Search

Background Individuals living in poverty often visit their primary care physician for health problems resulting from unmet legal needs. Providing legal services for those in need may therefore improve health outcomes. Poverty is a social determinant of health. Impoverished areas tend to have poor health outcomes, with higher rates of mental illness, chronic disease, and comorbidity. This study reports on a medical-legal collaboration delivered in a healthcare setting between health professionals and lawyers as a novel way to approach the inaccessibility of legal services for those in need. Methods In this observational study, patients aged 18 or older were either approached or referred to complete a screening tool to identify areas of concern. Patients deemed to have a legal problem were offered an appointment at the Legal Health Clinic, where lawyers provided legal advice, referrals, and services for patients of the physicians. Fisher’s exact test was used to compare populations. Binary logistic regression was used to determine the factors predicting booking an appointment with the clinic. Results Eighty-four percent (n = 648) of the 770 patients screened had unmet legal needs and could benefit from the intervention, with an average of 3.44 (SD = 3.42) legal needs per patient screened. Patients with legal needs had significantly higher odds of attending the Legal Health Clinic if they were an ethnicity that was not white (OR = 2.48; 95% CI 1.14–5.39), did not have Canadian citizenship (OR = 4.40; 95% CI 1.48–13.07), had housing insecurity (OR = 3.33; 95% CI 1.53–7.24), and had difficulty performing their usual activities (OR = 2.83; 95% CI 1.08–7.43). As a result of the clinic consultations, 58.0% (n = 40) were referred to either Legal Aid Ontario or Hamilton Community Legal Clinic, 21.74% (n = 15) were referred to a private lawyer; one case was taken on by the clinic lawyer. Conclusion The Legal Health Clinic was found to fulfill unmet legal needs which were abundant in this urban family practice. This has important implications for the future health of patients and clinical practice. Utilizing a Legal Health Clinic could translate into improved health outcomes for patients by helping overcome barriers in accessing legal services and addressing social causes of adverse health outcomes.

(1) The majority of Canadian youth are insufficiently active, and moderate-to-vigorous physical activity (MVPA) decreases substantially during secondary school. School factors within the comprehensive school health (CSH) framework may help attenuate this decline. This study aimed to examine how youth MVPA changes over a three-year period and evaluate the school characteristics associated with preventing the decline in MVPA over time, guided by the CSH framework. (2) This study uses COMPASS survey data from 78 secondary schools in Ontario and Alberta that participated in Year 2 (2013/14), Year 3 (2014/15), and Year 4 (2015/16), and 17,661 students attending these schools. Multilevel (linear mixed effects) models were used to determine the association between school-level factors and student MVPA (weekly minutes) over time, stratified by gender. (3) Both male and female students had a significant decline in MVPA across the 3 years, with a greater decrease observed among female students. Within the CSH framework, the school’s social environment, partnerships, and policies were associated with student MVPA over time, however the specific school factors and directions of associations varied by gender. (4) School-based interventions (e.g., public health partnerships) may help avoid the decline in MVPA observed in this critical period and support student health.

ObjectivesTo evaluate the cost-effectiveness of the Community Paramedicine at Clinic (CP@clinic) programme compared with usual care in seniors residing in subsidised housing.DesignA cost–utility analysis was conducted within a large pragmatic cluster randomised controlled trial (RCT). Subsidised housing buildings were matched by sociodemographics and location (rural/urban), and allocated to intervention (CP@clinic for 1 year) or control (usual care) via computer-assisted paired randomisation.SettingThirty-two subsidised seniors’ housing buildings in Ontario.ParticipantsBuilding residents 55 years and older.InterventionCP@clinic is a weekly community paramedic-led, chronic disease prevention and health promotion programme in the building common areas. CP@clinic is free to residents and includes risk assessments, referrals to resources, and reports back to family physicians.Outcome measuresQuality-adjusted life years (QALYs) gained, measured with EQ-5D-3L. QALYs were estimated using area-under-the curve over the 1-year intervention, controlling for preintervention utility scores and building pairings. Programme cost data were collected before and during implementation. Costs associated with emergency medical services (EMS) use were estimated. An incremental cost effectiveness ratio (ICER) based on incremental costs and health outcomes between groups was calculated. Probabilistic sensitivity analysis using bootstrapping was performed.ResultsThe RCT included 1461 residents; 146 and 125 seniors completed the EQ-5D-3L in intervention and control buildings, respectively. There was a significant adjusted mean QALY gain of 0.03 (95% CI 0.01 to 0.05) for the intervention group. Total programme cost for implementing in five communities was $C128 462 and the reduction in EMS calls avoided an estimated $C256 583. The ICER was $C2933/QALY (bootstrapped mean ICER with Fieller’s 95% CI was $4850 ($2246 to $12 396)) but could be even more cost effective after accounting for the EMS call reduction.ConclusionThe CP@clinic ICER was well below the commonly used Canadian cost–utility threshold of $C50 000. CP@clinic scale-up across subsidised housing is feasible and could result in better health-related quality-of-life and reduced EMS use in low-income seniors.Trial registration numberClinicaltrials.gov, NCT02152891.

Background The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population. Methods This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed. Results There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3–84.6%) and South Asian (87.3–92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease. Conclusion Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

BackgroundPoverty and food insecurity have been linked to poor health and morbidity, especially in older adults. Housing is recognized as a social determinant of health, and very little is known about subjective poverty and food insecurity in the marginalized population of older adults living in subsidized social housing. We sought to understand poverty and food insecurity, as well as the risk factors associated with both outcomes, in older adults living in social housing in Ontario.MethodsThis was a cross-sectional study using data collected from the Community Paramedicine at Clinic (CP@clinic) program. A total of 806 adult participants residing in designated seniors’ or mixed family-seniors’ social housing buildings attended CP@clinic within 14 communities across Ontario, Canada.ResultsThe proportion of older adults reporting poverty and food insecurity were 14.9 and 5.1%, respectively. Statistically significant risk factors associated with poverty were being a smoker (AOR = 2.38, 95% CI: 1.23–4.62), self-reporting feeling extremely anxious and/or depressed (AOR = 3.39, 95% CI: 1.34–8.62), and being food insecure (AOR = 23.52, 95% CI: 8.75–63.22). Statistically significant risk factors associated with food insecurity were being underweight (AOR = 19.79, 95% CI: 1.91–204.80) and self-reporting experiencing poverty (AOR = 23.87, 95% CI: 8.78–64.90). In those who self-reported being food secure, the dietary habits reported were consistent with a poor diet.ConclusionThe poverty rate was lower than expected which could be related to the surrounding environment and perceptions around wealth. Food insecurity was approximately twice that of the general population of older adults in Canada, which could be related to inaccessibility and increased barriers to healthy foods. For those who reported being food secure, dietary habits were considered poor. While social housing may function as a financial benefit and reduce perceived poverty, future interventions are needed to improve the quality of diet consumed by this vulnerable population.

Housing is a social determinant of health that fundamentally affects health and wellbeing.1 A UK study found housing to be a unique predictor of health outcomes, after accounting for income.1 Although social housing can improve health through the financial benefit of lower rent,2 it also has negative impacts due to building disrepair,2 and policies resulting in clusters of residents with poor mental health and substance issues.3 Social housing exists in many formats across the globe: council estates in the UK; projects or public housing in the US; social housing in Canada; social or public housing in Australia; and state housing in New Zealand. In the US, it is predicted that, by 2035, one in three public housing units will be occupied by an individual aged ≥65 years,4 while in the UK that is already the situation.5 In Ontario, Canada alone, approximately 75 000 older adults live in social housing.6 Older adults on low incomes are a vulnerable population with increased risk of chronic disease, falls, social isolation,7 and poor outcomes from COVID-19. In-person restrictions have heightened the importance of internet-based solutions for access to health care, information, basic …

Objectives This study aimed to describe the risk of developing diabetes and the probable prevalence of diabetes and prediabetes in residents of subsidized or social housing who were 55 years of age or older. Methods We conducted a cross-sectional study using data collected from an ongoing community health program in social housing buildings—the Community Paramedicine at Clinic (CP@clinic) program. Community paramedics staffing the CP@clinic program conducted lifestyle-related modifiable risk factor assessments of participating social housing residents who were 55 years of age or older. The Canadian Diabetes risk assessment (CANRISK) tool was administered to all participants, and those with moderate-to-high risk of developing diabetes were asked to return for a fasting capillary blood glucose (CBG) measurement. Data were collected from program participants who attended the sessions between December 2014 and May 2018. Results There were 728 participants. Most were women (80.5%), aged 65 to 84 (68.1%), white (85.4%) and educated to the high school level or less (69.2%). At baseline, 71.3% were identified as having overweight or obesity, and 12.5% were diagnosed with diabetes. Of participants not diagnosed with diabetes (N=632), 66.6% were at high risk of developing diabetes, and 30.1% were categorized as moderate risk. The CBG assessments showed that 37.7% (N=158) of those with high risk and 22.0% (N=42) of those with moderate risk had blood glucose readings indicating impaired fasting glucose or probable diabetes. Conclusions This study shows that 96.7% of low-income older adults in social housing buildings had moderate-to-high risk of developing diabetes and that the probable prevalence of undiagnosed prediabetes and diabetes was 32.0%.

Background Falls in older adults is a widely researched topic. However, older adults residing in public housing are a vulnerable population that may have unique risk factors for falls. This study aims to describe the prevalence and risk factors for falls, fear of falling, and seeking medical attending for falls in this population. Methods Sociodemographic and health-related data was collected as part of a community-based health assessment program with older adults in public housing. Three pre-screening questions identified individuals at potential risk for falls; individuals who screened positive performed the objective Timed Up and Go (TUG) test. Logistic regression was used to evaluate risk factors for four outcome variables: falls in the past year, seeking medical attention for falls, fear of falling, and objectively measured fall risk via TUG test. Results A total of 595 participants were evaluated, of which the majority were female (81.3%), white (86.7%), did not have a high school diploma (50.0%), and reported problems in mobility (56.2%). The prevalence of falls in the past year was 34.5%, seeking medical attention for falls was 20.2% and fear of falling was 38.8%. The TUG test was completed by 257 participants. Notably, males had significantly reduced odds of seeking medical attention for a fall (OR = 0.50, 95%CI 0.25–0.98) and having a fear of falling (OR = 0.42, 95%CI 0.24–0.76); daily fruit and vegetable consumption was associated with decreased odds of having a fall in the past year (OR = 0.55, 95%CI 0.37–0.83), and alcohol consumption was associated with increased odds of fear of falling (OR = 1.72, 95%CI 1.03–2.88). Conclusion Older adults residing in public housing have unique risk factors associated with social determinants of health, such as low fruit and vegetable consumption, which may increase their risk for falls. The findings of this study can be used to inform falls interventions for this population and identify areas for further research.

Aim: To describe activities and outcomes of a cross-team capacity building strategy that took place over a five-year funding period within the broader context of 12 community-based primary health care (CBPHC) teams. Background: In 2013, the Canadian Institutes of Health Research funded 12 CBPHC Teams (12-Teams) to conduct innovative cross-jurisdictional research to improve the delivery of high-quality CBPHC to Canadians. This signature initiative also aimed to enhance CBPHC research capacity among an interdisciplinary group of trainees, facilitated by a collaboration between a capacity building committee led by senior researchers and a trainee-led working group. Methods: After the committee and working group were established, capacity building activities were organized based on needs and interests identified by trainees of the CBPHC Teams. This paper presents a summary of the activities accomplished, as well as the outcomes reported through an online semistructured survey completed by the trainees toward the end of the five-year funding period. This survey was designed to capture the capacity building and mentorship activities that trainees either had experienced or would like to experience in the future. Descriptive and thematic analyses were conducted based on survey responses, and these findings were compared with the existing core competencies in the literature. Findings: Since 2013, nine webinars and three online workshops were hosted by trainees and senior researchers, respectively. Many of the CBPHC Teams provided exposure for trainees to innovative methods, CBPHC content, and showcased trainee research. A total of 27 trainees from 10 of the 12-Teams responded to the survey (41.5%). Trainees identified key areas of benefit from their involvement in this initiative: skills training, networking opportunities, and academic productivity. Trainees identified gaps in research and professional skill development, indicating areas for further improvement in capacity building programs, particularly for trainees to play a more active role in their education and preparation.

BackgroundDetermining the effectiveness of community-based health promotion and disease prevention programs requires an appropriate data collection tool. This study aimed to develop a comprehensive health questionnaire for older adults, called the HABiT, and evaluate its reliability, content validity, and face validity in assessing individual health-related items (e.g., health status, healthcare utilization) and five specific scales: knowledge, current health behaviors (risk factors), health-related quality of life (HRQoL), perceived risk and understanding, and self-efficacy.MethodsIterative survey development and evaluation of its psychometric properties in a convenience sample of 28 older adults (≥ 55 years old), half from a low-income population. Following item generation, the questionnaire was assessed for content validity (expert panel), face validity (participant feedback), internal consistency of each scale (Cronbach’s alpha), and test-retest reliability for each item and scale (Pearson’srand phi correlations, as appropriate).ResultsQuestions were drawn from 15 sources, but primarily three surveys: Canadian Community Health Survey, Canadian Diabetes Risk Questionnaire (CANRISK), and a survey by the Canadian Hypertension Education Program. Expert consensus was attained for item inclusion and representation of the desired constructs. Participants completing the questionnaire deemed the questions to be clear and appropriate. Test-retest reliability for many individual items was moderate-to-high, with some exceptions for items that can reasonably change in a short period (e.g., perceived day-to-day stress). Of the five potential scales evaluated, two had acceptable internal consistency (Cronbach’s alpha ≥ 0.60) and a subset of one scale also had acceptable internal consistency. Test-retest reliability was high (correlation ≥ 0.80) for all scales and sub-scales.ConclusionsThe HABiT is a reliable and suitable comprehensive tool with content and face validity that can be used to evaluate health promotion and chronic disease prevention programs in older adults, including low-income older adults. Some noted limitations are discussed. Data collected using this tool also provides a diabetes risk score, health literacy score, and quality-adjusted life years (QALYs) for economic analysis.

BackgroundThe Cardiovascular Health Awareness Program (CHAP) uses volunteers to provide cardiovascular disease (CVD) and diabetes screening in a community setting, referrals to primary care providers, and locally available programs targeting lifestyle modification. CHAP has been adapted to target older adults residing in social housing, a vulnerable segment of the population. Older adults living in social housing report poorer health status and have a higher burden of a multitude of chronic illnesses, such as CVD and diabetes. The study objective is to evaluate whether there is a reduction in unplanned CVD-related Emergency Department (ED) visits and hospital admissions among residents of social seniors’ housing buildings receiving the CHAP program for 1 year compared to residents in matched buildings not receiving the program.Methods/designThis is a pragmatic, cluster randomized controlled trial in community-based social (subsidized) housing buildings in Ontario and Quebec. All residents of 14 matched pairs (intervention/control) of apartment buildings will be included. Buildings with 50–200 apartment units with the majority of residents aged 55+ and a unique postal code are included. All individuals residing within the buildings at the start of the intervention period are included (intention to treat, open cohort). The intervention instrument consists of CHAP screens for high blood pressure using automated blood pressure monitors and for diabetes using the Canadian Diabetes Risk (CANRISK) assessment tool. Monthly drop-in sessions for screening/monitoring are held within a common area of the building. Group health education sessions are also held monthly. Reports are sent to family doctors, and attendees are encouraged to visit their family doctor. The primary outcome measure is monthly CVD-related ED visits and hospitalizations over a 1-year period post randomization. Secondary outcomes are all ED visits, hospitalizations, quality of life, cost-effectiveness, and participant experience.DiscussionIt is anticipated that CVD-related ED visits and hospitalizations will decrease in the intervention buildings. Using the volunteer-led CHAP program, there is significant opportunity to improve the health of older adults in social housing.Trial registrationClinicalTrials.gov,NCT03549845. Registered on 15 May 2018. Updated on 21 May 2019.

OBJECTIVES: This study aimed to assess functional health literacy levels among older adults living in subsidized housing in Hamilton, Ontario, and to assess the relationships between health literacy and other important health indicators, such as education level, age, ethnicity, body mass index (BMI), and self-reported health status. METHODS: Older adults (n = 237) living in subsidized housing buildings in Hamilton, ON, were assessed using the NVS-UK as a measure of functional health literacy in addition to a health indicator questionnaire through structured interview. Health literacy levels were analyzed using descriptive statistics and logistic regression to determine relationships between health literacy levels and other health indicators. RESULTS: Participants’ mean age was 73 years, 67% were female, 70% were not educated beyond high school, and 91% were white. Over 82% of participants had below adequate health literacy levels using the NVS-UK. Multivariable logistic regression revealed significant relationships between functional health literacy and BMI, education level, and pain and discomfort levels. No significant relationships were found between health literacy level and age group, anxiety and depression levels, CANRISK (Diabetes risk) score, gender, marital status, mobility issues, self-care issues, self-reported health status, or performance of usual activities. CONCLUSIONS: As the population of older adults continues to grow, the appropriate resources must be available to both improve and support the health literacy level of the population. Future health research should gather information on the health literacy levels of target populations to ensure more equitable health service. This research provides a significant opportunity to better understand populations with health literacy barriers.

BACKGROUND: Low-income older adults who live in subsidized housing have higher mortality and morbidity. We aimed to determine if a community paramedicine program — in which paramedics provide health care services outside of the traditional emergency response — reduced the number of ambulance calls to subsidized housing for older adults. METHODS: We conducted an open-label pragmatic cluster-randomized controlled trial (RCT) with parallel intervention and control groups in subsidized apartment buildings for older adults. We selected 6 buildings using predefined criteria, which we then randomly assigned to intervention (Community Paramedicine at Clinic [CP@clinic] for 1 yr) or control (usual health care) using computer-generated paired randomization. CP@clinic is a paramedic-led, community-based health promotion program to prevent diabetes, cardiovascular disease and falls for residents 55 years of age and older. The primary outcome was building-level mean monthly ambulance calls. Secondary outcomes were individual-level changes in blood pressure, health behaviours and risk of diabetes assessed using the Canadian Diabetes Risk Questionnaire. We analyzed the data using generalized estimating equations and hierarchical linear modelling. RESULTS: The 3 intervention and 3 control buildings had 455 and 637 residents, respectively. Mean monthly ambulance calls in the intervention buildings (3.11 [standard deviation (SD) 1.30] calls per 100 units/mo) was significantly lower (−0.88, 95% confidence interval [CI] −0.45 to −1.30) than in control buildings (3.99 [SD 1.17] calls per 100 units/mo), when adjusted for baseline calls and building pairs. Survey participation was 28.4% (n = 129) and 20.3% (n = 129) in the intervention and control buildings, respectively. Residents living in the intervention buildings showed significant improvement compared with those living in control buildings in quality-adjusted life years (QALYs) (mean difference 0.09, 95% CI 0.01 to 0.17) and ability to perform usual activities (odds ratio 2.6, 95% CI 1.2 to 5.8). Those who received the intervention had a significant decrease in systolic (mean change 5.0, 95% CI 1.0 to 9.0) and diastolic (mean change 4.8, 95% CI 1.9 to 7.6) blood pressure. INTERPRETATION: A paramedic-led, community-based health promotion program (CP@clinic) significantly lowered the number of ambulance calls, improved QALYs and ability to perform usual activities, and lowered systolic blood pressure among older adults living in subsidized housing. Trial registration: Clinicaltrials.gov, no. NCT02152891

Introduction Chronic diseases and falls substantially contribute to morbidity/mortality among seniors, causing this population to frequently seek emergency medical care. Research suggests the paramedic role can be successfully expanded to include community-based health promotion and prevention. This study implements a community paramedicine programme targeting seniors in subsidised housing, a high-risk population and frequent users of emergency medical services (EMS). The aims are to reduce EMS calls, improve health outcomes and healthcare utilisation. Methods/analysis This is a pragmatic clustered randomised control trial in four communities across Ontario, Canada. Within each, four to eight seniors’ apartment buildings will be paired and within each pair one building will be randomly assigned to receive the Community Health Assessment Programme through EMS (CHAP-EMS) intervention, while the other building receives no intervention. During the 1-year intervention, paramedics will run weekly sessions in a common area of the building, assessing risk factors for cardiovascular disease, diabetes and falls; providing health education and referrals to community programmes; and communicating results to the participant9s primary physician. The primary outcomes are rate of emergency calls per 100 residents, change in blood pressure and change in Canadian Diabetes Risk (CANRISK) score, as collected by the local EMS and study databases. The secondary outcomes are change in health behaviours, measured using a preintervention and postintervention survey and healthcare utilisation, available through administrative databases. Analysis will mainly consist of descriptive statistics and generalised estimating equations, including subgroup cluster analysis. Ethics/dissemination This study is approved by the Hamilton Integrated Research Ethics Board and will follow the Tri-Council Policy Statement. Findings will be disseminated through reports to local stakeholders, publication in peer-reviewed journals and conference presentations. Trial registration number NCT02152891.

Background Seniors living in subsidized housing have lower income, poorer health, and increased risk for cardiometabolic diseases and falls. Seniors also account for more than one third of calls to Emergency Medical Services (EMS). This study examines the effectiveness of the Community Health Assessment Program through EMS (CHAP-EMS) in reducing blood pressure, diabetes risk, and EMS calls. Methods Paramedics on modified duty (e.g. injured) conducted weekly, one-on-one drop-in sessions in a common area of one subsidized senior’s apartment building in Hamilton, Ontario. Paramedics assessed cardiovascular, diabetes, and fall risk, provided health education, referred participants to local resources, and encouraged participants to return to CHAP-EMS for follow-up. Reports were faxed to the family physician regularly. Blood pressure was collected throughout the one year intervention, while diabetes risk was assessed at baseline and after 6–12 months. EMS call volumes were collected from the Hamilton Paramedic Service for two years pre-intervention and one year during the intervention. Results There were 79 participants (mean age = 72.2 years) and 1,365 participant visits to CHAP-EMS. The majority were female (68%), high school educated or less (53%), had a family doctor (90%), history of hypertension (58%), high waist circumference (64%), high body mass index (61%), and high stress (53%). Many had low physical activity (42%), high fat intake (33%), low fruit/vegetable intake (30%), and were current smokers (29%). At baseline, 42% of participants had elevated blood pressure. Systolic blood pressure decreased significantly by the participant’s 3rd visit to CHAP-EMS and diastolic by the 5th visit (p