Equity and inclusivity in research: co-creation of a digital platform with representatives of marginalized populations to enhance the involvement in research of people with limited literacy skills.

To improve health equity, as well as equity in research, community-engaged research and participatory research needs to be inclusive. Equity in health research refers to the principle that anyone affected by research or who can benefit from its outcomes should have equal opportunities to contribute to it. Many researchers advocate the importance of promoting equity in research and engage in processes that foster the research involvement of lay persons, patients, and community members who are otherwise "absent" or "silent". Still, people with limited literacy skills who experience unwarranted structural barriers to healthcare access have little involvement in research. Low literacy is a major barrier to equity in health research. Yet there exist approaches and methods that promote the engagement in research of people with literacy challenges. Building on our previous research projects conducted with community members using participatory visual and sound methods (participatory mapping, photovoice, digital storytelling, etc.), we embarked on the co-creation of a digital platform in 2017. Our aim in this commentary is to report on this co-creation experience that was based on a social justice-oriented partnership. The development of the online platform was overseen by a steering committee made up of workers from community organizations involved with people with limited literacy skills, students, and researchers. In the development process, the co-creation steps included a literature review, informal interviews with key informants, and discussion and writing sessions about format and content. After numerous challenges raised and addressed during co-creation, the Engage digital platform for engagement in research went live in the winter of 2020. This platform presents, on an equal footing, approaches and methods from academic research as well as from the literacy education community engaged with people with limited literacy skills.

People with limited literacy skills are often excluded from health research. Engaging patients and community members with limited literacy in research requires tailored approaches and methods that have been tried and tested with them. In 2017, building on an existing partnership between researchers well-versed in using participatory visual and sound methods and community partners, we undertook the co-creation of a digital platform. Our aim was to empower both academic researchers and community researchers and partners (lay persons, clinicians, stakeholders, community organizations) to engage in research projects with people with limited literacy skills. The result was a digital platform ( https://www.engageplus.org ) comprising several modules and resources available in French and English and accessible on the Web. In this commentary, we share our experience in co-creating this digital platform and discuss the facilitators and challenges encountered.

Providing care to vulnerable populations: a qualitative study among GPs working in deprived areas in Montreal, Canada.

BACKGROUND: Communication barriers between persons living in poverty and healthcare professionals reduce care effectiveness. Little is known about the strategies general practitioners (GPs) use to enhance the effectiveness of care for their patients living in poverty. OBJECTIVE: The aim of this study was to identify strategies adopted by GPs to deliver appropriate care to patients living in poverty. METHODS: We conducted in-depth semi-structured interviews with 35 GPs practising in Montreal, Canada, who regularly provide care to underprivileged patients in primary care clinics located in deprived urban areas. Analysis consisted of interview debriefing, transcript coding, thematic analysis and data interpretation. RESULTS: GPs develop specific skills for caring for these patients that are responsive to their complex medical needs and challenging social context. Our respondents used three main strategies in working with their patients: building a personal connection to overcome social distance, aligning medical expectations with patients' social vulnerability and working collaboratively to empower patients. With these strategies, the physicians were able to enhance the patient-physician relationship and to take into account the impact of poverty on illness self-management. CONCLUSIONS: Our results may help GPs improve the health and care experience of their vulnerable patients by adopting these strategies. The strategies' impacts on patients' experience of care and health outcomes should be evaluated as a prelude to integrating them into primary care practice and the training of future physicians.

Medical residents reflect on their prejudices toward poverty: a photovoice training project.

BACKGROUND: Clinicians face challenges in delivering care to socioeconomically disadvantaged patients. While both the public and academic sectors recognize the importance of addressing social inequities in healthcare, there is room for improvement in the training of family physicians, who report being ill-equipped to provide care that is responsive to the living conditions of these patients. This study explored: (i) residents' perceptions and experience in relation to providing care for socioeconomically disadvantaged patients, and (ii) how participating in a photovoice study helped them uncover and examine some of their prejudices and assumptions about poverty. METHODS: We conducted a participatory photovoice study. Participants were four family medicine residents, two medical supervisors, and two researchers. Residents attended six photovoice meetings at which they discussed photos they had taken. In collaboration with the researchers, the participants defined the research questions, took photos, and participated in data analysis and results dissemination. Meetings were recorded and transcribed for analysis, which consisted of coding, peer debriefing, thematic analysis, and interpretation. RESULTS: The medical residents uncovered and examined their own prejudices and misconceptions about poverty. They reported feeling unprepared to provide care to socioeconomically disadvantaged patients. Supported by medical supervisors and researchers, the residents underwent a three-phase reflexive process of: (1) engaging reflexively, (2) break(ing) through, and (3) taking action. The results indicated that medical residents subsequently felt encouraged to adopt a care approach that helped them overcome the social distance between themselves and their socioeconomically disadvantaged patients. CONCLUSIONS: This study highlights the importance of providing medical training on issues related to poverty and increasing awareness about social inequalities in medical education to counteract prejudices toward socioeconomically disadvantaged patients. Future studies should examine which elective courses and training could provide suitable tools to clinicians to improve their competence in delivering care to socioeconomically disadvantaged patients.

[Adaptability of physicians offering primary care to the poor: social competency revisited]. / La flexibilité des médecins offrant des soins de première ligne aux personnes en situation de pauvreté: la compétence sociale revisitée.

This paper attempts to go deeper into the topic of social competency of physicians who provide primary care to populations living in poverty in Montreal. Adaptability as well as the ability to tailor practices according to patient expectations, needs and capabilities were found to be important in the development of the concept of social competency. The case of paternalism is used to demonstrate how a historically and socially contested medical approach is readapted by players in certain contexts in order to better meet patient expectations. This paper presents data collected in a qualitative study comprising 25 semi-supervised interviews with physicians recognized by their peers as having developed exemplary practices in Montreal's impoverished neighbourhoods.

Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol.

BACKGROUND: Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations. METHODS/DESIGN: This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews. DISCUSSION: The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty.