Should we screen for poverty in primary care?

Is it possible to identify populations experiencing material disadvantage in primary care? A feasibility study using the Clinical Practice Research Database

BACKGROUND

Material disadvantage is associated with poor health, but commonly available area-based metrics provide a poor proxy for it. We investigate if a measure of material disadvantage could be constructed from UK primary care electronic health records.

METHODS

Using data from Clinical Practice Research Datalink Aurum (May 2022) linked to the 2019 English Index of Multiple Deprivation (IMD), we sought to (1) identify codes that signified material disadvantage, (2) aggregate these codes into a binary measure of material disadvantage and (3) compare the proportion of people with this binary measure against IMD quintiles for validation purposes.

RESULTS

We identified 491 codes related to benefits, employment, housing, income, environment, neglect, support services and transport. Participants with one or more of these codes were defined as being materially disadvantaged. Among 30,897,729 research-acceptable patients aged ≥18 with complete data, only 6.1% (n=1,894,225) were classified as disadvantaged using our binary measure, whereas 42.2% (n=13,038,085) belonged to the two most deprived IMD quintiles.

CONCLUSION

Data in a major primary care research database do not currently contain a useful measure of individual-level material disadvantage. This represents an omission of one of the most important health determinants. Consideration should be given to creating codes for use by primary care practitioners.

Co-design workshops with families experiencing multiple and interacting adversities including parental mental health, substance use, domestic violence, and poverty: intervention principles and insights from mothers, fathers, and young people

BACKGROUND

Clustering and co-occurring of family adversities, including mental health problems, substance use, domestic violence and abuse, as well as poverty can increase health and behavioural risks for children, which persist throughout the life course. Yet, interventions that acknowledge and account for the complex interactive nature of such risks are limited. This study aimed to develop intervention principles based on reflections from mothers, fathers, and young people who experience multiple and interacting adversities. These principles will show how family members perceive an intervention may bring about positive change and highlight key insights into design and delivery.

METHODS

A series of six co-design workshops with mothers, fathers, and young people who experienced multiple and interacting adversities (n = 41) were iteratively conducted across two regions in England (London and North-East) by four researchers. Workshop content and co-design activities were informed by advisory groups. Data from facilitator notes and activities were analysed thematically, resulting in a set of intervention principles.

RESULTS

The intervention principles highlighted that: (1) to reduce isolation and loneliness parents and young people wanted to be connected to services, resources, and peer support networks within their local community, particularly by a knowledgeable and friendly community worker; (2) to address feelings of being misunderstood, parents and young people wanted the development of specialised trauma informed training for practitioners and to have the space to build trusting, gradual, and non-stigmatising relationships with practitioners; and (3) to address the needs and strengths of individual family members, mothers, fathers, and young people wanted separate, tailored, and confidential support.

CONCLUSIONS

The current study has important implications for practice in supporting families that experience multiple and interacting adversities. The intervention principles from this study share common characteristics with other intervention models currently on offer in the United Kingdom, including social prescribing, but go beyond these to holistically consider the whole families' needs, environments, and circumstances. There should be particular focus on the child's as well as the mothers' and fathers' needs, independently of the family unit. Further refinement and piloting of the developing intervention are needed.

Primary care physicians' perceptions of social determinants of health recommendations: a qualitative study

BACKGROUND

Several organisations have called for primary care professionals to address social determinants of health (SDoH) in clinical settings. For primary care physicians to fulfill their community health responsibilities, the implications of the SDoH recommendations need to be clarified.

AIM

To describe primary care physicians' views about being asked to address SDoH in clinical settings, from both positive and negative perspectives.

DESIGN & SETTING

A qualitative study in Japan. Twenty-one physicians were purposively recruited.

METHOD

'Love and breakup letter' methodology was used to collect qualitative data that contained both positive and negative feelings. Participants wrote love and breakup letters about being asked to address SDoH in a clinical setting, then undertook an in-depth online interview. Data were analysed via thematic analysis using the framework approach.

RESULTS

The following themes were identified: (i) primary care physicians take pride in being expected to address SDoH; (ii) primary care physicians rely on the recommendations as a partner, even in difficult situations; (iii) primary care physicians consider the recommendations to be bothersome, with unreasonable demands and challenges, especially when supportive surroundings are lacking; and (iv) primary care physicians reconstruct the recommendations on the basis of their experience.

CONCLUSION

Primary care physicians felt both sympathy and antipathy towards recommendations asking them to address SDoH in their clinical practice. The recommendations were not followed literally, instead contributing to physicians' clinical mindlines. Professional organisations that plan to develop and publish recommendations about SDoH should consider how their recommendations might be perceived by their target audience.