Figure 1, shows a thematic map connecting our four main themes: Social disadvantage, the clinical encounter, equity-oriented health care, and improving health outcomes.
An overview of the themes is discussed below. The complete set of themes, subthemes and illustrative quotes that were derived from the transcripts is shown in Table 2.
Themes, Subthemes, and Illustrative Quotes from Interview Transcripts
theme - subtheme
1. increased health risks.
2. Lack of resources to seek care.
“I think my practice reflects what we know in the general population which is that as you go down the income scale and down the scale of housing security and other forms of social security that type of risky behaviour tends to increase. But I think that is absolutely true in my practice as well. So (individuals with) major mental health diagnoses are much more likely to smoke, people who are living in poverty who experienced homelessness, people who have experienced trauma, people who experience other forms of social pressure like racism, people who are racialized, people who…you know identify as LGBT or trans. I mean I'd say people from any one of these groups have a higher likelihood of smoking.” (FP10)
“They're all doing work hours, so people who work shiftwork, people who are taking care of children, all of these sorts of folks who are generally going to be less socially advantaged. These people are not able to take off time because they're not necessarily protected in their jobs or have job security. These folks are not going to come to my office with all this information saying I want a CT for lung cancer screening.” (FP11)
“For socially vulnerable patients (…)I need to be more attune to them in terms of how they can be notified of their appointments so they'll have phones that sometimes are connected, sometimes aren't. Some of them much prefer to have appointment notifications through email because they can. They have their computers and they can check email at like the shelters they're staying at, whereas for others, that won’t work for them at all. So it's hard because there's not like one answer that works best for this particular population.” (FP2)
1. Factors influencing referral to screening.
2. Value of team based approach to care.
“They only seek medical care episodically in crisis that they're often challenging to accept into family practices because of time restrictions. Our model of seeing patients isn't very amendable to super complex patients who have health complex needs as well as socio-economic needs so it's hard to build a relationship. It's hard to keep appointments where you need to be at an appointment at a certain time.” (FP5)
“I mean our appointments are 15 minutes usually. And I mean we try to practice patient-centered care. So for instance, I had somebody who had a major medical issue and I'm quite focused on managing that. Making sure that she doesn’t go into liver failure, but her priority coming in is to deal with housing issues, and so those are two large topics and therefore like bringing up that she's due for a screening test there's not always time and I'm distracted by these other big issues that I think are potentially more urgent. So this distracts my attention.” (FP8)
“If there was maybe some type of patient navigator who is quite familiar with the system and was a bit of a quarterback to coordinate the appointments and help people with transit and putting the pieces together and identifying the gaps to bring to the social worker or the teams that might help.” (FP4)
“At a Community Health Centre they have social workers and like they are part of a team. So if you're in a primary care model where you're part of a team it is possible to help a patient get a little bit more stabilized, so if it's a mental health issue than you know have them either see a psychiatrist If it's social situation then yeah, I wouldn’t manage that myself but I would refer to the social worker and we have social workers.” (FP1)
“Maybe hooking them up with a social worker or a counsellor …(and) maybe having a coordinator involved just to make sure they make their appointments.” (FP7)
equity-oriented health care:
1. Neglect of structural origin of health risks.
2. Trauma- informed care.
“I really try to help people understand what an addiction truly is. I'm like this is not a judgment on you that you're still smoking. It's not because you're lazy or just don't have enough willpower, like when you started smoking that early in your life you know it really changed your brain.” (FP3)
“I think probably a combination of boredom, of culture, of you know, it (smoking) is something that's done in peer groups so I think that it's more socially acceptable.”(FP5)
“Factory workers, people who work in a warehouse, in most of these kinds of jobs it is just the acceptable way to take a break… Some people are smoking because they need to stay awake because they have a very long-distance drive … They don't usually go anywhere (with smoking cessation) until they change their job.” (FP9)
“I'd say that in our first few encounters I noted the smoking history. I gently flagged it as an issue but I spent very little time on it in our first few encounters. Well really I mean first two years of knowing him because we were really working on stabilizing all the other things going on in his life and those were clearly his priorities and clearly my priorities; right. I didn't think the smoking mattered all that much in the context of everything else that was going on for him which was far greater threats to his health than the smoking. Progressively over time his social situation really stabilized in very significant ways. He became housed, he got on ODSP so he got steady income…the conversations around smoking just started to just take up more time in our interactions progressively and you can probably almost put a like linear graph to that in terms of how much time they were taking up and you could just sort of see smoking rising up as an issue in terms of the list of priorities as other things kind of stabilized.” (FP10)
improving health outcomes:
1. Improving access to care.
2. Improving social disadvantage.
“Taxi chits … phone call reminders, you know because often we get patients who will miss my appointments.” (FP8)
“Different language literature, pictorial designs that makes it easy to understand. Maybe a navigator in different languages. Community programs. Community websites.” (FP9)
“I think automating it where possible so that the smoking history, anyone with a heavy smoking history will be automatically flagged.” (FP6)
“Compensation for physicians when we make phone calls or do emails cause it's not just outside of our work time like it cuts into our work-life balance, but we do it, but I think we'd do a little bit more of it maybe if there was some sort of acknowledgement.”(FP8)
“How likely are they (low income patients) to tolerate chemotherapy or treatment or surgery? You know going through those very, very intensive treatments or follow ups; and it's not easy when they're coming home to a shelter bed or they're coming home and they're choosing. A lot of the time they have to make choices between food and bills and those sort of costs are very, very significant. So, I think one question is are we screening them enough? And the other question is are we supporting them enough to get treatment? So, even if I had, if I was able to get everyone screened at the point of detecting lung cancer what then would happen to these patients?” (FP11)
“Help people get housed and help them get a better income quite honestly. I mean I don't think the answer lies in tweaks in a screening program. I think that these are systemic issues and I think it would be a mistake, and I think it would reinforce the systemic problems that we have to sort of say you know, we can finance this population in how we offer this program….(and create) a diversion of resources to this type of screening (and away from) what's most important for building a foundation for good health.” (FP10)
FPs associated conditions of social disadvantage with: (i) increased health risks, and (ii) lack of resources required to access health services.
When speaking of health risks, FPs described the clustering of social disadvantage in populations that were more likely to smoke. Specifically, FPs recounted how a poor quality of distribution of the SDH such as income and housing, and marginalized social identities such as race, and sexual orientation were specifically linked with risky lifestyle behaviours and a higher incidence of smoking.
FPs also described the variety of resources that are needed to access health services. Specifically, FPs mentioned the need for flexible working hours and access to childcare as a prerequisite to seeking preventative health care. Additionally, FPs spoke of the difficulty in communicating health services to patients living with low income given their lack of a consistent mailing address, inability to have and access emails, and a high frequency of disconnected phone lines.
FP’s described clinical encounters with low income patients as challenging. Specifically, FPs discussed: (i) factors influencing their ability to refer patients to screening, and (ii) the value of a team based approach to care.
FPs mentioned that care for socially disadvantaged patients was frequently episodic and centred around crisis management. When speaking of the clinical encounter, FPs described how the structure of clinic appointments such as, a fifteen minute time slot created a mismatch to the often complex and underlying health needs of patients who came from a low income demographic. Subsequently, the focus of the short clinic encounter was frequently left to managing acute health needs rather than preventative health care.
Several FPs considered that shared clinical management, particularly with other front line care providers could alleviate some of the pressures of delivering holistic care within a short clinic appointment. Specifically, FPs described the role of nurses and social workers in facilitating appointments, transportation and cancer screening.
Equity-oriented health care (EOHC)
EOHC is an approach to improving health equity at the point of care by creating: “safe and respectful environments while tailoring health care to fit the needs, priorities, history, and contexts of individual patients and populations served” (18). FPs approach to managing health risks, such as smoking behaviour fell into one of the following categories: (i) a neglect of the structural origin of health risks, or (ii) trauma-informed care.
While all FPs linked conditions of social disadvantage with a higher incidence of smoking, several FPs described smoking as a personal choice that was influenced by peers and working conditions. For these FPs, the locus of healthy behaviour resided within the individual and smoking was a choice that patients could control or influence, thereby neglecting the underlying societal structures that shape health risk or the biological basis of addiction which has evidence based treatments covered by Ontario Drug Benefits.
One FP described their approach to care as being centred around the living conditions and social needs of patients, with a focus on empowering patients by enhancing their SDH. For this FP, secure housing and stable income were pre-conditions to smoking cessation. This description of care falls within the realm of trauma-informed care, which is an approach to care that acknowledges and addresses the effects of structural violence on individuals health and health seeking choices (18).
Improving health outcomes
All FPs discussed barriers to LCS and described ways to enhance health outcomes through LCS. These perspectives towards health promotion fell into one of two groups: (i) improving access to care, or (ii) improving social disadvantage.
When discussing potential interventions to address barriers to LCS, most FP’s suggested ways in which to increase access to care such as providing taxi fare or phone reminders. FPs also discussed enhancing communication about the program through community outreach and multilingual information resources. Further, FPs described ways in which they could be facilitated to refer patients to LCS through electronic medical record (EMR) reminders and financial incentives to care for complex patients.
Two FPs were less concerned with improving access at the point of care. Rather, one FP spoke of his concern about screening low income patients for lung cancer given that a lack of appropriate housing, or secure income could undermine the ability of patients to follow through on therapy for lung cancer if indeed the screening result came out positive. Another FP questioned the allocation of resources towards screening all together, arguing that resources would be better spent on housing and income security in order to create a better foundation for overall health.