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

‘Codesign’ and associated terms such as ‘coproduction’ or ‘patient engagement’, are increasingly common in the health research literature, due to an increased emphasis on the importance of ensuring that research related to service/systems development is meaningful to end-users.  However, there continues to be a lack of clarity regarding the key principles and practices of codesign, and wide variation in the extent to which service users are meaningfully engaged in the process. These issues are particularly acute when end-users include populations who have significant health and healthcare disparities that are linked to a range of intersecting vulnerabilities (eg, poverty, language barriers, age, disability, minority status, stigmatised conditions).  The purpose of this paper is to prompt critical reflection on the nature of codesign research with vulnerable populations, including key issues to consider in the initial planning phases, the implementation process, and final outputs.  Risks and tensions will be identified in each phase of the process, followed by a tool to foster reflexivity in codesign processes to address these issues.

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

Public safety personnel (PSP) such as firefighters, paramedics, and police are exposed to traumatic situations, which increase their risk for mental health issues. However, many PSP do not seek help in a timely manner. Peer support interventions have the potential to decrease stigma and increase treatment-seeking behaviours among PSP. However, little is known regarding how the organizational culture of public safety organizations (PSOs) affects the implementation of a peer-based intervention. This study aims to understand the extent to which organizational culture, including masculinity contest cultures (MCC), within Canadian PSOs could affect implementation of PeerOnCall, a new peer support app for PSP. A qualitative multiple case study design was adopted, integrating semi-structured interviews with organizational champions from five PSOs. One to three champions from each PSO acted as key informants regarding their organizations. Interviews explored champions' perceptions of how organizational culture might shape implementation. Interview data were analyzed using inductive thematic analysis. Three themes were identified in analysis of the champion interviews. The first theme focused on external drivers and the second theme focused on internal drivers of organizational culture shift. The third theme focused on how culture can create resistance to implementation. Importantly, the MCC norm of show no weakness was described as a source of potential resistance when implementing the app. Each PSO had a unique and changing culture. Understanding how champions anticipate the role of culture in shaping implementation of an app-based intervention like PeerOnCall can guide the creation of contextually relevant strategies that optimize implementation within PSOs. Recommendations for optimizing implementation and areas for further study are provided. •Public safety culture around mental health is evolving.•Organizations are becoming more supportive of employees' mental health needs.•Mobile apps are a promising way to increase access to peer support in public safety organizations.•Mental health programs for public safety personnel must establish trust at the employee-level.•Mental health programs in public safety organizations should apply a gendered lens.

Public safety personnel (PSP), including correctional workers, firefighters, paramedics, police, and public safety communicators, are at increased risk for posttraumatic stress injury, yet face barriers in receiving timely support. Mobile health (mHealth) applications (apps) offer promising avenues for confidential, on-demand access to relevant information and support. The purpose of this study was to assess implementation of PeerOnCall, a new mHealth platform designed by and for PSP (the platform includes two parallel apps: one for frontline workers and one for peer support providers). A multi-site mixed methods implementation trial was conducted over 3−6 months in 42 public safety organizations across Canada. App usage trends were tracked through software analytics, and facilitators and barriers to app use were explored via interviews with organizational champions. Over 11,300 employees across 42 organizations were invited to use the PeerOnCall app over the trial period, with approximately 1759 PSP (15% of total) downloading the app. Variation within and across sectors was evident in app downloads and feature use. Approaches to communication (mode, timing, and messenger), and organizational culture related to mental health and help outreach affected uptake levels. PeerOnCall is a promising tool to facilitate access to peer support; however, culturally relevant strategies are needed to overcome barriers and integrate this tool into workplace practices.

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

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

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

Experience-based co-design (EBCD) is an innovative, evidence-based approach to health and social system change based on principles of participatory action research, narrative and learning theory, and design thinking. Unique elicitation strategies such as experience mapping, trigger videos, and prototype development are used in EBCD to engage service users and service providers in a collaborative process of identifying touchpoints and solutions to system-level problems. In this article, we present findings from interviewing a purposeful sample of 18 participants (4 youth, 6 service providers, 6 family members, and 2 employers) across three co-design projects designed to address either mental health or employment services for youth (aged 16–24) with mental health issues in one urban center. Through interviewing participants, perceptions were explored relating to three elicitation techniques: creating experience maps, creating and viewing trigger videos, and co-designing visual “prototype” solutions. Analysis of participants’ comments indicated that these techniques can be powerful tools to foster mutual understanding and collaborative ideas, but they require a social, spatial, and temporal context that optimizes their value. A “safe space” is needed within which the essential elements of elicitation—building trust, finding voice, sharing perspectives, and creating a common vision—can occur. Three core, overlapping processes of co-design elicitation were identified: “building common perspectives,” “building mutual understanding,” and “building innovation.” We present a conceptual framework depicting the interplay of processes and elicitation techniques, essential to building mutual understanding and innovation during the EBCD process.

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