Improving Equity Through Primary Care: Proceedings of the 2019 Toronto International Conference on Quality in Primary Care.

Health equity allows people to reach their full health potential and receive high-quality care that is appropriate for them and their needs, no matter where they live, what they have, or who they are. It is a core element of quality in health care. Around the world, there are many efforts to improve equity through primary care. In order to advance these efforts, it is important to share successes and challenges. Building on our work with international stakeholders to identify key primary care research priorities, we organized the Toronto International Conference on Quality in Primary Care that was held on November 16, 2019. Participants from 8 countries took part. Key recommendations included the establishment of continuous relationships between providers and patients over time, relationships between providers in the health and social sectors, and resources supported proportionally to patient need. Solutions must be generated using team-based approaches that explicitly include people with who have experienced discrimination. Progress will require confronting structural determinants including racism, capitalism, and colonialism. Conference participants suggested practical solutions, such as developing a public transportation program for rural residents to improve community building and the ability to attend medical appointments, and identifying patients who have recently missed clinic visits that may benefit from additional care. These approaches will need to be evaluated through high-quality research and quality improvement, with a knowledge translation that facilitates sustainability and expansion across settings.

Teaching poverty and health: importing transformative learning into the structures and paradigms of medical education.

Background: As a paradigm of education that emphasizes equity and social justice, transformative education aims to improve societal structures by inspiring learners to become agents of social change. In an attempt to contribute to transformative education, the University of Toronto MD program implemented a workshop on poverty and health that included tutors with lived experience of poverty. This research aimed to examine how tutors, as members of a group that faces structural oppression, understood their participation in the workshop. Methods: This research drew on qualitative case study methodology and interview data, using the concept of transformative education to direct data analysis and interpretation. Results: Our findings centred around two broad themes: misalignments between transformative learning and the structures of medical education; and unintended consequences of transformative education within the dominant paradigms of medical education. These misalignments and unintended consequences provided insight into how courses operating within the structures, hierarchies and paradigms of medical education may be limited in their potential to contribute to transformative education. Conclusions: To be truly transformative, medical education must be willing to try to modify structures that reinforce oppression rather than integrating marginalized persons into educational processes that maintain social inequity.

Contexte: En tant que paradigme favorisant l'équité et la justice sociale, l'éducation axée sur la transformation vise à améliorer les structures sociétales en inspirant les apprenants à devenir des agents du changement social. Dans une visée d'éducation transformatrice, le programme de doctorat en médecine de l'Université de Toronto a mis en place un atelier sur le thème de la santé et la pauvreté auquel participaient des tuteurs ayant une expérience vécue de la pauvreté. Notre recherche visait à examiner comment les tuteurs, en tant que membres d'un groupe confronté à l'oppression structurelle, ont compris leur participation à l'atelier. Méthodes: Cette recherche qualitative s'est appuyée sur une méthodologie d'étude de cas et sur des données d'entrevue, en utilisant le concept d'éducation transformatrice comme prisme pour l'analyse et l'interprétation des données. Résultats: Nos résultats s'articulent autour de deux grands thèmes : les décalages entre l'apprentissage transformateur et les structures de l'éducation médicale, et les conséquences inattendues de l'éducation transformatrice au sein des paradigmes dominants de l'éducation médicale. Ces divergences et ces conséquences non voulues ont permis de constater que les cours qui sont ancrés dans les structures, les hiérarchies et les paradigmes contribueront peu à l'éducation transformatrice. Conclusions: Pour que l'éducation médicale soit véritablement transformatrice, il faut qu'il y ait une volonté de modifier les structures qui renforcent l'oppression plutôt que de faire entrer les personnes marginalisées dans des processus éducatifs qui perpétuent l'inégalité sociale.

Evidence-informed interventions and best practices for supporting women experiencing or at risk of homelessness: a scoping review with gender and equity analysis. / Interventions fondées sur des données probantes et pratiques exemplaires en matière de soutien apporté aux femmes en situation ou à risque d'itinérance : examen de la portée avec analyse fondée sur le sexe et l'équité.

INTRODUCTION: While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada's homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness. METHODS: We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations. RESULTS: Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being. CONCLUSION: Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women.

Meaningful inclusion of consumers in research and service delivery.

OBJECTIVE: Although participatory methods have become increasingly popular, people with lived experience of mental illness and homelessness have been historically excluded from service planning and research. To better plan for meaningful inclusion of consumers, this study examines lessons learned from the People with Lived Experience Caucus in the Toronto Site of the At Home/Chez Soi Research Demonstration Project on Homelessness and Mental Health. METHOD: The inclusion of the People with Lived Experience Caucus was evaluated using qualitative methods and multiple data sources, including review of 42 documents, 11 individual interviews, and three focus groups. Caucus members were included in the study team. Transcripts were analyzed using grounded theory methodology. RESULTS: Findings revealed a complex story of Caucus engagement: Facing time constraints and given little direction, the Caucus developed through a tumultuous process related to both internal and external barriers to meaningful inclusion. Despite the challenges, the Caucus contributed meaningfully to various aspects of the research demonstration project. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is possible to successfully integrate psychiatric consumers with experience of homelessness in many aspects of research and service planning. Suggestions for future initiatives hoping to engage consumers include: early involvement, purposeful selection of members, clear communication of roles and responsibilities, a consumer coordinating group, and space for critical dialog throughout the process. Lessons learned can inform the inclusion of consumers in similar endeavors in other jurisdictions.