Figure 2, 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.
Social disadvantage
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.
Clinical encounter
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)
Equity-oriented healthcare (EOHC) s 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” (23). At the patient-provider interaction level, EOHC is responsive to social structural inequalities which underpin health differences by using a trauma-informed approach to the delivery of care (23). In our analysis, we found that 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 through theacknowledgement and address of the effects of structural violence on individuals health and health seeking choices (23).
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.