National primary care responses to COVID-19: a rapid review of the literature

OBJECTIVE

The aim of this review, conducted in April 2020, is to examine available national primary care guidelines for COVID-19 and to explore the ways in which these guidelines support primary care facilities in responding to the demands of the COVID-19 pandemic.

DESIGN

Rapid review and narrative synthesis.

DATA SOURCES

PubMed, Embase and Google, as well as the websites of relevant national health departments, were searched from 1 January 2020 to 24 April 2020.

ELIGIBILITY CRITERIA

Documents included must be issued by a national health authority, must be specific to COVID-19 care, directed at healthcare workers or managers, and must refer to the role of primary care in the COVID-19 response.

RESULTS

We identified 17 documents from 14 countries. An adapted framework on primary care challenges and responses to pandemic influenza framed our analysis. Guidelines generally reported on COVID-19 service delivery and mostly made specific recommendations for ensuring continued delivery of essential primary care services through telehealth or other virtual care modalities. Few offered guidance to support surveillance as a public health function. All offered guidance on implementing outbreak control measures, largely through flexible and coordinated organisational models with partners from various sectors. There was a lack of guidance to support supply chain management and practice resilience in primary care, and lack of personal protective equipment represents a serious threat to the provision of quality care during the pandemic.

CONCLUSIONS

Current national primary care guidelines for COVID-19 provide guidance on infection control and minimising the risk of spread in primary care practices, while supporting the use of new technology and coordinated partnerships. However, to ensure primary care practice resilience and quality of care are upheld, guidelines must offer recommendations on supply chain management and operational continuity, supported by adequate resources.

Contrasting current challenges from the Brazilian and Canadian national health systems: The Besrour Papers: a series on the state of family medicine in Canada and Brazil

OBJECTIVE

To compare the national health systems of Canada and Brazil and how both countries have addressed similar challenges in their primary care sectors.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades.

METHODS

Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil.

REPORT

The Brazilian and Canadian primary care systems are faced with similar challenges, including geography, demographic changes, population health inequities, and gaps in universal access to comprehensive primary care services. Although the approaches to addressing these challenges are different in both settings, they highlight the central importance of family physicians in both systems. Both countries continue to face considerable challenges in the context of mental health services in primary care. It remains important for Canada to draw lessons from the primary care systems and reforms of other countries, such as Brazil.

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.

Framework for ethical international academic partnerships in family medicine: The Besrour Papers: a series on the state of family medicine in Canada and Brazil

OBJECTIVE

To develop an ethical framework for collaboration in international academic partnerships in family medicine.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada including family medicine and bioethics experts began to collaborate in 2014 to undertake the development of an ethical framework and tools for the establishment of ethically sound international academic partnerships.

METHODS

Following 2 consultative workshops and a wider consultation process with the Besrour Centre global community, the authors developed an ethical framework and tools for approval by the Besrour Centre leadership in November 2017.

REPORT

Partnerships are essential to family practice and to the field of international development. The flawed nature of many North-South research partnerships underlines the importance of and need for delineating core principles for ethically sound partnerships, of which 10 have been identified in this process: accountability, cost and efficiencies, excellence, equity, humility, justice, leadership, reciprocity, respect for self-determination, and transparency. Based on these principles, a decision-making framework was created to translate these values into actions and to promote a cohesive and transparent structure for discussions. Fostering fairness, transparency, and consistency in decision making reduces the potential for inequity in a partnership, leading to lasting relationships that endure beyond the scope of a partnership agreement.

Primary care financing: a systematic assessment of research priorities in low- and middle-income countries

INTRODUCTION

Financing of primary healthcare (PHC) is the key to the provision of equitable universal care. We aimed to identify and prioritise the perceived needs of PHC practitioners and researchers for new research in low- and middle-income countries (LMIC) about financing of PHC.

METHODS

Three-round expert panel consultation using web-based surveys of LMIC PHC practitioners, academics and policy-makers sampled from global networks. Iterative literature review conducted in parallel. First round (Pre-Delphi survey) elicited possible research questions to address knowledge gaps about financing. Responses were independently coded, collapsed and synthesised to two lists of questions. Round 2 (Delphi Round 1) invited panellists to rate importance of each question. In Round 3 (Delphi Round 2), panellists ranked questions in order of importance.

RESULTS

A diverse range of PHC practitioners, academics and policy-makers in LMIC representing all global regions identified 479 knowledge gaps as potentially critical to improving PHC financing. Round 2 provided 31 synthesised questions on financing for rating. The top 16 were ranked in Round 3e to produce four prioritised research questions.

CONCLUSIONS

This novel exercise created an expansive and prioritised list of critical knowledge gaps in PHC financing research questions. This offers valuable guidance to global supporters of primary care evaluation and implementation, including research funders and academics seeking research priorities. The source and context specificity of this research, informed by LMIC practitioners and academics on a global and local basis, should increase the likelihood of local relevance and eventual success in implementing the findings.

Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach

Introduction

Since the Alma-Ata Declaration 40 years ago, primary healthcare (PHC) has made great advances, but there is insufficient research on models of care and outcomes—particularly for low-income and middle-income countries (LMICs). Systematic efforts to identify these gaps and develop evidence-based strategies for improvement in LMICs has been lacking. We report on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.

Methods

Three-round modified Delphi using web-based surveys. PHC practitioners and academics and policy-makers from LMICs sampled from global networks. First round (pre-Delphi survey) collated possible research questions to address knowledge gaps about organisation. Responses were independently coded, collapsed and synthesised. Round 2 (Delphi round 1) invited panellists to rate importance of each question. In round 3 (Delphi round 2), panellists ranked questions into final order of importance. Literature review conducted on 36 questions and gap map generated.

Results

Diverse range of practitioners and academics in LMICs from all global regions generated 744 questions for PHC organisation. In round 2, 36 synthesised questions on organisation were rated. In round 3, the top 16 questions were ranked to yield four prioritised questions in each area. Literature reviews confirmed gap in evidence on prioritised questions in LMICs.

Conclusion

In line with the 2018 Astana Declaration, this mixed-methods study has produced a unique list of essential gaps in our knowledge of how best to organise PHC, priority-ordered by LMIC expert informants capable of shaping their mitigation. Research teams in LMIC have developed implementation plans to answer the top four ranked research questions.

Calling non-governmental organisations to strengthen primary health care: Lessons following Alma-Ata

Background

The Alma-Ata Declaration’s commitment to primary health care (PHC) reaches its 40th anniversary in 2018. Over the last 40 years, the number of non-governmental organisations (NGOs) working in low-income countries (LICs) has rapidly multiplied, and over time, NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems in LICs.

Aim

The authors aim to demonstrate that at the 40th anniversary of the Alma-Ata Declaration’s commitment to PHC, NGOs are particularly poised to strengthen PHC in LICs.

Methods

In this letter, the authors reflect on how NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems based on their experience working with NGOs in LICs.

Results

NGOs are poised to strengthen PHC in LICs in four distinct ways: assisting with local human resources development, strengthening local information systems, enabling community-based health services and testing innovative service delivery projects.

Conclusions

The authors call for NGOs to commit their expertise and resources to long-term strengthening of PHC in LICs and to critically examine the factors that prevent or assist them in this goal. As the principles of Alma-Ata are renewed, NGOs should be responsibly engaged in strengthening the declaration’s goal of ‘health for all’.

Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices

BACKGROUND AND OBJECTIVES

There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali.

METHODS

Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study.

RESULTS

Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships.

CONCLUSIONS

A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

Primary Care Research Priorities in Low-and Middle-Income Countries

PURPOSE

To identify and prioritize the needs for new research evidence for primary health care (PHC) in low-and middle-income countries (LMICs) about organization, models of care, and financing of PHC.

METHODS

Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre-Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking.

RESULTS

One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC.

CONCLUSIONS

This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings.

An interprofessional urban health elective focused on the social determinants of health

BACKGROUND

More than half of the world's population now lives in cities. Health professionals should understand how social factors and processes in urban spaces determine individual and population health. We report on lessons from an interprofessional urban health elective developed to focus on the social determinants of health (SDOH).

METHODS

An interprofessional committee developed an urban health elective based in downtown Toronto. Course objectives included promoting collaboration to address SDOH, identifying barriers to care, accessing community-based resources, and learning to advocate at individual- and community-levels.

RESULTS

Seventeen students from eight disciplines participated during the 2011-2012 academic year. Sessions were co-facilitated with community partners and community members identified as experts based on their personal experience. Topics included housing, income and food security, Indigenous communities in urban spaces, and advocacy. Students collaborated on self-directed projects, which ranged from literature reviews to policy briefs for government. Students particularly valued learning about community agencies and hearing from people with lived experience.

CONCLUSION

The specific health challenges faced in urban settings can benefit from an interprofessional approach informed by the experiences and needs of patient communities. This elective was innovative in engaging students in interprofessional learning on how health and social agencies collaborate to tackle social determinants in urban spaces.

Identifying top 10 primary care research priorities from international stakeholders using a modified Delphi method

BACKGROUND

High quality primary care is fundamental to achieving health for all. Research priority setting is a key facilitator of improving how research activity responds to concrete needs. There has never before been an attempt to identify international primary care research priorities, in order to guide resource allocation and to enhance global primary care. This study aimed to identify a list of top 10 primary care research priorities, as identified by members of the public, health professionals working in primary care, researchers, and policymakers.

METHODS

We adapted the James Lind Alliance Priority Setting Partnership process, to conduct multiple rounds of stakeholder recruitment and prioritization. The study included an online survey conducted in three languages, followed by an in-person priority setting exercise involving primary care stakeholders from 13 countries.

FINDINGS

Participants identified a list of top 10 international primary care research priorities. These were focused on diverse topics such as enhancing use of information and communication technology, and improving integration of indigenous communities' knowledge in the design of primary care services. The main limitations of the study related to challenges in engaging an adequate diversity and number of appropriate stakeholders, particularly members of the public, in aggregating the diverse set of responses into coherent categories representative of the participants' perspectives and in adequately representing the diversity of submitted responses while ensuring research priorities on the final list are sufficiently actionable to guide resource allocation.

CONCLUSIONS

The top 10 identified research priorities have the potential to guide research resource allocation, supporting funding agencies and initiatives to promote global primary care research and practice.

Temperament Is Associated With Outdoor Free Play in Young Children: A TARGet Kids! Study

OBJECTIVE

Outdoor free play is important for preschoolers' physical activity, health, and development. Certain temperamental characteristics are associated with obesity, nutrition, and sedentary behaviors in preschoolers, but the relationship between temperament and outdoor play has not been examined. This study examined whether there is an association between temperament and outdoor play in young children.

METHODS

Healthy children aged 1 to 5 years recruited to The Applied Research Group for Kids (TARGet Kids!), a community-based primary care research network, from July 2008 to September 2013 were included. Parent-reported child temperament was assessed using the Childhood Behavior Questionnaire. Outdoor free play and other potential confounding variables were assessed through validated questionnaires. Multivariable linear regression was used to determine the association between temperament and outdoor play, adjusted for potential confounders.

RESULTS

There were 3393 children with data on outdoor play. The association between negative affectivity and outdoor play was moderated by sex; in boys, for every 1-point increase in negative affectivity score, mean outdoor play decreased by 4.7 minutes per day. There was no significant association in girls. Surgency was associated with outdoor play; for every 1-point increase in surgency/extraversion, outdoor play increased by 4.6 minutes per day.

CONCLUSIONS

Young children's temperamental characteristics were associated with their participation in outdoor free play. Consideration of temperament could enhance interventions and strategies to increase outdoor play in young children. Longitudinal studies are needed to elucidate the relationship between children's early temperament and physical activity.

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.

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.

A Cell-Surface Membrane Protein Signature for Glioblastoma

We present a systems strategy that facilitated the development of a molecular signature for glioblastoma (GBM), composed of 33 cell-surface transmembrane proteins. This molecular signature, GBMSig, was developed through the integration of cell-surface proteomics and transcriptomics from patient tumors in the REMBRANDT (n = 228) and TCGA datasets (n = 547) and can separate GBM patients from control individuals with a Matthew's correlation coefficient value of 0.87 in a lock-down test. Functionally, 17/33 GBMSig proteins are associated with transforming growth factor β signaling pathways, including CD47, SLC16A1, HMOX1, and MRC2. Knockdown of these genes impaired GBM invasion, reflecting their role in disease-perturbed changes in GBM. ELISA assays for a subset of GBMSig (CD44, VCAM1, HMOX1, and BIGH3) on 84 plasma specimens from multiple clinical sites revealed a high degree of separation of GBM patients from healthy control individuals (area under the curve is 0.98 in receiver operating characteristic). In addition, a classifier based on these four proteins differentiated the blood of pre- and post-tumor resections, demonstrating potential clinical value as biomarkers.

Evolution of Family Medicine in Kenya (1990s to date): a case study

Background: Successful Family Medicine practices and academic programmes are found in western countries, Australia, Singapore, Cuba and among other non-western countries. Documenting the enablers and challenges of different contexts would, it is hoped, inform current and future process of developing academic and practice programmes in Family Medicine in countries where the discipline is starting. Methods: A qualitative study was undertaken that conducted a focused literature review and in-depth interviews of key informants on the early development of the Family Medicine in Kenya. All interviews were audio recorded. Pattern matching, explanation building, time-series analysis and logic models were used in analysis. Results: Representatives of Kenyan and foreign organisations worked well as a team to write and implement the first curriculum of Family Medicine. The challenges include lack of teachers; starting a graduate programme in medical schools that did not have one and starting these health services delivery departments in a system that did not have any. Conclusions: The main enablers of the evolution of Family Medicine in Kenya include committed partnerships and teamwork among Kenyan and non-Kenyan stakeholders. The challenges include the lack of Kenyan teachers of the programme and the introduction of a new discipline. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: /10.1080/20786190.2016.12481420

The effectiveness of an integrated collaborative care model vs. a shifted outpatient collaborative care model on community functioning, residential stability, and health service use among homeless adults with mental illness: a quasi-experimental study

Background

Although a growing number of collaborative mental health care models have been developed, targeting specific populations, few studies have utilized such interventions among homeless populations. This quasi-experimental study compared the outcomes of two shelter-based collaborative mental health care models for men experiencing homelessness and mental illness: (1) an integrated multidisciplinary collaborative care (IMCC) model and (2) a less resource intensive shifted outpatient collaborative care (SOCC) model.

Methods

In total 142 participants, 70 from IMCC and 72 from SOCC were enrolled and followed for 12 months. Outcome measures included community functioning, residential stability, and health service use. Multivariate regression models were used to compare study arms with respect to change in community functioning, residential stability, and health service use outcomes over time and to identify baseline demographic, clinical or homelessness variables associated with observed changes in these domains.

Results

We observed improvements in both programs over time on measures of community functioning, residential stability, hospitalizations, emergency department visits and community physician visits, with no significant differences between groups over time on these outcome measures.

Conclusions

Our findings suggest that shelter-based collaborative mental health care models may be effective for individuals experiencing homelessness and mental illness. Future studies should seek to confirm these findings and examine the cost effectiveness of collaborative care models for this population.

Global Health in Family Medicine Summer Primer: Course for residents and faculty

PROBLEM ADDRESSED

Despite the rapid emergence of global health training across North American universities, there remains a gap in educational programs focusing on the unique role of family medicine and primary care in global health.

OBJECTIVE OF PROGRAM

The objective of the Global Health in Family Medicine Summer Primer, developed in 2013 by the Department of Family and Community Medicine at the University of Toronto in Ontario, is to strengthen global health competencies among family medicine residents and faculty.

PROGRAM DESCRIPTION

The course covers the meaning of global health; global health ethics; the place of family medicine, primary care, and primary health care in the global health context; epidemiology; infectious diseases; the social determinants of health; and care of vulnerable populations locally and globally. The course is delivered in an intensive 5-day format with didactic lectures, group discussions, interactive workshops, and lived-experience panels.

CONCLUSION

The Global Health in Family Medicine Summer Primer has proven to be a successful educational initiative and provides valuable lessons learned for other academic science centres in developing global health training programs for family medicine residents and faculty.

The dawn of family medicine in Ethiopia

This article describes the development of the first training program in family medicine in Ethiopia that was launched on February 4, 2013, at Addis Ababa University (AAU). The postgraduate program will prepare highly trained doctors for all parts of the country who choose generalism for their lifelong career. The paper describes a series of strategies that were used from 2008 to 2013 to take the Ethiopian family medicine program from vision to reality. There is no single model for the development of family medicine in a country where it does not yet exist. In this case the strategies included Continuing Medical Education events, discussions with stakeholders, international collaboration, needs assessment, curriculum design, and faculty development. The article also reviews both the potential for a new program in family medicine to contribute to the country's health system plus the challenges that are expected in the early stages of establishing a new specialty. The challenges include the ambiguous roles of the family physician in the Ethiopian health care system, uncertainty about career opportunities, adaptation of the curriculum to address local needs, expansion of the training programs to produce larger numbers of family physicians, development of Ethiopian faculty who will be teachers of family medicine, and internal and external brain drain. Family physicians will need to maintain a respectful relationship with other specialist physicians as well as nonphysician primary care providers. The development of this AAU family medicine residency is an example of a successful inter- institutional relationship between local and international partners to create a sustainable, Ethiopian-led training program. Insights from this article may guide development of similar training programs.

A case study of global health at the university: implications for research and action

BACKGROUND

Global health is increasingly a major focus of institutions in high-income countries. However, little work has been done to date to study the inner workings of global health at the university level. Academics may have competing objectives, with few mechanisms to coordinate efforts and pool resources.

OBJECTIVE

To conduct a case study of global health at Canada's largest health sciences university and to examine how its internal organization influences research and action.

DESIGN

We drew on existing inventories, annual reports, and websites to create an institutional map, identifying centers and departments using the terms 'global health' or 'international health' to describe their activities. We compiled a list of academics who self-identified as working in global or international health. We purposively sampled persons in leadership positions as key informants. One investigator carried out confidential, semi-structured interviews with 20 key informants. Interview notes were returned to participants for verification and then analyzed thematically by pairs of coders. Synthesis was conducted jointly.

RESULTS

More than 100 academics were identified as working in global health, situated in numerous institutions, centers, and departments. Global health academics interviewed shared a common sense of what global health means and the values that underpin such work. Most academics interviewed expressed frustration at the existing fragmentation and the lack of strategic direction, financial support, and recognition from the university. This hampered collaborative work and projects to tackle global health problems.

CONCLUSIONS

The University of Toronto is not exceptional in facing such challenges, and our findings align with existing literature that describes factors that inhibit collaboration in global health work at universities. Global health academics based at universities may work in institutional siloes and this limits both internal and external collaboration. A number of solutions to address these challenges are proposed.

Exploring and understanding academic leadership in family medicine

OBJECTIVE

To explore how family physicians understand the concept of academic leadership.

DESIGN

Case study.

SETTING

Department of Family and Community Medicine at the University of Toronto in Ontario.

PARTICIPANTS

Thirty family physician academic leaders.

METHODS

Focus groups and interviews were conducted with family physicians from a large multisite urban university who were identified by peers as academic leaders at various career stages. Transcripts from the focus groups and interviews were anonymized and themes were analyzed and negotiated among 3 researchers.

MAIN FINDINGS

Participants identified qualities of leadership among academic leaders that align with those identified in the current literature. Despite being identified by others as academic leaders, participants were reluctant to self-identify as such. Participants believed they had taken on early leadership roles by default rather than through planned career development.

CONCLUSION

This study affirms the need to define academic leadership explicitly, advance a culture that supports it, and nurture leaders at all levels with a variety of strategies.

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.

Collaborative mental health care for the homeless: the role of psychiatry in positive housing and mental health outcomes

OBJECTIVE

Factors associated with positive outcomes for homeless men referred to a shelter-based collaborative mental health care team were examined.

METHOD

A chart review of 73 clients referred over 12 months was completed. Two outcome measures were examined, clinical status and housing status, 6 months after their referral to the program.

RESULT

Among the referred clients, the prevalence of severe and persistent mental illness and substance use disorders was 76.5% and 48.5%, respectively. At 6 months, 24 clients (35.3%) had improved clinically, and 33 (48.5%) were housed. Logistic regression identified 2 factors associated with clinical improvement: the number of visits with a psychiatrist and treatment adherence. The same 2 factors were associated with higher odds of housing, and presence of substance use disorder was associated with lower odds of housing at 6-month follow-up.

CONCLUSION

Care by a mental health specialist is positively associated with improved outcomes. Strategies to improve treatment adherence, access to mental health specialists, and innovative approaches to treatment of substance use disorders should be considered for this population. Having a psychiatrist as a member of a shelter-based collaborative care team is one possible way of addressing the complex physical and mental health needs of homeless individuals.

Novel amide-based inhibitors of inosine 5'-monophosphate dehydrogenase

A series of novel amide-based small molecule inhibitors of inosine monophosphate dehydrogenase (IMPDH) was explored. The synthesis and the structure-activity relationships (SARs) derived from in vitro studies are described.

Novel guanidine-based inhibitors of inosine monophosphate dehydrogenase

A series of novel guanidine-based small molecule inhibitors of inosine monophosphate dehydrogenase (IMPDH) was explored. IMPDH catalyzes the rate determining step in guanine nucleotide biosynthesis and is a target for anticancer, immunosuppressive and antiviral therapy. The synthesis and the structure-activity relationships (SARs), derived from in vitro studies, for this new series of inhibitors is given.

Novel inhibitors of IMPDH: a highly potent and selective quinolone-based series

A series of novel quinolone-based small molecule inhibitors of inosine monophosphate dehydrogenase (IMPDH) was explored. The synthesis and the structure-activity relationships (SARs) derived from in vitro studies are described.

A survey of cyclic replacements for the central diamide moiety of inhibitors of inosine monophosphate dehydrogenase

A series of heterocyclic replacements for the central diamide moiety of 1, a potent small molecule inhibitor of inosine monophosphate dehydrogenase (IMPDH) were explored The synthesis and the structure-activity relationships (SARs), derived from in vitro studies, for these new series of inhibitors is given.

Onset of Tlx-3 expression in the chick cerebellar cortex correlates with the morphological development of fissures and delineates a posterior transverse boundary

Recent studies have shown that the mammalian cerebellar cortex can be subdivided into a reproducible array of zones and stripes. In particular, discontinuous patterns of gene expression together with mutational analysis suggest that there are at least four distinct transverse zones along the rostrocaudal axis in mouse: the anterior zone (lobules I-V), the central zone (lobules VI and VII), the posterior zone (lobules VIII and IX), and the nodular zone (lobule X). Here we show that the divergent homeobox-containing transcription factor, Tlx- 3 (also known as Hox11L2 or Rnx) is transiently expressed in external granule cells in a distinct transverse domain of the developing chick cerebellar cortex. Expression is first detected at Hamburger and Hamilton (HH) stage 35. Interestingly, Tlx-3 mRNA expression is initially confined to, and coincident with, the morphological development of fissures. Slightly later, at HH stage 38, expression extends throughout the developing external granular layer (EGL) of lobules I-IXab. Notably, no Tlx-3 expression was detected in lobules IXc and X at any developmental time point examined. Expression is noticeably stronger in nonproliferating cells located in the deep layer of the EGL. Tlx-3 expression is downregulated as granule cells migrate inward to form the internal granule layer and is undetectable shortly after birth. These results suggest that Tlx-3 is expressed as granule cells become postmitotic and suggest that Tlx-3 may play a role in the differentiation of distinct neuronal populations in the cerebellum.

Novel diamide-based inhibitors of IMPDH

A series of novel amide-based small molecule inhibitors of inosine monophosphate dehydrogenase is described. The synthesis and the structure-activity relationships (SARs) derived from in vitro studies are presented.