Advancing a collective vision for equity-based cocreation through prototyping at an international forum.

BACKGROUND: Cocreation has the potential to engage people with lived and living experiences in the design and evaluation of health and social services. However, guidance is needed to better include people from equity-deserving groups (EDGs), who are more likely to face barriers to participation, experience ongoing or historical harm, and benefit from accessible methods of engagement. OBJECTIVE: The aim of this international forum (CoPro2022) was to advance a collective vision for equity-based cocreation. DESIGN: A participatory process of engagement in experiential colearning and arts-based creative and reflective dialogue. Visual prototypes were created and synthesised to generate a collective vision for inclusive equity-based cocreation. SETTING AND PARTICIPANTS: The Forum was held at the Gathering Place by the Grand River in Ohsweken, Ontario, Canada. A total of 48 participants attended the forum. They were purposely invited and have intersecting positionalities (21 academic experts, six experience experts, 10 trainees, and 11 members of EDGs) from nine countries (Bangladesh, Botswana, Canada, England, Italy, Norway, Scotland, Singapore, Sweden). COPRO2022 ACTIVITIES: CoPro2022 was an immersive experience hosted on Indigenous land that encouraged continuous participant reflection on their own worldviews and those of others as participants openly discussed the challenges and opportunities with engaging EDGs in cocreation activities. Visual prototypes and descriptions created in small groups were informed by participants' reflections on the panel presentations at the Forum and their own experiences with equity-based cocreation. Following the event, the authorship team inductively coded themes from the prototype descriptions and met to discuss the cross-cutting themes. These informed the design of an illustrated collective vision for Equity Based Co-Creation (EqCC). RESULTS: Six prototypes were cocreated by each small group to illustrate their vision for EqCC. Within these, four cross-cutting themes were identified: (i) go to where people are, (ii) nurture relationships and creativity, (iii) reflect, replenish and grow, (iv) and promote thriving and transformation. These four themes are captured in the Collective EqCC Vision to guide a new era of inclusive excellence in cocreation activities. PATIENT OR PUBLIC CONTRIBUTION: Service users, caregivers, and people with lived experience were involved in leading the design of the CoPro2022 and co-led the event. This included activities at the event such as presenting, facilitating small and large group discussion, leading art-based activities, and reflecting with the team on the lessons learned. People with lived experience were involved in the analysis and knowledge sharing from this event. Several members of the research team (students and researchers) also identified as members of EDGs and were invited to draw from their personal and academic knowledge.

Adopting, implementing and assimilating coproduced health and social care innovations involving structurally vulnerable populations: findings from a longitudinal, multiple case study design in Canada, Scotland and Sweden.

BACKGROUND: Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups. METHODS: We conducted a 4 year longitudinal multiple case study (2019-2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau's Compatibility Gaps to understand assimilation. RESULTS: The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change. CONCLUSIONS: In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

Understanding the Conceptualization and Operationalization of Trauma-Informed Care Within and Across Systems: A Critical Interpretive Synthesis.

Policy Points In order to achieve successful operationalization of trauma-informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration. Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level. CONTEXT: Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma-informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC. METHODS: Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information-rich websites. We used a coding tool, adapted to the TIC literature, for data extraction. FINDINGS: Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information-rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider "buy-in," have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma-affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language. CONCLUSIONS: Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

Performance-based outcome measures of dexterity and hand function in person with hands and wrist injuries: A scoping review of measured constructs.

BACKGROUND: Dexterity impairments are common and disabling. Currently, there is no consensus on an operational definition to measure dexterity. PURPOSE: This review aims to provide an overview of constructs measured by performance-based outcome measures of dexterity and hand function (PBOMD) validated for use in persons with musculoskeletal hand and wrist conditions. STUDY DESIGN: Scoping review, with qualitative content analysis. METHODS: MEDLINE, Embase, CINAHL, PsycINFO were searched from inception until November 2019. Three reviewers identified studies investigating the psychometric properties of PBOMD in persons with hand and wrist conditions. Original articles and manuals of validated PBOMD were obtained. Reviewers independently extracted and performed a content analysis of constructs comparing the theoretical concepts of dexterity and function. RESULTS: Twenty PBOMD were identified. PBOMD featured 1-57 tasks and 1-8 potential grasps patterns per tool. Description of the constructs measured indicated overlap between dexterity and hand function. In newer tools, there was a greater representation of daily activities to include domains like self-care and domestic life; and measurement of qualitative aspects of performance. Concurrently, there was less focus on mobility. The majority of identified tools (70%) used speed as the criterion evaluation of performance. None of the PBOMD evaluated dexterity associated with leisure activities or modern technologies like smartphones, nor measured the ability to adapt to changing demands when completing tasks. CONCLUSIONS: Hand function and dexterity are imprecisely defined and operationalized in PBOMD. Dexterity is a complex construct that current PBOMD incompletely captures. PBOMD often quantified as the speed of movement, ignoring other important aspects like accommodating environmental changes during task performance. Clinicians should consider tasks included in PBOMD, the quantification method, and each PBOMD's limitations when choosing PBOMD.

The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study.

BACKGROUND: In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes. METHODS: We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth). RESULTS: Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (ß = - 0.070; 95% CI: - 0.110 to - 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (ß = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (ß = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (ß = - 0.144; 95% CI: - 0.255 to - 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (ß = - 0.018; 95% CI: - 0.026 to - 0.009; p < 0.001). No other significant level or trend changes were noted. CONCLUSIONS: The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.

Codesigning health and other public services with vulnerable and disadvantaged populations: Insights from an international collaboration.

BACKGROUND: Codesign has the potential to transform health and other public services. To avoid unintentionally reinforcing existing inequities, better understanding is needed of how to facilitate involvement of vulnerable populations in acceptable, ethical and effective codesign. OBJECTIVE: To explore citizens' involvement in codesigning public services for vulnerable groups, identify challenges and suggest improvements. DESIGN: A modified case study approach. Pattern matching was used to compare reported challenges with a priori theoretical propositions. SETTING AND PARTICIPANTS: A two-day international symposium involved 28 practitioners, academics and service users from seven countries to reflect on challenges and to codesign improved processes for involving vulnerable populations. INTERVENTION STUDIED: Eight case studies working with vulnerable and disadvantaged populations in three countries. RESULTS: We identified five shared challenges to meaningful, sustained participation of vulnerable populations: engagement; power differentials; health concerns; funding; and other economic/social circumstances. In response, a focus on relationships and flexibility is essential. We encourage codesign projects to enact a set of principles or heuristics rather than following pre-specified steps. We identify a set of principles and tactics, relating to challenges outlined in our case studies, which may help in codesigning public services with vulnerable populations. DISCUSSION AND CONCLUSIONS: Codesign facilitators must consider how meaningful engagement will be achieved and how power differentials will be managed when working with services for vulnerable populations. The need for flexibility and responsiveness to service user needs may challenge expectations about timelines and outcomes. User-centred evaluations of codesigned public services are needed.

Internationally educated occupational therapists transitioning to practice in Canada: A qualitative study.

BACKGROUND/AIM: While internationally educated occupational therapists (IEOTs) may assist Western countries in addressing workforce shortages, their transition to practice can be difficult. Provincial and national levels of government in Canada have funded initiatives to address the barriers experienced by IEOTs. The purpose of this study is to identify the key forces shaping the experiences of IEOTs transitioning to practice in Canada. METHODS: An interpretive description approach was taken to interview 11 IEOTs who graduated from the Occupational Therapy Examination and Practice Preparation (OTepp) program. Data analysis was guided by the theoretical scaffolding of the occupational therapy profession. Two team members, who are also occupational therapists, developed codes and categories independently and then through discussion reached a higher level of interpretation. RESULTS: The experiences of IEOTs in Canada were shaped by two key forces: Realising that more than exam preparation is required and the impact of previous person, environment and occupation transactions. Participants underestimated their learning needs related to their transition to Canadian practice. As they engaged in the OTepp program, they realised that their learning extended beyond that required for the national certification exam. Also, the extent to which the participant (person), previous context (environment) and previous practice (occupation) were similar to Canadian therapists, influenced IEOTs' performance in OTepp and their overall transition to practice. The Person-Environment-Occupation (PEO) model provided a framework to contextualise this theme. CONCLUSION: IEOTs will benefit from individualised learning needs assessments and education plans to address their specific needs. At an international level, the occupational therapy profession must engage in dialogue about the differences between education programs and the resulting implications for the profession. More research is also needed to understand the experiences of IEOTs who withdraw from or do not engage in formal supports.

Beyond Silence: A Randomized, Parallel-Group Trial Exploring the Impact of Workplace Mental Health Literacy Training with Healthcare Employees.

OBJECTIVE: This study sought to evaluate whether a contact-based workplace education program was more effective than standard mental health literacy training in promoting early intervention and support for healthcare employees with mental health issues. METHOD: A parallel-group, randomised trial was conducted with employees in 2 multi-site Ontario hospitals with the evaluators blinded to the groups. Participants were randomly assigned to 1 of 2 group-based education programs: Beyond Silence (comprising 6 in-person, 2-h sessions plus 5 online sessions co-led by employees who personally experienced mental health issues) or Mental Health First Aid (a standardised 2-day training program led by a trained facilitator). Participants completed baseline, post-group, and 3-mo follow-up surveys to explore perceived changes in mental health knowledge, stigmatized beliefs, and help-seeking/help-outreach behaviours. An intent-to-treat analysis was completed with 192 participants. Differences were assessed using multi-level mixed models accounting for site, group, and repeated measurement. RESULTS: Neither program led to significant increases in help-seeking or help-outreach behaviours. Both programs increased mental health literacy, improved attitudes towards seeking treatment, and decreased stigmatized beliefs, with sustained changes in stigmatized beliefs more prominent in the Beyond Silence group. CONCLUSION: Beyond Silence, a new contact-based education program customised for healthcare workers was not superior to standard mental health literacy training in improving mental health help-seeking or help-outreach behaviours in the workplace. The only difference was a reduction in stigmatized beliefs over time. Additional research is needed to explore the factors that lead to behaviour change.

Workplace Mental Health Training in Health Care: Key Ingredients of Implementation.

OBJECTIVES: Despite growing awareness of the importance of workplace mental health training and an increasing number of educational resources, there is a gap in knowledge regarding what shapes training effectiveness. The purpose of this study was to compare and describe the active ingredients of 2 workplace mental health education programs for health care workers. METHODS: Within the context of a randomized clinical trial, a multimethod process evaluation was conducted to explore key process elements shaping implementation outcomes: the innovation, service recipients, service providers, and the organizational context. Data collection included descriptive statistics regarding program participation, postprogram interviews with a purposive sample of 18 service recipients, 182 responses to open-ended questions on postgroup and follow-up surveys, and field journal reflections on the process of implementation. Data analysis was informed by an interpretive description approach, using a process evaluation framework to categorize responses from all data sources, followed by within and cross-case comparison of data from both programs. RESULTS: Five key forces shaped the implementation and perceived outcomes of both programs: a contact-based education approach, information tailored to the workplace context, varied stakeholder perspectives, sufficient time to integrate and apply learning, and organizational support. The Beyond Silence program provided more opportunity for contact-based education, health care-specific content, and in-depth discussion of diverse perspectives. CONCLUSIONS: To increase mental health literacy and reduce stigma, workplace training should be based on best practice principles of contact-based education, with contextually relevant examples and support from all levels of the organization.

Depression in youth recovering from concussion: Correlates and predictors.

OBJECTIVES: Although depression can be a serious consequence of concussion, little is known about the factors that predict depression and concussion recovery outcomes in children. The purpose of this study was to explore the risk and possible predictors of developing significant depressive symptoms in children recovering from concussion. METHODS: A prospective cohort study was conducted in a paediatric tertiary care clinic. Depression data were collected from 92 children using the Children's Depression Inventory-2 (CDI-2) screening tool. Correlations, t-tests and logistic regression were used to examine the associations between depression scores and demographic as well as injury-related factors. RESULTS: Depressive symptoms were found in 22% of the children (T score on CDI-2 >65). Children with evidence of depressive symptomatology had significantly higher mean post-concussive symptom inventory (PCSI) scores in recovery (p = 0.004) than children who were not depressed. Variables of i) Sex; ii) hospital admission; iii) number of head injuries; iv) post-concussion symptom score and v) experience of prolonged symptoms were predictive of clinically significant CDI T scores, explaining 36% of the variation in the binary logistic model. CONCLUSION: Depression is commonly reported in this subset of children. High post-concussive symptom scores and hospital admission were strong predictors of depression. Screening for depression should be standard practice in concussion management in children and youth.

Evaluating Mental Health Literacy in the Workplace: Development and Psychometric Properties of a Vignette-Based Tool.

Purpose Early intervention and support for workers with mental health problems may be influenced by the mental health literacy of the worker, their colleagues and their supervisor. There are gaps, however, in our understanding of how to develop and evaluate mental health literacy within the context of the workplace. The purpose of this study was to evaluate the psychometric properties of a new Mental Health Literacy tool for the Workplace (MHL-W). Methods The MHL-W is a 16-question, vignette-based tool specifically tailored for the workplace context. It includes four vignettes featuring different manifestations of mental ill-health in the workplace, with parallel questions that explore each of the four dimensions of mental health literacy. In order to establish reliability and construct validity, data were collected from 192 healthcare workers who were participating in a mental health training project. Baseline data was used to examine the scale's internal consistency, factor structure and correlations with general knowledge ratings, confidence ratings, attitudes towards people with mental illness, and attitudes towards seeking help. Paired t-tests were used to examine pre and post intervention scores in order to establish responsiveness of the scale. Results There was strong support for internal consistency of the tool and a one-factor solution. As predicted, the scores correlated highly with an overall rating of knowledge and confidence in addressing mental health issues, and moderately with attitudes towards seeking professional help and (decreased) stigmatized beliefs. It also appears to be responsive to change. Conclusions The MHL-W scale is promising tool to track the need for and impact of mental health education in the workplace.

Beyond silence: protocol for a randomized parallel-group trial comparing two approaches to workplace mental health education for healthcare employees.

BACKGROUND: Mental illness is a significant and growing problem in Canadian healthcare organizations, leading to tremendous personal, social and financial costs for individuals, their colleagues, their employers and their patients. Early and appropriate intervention is needed, but unfortunately, few workers get the help that they need in a timely way due to barriers related to poor mental health literacy, stigma, and inadequate access to mental health services. Workplace education and training is one promising approach to early identification and support for workers who are struggling. Little is known, however, about what approach is most effective, particularly in the context of healthcare work. The purpose of this study is to compare the impact of a customized, contact-based education approach with standard mental health literacy training on the mental health knowledge, stigmatized beliefs and help-seeking/help-outreach behaviors of healthcare employees. METHODS/DESIGN: A multi-centre, randomized, two-group parallel group trial design will be adopted. Two hundred healthcare employees will be randomly assigned to one of two educational interventions: Beyond Silence, a peer-led program customized to the healthcare workplace, and Mental Health First Aid, a standardized literacy based training program. Pre, post and 3-month follow-up surveys will track changes in knowledge (mental health literacy), attitudes towards mental illness, and help-seeking/help-outreach behavior. An intent-to-treat, repeated measures analysis will be conducted to compare changes in the two groups over time in terms of the primary outcome of behavior change. Linear regression modeling will be used to explore the extent to which knowledge, and attitudes predict behavior change. Qualitative interviews with participants and leaders will also be conducted to examine process and implementation of the programs. DISCUSSION: This is one of the first experimental studies to compare outcomes of standard mental health literacy training to an intervention with an added anti-stigma component (using best-practices of contact-based education). Study findings will inform recommendations for designing workplace mental health education to promote early intervention for employees with mental health issues in the context of healthcare work. TRIAL REGISTRATION: May 2014 - ClinicalTrials.gov: NCT02158871.

"Do-Live-Well": a Canadian framework for promoting occupation, health, and well-being.

BACKGROUND: Occupational therapists can bring a unique and valuable perspective to the national dialogue on health promotion. Current approaches have a narrow focus on diet and exercise; a broader focus on occupation has the potential to enrich understanding regarding forces that contribute to health and well-being. PURPOSE: A new "Do-Live-Well" framework will be presented that is grounded in evidence regarding the links between what people do every day and their health and well-being. KEY ISSUES: Elements of the framework include eight different dimensions of experience and five key activity patterns that impact health and well-being outcomes. Personal and social forces that shape activity engagement also affect the links to health and well-being. IMPLICATIONS: The framework is designed to facilitate individual reflection, community advocacy, and system-level dialogue about the impact of day-to-day occupations on the health and well-being of Canadians.

The effect of electronic energy loss on irradiation-induced grain growth in nanocrystalline oxides.

Grain growth of nanocrystalline materials is generally thermally activated, but can also be driven by irradiation at much lower temperature. In nanocrystalline ceria and zirconia, energetic ions deposit their energy to both atomic nuclei and electrons. Our experimental results have shown that irradiation-induced grain growth is dependent on the total energy deposited, where electronic energy loss and elastic collisions between atomic nuclei both contribute to the production of disorder and grain growth. Our atomistic simulations reveal that a high density of disorder near grain boundaries leads to locally rapid grain movement. The additive effect from both electronic excitation and atomic collision cascades on grain growth demonstrated in this work opens up new possibilities for controlling grain sizes to improve functionality of nanocrystalline materials.

The web of silence: a qualitative case study of early intervention and support for healthcare workers with mental ill-health.

BACKGROUND: There is a high rate of stress and mental illness among healthcare workers, yet many continue to work despite symptoms that affect their performance. Workers with mental health issues are typically ostracized and do not get the support that they need. If issues are not addressed, however, they could become worse and compromise the health and safety, not only of the worker, but his/her colleagues and patients. Early identification and support can improve work outcomes and facilitate recovery, but more information is needed about how to facilitate this process in the context of healthcare work. The purpose of this study was to explore the key individual and organizational forces that shape early intervention and support for healthcare workers who are struggling with mental health issues, and to identify barriers and opportunities for change. METHODS: A qualitative, case study in a large, urban healthcare organization was conducted in order to explore the perceptions and experiences of employees across the organization. In-depth interviews were conducted with eight healthcare workers who had experienced mental health issues at work as well as eight workplace stakeholders who interacted with workers who were struggling (managers, coworkers, union leaders). An online survey was completed by an additional 67 employees. Analysis of the interviews and surveys was guided by a process of interpretive description to identify key barriers to early intervention and support. RESULTS: There were many reports of silence and inaction in response to employee mental health issues. Uncertainty in identifying mental health problems, stigma regarding mental ill health, a discourse of professional competence, social tensions, workload pressures, confidentiality expectations and lack of timely access to mental health supports were key forces in preventing employees from getting the help that they needed. Although there were a few exceptions, the overall study findings point to many barriers to supporting employees with mental health issues. CONCLUSIONS: In order to address the complex knowledge, attitudinal, interpersonal and organizational barriers to action, a multi-layered knowledge translation strategy is needed, that considers not only mental health literacy and anti-stigma interventions, but addresses the unique context of the work environment that can act as a barrier to change.

Accommodating Students with Disabilities: Fieldwork Educators' Experiences.

Background. Fieldwork is an essential part of experiential learning in occupational therapy education. Fieldwork educators identify limits on reasonable accommodation and difficulty implementing disability-related accommodations. Student occupational therapists with disabilities report discrimination from within the profession, including inflexible fieldwork environments. Purpose. To understand the experiences of occupational therapy fieldwork educators in Canada in accommodating students with disabilities and to develop action-oriented practice recommendations. Method. In this interpretive description study, we interviewed 11 fieldwork educators about their experiences accommodating students with disabilities. Interviews were recorded, transcribed, and analyzed using a constant comparative approach. Findings. Educators emphasized a meta-theme of "Learning" when asked about disability-related accommodations. Three subthemes about student learning emerged: 1. Educators focused on "Student Learning in Preparation for Professional Practice" rather than their fieldwork setting only; 2. Educators were "Using Occupational Therapy Skills for Student Learning" in fieldwork; and 3. Educators recognized that their professional and personal "Context Influences Student Learning." Conclusion. Fieldwork educators can work with students to align their accommodations with required learning outcomes for professional practice and use their occupational therapy skills to assist with implementation. Fieldwork educators require time and other supports to work effectively with all students.

Tande nou gwonde! (Hear us roar!)- Youth perspectives of maternal near-misses: Protocol for a photovoice study of young childbearing people's perspectives of maternal near-misses in northwest Haiti.

INTRODUCTION: Globally, a shift is occurring to recognize the importance of young peoples' health and well-being, their unique health challenges, and the potential they hold as key drivers of change in their communities. In Haiti, one of the four leading causes of death for those 20-24 years old is pregnancy, childbirth, and the weeks after birth or at the end of a pregnancy. Important gaps remain in existing knowledge about youth perspectives of maternal health and well-being within their communities. Youth with lived experiences of maternal near-misses are well-positioned to contribute to the understanding of maternal health in their communities and their potential role in bringing about change. OBJECTIVES: To explore and understand youth perspectives of maternal near-miss experiences that occurred in a local healthcare facility or at home in rural Haiti. METHODS: We will conduct a qualitative, community-based participatory research study regarding maternal near-miss experiences to understand current challenges and identify solutions to improve community maternal health, specifically focused on youth maternal health. We will use Photovoice to seek an understanding of the lived experiences of youth maternal near-miss survivors. Participants will be from La Pointe, a Haitian community served by their local healthcare facility. We will undertake purposeful sampling to recruit approximately 20 female youth, aged 15-24 years. Data will be generated through photos, individual interviews and small group discussions (grouped by setting of near-miss experience). Data generation and analysis are expected to occur over a three-month period. ETHICS AND DISSEMINATION: Ethics approval will be sought from Centre Médical Béraca in La Pointe, Haiti, and from the Hamilton Integrated Research Ethics Board in Hamilton ON, Canada. We will involve community stakeholders, especially youth, in developing dissemination and knowledge mobilisation strategies. Our findings will be disseminated as an open access publication, be presented publicly, at conferences, and defended as part of a doctoral thesis.

Co-creating a new Charter for equitable and inclusive co-creation: insights from an international forum of academic and lived experience experts.

BACKGROUND: Co-creation approaches, such as co-design and co-production, aspire to power-sharing and collaboration between service providers and service users, recognising the specific insights each group can provide to improve health and other public services. However, an intentional focus on equity-based approaches grounded in lived experience and epistemic justice is required considering entrenched structural inequities between service-users and service-providers in public and institutional spaces where co-creation happens. OBJECTIVES: This paper presents a Charter of tenets and principles to foster a new era of 'Equity-based Co-Creation' (EqCC). METHODS: The Charter is based on themes heard during an International Forum held in August 2022 in Ontario, Canada, where 48 lived experience experts and researchers were purposively invited to deliberate challenges and opportunities in advancing equity in the co-creation field. RESULTS: The Charter's seven tenets-honouring worldviews, acknowledging ongoing and historical harms, operationalising inclusivity, establishing safer and brave spaces, valuing lived experiences, 'being with' and fostering trust, and cultivating an EqCC heartset/mindset-aim to promote intentional inclusion of participants with intersecting social positions and differing historic oppressions. This means honouring and foregrounding lived experiences of service users and communities experiencing ongoing structural oppression and socio-political alienation-Black, Indigenous and people of colour; disabled, Mad and Deaf communities, women, 2S/LGBTQIA+ communities, people perceived to be mentally ill and other minoritised groups-to address epistemic injustice in co-creation methodologies and practice, thereby providing opportunities to begin to dismantle intersecting systems of oppression and structural violence. CONCLUSIONS: Each Charter tenet speaks to a multilayered, multidimensional process that is foundational to shifting paradigms about redesigning our health and social systems and changing our relational practices. Readers are encouraged to share their reactions to the Charter, their experiences implementing it in their own work, and to participate in a growing international EqCC community of practice.

When health care workers experience mental ill health: institutional practices of silence.

Based on findings from an institutional ethnography in a large mental health organization, we explore how institutional forces shape the experiences of health care workers with mental health issues. We interviewed 20 employees about their personal experiences with mental health issues and work and 12 workplace stakeholders about their interactions with workers who had mental health issues. We also reviewed organizational texts related to health, illness, and productivity. In analyzing transcripts and texts, silence emerged as a core underlying process characterizing individual and organizational responses to employees with mental health issues. Silence was an active practice that took many forms; it was pervasive, complex, and at times, paradoxical. It served many functions for workers and the organization. We discuss the theoretical and practical implications of the findings for workers with mental health issues.