Transformed through the CARTA experience: changes reported by CARTA fellows about their PhD journey.

Transformative learning occurs when a person, group, or larger social unit encounters ideas that are at odds with their prevailing perspective. This discrepant perspective can lead to an examination of previously held beliefs, values, and assumptions. The Consortium for Advanced Research Training in Africa (CARTA) has since 2011 been training and supporting faculty from different African universities, to become more reflective and productive researchers, research leaders, educators, and change agents who will drive institutional changes in their institutions. As part of a mid-term evaluation of CARTA, an open-ended question was posed to the CARTA fellows asking them to describe any changes they had experienced in their professional lives as a result of the CARTA Programme. The 135 responses were inductively coded and analysed using qualitative thematic analysis. These themes were subsequently mapped onto Hoggan's typology of transformative learning outcomes. CARTA fellows reported shifts in their sense of self; worldviews; beliefs about the definition of knowledge, how it is constructed and evaluated; and changes in behaviour/practices and capacities. This paper argues that the changes described by the CARTA fellows reflect transformative learning that is embedded in CARTA's Theory of Change. The reported transformation was enabled by a curriculum intentionally designed to facilitate critical reflection, further exploration, and questioning, both formally and informally during the fellows' PhD journey with the support of CARTA facilitators. Documenting and disseminating these lessons provide a guide for future practice, and educators wishing to revitalise their PhD training may find it useful to review the CARTA PhD curriculum.

Teaching compassion for social accountability: A parallaxic investigation.

BACKGROUND: In an arts integrated interdisciplinary study set to investigate ways to improve social accountability (SA) in medical education, our research team has established a renewed understanding of compassion in the current SA movement. AIM: This paper explores the co-evolution of compassion and SA. METHODS: The study used an arts integrated approach to investigate people's perceptions of SA in four medical schools across Australia, Canada, and the USA. Each school engaged approximately 25 participants who partook in workshops and in-depth interviews. RESULTS: We began with a study of SA and the topic of compassion emerged out of our qualitative data and biweekly meetings within the research team. Content analysis of the data and pedagogical discussion brought us to realize the importance of compassion in the practice of SA. CONCLUSIONS: The cultivation of compassion needs to play a significant role in a socially accountable medical educational system. Medical schools as educational institutions may operate themselves with compassion as a driving force in engaging partnership with students and communities. Social accountability without compassion is not SA; compassion humanizes institutional policy by engaging sympathy and care.

Community engagement by faculties of medicine: A scoping review of current practices and practical recommendations.

PURPOSE: Social accountability (SA) is the responsibility of faculties of medicine (FoMs) to address the health priorities of the communities they serve. Community engagement (CE) is a vital, but often ambiguous, component of SA. Practical guidance on how to engage community partners (CPs) is key for meaningful CE. We conducted a systematic scoping review of CE involving FoMs to map out how FoMs engage their communities, to provide practical recommendations for FoMs to take part in CE, and to highlight gaps in the literature. MATERIALS AND METHODS: We searched electronic databases for articles describing projects or programs involving FoMs and CPs. Descriptive information was analyzed thematically. RESULTS: Thirty-eight of 1406 articles were included, revealing three themes: (1) Partners (Who to Engage)-deciding who to engage establishes the basis for responsibility and creates space for communities to engage FoMs; (2) Partnerships (How to Engage)-fostering creative and authentic collaboration, enabling meaningful community contributions; and (3) Projects and Programs (With What to Engage)-identifying opportunities for communities to have a voice in many spaces within FoMs. Under these themes emerged 32 practical recommendations. CONCLUSION: Practical guidance facilitates meaningful commitments to communities. The literature is rich with examples of community-FoM partnerships. We provide recommendations for CE that are clear, evidence-based, and responsive.

Effective supervision of doctoral students in public and population health in Africa: CARTA supervisors' experiences, challenges and perceived opportunities.

The quality and success of postgraduate education largely rely on effective supervision. Since its inception in 2008, the Consortium for Advanced Research Training in Africa (CARTA) has been at the forefront of providing training to both students and supervisors in the field of public and population health. However, there are few studies on supervisors' perceptions on effective doctoral supervision. We used a mostly descriptive study design to report CARTA-affiliated doctoral supervisors' reflections and perceptions on doctoral supervision, challenges and opportunities. A total of 77 out of 160 CARTA supervisors' workshop participants responded to the evaluation. The respondents were affiliated with 10 institutions across Africa. The respondents remarked that effective supervision is a two-way process, involving both supervisor and supervisee's commitment. Some reported that the requirements for effective supervision included the calibre of the PhD students, structure of the PhD programme, access to research infrastructure and resources, supervision training, multidisciplinary exposure and support. Male supervisors have significantly higher number of self-reported PhD graduates and published articles on Scopus but no difference from the females in h-index. We note both student and systemic challenges that training institutions may pursue to improve doctoral supervision in Africa.

The Opioid Awareness and Support Team: an innovative example of medical education and community partnership.

The Opioid Awareness and Support Team (OAST) at the Memorial University Faculty of Medicine is a novel student-led initiative designed to supplement medical student learning related to opioid use disorder and the opioids crisis. OAST has focused on grounding educational initiatives related to opioid use disorder in the local community context, working with community partners, and bringing in individuals with lived experience. We present initial findings from an Opioid Education Day that suggest student-led supplemental education for medical students can improve student knowledge surrounding opioid use.

L'équipe d'aide et de sensibilisation aux opioïdes (OAST) est une initiative des étudiants de la faculté de médecine de l'Université Memorial qui apporte un complément à la formation que reçoivent les étudiants sur le trouble lié à l'usage d'opioïdes. L'OAST s'est efforcée d'inscrire les initiatives éducatives liées à la crise des opïodes dans un contexte local en collaboration avec des partenaires communautaires et de faire participer des personnes ayant une expérience de terrain. Nous présentons les résultats préliminaires d'une journée de sensibilisation aux opioïdes qui suggèrent que cette activité éducative menée par les étudiants en médecine peut améliorer les connaissances des apprenants sur la consommation d'opioïdes.

Timeliness of diagnosis of HIV in Newfoundland and Labrador, Canada: A mixed-methods study.

Background: Late diagnosis of HIV is associated with poor outcomes and increased cost. Novel HIV testing promotion strategies may reduce late diagnosis. The purpose of this study was to determine the timeliness of HIV testing in Newfoundland and Labrador (NL), missed opportunities for testing, and barriers to HIV testing. Methods: Demographic and clinical information from individuals diagnosed with HIV in NL from 2006-2016 was retrospectively reviewed. Patients were also invited to participate in semi-structured interviews regarding knowledge about HIV transmission, risk associated with their behaviour, testing decision making, and testing opportunities. Results: Fifty-eight new HIV diagnoses occurred during the study period: 53/58 (91.4%) were male and 33/58 (56.9%) were men who have sex with men. The mean age at diagnosis was 40.6 (SD 11.05) years. CD4 count at diagnosis ranged from 2 to 1,408 cells/mm3, with a mean of 387 cells/mm3. For 39/58 (67.2%) of individuals, the first-ever HIV test was positive. Of the 58 patients, 55 (94.8%) had had health care contact within the 5 years prior to diagnosis (mean 13.7 contacts). Heterosexual men were more likely to present with a late diagnosis (p = 0.049). Ten (17.2%) individuals agreed to an interview. Thematic analysis revealed that barriers to testing were stigma, negative health care interactions, denial, and fear of the diagnosis. Conclusions: HIV diagnosis is made later in NL than in other Canadian provinces. Late diagnosis may be prevented if HIV testing became a routine testing procedure.

Historique: Un diagnostic tardif de VIH s'associe à un mauvais pronostic et à des coûts élevés. De nouvelles stratégies de promotion du test de dépistage du VIH limiteraient les diagnostics tardifs. La présente étude visait à déterminer la rapidité d'exécution du test de VIH à Terre-Neuve-et-Labrador (TNL), les occasions ratées d'effectuer le test et les obstacles à l'effectuer. Méthodologie: Les auteurs ont procédé à une analyse rétrospective de l'information démographique et clinique des personnes ayant reçu un diagnostic de VIH à TNL entre 2006 et 2016. Les patients ont également été invités à participer à des entrevues semi-structurées au sujet de leurs connaissances sur la transmission du VIH, du risque associé à leurs comportements, de la décision de subir le test et des possibilités de le subir. Résultats: Cinquante-huit nouveaux diagnostics de VIH ont été posés pendant la période de l'étude : 53 sur 58 (91,4 %) étaient des hommes et 33 sur 58 (56,9 %), des hommes ayant des relations sexuelles avec d'autres hommes. Les patients avaient un âge moyen de 40,6 ans (± 11,05) au diagnostic. Leur numération de lymphocytes T CD4 au diagnostic se situait entre 2 et 1 408 cellules/mm3, pour une moyenne de 387 cellules/mm3. Pour 39 des 58 patients (67,2 %), le tout premier test de dépistage du VIH avait été positif. Des 58 patients, 55 (94,8 %) avaient eu des contacts avec le milieu de la santé dans les cinq années précédant le diagnostic (moyenne de 13,7 contacts). Les hommes hétérosexuels étaient plus susceptibles d'obtenir un diagnostic tardif (p = 0,049). Dix patients (17,2 %) ont accepté une entrevue. Une analyse thématique a révélé que les préjugés, des interactions négatives avec le milieu de la santé, le déni et la crainte du diagnostic étaient les obstacles aux tests. Conclusions: Le diagnostic de VIH est plus tardif à TNL que dans les autres provinces canadiennes. Il serait possible de prévenir les diagnostics tardifs si le test du VIH devenait systématique.

The effects of individual and community-level factors on maternal health outcomes in Ghana.

BACKGROUND: Utilization of maternal health care services is key to reducing the number of perinatal deaths and post-natal complications in sub-Saharan Africa. With a few exceptions, many studies that examine the use of maternal health services in sub-Saharan Africa have focused largely on individual-level explanations and have ignored the importance of contextual and community-level explanations. In Ghana, progress has been made in reducing maternal mortality ratio from 740/100,000 in the late 1990s to 319/100,000 in 2015 but these rates are still high. Our study focuses on impact of individual and community level-factors on maternal outcomes with the hope that it will inform public policy in Ghana. This approach highlights latent or unacknowledged aspects of fragility within health systems designed to improve maternal health and opportunities for improving uptake of services. METHODS AND FINDINGS: Using the 2014 Ghana Demographic and Health Survey, we examined the effects of individual and community-level factors on antenatal care, facility-based delivery, and post-natal care. Multilevel logistic regression models were used to examine the effects of individual and community-level factors on the outcome variables. Our analysis revealed that overall utilization of antenatal, facility-based delivery and post-natal care was substantial across the board; however, both individual and community-level factors were significant predictors of these maternal health outcomes. Wealthier and better educated women were more likely to use antenatal services and facility-based delivery; in contrast poor and uneducated women were more likely to use antenatal and postnatal care but not facility-based delivery. Additionally, use of National Health Insurance Scheme was statistically associated with the utilization of maternal health services. CONCLUSIONS: The findings point to areas where services can be better tailored to meet community-specific needs. Policy makers must consider factors such as educational levels and economic security at both individual and community-levels that shape women's preferences and uptake of maternal health care in Ghana.

Enhanced skills in global health and health equity: Guidelines for curriculum development.

INTRODUCTION: Global health addresses health inequities in the care of underserved populations, both domestic and international. Given that health systems with a strong primary care foundation are the most equitable, effective and efficient, family medicine is uniquely positioned to engage in global health. However, there are no nationally recognized standards in Canada for postgraduate family medicine training in global health. OBJECTIVE: To generate consensus on the essential components of a Global Health/Health Equity Enhanced Skills Program in family medicine. METHODS: A panel comprised of 34 experts in global health education and practice completed three rounds of a Delphi small group process. RESULTS: Consensus (defined as ≥ 75% agreement) was achieved on program length (12 months), inclusion of both domestic and international components, importance of mentorship, methods of learner assessment (in-training evaluation report, portfolio), four program objectives (advocacy, sustainability, social justice, and an inclusive view of global health), importance of core content, and six specific core topics (social determinants of health, principles and ethics of health equity/global health, cultural humility and competency, pre and post-departure training, health systems, policy, and advocacy for change, and community engagement). CONCLUSION: Panellists agreed on a number of program components forming the initial foundation for an evidence-informed, competency-based Global Health/Health Equity Enhanced Skills Program in family medicine.

Life in unexpected places: Employing visual thinking strategies in global health training.

BACKGROUND: The desire to make meaning out of images, metaphor, and other representations indicates higher-order cognitive skills that can be difficult to teach, especially in the complex and unfamiliar environments like those encountered in many global health experiences. Because reflecting on art can help develop medical students' imaginative and interpretive skills, we used visual thinking strategies (VTS) during an immersive 4-week global health elective for medical students to help them construct new understanding of the social determinants of health in a low-resource setting. We were aware of no previous formal efforts to use art in global health training. METHODS: We assembled a group of eight medical students in front of a street mural in Kathmandu and used VTS methods to interpret the scene with respect to the social determinants of health. We recorded and transcribed the conversation and conducted a thematic analysis of student responses. RESULTS: Students shared observations about the mural in a supportive, nonjudgmental fashion. Two main themes emerged from their observations: those of human-environment interactions (specifically community dynamics, subsistence land use, resources, and health) and entrapment/control, particularly relating to expectations of, and demands on, women in traditional farming communities. They used the images as well as their experience in Nepali communities to consolidate complex community health concepts. DISCUSSION: VTS helped students articulate their deepening understanding of the social determinants of health in Nepal, suggesting that reflection on visual art can help learners apply, analyze, and evaluate complex concepts in global health. We demonstrate the relevance of drawing upon many aspects of cultural learning, regarding art as a kind of text that holds valuable information. These findings may help provide innovative opportunities for teaching and evaluating global health training in the future.

Clinical ethics issues in HIV care in Canada: an institutional ethnographic study.

BACKGROUND: This is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups. METHODS: We used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues. RESULTS: We found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities ("treatment as prevention"), difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being. CONCLUSIONS: Some ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients - such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern.

Rural Community as Context and Teacher for Health Professions Education.

Nepal is a low-income, landlocked country located on the Indian subcontinent between China and India. The challenge of finding human resources for rural community health care settings is not unique to Nepal. In spite of the challenges, the health sector has made significant improvement in national health indices over the past half century. However, in terms of access to and quality of health services and impact, there remains a gross urban-rural disparity. The Patan Academy of Health Sciences (PAHS) has adopted a community-based education model, termed "community based learning and education" (CBLE), as one of the principal strategies and pedagogic methods. This method is linked to the PAHS mission of improving rural health in Nepal by training medical students through real-life experience in rural areas and developing a positive attitude among its graduates towards working in rural areas. This article outlines the PAHS approach of ruralizing the academy, which aligns with the concept of community engagement in health professional education. We describe how PAHS has embedded medical education in rural community settings, encouraging the learning context to be rural, fostering opportunities for community and peripheral health workers to participate in teaching-learning as well as evaluation of medical students, and involving community people in curriculum design and implementation.

The ethical case for providing cost-free access to lifesaving HIV medications in Canada: Implications of a qualitative study.

Antiretroviral therapy for HIV can be expensive if paid for out of pocket. In Canada, there are a variety of federal, provincial, and private prescription drug plans that lower the cost of these lifesaving medications for people living with HIV, and in some cases, these plans result in cost-free access. However, many people living with HIV must contend with high deductibles for their antiretroviral therapies, and many experience difficulty managing the administrative requirements of their drug plans. This article comments on some of the results of a qualitative study into ethical issues in HIV care. Access to antiretrovirals was a theme that emerged in this study. We argue on ethical grounds that provincial drug plans should guarantee cost-free access to antiretroviral therapies for people living with HIV with minimal administrative requirements.

Enduring politics: the culture of obstacles in legislating for assisted reproduction technologies in Ireland.

Assisted reproductive technology has become a normalized part of reproductive medicine in many countries around the world. Access, however, is uneven and inconsistent, facilitated and restricted by such factors as affordability, social and moral acceptance or refusal and local cultures of medical practice. In Ireland, assisted reproductive technology has been available since 1987 but remains unregulated by legislation. This creates an uncertain and untenable legal circumstance given the contested issues related to constitutional protection of the right to life of the unborn and the indeterminate legal status of embryos in vitro. This paper examines the impact of an enduring political impasse. It explores how clinical assisted reproductive technology services in Ireland operate both inside and outside dominant institutional frameworks, meeting a pronatalist and pro-family social and political agenda, while sometimes contradicting the pro-life politics that has continued to shape women's reproductive lives. The medical approaches to infertility thus intersect with the ongoing debates around abortion, the failure of the government to regulate, and notions of embodied motherhood and responsibility within changing meanings of family and kinship. At the same time women and their partners seek assisted reproductive technology treatment in other countries throughout the European Union where laws differ and availability of services varies. A decade has passed since the Commission on Assisted Human Reproduction in Ireland released its recommendations; the enduring legislative vacuum leaves women, families and practitioners in potential legal limbo.

Introducing global health into the undergraduate medical school curriculum using an e-learning program: a mixed method pilot study.

BACKGROUND: Physicians need global health competencies to provide effective care to culturally and linguistically diverse patients. Medical schools are seeking innovative approaches to support global health learning. This pilot study evaluated e-learning versus peer-reviewed articles to improve conceptual knowledge of global health. METHODS: A mixed methods study using a randomized-controlled trial (RCT) and qualitative inquiry consisting of four post-intervention focus groups. Outcomes included pre/post knowledge quiz and self-assessment measures based on validated tools from a Global Health CanMEDS Competency Model. RCT results were analyzed using SPSS-21 and focus group transcripts coded using NVivo-9 and recoded using thematic analysis. RESULTS: One hundred and sixty-one pre-clerkship medical students from three Canadian medical schools participated in 2012-2013: 59 completed all elements of the RCT, 24 participated in the focus groups. Overall, comparing pre to post results, both groups showed a significant increase in the mean knowledge (quiz) scores and for 5/7 self-assessed competencies (p < 0.05). These quantitative data were triangulated with the focus groups findings that revealed knowledge acquisition with both approaches. There was no statistically significant difference between the two approaches. Participants highlighted their preference for e-learning to introduce new global health knowledge and as a repository of resources. They also mentioned personal interest in global health, online convenience and integration into the curriculum as incentives to complete the e-learning. Beta version e-learning barriers included content overload and technical difficulties. CONCLUSIONS: Both the e-learning and the peer reviewed PDF articles improved global health conceptual knowledge. Many students however, preferred e-learning given its interactive, multi-media approach, access to links and reference materials and its capacity to engage and re-engage over long periods of time.

Conceiving silence: infertility as discursive contradiction in Ireland.

This article examines the production and reproduction of silence around infertility in Ireland. Based on narratives collected during 18 months of fieldwork, this article locates the contradictory role of silence in both the private experiences of individuals faced with a difficulty conceiving and in institutions constituted as mechanisms of public support. For many people who experience infertility, silence is rooted in the social stigma associated with reproductive failure or sexual inadequacy. Silence protects privacy while at the same time foreclosing both challenges to assumptions that fertility is the norm and any counterdiscourse to the heteronormative, profamily society in Ireland. I show how the reproduction of silence about infertility is a legacy of Ireland's history, reproductive politics, and the cultural idiom of choice. I argue that support networks and Internet bulletin boards on websites create opportunities to dialogue in silence, reproducing isolation rather than creating public discourse.

From biopolitics to bioethics: church, state, medicine and assisted reproductive technology in Ireland.

This paper examines the emerging bioethical debate on assisted reproductive technology (ART) in Ireland, which is shaped by the long-standing contentious issue of abortion and the constitutional protection afforded to the 'unborn'. The focus of the paper is on the way in which the terms of this debate are shaped and constrained by the historical relations of power between church, state and medicine. Since the representation of Ireland as a post-Catholic, plural republic is becoming increasingly mainstream to cultural and political discourse, we pay particular attention to how the Catholic Church embraces bioethics as a meta frame or code for refocusing questions of values, beliefs and meanings to sustain the ideal of Ireland as a 'pro-life' and essentially Catholic nation. The Catholic Church is not simply asserting its voice of dissent in the context of public debate as one voice amongst a plurality of other voices, but to shape the emerging debate as a powerful, institutional actor. The opportunity to do so is afforded by the lack of public debate on bioethical issues and the exceedingly slow pace at which bioethics is moving towards an institutionalised framework in Ireland. These events can be explained by the legacy of the social power of the Catholic Church in Ireland and the direct and indirect influence it has long exercised over public policy vis-à-vis the state and its institutions, including medicine. There are two interconnected threads to the contextual analysis presented in our case study: first, the legacy of the social power wielded by the Catholic Church, and its slow and incremental demise reflected in the pace of secularisation in Ireland and the privatisation of morality; second, the emergence of a bioethical regulatory debate on ART, which is mired in the abortion controversy. Our analysis focuses on a number of key contradictions and tensions in the way in which the key institutions of church, state and medicine navigate their own positions vis-à-vis a bioethics debate, and how this constrains public participation.