Peer-to-peer intervention to address financial strain

By Monica Da Ponte and Andrew Pinto

The ongoing COVID-19 pandemic is shining a light on financial precarity among Canadians. Prior to this crisis, 44% of Canadians said it would be difficult to meet their financial obligations if their pay was late, and more than 1 in 10 families with debt skipped or delayed a non-mortgage payment. COVID-19 has had an enormous impact on our economy, with 5.5 million Canadian workers affected by the shutdown between February to April. The unemployment rate was at a “record high” of 13.7% in May.

We have long known that, on average, wealthier people are healthier than poorer people. Living on a low income impacts everything from food security, and housing stability, to access to healthcare and our stress levels. Given this, we need to think about individual and systemic mechanisms that can help enable financial resiliency for all Canadians.

On the individual front, peer-to-peer interventions may have potential. They can build individual capabilities, address issues of shame, and support individual action. They can help individuals maneuver complicated administrative systems and build self-advocacy skills. In time, taking part in such interventions could help support people to join movements that lead to system change. 

Strive is one such peer-to-peer intervention. It uses facilitated peer-to-peer learning to help participants build the core skills required for financial resiliency. In addition, Strive includes a variety of mechanisms to support and encourage participants to take action. 

Strive emerged out of the Banff Centre’s Alt/ Now Economic Inequality program in 2016. Supported by a grant from the Institute for Global Health Equity and Innovation at the Dalla Lana School for Public Health, our study team implemented and evaluated the Strive peer-to-peer financial empowerment intervention within the St. Michael’s Hospital Academic Family Health Team

The study brought together three groups of patients: millennials who were no longer in school, precariously employed adults and older adults nearing retirement. We held in-person facilitated peer-to-peer sessions lasting two hours each over 10 consecutive weeks. The sessions guided groups through a curriculum designed to address the key enablers of financial success and covered subjects ranging from budgeting and credit basics to understanding risks and strategies to increase income. Throughout the sessions, participants were encouraged to set goals, report back on progress, successes and challenges. Participants did not receive payment or honorariums, but they had the opportunity to win one of three weekly prizes of $10 used to encouraged action and progress. 

Our evaluation, published in Family Practice, found some hopeful insights. At 3 months, participants were more optimistic about their financial situation (54% improved compared to baseline), felt more in control of their finances (55% improved compared to baseline), and had less stress about their finances (50% improved compared to baseline). In focus groups after the sessions ended, participants reported receiving support from each other and that they saw they were not alone in their struggles. 

Strive has since been piloted at York University with two cohort groups of students and received similar results and positive feedback. Further research is needed to test Strive in other settings, but such peer-to-peer interventions hold promise.

Monica Da Ponte is an adjunct professor at the Schulich School of Business at York University and the founder of Shift & Build, a boutique consultancy focused on helping to advance social change. She is the creator of Strive, and those interested in learning more can contact monicadaponte [ at ] letsstrive.ca. Andrew Pinto is the founder and director of the Upstream Lab, and an associate professor at the University of Toronto.

Social resources during COVID-19

By Jillian Macklin, MD/PhD candidate at the University of Toronto & Rachelle Perron, RN and eMHI candidate at the University of Toronto

What did we do?

The Upstream Lab worked with the Centre for Effective Practice and the Department of Family and Community Medicine at the University of Toronto to develop the COVID-19 Social Care Guidance. This helps providers support people during COVID-19. It provides a suggested script and questions to ask each person about key social determinants of health: income, food, housing, social connection and protection from violence. This Guidance also includes a framework and approach for engaging in conversations with people grounded in empathy and non-judgemental care.

COVID-19 Social Care Guidance

When providers pose these questions we want to ensure they have resources at their fingertips. We worked with over 60 volunteers across Canada to compile lists of social resources across Canada. We learned a lot about rapid collaboration and managing a team, and are so thankful for our volunteers’ efforts!

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Why does this matter?

The COVID-19 pandemic is having a disproportionate impact on marginalized populations. Public health measures aimed at limiting the spread of COVID-19, such as physical distancing, self-isolation and the closure of non-essential businesses, have the potential to have the unintended consequence of worsening social conditions that can lead to poor health. Early evidence suggests that food insecurity, social isolation, housing insecurity, unemployment and interpersonal violence have increased. People made vulnerable by how our society is organized have found themselves with even less access to the resources and supports needed to keep healthy and safe.

Health and social care providers come in frequent contact with people who are struggling with complex social issues and are well suited to assist these individuals to connect with services that address social needs. However, since COVID-19 began, many community organizations have closed or altered their service delivery and numerous new resources and programs have been created. For health and social care providers, a central problem is being able to quickly connect individuals with the right resources at the point-of-care.

What are our next steps?

Our next step is an online COVID Social Resource Connector that will help providers across Canada link clients with social supports during COVID-19. The Connector will help providers screen for unmet social needs, identify relevant and appropriate supports, and complete referrals to community resources. Through our site, community organizations will be able to share service information and accept referrals, free of charge. By supporting health and social care providers to address the social determinants of health during COVID-19, we hope that this Connector will help reduce the social harms of the COVID-19 pandemic.

Collecting data on race during COVID-19: Recommendations

Last week, evidence emerged from the US that COVID-19 outcomes may be associated with race. Our COVID-19 page provides more detail. Briefly, numerous jurisdictions reported that Black individuals were significantly over-represented in COVID-19 related deaths. Some very early data has been brought together by the CDC.

This led to many people asking: Are the same health inequities happening in Canada? We unfortunately do not routinely collect this data in health care settings. Shree Paradkar explored this issue in an article for the Toronto Star, and I had a chance to share some of our experiences with collecting data on race in primary care, and our efforts with the SPARK Study. The issue has become more contentious as public health leaders have put forward different views on whether such data should be collected.

We have put together a short report on this issue, and include recommendations. We hope this is useful during COVID-19 and beyond.

Community Health Workers to address unmet social needs: RCT

Our Upstream Lab journal club focused on this interesting study: Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: a randomized clinical trial (JAMA Intern Med 2018; 178(12): 1635-1643). This is led by Dr. Shreya Kangovi, who is the founding director of the Penn Centre for Community Health Workers.

At the heart of this study is the intervention called IMPaCT, which the Penn Centre website describes as “a standardized, scalable program that leverages community health workers (CHW) –trusted laypeople from local communities– to improve health.” In the paper, the authors note 3 stages:

  1. Goal-setting using a semi-structured interview guide to collect data on social determinants, open-ended questions and asking participants what they need to reach their health goals. Strategies discussed are familiar to those who motivational interviewing (MI) techniques in their clinical care.
  2. Tailored support over 6 months, including weekly contact and meeting face-to-face at least once a month.
  3. Connection with long-term support, which could include neighbours, family or even a weekly CHW facilitated support group.

Getting to the results, in this RCT comparing goal setting alone (n=288) vs goal setting plus CHW (n=304), there was no difference in self-rated health at 6 months (assessed using the SF-12v2 Physical Component). However, those in the intervention group had a substantial reduction in total days in hospital (absolute event reduction of 69% at 6 months), due to shorter average length of stay and lower mean number of hospitalizations.

This is quite striking, and in sharp contrast to our study from last week, which found no impact on health service use. Dr. Kangovi and colleagues recently published a study in Health Affairs finding a positive return on investment of IMPaCT, where every dollar invested in this intervention would return $2.47 to the average payer (e.g. Medicaid) within the fiscal year.

We’ll certainly apply lessons learned to our work, particularly the SPARK Study, but also several other projects where we screen and intervene on social needs at the individual-level.

Negative RCT of health care hotspotting in NEJM: What outcomes are important?

At the Upstream Lab, we’ve started up a regular journal club as part of our weekly meetings. We’ll be sharing a brief summary here on our blog. This week we looked at this study: Health care hotspotting – a randomized controlled trial (NEJM 2020; 382: 152-162). This was also the focus of discussion last week at MAP, the centre where we are based.

You may remember Atul Gawande‘s 2011 article on “The hot spotters”, profiling the work of the Camden Coalition of Healthcare Providers in Camden, New Jersey. This article got a lot of people interested in the idea that the solution to rising health costs was to focus on the people who were disproportionately using a huge amount of health services. Here in Ontario, we also started to focus on so-called “high-cost users”, leading to a new program called Health Links. I was involved in a study led by my colleague Dr. Laura Rosella that essentially found that social determinants played a big role in who would end up being a high-cost user. Maybe not surprising to visitors of this blog, but we thought it was really important to point this out. Most of the solutions being proposed were focused on just getting these folks more traditional health services.

Getting back to the article, this RCT focused on “superutilizers of the health care system — persons with medically and socially complex needs who have frequent hospital admissions”. These patients were identified during an admission and were connected to a multidisciplinary team with nurses, social workers, community health workers and health coaches. This team did a lot, including home visits, got people to appointments, helped with medications, measured BP and blood sugars, coached patients and helped patients apply for social services and behavioral health programs. That last part about social services sounds similar to some interventions we are studying.

The study found no difference in readmission to hospital after 6 months, between people who got the intervention compared to controls. Why not? Regression to the mean, is one explanation . Another is that people are on trajectories that are hard to change. A NYTimes article on the study made the case that it is really tough to make a difference in readmission to hospital, and mentions future work by the Camden Coalition will focus on housing. They are teaming up with lawyers to prevent evictions, something we’ve also been studying with the Health Justice Initiative.

For such studies, what outcomes are important to patients, families, providers and policymakers? I suspect that if outcomes included reduced stress, improved quality of life, and knowing where to go for help when in crisis, maybe the study would have been positive. Like so many studies of complex interventions, more work is required to really understand what is going on.