Advancing Curriculum Development and Design in Health Professions Education: A Health Equity and Inclusion Framework for Education Programs

ABSTRACT

The COVID-19 pandemic has exacerbated pre-existing health inequities in vulnerable and marginalized patient populations. Continuing professional development (CPD) can be a critical driver of change to improve quality of care, health inequities, and system change. In order for CPD to address these disparities in care for patient populations most affected in the health care system, CPD programs must first address issues of equity and inclusion in their education development and delivery. Despite the need for equitable and inclusive CPD programs, there remains a paucity of tools and frameworks available in the literature to guide CPD and broader education providers on how best to develop and deliver equitable and inclusive education programs. In this article, we describe the development and application of a Health Equity and Inclusion (HEI) Framework for education and training grounded in the Analyze, Design, Develop, Implement, and Evaluate model for instructional design. Using a case example, specifically a hospital-wide trauma-informed de-escalation for safety program, we demonstrate how the HEI Framework can be applied practically to CPD programs to support equity and inclusion in the planning, development, implementation, and evaluation phases of education program delivery. The case example illustrates how the HEI Framework can be used by CPD providers to respect learner diversity, improve accessibility for all learners, foster inclusion, and address biases and stereotypes. We suggest that the HEI Framework can serve as an educational resource for CPD providers and health professions educators aiming to create equitable and inclusive CPD programs.

Interprofessional continuing professional development programs can foster lifelong learning in healthcare professionals: experiences from the Project ECHO model

BACKGROUND

The success of continuing professional development (CPD) programs that foster skills in lifelong learning (LLL) has been well established. However, healthcare professionals often report barriers such as access to CPD and cost which limit uptake. Further research is required to assess how accessible CPD programs, such as those delivered virtually, impact orientation to LLL. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a CPD model that has a growing body of evidence demonstrating improvements in knowledge and skills. Central to this model is the use of a virtual platform, varied teaching approaches, the promotion of multi-directional learning and provider support through a community of practice. This study aimed to explore whether participation in a provincial mental health ECHO program had an effect on interprofessional healthcare providers' orientation to LLL.

METHODS

Using a pre-post design, orientation to LLL was measured using the Jefferson Scale of Lifelong Learning. Eligible participants were healthcare professionals enrolled in a cycle of ECHO Ontario Mental Health from 2017 to 2020. Participants were classified as 'high' or 'low' users using median session attendance as a cut-point.

RESULTS

The results demonstrate an increase in orientation to LLL following program participation (Pre: 44.64 ± 5.57 vs. Post: 45.94 ± 5.70, t (66) = - 3.023, p < .01, Cohen's d = 0.37), with high ECHO users demonstrating greater orientation to LLL post-ECHO.

CONCLUSION

Findings are discussed in the context of self-determination theory and suggest there may be components of CPD programs that more readily support increased motivation for LLL for interprofessional healthcare professionals.

Moving beyond ‘think leadership, think white male’: the contents and contexts of equity, diversity and inclusion in physician leadership programmes

The lack of both women and physicians from groups under-represented in medicine (UIM) in leadership has become a growing concern in healthcare. Despite increasing recognition that diversity in physician leadership can lead to reduced health disparities, improved population health and increased innovation and creativity in organisations, progress toward this goal is slow. One strategy for increasing the number of women and UIM physician leaders has been to create professional development opportunities that include leadership training on equity, diversity and inclusivity (EDI). However, the extent to which these concepts are explored in physician leadership programming is not known. It is also not clear whether this EDI content challenges structural barriers that perpetuate the status quo of white male leadership. To explore these issues, we conducted an environmental scan by adapting Arksey and O’Malley’s scoping review methodology to centre on three questions: How is EDI currently presented in physician leadership programming? How have these programmes been evaluated in the peer-reviewed literature? How is EDI presented and discussed by the wider medical community? We scanned institutional websites for physician leadership programmes, analysed peer-reviewed literature and examined material from medical education conferences. Our findings indicate that despite an apparent increase in the discussion of EDI concepts in the medical community, current physician leadership programming is built on theories that fail to move beyond race and gender as explanatory factors for a lack of diversity in physician leadership. To address inequity, physician leadership curricula should aim to equip physicians to identify and address the structural factors that perpetuate disparities.

Developing an evaluation framework for assessing the impact of recovery colleges: protocol for a participatory stakeholder engagement process and cocreated scoping review

INTRODUCTION

Recovery colleges (RCs) are mental health centres aimed at equipping people with skills to live a meaningful life despite the presence of mental distress. Unique to them is the aspect of cocreation; RCs are designed collaboratively with people of lived experiences of mental health and addictions and care providers. Despite established benefits, there remains a lack of empirical evidence on how RCs work and on their impact.

AIMS

We aim to address this gap by designing a cocreated evaluation framework for RCs. This will be accomplished by engaging RC student/facilitators to provide perspectives on RCs/RC evaluation and cocreate a scoping review identifying evaluation gaps in the literature. Themes identified through these processes will form the evaluation framework.

METHODS AND ANALYSIS

Two methodologies will be used to explore RC evaluation: student/facilitator engagement and a scoping review of current published and grey literature on RC evaluation. Engagement will be achieved using a participatory action research approach consisting of informant interviews of ~25 RC students/facilitators across Canada, which will be thematically analysed. The scoping review will follow methodology described by Arksey and O'Malley modified to support cocreation. Concurrent conducting of the engagement process and scoping review will allow RC students and peer facilitators the opportunity to shape RC evaluations, address gaps in the literature and codesign an evaluation framework focused on recovery-oriented processes and outcomes mattering most to RCs students/facilitators.

ETHICS AND DISSEMINATION

Ethics approval was received for the RC student/facilitator engagement component from the Centre for Addictions and Mental Health Research Ethics Board (#042-2020) and Ontario Shores Centre for Mental Health Sciences (#20-013-B). Scoping review results will be copresented through national and international medical education conferences and published in open-access peer-reviewed journals. Furthermore, a dissemination strategy on evaluation for the national RC community will be created.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia

OBJECTIVE

Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration.

METHODS

TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change.

RESULTS

All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers.

CONCLUSION

Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

"Time is a Great Teacher, but Unfortunately It Kills All Its Pupils": Insights from Psychiatric Service User Engagement

In this Foundations article, the authors reflect on the meaning of time through their past work creating novel roles for psychiatric service users to be involved in the education of health professions trainees and faculty. Inspired by music composer Hector Berlioz, the authors explore and critique the ableist, chrononormative temporalities of academia, and medical education. The authors introduce the conception of crip time from critical disability studies and use it to reflect on their experiences of the different temporalities that people bring to service user engagement and other collaborative projects. "Crip time" can help challenge notions of pace and productivity to create a more inclusive space for teachers and learners in health professions education.

Patient, family and provider views of measurement-based care in an early-psychosis intervention programme

Background

Measurement-based care (MBC) in mental health improves patient outcomes and is a component of many national guidelines for mental healthcare delivery. Nevertheless, MBC is not routinely integrated into clinical practice. Several known reasons for the lack of integration exist but one lesser explored variable is the subjective perspectives of providers and patients about MBC. Such perspectives are critical to understand facilitators and barriers to improve the integration of MBC into routine clinical practice.

Aims

This study aimed to uncover the perspectives of various stakeholders towards MBC within a single treatment centre.

Method

Researchers conducted qualitative semi-structured interviews with patients (n = 15), family members (n = 7), case managers (n = 8) and psychiatrists (n = 6) engaged in an early-psychosis intervention programme. Data were analysed using thematic analysis, informed by critical realist theory.

Results

Analysis converged on several themes. These include (a) implicit negative assumptions; (b) relevance and utility to practice; (c) equity versus flexibility; and (d) shared decision-making. Providers assumed patients’ perspectives of MBC were negative. Patients’ perspectives of MBC were actually favourable, particularly if MBC was used as an instrument to engage patients in shared decision-making and communication rather than as a dogmatic and rigid clinical decision tool.

Conclusions

This qualitative study presents the views of various stakeholders towards MBC, providing an in-depth examination of the barriers and facilitators to MBC through qualitative investigation. The findings from this study should be used to address the challenges organisations have experienced in implementing MBC.

Correction to: Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment

A Correction to this paper has been published: 10.1007/s40596-021-01471-6

Using Digital Tools to Engage Patients With Psychosis and Their Families in Research: Survey Recruitment and Completion in an Early Psychosis Intervention Program

BACKGROUND

Barriers to recruiting and retaining people with psychosis and their families in research are well-established, potentially biasing clinical research samples. Digital research tools, such as online platforms, mobile apps, and text messaging, have the potential to address barriers to research by facilitating remote participation. However, there has been limited research on leveraging these technologies to engage people with psychosis and their families in research.

OBJECTIVE

The objective of this study was to assess the uptake of digital tools to engage patients with provisional psychosis and their families in research and their preferences for different research administration methods.

METHODS

This study used Research Electronic Data Capture (REDCap)-a secure web-based platform with built-in tools for data collection and storage-to send web-based consent forms and surveys on service engagement via text message or email to patients and families referred to early psychosis intervention services; potential participants were also approached or reminded about the study in person. We calculated completion rates and timing using remote and in-person methods and compensation preferences.

RESULTS

A total of 447 patients with provisional psychosis and 187 of their family members agreed to receive the web-based consent form, and approximately half of the patients (216/447, 48.3%) and family members (109/187, 58.3%) consented to participate in the survey. Most patients (182/229, 79.5%) and family members (75/116, 64.7%) who completed the consent form did so remotely, with more family members (41/116, 35.3%) than patients (47/229, 20.5%) completing it in person. Of those who consented, 77.3% (167/216) of patients and 72.5% (79/109) of family members completed the survey, and most did the survey remotely. Almost all patients (418/462, 90.5%) and family members (174/190, 91.6%) requested to receive the consent form and survey by email, and only 4.1% (19/462) and 3.2% (6/190), respectively, preferred text message. Just over half of the patients (91/167, 54.5%) and family members (42/79, 53.2%) preferred to receive electronic gift cards from a coffee shop as study compensation. Most surveys were completed on weekdays between 12 PM and 6 PM.

CONCLUSIONS

When offered the choice, most participants with psychosis and their families chose remote administration methods, suggesting that digital tools may enhance research recruitment and participation in this population, particularly in the context of the COVID-19 global pandemic.

"It was great to break down the walls between patient and provider": liminality in a co-produced advisory course for psychiatry residents

Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.

Digital Interventions to Support Population Mental Health in Canada During the COVID-19 Pandemic: Rapid Review

BACKGROUND

The COVID-19 pandemic has resulted in a number of negative health related consequences, including impacts on mental health. More than 22% of Canadians reported that they had felt depressed in the last week, in response to a December 2020 national survey. Given the need to physically distance during the pandemic, and the increase in demand for mental health services, digital interventions that support mental health and wellness may be beneficial.

OBJECTIVE

The purpose of this research was to identify digital interventions that could be used to support the mental health of the Canadian general population during the COVID-19 pandemic. The objectives were to identify (1) the populations these interventions were developed for, inclusive of exploring areas of equity such as socioeconomic status, sex/gender, race/ethnicity and culture, and relevance to Indigenous peoples and communities; (2) the effect of the interventions; and (3) any barriers or facilitators to the use of the intervention.

METHODS

This study was completed using a Cochrane Rapid Review methodology. A search of Embase, PsycInfo, Medline, and Web of Science, along with Google, Million Short, and popular mobile app libraries, was conducted. Two screeners were involved in applying inclusion criteria using Covidence software. Academic articles and mobile apps identified were screened using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields resource, the American Psychiatric Association App Evaluation Framework, and the Mental Health Commission of Canada's guidance on app assessment and selection.

RESULTS

A total of 31 mobile apps and 114 web-based resources (eg, telemedicine, virtual peer support groups, discussion forums, etc) that could be used to support the mental health of the Canadian population during the pandemic were identified. These resources have been listed on a publicly available website along with search tags that may help an individual make a suitable selection. Variability exists in the populations that the interventions were developed for, and little assessment has been done with regard to areas of equity. The effect of the interventions was not reported for all those identified in this synthesis; however, for those that did report the effect, it was shown that they were effective in the context that they were used. A number of barriers and facilitators to using these interventions were identified, such as access, cost, and connectivity.

CONCLUSIONS

A number of digital interventions that could support population mental health in Canada during the global COVID-19 pandemic were identified, indicating that individuals have several options to choose from. These interventions vary in their purpose, approach, design, cost, and targeted user group. While some research and digital interventions addressed equity-related considerations, more research and focused attention should be given to this area.

Using Rapid Design Thinking to Overcome COVID-19 Challenges in Medical Education

The rapid rise of cases of coronavirus disease 2019 (COVID-19) has led to the implementation of public health measures on an unprecedented scale. These measures have significantly affected the training environment and the mental health of health care providers and learners. Design thinking offers creative and innovative solutions to emergent complex problems, including those related to training and patient care that have arisen as a result of the COVID-19 pandemic. Design thinking can accelerate the development and implementation of solution prototypes through a process of inspiration, ideation, and implementation. Digital technology can be leveraged as part of this process to provide care and education in new or enhanced ways. Online knowledge hubs, videoconference-based interactive sessions, virtual simulations, and technology-enhanced coaching for health care providers are potential solutions to address identified issues. Limitations of this model include inherent bias toward utilitarian instead of egalitarian principles and the subsequent threat to diversity, equity, and inclusion in solutions. Although medical educators have embraced digital transformation during the COVID-19 pandemic, there is a need to ensure that these changes are sustained.

From hermeneutics to heteroglossia: 'The Patient's View' revisited

This article explores conceptual and methodological challenges surrounding the recovery of patients' voices in the history of medicine. We examine the debate that followed Roy Porter's seminal article, 'The Patient's View: Doing Medical History from Below' (1985). Porter argued that patients should be given a central role in medical history, aiming to restore to patients a voice and agency that is often lost in 'physician-centered' historical narratives. His work carried significant influence but also sparked an ongoing debate about the possibility of conducting 'patient-centered' history of medicine. The growth of the medical humanities has afforded renewed attention to patient narratives, supporting the need to recognise patients' voices in contemporary healthcare and medical education. However, several barriers complicate and problematise the expansion of a patient-centred epistemology across historical periods. Postmodern critics have expressed scepticism that 'the patient's view' can be recovered from history, with some claiming that 'the patient' is a construct of the 'medical gaze' whose subjectivity cannot be reconstituted outside of sociohistorical discourses of knowledge and power. Psychiatry in the mid-20th century presents a particular challenge for patient-centred history. We discuss the influence of postmodern theorists, especially Michel Foucault, whose work is seen as undermining the possibility of a patient-centred epistemology. We argue against Foucault's erasure of the patient, and instead explore alternate constructivist epistemologies, focusing on the hermeneutics of Hans-Georg Gadamer and dialogism of Mikhail Bakhtin, to help address historiographical challenges in recovering 'the patient's view'. To illustrate the value of Gadamerian and Bakhtinian approaches, we apply them to a case study from the Verdun Protestant Hospital (Québec, Canada) from 1941 to 1956, which sheds light on the introduction of the first antipsychotic, chlorpromazine, into clinical practice. We highlight how Gadamer's hermeneutics and Bakhtin's dialogism together offer insights into patient perspectives during this liminal period in the history of psychiatry.

INNOVATE Research: Impact of a workshop to develop researcher capacity to engage youth in research

Background

Engaging youth in research provides substantial benefits to research about youth‐related needs, concerns and interventions. However, researchers require training and capacity development to work in this manner.

Methods

A capacity‐building intervention, INNOVATE Research, was co‐designed with youth and adult researchers and delivered to researchers in three major academic research institutions across Canada. Fifty‐seven attendees participated in this research project evaluating youth engagement practices, attitudes, perceived barriers, and perceived capacity development needs before attending the intervention and six months later.

Results

The intervention attracted researchers across various career levels, roles and disciplines. Participants were highly satisfied with the workshop activities. Follow‐up assessments revealed significant increases in self‐efficacy six months after the workshop (P = .035). Among possible barriers to youth engagement, four barriers significantly declined at follow‐up. The barriers that decreased were largely related to practical knowledge about how to engage youth in research. Significantly more participants had integrated youth engagement into their teaching activities six months after the workshop compared to those who were doing so before the workshop (P = .007). A large proportion (71.9%) of participants expressed the need for a strengthened network of youth‐engaged researchers; other future capacity‐building approaches were also endorsed.

Conclusions

The INNOVATE Research project provided improvements in youth engagement attitudes and practices among researchers, while lifting barriers. Future capacity‐building work should continue to enhance the capacity of researchers to engage youth in research. Researchers notably pointed to the need to establish a network of youth‐engaged researchers to provide ongoing, sustainable gains in youth engagement.

Mental health interventions and supports during COVID- 19 and other medical pandemics: A rapid systematic review of the evidence

BACKGROUND

Novel coronavirus pneumonia (COVID-19) is a global reminder of the need to attend to the mental health of patients and health professionals who are suddenly facing this public health crisis. In the last two decades, a number of medical pandemics have yielded insights on the mental health impact of these events. Based on these experiences and given the magnitude of the current pandemic, rates of mental health disorders are expected to increase. Mental health interventions are urgently needed to minimize the psychological sequelae and provide timely care to affected individuals.

METHOD

We conducted a rapid systematic review of mental health interventions during a medical pandemic, using three electronic databases. Of the 2404 articles identified, 21 primary research studies are included in this review.

RESULT

We categorized the findings from the research studies using the following questions: What kind of emotional reactions do medical pandemics trigger? Who is most at risk of experiencing mental health sequelae? What works to treat mental health sequelae (psychosocial interventions and implementation of existing or new training programs)? What do we need to consider when designing and implementing mental health interventions (cultural adaptations and mental health workforce)? What still needs to be known?

CONCLUSION

Various mental health interventions have been developed for medical pandemics, and research on their effectiveness is growing. We offer recommendations for future research based on the evidence for providing mental health interventions and supports to those most in need.

Increasing participation in research with therapy dogs: A qualitative study at a large urban mental health and addiction hospital

The benefits of involving patients as partners in research across diverse medical and psychiatric settings are well established in the literature. However, researchers continue to struggle to access, engage and retain participants from hard-to-reach populations. The main objective of this study was to co-create pet therapy activities with patients admitted for serious and complex mental illness to a large urban mental health and addiction hospital. Informed by the principles of participatory action research methodology, we conducted focus group discussions with 38 inpatients in seven different clinical units. An experienced volunteer handler and a certified therapy dog helped facilitate our discussions. Participating researchers, recreational therapists, volunteer handlers and our participants all reported that the presence of a certified therapy dog at each of our discussions was integral to their success. Certified therapy dogs increased the motivation to participate in our study, helped to build rapport with participants and created connections in our discussions that enriched our data. To our knowledge our study is the first to demonstrate the value of using a therapy dog as a participatory research tool in a healthcare setting. The authors believe that therapy dogs are a low-tech intervention that could be used effectively to engage hard-to-reach populations in research about their treatment and care in a diverse range of medical settings. These findings support the creation of a pilot study to test the value of including therapy dogs in patient-centered research with vulnerable and hard-to-reach populations.