Storylines of family medicine II: foundational building blocks-context, community and health.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Storylines of family medicine X: standing up for diversity, equity and inclusion.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Innovative Approaches to Improve COVID-19 Case Investigation and Contact Tracing Among Refugees, Immigrants, and Migrants: Lessons Learned from a Newly Established National Resource Center.

Effective COVID-19 case investigation and contact tracing (CICT) among refugee, immigrant, and migrant (RIM) communities requires innovative approaches to address linguistic, cultural and community specific preferences. The National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) is a CDC-funded initiative to support state and local health departments with COVID-19 response among RIM communities, including CICT. This note from the field will describe NRC-RIM and initial outcomes and lessons learned, including the use of human-centered design to develop health messaging around COVID-19 CICT; training developed for case investigators, contact tracers, and other public health professionals working with RIM community members; and promising practices and other resources related to COVID-19 CICT among RIM communities that have been implemented by health departments, health systems, or community-based organizations.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda.

BACKGROUND: Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB. METHODS: We conducted a prospective study as part of a larger study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL. RESULTS: Of the 162 participants enrolled in the larger study, 32 (19.8%) had PTB + CPA and 130 (80.2%) had PTB. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB group rated their HR-QoL as "very good" compared to those who had PTB + CPA (68 [54.0%] versus 8 [25.8%]). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 [0-12.4] versus 14.4 [0-42.9], p < 0.001), activity ((0 [0-17.1] versus 12.2 [0-35.5], p = .03), impact (0 [0-4.0] versus 3.1 [0-22.5], p = 0.004), and total scores ((0 [0-8.5] versus 7.6[(0-27.4], p = 0.005). CONCLUSION: CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

A pragmatic approach to equitable global health partnerships in academic health sciences.

Global partnerships offer opportunities for academic departments in the health sciences to achieve mutual benefits. However, they are often challenged by inequities in power, privilege and finances between partners that have plagued the discipline of global health since its founding. In this article, a group of global health practitioners in academic medicine offer a pragmatic framework and practical examples for designing more ethical, equitable and effective collaborative global relationships between academic health science departments, building on the principles laid out by the coalition Advocacy for Global Health Partnerships in the Brocher declaration.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda.

Background Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB. Methods We conducted a prospective study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL. Results Of the 162 participants enrolled, 32 (19.8%) had CPA + PTB and 130 (80.2%) had PTB only. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB only group rated their HR-QoL as "very good" compared to those who had both TB and CPA (68 (54.0%) versus 8 (25.8%)). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB only group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 (0 - 12.4) versus 14.4 (0 - 42.9), p < 0.001), activity ((0 (0 - 17.1) versus 12.2 (0 - 35.5), p = .03), impact (0 (0 - 4.0) versus 3.1 (0 - 22.5), p = 0.004), and total scores ((0 (0 - 8.5) versus 7.6 (0 - 27.4), p = 0.005). Conclusion CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

Characteristics of International Rotations for Undergraduate Medical Education at United States Medical Schools: A National Study.

Objective: Medical education is criticized that it does not prepare students to serve in an increasingly globalized society. Evidence that global educational experiences can alleviate these concerns have contributed to the rise in international medical education experiences. This study explores surrounding characteristics and institutional support for international rotations across medical schools in the US. Methods: The authors conducted a sequential mixed methods exploratory national survey of international rotation coordinators at 185 US medical schools and 15 semi-structured interviews in fall 2018. Quantitative data were analyzed with descriptive statistics and qualitative data were coded and analyzed using interpretive description to identify themes across data. Results: There were 57 responses to the survey for an overall response rate of 31%, with 77% percent of respondents (n = 44) indicating that their medical school offered international rotations. Fifteen individuals representing 13 medical schools were identified as interviewees for the second stage of the study. International rotation coordinators described components of international rotations, including partnerships with host communities, use of third-party organizations, and supporting administrative and academic structures. Conclusion: Although international rotations are common in medical education, they are not positioned as core academic programming within medical schools. This leads to challenges in planning, implementation, and evaluation, and immense variation in rotation components across medical programs. Future research should explore best practices for pre-departure preparation, post-travel debriefing, and evaluation of student activity as well as impact on the host site. Additional research should include exploration of unique benefits of international versus domestic sites, and aspects of sustainable partnerships between medical schools and host communities.

Building the foundation for universal healthcare: Academic family medicine's ability to train family medicine practitioners to meet the needs of their community across the globe.

BACKGROUND:  The Declaration of Astana marked a revived global interest in investing in primary care as a means to achieve universal healthcare. Family medicine clinicians are uniquely trained to provide high-quality, comprehensive primary care throughout the lifespan. Yet little focus has been placed on understanding the needs of family medicine training programs. AIM:  This study aims to assess broad patterns of strengths and resource challenges faced by academic programs that train family medicine clinicians. METHODS:  An anonymous online survey was sent to family medicine faculty using World Organization of Family Doctors (WONCA) listservs. RESULTS:  Twenty-nine representatives of academic family medicine programs from around the globe answered the survey. Respondents cited funding for the program and/or individual trainees as one of either their greatest resources or greatest limitations. Frequently available resources included quality and quantity of faculty and reliable clinical training sites. Frequently noted limitations included recruitment capacity and social capital. Over half of respondents reported their program had at some point faced a disruption or gap in its ability to recruit or train, most often because of loss of government recognition. Reflecting on these patterns, respondents expressed strong interest in partnerships focusing on faculty development and research collaboration. LESSONS LEARNT:  This study provides a better understanding of the challenges family medicine training programs face and how to contribute to their sustainability and growth, particularly in terms of areas for investment, opportunities for government policy and action and areas of collaboration.

Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health.

Short- term experiences in global health (STEGH), also known as short-term medical missions continue to be a popular mode of engagement in global health activities for students, healthcare providers, and religious groups, driven primarily by organizations from high-income countries. While STEGH have the potential to be beneficial, a large proportion of these do not sustainably benefit the communities they intend to serve, may undermine local health systems, operate without appropriate licenses, go beyond their intended purposes, and may cause harm to patients. With heightened calls to "decolonize" global health, and to achieve ethical, sustainable, and practical engagements, there is a need to establish strong guiding principles for global health engagements. The Advocacy for Global Health Partnerships (AGHP), a multi-sectoral coalition, was established to reflect on and address the concerns relating to STEGH. Towards this end, AGHP created the Brocher Declaration to lay out six main principles that should guide ethical and appropriate STEGH practices. A variety of organizations have accepted the Declaration and are using it to provide guidance for effective implementation of appropriate global health efforts. The Declaration joins broader efforts to promote equity in global health and a critical reevaluation of volunteer-centric, charity-based missions. The current state of the world's health demands a new model of collaboration - one that sparks deep discussions of shared innovation and builds ethical partnerships to address pressing issues in global health.

Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda.

BACKGROUND: The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated. METHODS: We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda, between July 2020 and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest X-ray (CXR), and compatible symptoms >3 months. RESULTS: We enrolled 162 participants (median age 30 years; IQR: 25-40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intracavitary fungal balls and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio [aOR]: 6.61, 95% CI: 1.85-23.9, p = .004), and far advanced CXR changes (aOR: 4.26, 95% CI: 1.72-10.52, p = .002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA. CONCLUSIONS: Chronic pulmonary aspergillosis may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.

Strengthening global health security by improving disease surveillance in remote rural areas of low-income and middle-income countries.

The COVID-19 pandemic has underscored the need to strengthen national surveillance systems to protect a globally connected world. In low-income and middle-income countries, zoonotic disease surveillance has advanced considerably in the past two decades. However, surveillance efforts often prioritise urban and adjacent rural communities. Communities in remote rural areas have had far less support despite having routine exposure to zoonotic diseases due to frequent contact with domestic and wild animals, and restricted access to health care. Limited disease surveillance in remote rural areas is a crucial gap in global health security. Although this point has been made in the past, practical solutions on how to implement surveillance efficiently in these resource-limited and logistically challenging settings have yet to be discussed. We highlight why investing in disease surveillance in remote rural areas of low-income and middle-income countries will benefit the global community and review current approaches. Using semi-arid regions in Kenya as a case study, we provide a practical approach by which surveillance in remote rural areas can be strengthened and integrated into existing systems. This Viewpoint represents a transition from simply highlighting the need for a more holistic approach to disease surveillance to a solid plan for how this outcome might be achieved.

Rethinking our Rigor Mortis: Creating space for more adaptive and inclusive truth-seeking in community-based global health research in Kenya.

As global health researchers, we have long embraced the conviction that the answers to complex problems of poverty and disease will reveal themselves if only we apply enough scientific rigor. Yet, at the community level, our group of American and Kenyan investigators has begun to question whether our veneration of rigor is itself contributing to the intractability of certain types of global health problems. Here, we illustrate examples from our experience among the remote island communities of Lake Victoria, Kenya, and join a chorus of emerging voices, to examine how our culture of control as global health scientists may marginalise truth-seekers and change-makers within communities we seek to serve. More broadly, we seek to acknowledge the limitations of control over truth that rigorous academic research affords. We suggest that by relinquishing this pervasive illusion of control, we can more fully appreciate complementary modes of answering important questions that rely upon the intrinsic resourcefulness and creativity of community-based enterprises taking place across sub-Saharan Africa. While such inquiries may never solve all problems facing the diverse populations of the continent, we advocate for a deeper appreciation of the inherent capacity of adaptive, locally contextualised investigations to identify meaningful and enduring solutions.

Falling through the net: An adaptive assessment of the 'Three Delays' encountered by patients seeking emergency maternal and neonatal care within a remote health system on Lake Victoria, Kenya.

In rural sub-Saharan Africa, preventable delays in accessing emergency care remain a dominant factor in maternal and neonatal deaths. The MOMENTUM study is a pragmatic cohort investigation designed to measure the "Three Delays", i.e. delays in recognizing need for care (Type 1), reaching care (Type 2), and receiving care (Type 3) within a remote island health system on Lake Victoria, Kenya. The study utilizes an adaptive methodology to provide actionable data for a locally-directed "Health Navigation" intervention. We present analysis of 56 maternal and neonatal emergency cases occurring between January 2019 and February 2020. The mean Total Delay Interval (Type 1-3) reported was 39.3 ± 32.3hours. Notably, 18 cases in this cohort resulted in a neonatal (n = 16) or maternal death (n = 2). Sub-analysis indicates significant delay interval reductions associated with involvement of a "Health Navigator" in emergency care coordination for Type 2 Delay Intervals (0.5 ± 0.3 vs. 1.2 ± 1.1 hrs., p = 0.002) and Type 3 Delay Intervals (17.9 ± 14.1 vs. 32.9 ± 33.7 hrs., p = 0.030). Prolonged delays, complex barriers, and high mortality highlight the fraught nature of maternal emergencies in this remote setting. We discuss practical considerations for application of the Three Delays model, and avenues for further investigation.

Social vulnerability during the COVID-19 pandemic in Peru.

The COVID-19 pandemic has demanded governments and diverse organizations to work on strategies to prepare and help communities. Increasing recognition of the importance of identifying vulnerable populations has raised a demand for better tools. One of these tools is the Social Vulnerability Index (SVI). The SVI was created in 2011 to identify and plan assistance for socially vulnerable populations during hazardous events, by providing disaster management personnel information to target specific areas. We aimed to evaluate and determine the social vulnerability in different provinces and districts of Peru in the context of the COVID-19 pandemic using an adapted version of the SVI index. Ecological, observational, and cross-sectional study was conducted. We adapted the SVI and collected indicators related to COVID-19. We organized and analyzed the population data of the 196 provinces of Peru, using data from government institutions. We found a distribution of high and very high SVI in the mountainous areas of Peru. High and very high social vulnerability indexes, due to the presence of some or all the variables were predominantly distributed in the provinces located in the southern and highlands of the country. The association between mortality rate and social SVI-COVID19 was inverse, the higher the vulnerability, the lower the mortality. Our results identify that the provinces with high and very high vulnerability indexes are mostly located in rural areas nearby the Andes Mountains, not having a direct correlation with COVID-19 mortality.

Expanding Family Medicine Scholarship to All Faculty: The Minnesota Model for Harmonizing Clinical Care, Education, and Research Missions.

BACKGROUND: The Department of Family Medicine and Community Health at the University of Minnesota engaged in a 5-year transformation to expand research and scholarship opportunities to all faculty. A harmonization framework was used to integrate the 3 missions of clinical care, education, and research to ensure that research and scholarship were an ongoing focus of the department. METHODS: The key elements of our transformation included as follows: (1) a general culture of inquiry, (2) harmonized leadership, (3) training and mentoring, and (4) infrastructure and resources. Components of each of these elements were intentionally instituted simultaneously and iteratively across the 5 years to provide robust and sustainable research and scholarship opportunities for all faculty. RESULTS: Outputs and outcomes of the harmonized transformation indicated that clinical and research faculty publications increased, and the percentage of clinical faculty trained in research and scholarship skills increased across the 5 years. CONCLUSIONS: Important lessons learned during the harmonized transformation included the following: (1) key elements of the transformation need to be balanced as an ensemble, (2) cultural and organizational shifts take concerted effort and time, (3) embrace iteration: allow "bumps in the road" to propel the work forward, (4) transformation is financially feasible, (5) career research faculty can mutually benefit from clinical faculty engaging in scholarship, and (6) honor skepticism or disinterest and let people cultivate enthusiasm for research and scholarship rather than being forced.

Family Medicine, Community, and Race: A Minneapolis Practice Reflects.

The uprisings for racial justice that followed the brutal murder of George Floyd on May 28, 2020 in Minneapolis, Minnesota damaged the physical building where a family medicine residency is situated. We discuss the emotions that follow that event and reflect on ways that family medicine should address racism and discrimination. We also call on those in family medicine to work more in the communities that we serve, and to make advocacy a core part of the identity of family medicine.