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Hassan S, Rac VE, Hodges BD, Leake P, Cobbing S, Gray CM, Bartley N, Etherington A, Abdulwasi M, Cheung HCK, Anderson M, Woods NN. Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol. BMJ Open 2023; 13:e072570. [PMID: 37612108 PMCID: PMC10450069 DOI: 10.1136/bmjopen-2023-072570] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023] Open
Abstract
INTRODUCTION Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work. METHODS AND ANALYSIS This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT. ETHICS AND DISSEMINATION Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes. PROSPERO REGISTRATION NUMBER CRD42022369208.
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Affiliation(s)
- Samah Hassan
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Valeria E Rac
- University Health Network, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto Health Economics and Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Diabetes Action Canada, CIHR SPOR Network, Toronto, Ontario, Canada
| | - Brian David Hodges
- University Health Network, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patti Leake
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Saul Cobbing
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Department of Physiotherapy, University of KwaZulu-Natal, Durban, South Africa
| | - Catharine Marie Gray
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Nicola Bartley
- University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Andrea Etherington
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Munira Abdulwasi
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Hei-Ching Kristy Cheung
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- Wilson Centre, University Health Network, Toronto, Ontario, Canada
| | - Melanie Anderson
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Nicole N Woods
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
- Wilson Centre, University Health Network, Toronto, Ontario, Canada
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Blanchette V, Patry J, Brousseau-Foley M, Todkar S, Libier S, Leclerc AM, Armstrong DG, Tremblay MC. Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens. Front Endocrinol (Lausanne) 2023; 14:1177020. [PMID: 37645408 PMCID: PMC10461566 DOI: 10.3389/fendo.2023.1177020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens. Methods A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR). Results Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA. Discussion This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare. Conclusion Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting. Systematic review registration Open Science Framework https://osf.io/j9pu7, identifier j9pu7.
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Affiliation(s)
- Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Jérôme Patry
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
| | - Magali Brousseau-Foley
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Faculty of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie et du Centre-du-Québec Affiliated with Université de Montréal, Trois-Rivières Family Medicine University Clinic, Trois-Rivières, QC, Canada
| | - Shweta Todkar
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Solène Libier
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Anne-Marie Leclerc
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Marie-Claude Tremblay
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
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Tan TW, Crocker RM, Palmer KNB, Gomez C, Armstrong DG, Marrero DG. A qualitative study of barriers to care-seeking for diabetic foot ulceration across multiple levels of the healthcare system. J Foot Ankle Res 2022; 15:56. [PMID: 35932076 PMCID: PMC9356391 DOI: 10.1186/s13047-022-00561-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The mechanisms for the observed disparities in diabetes-related amputation are poorly understood and could be related to access for diabetic foot ulceration (DFU) care. This qualitative study aimed to understand patients’ personal experiences navigating the healthcare system and the barriers they faced. Methods Fifteen semi-structured interviews were conducted over the phone between June 2020 to February 2021. Participants with DFUs were recruited from a tertiary referral center in Southern Arizona. The interviews were audio-recorded and analyzed according to the NIMHD Research Framework, focusing on the health care system domain. Results Among the 15 participants included in the study, the mean age was 52.4 years (66.7% male), 66.7% was from minority racial groups, and 73.3% was Medicaid or Indian Health Service beneficiaries. Participants frequently reported barriers at various levels of the healthcare system. On the individual level, themes that arose included health literacy and inadequate insurance coverage resulting in financial strain. On the interpersonal level, participants complained of fragmented relationships with providers and experienced challenges in making follow-up appointments. On the community level, participants reported struggles with medical equipment. On the societal level, participants also noted insufficient preventative foot care and education before DFU onset, and many respondents experienced initial misdiagnoses and delays in receiving care. Conclusions Patients with DFUs face significant barriers in accessing medical care at many levels in the healthcare system and beyond. These data highlight opportunities to address the effects of diabetic foot complications and the inequitable burden of inadequately managed diabetic foot care.
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Affiliation(s)
- Tze-Woei Tan
- Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, Tucson, USA. .,Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Ste 4300, Los Angeles, CA, 90033, USA.
| | - Rebecca M Crocker
- Center for Health Disparities Research (CHDR), University of Arizona Health Sciences, Tucson, AZ, USA
| | - Kelly N B Palmer
- Center for Health Disparities Research (CHDR), University of Arizona Health Sciences, Tucson, AZ, USA
| | - Chris Gomez
- University of Arizona College of Medicine, Tucson, AZ, USA
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, Tucson, USA.,Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Ste 4300, Los Angeles, CA, 90033, USA
| | - David G Marrero
- Center for Health Disparities Research (CHDR), University of Arizona Health Sciences, Tucson, AZ, USA
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