Access to Virtual Mental Healthcare and Support for Refugee and Immigrant Groups: A Scoping Review

Immigrant and refugee populations face multiple barriers to accessing mental health services. This scoping review applies the (Levesque et al. in Int J Equity Health 12:18, 2013) Patient-Centred Access to Healthcare model in exploring the potential of increased access through virtual mental healthcare services VMHS for these populations by examining the affordability, availability/accommodation, and appropriateness and acceptability of virtual mental health interventions and assessments. A search in CINAHL, MEDLINE, PSYCINFO, EMBASE, SOCINDEX and SCOPUS following (Arksey and O'Malley in Int J Soc Res Methodol 8:19-32, 2005) guidelines found 44 papers and 41 unique interventions/assessment tools. Accessibility depended on individual (e.g., literacy), program (e.g., computer required) and contextual/social factors (e.g., housing characteristics, internet bandwidth). Participation often required financial and technical support, raising important questions about the generalizability and sustainability of VMHS' accessibility for immigrant and refugee populations. Given limitations in current research (i.e., frequent exclusion of patients with severe mental health issues; limited examination of cultural dimensions; de facto exclusion of those without access to technology), further research appears warranted.

Characterizing Hospital Admissions after Proton Beam Therapy Using the National Inpatient Sample Database

PURPOSE/OBJECTIVE(S)

To characterize the diagnoses, comorbidities, and length of stay in patients who received proton beam therapy during their hospital stay as part of their cancer treatment regimen.

MATERIALS/METHODS

The National Inpatient Sample database was queried using ICD-10 codes to identify all hospitalizations with proton beam therapy between 2016 and 2018. Weighted frequencies for categorical variables and geometric mean with standard error for continuous variables were derived. Generalized linear models for clustered data in SAS v 9.4 (Cary, NC) were used to determine the association between length of stay with patient and hospital baseline characteristics.

RESULTS

We studied 511 patients, representing a weighted estimate of 2,555 patients from the National Inpatient Sample from 2016 to 2018 who received proton beam therapy during hospitalization. The mean age was 40 years (StdErr = 3.0). The estimated average length of stay was 7.7 days (StdErr = 0.4). The cohort was 53.6% White, 15.3% Black, 10.4% Hispanic, 7.0% Asian or Pacific Islander, and 0.2% Native American. The most frequent diagnoses at admission were encounter for antineoplastic chemotherapy (10.0%), secondary malignant neoplasm of brain (9.2%), secondary malignant neoplasm of bone (9.0%), encounter for antineoplastic radiation therapy (6.1%), and neoplasm-related pain (3.3%). Large- and medium-sized hospitals were associated with significantly longer lengths of stay than small-sized hospitals (p<0.0001 and p = 0.0186, respectively). Compared to private investor-owned (proprietary) hospitals, nonfederal government-owned (public) hospitals are associated with prolonged length of stay (p = 0.0033). Hospital region and patient age, race, sex, comorbidity, and income quartile were not associated with a longer length of stay.

CONCLUSION

Our findings demonstrate that hospital-level characteristics are more important than patient-level characteristics in predicting length of stay in patients undergoing proton beam therapy while hospitalized. Patients undergoing proton beam therapy while hospitalized at large- and medium-sized hospitals had longer lengths of stay than those at small-sized hospitals. Additionally, publicly owned hospitals were associated with prolonged length of stay compared to private hospitals. The underlying reason for this difference in length of stay is unclear but may suggest different management strategies, protocols, and discharge criteria for patients receiving proton beam therapy in larger and publicly-owned hospitals compared to smaller and privately-owned hospitals. Future investigations should explore the underlying causes for these discrepancies and identify potential strategies to shorten unnecessarily prolonged hospital stays in patients undergoing proton beam therapy.

How do South Asian seniors in a large Canadian city perceive long-term care?

OBJECTIVE

To understand how community-dwelling South Asian older adults understand and envision long-term care (LTC).

DESIGN

Descriptive qualitative study.

SETTING

The Region of Waterloo in Ontario.

PARTICIPANTS

Participants included 3 key informants (geriatrician, social worker, and medical translator, all South Asian), 1 family caregiver, and 15 community-dwelling South Asian adults aged 65 and older.

METHODS

In-depth interviews and focus groups were recorded, transcribed verbatim, and analyzed using a framework analysis approach.

MAIN FINDINGS

High-level themes included the emotional impacts of failure to provide culturally competent care, such as fear and isolation; a desire for a model of culturally competent care with an emphasis on food and language; and the need for LTC to be more integrated with the broader community and connected to families.

CONCLUSION

As the delivery of LTC is rethought in this country, there is the potential to deliver on the promise of culturally competent care for this growing population. These findings are among the first to communicate the LTC care needs of South Asian older adults in their own words.

Snapshot of family medicine around the world: Introducing the global family medicine website

OBJECTIVE

To develop an interactive, living map of family medicine training and practice; and to appreciate the role of family medicine within, and its effect on, health systems across the world.

COMPOSITION OF THE COMMITTEE

A subgroup of the College of Family Physicians of Canada's Besrour Centre for Global Family Medicine developed connections with selected international colleagues with expertise in international family medicine practice and teaching, health systems, and capacity building to map family medicine globally. In 2022, this group received support from the Foundation for Advancing Family Medicine's Trailblazers initiative to advance this work.

METHODS

In 2018 groups of Wilfrid Laurier University (Waterloo, Ont) students conducted broad searches of relevant articles about family medicine in different regions and countries around the world; they conducted focused interviews and then synthesized and verified information, developing a database of family medicine training and practice around the world. Outcome measures were age of family medicine training programs and duration and type of family medicine postgraduate training.

REPORT

To approach the question of how delivery of the family medicine model of primary care can affect health system performance, relevant data on family medicine were collated-the presence, nature, duration, and type of training and role within health care systems. The website https://www.globalfamilymedicine.org now has up-to-date country-level data on family medicine practice around the world. This publicly available information will allow such data to be correlated together with health system outputs and outcomes and will be updated as necessary through a wiki-type process. While Canada and the United States only have residency training, countries such as India have master's or fellowship programs, in part accounting for the complexity of the discipline. The maps also identify where family medicine training does not yet exist.

CONCLUSION

Mapping family medicine around the world will allow researchers, policy makers, and health care workers to have an accurate picture of family medicine and its impact using relevant, up-to-date information. The group's next aim is to develop data on parameters by which performance in various domains can be measured across settings and to display these in an accessible form.

Understanding racialised older adults' experiences of the Canadian healthcare system, and codesigning solutions: protocol for a qualitative study in nine languages

INTRODUCTION

Racialised immigrant older adults (RIOAs) in Canada have poorer self-rated health and are more likely to report chronic conditions, while they concurrently experience well-documented challenges in navigating and accessing the healthcare system. There is strong evidence that patient and caregiver engagement in their healthcare leads to improved management of chronic disease and better health outcomes. International research suggests that engagement has the potential to reduce health disparities and improve quality of care. We aim to (1) describe what role(s) RIOAs are/are not taking in their own healthcare, from the perspectives of participant groups (RIOAs, caregivers and healthcare providers (HCPs)); and (2) develop a codesign process with these participants, creating linguistically aligned and culturally aligned tools, resources or solutions to support patient engagement with RIOAs.

METHODS AND ANALYSIS

Using a cross-cultural participatory action research approach, our work will consist of three phases: phase 1, strengthen existing partnerships with RIOAs and appropriate agencies and cultural associations; phase 2, on receipt of informed consent, in-depth interviews with RIOAs and caregivers (n=~45) and HCPs (n=~10), professionally interpreted as needed. Phase 3, work with participants, in multiple interpreted sessions, to codesign culturally sensitive and linguistically sensitive/aligned patient engagement tools. We will conduct this research in the Waterloo-Wellington region of Ontario, in Arabic, Bangla, Cantonese, Hindi, Mandarin, Punjabi, Tamil and Urdu, plus English. Data will be transcribed, cleaned and entered into NVivo V.12, the software that will support team-based analysis. Analysis will include coding, theming and interpreting the data, and, preparing narrative descriptions that summarise each language group and each participant group (older adults, caregivers and HCPs), and illustrate themes.

ETHICS AND DISSEMINATION

Ethics clearance was obtained through the University of Waterloo Office of Research Ethics (ORE #43297). Findings will be disseminated through peer-reviewed publications, presentations and translated summary reports for our partners and participants.

Assessing Virtual Mental Health Access for Refugees during the COVID-19 Pandemic Using the Levesque Client-Centered Framework: What Have We Learned and How Will We Plan for the Future?

During the COVID-19 pandemic, mental health services rapidly transitioned to virtual care. Although such services can improve access for underserved populations, they may also present unique challenges, especially for refugee newcomers. This study examined the multidimensional nature of access to virtual mental health (VMH) care for refugee newcomers during the COVID-19 pandemic, using Levesque et al.'s Client-Centered Framework for Assessing Access to Health Care. One hundred and eight structured and semi structured interviews were conducted in four Canadian provinces (8 community leaders, 37 newcomer clients, 63 mental health or service providers or managers). Deductive qualitative analysis, based on the Client-Centered Framework, identified several overarching themes: challenges due to the cost and complexity of using technology; comfort for VMH outside clinical settings; sustainability post-COVID-19; and communication and the therapeutic alliance. Mental health organizations, community organizations, and service providers can improve access to (virtual) mental health care for refugee newcomers by addressing cultural and structural barriers, tailoring services, and offering choice and flexibility to newcomers.

The role of educating health-care personnel in prevention, diagnosis, or treatment of COVID-19: A narrative mini review

Front-line clinicians and health-care workers need to be educated to provide care in critical situations such as large-scale catastrophes and pandemics. This narrative review is focused on investigating educational strategies in confrontation with coronavirus disease 2019 (COVID-19) pandemic. We conducted a literature search in December 2020 through LitCovid, PubMed, ERIC, and Cochrane Library in order to retrieve relevant studies regarding the role of education in prevention, diagnosis, and treatment of COVID-19. There were 12 reviewed studies related to this specific subject. The articles selected for this study demonstrated that education and training had a positive impact on the knowledge and attitude of the participants and also the educational interventions, whether they were simulation-based or other formats of training, would be deemed crucial for enhancing participants' level of perceptions and confidence. Therefore, it is highly recommended that public health policymakers consider this important issue.

Caring for refugees and newcomers in the post-COVID-19 era: Evidence review and guidance for FPs and health providers

OBJECTIVE

To guide clinicians working in a range of primary care clinical settings on how to provide effective care and support for refugees and newcomers during and after the coronavirus disease 2019 (COVID-19) pandemic.

SOURCES OF INFORMATION

The described approach integrates recommendations from evidence-based clinical guidelines on refugee health and COVID-19, practical lessons learned from Canadian Refugee Health Network clinicians working in a variety of primary care settings, and contributions from persons with lived experience of forced migration.

MAIN MESSAGE

The COVID-19 pandemic has amplified health and social inequities for refugees, asylum seekers, undocumented migrants, transient migrant workers, and other newcomers. Refugees and newcomers face front-line exposure risks, difficulties accessing COVID-19 testing, exacerbation of mental health concerns, and challenges accessing health care, social, and settlement supports. Existing guidelines for clinical care of refugees are useful, but creative case-by-case strategies must be employed to overcome additional barriers in the context of COVID-19 and new care environments, such as the need for virtual interpretation and digital literacy skills. Clinicians can address inequities and advocate for improved services in collaboration with community partners.

CONCLUSION

The COVID-19 pandemic is amplifying structural inequities. Refugees and newcomers require and deserve effective health care and support during this challenging time. This article outlines practical approaches and advocacy priorities for providing care in the COVID-19 context.

Soigner les réfugiés et les nouveaux arrivants à l'ère post-COVID-19: Revue des données probantes et conseils pour les MF et les professionnels de la santé

OBJECTIF

Guider les cliniciens qui travaillent dans divers milieux cliniques de soins primaires quant aux façons de prodiguer des soins et du soutien efficaces aux réfugiés et aux nouveaux arrivants, durant et après la pandémie de la maladie à coronavirus 2019 (COVID-19).

SOURCES D'INFORMATION

L'approche décrite intègre les recommandations tirées de guides de pratique clinique fondés sur des données probantes portant sur la santé des réfugiés et la COVID-19, de leçons concrètes apprises de cliniciens du Réseau canadien sur la santé des réfugiés (Canadian Refugee Health Network) qui travaillent dans divers milieux de soins primaires, ainsi que de contributions de personnes ayant vécu l'expérience d'une migration forcée.

MESSAGE PRINCIPAL

La pandémie de la COVID-19 a amplifié les iniquités sociales et de santé pour les réfugiés, les demandeurs d'asile, les migrants sans papiers, les travailleurs transitoires de l'étranger et d'autres nouveaux arrivants. Les réfugiés et les nouveaux arrivants sont confrontés à des risques d'exposition en première ligne, à des problèmes d'accès aux tests de dépistage de la COVID-19, à l'exacerbation des préoccupations liées à la santé mentale, et aux difficultés d'accéder aux soins de santé et aux services sociaux et d'établissement. Les lignes directrices existantes sur les soins cliniques aux réfugiés sont utiles, mais des stratégies créatives au cas par cas doivent être utilisées pour surmonter les obstacles additionnels dans le contexte de la COVID-19 et des nouveaux environnements de soins, comme la nécessité d'une traduction simultanée virtuelle et d'habiletés en littératie numérique. Les cliniciens peuvent lutter contre les iniquités et plaider en faveur de meilleurs services en collaboration avec des partenaires communautaires.

CONCLUSION

La pandémie de la COVID-19 amplifie les iniquités structurelles. Les réfugiés et les nouveaux arrivants nécessitent et méritent des soins de santé et du soutien efficaces durant ces moments éprouvants. Cet article présente des approches pratiques et les priorités en matière de défense des droits pour offrir des soins dans le contexte de la COVID-19.

Natriuretic effect of 2 weeks of dapagliflozin treatment in patients with type 2 diabetes and preserved kidney function: results of the DAPASALT trial

Background

Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk for heart failure hospitalization, potentially by inducing sodium excretion, osmotic diuresis and plasma volume contraction, leading to more favorable systemic hemodynamic function. However, this hypothesis has never been formally investigated as no studies have assessed cumulative sodium excretion with SGLT2 inhibition during standardized sodium intake.

Methods

We conducted a mechanistic open label study in patients with type 2 diabetes mellitus (T2D) with preserved kidney function, who were receiving a standardized sodium intake (150 mmol/day) to evaluate the acute effects (average day 2–4), effects at steady state (average day 12–14) and effects during three days wash-out of dapagliflozin on sodium balance and blood pressure. Primary outcome measure was 24-hr sodium excretion during the acute phase. Secondary outcomes included 24-hr glucose excretion and 24-hr blood pressure at each time period and sodium excretion at steady state and during follow-up.

Results

Seventeen patients with T2D were enrolled (64.7% male, mean ± SD age 64.24±7.33 years, weight 99.54±17.36 kg, eGFR 94.53±10.10 mL/min/1.73m2, HbA1c 7.20±0.63%). Average sodium excretion at baseline was 147±32 mmol/24 hr, which did not significantly change during treatment (Change at day 2–4 [95% CI]: −5.21 [19.54, 9.12] mmol/24 hr; Change at Day 12–14 [95% CI]: 3.69 [−24.82, 32.20] mmol/24 hr). However, sodium excretion was reduced following washout compared to end of treatment (Change at Day 15–17 [95% CI]: −16.72 [−34.11, 0.66] mmol/24 hr). Glucose excretion was significantly increased throughout the study. Systolic blood pressure was 127.0±10.3 mmHg at baseline and significantly reduced at Day 3 [95% CI]: −5.27 [−8.55, −1.99] mmHg and Day 14 [95% CI]: −7.10 [−10.04, −4.16] mmHg compared to baseline and remained lower following washout.

Conclusions

This study shows that, during a standardized sodium intake, the SGLT-2 inhibitor dapagliflozin acutely reduces blood pressure without altering sodium excretion, indicating possible direct vascular effects independent of sodium balance.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Astra Zeneca

Multi-dimensional effects of the COVID-19 pandemic considering the WHO's ecological approach

At the end of 2019, a new virus named SARS-CoV-2 emerged in China, provoking coronavirus disease 2019 or COVID-19. Self-isolation and quarantine as key strategies to overcoming the spread of the disease have had major, micro, and macroscopic consequences. This commentary, therefore, seeks to review critical factors impacting the COVID-19 pandemic through the spectrum of levels, categorising effects in the WHO's ecological framework (individual, relational, community, and societal aspects). We further describe the management of the crisis at each level to help guide health personnel, communities, governments, and international policymakers in understanding how their actions fit into a larger picture as they seek to manage the crisis.

Determinants of Implementation of a Clinical Practice Guideline for Homeless Health

Clinical practice guidelines can improve the clinical and social care for marginalized populations, thereby improving health equity. The aim of this study is to identify determinants of guideline implementation from the perspective of patients and practitioner stakeholders for a homeless health guideline. We completed a mixed-method study to identify determinants of equitable implementation of homeless health guidelines, focusing on the Grading of Recommendations Assessment, Development and Evaluation Feasibility, Acceptability, Cost, and Equity Survey (GRADE-FACE) health equity implementation outcomes. The study included a survey and framework analysis. Eighty-eight stakeholders, including practitioners and 16 persons with lived experience of homelessness, participated in the study. Most participants favourably rated the drafted recommendations' priority status, feasibility, acceptability, cost, equity impact, and intent-to-implement. Qualitative analysis uncovered stakeholder concerns and perceptions regarding "fragmented services". Practitioners were reluctant to care for persons with lived experience of homelessness, suggesting that associated social stigma serves as a barrier for this population to access healthcare. Participants called for improved "training of practitioners" to increase knowledge of patient needs and preferences. We identified several knowledge translation strategies that may improve implementation of guidelines for marginalized populations. Such strategies should be considered by other guideline development groups who aim to improve health outcomes in the context of limited and fragmented resources, stigma, and need for advocacy.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

BACKGROUND

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

METHODS AND FINDINGS

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.

CONCLUSIONS

Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Peace through Health and Medical Education: First Steps in Inclination of Healthcare Workers Toward Conflict-Preventive Activities

BACKGROUND

The number of deaths and disabilities due to all types of violence has increased; violence and especially war heavily affect public and individual health and all sectors, including the health sector, are responsible for making attempts to take part in mitigation of war effects. However, "peace through health" has not been so far included globally in the curriculum of basic medical schools. The study aims to prepare data on responsibilities that could be devolved to health sector, and the importance and role of education for those health workers who are willing to participate in the peace field.

METHODS

A systematic search in Web of Science, PubMed, Scopus and ERIC was conducted looking for relevant documents following combination of the key terms: peace, health and education.

RESULTS

Health professionals consider war as a serious contagious disease that needs to be prevented like any other diseases. Prevention maneuvers at the primordial, primary, secondary and tertiary stages are important tasks that can be carried out by health professionals; there is an increasing demand for establishment of some courses; the roles and the manner of performing these tasks are not part of medical curriculum and for better execution of these roles, peace through health courses should be developed and then integrated to the current curriculum of health-related universities.

CONCLUSION

The work of developing peace through health courses has been started before and it will continue until it completely becomes an accepted global course.

Educating Health Science Students About Peace through Health Topic; A Panel Discussion

This report describes an experience of the first international health for peace conference held in November 2018 in Shiraz University of Medical Sciences. This paper discusses the panel on peace education in medical and paramedical schools and the way for the future.

Global health training in Canadian family medicine residency programmes

Objective

Canadian family medicine (FM) residency programmes are responding to the growing demand to provide global health (GH) education to their trainees; herein, we describe the various GH activities (GHAs) offered within Canadian FM programmes.

Design

A bilingual online survey was sent out to all 17 Canadian FM program directors (PDs) and/or an appointed GH representative.

Setting

Online survey via Qualtrics

Participants

All 17 Canadian FM PDs and/or an appointed GH representative.

Results

The response rate was 100% and represented 3250 first-year and second-year FM residents across English and French Canada. All schools stated that they participate in some form of GHAs. There was variation in the level of organisation, participation and types of GHAs offered. Overall, most GHAs are optional, and there is a large amount of variation in terms of resident participation. Approximately one third of programmes receive dedicated funding for their GHAs, and two thirds wish to increase the scope/variety of GHAs.

Conclusion

These results suggest nationwide interest in developing a workforce trained in GH, but show great discrepancies in training, implementation and education.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Prevalence of Nutritional Deficiencies Among Populations of Newly Arriving Government Assisted Refugee Children to Kitchener/Waterloo, Ontario, Canada

This study examined the variation among ethnic populations in prevalence of anemia, vitamin D and B12 deficiencies among refugee children. A retrospective chart review of 388 government assisted refugee children ≤ 16 years of age, seen at the Refugee Health Clinic in Kitchener, Canada from January 2009 to December 2014 was conducted. Vitamin D levels were only collected until December 1st 2010 (116 children). 15.7% were anemic (25% < 5 years, 8.7% 5-11 years, and 18.3% 12-16 years old) with Somali children having the lowest hemoglobin levels compared to those from Iraq, Afghanistan and Myanmar. 53.5% were vitamin D deficient (25(OH)D < 50 nmol/L), seen most commonly in Iraqis and Afghans. 11.2% had vitamin B12 levels < 150 pmol/L. Providers' knowledge of prevalence of nutritional deficiencies related to region of origin, can guide appropriate screening and treatment options to promote longer term cognitive, physical and developmental health.

Establishing a mental health system in the Occupied Palestinian Territories

What is ‘mental health’ during the societal crisis and upheaval occasioned by war? Perhaps the primary psychological effect of war on victims generally is through their witnessing the destruction of a social world embodying their history, identity, values and roles of everyday life. Such suffering has largely to be resolved collectively, in this same social world, albeit one which has been intentionally weakened. Thus, as the World Health Organization and other authorities confirm, the major thrust of humanitarian interventions must be towards the depleted social fabric and its institutions, for herein lie the sources of resilience and capacity for recovery for all (Kawachi & Berkman, 2000). Beyond that, history has shown that social or political reform is the best medicine, and for victims of oppressive violence this means acknowledgement and justice (Summerfield, 2002).

Developing family practice to respond to global health challenges: The Besrour Papers: a series on the state of family medicine in the world

OBJECTIVE

To assess family medicine's role in developing strong, coordinated, community-based, integrated health care systems in low-resource settings globally.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with selected international colleagues with expertise in international family medicine practice, health systems and capacity building, and teaching to map family medicine globally and give a bird's eye view of family medicine internationally.

METHODS

Following a background literature review, the authors collectively reflected on their substantial international experience to attempt to describe best practices for various contexts.

REPORT

With the failure of vertical, disease-oriented models to provide sustained improvements in health outcomes, the need to develop integrated primary care involving the most appropriate health professionals for differing contexts is becoming apparent worldwide. Health system planning is required to develop policies on health professional training to achieve this. Advocating and offering appropriate incentives for, and coordination of, local opportunities within the health system also becomes paramount. The adaptability and generalist nature of family medicine allows it to respond to the unique needs of a given population. Family physicians with adequate financial and physical resources can function most effectively as members of interdisciplinary teams, thus providing valuable, comprehensive health services in any area of the world.

The Palestinian-Israeli conflict: a disease for which root causes must be acknowledged and treated

Fourth of June 2017 marks a half century of the Six Day War, three decades post the first Intifada, seven decades post the Palestinian Nakba (catastrophe), the 70th anniversary of Israeli Independence, and one century post the Balfour Declaration. Both Palestinians and Israelis remain occupied. Five million Palestinians remain sick with hopelessness and despair rendered by years of subjugation. Israelis are stuck, occupied by their historical narrative and transcendental fears. Over two decades have passed since the Oslo accords, which both Israelis and Palestinians hoped might be a historic turning point. This was supposed to put an end to the chronic disease of protracted conflict, allowing Palestinians to enjoy freedom in an independent state side by side to Israel and Israelis to live within peaceful, secure borders with the respect of the international community. Palestinians were ready to give up 78% of their land. Free Palestine would be in the remaining 22%, with East Jerusalem as the capital and a satisfactory solution to the Right of Return. The patient's diagnosis and seeking therapy has been delayed by greed, ignorance, ideology, violence and fear. Accurate diagnosis is needed to successfully heal the wounds and cure this chronic disease.

Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world

OBJECTIVE

To demonstrate how family medicine has been recognized and integrated into primary health care systems in contrasting contexts around the world and to provide an overview of how family physicians are trained and certified.

COMPOSITION OF THE COMMITTEE

Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences.

METHODS

An initial search was conducted in PubMed using a family medicine hedge of MeSH terms, text words, and family medicine journals, combined with text words and terms representing low- and middle-income countries and the concept of family medicine training programs. A second search was completed using only family medicine terms in the CAB Direct and World Bank databases. Subsequent PubMed searches were conducted to identify articles about specific conditions or services based on suggestions from the authors of the articles selected from the second search. Additional articles were identified through reference lists of key articles and through Google searches. We then attempted to verify and augment the information through colleagues and partners.

REPORT

The scope of family medicine and the nature of family medicine training vary considerably worldwide. Challenges include limited capacity, incomplete understanding of roles, and variability of standards and recognition. Opportunities for advancement might include technology, collaboration, changes in pedagogy, flexible training methods, and system-wide support.

The role of public health in the prevention of war: rationale and competencies

In 2009 the American Public Health Association approved the policy statement, "The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War." Despite the known health effects of war, the development of competencies to prevent war has received little attention. Public health's ethical principles of practice prioritize addressing the fundamental causes of disease and adverse health outcomes. A working group grew out of the American Public Health Association's Peace Caucus to build upon the 2009 policy by proposing competencies to understand and prevent the political, economic, social, and cultural determinants of war, particularly militarism. The working group recommends that schools of public health and public health organizations incorporate these competencies into professional preparation programs, research, and advocacy.

General Practitioners' responses to global climate change - lessons from clinical experience and the clinical method

BACKGROUND

Climate change is a global public health problem that will require complex thinking if meaningful and effective solutions are to be achieved. In this conceptual paper we argue that GPs have much to bring to the issue of climate change from their wide-ranging clinical experience and from the principles underpinning their clinical methods. This experience and thinking calls forth particular contributions GPs can and should make to debate and action.

DISCUSSION

We contend that the privileged experience and GP way of thinking can make valuable contributions when applied to climate change solutions. These include a lifetime of experience, reflection and epistemological application to first doing no harm, managing uncertainty, the ability to make necessary decisions while possessing incomplete information, an appreciation of complex adaptive systems, maintenance of homeostasis, vigilance for unintended consequences, and an appreciation of the importance of transdisciplinarity and interprofessionalism.

SUMMARY

General practitioners have a long history of public health advocacy and in the case of climate change may bring a way of approaching complex human problems that could be applied to the dilemmas of climate change.

Developing a curriculum framework for global health in family medicine: emerging principles, competencies, and educational approaches

BACKGROUND

Recognizing the growing demand from medical students and residents for more comprehensive global health training, and the paucity of explicit curricula on such issues, global health and curriculum experts from the six Ontario Family Medicine Residency Programs worked together to design a framework for global health curricula in family medicine training programs.

METHODS

A working group comprised of global health educators from Ontario's six medical schools conducted a scoping review of global health curricula, competencies, and pedagogical approaches. The working group then hosted a full day meeting, inviting experts in education, clinical care, family medicine and public health, and developed a consensus process and draft framework to design global health curricula. Through a series of weekly teleconferences over the next six months, the framework was revised and used to guide the identification of enabling global health competencies (behaviours, skills and attitudes) for Canadian Family Medicine training.

RESULTS

The main outcome was an evidence-informed interactive framework http://globalhealth.ennovativesolution.com/ to provide a shared foundation to guide the design, delivery and evaluation of global health education programs for Ontario's family medicine residency programs. The curriculum framework blended a definition and mission for global health training, core values and principles, global health competencies aligning with the Canadian Medical Education Directives for Specialists (CanMEDS) competencies, and key learning approaches. The framework guided the development of subsequent enabling competencies.

CONCLUSIONS

The shared curriculum framework can support the design, delivery and evaluation of global health curriculum in Canada and around the world, lay the foundation for research and development, provide consistency across programmes, and support the creation of learning and evaluation tools to align with the framework. The process used to develop this framework can be applied to other aspects of residency curriculum development.