Leading Change from Within: Student-Led Reforms to Advance Anti-Racism within Medical Education

Racism, physician biases against Indigenous, Black, and racialized people, and the resultant poor health outcomes have been the subject of many institutional position statements and calls to action. Across Canada, undergraduate medical education programs have recognized the importance of addressing racism, but material changes to curriculum and learning environments to incorporate anti-racist lenses have yet to be actualized. To bridge a gap seen within the curriculum, the authors of this manuscript led the co-development, organization, and implementation of a student-led anti-racism initiative at the University of Calgary's Cumming School of Medicine. The initiative consisted of a class-wide anti-racism training session and a strategic review of student governance policies, including elections and decision-making processes through an anti-racist lens to advance equity within student learning environments. Anti-racism praxis was embedded within the co-creation of the anti-racism training by incorporating cultural safety and ethical engagement principles along with paid consultations with racialized students and faculty to identify pertinent topics and inform training priorities. Through this initiative, the authors offer an approach for the larger medical community to consider in their own local efforts to advance anti-racism advocacy and curricular change. This initiative highlighted the unique role of students in disrupting the status quo and modeling an anti-racist lens in their actions and self-governance.

Equity, diversity, and…exclusion? A national mixed methods study of "belonging" in Canadian undergraduate medical education

Equity, diversity, and inclusion remain a prominent focus in medical schools, yet the phenomenon of "belonging" has arguably been overlooked. Little is known regarding how belonging is experienced by medical students from groups that face systemic oppression and exclusion. We employed a sequential explanatory mixed methods design to explore how students from equity-deserving groups (EDGs) experience belonging during medical school, including those who are women, racialized, Indigenous, disabled, and 2SLGBTQIA+. First, we conducted a national cross-sectional survey of medical students (N = 480) measuring four constructs: belonging, imposter syndrome, burnout, and depression. Belonging scores were overall lower for students from EDGs and, more specifically, significantly lowest amongst racialized students. Structural equation models show that poor sense of belonging precedes imposter syndrome and further exacerbates burnout and depression. Next, we sampled and interviewed students (N = 16) from the EDG whose belonging scores were significantly lowest. Participants described the essence of belonging as being able to exist as one's "true self" while emphasizing feelings of acceptance, comfort, and safety as well as being valued and seen as an equal - yet described how routine experiences of "othering" inhibited a sense of belonging, often due to differences in social identity and structural privilege. Poor sense of belonging negatively affected learners' well-being and career trajectory. We illuminate the range of psychological and professional consequences associated with diminished sense of belonging and highlight the need to expand traditional notions of equity, diversity, and inclusion to consider structural barriers to belonging.

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

"How can we leave the traditions of our Baab Daada" socio-cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan

INTRODUCTION

Despite the growing attention to the relationship between menstruation and girls schooling, there remain many challenges to addressing the issue. Current interventions, which mostly focus on developing WASH infrastructure and sanitary hygiene management products, while necessary, may not be sufficient. This paper aimed to identify the root causes of poorly maintained WASH infrastructure, and understand the deeply embedded socio-cultural values around menstrual hygiene management that need to be addressed in order to provide truly supportive school environments for menstruating girls.

METHODS

Qualitative data were collected in rural and urban sites in three provinces in Pakistan using participatory activities with 312 girls aged 16-19 years, observations of 7 School WASH facilities, 42 key informant interviews and a document review.

RESULTS

Three key themes emerged from our data: (1) a poorly maintained, girls-unfriendly School WASH infrastructure was a result of gender-insensitive design, a cultural devaluation of toilet cleaners and inadequate governing practices; (2) the design of WASH facilities did not align with traditionally-determined modes of disposal of rag-pads, the most common used absorbents; (3) traditional menstrual management practices situate girls in an 'alternate space' characterised by withdrawal from many daily routines. These three socio-culturally determined practices interacted in a complex manner, often leading to interrupted class engagement and attendance.

CONCLUSIONS

To be truly effective, current menstrual hygiene management strategies need to address the root causes of poor WASH infrastructure and ensure facility design is sensitive to the gendered and deeply embedded local socio-cultural values and beliefs around menstrual hygiene management.