaux arrivants nécessitent et méritent des soins de santé et du soutien efficaces durant ces moments éprouvants. Cet article présente des approches pratiques et les priorités en matière de défense des droits pour offrir des soins dans le contexte de la COVID-19.

Outbreak of SARS-CoV-2 infection at a large refugee shelter in Toronto, April 2020: a clinical and epidemiologic descriptive analysis.

BACKGROUND: There is high risk of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in congregate settings, including shelters. This study describes a coronavirus disease 2019 (COVID-19) outbreak and corresponding reported symptomatology at a shelter in Toronto. METHODS: This clinical and epidemiologic analysis focuses on a COVID-19 outbreak at a dedicated refugee shelter in downtown Toronto. All adult residents on site at the shelter were offered SARS-CoV-2 testing on Apr. 20, 2020. At the time of testing, residents were screened for 3 typical COVID-19 symptoms (fever, cough and shortness of breath). Among those who tested positive, a more comprehensive clinical assessment was conducted 1 day after testing and a standardized 15-item symptom screen was administered by telephone 14 days after testing. We report rates of positive test results and clinical symptoms with each assessment interval. RESULTS: Of the 63 adult residents on site at the shelter, 60 agreed to be tested. Among those tested, 41.7% (n = 25) were positive for SARS-CoV-2 infection. Of those who tested positive (n = 25), 20.0% (n = 5) reported fever, cough or shortness of breath at the time of testing. On more detailed assessment 1 day later, 70.8% (17/24) reported a broader range of symptoms. During the 14 days after testing, 87.5% (21/24) reported symptoms of infection. INTERPRETATION: We found a high rate of SARS-CoV-2 infection in this shelter population. Our study underscores the high risk of SARS-CoV-2 transmission in congregate living settings and the importance of mobilizing timely testing and management of symptomatic, paucisymptomatic and asymptomatic residents in shelters.

A multidimensional approach to inform family planning needs, preferences and behaviours amongst women in South Africa through body mapping.

BACKGROUND: In recent decades there have been great improvements in the reproductive health of women in low- and middle-income countries and increases in the use of modern contraceptive methods. Nonetheless, many women are not able to access information, contraceptive technologies and services that could facilitate preventing unintended pregnancies and planning the number and timing of desired pregnancies. In South Africa, the contraceptive prevalence rate is 64.6%. However, this relatively high contraceptive prevalence rate masks problems with quality contraceptive service delivery, equitable access, and women's ability to correctly and consistently, use contraceptive methods of their choice. This study set out to understand the specific family planning and contraceptive needs and behaviours of women of reproductive age in South Africa, through a lived experience, multisensory approach. METHODS: Participatory qualitative research methods were used including body mapping workshops amongst reproductive aged women recruited from urban and peri urban areas in the Western Cape South Africa. Data including body map images were analysed using a thematic analysis approach. RESULTS: Women had limited biomedical knowledge of the female reproductive anatomy, conception, fertility and how contraceptives worked, compounded by a lack of contraceptive counseling and support from health care providers. Women's preferences for different contraceptive methods were not based on a single, sensory or experiential factor. Rather, they were made up of a composite of sensory, physical, social and emotional experiences underscored by potential for threats to bodily harm. CONCLUSIONS: This study highlighted the need to address communication and knowledge gaps around the female reproductive anatomy, different contraceptive methods and how contraception works to prevent a pregnancy. Women, including younger women, identified sexual and reproductive health knowledge gaps themselves and identified these gaps as important factors that influenced uptake and effective contraceptive use. These knowledge gaps were overwhelmingly linked to poor or absent communication and counseling provided by health care providers. Body mapping techniques could be used in education and communication strategies around sexual and reproductive health programmes in diverse settings.

Unmet contraceptive needs among refugees.

OBJECTIVE: To describe what women of reproductive age who received primary care at a refugee health clinic were using for contraception upon arrival to the clinic, and to quantify the unmet contraceptive needs within that population. DESIGN: Retrospective chart review. SETTING: Crossroads Clinic in downtown Toronto, Ont. PARTICIPANTS: Women of reproductive age (15 to 49 years) who first presented for care between December 1, 2011, and December 1, 2012. To be included, a woman had to have had 2 or more clinic visits or an annual health examination. Exclusion criteria for the contraception prevalence calculation were female sexual partner, menopause, hysterectomy, pregnancy, or trying to conceive. MAIN OUTCOME MEASURES: Contraception use prevalence was measured, as was unmet contraceptive need, which was calculated using a modified version of the World Health Organization's definition: the number of women with an unmet need was expressed as a percentage of women of reproductive age who were married or in a union, or who were sexually active. RESULTS: Overall, 52 women met the criteria for inclusion in the contraceptive prevalence calculation. Of these, 16 women (30.8%) did not use any form of contraception. Twelve women were pregnant at some point in the year and stated the pregnancy was unwanted or mistimed. An additional 14 women were not using contraception but had no intention of becoming pregnant within the next 2 years. There were no women with postpartum amenorrhea not using contraception and who had wanted to delay or prevent their previous pregnancy. In total, 97 women were married or in a union, or were sexually active. Unmet need was calculated as follows: (12 + 14 + 0)/97 = 26.8%. CONCLUSION: There was a high unmet contraceptive need in the refugee population in our study. All women of reproductive age should be screened for contraceptive need when first seeking medical care in Canada.

Determination of the volume scattering function of aqueous particle suspensions with a laboratory multi-angle light scattering instrument.

We describe a methodology for determining the volume scattering function ß(ψ) of aqueous particle suspensions from measurements with a laboratory multi-angle light scattering instrument called DAWN (Wyatt Technology Corporation). In addition to absolute and angular calibration, the key component of the method is the algorithm correcting for reflection errors that reduce the percent error in ß(ψ) from as much as ~300% to <13% at backward scattering angles. The method is optimized and tested with simulations of three-dimensional radiative transfer of exact measurement geometry including the key components of the instrument and also validated experimentally using aqueous suspensions of polystyrene beads. Example applications of the method to samples of oceanic waters and comparisons of these measurements with results obtained with other light scattering instruments are presented.

A randomised non-inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour.

BACKGROUND: Almost one third of women suffer continuous lower back pain during labour. Evidence from three systematic reviews demonstrates that sterile water injections (SWI) provide statistically and clinically significant pain relief in women experiencing continuous lower back pain during labour. The most effective technique to administer SWI is yet to be determined. Therefore, the aim of this study is to determine if the single injection SWI technique is no less effective than the routinely used four injection SWI method in reducing continuous lower back pain during labour. METHODS/DESIGN: The trial protocol was developed in consultation with an interdisciplinary team of clinical researchers. We aim to recruit 319 women presenting at term, seeking analgesia for continuous severe lower back pain during labour. Participants will be recruited from two major maternity hospitals in Australia. Randomised participants are allocated to receive a four or single intradermal needle SWI technique. The primary outcome is the change in self-reported pain measured by visual analogue scale at baseline and thirty minutes post intervention. Secondary outcomes include VAS change scores at 10, 60, 90 and 120 min, analgesia use, mode of birth and maternal satisfaction. STATISTICAL ANALYSIS: Sample size was calculated to achieve 90% power at an alpha of 0.025 to detect a non-inferiority margin of ≤1 cm on the VAS, using a one-sided, two-sample t-test. Baseline demographic and clinical characteristics will be analysed for comparability between groups. Differences in primary (VAS pain score) and secondary outcomes between groups will be analysed by intention to treat and per protocol analysis using Student's t-test and ANOVA. CONCLUSION: This study will determine if a single intradermal SWI technique is no less effective than the routinely used four injection technique for lower back pain during labour. The findings will allow midwives to offer women requesting SWI during labour an evidence-based alternative technique more easily administered by staff and accepted by labouring women. TRIAL REGISTRATION: ACTRN12609000964213.

Action learning: a tool for the development of strategic skills for Nurse Consultants?

AIM: This paper will discuss the process of action learning and the outcomes of using action learning as a tool to achieve a more strategic function from Nurse Consultant posts. BACKGROUND: It is documented that one of the most challenging aspect of Nurse Consultant roles, in terms of leadership, is the strategic contribution they make at a senior corporate Trust level, often across organizations and local health economies. A facilitated action learning set was established in Brighton, England, to support the strategic leadership development of eight nurse consultant posts across two NHS Trusts. EVALUATION: Benefits to patient care, with regard to patient pathways and cross-organizational working, have been evident outcomes associated with the nurse consultant posts involved in the action learning set. KEY ISSUES: Commitment by organizational nurse leaders is essential to address the challenges facing nurse consultants to implement change at strategic levels. CONCLUSIONS: The use of facilitated action learning had been a successful tool in developing the strategic skills of Nurse Consultant posts within this setting. IMPLICATIONS FOR NURSING MANAGEMENT: Action learning sets may be successfully applied to a range of senior nursing posts with a strategic remit and may assist post holders in achieving better outcomes pertinent to their roles.