A Call to Disrupt Heteronormativity and Cisnormativity in Physical Therapy: Perspectives of 2SLGBTQIPA+ Participants on Future Directions for PT Curricula.

Purpose: To explore the perspectives of individuals with self-reported expertise and/or lived experiences regarding aspects of 2SLGBTQIPA+ health that should be included in pre-licensure physical therapy (PT) curricula across Canada, including how, when, and by whom this content should be delivered. Method: We conducted a critical qualitative, cross-sectional study with semi-structured virtual interviews. We analyzed participants' perspectives thematically using the DEPICT method. Results: Thirteen participants across Canada with a variety of gender identities and sexual orientations were interviewed. Participants described how transformative change on 2SLGBTQIPA+ issues in PT requires an approach that is based on interrupting heteronormativity and cisnormativity in PT curricula. Participants explained how this could be achieved by (1) emphasizing both historical inequities and present-day considerations for safe and inclusive practice, (2) introducing the content early and integrating it throughout the programme using a variety of large- and small-group sessions, and (3) including 2SLGBTQIPA+ individuals in content delivery and creation. Conclusions: This study brings attention to the need for the PT profession to understand how the pervasive social structures of heteronormativity and cisnormativity shape education and practice, and offer strategies for disrupting complicity with these systems of inequality.

Objectif: explorer les points de vue des personnes qui déclarent avoir des compétences ou des expériences de vie relativement à des aspects de la santé des LGBTQIPA2+ qui pourraient être inclus dans le programme de physiothérapie avant l'obtention du permis au Canada, y compris la manière de transmettre la matière, ainsi que le moment où la transmettre et par qui elle doit être transmise. Méthodologie: étude qualitative transversale critique comprenant des entrevues virtuelles semi-structurées. Les chercheurs ont analysé les points de vue des participants par thèmes, à l'aide de la méthode DEPICT. Résultats: au total, 13 participants du Canada de diverses identités de genre et orientations sexuelles ont participé à une entrevue. Ils ont décrit que, pour parvenir à un changement transformatif des enjeux LGBTQIPA2+ en physiothérapie, il faut adopter une approche reposant sur l'interruption de l'hétéronormativité et de la cisnormativité au sein du programme de physiothérapie. Les participants expliquent comment y parvenir : 1) en soulignant à la fois les iniquités historiques et les considérations actuelles en matière de pratique inclusive sécuritaire, 2) en présentant la matière tôt et en l'intégrant à tout le programme dans le cadre de séances en grands et en petits groupes 3) en faisant participer les personnes LGBTQIPA2+ à la présentation et à la création de la matière. Conclusions: la présente étude fait ressortir toute l'importance de faire comprendre à la profession comment les structures sociales d'hétéronormativité et de cisnormativité omniprésentes modèlent l'éducation et la pratique, et comment offrir des stratégies pour enrayer la complicité avec ces systèmes d'inégalité.

Evaluation of a knowledge translation intervention for HIV and rehabilitation advocacy in physiotherapy in three sub-Saharan African countries.

PURPOSE: To evaluate a knowledge translation intervention to determine knowledge, attitudes and self-efficacy related to HIV and rehabilitation advocacy in physiotherapy students. METHODS: A pre and post-test study was conducted at three physiotherapy-training programs in Sub Saharan Africa - the University of the Witwatersrand (Wits), the University of Zambia (UNZA) and Kenya Medical Technical College (KMTC). For each site, the knowledge, attitude and self-efficacy of physiotherapy students were tested pre- and post-intervention using a standardized questionnaire. RESULTS: Students' knowledge improved with regard to being able to describe the challenges faced by their patients, knowing what resources are available and understanding their role as an advocate. In terms of self-efficacy, they felt more confident clinically, as well as being a resource person to colleagues and an advocate for their patients.This study highlights the need to contextualize knowledge translation interventions to meet the unique needs of individual academic sites. Students who have clinical experience working with people living with HIV are more likely to embrace their role as advocates in the area of HIV and rehabilitation.Implications for RehabilitationThe knowledge translation process used in this study gives a concrete example of how to use research evidence on HIV knowledge in rehabilitation applied within the advocacy process.Applying the principles of advocacy translates to understanding the management of HIV practically.Clinical experience in managing people living with HIV strengthens knowledge and improves the attitude of physiotherapy studentsPhysiotherapy students need guidance in realizing their potential as advocates for holistic rehabilitation care for people living with HIV.

Turning the tide on inequity through systematic equity action-analysis.

BACKGROUND: Collective agreement about the importance of centering equity in health research, practice, and policy is growing. Yet, responsibility for advancing equity is often situated as belonging to a vague group of 'others', or delegated to the leadership of 'equity-seeking' or 'equity-deserving' groups who are tasked to lead systems transformation while simultaneously navigating the violence and harms of oppression within those same systems. Equity efforts also often overlook the breadth of equity scholarship. Harnessing the potential of current interests in advancing equity requires systematic, evidence-guided, theoretically rigorous ways for people to embrace their own agency and influence over the systems in which they are situated. ln this article, we introduce and describe the Systematic Equity Action-Analysis (SEA) Framework as a tool that translates equity scholarship and evidence into a structured process that leaders, teams, and communities can use to advance equity in their own settings. METHODS: This framework was derived through a dialogic, critically reflective and scholarly process of integrating methodological insights garnered over years of equity-centred research and practice. Each author, in a variety of ways, brought engaged equity perspectives to the dialogue, bringing practical and lived experience to conversation and writing. Our scholarly dialogue was grounded in critical and relational lenses, and involved synthesis of theory and practice from a broad range of applications and cases. RESULTS: The SEA Framework balances practices of agency, humility, critically reflective dialogue, and systems thinking. The framework guides users through four elements of analysis (worldview, coherence, potential, and accountability) to systematically interrogate how and where equity is integrated in a setting or object of action-analysis. Because equity issues are present in virtually all aspects of society, the kinds of 'things' the framework could be applied to is only limited by the imagination of its users. It can inform retrospective or prospective work, by groups external to a policy or practice setting (e.g., using public documents to assess a research funding policy landscape); or internal to a system, policy, or practice setting (e.g., faculty engaging in a critically reflective examination of equity in the undergraduate program they deliver). CONCLUSIONS: While not a panacea, this unique contribution to the science of health equity equips people to explicitly recognize and interrupt their own entanglements in the intersecting systems of oppression and injustice that produce and uphold inequities.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey.

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review.

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

HIV advocacy: knowledge translation and implementation at three diverse sites in sub-Saharan Africa.

PURPOSE: To explore how the gap in knowledge translation around HIV and rehabilitation could be addressed using advocacy. This article describes and reflects on lessons learned from incorporating content on HIV and advocacy into the curricula at three diverse physiotherapy (PT) programs in sub-Saharan Africa. METHODS: A realistic evaluation approach was followed. Three study sites were purposively chosen to reflect diverse settings with respect to pedagogical approach, university or college, degree or diploma programs, use of technology, and regional prevalence of HIV. A multi-faceted intervention was implemented that included three activities: (i) to develop three core components of a novel knowledge translation intervention designed to improve knowledge, attitudes, and self-efficacy in HIV and rehabilitation advocacy among PT students; (ii) to tailor and implement the knowledge translation intervention by local faculty according to the context and needs of their program and to implement this with a cohort of PT students at each of the three study sites; and (iii) to evaluate the adaptation and implementation of the intervention at each site. RESULTS: Differences exist between the three-country programmes, specifically in the length of time the degree takes, the extent of HIV inclusion in the curriculum and years of the study included in the project. CONCLUSIONS: This research adds to the call to shift the focus of HIV care from just test-and-treat, or on just keeping people alive, towards a broader approach that centres the whole person, that focuses not only on surviving but on thriving, and which commits to the goal of optimising functioning and living full, whole lives with HIV. Advocacy across the continuum of care plays a pivotal role in translating research findings into practice.Implications for rehabilitationResults are relevant for policymakers in government and at senior levels within universities whose mandates include informing, reviewing, and driving educational programs and curricula.The result from this project illuminates the role for rehabilitation and allows for incorporating HIV into curriculum and practice for physiotherapists and other related stakeholders so that they can advocate for and with patients.

Navigating the Grey Zone of Physiotherapy Assistant Autonomy in Home Care: Perspectives of Physiotherapists and Physiotherapy Assistants.

Purpose: To explore perspectives and experiences regarding the autonomy of physiotherapist assistants (PTAs) among physiotherapists and PTAs providing home care services in Ontario since the introduction of PTAs into home care rehabilitation teams. Method: For this qualitative study, we conducted semi-structured interviews with 10 physiotherapists and 5 PTAs working in home care. We analyzed interview transcripts using the DEPICT model. Results: Participants described navigating a grey zone characterized by a lack of clarity about acceptable levels of PTA autonomy. Four interrelating factors shaped the extent to which PTAs practised with autonomy: system influences (number of physiotherapy visits, professional guidelines), patient complexity (status, comorbidities), perceived PTA competence (skills, training), and the physiotherapist-PTA relationship (trust, communication). Conclusions: New practice models in home care have impacted the role of both physiotherapists and PTAs. Home care agencies should facilitate emerging professional relationships and address autonomy-related challenges, such as trust and competence, to promote high-quality client-centred care.

Objectif : explorer les perspectives et les expériences relatives à l'autonomie des assistants-physiothérapeutes (APT) chez les physiothérapeutes et les APT qui donnent des soins à domicile en Ontario depuis que les APT ont été intégrés aux équipes de réadaptation à domicile. Méthodologie : dans le cadre de cette étude qualitative, les auteurs ont réalisé des entrevues semi-structurées auprès de dix physiothérapeutes et de cinq APT en soins à domicile. Ils ont analysé les transcriptions d'entrevue au moyen du modèle DEPICT. Résultats : les participants ont décrit qu'ils évoluaient dans une zone grise caractérisée par l'absence de clarté quant aux taux d'autonomie acceptables pour les APT. Quatre facteurs interreliés déterminaient les limites de l'autonomie des APT : les influences des systèmes (nombre de visites en physiothérapie, directives professionnelles), complexité des patients (état, autres maladies), perception des compétences des APT (habiletés, formation) et relation entre le physiothérapeute et l'APT (confiance, communication). Conclusions : les nouveaux modèles d'exercice en soins à domicile ont des répercussions sur le rôle des physiothérapeutes tout autant que des APT. Les agences de soins à domicile devraient faciliter les relations professionnelles émergentes et aborder les problèmes liés à l'autonomie, comme la confiance et la compétence, pour promouvoir des soins de qualité axés sur le patient.

Impact of a family-centred early intervention programme in South India on caregivers of children with developmental delays.

BACKGROUND: This study evaluated the impact on caregiver strain and family empowerment among caregivers of children with disabilities who received training and education as part of a family-centred community-based early intervention programme in South India. METHODS: This prospective open cohort longitudinal study compared change from baseline to two years post-intervention among caregivers of the first cohort of children who were enrolled in the programme. Paired t-tests determined effect on the Modified Caregiver Strain Index (MCSI) and Family Empowerment Scale (FES), and p-values were adjusted for multiple comparisons using the False Discovery Rate approach. RESULTS: Of the 308 caregivers (91% women), 44% provided care to children with cerebral palsy and 56% to children with other developmental delays. The mean age of the children at baseline was 3.3 (±1.5 years). The overall mean change from baseline in the FES was 4.1 (95% CI: 3.3, 4.9; p < 0.001) representing improved empowerment. The mean change for the MCSI score was -3.7 (95% CI: -4.5, -2.9; p < 0.001) representing reduced caregiver strain. CONCLUSIONS: A family-centred early intervention programme that provides training and education to caregivers of children with developmental delays demonstrated positive change in caregiver strain and family empowerment.Implications for RehabilitationThe well-being of a child is influenced by the well-being of their caregiver.Improving caregiver well-being can help improve care and support for children with developmental delays.A family-centred early intervention therapy programme that includes training and education to caregivers can reduce strain and improve family empowerment.

The relationship between stigma and a rehabilitation framework [international classification of functioning, disability and health (ICF)]: three case studies of women living with HIV in Lusaka, Zambia.

PURPOSE: To explore how the International Classification of Functioning, Disability and Health, a rehabilitation framework, can provide a holistic understanding of stigma experiences of three women living with human immunodeficiency virus in Lusaka, Zambia. METHODS: A secondary analysis of three cases by drawing on interview transcripts collected as part of a larger longitudinal study with eighteen women living with the virus. The interview tool used the rehabilitation framework to ask questions about the impact of the virus on the body, daily activities, social participation and the future. Vignettes were produced for each of the eighteen women including information on stigma and the rehabilitation framework. Three case studies were developed from women who provided comprehensive accounts of stigma and the International Classification of Functioning, Disability and Health. RESULTS: Stigma experiences aligned well with three dimensions of the International Classification of Functioning, Disability and Health: participation restrictions, environmental and personal factors. These domains were used to understand stigma in three forms (i.e. enacted, self and structural stigma) as experienced by these women. CONCLUSIONS: More research is needed to ascertain how stigma and rehabilitation are related in other environments and populations and to explore how to mitigate stigma within the rehabilitation context.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals deal with aspects of stigma and discrimination in their clinical work and this analysis offers a way to consider HIV-related stigma within rehabilitation in an organized and theoretically-informed way.The insights from this study are important for the field of HIV and for advancing understanding of the complexities of stigma in the context of rehabilitation more broadly.This analysis offers guidance to rehabilitation providers about the nuanced and multi-faceted ways that stigma can occur in the context of rehabilitation, including within their own clinical practice.

Integrated care pathways for Black persons with traumatic brain injury: a protocol for a critical transdisciplinary scoping review.

BACKGROUND: Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI. METHODS: CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O'Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts. DISCUSSION: The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI. SYSTEMATIC REVIEW REGISTRATION: Not applicable.

Enabling Access to Rehabilitation in Acute Care: Exploring Physiotherapists' and Occupational Therapists' Perspectives on Patient Care When Assistants Become the Primary Therapy Providers.

Purpose: The aim of this study was to explore physiotherapists' and occupational therapists' perspectives on how the implementation of a new model of care in the acute medicine setting has affected their practice and patient care outcomes. Method: A qualitative case study was used to gain an in-depth understanding of therapists' experiences. Semi-structured, in-person interviews (45-60 min long) were conducted with eight clinicians (four occupational therapists and four physiotherapists). We used an iterative process of discussion and questioning to interpret the themes emerging from the data. Results: The findings are grouped into four categories - change in the therapist-patient relationship, change in therapists' access to first-hand patient information, developing processes to enhance information exchange, and developing processes to support patient care delivery - and two themes - therapists' expectations of patient care outcomes and redefining the value of the occupational therapists' and physiotherapists' role in contributing to patient care. Conclusions: Participants described the process of adapting their professional skills and behaviours as they evolved into the role of manager of therapy care. Occupational therapists and physiotherapists recognized the potential for occupational therapist assistants (OTAs) and physiotherapist assistants (PTAs) to provide more frequent and consistent care. The therapists highlighted the necessity of ensuring that effective working processes and interactions between the therapist and the OTAs and PTAs were in place to ensure high-quality patient care.

Objectif : explorer les points de vue des physiothérapeutes et des ergothérapeutes sur la mise sur pied d'un nouveau modèle de soins aigus qui a eu une incidence sur leur pratique et les résultats des soins aux patients. Méthodologie : les chercheurs ont privilégié une étude de cas qualitative pour tâcher de mieux comprendre les expériences des thérapeutes. Ils ont réalisé des entrevues individuelles semi-structurées (de 45 à 60 minutes) auprès de huit cliniciens (quatre ergothérapeutes et quatre physiothérapeutes). Ils ont privilégié un processus itératif de discussion et de questions pour interpréter les thèmes qui se sont dégagés. Résultats : les résultats sont divisés en quatre catégories (changement à la relation entre le thérapeute et le patient, changement à l'accès à l'information directe sur le patient, élaboration de processus pour améliorer l'échange d'information et élaboration de processus pour soutenir la prestation des soins aux patients) et en deux thèmes (attentes des thérapeutes quant aux résultats des soins au patient et redéfinition de la valeur du rôle de l'ergothérapeute et du physiothérapeute dans les soins au patient). Conclusion : les participants ont décrit le processus d'adaptation de leurs compétences et comportements professionnels dans l'évolution de leur rôle vers celui de gestionnaires des soins thérapeutiques. Les ergothérapeutes et les physiothérapeutes ont convenu de la possibilité que des soins plus fréquents et plus réguliers soient fournis par les assistants-ergothérapeutes et les assistants-physiothérapeutes. Les thérapeutes ont souligné la nécessité de s'assurer de la mise en place de processus de travail et d'interactions efficaces entre les assistants-ergothérapeutes, les assistants-physiothérapeutes et les autres thérapeutes pour garantir des soins de qualité aux patients.

Two approaches to longitudinal qualitative analyses in rehabilitation and disability research.

Purpose: Although relatively unknown within the field of rehabilitation, qualitative longitudinal research is ideal for rehabilitation and disability research that aims to understand health-related challenges over time. We describe the strengths and challenges of longitudinal qualitative research using two concrete examples.Materials and methods: Qualitative longitudinal research often involves in-depth interviews of participants on multiple occasions over time. Analytic approaches are complex, summarizing data both cross-sectionally and longitudinally. We present two detailed analytic approaches used in research with people living with HIV in Zambia and Canada.Results: Our experiences provide three recommendations. First, development of the initial analytic coding framework should include both inductive and deductive approaches. Second, given the large quantity of data generated through longitudinal qualitative research, it is important to proactively develop strategies for data analysis and management. Third, as retention of participants is challenging over time, we recommend the use of a consistent interviewer over the duration of the study to promote a trusting relationship.Conclusions: Longitudinal qualitative research has much to offer researchers and can provide clinicians with insights on the challenges of living with chronic and episodic disability. The flexibility in analytic approaches allows for diverse strategies to best address the rehabilitation and disability research questions and allow for insights into living with disability over time.

Perspectives on ART adherence among Zambian adults living with HIV: insights raised using HIV-related disability frameworks.

Anti-retroviral treatment (ART) has improved the survival of people living with HIV in Africa. Living with chronic HIV comes with new health and functional challenges and the need to manage ART adherence. The Sepo Study applied disability frameworks to better understand living with chronic HIV while using ART. The study followed 35 people (18 women, 17 men) living with HIV and on ART 6 months or longer in private and public health facilities in Lusaka, Zambia over 18-months (2012-2015). A total of 99 in-depth interviews were conducted. Conventional content analysis and NVIVOv10 were applied to analyse the data. Participants were adhering to ART at the times of the interviews and therefore less likely to report major challenges with adherence. Three main themes emerged from the data related to adherence. Firstly, ART was regarded as "giving life", which underscored adherence. Secondly, all participants described strategies for to managehealth and functional limitations, which they attributed as side-effects or chronicity. Thirdly, participants described experiences of uncertainty, including the efficacy of new regimens, potential loss of functioning, risk of new health problems, and death. Long-term ART managment in Africa needs to integrate rehabilitation approaches to address functional limitations, uncertainties, strengthen and support for adherence.

I Work Out, Who Cares if I'm Bigger: What Matters to Youth with ASD regarding Weight and Their Bodies?

Background: Childhood overweight and obesity, in addition to weight stigma, can result in numerous physical and psychosocial conditions. Children with Autism Spectrum Disorder (ASD) are at a higher risk of developing overweight/obesity than their typically developing peers, yet we know little about what matters to them with regards to weight and their bodies.Methods: Eight semi-structured interviews were conducted with youth with ASD. Interviews were transcribed and analyzed using a phenomenological approach within an interpretive paradigm.Results: Participants mostly showed little concern about their weight. Participants highly valued moving their bodies and reported feeling good about their bodies.Discussion: Findings suggest that children with ASD may be more engaged in healthcare discussions focusing on growth and health rather than size and weight. This approach can also reduce stigmatizing discussions.

Types of episodic disability among people living with HIV in Zambia.

HIV is increasingly recognized as a chronic illness which may result in episodic disability related to the effects of the virus, side effects of medication, co-morbidities and consequences of aging. Little is known about the episodic disability experiences of people living long-term with HIV in resource-limited countries, which is best understood by following people over time. This qualitative longitudinal study examined the episodic disability experiences and the applicability of four types of episodic disability among people living with HIV and on anti-retroviral therapy in Zambia. We interviewed 31 men and women living with HIV on 3 occasions at 6-month intervals (total of 93 interviews) examining the processes of change over time. We used disability models to inform the interviews exploring impairments/symptoms, activity limitations and participation restrictions. Longitudinal analyses of transcribed interviews confirmed the applicability of four types over time: stable, increasing disability, decreasing disability and significant fluctuations. Analyses highlighted the extent to which determinants of health contributed to the disability experienced. The use of disability models revealed the importance of environmental and social influences on disability and quality of life. The indicators of the type of episodic disability could be used clinically to help understand the nature and potential triggers of the episodes.

Systematic analysis of global health research funding in Canada, 2000-2016.

OBJECTIVES: Considering recent shifts in global funding landscapes, this study analyzes Canada's long-term global health research funding trends in the hope of informing a new Canadian global health research strategy. Examining past investments can help prioritize limited future resources to either build on Canada's existing strengths or fill gaps where needed, while simultaneously informing the investments of research funders in other countries. METHODS: Administrative data were analyzed covering all 1584 global health research grants awarded by the Canadian Institutes of Health Research (CIHR) to 927 unique principal investigators from 2000 to 2016, totalling C$341 million. Existing metadata associated with each grant was supplemented by additional qualitative coding. Descriptive time-series analyses of global health research grant data were conducted using various measures related to each grant's recipient (e.g., province, university, sex, distribution) and subject matter (e.g., research theme, area, focus). RESULTS: CIHR's total annual global health research funding increased sharply from $3.6 million in FY2000/2001 to $30.3 million in FY2015/2016, with the largest share of research funding now focused on health equity-representing nearly 50% of CIHR's global health research funding. Past grants have concentrated on infectious disease and public health research. One third of CIHR's global health grant funding went to 20 principal investigators. Only 42.2% of global health research funding came from CIHR's open investigator-driven competitions, with the rest coming from strategic priority-driven competitions. CONCLUSION: Global health research has seen steady increases in funding from CIHR's open competitions when preceded by investment in strategic competitions, which suggests the level of a national research funding agency's strategic investments in global health research may determine the size of the field in their country. The greatest concentration of past investment lies in health equity research, followed by infectious disease research. Future analyses of research funding would benefit from an internationally accepted keyword classification scheme and more granular administrative data.

The coin model of privilege and critical allyship: implications for health.

Health inequities are widespread and persistent, and the root causes are social, political and economic as opposed to exclusively behavioural or genetic. A barrier to transformative change is the tendency to frame these inequities as unfair consequences of social structures that result in disadvantage, without also considering how these same structures give unearned advantage, or privilege, to others. Eclipsing privilege in discussions of health equity is a crucial shortcoming, because how one frames the problem sets the range of possible solutions that will follow. If inequity is framed exclusively as a problem facing people who are disadvantaged, then responses will only ever target the needs of these groups without redressing the social structures causing disadvantages. Furthermore, responses will ignore the complicity of the corollary groups who receive unearned and unfair advantage from these same structures. In other words, we are missing the bigger picture. In this conceptualization of health inequity, we have limited the potential for disruptive action to end these enduring patterns.The goal of this article is to advance understanding and action on health inequities and the social determinants of health by introducing a framework for transformative change: the Coin Model of Privilege and Critical Allyship. First, I introduce the model, which explains how social structures produce both unearned advantage and disadvantage. The model embraces an intersectional approach to understand how systems of inequality, such as sexism, racism and ableism, interact with each other to produce complex patterns of privilege and oppression. Second, I describe principles for practicing critical allyship to guide the actions of people in positions of privilege for resisting the unjust structures that produce health inequities. The article is a call to action for all working in health to (1) recognize their positions of privilege, and (2) use this understanding to reorient their approach from saving unfortunate people to working in solidarity and collective action on systems of inequality.