A consensus study leading to HALT- a tool to prevent homelessness in primary care

A consensus study leading to HALT- a tool to prevent homelessness in primary care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A consensus study leading to HALT- a tool to prevent homelessness in primary care Alexandra Huey, Grainne P Kearney, Nigel D Hart This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6783597/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Reducing health inequalities is a global health priority. People experiencing homelessness experience health at the extreme end of health inequality; homelessness must be prevented where possible. Healthcare tools developed to identify patients living in insecure housing to signpost to support services are not routinely used in primary care across the UK and Ireland. This study explores which tools would be feasible to use in our local context and aimed to develop a tool that could identify patients at risk of homelessness for use in primary care in the UK and Ireland Methods This two-stage study involved a literature search using online databases for healthcare tools that identify housing insecurity and a consensus study where a panel of General Practitioners reached agreement on housing questions feasible to use in the UK and Ireland. The consensus study had two rounds that took place online: a questionnaire and a workshop. Results Eleven primary care physicians participated in round one with eight in round two. Housing questions from two tools met consensus criteria. Once ranked in order of preference, suggested modifications were made for a UK and Ireland context. The outcome is ‘HALT’: a four-question housing tool. Conclusion HALT provides a memorable framework to enquire about patients’ housing to identify those at risk of experiencing of homelessness for signposting to support services. Further research is required to assess the acceptability of, and to validate, HALT. Health inequities housing instability social determinants of health Delphi technique family practice primary health care general practice Figures Figure 1 Figure 2 Introduction Tackling the gap in health inequalities has been highlighted as a priority for the UK’s National Health Service; the King’s Fund have emphasised that primary care is best placed to identify and address issues early( 1 ).People experiencing homelessness (PEH) are at the extreme end of health inequalities; the well-documented linear relationship between poorer health outcomes and increasing socio-economic deprivation (the slope) becomes a cliff for people experiencing homelessness : ‘slopes and cliffs’ ( 2 , 3 ). PEH having significantly increased prevalence of multimorbidity and premature mortality ( 3 ). Homelessness takes different forms: rough sleeping, living under threat of violence or eviction, in insecure tenancies, temporary accommodation, unfit housing and extreme overcrowding( 4 ). As reducing the gap in health inequalities has become a priority in primary and secondary case, preventing homelessness and the subsequent health outcomes should be a public health and primary care priority. Healthcare in general, and primary care in particular, are among common touch points for people experiencing, or those at-risk of, homelessness; thus, everyday General Practice consultations could provide an opportunity to identify risk and initiate action ( 5 ).While a range of validated questionnaire tools to identify housing insecurity for referral or signposting to support services are in use in healthcare settings internationally, there is no evidence that a tool has been developed for or integrated into the primary care setting in the UK or Ireland; this is a gap in local services. The demands on healthcare continue to grow, hence any proposal to add the identification of homelessness or its risk, would need to take account of this growing demand( 6 ). Inspired by the memorable CAGE questionnaire, used to screen for excessive alcohol use in primary care, the aim of this study was to develop a tool to identify those at risk of homelessness for use in primary care settings in the UK and Ireland to enable early intervention and prevent the poor health associated with homelessness( 7 ). Methods This was a two-part study involving a structured literature search and a modified Delphi study. Stage one: Literature Search Aim: Search for healthcare tools with housing questions that could be used in primary care to identify housing insecurity. Embase and MEDLINE were searched for screening tools which included housing questions developed for use in healthcare settings to identify patients experiencing housing insecurity that could be adapted for use in UK and Ireland primary care. The search was limited to studies published within five years of the search date and papers in the English language. As detailed in the results section, all tools identified in the search were developed outside the UK and Ireland. There was no gold standard tool, validity data was not available for all tools and the data that was available was variable making comparison difficult. Therefore, consensus methods with an expert panel were appropriate to answer our research question. Stage two: Modified Delphi Study Aim: Reach consensus on which tool or tools would be feasible to use in a UK and Ireland primary care context. Study panel to review to the questions from the tool that meets panel consensus and suggest modifications as appropriate for local context. Delphi is a consensus method that is popular within healthcare to address research questions where statistical evidence or knowledge in an area is limited, and where consensus from a panel of experts is required ( 8 , 9 ). A modified Delphi process was used to include an online meeting between round one feedback and the round two questionnaire( 10 ). A Nominal Group technique (NGT) approach was used as the framework for the online meeting. NGT uses facilitated, structured group discussion affording participants equal opportunity to express their views through round-robin discussions, clarification, voting and ranking ( 11 ) ( 12 ). The aim was to recruit fifteen general practitioners (GPs) in keeping with literature advising 10–18 participants per area of expertise( 13 ). We chose to recruit a panel of general practitioners as our research question focused on tool use in primary care and the understanding that reference to housing may be a cue in GP consultation that is often not picked up or acted upon( 9 ). Results Stage one: literature search Two databases were used: Embase and Medline. See Fig. 2 for search terms and PRISMA diagram. Twenty-two studies were included; sixteen tools that included housing questions were identified. See Table 1 for full list ( 5 , 14 – 32 ). Where housing questions from a named tool weren’t available within the article, article references or supplementary material, an internet search was used to access them. Some tools were not named and therefore couldn’t be included. Search terms: ‘screening’ or ‘screening test’ or ‘screening tool’ and ‘homelessness’ or ‘homeless’ or ‘homeless person’ or ‘housing’ or ‘housing insecurity’ or ‘housing instability’. Table 1 Housing tools identified in the literature search 1 Homelessness screening clinical reminder (HSCR) 2 Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) 3 WE CARE 4 Income, Housing, Education, Legal status, Language/ Immigration, Personal Safety (iHELLP) 5 The Accountable Health Communities Screening Tool 6 HealthLeads 7 Health Begins 8 The QRAFT 9 Medical-legal partnership 10 Your Current Life Situation 11 Urban Life Stressors Score 12 WellRx 13 Total Health Assessment for Medicaid members 14 Social History Template 15 Structural Vulnerability assessment tool 16 Social Needs Checklist 17 Children’s Health Watch: Housing Stability Vital Signs Two members of the research team (AH and a data scientist from Centre for Homelessness Impact) reviewed the housing questions from the tools against the following inclusion criteria: Validity data available Suitable for primary care Brief (less than 10 housing questions) Included questions to identify people experiencing housing insecurity or homelessness Housing questions from three tools identified through the literature search met the inclusion criteria: Homelessness Screening Clinical Reminder, Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) and WECARE( 16 , 17 , 31 ). A further tool that met the inclusion criteria was identified through hand searching, Children’s Health Watch: Housing Stability Vital Signs ( 33 , 34 ). See Box 1 for a summary of these tools alongside the available validity data. Tool Construction Housing Questions Validity data Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) PRAPARE includes questions relating to multiple social determinants of health, and the validity data applies to the whole tool. Developed in the United States 1. What is your housing situation today? a. I have housing b. I do not have housing (staying with others, in a hotel, in a shelter) c. I choose not to answer t Question 2. Are you worried about losing your housing? a. Yes b. No c. I choose not to answer Question 3. What address do you live at? Wan et al reported a Cronbach’s alpha of 0.86 and a greatest lower bound of 0.935 indicating good to excellent internal consistency ( 35 ). WECARE WECARE includes questions relating to multiple social determinants of health, and the validity data applies to the whole tool. Developed in the United States 1. Do you think you are at risk of becoming homeless? a. Yes b. No 2. If yes, would you like help with this? a. Yes b. No c. Maybe Later A randomised control trial took place in eight Boston, USA, health centres. The proportion of low-income patients divided the health centres into two strata. Within each stratum health centres were randomised to the control or intervention arm. The intervention arm used the WECARE questionnaire. The study found that more mothers in the WECARE arm were referred at the first visit (70% versus 8%, adjusted odds ratio (aOR) of 29.6, 95% confidence interval (CI) 14.7–59.6), at the 12-month visit more WECARE mothers had lower odds of living in a homeless shelter (aOR 0.2, 95% CI 0.1–0.9), had greater odds of being enrolled in a new community resource and had a greater odds of being employed ( 17 ). Of note WECARE has a test-retest reliability of 0.92( 36 ). WECARE includes multiple social determinants of health, and the reported statistics apply to the whole tool. Homelessness Screening Clinical Reminder (HSCR) The HSCR was developed for use by the Veteran’s Administration. It is a two-part tool with stage one aiming to identify those at imminent risk of homelessness and stage two to assess the severity. Stage one questions were used in this study. Developed in the United States 1. In the last 2 months have you been living in stable housing that you own, rent, or stay in as part of a household? (No indicates patient is positive for current housing instability) 2. Are you worried or concerned that in the next 2 months you may NOT have housing that you own, rent or stay in as part of a household? (Yes indicates patient is positive for risk of housing instability) If patient is positive for current housing instability or risk of housing instability ask: a) Where have you lived for most of the past 2 months? b) Would you like to referred to talk more about your housing situation? c) What is the best way to reach you? Stage one questions have an internal consistency of 0.61( 15 ). In a study by Fargo et al., of participants who screened positive for current housing instability, 69.1% were currently homeless, and of those who screened positive for risk of housing instability a majority were not currently homeless. This demonstrates the criterion validity of the HSCR in terms of ability to differentiate between current, and at risk of, housing stability ( 37 ). Children’s Health Watch (CHW): Housing stability vital signs Developed in the United States In the past 12 months, was there a time when you were not able to pay the mortgage or rent on time? In the past 12 months, how many times have you moved where you were living? At any time in the past 12 months, were you homeless or living in shelter [including now]? The screen is considered positive (at risk for housing instability) if the patient has moved more than twice, been homeless or not been able to pay the mortgage or rent on time in the previous 12 months Sandel et al found that three housing circumstances were statistically significant for poor health and material hardship: being behind on rent, experiencing multiple moves, and current homelessness. 26, 845 caregivers in Minneapolis and Baltimore were screened using the CHW questions. Compared with those in stable housing (absence of all 3 housing circumstances), caregivers behind on rent had increased adjusted of fair and or poor health (aOR: 1.91; 95% CI: 1.77–2.05) and maternal depressive symptoms, children in those households had increased odds of caregiver reported fair and/or poor health(aOR: 1.41; 95% CI: 1.28– 1.56) and lifetime hospitalisations (aOR: 1.19; 95% CI: 1.10–1.27). Caregivers and children who had experienced multiple moves had increased odds of caregiver reported fair and/or poor health, and children had increased odds of developmental risk. Current or recent homelessness was associated with increased caregiver odds of fair and/or poor health and for children in those households increased odds of fair and/or poor health, lifetime hospitalisations and developmental risk ( 38 ). Box 1- Validity data published for housing tools that met inclusion criteria Stage two: modified Delphi Recruitment and panel selection GPs were recruited via Twitter (now X) and via email through existing networks, by completing an expression of interest Microsoft Form. The Form included demographic details of their place of clinical practice: location, deprivation area (high, low, or mixed deprivation), and whether rural or urban. A maximum variation of participants from across the UK and Ireland was selected for the panel. Twenty-seven GPs expressed interest with fifteen invited to participate: eight from England, two from Wales, two from Northern Ireland, two from Ireland and the sole GP from Scotland who expressed interest. See Table 2 for participant demographics. Table 2 participant demographics Round 1 Round 2 Total 11 8 Female 6 5 Male 4 3 England 6 4 Ireland 2 2 Northern Ireland 2 2 Scotland 0 0 Wales 1 0 Ethnicity White 9 7 Asian/Asian British 2 1 Age 30–39 5 4 40–49 3 3 50–59 3 1 Work-place demographics (self-reported) High deprivation 5 3 Low deprivation 1 1 Mixed Deprivation 5 4 Urban 9 7 Rural 2 1 Round one: online survey Participants received study background information and the round one questionnaire by email. Eleven responded to the round one questionnaire (73% response rate). Participants rated on a 5-point Likert scale the extent to which they agreed (from strongly agree to strongly disagree) that each set of housing questions was usable in a UK and Ireland context. In round one there were two statements to rate, one focused on acceptability, the other on perceived effectiveness if used in their work context: Please indicate the extent to which you agree that this set of screening questions would be acceptable to ask patients in a GP setting. Please indicate the extent to which you agree that this set of screening questions would identify a patient who is at risk of losing their home or experiencing homelessness. There was an optional comment box for participants to explain the reasoning for their rating. Consensus It is accepted that consensus among participants increases when there is agreement of at least 75% and decreases when it is less than 75%( 39 ). Therefore, panel agreement of ≥ 75% was set as an indication of consensus in this study ( 40 , 41 ). The tools with ≥ 75% of the panel agreeing on acceptability and perceived effectiveness proceeded to round two. Round one agreement scores Housing questions from the PRAPARE tool met consensus criteria for acceptability and questions from the Homelessness Screening Clinical Reminder tool met consensus criteria for perceived effectiveness. No tool met consensus criteria for both acceptability and perceived effectiveness, therefore all four tools were brought forward to round two. See Table 3 . Table 3 – round one agreement scores (percentages underlined indicate consensus > 75%) Strongly disagree Disagree Neutral Agree Strongly Agree PRAPARE Effectiveness 18.18% 27.27% 54.54% Acceptability 18.2% 54.54% 27.27% WeCare Effectiveness 9.09% 27.28% 45.45% 18.18% Acceptability 36.36% 45.45% 18.18% Homelessness Screening Clinical Reminder (HSCR) Effectiveness 18.18% 45.45% 36.36% Acceptability 9.09% 18.18% 36.36% 27.27% 9.09% Children’s Health Watch: Housing Stability Vital Signs (CHW) Effectiveness 9.09% 27.23% 27.23% 36.36% Acceptability 27.27% 45.45% 27.27% Between round one and two, participants were sent a summary of round one results including their individual Likert ratings alongside a summary of the anonymised group agreement scores and all free text comments. Participants were asked to read and consider the summary before attending round two. Round two: online workshop The allocated workshop time was 2.5 hours and took place on Microsoft Teams with the primary researcher (AH) acting as facilitator. Eight of the eleven panel members from round one responded in round two (73% response rate). Round-robin Participants gave their views on the feasibility of using the four sets of housing questions in their day-to-day job as a GP and were able to feedback their tool preference with reasoning. No interruptions or comments from other participants were permitted during this stage. NH and GK noted points for discussion. These were then discussed by the panel within the designated discussion time. Clarification and group discussion All the discussion points were fed back to the panel members who could state if they thought any themes needed to be added. Prior to the discussion, the facilitator emphasised that the panel did not need to reach agreement during the discussion as there would be an online survey, like round one, following discussion to determine consensus. See Box 2 for discussion summary. Point raised by panel Discussion summary For widespread uptake, a tool must be simple but effective For a tool to be adopted by mainstream primary it needs to be simple and perceived by GPs to be effective in achieving its aim. An overly complex tool, or one that lacks substance, would deter uptake. A tool would need to fit within the flow of a consultation. The panel recognised that brief or one-question tools are easy to remember, however members of the panel commented that if a tool that is too simplistic identification of a housing issue might be missed, or with a yes/no question it might shut down the conversation without the patient having considered their housing situation as being precarious. Introducing the tool to the patient with an opening statement is important Some panel members had experience of working with patients experiencing housing instability or homelessness and highlighted the importance of patients understanding they are being asked personal questions about their housing so that support can be offered if they wish. Example phrasing for an introductory statement was given: ‘we’re talking to a lot of people about finances at the minute, we do have pathways or links or services there, do you think that’s something you want to discuss?’ The economic climate and housing crisis was seen as a way to introduce the topic: ‘we know lots of people are struggling at the moment’...or ‘we know housing can have a big impact...’ Patients and clinicians should understand the term insecure housing encompasses A panel member felt that including a brief but comprehensive definition of what homelessness or insecure housing is alongside the tool would ensure clinicians understand what insecure housing can look like and in turn patients can understand if it applies to them or not. A stigmatising topic Care around wording was considered important for an area that might feel sensitive to patients and some of the questions were seen as potential triggers that might apportion blame. There was discussion around normalising conversations around housing and poverty as well as the importance of not adding to stigma in approaching these conversations. One participant likened a housing history to information gathering for a sexual history, and the importance of explaining why you’re taking a detailed history is important for ongoing care. An unexpected question Patients may not expect to be asked about housing in a GP consultation so it might be useful to link the topic of housing to health and explain the link between housing and health outcomes. One panel member felt checking patient details such as date of birth and address might be a useful trigger point for GPs to ask about housing and aid consultation flow. A tool of two parts One participant felt that a simple and carefully worded question would be easy to promote and referenced the ‘hello, my name is...’ campaign. A similar initiative with a simple question as a prompt would raise awareness about homelessness and could be followed up with a more in-depth tool if an issue is raised. Box 2- Workshop group discussion Round two questionnaire A second questionnaire was sent in the Teams ‘chat’ function after this discussion for participants to complete during the workshop. For the round two questionnaire the research team agreed to seek views on ‘feasibility’ as it encapsulated our overarching research question more succinctly. See the round two questionnaire statement below: Please indicate the extent to which you agree that this set of screening questions would be feasible to use in response to a patient cue that raises a concern about housing during a routine consultation Round two agreement scores As seen in Table 4 questions from PRAPARE and WECARE met panel consensus in round two. Table 4 round two agreement scores (percentages underlined indicate consensus > 75%) Strongly disagree Disagree Neutral Agree Strongly Agree PRAPARE 25% 50% 25% WECARE 12.5% 62.5% 25% HSCR 25% 37.5% 37.5% CHW 25% 25% 50% As set out a priori, all tools that met the consensus criteria (> 75%) would be ranked in order of preference; housing questions from PRAPARE and WeCare proceeded to this stage due to meeting consensus. The tool ranked highest by the panel would be brought forward to the final stage of the study. Ranking resulted in a tie with 4 (50%) participants ranking PRAPARE and four (50%) ranking WeCare as their preference. As set out a priori in the circumstances of a tie, the panel discussed the merits and drawbacks of the tools before ranking again. After panel discussion and re-ranking 7 (87.5%) out of 8 participants ranked PRAPARE as their preference. Panel review of PRAPARE questions The final stage of the workshop was a review of the housing questions from the agreed tool by the expert panel. The panel were asked to suggest any necessary modifications to the wording for use in the UK and Ireland context, or any important aspects they felt missing from the questions. This is in keeping with the approach used in other studies where social determinants of health tools having been adapted from other pre-existing tools ( 31 , 33 ). Following the workshop, the research team reviewed the discussion transcript and finalised the questions based on panel discussion. Seeking to create something memorable the team assigned ‘HALT’ as an acronym so that GPs could easily bring the tool to mind and recall the four questions in a similar way to CAGE. Box 3 details a summary of the panel discussion and the finalised questions. PRAPARE question Panel review Finalised question What is your housing situation today? The panel felt that the opening question should be more open and broad, as someone’s housing situation today might be different than their housing situation over the previous few weeks or months. “you might have someone who, OK, well last night I was staying in my mum’s but actually, I’ve been dotting here, there and everywhere’ and ‘today’ closes it down slightly”. ‘Can I ask about your housing situation at the moment?’ was suggested as an alternative; an open question which asks the patient’s permission, giving the patient the option to say no. Can I ask about your Housing situation at the moment? Are you worried about losing your housing? This question implies that someone does have housing. The suggested alternative was a broader question around housing concerns: ‘Are you worried about your housing situation?’ By keeping the question more open, it allows patients to answer relative to how they view their housing. One participant commented that a patient might say: ‘I’m sofa surfing but I’m not worried about it, I’m quite enjoying it,’ or ‘I may be in my own house, but I am worried about it.’ Another panel member commented that this question would lead into other questions possibly around affordability of rent or mortgage payments and gives opportunity to pick up on other challenges other than housing in isolation. Intervention at this point could prevent a possible housing crisis in time. Do you Agonise or worry about your housing situation? What address do you live at? Street:________ City/State/Zip code: __________ A question to ensure the correct contact details were on the patient’s record was felt to be an important aspect of the tool. One panel member commented that ‘there’s so many DNAs (did not attend) because we don’t check the address’ , and there was discussion the importance of correct contact details to ensure patients receive phone calls and letters for follow-up appointments and referrals. The panel commented that primary care teams need to allow patients to give the name or contact details of a family member, a friend, or a local organisation like a specialist healthcare service for people experiencing homelessness, that might be more reliable than their current address. Can I confirm what contact details would be best to Link in with you for follow-up? The panel agreed a question asking if the patient would like referral was necessary Would you like to Talk to someone who might be able to help with your housing? Box 3- HALT tool development The panel suggested that a reference guide for clinicians to demonstrate what would be considered precarious housing would be useful; in response, the research team included an overview of FEANTSAs typology of homelessness alongside the tool as seen in Fig. 3 ( 4 ). Discussion In this study, the modified Delphi approach enabled a panel of GPs from the UK and Ireland with experience of the demanding primary care workload to agree on which housing questions from four tools validated outside of the UK and Ireland would be feasible to use in the national primary care context. Prior to this study there was no tool developed for this purpose within the UK and Ireland. Housing questions from two tools, WeCare, and PRAPARE, met study consensus criteria of ≥ 75% with PRAPARE being the panel preference on final ranking. The HALT tool is the product of the panel’s suggested modifications to PRAPARE questions for use in the context of UK and Irish primary care. HALT is a tool that a panel of GPs agree is feasible for use in everyday primary care workplaces without overwhelming clinicians. Primary care teams can use HALT to respond to patient cues that suggest that a patient is living in an unstable housing situation and provides a structured approach for staff who do not currently use a framework to ask about housing within their consultations. Clinicians can identify patients living in insecure housing and refer to support services in line with the patient’s wishes. HALT is a means by which primary care teams can contribute to reducing health inequalities for patients living in insecure housing and prevent the ‘cliff edge’ health consequences, and could fill an important gap in current UK and Ireland primary care practice. ( 2 ). This study was designed in response to recognition of the impact of homelessness on the wellness and health of patients known to primary care teams, and the lack of a recognised tool or structured approach to identify housing insecurity in use within a UK and Ireland primary context. The HALT tool could fill this gap for primary care teams. North America has been progressive in this research field. The PRAPARE implementation and action toolkit suggests various ways that PRAPARE can be integrated into various workflows before, during and after the clinical visit using both clinical and non-clinical staff( 42 ). HALT could be implemented in our local context using knowledge from these workflows The Delphi approach is often used to develop guidelines or develop tools where statistical evidence is limited in an area and expert consensus is appropriate( 9 ). We used a modified-Delphi in a novel way, asking a panel of GPs to agree which of a set of pre-existing tools with published validity data would be feasible to use in a UK and Ireland context, allowing us to model our tool (HALT) on a tool with a pre-existing evidence base. Strengths and limitations Strengths HALT is a tool that has been developed from housing questions in a pre-existing, previously validated tool in use across health care centres within the United States and internationally; adapting a tool with an existing evidence base was preferable to developing a new tool. The round two workshop using the nominal group technique structure provided rich discussion around introducing a housing tool in a primary care context. The six discussion points raised by the panel of expert GPs are applicable to other areas of research considering tool design in the UK and Ireland primary care setting. Using a traditional Delphi process instead of a modified Delphi including aspects of Nominal Group Technique may not have captured this rich data. The aim of this study was to develop a tool that is feasible for general practitioners to use in their everyday work. We worked with the Centre for Homelessness Impact to develop the inclusion criteria for the study; a data scientist from CHI worked alongside AH to assess which tools met those criteria. CHI shared valuable insights into question wording and possible tool acronyms with an emphasis on ensuring these are not stigmatising for patients. The primary researcher visited the Inclusion Health Hub in Belfast prior to study design, this team provides healthcare to people experiencing homelessness in Belfast. This visit gave insight into the lived realities and health experiences of people experiencing homelessness and highlighted the need for earlier intervention to prevent experiences of homelessness, giving purpose to this research study. Limitations We recruited GPs only for this study; we did not include other members of the primary care multi-disciplinary team such as advanced nurse practitioners, practice nurses, social workers, link workers, physiotherapists, mental health workers and administrative staff whose inclusion may have provided a wider range of perspectives. However, it is hoped that subsequent work will provide the opportunity to involve perspectives from the wider primary care team. The views of those with lived experience of housing insecurity and homelessness are not directly represented; this is because the primary care team will be administering the tool and the aim of this study was to ensure a tool that would be used by primary care teams. A further step in this programme of work is acceptability with the public. We recruited using email and Twitter(X), asking for GPs who were interested in homelessness prevention. We therefore had a high proportion of GPs who worked in areas of high deprivation and from the group discussion, it was evident that a number had worked within specialist services for people experiencing homelessness. Only one participant indicated they worked in an area of low deprivation. Otherwise, there was an even spread of mixed and high deprivation areas for the remainder of participants. Future work would seek the views of a broader section of the primary care workforce. It has been suggested that there should be a minimum of 10–18 panel members per area of expertise( 13 ). We invited 15 to take the panel, we had a dropout rate of 20% with eleven completing round one. With further drop out of 3 participants (27%) we had 8 participants in round two. Other Delphi studies have shown a dropout rate of 20–30% between rounds is common, with this knowledge we might have recruited a larger number to the panel at the outset. ( 43 ). Despite the low sample size it is recognised that Delphi studies rely on group dynamics rather than statistical power to achieve consensus ( 13 ). Implications for clinical practice and research Across healthcare there is recognition of the need to tackle health inequalities. The Royal College of Physicians (RCP) convene ‘The Inequalities in Health Alliance’, a coalition of not for profit organisations who collaborate to campaign for cross-government strategies to address inequalities( 44 ). In primary and secondary care respectively the Royal College of General Practitioners (RCGP) and the RCP are working towards reducing health inequalities through increasing awareness, developing guidance, highlighting best practice, and encouraging local health care providers to create networks with local communities and third sector organisations( 45 , 46 ). HALT could provide a practical way for primary care teams to identify and address those who experience the most profound inequalities, and work alongside statutory and community organisations to achieving this aim. Future research would include assessing HALT tool acceptability, recognising that the acceptability of healthcare interventions for both intervention deliverers and recipients will impact successful implementation ( 47 ). Validation of HALT tool including measuring its sensitivity and specificity would also be necessary before widespread implementation within primary care. Conclusion Internationally tools have been developed and used in primary care settings to identify housing insecurity for signposting or referral to support services, however prior to this study no tool had been assessed or developed for use in general practice in the UK or Ireland. Using consensus methods, a panel of GPs from across the UK and Ireland agreed that housing questions from a tool developed and validated in other national contexts would be feasible to use in primary care in the UK and Ireland, these questions were critiqued by the panel, changes were made, and a memorable acronym assigned forming the ‘HALT tool’. HALT provides clinicians with a framework of questions to ask to identify housing concerns for referral to support service. Early intervention could prevent a housing crisis and experiences of homelessness for patients and their families. Abbreviations PEH: People experiencing homelessness GP: General practitioner RCP: Royal College of Physicians Declarations Ethics approval and consent to participate Ethical approval was granted by Queen’s University Belfast Faculty of Medicine, Health and Life Sciences Research Ethics Committee (Faculty REC), reference number MHLS 22_108. The study adhered to the Declaration of Helsinki. All participants received study information prior to their involvement and gave informed consent to participate. Consent for publication Participants completed consent forms prior to the study giving their permission to publish anonymised data. Availability of data and materials Anonymised datasets are available from the corresponding author on reasonable request. Competing interests No competing interests to declare Funding Alexandra Huey was funded by Northern Ireland Research and Development through their support of the General Practice Academic and Research Training Scheme. The Centre for Homelessness Impact provided funding for participant reimbursement for their time. Acknowledgements We would like to thank the Centre for Homelessness Impact for their support with this research: the financial contribution they gave so participants received reimbursement for their professional time, and to the data scientist who worked with the research team during the study. The HALT tool was developed based on the housing questions in the PRAPARE tool. We acknowledge the PRAPARE team’s work in the development, validation, and implementation of their tool. The research team tried to contact the PRAPARE team between October 2022 and February 2023 to discuss this study, no correspondence was received. References Morris. L RR. Tackling health inequalities: seven priorities for the NHS2024 [cited 2025 7/4/2025]. Available from: https://www.kingsfund.org.uk/insight-and-analysis/long-reads/tackling-health-inequalities-seven-priorities-nhs. Story A. Slopes and cliffs in health inequalities: comparative morbidity of housed and homeless people. The Lancet. 2013;382:S93. Lewer D, Aldridge RW, Menezes D, Sawyer C, Zaninotto P, Dedicoat M, et al. Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ Open. 2019;9(4):e025192. FEANTSA. ETHOS- European Typology of Homelessness and Housing Exclusion 2005 [Available from: https://www.feantsa.org/en/toolkit/2005/04/01/ethos-typology-on-homelessness-and-housing-exclusion. Keogh C, O’Brien KK, Hoban A, O’Carroll A, Fahey T. Health and use of health services of people who are homeless and at risk of homelessness who receive free primary health care in Dublin. BMC Health Services Research. 2015;15(1):58. Pressures in general practice data analysis: British Medical Association; 2025 [updated 27/03/3035; cited 2025 7/4/2025]. Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis. O’Brien CP. The CAGE Questionnaire for Detection of Alcoholism. JAMA. 2008;300(17):2054. Trevelyan E, Prof Robinson, Nicola. Delphi methodology in health research: how to do it? European Journal of Integrative Medicine. 2016;7(4):423-8. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021;11(4):116-29. Khodyakov D, Grant S, Denger B, Kinnett K, Martin A, Peay H, et al. Practical Considerations in Using Online Modified-Delphi Approaches to Engage Patients and Other Stakeholders in Clinical Practice Guideline Development. The Patient - Patient-Centered Outcomes Research. 2020;13(1):11-21. Søndergaard E, Ertmann RK, Reventlow S, Lykke K. Using a modified nominal group technique to develop general practice. BMC Family Practice. 2018;19(1). McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655-62. Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Information & Management. 2004;42(1):15-29. Henrikson NB, Blasi PR, Dorsey CN, Mettert KD, Nguyen MB, Walsh-Bailey C, et al. Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review. American Journal of Preventive Medicine. 2019;57(6):S13-S24. Montgomery AE, Fargo JD, Kane V, Culhane DP. Development and Validation of an Instrument to Assess Imminent Risk of Homelessness among Veterans. Public Health Reports. 2014;129(5):428-36. Montgomery AE, Fargo JD, Byrne TH, Kane VR, Culhane DP. Universal screening for homelessness and risk for homelessness in the Veterans Health Administration. Am J Public Health. 2013;103 Suppl 2(Suppl 2):S210-1. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-304. Colvin JD. IHELP Pediatric Social History Tool Social Interventions Research and Evaluation Network2017 [cited 2022 29/7/2022]. Available from: https://sirenetwork.ucsf.edu/tools-resources/resources/ihelp-pediatric-social-history-tool. Farrell AF, Dibble KE, Randall KG, Britner PA. Screening for Housing Instability and Homelessness Among Families Undergoing Child Maltreatment Investigation. Am J Community Psychol. 2017;60(1-2):25-32. Hensley C JA, Shah S, O’Dea C, Carameli K. Addressing social determinants of health at a federally qualified health center. Public Health Journal. 2017;9(2):189-98. Hershey JA, Morone J, Lipman TH, Hawkes CP. Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes. Can J Diabetes. 2021;45(5):444-50.e1. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. NAM Perspectives. 2017;7(5). Tobin-Tyler E, Teitelbaum JB. Medical-Legal Partnership: A Powerful Tool for Public Health and Health Justice. Public Health Rep. 2019;134(2):201-5. Sundar KR. Universal Screening for Social Needs in a Primary Care Clinic: A Quality Improvement Approach Using the Your Current Life Situation Survey. Perm J. 2018;22:18-089. Jaffee KD, Liu GC, Canty-Mitchell J, Qi RA, Austin J, Swigonski N. Race, urban community stressors, and behavioral and emotional problems of children with special health care needs. Psychiatr Serv. 2005;56(1):63-9. Page-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, Ianakieva V, et al. Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico. The Journal of the American Board of Family Medicine. 2016;29(3):414-8. Freedman D, Vanderhorst N. PS3-55: Utilization of High-Technology to Collect Health Risk Assessment Information from Medicare Members: A Feasibility Study of Interactive Voice Response (IVR) and an Online Survey Tool. Clinical Medicine & Research. 2013;11(3):175-6. Beck AF, Klein MD, Kahn RS. Identifying social risk via a clinical social history embedded in the electronic health record. Clin Pediatr (Phila). 2012;51(10):972-7. Bourgois P, Holmes SM, Sue K, Quesada J. Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care. Acad Med. 2017;92(3):299-307. Cook CAL, Freedman JA, Freedman LD, Arick RK, Miller ME. Screening for Social and Environmental Problems in a VA Primary Care Setting. Health & Social Work. 1996;21(1):41-7. LaForge K, Gold R, Cottrell E, Bunce AE, Proser M, Hollombe C, et al. How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview. J Ambul Care Manage. 2018;41(1):2-14. Kusnoor SV, Koonce TY, Hurley ST, McClellan KM, Blasingame MN, Frakes ET, et al. Collection of social determinants of health in the community clinic setting: a cross-sectional study. BMC Public Health. 2018;18(1):550. Anderst A, Hunter K, Andersen M, Walker N, Coombes J, Raman S, et al. Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review. BMJ Open. 2022;12(4):e054338. Ng R, Gunatillaka N, Skouteris H, Blane D, Blewitt C, Nielsen S, et al. Screening for Unstable Housing in a Healthcare Setting. Public Health Rev. 2023;44:1606438. Wan W, Li V, Chin MH, Faldmo DN, Hoefling E, Proser M, et al. Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes. The Journal of the American Board of Family Medicine. 2022;35(4):668-79. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project. Pediatrics. 2007;120(3):547-58. Fargo JD, Montgomery AE, Byrne T, Brignone E, Cusack M, Gundlapalli AV. Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness. Stud Health Technol Inform. 2017;235:574-8. Sandel M, Sheward R, Ettinger De Cuba S, Coleman SM, Frank DA, Chilton M, et al. Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics. 2018;141(2):e20172199. Barrios M, Guilera G, Nuño L, Gómez-Benito J. Consensus in the delphi method: What makes a decision change? Technological Forecasting and Social Change. 2021;163:120484. Jünger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliative Medicine. 2017;31(8):684-706. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. Journal of Clinical Epidemiology. 2014;67(4):401-9. (NACHC) NAoCHC. PRAPARE Reach 2023 [Available from: https://prapare.org/prapare-reach/. Bardecki MJ. Participants' response to the Delphi method: An attitudinal perspective. Technological Forecasting and Social Change. 1984;25(3):281-92. Parliamentary briefing from the Inequalities in Health Alliance [Available from: https://www.rcp.ac.uk/media/lpegesv0/iha-parliamentary-briefing-for-mps-and-peers-november-2024.pdf. RCGP. Royal College of General Practitioners: Strategic plan 2023 to 2026: Building a sustainable future for general practice London2023 [cited 2024 11 June 2024]. Available from: https://www.rcgp.org.uk/about. Bridging the gap: a guide to making health inequalities a strategic priority for NHS leaders 2024 [updated 16/12/24. Available from: https://www.rcp.ac.uk/improving-care/resources/bridging-the-gap-a-guide-to-making-health-inequalities-a-strategic-priority-for-nhs-leaders/. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Services Research. 2017;17(1):88. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6783597","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":483043688,"identity":"cf073b45-e3da-4747-bdfb-0ea63a6c049f","order_by":0,"name":"Alexandra Huey","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Huey","suffix":""},{"id":483043689,"identity":"1235e019-cd65-46df-bb40-1ab707c0cc32","order_by":1,"name":"Grainne P Kearney","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Grainne","middleName":"P","lastName":"Kearney","suffix":""},{"id":483043690,"identity":"f7e78867-a1cb-4bbb-bb3a-83f86c1e9576","order_by":2,"name":"Nigel D Hart","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYFACHhBhw8AgAeEaEKklIY10LYdJ0GLOwHvwc+WP87IbbjcwfvjBcNiYoBbLBr5kyTMJt4033DnALNnDcNiMoBaDAzwGkg0JtxM33EhgkGZgOGxDjBbjnw0J50BamH8Tq8UMaMsBkBY2kC1EOOwwj5llQ1qy8cw7B9ssewzSCXvf4HiP8c0GGzvZvtvNh2/8qLA2bCCohxlCMTaAEFERCQOMhA0fBaNgFIyCEQsAshU7DDpqEkcAAAAASUVORK5CYII=","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":true,"prefix":"","firstName":"Nigel","middleName":"D","lastName":"Hart","suffix":""}],"badges":[],"createdAt":"2025-05-30 10:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6783597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6783597/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86757815,"identity":"e1f48078-f821-46c7-9bd2-8af87c3c4316","added_by":"auto","created_at":"2025-07-15 09:45:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48868,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2- Literature search: search terms and PRIMSA flow diagram\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6783597/v1/b33c2e9950bbe5290444ab2b.png"},{"id":86757817,"identity":"52967f5e-3037-415f-80ab-885f3350a781","added_by":"auto","created_at":"2025-07-15 09:45:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":229205,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 3- The HALT tool\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6783597/v1/9f11780bc0a1a0fad09abcbb.png"},{"id":86760184,"identity":"e8d68d94-db10-480d-9b7c-d81b46b702e3","added_by":"auto","created_at":"2025-07-15 10:09:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1113349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6783597/v1/1e901d9e-83b4-412e-99c1-056d912da857.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A consensus study leading to HALT- a tool to prevent homelessness in primary care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTackling the gap in health inequalities has been highlighted as a priority for the UK’s National Health Service; the King’s Fund have emphasised that primary care is best placed to identify and address issues early(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).People experiencing homelessness (PEH) are at the extreme end of health inequalities; the well-documented linear relationship between poorer health outcomes and increasing socio-economic deprivation (the slope) becomes a cliff for people experiencing homelessness : ‘slopes and cliffs’ (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). PEH having significantly increased prevalence of multimorbidity and premature mortality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Homelessness takes different forms: rough sleeping, living under threat of violence or eviction, in insecure tenancies, temporary accommodation, unfit housing and extreme overcrowding(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As reducing the gap in health inequalities has become a priority in primary and secondary case, preventing homelessness and the subsequent health outcomes should be a public health and primary care priority.\u003c/p\u003e\u003cp\u003eHealthcare in general, and primary care in particular, are among common touch points for people experiencing, or those at-risk of, homelessness; thus, everyday General Practice consultations could provide an opportunity to identify risk and initiate action (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).While a range of validated questionnaire tools to identify housing insecurity for referral or signposting to support services are in use in healthcare settings internationally, there is no evidence that a tool has been developed for or integrated into the primary care setting in the UK or Ireland; this is a gap in local services.\u003c/p\u003e\u003cp\u003eThe demands on healthcare continue to grow, hence any proposal to add the identification of homelessness or its risk, would need to take account of this growing demand(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Inspired by the memorable CAGE questionnaire, used to screen for excessive alcohol use in primary care, the aim of this study was to develop a tool to identify those at risk of homelessness for use in primary care settings in the UK and Ireland to enable early intervention and prevent the poor health associated with homelessness(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a two-part study involving a structured literature search and a modified Delphi study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStage one: Literature Search\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAim: Search for healthcare tools with housing questions that could be used in primary care to identify housing insecurity.\u003c/p\u003e\u003cp\u003eEmbase and MEDLINE were searched for screening tools which included housing questions developed for use in healthcare settings to identify patients experiencing housing insecurity that could be adapted for use in UK and Ireland primary care. The search was limited to studies published within five years of the search date and papers in the English language.\u003c/p\u003e\u003cp\u003eAs detailed in the results section, all tools identified in the search were developed outside the UK and Ireland. There was no gold standard tool, validity data was not available for all tools and the data that was available was variable making comparison difficult. Therefore, consensus methods with an expert panel were appropriate to answer our research question.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStage two: Modified Delphi Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAim: Reach consensus on which tool or tools would be feasible to use in a UK and Ireland primary care context. Study panel to review to the questions from the tool that meets panel consensus and suggest modifications as appropriate for local context.\u003c/p\u003e\u003cp\u003eDelphi is a consensus method that is popular within healthcare to address research questions where statistical evidence or knowledge in an area is limited, and where consensus from a panel of experts is required (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A modified Delphi process was used to include an online meeting between round one feedback and the round two questionnaire(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A Nominal Group technique (NGT) approach was used as the framework for the online meeting. NGT uses facilitated, structured group discussion affording participants equal opportunity to express their views through round-robin discussions, clarification, voting and ranking (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe aim was to recruit fifteen general practitioners (GPs) in keeping with literature advising 10–18 participants per area of expertise(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We chose to recruit a panel of general practitioners as our research question focused on tool use in primary care and the understanding that reference to housing may be a cue in GP consultation that is often not picked up or acted upon(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eStage one: literature search\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTwo databases were used: Embase and Medline. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e for search terms and PRISMA diagram. Twenty-two studies were included; sixteen tools that included housing questions were identified. See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for full list (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Where housing questions from a named tool weren\u0026rsquo;t available within the article, article references or supplementary material, an internet search was used to access them. Some tools were not named and therefore couldn\u0026rsquo;t be included.\u003c/p\u003e\u003cp\u003eSearch terms:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;screening\u0026rsquo; or \u0026lsquo;screening test\u0026rsquo; or \u0026lsquo;screening tool\u0026rsquo; \u003c/p\u003e\n\u003cp\u003eand\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;homelessness\u0026rsquo; or \u0026lsquo;homeless\u0026rsquo; or \u0026lsquo;homeless person\u0026rsquo; or \u0026lsquo;housing\u0026rsquo; or \u0026lsquo;housing insecurity\u0026rsquo; or \u0026lsquo;housing instability\u0026rsquo;.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHousing tools identified in the literature search\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHomelessness screening clinical reminder (HSCR)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProtocol for Responding to and Assessing Patients\u0026rsquo; Assets, Risks and Experiences (PRAPARE)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWE CARE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncome, Housing, Education, Legal status, Language/ Immigration, Personal Safety (iHELLP)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Accountable Health Communities Screening Tool\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthLeads\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Begins\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe QRAFT\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical-legal partnership\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYour Current Life Situation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban Life Stressors Score\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWellRx\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal Health Assessment for Medicaid members\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial History Template\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStructural Vulnerability assessment tool\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Needs Checklist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChildren\u0026rsquo;s Health Watch: Housing Stability Vital Signs\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTwo members of the research team (AH and a data scientist from Centre for Homelessness Impact) reviewed the housing questions from the tools against the following inclusion criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eValidity data available\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSuitable for primary care\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBrief (less than 10 housing questions)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIncluded questions to identify people experiencing housing insecurity or homelessness\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eHousing questions from three tools identified through the literature search met the inclusion criteria: Homelessness Screening Clinical Reminder, Protocol for Responding to and Assessing Patients\u0026rsquo; Assets, Risks and Experiences (PRAPARE) and WECARE(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA further tool that met the inclusion criteria was identified through hand searching, Children\u0026rsquo;s Health Watch: Housing Stability Vital Signs (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). See Box 1 for a summary of these tools alongside the available validity data.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTool\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConstruction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHousing Questions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValidity data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtocol for Responding to and Assessing Patients\u0026rsquo; Assets, Risks and Experiences (PRAPARE)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePRAPARE includes questions relating to multiple social determinants of health, and the validity data applies to the whole tool.\u003c/p\u003e\u003cp\u003eDeveloped in the United States\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.\u0026nbsp;What is your housing situation today?\u003c/p\u003e\u003cp\u003ea.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;I have housing\u003c/p\u003e\u003cp\u003eb.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;I do not have housing (staying with others, in a hotel, in a shelter)\u003c/p\u003e\u003cp\u003ec.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;I choose not to answer t \u003c/p\u003e\u003cp\u003eQuestion 2.\u0026nbsp;Are you worried about losing your housing?\u003c/p\u003e\u003cp\u003ea.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Yes\u003c/p\u003e\u003cp\u003eb.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;No\u003c/p\u003e\u003cp\u003ec.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;I choose not to answer \u003c/p\u003e\u003cp\u003eQuestion 3.\u0026nbsp;What address do you live at?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWan et al reported a Cronbach\u0026rsquo;s alpha of 0.86 and a greatest lower bound of 0.935 indicating good to excellent internal consistency (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWECARE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWECARE includes questions relating to multiple social determinants of health, and the validity data applies to the whole tool.\u003c/p\u003e\u003cp\u003eDeveloped in the United States\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Do you think you are at risk of becoming homeless?\u003c/p\u003e\u003cp\u003ea.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Yes\u003c/p\u003e\u003cp\u003eb.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;No\u003c/p\u003e\u003cp\u003e2.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;If yes, would you like help with this?\u003c/p\u003e\u003cp\u003ea.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Yes\u003c/p\u003e\u003cp\u003eb.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;No\u003c/p\u003e\u003cp\u003ec.\u0026nbsp; \u0026nbsp; \u0026nbsp;Maybe Later\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eA randomised control trial took place in eight Boston, USA, health centres. The proportion of low-income patients divided the health centres into two strata. Within each stratum health centres were randomised to the control or intervention arm. The intervention arm used the WECARE questionnaire. The study found that more mothers in the WECARE arm were referred at the first visit (70% versus 8%, adjusted odds ratio (aOR) of 29.6, 95% confidence interval (CI) 14.7\u0026ndash;59.6), at the 12-month visit more WECARE mothers had lower odds of living in a homeless shelter (aOR 0.2, 95% CI 0.1\u0026ndash;0.9), had greater odds of being enrolled in a new community resource and had a greater odds of being employed (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Of note WECARE has a test-retest reliability of 0.92(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). WECARE includes multiple social determinants of health, and the reported statistics apply to the whole tool.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHomelessness Screening Clinical Reminder (HSCR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe HSCR was developed for use by the Veteran\u0026rsquo;s Administration. It is a two-part tool with stage one aiming to identify those at imminent risk of homelessness and stage two to assess the severity.\u003c/p\u003e\u003cp\u003eStage one questions were used in this study.\u003c/p\u003e\u003cp\u003eDeveloped in the United States\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. In the last 2 months have you been living in stable housing that you own, rent, or stay in as part of a household?\u003c/p\u003e\u003cp\u003e(No indicates patient is positive for current housing instability)\u003c/p\u003e\u003cp\u003e2. Are you worried or concerned that in the next 2 months you may NOT have housing that you own, rent or stay in as part of a household?\u003c/p\u003e\u003cp\u003e(Yes indicates patient is positive for risk of housing instability)\u003c/p\u003e\u003cp\u003eIf patient is positive for current housing instability or risk of housing instability ask:\u003c/p\u003e\u003cp\u003ea) Where have you lived for most of the past 2 months?\u003c/p\u003e\u003cp\u003eb) Would you like to referred to talk more about your housing situation?\u003c/p\u003e\u003cp\u003ec) What is the best way to reach you?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStage one questions have an internal consistency of 0.61(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In a study by Fargo et al., of participants who screened positive for current housing instability, 69.1% were currently homeless, and of those who screened positive for risk of housing instability a majority were not currently homeless. This demonstrates the criterion validity of the HSCR in terms of ability to differentiate between current, and at risk of, housing stability (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChildren\u0026rsquo;s Health Watch (CHW): Housing stability vital signs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeveloped in the United States\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIn the past 12 months, was there a time when you were not able to pay the mortgage or rent on time?\u003c/p\u003e\u003cp\u003eIn the past 12 months, how many times have you moved where you were living?\u003c/p\u003e\u003cp\u003eAt any time in the past 12 months, were you homeless or living in shelter [including now]?\u003c/p\u003e\u003cp\u003eThe screen is considered positive (at risk for housing instability) if the patient has moved more than twice, been homeless or not been able to pay the mortgage or rent on time in the previous 12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSandel et al found that three housing circumstances were statistically significant for poor health and material hardship: being behind on rent, experiencing multiple moves, and current homelessness.\u003c/p\u003e\u003cp\u003e26, 845 caregivers in Minneapolis and Baltimore were screened using the CHW questions.\u003c/p\u003e\u003cp\u003eCompared with those in stable housing (absence of all 3 housing circumstances), caregivers behind on rent had increased adjusted of fair and or poor health (aOR: 1.91; 95% CI: 1.77\u0026ndash;2.05) and maternal depressive symptoms, children in those households had increased odds of caregiver reported fair and/or poor health(aOR: 1.41; 95% CI: 1.28\u0026ndash; 1.56) and lifetime hospitalisations (aOR: 1.19; 95% CI: 1.10\u0026ndash;1.27).\u003c/p\u003e\u003cp\u003eCaregivers and children who had experienced multiple moves had increased odds of caregiver reported fair and/or poor health, and children had increased odds of developmental risk. Current or recent homelessness was associated with increased caregiver odds of fair and/or poor health and for children in those households increased odds of fair and/or poor health, lifetime hospitalisations and developmental risk (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBox 1- Validity data published for housing tools that met inclusion criteria\u003c/p\u003e\u003cp\u003e\u003cb\u003eStage two: modified Delphi\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRecruitment and panel selection\u003c/p\u003e\u003cp\u003eGPs were recruited via Twitter (now X) and via email through existing networks, by completing an expression of interest Microsoft Form. The Form included demographic details of their place of clinical practice: location, deprivation area (high, low, or mixed deprivation), and whether rural or urban. A maximum variation of participants from across the UK and Ireland was selected for the panel. Twenty-seven GPs expressed interest with fifteen invited to participate: eight from England, two from Wales, two from Northern Ireland, two from Ireland and the sole GP from Scotland who expressed interest. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for participant demographics.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eparticipant demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRound 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRound 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEngland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIreland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorthern Ireland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScotland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian/Asian British\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWork-place demographics (self-reported)\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh deprivation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow deprivation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed Deprivation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRound one: online survey\u003c/p\u003e\u003cp\u003eParticipants received study background information and the round one questionnaire by email. Eleven responded to the round one questionnaire (73% response rate). Participants rated on a 5-point Likert scale the extent to which they agreed (from strongly agree to strongly disagree) that each set of housing questions was usable in a UK and Ireland context. In round one there were two statements to rate, one focused on acceptability, the other on perceived effectiveness if used in their work context:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePlease indicate the extent to which you agree that this set of screening questions would be acceptable to ask patients in a GP setting.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePlease indicate the extent to which you agree that this set of screening questions would identify a patient who is at risk of losing their home or experiencing homelessness.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThere was an optional comment box for participants to explain the reasoning for their rating.\u003c/p\u003e\u003cp\u003eConsensus\u003c/p\u003e\u003cp\u003eIt is accepted that consensus among participants increases when there is agreement of at least 75% and decreases when it is less than 75%(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Therefore, panel agreement of \u0026ge;\u0026thinsp;75% was set as an indication of consensus in this study (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The tools with \u0026ge;\u0026thinsp;75% of the panel agreeing on acceptability and perceived effectiveness proceeded to round two.\u003c/p\u003e\u003cp\u003eRound one agreement scores\u003c/p\u003e\u003cp\u003eHousing questions from the PRAPARE tool met consensus criteria for acceptability and questions from the Homelessness Screening Clinical Reminder tool met consensus criteria for perceived effectiveness. No tool met consensus criteria for both acceptability and perceived effectiveness, therefore all four tools were brought forward to round two.\u003c/p\u003e\u003cp\u003eSee Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026ndash; round one agreement scores (percentages underlined indicate consensus\u0026thinsp;\u0026gt;\u0026thinsp;75%)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrongly disagree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDisagree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNeutral\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAgree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrongly Agree\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003ePRAPARE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.54%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e54.54%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e27.27%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eWeCare\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.09%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.28%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.18%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.36%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.18%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eHomelessness Screening Clinical Reminder (HSCR)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e45.45%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e36.36%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.09%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.18%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.36%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.09%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eChildren\u0026rsquo;s Health Watch: Housing Stability Vital Signs (CHW)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.09%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.23%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.23%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36.36%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.27%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27.27%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBetween round one and two, participants were sent a summary of round one results including their individual Likert ratings alongside a summary of the anonymised group agreement scores and all free text comments. Participants were asked to read and consider the summary before attending round two.\u003c/p\u003e\u003cp\u003eRound two: online workshop\u003c/p\u003e\u003cp\u003eThe allocated workshop time was 2.5 hours and took place on Microsoft Teams with the primary researcher (AH) acting as facilitator. Eight of the eleven panel members from round one responded in round two (73% response rate).\u003c/p\u003e\u003cp\u003eRound-robin\u003c/p\u003e\u003cp\u003eParticipants gave their views on the feasibility of using the four sets of housing questions in their day-to-day job as a GP and were able to feedback their tool preference with reasoning. No interruptions or comments from other participants were permitted during this stage.\u003c/p\u003e\u003cp\u003eNH and GK noted points for discussion. These were then discussed by the panel within the designated discussion time.\u003c/p\u003e\u003cp\u003eClarification and group discussion\u003c/p\u003e\u003cp\u003eAll the discussion points were fed back to the panel members who could state if they thought any themes needed to be added. Prior to the discussion, the facilitator emphasised that the panel did not need to reach agreement during the discussion as there would be an online survey, like round one, following discussion to determine consensus. See Box 2 for discussion summary.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoint raised by panel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiscussion summary\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFor widespread uptake, a tool must be simple but effective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor a tool to be adopted by mainstream primary it needs to be simple and perceived by GPs to be effective in achieving its aim. An overly complex tool, or one that lacks substance, would deter uptake. A tool would need to fit within the flow of a consultation.\u003c/p\u003e\u003cp\u003eThe panel recognised that brief or one-question tools are easy to remember, however members of the panel commented that if a tool that is too simplistic identification of a housing issue might be missed, or with a yes/no question it might shut down the conversation without the patient having considered their housing situation as being precarious.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntroducing the tool to the patient with an opening statement is important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome panel members had experience of working with patients experiencing housing instability or homelessness and highlighted the importance of patients understanding they are being asked personal questions about their housing so that support can be offered if they wish. Example phrasing for an introductory statement was given: \u0026lsquo;we\u0026rsquo;re talking to a lot of people about finances at the minute, we do have pathways or links or services there, do you think that\u0026rsquo;s something you want to discuss?\u0026rsquo;\u003c/p\u003e\u003cp\u003eThe economic climate and housing crisis was seen as a way to introduce the topic: \u0026lsquo;we know lots of people are struggling at the moment\u0026rsquo;...or \u0026lsquo;we know housing can have a big impact...\u0026rsquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients and clinicians should understand the term insecure housing encompasses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA panel member felt that including a brief but comprehensive definition of what homelessness or insecure housing is alongside the tool would ensure clinicians understand what insecure housing can look like and in turn patients can understand if it applies to them or not.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA stigmatising topic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCare around wording was considered important for an area that might feel sensitive to patients and some of the questions were seen as potential triggers that might apportion blame. There was discussion around normalising conversations around housing and poverty as well as the importance of not adding to stigma in approaching these conversations. One participant likened a housing history to information gathering for a sexual history, and the importance of explaining why you\u0026rsquo;re taking a detailed history is important for ongoing care.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAn unexpected question\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients may not expect to be asked about housing in a GP consultation so it might be useful to link the topic of housing to health and explain the link between housing and health outcomes. One panel member felt checking patient details such as date of birth and address might be a useful trigger point for GPs to ask about housing and aid consultation flow.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA tool of two parts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne participant felt that a simple and carefully worded question would be easy to promote and referenced the \u0026lsquo;hello, my name is...\u0026rsquo; campaign. A similar initiative with a simple question as a prompt would raise awareness about homelessness and could be followed up with a more in-depth tool if an issue is raised.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBox 2- Workshop group discussion\u003c/p\u003e\u003cp\u003eRound two questionnaire\u003c/p\u003e\u003cp\u003eA second questionnaire was sent in the Teams \u0026lsquo;chat\u0026rsquo; function after this discussion for participants to complete during the workshop. For the round two questionnaire the research team agreed to seek views on \u0026lsquo;feasibility\u0026rsquo; as it encapsulated our overarching research question more succinctly. See the round two questionnaire statement below:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePlease indicate the extent to which you agree that this set of screening questions would be feasible to use in response to a patient cue that raises a concern about housing during a routine consultation\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eRound two agreement scores\u003c/p\u003e\u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e questions from PRAPARE and WECARE met panel consensus in round two.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eround two agreement scores (percentages underlined indicate consensus\u0026thinsp;\u0026gt;\u0026thinsp;75%)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrongly disagree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDisagree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNeutral\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAgree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStrongly Agree\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRAPARE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e50%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e25%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWECARE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e62.5%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e25%\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHSCR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCHW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs set out a priori, all tools that met the consensus criteria (\u0026gt;\u0026thinsp;75%) would be ranked in order of preference; housing questions from PRAPARE and WeCare proceeded to this stage due to meeting consensus. The tool ranked highest by the panel would be brought forward to the final stage of the study. Ranking resulted in a tie with 4 (50%) participants ranking PRAPARE and four (50%) ranking WeCare as their preference.\u003c/p\u003e\u003cp\u003eAs set out a priori in the circumstances of a tie, the panel discussed the merits and drawbacks of the tools before ranking again. After panel discussion and re-ranking 7 (87.5%) out of 8 participants ranked PRAPARE as their preference.\u003c/p\u003e\u003cp\u003ePanel review of PRAPARE questions\u003c/p\u003e\u003cp\u003eThe final stage of the workshop was a review of the housing questions from the agreed tool by the expert panel. The panel were asked to suggest any necessary modifications to the wording for use in the UK and Ireland context, or any important aspects they felt missing from the questions. This is in keeping with the approach used in other studies where social determinants of health tools having been adapted from other pre-existing tools (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Following the workshop, the research team reviewed the discussion transcript and finalised the questions based on panel discussion. Seeking to create something memorable the team assigned \u0026lsquo;HALT\u0026rsquo; as an acronym so that GPs could easily bring the tool to mind and recall the four questions in a similar way to CAGE. Box 3 details a summary of the panel discussion and the finalised questions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRAPARE question\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePanel review\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinalised question\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhat is your housing situation today?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe panel felt that the opening question should be more open and broad, as someone\u0026rsquo;s housing situation today might be different than their housing situation over the previous few weeks or months.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;you might have someone who, OK, well last night I was staying in my mum\u0026rsquo;s but actually, I\u0026rsquo;ve been dotting here, there and everywhere\u0026rsquo; and \u0026lsquo;today\u0026rsquo; closes it down slightly\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Can I ask about your housing situation at the moment?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003ewas suggested as an alternative; an open question which asks the patient\u0026rsquo;s permission, giving the patient the option to say no.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCan I ask about your \u003cb\u003eHousing\u003c/b\u003e situation at the moment?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAre you worried about losing your housing?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThis question implies that someone does have housing. The suggested alternative was a broader question around housing concerns:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Are you worried about your housing situation?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBy keeping the question more open, it allows patients to answer relative to how they view their housing. One participant commented that a patient might say:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;I\u0026rsquo;m sofa surfing but I\u0026rsquo;m not worried about it, I\u0026rsquo;m quite enjoying it,\u0026rsquo; or \u0026lsquo;I may be in my own house, but I am worried about it.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother panel member commented that this question would lead into other questions possibly around affordability of rent or mortgage payments and gives opportunity to pick up on other challenges other than housing in isolation. Intervention at this point could prevent a possible housing crisis in time.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDo you \u003cb\u003eAgonise\u003c/b\u003e or worry about your housing situation?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhat address do you live at?\u003c/p\u003e\u003cp\u003eStreet:________\u003c/p\u003e\u003cp\u003eCity/State/Zip code: __________\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA question to ensure the correct contact details were on the patient\u0026rsquo;s record was felt to be an important aspect of the tool.\u003c/p\u003e\u003cp\u003eOne panel member commented that \u003cem\u003e\u0026lsquo;there\u0026rsquo;s so many DNAs (did not attend) because we don\u0026rsquo;t check the address\u0026rsquo;\u003c/em\u003e, and there was discussion the importance of correct contact details to ensure patients receive phone calls and letters for follow-up appointments and referrals.\u003c/p\u003e\u003cp\u003eThe panel commented that primary care teams need to allow patients to give the name or contact details of a family member, a friend, or a local organisation like a specialist healthcare service for people experiencing homelessness, that might be more reliable than their current address.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCan I confirm what contact details would be best to \u003cb\u003eLink\u003c/b\u003e in with you for follow-up?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe panel agreed a question asking if the patient would like referral was necessary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWould you like to \u003cb\u003eTalk\u003c/b\u003e to someone who might be able to help with your housing?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBox 3- HALT tool development\u003c/p\u003e\u003cp\u003eThe panel suggested that a reference guide for clinicians to demonstrate what would be considered precarious housing would be useful; in response, the research team included an overview of FEANTSAs typology of homelessness alongside the tool as seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the modified Delphi approach enabled a panel of GPs from the UK and Ireland with experience of the demanding primary care workload to agree on which housing questions from four tools validated outside of the UK and Ireland would be feasible to use in the national primary care context. Prior to this study there was no tool developed for this purpose within the UK and Ireland.\u003c/p\u003e\u003cp\u003eHousing questions from two tools, WeCare, and PRAPARE, met study consensus criteria of \u0026ge;\u0026thinsp;75% with PRAPARE being the panel preference on final ranking. The HALT tool is the product of the panel\u0026rsquo;s suggested modifications to PRAPARE questions for use in the context of UK and Irish primary care.\u003c/p\u003e\u003cp\u003eHALT is a tool that a panel of GPs agree is feasible for use in everyday primary care workplaces without overwhelming clinicians. Primary care teams can use HALT to respond to patient cues that suggest that a patient is living in an unstable housing situation and provides a structured approach for staff who do not currently use a framework to ask about housing within their consultations. Clinicians can identify patients living in insecure housing and refer to support services in line with the patient\u0026rsquo;s wishes. HALT is a means by which primary care teams can contribute to reducing health inequalities for patients living in insecure housing and prevent the \u0026lsquo;cliff edge\u0026rsquo; health consequences, and could fill an important gap in current UK and Ireland primary care practice. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study was designed in response to recognition of the impact of homelessness on the wellness and health of patients known to primary care teams, and the lack of a recognised tool or structured approach to identify housing insecurity in use within a UK and Ireland primary context. The HALT tool could fill this gap for primary care teams.\u003c/p\u003e\u003cp\u003eNorth America has been progressive in this research field. The PRAPARE implementation and action toolkit suggests various ways that PRAPARE can be integrated into various workflows before, during and after the clinical visit using both clinical and non-clinical staff(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). HALT could be implemented in our local context using knowledge from these workflows\u003c/p\u003e\u003cp\u003eThe Delphi approach is often used to develop guidelines or develop tools where statistical evidence is limited in an area and expert consensus is appropriate(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). We used a modified-Delphi in a novel way, asking a panel of GPs to agree which of a set of pre-existing tools with published validity data would be feasible to use in a UK and Ireland context, allowing us to model our tool (HALT) on a tool with a pre-existing evidence base.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStrengths\u003c/p\u003e\u003cp\u003eHALT is a tool that has been developed from housing questions in a pre-existing, previously validated tool in use across health care centres within the United States and internationally; adapting a tool with an existing evidence base was preferable to developing a new tool.\u003c/p\u003e\u003cp\u003eThe round two workshop using the nominal group technique structure provided rich discussion around introducing a housing tool in a primary care context. The six discussion points raised by the panel of expert GPs are applicable to other areas of research considering tool design in the UK and Ireland primary care setting. Using a traditional Delphi process instead of a modified Delphi including aspects of Nominal Group Technique may not have captured this rich data.\u003c/p\u003e\u003cp\u003eThe aim of this study was to develop a tool that is feasible for general practitioners to use in their everyday work. We worked with the Centre for Homelessness Impact to develop the inclusion criteria for the study; a data scientist from CHI worked alongside AH to assess which tools met those criteria. CHI shared valuable insights into question wording and possible tool acronyms with an emphasis on ensuring these are not stigmatising for patients. The primary researcher visited the Inclusion Health Hub in Belfast prior to study design, this team provides healthcare to people experiencing homelessness in Belfast. This visit gave insight into the lived realities and health experiences of people experiencing homelessness and highlighted the need for earlier intervention to prevent experiences of homelessness, giving purpose to this research study.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eWe recruited GPs only for this study; we did not include other members of the primary care multi-disciplinary team such as advanced nurse practitioners, practice nurses, social workers, link workers, physiotherapists, mental health workers and administrative staff whose inclusion may have provided a wider range of perspectives. However, it is hoped that subsequent work will provide the opportunity to involve perspectives from the wider primary care team.\u003c/p\u003e\u003cp\u003eThe views of those with lived experience of housing insecurity and homelessness are not directly represented; this is because the primary care team will be administering the tool and the aim of this study was to ensure a tool that would be used by primary care teams. A further step in this programme of work is acceptability with the public.\u003c/p\u003e\u003cp\u003eWe recruited using email and Twitter(X), asking for GPs who were interested in homelessness prevention. We therefore had a high proportion of GPs who worked in areas of high deprivation and from the group discussion, it was evident that a number had worked within specialist services for people experiencing homelessness. Only one participant indicated they worked in an area of low deprivation. Otherwise, there was an even spread of mixed and high deprivation areas for the remainder of participants. Future work would seek the views of a broader section of the primary care workforce.\u003c/p\u003e\u003cp\u003eIt has been suggested that there should be a minimum of 10\u0026ndash;18 panel members per area of expertise(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We invited 15 to take the panel, we had a dropout rate of 20% with eleven completing round one. With further drop out of 3 participants (27%) we had 8 participants in round two. Other Delphi studies have shown a dropout rate of 20\u0026ndash;30% between rounds is common, with this knowledge we might have recruited a larger number to the panel at the outset. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Despite the low sample size it is recognised that Delphi studies rely on group dynamics rather than statistical power to achieve consensus (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for clinical practice and research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcross healthcare there is recognition of the need to tackle health inequalities. The Royal College of Physicians (RCP) convene \u0026lsquo;The Inequalities in Health Alliance\u0026rsquo;, a coalition of not for profit organisations who collaborate to campaign for cross-government strategies to address inequalities(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In primary and secondary care respectively the Royal College of General Practitioners (RCGP) and the RCP are working towards reducing health inequalities through increasing awareness, developing guidance, highlighting best practice, and encouraging local health care providers to create networks with local communities and third sector organisations(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). HALT could provide a practical way for primary care teams to identify and address those who experience the most profound inequalities, and work alongside statutory and community organisations to achieving this aim.\u003c/p\u003e\u003cp\u003eFuture research would include assessing HALT tool acceptability, recognising that the acceptability of healthcare interventions for both intervention deliverers and recipients will impact successful implementation (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Validation of HALT tool including measuring its sensitivity and specificity would also be necessary before widespread implementation within primary care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eInternationally tools have been developed and used in primary care settings to identify housing insecurity for signposting or referral to support services, however prior to this study no tool had been assessed or developed for use in general practice in the UK or Ireland. Using consensus methods, a panel of GPs from across the UK and Ireland agreed that housing questions from a tool developed and validated in other national contexts would be feasible to use in primary care in the UK and Ireland, these questions were critiqued by the panel, changes were made, and a memorable acronym assigned forming the \u0026lsquo;HALT tool\u0026rsquo;. HALT provides clinicians with a framework of questions to ask to identify housing concerns for referral to support service. Early intervention could prevent a housing crisis and experiences of homelessness for patients and their families.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePEH: People experiencing homelessness\u003c/p\u003e\n\u003cp\u003eGP: General practitioner\u003c/p\u003e\n\u003cp\u003eRCP: Royal College of Physicians\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by Queen\u0026rsquo;s University Belfast Faculty of Medicine, Health and Life Sciences Research Ethics Committee (Faculty REC), reference number MHLS 22_108.\u003c/p\u003e\n\u003cp\u003eThe study adhered to the Declaration of Helsinki. All participants received study information prior to their involvement and gave informed consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants completed consent forms prior to the study giving their permission to publish anonymised data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnonymised datasets are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo competing interests to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlexandra Huey was funded by Northern Ireland Research and Development through their support of the General Practice Academic and Research Training Scheme. The Centre for Homelessness Impact provided funding for participant reimbursement for their time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the Centre for Homelessness Impact for their support with this research: the financial contribution they gave so participants received reimbursement for their professional time, and to the data scientist who worked with the research team during the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe HALT tool was developed based on the housing questions in the PRAPARE tool. We acknowledge the PRAPARE team\u0026rsquo;s work in the development, validation, and implementation of their tool. The research team tried to contact the PRAPARE team between October 2022 and February 2023 to discuss this study, no correspondence was received.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMorris. L RR. Tackling health inequalities: seven priorities for the NHS2024 [cited 2025 7/4/2025]. Available from: https://www.kingsfund.org.uk/insight-and-analysis/long-reads/tackling-health-inequalities-seven-priorities-nhs.\u003c/li\u003e\n\u003cli\u003eStory A. Slopes and cliffs in health inequalities: comparative morbidity of housed and homeless people. The Lancet. 2013;382:S93.\u003c/li\u003e\n\u003cli\u003eLewer D, Aldridge RW, Menezes D, Sawyer C, Zaninotto P, Dedicoat M, et al. Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ Open. 2019;9(4):e025192.\u003c/li\u003e\n\u003cli\u003eFEANTSA. ETHOS- European Typology of Homelessness and Housing Exclusion 2005 [Available from: https://www.feantsa.org/en/toolkit/2005/04/01/ethos-typology-on-homelessness-and-housing-exclusion.\u003c/li\u003e\n\u003cli\u003eKeogh C, O\u0026rsquo;Brien KK, Hoban A, O\u0026rsquo;Carroll A, Fahey T. Health and use of health services of people who are homeless and at risk of homelessness who receive free primary health care in Dublin. BMC Health Services Research. 2015;15(1):58.\u003c/li\u003e\n\u003cli\u003ePressures in general practice data analysis: British Medical Association; 2025 [updated 27/03/3035; cited 2025 7/4/2025]. Available from: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien CP. The CAGE Questionnaire for Detection of Alcoholism. JAMA. 2008;300(17):2054.\u003c/li\u003e\n\u003cli\u003eTrevelyan E, Prof Robinson, Nicola. Delphi methodology in health research: how to do it? European Journal of Integrative Medicine. 2016;7(4):423-8.\u003c/li\u003e\n\u003cli\u003eNasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021;11(4):116-29.\u003c/li\u003e\n\u003cli\u003eKhodyakov D, Grant S, Denger B, Kinnett K, Martin A, Peay H, et al. Practical Considerations in Using Online Modified-Delphi Approaches to Engage Patients and Other Stakeholders in Clinical Practice Guideline Development. The Patient - Patient-Centered Outcomes Research. 2020;13(1):11-21.\u003c/li\u003e\n\u003cli\u003eS\u0026oslash;ndergaard E, Ertmann RK, Reventlow S, Lykke K. Using a modified nominal group technique to develop general practice. BMC Family Practice. 2018;19(1).\u003c/li\u003e\n\u003cli\u003eMcMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655-62.\u003c/li\u003e\n\u003cli\u003eOkoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Information \u0026amp;amp; Management. 2004;42(1):15-29.\u003c/li\u003e\n\u003cli\u003eHenrikson NB, Blasi PR, Dorsey CN, Mettert KD, Nguyen MB, Walsh-Bailey C, et al. Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review. American Journal of Preventive Medicine. 2019;57(6):S13-S24.\u003c/li\u003e\n\u003cli\u003eMontgomery AE, Fargo JD, Kane V, Culhane DP. Development and Validation of an Instrument to Assess Imminent Risk of Homelessness among Veterans. Public Health Reports. 2014;129(5):428-36.\u003c/li\u003e\n\u003cli\u003eMontgomery AE, Fargo JD, Byrne TH, Kane VR, Culhane DP. Universal screening for homelessness and risk for homelessness in the Veterans Health Administration. Am J Public Health. 2013;103 Suppl 2(Suppl 2):S210-1.\u003c/li\u003e\n\u003cli\u003eGarg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-304.\u003c/li\u003e\n\u003cli\u003eColvin JD. IHELP Pediatric Social History Tool Social Interventions Research and Evaluation Network2017 [cited 2022 29/7/2022]. Available from: https://sirenetwork.ucsf.edu/tools-resources/resources/ihelp-pediatric-social-history-tool.\u003c/li\u003e\n\u003cli\u003eFarrell AF, Dibble KE, Randall KG, Britner PA. Screening for Housing Instability and Homelessness Among Families Undergoing Child Maltreatment Investigation. Am J Community Psychol. 2017;60(1-2):25-32.\u003c/li\u003e\n\u003cli\u003eHensley C JA, Shah S, O\u0026rsquo;Dea C, Carameli K. Addressing social determinants of health at a federally qualified health center. Public Health Journal. 2017;9(2):189-98.\u003c/li\u003e\n\u003cli\u003eHershey JA, Morone J, Lipman TH, Hawkes CP. Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes. Can J Diabetes. 2021;45(5):444-50.e1.\u003c/li\u003e\n\u003cli\u003eBillioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. NAM Perspectives. 2017;7(5).\u003c/li\u003e\n\u003cli\u003eTobin-Tyler E, Teitelbaum JB. Medical-Legal Partnership: A Powerful Tool for Public Health and Health Justice. Public Health Rep. 2019;134(2):201-5.\u003c/li\u003e\n\u003cli\u003eSundar KR. Universal Screening for Social Needs in a Primary Care Clinic: A Quality Improvement Approach Using the Your Current Life Situation Survey. Perm J. 2018;22:18-089.\u003c/li\u003e\n\u003cli\u003eJaffee KD, Liu GC, Canty-Mitchell J, Qi RA, Austin J, Swigonski N. Race, urban community stressors, and behavioral and emotional problems of children with special health care needs. Psychiatr Serv. 2005;56(1):63-9.\u003c/li\u003e\n\u003cli\u003ePage-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, Ianakieva V, et al. Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico. The Journal of the American Board of Family Medicine. 2016;29(3):414-8.\u003c/li\u003e\n\u003cli\u003eFreedman D, Vanderhorst N. PS3-55: Utilization of High-Technology to Collect Health Risk Assessment Information from Medicare Members: A Feasibility Study of Interactive Voice Response (IVR) and an Online Survey Tool. Clinical Medicine \u0026amp;amp; Research. 2013;11(3):175-6.\u003c/li\u003e\n\u003cli\u003eBeck AF, Klein MD, Kahn RS. Identifying social risk via a clinical social history embedded in the electronic health record. Clin Pediatr (Phila). 2012;51(10):972-7.\u003c/li\u003e\n\u003cli\u003eBourgois P, Holmes SM, Sue K, Quesada J. Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care. Acad Med. 2017;92(3):299-307.\u003c/li\u003e\n\u003cli\u003eCook CAL, Freedman JA, Freedman LD, Arick RK, Miller ME. Screening for Social and Environmental Problems in a VA Primary Care Setting. Health \u0026amp; Social Work. 1996;21(1):41-7.\u003c/li\u003e\n\u003cli\u003eLaForge K, Gold R, Cottrell E, Bunce AE, Proser M, Hollombe C, et al. How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview. J Ambul Care Manage. 2018;41(1):2-14.\u003c/li\u003e\n\u003cli\u003eKusnoor SV, Koonce TY, Hurley ST, McClellan KM, Blasingame MN, Frakes ET, et al. Collection of social determinants of health in the community clinic setting: a cross-sectional study. BMC Public Health. 2018;18(1):550.\u003c/li\u003e\n\u003cli\u003eAnderst A, Hunter K, Andersen M, Walker N, Coombes J, Raman S, et al. Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review. BMJ Open. 2022;12(4):e054338.\u003c/li\u003e\n\u003cli\u003eNg R, Gunatillaka N, Skouteris H, Blane D, Blewitt C, Nielsen S, et al. Screening for Unstable Housing in a Healthcare Setting. Public Health Rev. 2023;44:1606438.\u003c/li\u003e\n\u003cli\u003eWan W, Li V, Chin MH, Faldmo DN, Hoefling E, Proser M, et al. Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes. The Journal of the American Board of Family Medicine. 2022;35(4):668-79.\u003c/li\u003e\n\u003cli\u003eGarg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children\u0026apos;s well-child care visits: the WE CARE Project. Pediatrics. 2007;120(3):547-58.\u003c/li\u003e\n\u003cli\u003eFargo JD, Montgomery AE, Byrne T, Brignone E, Cusack M, Gundlapalli AV. Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness. Stud Health Technol Inform. 2017;235:574-8.\u003c/li\u003e\n\u003cli\u003eSandel M, Sheward R, Ettinger De Cuba S, Coleman SM, Frank DA, Chilton M, et al. Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics. 2018;141(2):e20172199.\u003c/li\u003e\n\u003cli\u003eBarrios M, Guilera G, Nu\u0026ntilde;o L, G\u0026oacute;mez-Benito J. Consensus in the delphi method: What makes a decision change? Technological Forecasting and Social Change. 2021;163:120484.\u003c/li\u003e\n\u003cli\u003eJ\u0026uuml;nger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliative Medicine. 2017;31(8):684-706.\u003c/li\u003e\n\u003cli\u003eDiamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. Journal of Clinical Epidemiology. 2014;67(4):401-9.\u003c/li\u003e\n\u003cli\u003e(NACHC) NAoCHC. PRAPARE Reach 2023 [Available from: https://prapare.org/prapare-reach/.\u003c/li\u003e\n\u003cli\u003eBardecki MJ. Participants\u0026apos; response to the Delphi method: An attitudinal perspective. Technological Forecasting and Social Change. 1984;25(3):281-92.\u003c/li\u003e\n\u003cli\u003eParliamentary briefing from the Inequalities in Health Alliance [Available from: https://www.rcp.ac.uk/media/lpegesv0/iha-parliamentary-briefing-for-mps-and-peers-november-2024.pdf.\u003c/li\u003e\n\u003cli\u003eRCGP. Royal College of General Practitioners: Strategic plan 2023 to 2026: Building a sustainable future for general practice London2023 [cited 2024 11 June 2024]. Available from: https://www.rcgp.org.uk/about.\u003c/li\u003e\n\u003cli\u003eBridging the gap: a guide to making health inequalities a strategic priority for NHS leaders 2024 [updated 16/12/24. Available from: https://www.rcp.ac.uk/improving-care/resources/bridging-the-gap-a-guide-to-making-health-inequalities-a-strategic-priority-for-nhs-leaders/.\u003c/li\u003e\n\u003cli\u003eSekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Services Research. 2017;17(1):88.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health inequities, housing instability, social determinants of health, Delphi technique, family practice, primary health care, general practice","lastPublishedDoi":"10.21203/rs.3.rs-6783597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6783597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eReducing health inequalities is a global health priority. People experiencing homelessness experience health at the extreme end of health inequality; homelessness must be prevented where possible. Healthcare tools developed to identify patients living in insecure housing to signpost to support services are not routinely used in primary care across the UK and Ireland. This study explores which tools would be feasible to use in our local context and aimed to develop a tool that could identify patients at risk of homelessness for use in primary care in the UK and Ireland\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis two-stage study involved a literature search using online databases for healthcare tools that identify housing insecurity and a consensus study where a panel of General Practitioners reached agreement on housing questions feasible to use in the UK and Ireland. The consensus study had two rounds that took place online: a questionnaire and a workshop.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEleven primary care physicians participated in round one with eight in round two. Housing questions from two tools met consensus criteria. Once ranked in order of preference, suggested modifications were made for a UK and Ireland context. The outcome is \u0026lsquo;HALT\u0026rsquo;: a four-question housing tool.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eHALT provides a memorable framework to enquire about patients\u0026rsquo; housing to identify those at risk of experiencing of homelessness for signposting to support services. Further research is required to assess the acceptability of, and to validate, HALT.\u003c/p\u003e","manuscriptTitle":"A consensus study leading to HALT- a tool to prevent homelessness in primary care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 09:45:18","doi":"10.21203/rs.3.rs-6783597/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-15T12:09:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T01:58:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86143037962222740650798985174460579539","date":"2026-04-06T18:17:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T13:55:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213995951174663659312524281182347063485","date":"2026-02-14T15:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282115849361368537623409882123859834537","date":"2025-12-14T03:05:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-28T09:07:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78514880967578033811425493925579350526","date":"2025-09-29T00:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304401157329270704362439421742070035232","date":"2025-07-09T14:58:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T14:47:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-03T12:41:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-01T12:20:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T11:21:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-07-01T11:18:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"62a3b542-b173-4c01-8152-9fcd1b84b147","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-15T12:09:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T01:58:24+00:00","index":113,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T12:25:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 09:45:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6783597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6783597","identity":"rs-6783597","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}