Contraceptive Provision to Women With Intellectual and Developmental Disabilities Enrolled in Medicaid.

OBJECTIVE: To compare contraceptive provision to women with and without intellectual and developmental disabilities enrolled in North Carolina Medicaid. METHODS: Our retrospective cohort study used 2019 North Carolina Medicaid claims to identify women aged 15-44 years with and without intellectual and developmental disabilities at risk for pregnancy who were continuously enrolled during 2019 or had Family Planning Medicaid with at least one claim. We calculated the proportion in each cohort who received 1) most or moderately effective contraception, 2) long-acting reversible contraception, 3) short-acting contraception, and 4) individual methods. We classified contraceptive receipt by procedure type and disaggregated across sociodemographic characteristics. Adjusting for age, race, ethnicity, and urban or rural setting, we constructed logistic regression models to estimate most or moderately effective contraceptive provision odds by intellectual and developmental disability status and by level or type of intellectual and developmental disability. We performed subanalyses to estimate co-occurrence of provision and menstrual disorders. RESULTS: Among 9,508 women with intellectual and developmental disabilities and 299,978 without, a significantly smaller proportion with intellectual and developmental disabilities received most or moderately effective contraception (30.1% vs 36.3%, P <.001). With the exception of injectable contraception, this trend was consistent across all measures and remained statistically significant after controlling for race, ethnicity, age, and urban or rural status (adjusted odds ratio 0.75, 95% CI 0.72-0.79; P <.001). Among those who received most or moderately effective contraception, a significantly greater proportion of women with intellectual and developmental disabilities had co-occurring menstrual disorders (31.3% vs 24.3%, P <.001). CONCLUSION: These findings suggest disparities in contraceptive provision and potential differences in clinical indication by intellectual and developmental disability status. Future studies should investigate reasons for and barriers to contraceptive use among women with intellectual and developmental disabilities.

Toward an Integrated Framework in Health and Human Rights Education: Transformative Pedagogies in Social Medicine, Collective Health, and Structural Competency.

Global health equity is at a historically tenuous nexus complicated by economic inequality, climate change, mass migration, racialized violence, and global pandemics. Social medicine, collective health, and structural competency are interdisciplinary fields with their own histories and fragmentary implementation in health equity movements situated both locally and globally. In this paper, we review these three fields' historical backgrounds, theoretical underpinnings, and contemporary contributions to global health equity. We believe that intentional dialogue between these fields could promote a generative discourse rooted in a shared understanding of their historical antecedents and theoretical frameworks. We also propose pedagogical tools grounded within our own critical and transformative pedagogies that offer the prospect of bringing these traditions into greater dialogue for the purpose of actualizing the human right to health.

Parenting in a conflict-affected setting: Discipline practices, parent-child interactions, and parenting stress in Liberia.

Children in conflict-affected settings are at increased risk for exposure to violence, placing particular importance on caregiving environments. This study first describes parenting in urban Liberia by evaluating parent-child interactions, the use and acceptance of harsh and nonharsh discipline, discipline preferences, and the co-occurrence of positive interactions and harsh discipline. The relationship between parenting stress and harsh discipline attitudes and behaviors is then tested. Participants included 813 parents with a child aged 3 or 4 years old. A quantitative survey battery assessed parent-child interactions; discipline practices, preferences, and attitudes; and parenting stress. Parents reported frequent use and high acceptance of nonharsh discipline, as well as frequent positive interactions with their child. Though parents reported less frequent use and low acceptance of harsh discipline, preference for harsh discipline-based on hypothetical situations rather than self-report-was common. There was co-occurrence of frequent positive interactions and frequent harsh discipline, with one third reporting high frequency of both. Regression analysis revealed greater parenting stress (ß = .15, t = 4.49, p < .001) and stronger acceptance of harsh discipline (ß = .47, t = 15.49, p < .001) were associated with more frequent harsh discipline. Acceptance of harsh discipline interacted with parenting stress to predict the use of harsh discipline (ß = -.09, t = -3.09, p < .01). Among parents with lowest average acceptance of harsh practices, stress predicted more frequent harsh discipline, but acceptance did not moderate the association for those who are most accepting of harsh practices. Building on existing parenting strengths and addressing parenting stress could promote nurturing caregiving in conflict-affected settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparing fears about paediatric HIV disclosure to the lived experiences of parents and guardians: a prospective cohort study.

OBJECTIVE: We aimed to: (1) follow parents and guardians through the process of paediatric HIV disclosure to understand how often pre-disclosure worries are realised; and (2) estimate the effects of disclosure on child, caregiver, and family well-being. DESIGN: We conducted a 12-month prospective cohort study in Zimbabwe with 123 primary caregivers of children ages 9 to 15 years who were HIV positive but did not know their serostatus at baseline. By the end of the study period 65 caregivers reported that their child learned his or her HIV-positive status. MAIN OUTCOME MEASURES: We used three waves of data to compare caregivers' pre-disclosure worries to post-disclosure reports and to characterise associations between disclosure and well-being of the child (Strengths and Difficulties Questionnaire), caregiver (Patient Health Questionnaire-9), and family (Family Relationship Quality) over time. RESULTS: Caregivers' pre-disclosure worries and fears about how their child would react to disclosure of their HIV status largely went unrealised. Furthermore, we did not find strong evidence of clinically-important increases in problems on average following disclosure. CONCLUSION: Findings support the call to identify supportive intervention strategies that address caregiver fears at the beginning of the disclosure process.

Deploying machine learning with messy, real world data in low- and middle-income countries: Developing a global health use case.

The rapid emergence of machine learning in the form of large-scale computational statistics and accumulation of data offers global health implementing partners an opportunity to adopt, adapt, and apply these techniques and technologies to low- and middle-income country (LMIC) contexts where we work. These benefits reside just out of the reach of many implementing partners because they lack the experience and specific skills to use them. Yet the growth of available analytical systems and exponential growth of data require the global digital health community to become conversant in this technology to continue to make contributions to help fulfill our missions. In this community case study, we describe the approach we took at IntraHealth International to inform the use case for machine learning in global health and development. We found that the data needed to take advantage of machine learning were plentiful and that an international, interdisciplinary team can be formed to collect, clean, and analyze the data at hand using cloud-based (e.g., Dropbox, Google Drive) and open source tools (e.g., R). We organized our work as a "sprint" lasting roughly 10 weeks in length so that we could rapidly prototype these approaches in order to achieve institutional buy in. Our initial sprint resulted in two requests in subsequent workplans for analytics using the data we compiled and directly impacted program implementation.

The Health Innovation Impact Checklist: a tool to improve the development and reporting of impact models for global health innovations.

Donor financing is increasingly relying on performance-based measures that demonstrate impact. As new technologies and interventions enter the innovation space to address global health challenges, innovators often need to model their potential impact prior to obtaining solid effectiveness data. Diverse stakeholders rely on impact modeling data to make key funding and scaling decisions. With a lack of standardized methodology to model impact and various stakeholders using different modeling strategies, we propose that a universal innovation impact checklist be used to aid in transparent and aligned modeling efforts. This article describes a new Health Innovation Impact Checklist (HIIC) - a tool developed while evaluating the impact of health innovations funded under the Saving Lives at Birth (SL@B) program. SL@B, a global health Grand Challenge initiative, funded 116 unique maternal and newborn health innovations, four of which were selected for cost-effectiveness analyses (CEAs) within our evaluation. A key data source needed to complete a CEA was the lives saved estimate. HIIC was developed to help validate draft impact models from the SL@B donors and our own team's additional modeling efforts, to ensure the inclusion of standardized elements and to pressure test assumptions for modeling impact. This article describes the core components of HIIC including its strengths and limitations. It also serves as an open call for further reviewing and tailoring of this checklist for applicability across global efforts to model the impact of health innovations.

Applying WHO COVID-19 workforce estimate tools remotely in an African context: a case report from Mali and Kenya.

BACKGROUND: The COVID-19 pandemic has increased the burden on health systems, particularly in low- and middle-income countries, where health systems already struggle. To meet health workforce planning needs during the pandemic, IntraHealth International used two tools created by the World Health Organization (WHO) Regional Office for Europe. The Health Workforce Estimator (HWFE) allows the estimation of the quantity of health workers needed to treat patients during a surge, and the Adaptt Surge Planning Support Tool helps to predict the timing of a surge in cases and the number of health workers and beds needed for predicted caseload. These tools were adapted to fit the African context in a rapid implementation over 5 weeks in one region in Mali and one region in Kenya with the objective to test the feasibility of adapting these tools, which use a Workload Indicators of Staffing Need (WISN)-inspired human resources management methodology, to obtain daily and surge projections of COVID-19 human resources for health needs. CASE PRESENTATION: Using a remote team in the US and in-country teams in Mali and Kenya, IntraHealth enacted a phased plan to gather stakeholder support, collect data related to health systems and COVID-19 cases, populate data into the tools, verify modeled results with results on the ground, enact policy measures to meet projected needs, and conduct national training workshops for the ministries of health. CONCLUSIONS: This phased implementation in Mali and Kenya demonstrated that the WISN approach applied to the Health Workforce Estimator and Adaptt tools can be readily adapted to the local context for African countries to rapidly estimate the number of health workers and beds needed to respond to the predicted COVID-19 pandemic caseload. The results may also be used to give a proxy estimate for needed health supplies-e.g., oxygen, medications, and ventilators. Challenges included accurate and timely data collection and updating data. The success of the pilot can be attributed to the adapted WHO tools, the team composition in both countries, access to human resources data, and early support of the ministries of health, with the expectation that this methodology can be applied to other country contexts.

A method for translating search strategies efficiently into HMIC and SPP.

BACKGROUND: Small databases, such as Health Management Information Consortium (HMIC) and Social Policy and Practice (SPP), can add value to systematic searches. Search strategies designed for large databases may not be appropriate in small sources. A different approach to translating strategies could ensure that small databases are searched efficiently. OBJECTIVES: To establish the contribution HMIC and SPP made to public health guidelines (PHGs); and to recommend an efficient method of translating search strategies. METHODS: Eight PHGs were analysed to establish how many included publications were retrieved from HMIC and SPP. Six options for translating strategies from MEDLINE, using variations of free text and subject terms, were compared. RESULTS: Health Management Information Consortium contributed 15 and SPP eight of the 483 publications cited in the PHGs. The free-text only search was the one option to miss an included publication. The heading word (with truncation) option was more precise than applying subject headings. DISCUSSION: There is a risk of missing relevant publications in free-text only searches and it is preferable to include subject terms efficiently. CONCLUSION: The heading word (with truncation) option did not miss the evidence included in the PHGs and was the most efficient method for translating MEDLINE to HMIC and SPP.

Improving global maternal and newborn survival via innovation: Stakeholder perspectives on the Saving Lives at Birth Grand Challenge.

The Saving Lives at Birth (SL@B) funding partners joined in 2011 to source, support, and scale maternal and newborn health (MNH) innovations to improve maternal and newborn survival by focusing on the 24 hours around the time of birth. A multi-methods, retrospective portfolio evaluation was conducted to determine SL@B's impact. Forty semi-structured, key informant interviews (KIIs) were conducted with experts in global MNH based in low- and middle-income and in high-income countries to assess the SL@B program. KIIs were conducted with global MNH technical experts, innovators, government officials in low- and middle-income countries, donors, private investors, and implementing partners to include the full spectrum of voices involved in identifying and scaling innovations. Data were analyzed using thematic analysis. Stakeholders believe the SL@B program has been successful in changing the way maternal and newborn health programs are delivered with a focus on doing things differently through innovation. The open approach to sourcing innovation was seen as positive to the extent that it brought more interdisciplinary stakeholders to think about the problem of maternal and newborn survival. However, a demand-driven approach that aims to source innovations that address MNH priority needs and takes into account the needs of end users (e.g. individuals and governments) was suggested as a strategy for ensuring that more innovations go to scale.

The NICE MEDLINE and Embase (Ovid) health apps search filters: development of validated filters to retrieve evidence about health apps.

OBJECTIVES: Health apps are software programs that are designed to prevent, diagnose, monitor, or manage conditions. Inconsistent terminology for apps is used in research literature and bibliographic database subject headings. It can therefore be challenging to retrieve evidence about them in literature searches. Information specialists at the United Kingdom's National Institute for Health and Care Excellence (NICE) have developed novel validated search filters to retrieve evidence about apps from MEDLINE and Embase (Ovid). METHODS: A selection of medical informatics journals was hand searched to identify a "gold standard" (GS) set of references about apps. The GS set was divided into a development and validation set. The filters' search terms were derived from and tested against the development set. An external development set containing app references from published NICE products was also used to inform the development of the filters. The filters were then validated using the validation set. Target recall was >90 percent. The filters' overall recall, specificity, and precision were calculated using all the references identified from the hand search. RESULTS: Both filters achieved 98.6 percent recall against their validation sets. Overall, the MEDLINE filter had 98.8 percent recall, 71.3 percent specificity, and 22.6 percent precision. The Embase filter had 98.6 percent recall, 74.9 percent specificity, and 24.5 percent precision. CONCLUSIONS: The NICE health apps search filters retrieve evidence about apps from MEDLINE and Embase with high recall. They can be applied to literature searches to retrieve evidence about the interventions by information professionals, researchers, and clinicians.

The NICE UK geographic search filters for MEDLINE and Embase (Ovid): Post-development study to further evaluate precision and number-needed-to-read when retrieving UK evidence.

BACKGROUND: The National Institute for Health and Care Excellence's (NICE) United Kingdom (UK) geographic search filters for MEDLINE and Embase (OVID) retrieve evidence in literature searches for UK-focused research topics with high recall. Their precision and number-needed-to-read (NNR) was examined previously in case studies using a single review. This paper details a larger post-development study that was conducted to test the NICE UK filters' precision and NNR more extensively. METHODS: The filters' recall of included UK references from 100 reviews was calculated. As reproducible search strategies were not available for every review, the MEDLINE filter's precision and NNR were calculated using strategies from 25 reviews. Strategies from nine reviews were used for the Embase filter. RESULTS: The MEDLINE filter achieved an average of 96.4% recall for the included UK references from the 100 reviews and the Embase filter achieved an average of 97.4% recall. Compared to not using a filter, the MEDLINE filter achieved an average of 98.9% recall for the 25 reviews. Precision was increased by an average of 7.8 times, reducing the NNR from 357 to 46. The Embase filter achieved an average of 97.1% recall for the nine reviews. Precision was increased by an average of 5.1 times, reducing the NNR from 746 to 146. CONCLUSION: There is more evidence to demonstrate that the NICE UK filters retrieve the majority of UK evidence from MEDLINE and Embase while increasing precision and reducing NNR. The filters can save time spent on selecting evidence for UK-focused research topics.

Effects of a sister's death in childbirth on reproductive behaviors: Difference-in-difference analyses using sisterhood mortality data from Indonesia.

RATIONALE: Risk of maternal mortality increases rapidly during the intrapartum period making skilled care at delivery an effective intervention to reduce the risk of maternal death. Demand generation for skilled care typically focuses on institutional channels; however, much less attention has been paid to whether what women may learn through their social networks can potentially influence their choice of delivery care. OBJECTIVE: The objective of this study was to analyze whether a sister's death in childbirth has the potential to improve delivery care choices for women who experience this event. METHODS: This study uses retrospective reports of sister deaths - either in childbirth or from some other cause - reported in the sisterhood moratlity module from five waves of the Indonesia Demographic and Health Surveys (IDHS) spanning 1989 to 2012. A cross-sectional, difference-in-difference strategy compares delivery care behavior of women before and after losing a sister in childbirth to women before and after losing a sister of reproductive age from some other cause in an intent-to-treat framework. RESULTS: Women are less likely to give birth at home after losing a sister in childbirth relative to women who lose a sister from some other cause. Losing a sister in childbirth may trigger behaviors that help usher women of lower socioeconomic status into formal delivery care. CONCLUSION: This study extends the literature on health behavior change through social networks to improve delivery care. Public health campaigns should consider social networks when designing messages around maternal mortality in order to help women at risk of maternal mortality make decisions that reduce their risk of and ultimately avoid maternal death.

Using a Chord Diagram to Visualize Dynamics in Contraceptive Use: Bringing Data into Practice.

We applied a novel approach to visualizing contraceptive histories from the Demographic and Health Surveys (DHS) contraceptive calendar to elucidate patterns of contraceptive switching and discontinuation (e.g., "churn" in contraceptive use across 2 points in time). Taking the contraceptive calendar from the 2014 Kenya DHS, we used R, an open source statistical programming platform, and the chorddiag package to create interactive chord diagrams to visualize contraceptive use trajectories, including switching and discontinuation, for all contraceptive types queried in the DHS. We present screenshots from the interactive version. We also tested the usefulness of our chord diagram with potential users, including family planning researchers and advocates. Chord diagrams are visually appealing and provide users with the ability to investigate unique patterns in contraceptive discontinuation using publicly available data from the DHS. After receiving a brief orientation to a chord diagram, users found the chord diagram easy to understand and manipulate. The chord diagram is a potentially powerful way for family planning researchers, advocates, and program managers to visualize women's contraceptive trajectories and provides insights into the churn in contraceptive use between 2 discrete time periods.

The prevalence and process of pediatric HIV disclosure: A population-based prospective cohort study in Zimbabwe.

INTRODUCTION: The objective of this study was to estimate the prevalence of pediatric HIV disclosure in rural Zimbabwe and track the process of disclosure over time. METHODS: We recruited a population-based sample of 372 caregivers of HIV-positive children ages 9 to 15 to participate in a survey about disclosure. Using data from this cross-sectional sample, we then identified a prospective cohort of 123 caregivers who said their HIV-positive child did not know his or her HIV status, and we followed this non-disclosed cohort of caregivers through two additional waves of data collection over the next 12 months. At each wave, we inquired about the timing and process of disclosure and psychosocial factors related to HIV disclosure. RESULTS: The overall prevalence of disclosure in the cross-sectional sample was 66.9% (95% CI 62.0 to 71.5%). Only 26.9% of children knew how they were infected and that they can transmit the virus to others (i.e. "full disclosure"). Older children were more likely to know their status. Among the non-disclosed caregivers at baseline, nearly 60% of these children learned their HIV status over the course of the 12-month study period, but only 17.1% learned how they were infected and that they can transmit the virus to others. Most caregivers were satisfied with their child's disclosure experience. Caregivers who had not disclosed their child's HIV status to the child worried that disclosure would lead to stigma in the community, provoke questions from their child they would not be able to answer, or cause the child to reject the caregiver in anger. CONCLUSIONS: This study suggests that rates of pediatric HIV disclosure may be larger than typically reported, but also reinforces the idea that most children do not know key details about their illness, such as how they were infected and that they can infect others.

The Embase UK filter: validation of a geographic search filter to retrieve research about the UK from OVID Embase.

BACKGROUND: The authors developed a validated geographic search filter to retrieve research about the United Kingdom (UK) from OVID Embase. It was created to be used alongside their previously published OVID MEDLINE UK filter in systematic literature searches for context-sensitive topics. OBJECTIVES: To develop a validated geographic search filter to retrieve research about the UK from OVID Embase. METHODS: The Embase UK filter was translated from the MEDLINE UK filter. A gold standard set of references was generated using the relative recall method. The set contained references to publications about the UK that had informed National Institute for Health and Care Excellence (NICE) guidance and it was used to validate the filter. Recall, precision and number-needed-to-read (NNR) were calculated using a case study. RESULTS: The validated Embase UK filter demonstrated 99.8% recall against the references with UK identifiers in the gold standard set. In the case study, the Embase UK filter demonstrated 98.5% recall, 7.6% precision and a NNR of 13. CONCLUSION: The Embase UK filter can be used alongside the MEDLINE UK filter. The filters have the potential to save time and associated resource costs when they are used for context-sensitive topics that require research about UK settings.

The impact of the 2014 Ebola virus disease outbreak in Liberia on parent preferences for harsh discipline practices: a quasi-experimental, pre-post design.

BACKGROUND: This paper uses data from a cohort of parents and guardians of young children living in Monrovia, Liberia collected before and after the 2014 outbreak of Ebola virus disease (EVD) to estimate the impact of EVD exposure on implicit preferences for harsh discipline. We hypothesized that parents exposed to EVD-related sickness or death would exhibit a stronger preference for harsh discipline practices compared with non-exposed parents. METHODS: The data for this analysis come from two survey rounds conducted in Liberia as part of an intervention trial of a behavioral parenting skills intervention. Following a baseline assessment of 201 enrolled parents in July 2014, all program and study activities were halted due to the outbreak of EVD. Following the EVD crisis, we conducted a tracking survey with parents who completed the baseline survey 12 months prior. In both rounds, we presented parents with 12 digital comic strips of a child misbehaving and asked them to indicate how they would react if they were the parent in the stories. RESULTS: Parents from households with reported EVD sickness or death became more 'harsh' (Glass's delta = 1.41) in their hypothetical decision-making compared with non-exposed parents, t (167)=-2.3, p  <  0.05. Parents from households that experienced EVD-related sickness or death not only reported significantly more household conflict and anxiety, but also reported that their child exhibited fewer difficulties. CONCLUSIONS: Results support the need for family-based interventions, including strategies to help parents learn alternatives to harsh punishment.

The medline UK filter: development and validation of a geographic search filter to retrieve research about the UK from OVID medline.

BACKGROUND: A validated geographic search filter for the retrieval of research about the United Kingdom (UK) from bibliographic databases had not previously been published. OBJECTIVES: To develop and validate a geographic search filter to retrieve research about the UK from OVID medline with high recall and precision. METHODS: Three gold standard sets of references were generated using the relative recall method. The sets contained references to studies about the UK which had informed National Institute for Health and Care Excellence (NICE) guidance. The first and second sets were used to develop and refine the medline UK filter. The third set was used to validate the filter. Recall, precision and number-needed-to-read (NNR) were calculated using a case study. RESULTS: The validated medline UK filter demonstrated 87.6% relative recall against the third gold standard set. In the case study, the medline UK filter demonstrated 100% recall, 11.4% precision and a NNR of nine. CONCLUSION: A validated geographic search filter to retrieve research about the UK with high recall and precision has been developed. The medline UK filter can be applied to systematic literature searches in OVID medline for topics with a UK focus.

Where We Fall Down: Tensions in Teaching Social Medicine and Global Health.

BACKGROUND: As global health interest has risen, so too has the relevance of education on the social determinants of health and health equity. Social medicine offers a particularly salient framework for educating on the social determinants of health, health disparities, and health equity. SocMed and EqualHealth, 2 unique but related organizations, offer annual global health courses in Uganda, Haiti, and the United States, which train students to understand and respond to the social determinants of health through praxis, self-reflection and self-awareness, and building collaborative partnerships across difference. OBJECTIVES: The aim of this paper is to describe an innovative pedagogical approach to teaching social medicine and global health. We draw on the notion of praxis, which illuminates the value of iterative reflection and action, to critically examine our points of weakness as educators in order to derive lessons with broad applicability for those engaged in global health work. METHODS: The data for this paper were collected through an autoethnography of teaching 10 global health social medicine courses in Uganda and Haiti since 2010. It draws on revealing descriptions from participant observation, student feedback collected in anonymous course evaluations, and ongoing relationships with alumni. FINDINGS: Critical analysis reveals 3 significant and complicated tensions raised by our courses. The first point of weakness pertains to issues of course ownership by North American outsiders. The second tension emerges from explicit acknowledgment of social and economic inequities among our students and faculty. Finally, there are ongoing challenges of sustaining positive momentum toward social change after transformative course experiences. CONCLUSIONS: Although successful in generating transformative learning experiences, these courses expose significant fracture points worth interrogating as educators, activists, and global health practitioners. Ultimately, we have identified a need for building equitable partnerships and intentional community, embracing discomfort, and moving beyond reflection to praxis in global health education.

The necessity of social medicine in medical education.

Research and clinical experience reliably and repeatedly demonstrate that the determinants of health are most accurately conceptualized as biosocial phenomena, in which health and disease emerge through the interaction between biology and the social environment. Increased appreciation of biosocial approaches have already driven change in premedical education and focused attention on population health in current U.S. health care reform. Medical education, however, places primary emphasis on biomedicine and often fails to emphasize and educate students and trainees about the social forces that shape disease and illness patterns. The authors of this Commentary argue that medical education requires a comprehensive transformation to incorporate rigorous biosocial training to ensure that all future health professionals are equipped with the knowledge and skills necessary to practice social medicine. Three distinct models for accomplishing such transformation are presented: SocMed's monthlong, elective courses in Northern Uganda and Haiti; Harvard Medical School's semester-long, required social medicine course; and the Lebanese American University's curricular integration of social medicine throughout its entire four-year curriculum. Successful implementation of social medicine training requires the institutionalization of biosocial curricula; the utilization of innovative, engaging pedagogies; and the involvement of health professions students from broad demographic backgrounds and with all career interests. The achievement of such transformational and necessary change to medical education will prepare future health practitioners working in all settings to respond more proactively and comprehensively to the health needs of all populations.