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The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Persons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness. We searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings. Our search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement. Individuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

It has been said that ‘location is a matter of geography, but global is a matter of the heart’. This is very much the spirit that guided the creation of the Besrour Centre at the Canadian College of Family Physicians in 2015 and that has guided its mission to generate knowledge about family medicine globally. The Centre believes that family medicine lies at the heart of health systems and provides a much-needed intersection between the clinical domain of primary care and the broader aims of the primary health care sector more generally.

Immunisation against COVID-19 is crucial for controlling the pandemic, yet global challenges persist in vaccine coverage and equitable distribution. A well-integrated primary health care approach can enhance vaccination programmes. To explore the relationship between perceived PC (primary care)-PH (public health) integration, as well as other vaccination program implementation factors, and national COVID-19 vaccination coverage. A convenience sample of self-identified primary care professionals completed an online survey on COVID-19 vaccination programme implementation and their perceptions of PC-PH integration. Countries with ≥5 responses were included in the data analysis. COVID-19 vaccination implementation approach and perceived PC-PH integration against COVID-19 vaccination coverage was investigated using bivariate and subgroup analyses, Spearman correlation, and linear regression. A total of 394 responses from 32 countries were analysed. Participants included primary care providers, academics, and researchers. The median national COVID-19 vaccination coverage was 28.41% at time of study. Perceived barriers included patient hesitancy and vaccine supply shortages, while facilitators included vaccine product choices, equity, and community engagement. The study revealed a positive relationship between perceptions of PC-PH integration and national vaccination coverage in upper-middle and lower-middle income countries. Perceived PC-PH integration increased with decreasing economic quartiles and this perception was linked to actual national vaccination coverage. Integration may be especially important for countries with lesser vaccine supply. High-income countries may benefit from increased collaboration between PC and PH to enhance vaccination efficiency. The findings contribute to understanding the role of PC-PH integration in vaccination programmes in different settings.

Pottie et al discuss the clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. Homelessness encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it. Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person's gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care. As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended. Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.

Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social‐protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental‐health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost‐effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi‐experimental studies conducted among populations experiencing homelessness in high‐income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance‐use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random‐effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost‐effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high‐ and moderate‐needs populations with significant cimorbid mental illness and substance‐use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental‐health or substance‐use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short‐term improvement in depression and perceived stress levels were reported, no evidence of the long‐term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical‐ and social‐services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost‐effectiveness of income‐assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US $45 (95% CI, −$ 19, − $108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$ 20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost‐offset or cost‐effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US $52,574 vs. US$ 51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High‐intensity case management and income‐assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID‐19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence‐based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

BackgroundAn integrated primary health care approach, where primary care and public health efforts are coordinated, is a key feature of routine immunisation campaigns.AimThe aim of the study is to describe the approach used by a diverse group of international primary health care professionals in delivering their coronavirus disease 2019 (COVID-19) vaccination programmes, as well as their perspectives on public health and primary care integration while implementing national COVID-19 vaccination programmes in their own jurisdictions.SettingThis is a protocol for a study, which consists of a cross-sectional online survey disseminated among a convenience sample of international primary health care professional through member-based organisations and professional networks via email and online newsletters.MethodsSurvey development followed an iterative validation process with a formative committee developing the survey instrument based on study objectives, existing literature and best practices and a summative committee verifying and validating content.ResultsMain outcome measures are vaccination implementation approach (planning, coordination service deliver), level or type of primary care involvement and degree of primary care and public health integration at community level.ConclusionIntegrated health systems can lead to a greater impact in the rollout of the COVID-19 vaccine and can ensure that we are better prepared for crises that threaten human health, not only limited to infectious pandemics but also the rising tide of chronic disease, natural and conflict-driven disasters and climate change.ContributionThis study will provide insight and key learnings for improving vaccination efforts for COVID-19 and possible future pandemics.

Some countries, such as the United Kingdom and Germany, encourage PHEs for otherwise healthy adults aged 40-75 years, arguing that these groups have an increasing burden of lifestyle and chronic diseases that may be amenable to intervention.2 In Canada, however, the ongoing variability in practice, with a trend toward reducing or eliminating the use of PHEs in adults, may be confusing to patients. The PHE is an opportunity to perform evidence-based preventive manoeuvres, to counsel patients on lifestyle issues, update vaccinations and, importantly, to identify risk factors and diagnoses through updating the cumulative patient profile (i.e., patient history).3,4 However, this may not be necessary annually in patients at low risk. For resources on preventive manoeuvres, see Appendix 1 (available at www .cmaj.ca/lookup/suppl /doi :10 .1503 /cmaj.141125/-/DC1).

Many laboratories routinely test for HPV on Pap samples that have specific cellular abnormalities. Primary HPV testing (i.e., without cytology) is currently not offered in Canada. The evidence for this strategy is still being developed and may change practice in the near future. A recent meta-analysis of randomized controlled trials found a small absolute reduction in invasive cancer with primary HPV testing, but it is too early to assess mortality.5 Ages at which Pap screening should start vary by jurisdiction, but most guidelines agree that harm from false-positive results outweighs potential benefits of Pap screening in young women. 4 Women who have had a total hysterectomy for a benign disorder and women over 70 years of age who have had three normal test results within 10 years do not require Pap screening.4