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.

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.

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.

Rare variants in neuronal excitability genes influence risk for bipolar disorder.

We sequenced the genomes of 200 individuals from 41 families multiply affected with bipolar disorder (BD) to identify contributions of rare variants to genetic risk. We initially focused on 3,087 candidate genes with known synaptic functions or prior evidence from genome-wide association studies. BD pedigrees had an increased burden of rare variants in genes encoding neuronal ion channels, including subunits of GABAA receptors and voltage-gated calcium channels. Four uncommon coding and regulatory variants also showed significant association, including a missense variant in GABRA6. Targeted sequencing of 26 of these candidate genes in an additional 3,014 cases and 1,717 controls confirmed rare variant associations in ANK3, CACNA1B, CACNA1C, CACNA1D, CACNG2, CAMK2A, and NGF. Variants in promoters and 5' and 3' UTRs contributed more strongly than coding variants to risk for BD, both in pedigrees and in the case-control cohort. The genes and pathways identified in this study regulate diverse aspects of neuronal excitability. We conclude that rare variants in neuronal excitability genes contribute to risk for BD.

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.

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.

Approaching a global definition of family medicine: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To find a common global definition of family medicine. 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: Searching both definition of family medicine and history of family medicine yields a variety of defining features. Visiting family medicine training programs worldwide highlights this discrepancy. REPORT: It is not an easy task to define family medicine-one of its key attributes is its adaptability to a local context, but this makes aggregation of data challenging. There is a lack of clarity regarding whether family medicine is the same discipline globally and what the core features are that define it. Unifying components of the definition have always included comprehensive care at all life stages and the management of the common illnesses of a particular community. The emerging global emphasis on competency and social accountability demonstrates commitment to the principle that family doctors provide health care for all in the context of the community. Although the competencies are not universal, the fact that family physicians fill in primary care "gaps" and tailor learning strategies to community priorities is a unifying distinction. We argue for a focus on the core competencies that bind us as a discipline. CONCLUSION: Family medicine can be practised in various forms. The unifying elements are the socially accountable responsiveness to local need, the adaptation of existing health infrastructure, and the ongoing development of the skills required to succeed in that role-always grounded in relationships of care. In this way, family medicine will continue to evolve to suit the health needs of communities and health systems.

Learning globally to enhance local practice: an international programme in primary care & family health.

PURPOSE: In a global context of growing health inequities, international learning experiences have become a popular strategy for equipping health professionals with skills, knowledge, and competencies required to work with the populations they serve. This study sought to analyse the Chilean Interprofessional Programme in Primary Health Care (CIPPHC), a 5 week international learning experience funded by the Ministry of Health in Chile targeted at Chilean primary care providers and delivered in Toronto by the Department of Family and Community Medicine at the University of Toronto. METHOD: The study focused on three cohorts of students (2010-2012). Anonymous programme evaluations were analysed and semi-structured interviews conducted with programme alumni. Simple descriptive statistics were gathered from the evaluations and the interviews were analysed via thematic content analysis. RESULTS: The majority of participants reported high levels of satisfaction with the training programme, knowledge gain, particularly in the areas of the Canadian model of primary care, and found the materials delivered to be applicable to their local context. CONCLUSIONS: The CIPPHC has proven to be a successful educational initiative and provides valuable lessons for other academic centres in developing international interprofessional training programmes for primary care health care providers.

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.

Developing the evidentiary basis for family medicine in the global context: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To provide an overview of the main methodologic challenges to finding definitive evidence of the positive effects of family medicine and family medicine training on a global scale. COMPOSITION OF THE COMMITTEE: In 2012, 2013, and 2014, the College of Family Physicians of Canada 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: We performed a scoping review to determine the methodologic obstacles to understanding the positive effects of family medicine globally. REPORT: The main obstacle to evaluating family medicine globally is that one of its core dimensions and assets is its local adaptability. Family medicine takes on very different roles in different health systems, making aggregation of data difficult. In many countries family medicine competes with other disciplines rather than performing a gatekeeping role. Further, most research that has been conducted thus far comes from industrialized contexts, and patient continuity and its benefits might not be achievable in the short term in developing countries when clinical demands are great. We must find frameworks to permit strengthening the evidentiary basis of the discipline across different contexts without sacrificing its beneficial adaptability. CONCLUSION: We believe that developing family medicine and its attributes is one of the keys to achieving global health. These attributes­including its comprehensiveness, adaptability, and attention to both local and patient needs­are key to advancing global health priorities, but make common evaluative frameworks for the discipline a challenge. The spread of family medicine over the past decades is indirect evidence of its utility, but we need to generate more evidence. We present some of the initial challenges to a broader and more rigorous evaluative framework.

Health and growth status of immigrant and refugee children in Toronto, Ontario: A retrospective chart review.

OBJECTIVE: To describe selected anthropometric and health status variables among immigrant and refugee children ≤6 years of age within an inner city clinic in Toronto, Ontario. METHODS: A retrospective chart review of patients born between January 1, 1998 and December 31, 2008, was conducted at a Toronto community health centre serving a primarily immigrant and refugee population. Outcome measures included calculated age-specific percentiles for height and weight, and the prevalence of anemia, iron deficiency, enteric parasites, elevated lead levels, HIV and hepatitis B. Postal codes were collected and used to determine the patient's neighbourhood income quintile. RESULTS: A total of 331 patients, born between January 1, 1998 and December 31, 2008, were identified. Of these, a total of 210 charts were manually reviewed. The prevalence of height-for-age and weight-for-age under the third percentile on the Centers for Disease Control and Prevention Growth Charts were 7.2% and 11.6%, respectively, and 8.4% and 5.0%, respectively, on the WHO Growth Standards Chart. Prevalence rates were also calculated for anemia (22.8%), iron deficiency (53.3%), hepatitis B (2.5%), parasitic infections (33.6%), elevated blood lead levels (4.9%) and HIV (0%). Neighbourhood income quintiles revealed that 46.7% of patients were residing in the lowest (ie, poorest) income quintile neighbourhoods. CONCLUSION: These findings reveal a high burden of illness within the population presenting to an immigrant/refugee health clinic, and illustrate the need for further research in this area, as well as increased efforts to ensure appropriate screening within clinics serving a high volume of newcomer patients.

OBJECTIF: Décrire certaines variables anthropométriques et liées à la santé d'enfants immigrants et réfugiés de moins de six ans dans une clinique des quartiers pauvres de Toronto, en Ontario. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers de patients nés entre le 1er janvier 1998 et le 31 décembre 2008 dans un centre de santé communautaire de Toronto qui dessert une population surtout composée d'immigrants et de réfugiés. Les mesures de résultats incluaient le calcul des percentiles propres à l'âge pour la taille et le poids ainsi que la prévalence d'anémie, de carence en fer, de parasites entériques, de taux élevés de plomb, de VIH et d'hépatite B. Ils ont recueilli et utilisé les codes postaux pour déterminer le quintile de revenu du quartier de résidence des patients. RÉSULTATS: Au total, les chercheurs ont repéré 331 patients, nés entre le 1er janvier 1998 et le 31 décembre 2008, et révisé manuellement 210 dossiers. La prévalence de taille et de poids par rapport à l'âge se situant sous le troisième percentile selon les courbes de croissance des Centers for Disease Control and Prevention s'élevait à 7,2 % et 11,6 %, respectivement, et à 8,4 % et 5,0 %, respectivement, selon les courbes de croissance standard de l'OMS. Les chercheurs ont également calculé la prévalence d'anémie (22,8 %), de carence en fer (53,3 %), d'hépatite B (2,5 %), d'infections parasitaires (33,6 %), de taux élevés de plomb dans le sang (4,9 %) et de VIH (0 %). Les quintiles de revenu des quartiers de résidence ont révélé que 46,7 % des patients habitaient dans les quartiers aux quintiles de revenu les plus faibles (c'est-à-dire les plus pauvres). CONCLUSION: Ces observations révèlent un fardeau élevé de mala-die au sein des populations qui consultent dans une clinique de santé pour les immigrants et les réfugiés et démontrent la nécessité de pour-suivre les recherches dans ce domaine ainsi que d'accroître les efforts pour garantir un dépistage convenable dans les cliniques qui desservent un fort volume de nouveaux arrivants.

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.

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.

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.

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.