General practitioners can evaluate the material, social and health dimensions of patient social status

Individual-based socioeconomic vulnerability and deprivation indices: a scoping review

Several individual-based social deprivation and vulnerability indices have been developed to measure the negative impact of low socioeconomic status on health outcomes. However, their variables and measurable characteristics have not been unequivocally assessed. A comprehensive database literature scoping review was performed to identify all individual-based social deprivation and vulnerability indices. Area-based indices and those developed for pediatric populations were excluded. Data were extracted from all eligible studies and their methodology was assessed with quality criteria. A total of 14 indices were identified, of which 64% (9/14) measured social deprivation and 36% (5/14) measured socioeconomic vulnerability. Sum of weights was the most common scoring system, present in 43% (6/14) of all indices, with no exclusive domains to either vulnerability or deprivation indices. A total of 83 different variables were identified; a very frequent variable (29%; 5/14) related to an individual's social relationships was "seen any family or friends or neighbors." Only five deprivation indices reported a specific internal consistency measure, while no indices reported data on reproducibility. This is the first scoping review of individual-based deprivation and vulnerability indices, which may be used interchangeably when measuring the impact of SES on health outcomes.

Outreach work in Belgian primary care practices during COVID-19: results from the cross-sectional PRICOV-19 study

BACKGROUND

General practitioners (GPs) have a vital role in reaching out to vulnerable populations during and after the COVID-19 pandemic. Nonetheless, they experience many challenges to fulfill this role. This study aimed to examine associations between practice characteristics, patient population characteristics and the extent of deprivation of practice area on the one hand, and the level of outreach work performed by primary care practices (PCPs) during the COVID-19 pandemic on the other hand.

METHODS

Belgian data from the international PRICOV-19 study were analyzed. Data were collected between December 2020 and August 2021 using an online survey in PCPs. Practices were recruited through randomized and convenience sampling. Descriptive statistics and ordinal logistic regression analyses were performed. Four survey questions related to outreach work constitute the outcome variable. The adjusted models included four practice characteristics (practice type, being a teaching practice for GP trainees; the presence of a nurse or a nurse assistant and the presence of a social worker or health promotor), two patient population characteristics (social vulnerability and medical complexity) and an area deprivation index.

RESULTS

Data from 462 respondents were included. First, the factors significantly associated with outreach work in PCPs are the type of PCP (with GPs working in a group performing more outreach work), and the presence of a nurse (assistant), social worker or health promotor. Second, the extent of outreach work done by a PCP is significantly associated with the social vulnerability of the practice's patient population. This social vulnerability factor, affecting outreach work, differed with the level of medical complexity of the practice's patient population and with the level of deprivation of the municipality where the practice is situated.

CONCLUSIONS

In this study, outreach work in PCPs during the COVID-19 pandemic is facilitated by the group-type cooperation of GPs and by the support of at least one staff member of the disciplines of nursing, social work, or health promotion. These findings suggest that improving the effectiveness of outreach efforts in PCPs requires addressing organizational factors at the practice level. This applies in particular to PCPs having a more socially vulnerable patient population.

Barriers and Enablers Experienced by General Practitioners in Delivering Safe and Equitable Care during COVID-19: A Qualitative Investigation in Two Countries

Addressing equity in healthcare is fundamental for delivering safe care to vulnerable patients, especially during COVID-19. This paper aims to identify barriers and enabling factors for general practitioners (GPs) in delivering safe and equitable care during the COVID-19 pandemic. Semi-structured interviews took place during May-July 2020 among 18 Flemish and 16 Dutch GPs. Thematic analysis of the interviews demonstrated that while GPs acknowledged a smooth information flow by governments and professional organizations on care guidelines, the fast-changing information challenged them to stay up to date. Media communication facilitated information dissemination but also fueled misinformation and miscommunication, creating unrealistic patient expectations. Certain guidelines and patient reluctance delayed necessary care. A shortage of personal protective equipment made GPs concerned about patient safety during face-to-face contacts. Teleconsultations became a popular alternative, but posed increased patient safety risks. GPs struggled to identify and reach vulnerable patients. Equitable care was hindered by time constraints; thus, having the appropriate materials facilitated such care. An interprofessional collaboration involving paramedical, social, and city services benefited patient safety and equity in healthcare. However, limitations in this collaboration pressured GPs. The unprecedented and resource-constrained environment challenged GPs' capacity to provide the healthcare quality they aspired to deliver. A well-structured collaborative network involving all stakeholders could benefit safe and equitable care in future pandemics.

The Organization of Outreach Work for Vulnerable Patients in General Practice during COVID-19: Results from the Cross-Sectional PRICOV-19 Study in 38 Countries

The COVID-19 pandemic disproportionately affected vulnerable populations' access to health care. By proactively reaching out to them, general practices attempted to prevent the underutilization of their services. This paper examined the association between practice and country characteristics and the organization of outreach work in general practices during COVID-19. Linear mixed model analyses with practices nested in countries were performed on the data of 4982 practices from 38 countries. A 4-item scale on outreach work was constructed as the outcome variable with a reliability of 0.77 and 0.97 at the practice and country level. The results showed that many practices set up outreach work, including extracting at least one list of patients with chronic conditions from their electronic medical record (30.1%); and performing telephone outreach to patients with chronic conditions (62.8%), a psychological vulnerability (35.6%), or possible situation of domestic violence or a child-rearing situation (17.2%). Outreach work was positively related to the availability of an administrative assistant or practice manager (p < 0.05) or paramedical support staff (p < 0.01). Other practice and country characteristics were not significantly associated with undertaking outreach work. Policy and financial interventions supporting general practices to organize outreach work should focus on the range of personnel available to support such practice activities.

Routinely asking patients about income in primary care: a mixed-methods study

Background

Income is a key social determinant of health, yet it is rare for data on income to be routinely collected and integrated with electronic health records.

Aim

To examine response bias and evaluate patient perspectives of being asked about income in primary care.

Design & setting

Mixed-methods study in a large, multi-site primary care organisation in Toronto, Canada, where patients are asked about income in a routinely administered sociodemographic survey.

Method

Data were examined from the electronic health records of patients who answered at least one question on the survey between December 2013 and March 2016 (n = 14 247). The study compared those who responded to the income question with non-responders. Structured interviews with 27 patients were also conducted.

Results

A total of 10 441 (73%) patients responded to both parts of the income question: ‘What was your total family income before taxes last year?’ and ‘How many people does your income support?’. Female patients, ethnic minorities, caregivers of young children, and older people were less likely to respond. From interviews, many patients were comfortable answering the income question, particularly if they understood the connection between income and health, and believed the data would be used to improve care. Several patients found it difficult to estimate their income or felt the options did not reflect fluctuating financial circumstances.

Conclusion

Many patients will provide data on income in the context of a survey in primary care, but accurately estimating income can be challenging. Future research should compare self-reported income to perceived financial strain. Data on income linked to health records can help identify health inequities and help target anti-poverty interventions.

How French general practitioners adapt their care to patients with social difficulties?

Objective

Several studies have shown the role of the primary care system in access to care and in reducing social inequalities in health. The objective of this study was to describe the practices of general practitioners (GPs) in taking into account the social environment of their patient, and the ways they adapted to social difficulties.

Design

Qualitative study comprising interviews and focus groups.

Setting

French primary care settings.

Participants

Twenty semistructured interviews and two focus groups were conducted with 33 GPs. Sessions were audio recorded, transcribed verbatim and analysed using thematic analysis. The reporting of findings was guided by consolidated criteria for reporting qualitative research.

Result

This study identified adaptations at three levels: in the individual management of patients (alert system, full involvement in prevention, better communication, prioritised additional examinations, financial facilities, help in administrative tasks), in the collective management of patients in an office (consultation without appointment, pay-for-performance indicators, medical staffs, multidisciplinary protocols, medical practice in group, medical student), and in the community management (patients description, cooperation with associations, public health sector and politics).

Conclusion

In France, GPs can take into account the social determinants of health in practice through simple or more complex actions.

A systematic review of reasons for and against asking patients about their socioeconomic contexts

Background

People’s social and economic circumstances are important determinants of their health, health experiences, healthcare access, and healthcare outcomes. However, patients’ socioeconomic circumstances are rarely asked about or documented in healthcare settings. We conducted a systematic review of published reasons for why patients’ socioeconomic contexts (including education, employment, occupation, housing, income, or wealth) should, or should not, be enquired about.

Methods

Systematic review of literature published up to and including 2016. A structured literature search using databases of medicine and nursing (pubmed, embase, global health), ethics (Ethicsweb), social sciences (Web of Science), and psychology (PsychINFO) was followed by a ‘snowball’ search. Eligible publications contained one or more reasons for: asking patients about socioeconomic circumstances; collecting patients’ socioeconomic information; ‘screening’ patients for adverse socioeconomic circumstances; or linking other sources of individual socioeconomic data to patients’ healthcare records. Two authors conducted the screening: the first screened all references, the second author screened a 20% sample with inter-rater reliability statistically confirmed. ‘Reason data’ was extracted from eligible publications by two authors, then analysed and organised.

Results

We identified 138 eligible publications. Most offered reasons for why patients’ should be asked about their socioeconomic circumstances. Reasons included potential improvements in: individual healthcare outcomes; healthcare service monitoring and provision; population health research and policies. Many authors also expressed concerns for improving equity in health. Eight publications suggested patients should not be asked about their socioeconomic circumstances, due to: potential harms; professional boundaries; and the information obtained being inaccurate or unnecessary.

Conclusions

This first summary of literature on the subject found many published reasons for why patients’ social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician’s role in responding to patients’ social problems; the perceived importance of social health determinants compared with biomedical factors; the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

BACKGROUND

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation.

OBJECTIVES

To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population.

DESIGN

Secondary analysis from a nationwide cross-sectional study in Switzerland.

PARTICIPANTS

A random sample of 886 adult patients suffering from at least three chronic health conditions.

MAIN MEASURES

The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results.

KEY RESULTS

Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain.

CONCLUSION

Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons.

Eating Disorders in Lebanon: Directions for Public Health Action

Research in the field of eating disorders (ED) is limited in the Middle East. The aim of the present study was to profile Lebanese ED outpatients. A mixed-method design was used. Clinicians across Lebanon filled individual questionnaires about their 2013 ED outpatients (n = 104) and participated in focus groups. Results showed that bulimia nervosa was the most prevalent ED (46.1 %) followed by anorexia nervosa (39.4 %) and binge eating (14.4 %). The emerging socio-demographic profile of the Lebanese ED patient was that of a single female young adult of middle to high socio-economic status with severe ED symptoms (amenorrhea, multiple purging behaviors) and depression. Also, there was a general delay in seeking help which made patient recovery more difficult. The present study emphasizes the critical need for a public health approach to ED awareness and could help in developing preventive and remedial educational programs targeting youth in Lebanon and the Middle East.

Health workers who ask about social determinants of health are more likely to report helping patients: Mixed-methods study

OBJECTIVE

To assess the feasibility of implementing a clinical decision aid called the CLEAR Toolkit that helps front-line health workers ask their patients about social determinants of health, refer to local support resources, and advocate for wider social change.

DESIGN

A mixed-methods study using quantitative (online self-completed questionnaires) and qualitative (in-depth interviews, focus groups, and key informant interviews) methods.

SETTING

A large, university-affiliated family medicine teaching centre in Montreal, Que, serving one of the most ethnically diverse populations in Canada.

PARTICIPANTS

Fifty family doctors and allied health workers responded to the online survey (response rate of 50.0%), 15 completed in-depth interviews, 14 joined 1 of 2 focus groups, and 3 senior administrators participated in key informant interviews.

METHODS

Our multimethod approach included an online survey of front-line health workers to assess current practices and collect feedback on the tool kit; in-depth interviews to understand why they consider certain patients to be more vulnerable and how to help such patients; focus groups to explore barriers to asking about social determinants of health; and key informant interviews with high-level administrators to identify organizational levers for changing practice.

MAIN FINDINGS

Senior administrators consider asking about social determinants to be part of the mandate of health workers. However, barriers perceived by front-line clinicians include insufficient training in social history taking, uncertainty about how to address these issues in clinical practice, and a lack of knowledge of local referral resources. Health workers with specific ways of asking patients about their social challenges were more likely to report having helped their patients as compared with those who did not know how to ask (93.8% vs 52.9%; P = .003).

CONCLUSION

While health workers recognize the importance of social determinants, many are unsure how to ask about these often sensitive issues or where to refer patients. The CLEAR Toolkit can be easily adapted to local contexts to help front-line health workers initiate dialogue around social challenges and better support patients in clinical practice.

Factors associated with GPs' knowledge of their patients' socio-economic circumstances: a multilevel analysis

BACKGROUND

To determine appropriate management for individual patients, GPs are supposed to use their knowledge of the patient's socio-economic circumstances.

OBJECTIVE

To analyse factors associated with GPs' knowledge of these circumstances.

METHODS

Observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire about their own characteristics and randomly selected 70 patients from their patient list. Their knowledge was analysed as the agreement between the patients' and GPs' responses to questions about the patients' socio-economic characteristics in questionnaires completed by both groups. The association between agreement and the GPs' characteristics was analysed with a multilevel model adjusted for age, sex and the duration of the GP-patient relationship.

RESULTS

Agreement varied according to the socio-economic characteristics considered (from 51% to 90%) and between GPs. Globally, the GPs overestimated their patients' socio-economic level. GP characteristics associated with better agreement were sex (female), long consultations, the use of paper records or an automatic reminder system and participation in continuing medical education and in meetings to discuss difficult cases.

CONCLUSION

Knowledge of some patient characteristics, such as their complementary health insurance coverage or perceived financial situation, should be improved because their overestimation may lead to care that is too expensive and thus result in the patients' abandonment of the treatment. Besides determining ways to help GPs to organize their work more effectively, it is important to study methods to help doctors identify their patients' social-economic circumstances more accurately in daily practice.

Philosophical roots of Quaternary Prevention

This article explores two philosophical dimensions of quaternary prevention since it represents the family doctors’ response to overmedicalization. The first dimension refers to the theory of knowledge and the second to the theory of action. Despite their interconnectedness, they are addressed separately. Firstly, in the theories of knowledge (Epistemology) we argue that the positivism of Evidence-Based Medicine (EBM), so useful to select good practices, should be balanced against critical vision of the use of EBM coupled with a constructivist view through the narrative-based medicine. Secondly, in the theory of action (Ethics) we argue that the non-maleficence principle (primum non nocere) needs to be balanced by the beneficence principle. The latter is the primary medical obligation and doctors should cultivate this practical wisdom. Finally, some aspects of P4’s future challenges are discussed such as health inequalities, interprofessional collaboration, responsibility, managerialism, and the integrative medicine, where a philosophical position should be considered.