Supplemental data for Jorge M. G. et al, Subjectivity of drumlin manual mapping and inter-mapper differences in derived morphometrics.
S1 Table. Inter-mapper differences – results of the Wilcoxon signed-rank tests and absolute differences in morphometric medians for all pairs of mappers, for footprints from both DTMs (DTM2; DTM11).
S2 Files. The KML-format file contains the location of the mapped drumlins. The shapefile combines all the footprints mapped by the 14 mappers who participated in the study.
The use of ‘off-the-shelf’ acoustic Doppler velocity profilers (ADCPs) to estimate suspended sediment concentration and grain size in rivers requires robust methods to estimate sound attenuation by suspended sediment. Theoretical estimates of sediment attenuation require a priori knowledge of the concentration and grain size distribution (GSD), making the method impractical to apply in routine monitoring programs. In-situ methods use acoustic backscatter profile slope to estimate sediment attenuation, and are a more attractive option. However, the performance of in-situ sediment attenuation methods has not been extensively compared to theoretical methods. We used three collocated horizontally mounted ADCPs in the Fraser River at Mission, British Columbia and 298 observations of concentration and GSD along the acoustic beams to calculate theoretical and in-situ sediment attenuation. Conversion of acoustic intensity from counts to decibels is influenced by the instrument noise floor, which affects the backscatter profile shape and therefore in-situ attenuation. We develop a method that converts counts to decibels to maximize profile length, which is useful in rivers where cross-channel acoustic profile penetration is a fraction of total channel width. Nevertheless, the agreement between theoretical and in-situ attenuation is poor at low concentrations because cross-stream gradients in concentration, sediment size or GSD can develop, which affect the backscatter profiles. So we establish threshold concentrations below which in-situ attenuation is unreliable in Fraser River. Results call for careful examination of cross-stream changes in suspended sediment characteristics and acoustic profiles across a range of flows before in-situ attenuation methods are applied in river monitoring programs.
Developing an understanding of medical tourists' interactions with their health care workers while abroad is important for a number of reasons. Social support has been linked to improved health outcomes for patients (Berkman et al., 2000; Lee and Rotheram-Borus, 2001; Uchino, 2004, 2006), while a lack of social support has been found to lead to higher mortality rates (Brummett et al., 2001; Rutledge et al., 2004). While abroad, medical tourists are not in a position to draw on their usual social support networks as they are away from home. It could be the case that workers in medical tourism facilities are aware of this and work to form a supportive and trusting bond with the patients given that they are away from home and unable to draw on their usual support networks. Furthermore, when patients perceive their relationship with their health care workers as positive, they have been shown to have a higher chance of improved health outcomes (Stewart et al., 2000; Arora, 2003; Beach et al., 2006; Street et al., 2009). There is no reason to think this would be any different for medical tourists. The patient-health care worker relationship can have important implications for patient health and therefore we believe that research into this topic using medical tourists' own experiential accounts can help to identify strategies that can be used to secure and improve this relationship.
This chapter draws on our long term-research program examining medical tourism in Barbados and the wider Anglophone Caribbean. Since 2011 we have undertaken 69 semi-structured interviews and three focus groups with a wide range of health system and tourism sector stakeholders in Barbados, compiled a comprehensive collection of state and media reports discussing medical tourism, and collectively spent over a year conducting on-site ethnographic fieldwork that has included many informal conversations with users of the Barbadian health system from a wide range of backgrounds. Together, these datasets and experiences provide a rich understanding of the potential considerations and hopes arising from the ongoing discussion about medical tourism development in a small island setting. Exploring these considerations and hopes suggests ways in which Barbados and other small island states seeking to develop their medical tourism sectors can negotiate a structure for medical tourism that can best meet their development goals.
Access to health services such as palliative care is determined not only by health policy but a number of legacies linked to geography and settlement patterns. We use GIS to calculate potential spatio-temporal access to palliative care services. In addition, we combine qualitative data with spatial analysis to develop a unique mixed-methods approach.
Inpatient health care facilities with dedicated palliative care beds were sampled in two Canadian provinces: Newfoundland and Saskatchewan. We then calculated one-hour travel time catchments to palliative health services and extended the spatial model to integrate available beds as well as documented wait times.
26 facilities with dedicated palliative care beds in Newfoundland and 69 in Saskatchewan were identified. Spatial analysis of one-hour travel times and palliative beds per 100,000 population in each province showed distinctly different geographical patterns. In Saskatchewan, 96.7 % of the population living within a-1 h of drive to a designated palliative care bed. In Newfoundland, 93.2 % of the population aged 65+ were living within a-1 h of drive to a designated palliative care bed. However, when the relationship between wait time and bed availability was examined for each facility within these two provinces, the relationship was found to be weak in Newfoundland (R2 = 0.26) and virtually nonexistent in Saskatchewan (R2 = 0.01).
Our spatial analysis shows that when wait times are incorporated as a way to understand potential spatio-temporal access to dedicated palliative care beds, as opposed to spatial access alone, the picture of access changes.
Enabled by globalizing processes such as trade liberalization, medical tourism is a practice that involves patients’ intentional travel to privately obtain medical care in another country. Empirical legal research on this issue is limited and seldom based on the perspectives of destination countries receiving medical tourists. We consulted with diverse lawyers from across Barbados to explore their views on the prospective legal and regulatory implications of the developing medical tourism industry in the country.
We held a focus group in February 2014 in Barbados with lawyers from across the country. Nine lawyers with diverse legal backgrounds participated. Focus group moderators summarized the study objective and engaged participants in identifying the local implications of medical tourism and the anticipated legal and regulatory concerns. The focus group was transcribed verbatim and analyzed thematically.
Five dominant legal and regulatory themes were identified through analysis: (1) liability; (2) immigration law; (3) physician licensing; (4) corporate ownership; and (5) reputational protection.
Two predominant legal and ethical concerns associated with medical tourism in Barbados were raised by participants and are reflected in the literature: the ability of medical tourists to recover medical malpractice for adverse events; and the effects of medical tourism on access to health care in the destination country. However, the participants also identified several topics that have received much less attention in the legal and ethical literature. Overall this analysis reveals that lawyers, at least in Barbados, have an important role to play in the medical tourism sector beyond litigation – particularly in transactional and gatekeeper capacities. It remains to be seen whether these findings are specific to the ecology of Barbados or can be extrapolated to the legal climate of other medical tourism destination countries.
Recent studies have demonstrated an elevated risk of oral cavity cancers (OCC) among socioeconomically deprived populations, whose increasing presence in suburban neighbourhoods poses unique challenges for equitable health service delivery. The majority of studies to date have utilised aspatial methods to identify OCC. In this study, we use high-resolution geographical analyses to identify spatio-temporal trends in OCC incidence, emphasising the value of geospatial methods for public health research.
Using province-wide population incidence data from the British Columbia Cancer Registry (1981–2009, N = 5473), we classify OCC cases by census-derived neighbourhood types to differentiate between urban, suburban, and rural residents at the time of diagnosis. We map geographical concentrations by decade and contrast trends in age-adjusted incidence rates, comparing the results to an index of socioeconomic deprivation.
Suburban cases were found to comprise a growing proportion of OCC incidence. In effect, OCC concentrations have dispersed from dense urban cores to suburban neighbourhoods in recent decades. Significantly higher age-adjusted oral cancer incidence rates are observed in suburban neighbourhoods from 2006 to 2009, accompanied by rising socioeconomic deprivation in those areas. New suburban concentrations of incidence were found in neighbourhoods with a high proportion of persons aged 65+ and/or born in India, China, or Taiwan.
While the aging of suburban populations provides some explanation of these trends, we highlight the role of the suburbanisation of socioeconomically deprived and Asia-born populations, known to have higher rates of risk behaviours such as tobacco, alcohol, and betel/areca consumption. Specifically, betel/areca consumption among Asia-born populations is suspected to be a primary driver of the observed geographical shift in incidence from urban cores to suburban neighbourhoods. We suggest that such geographically-informed findings are complementary to potential and existing place-specific cancer control policy and targeting prevention efforts for high-risk sub-populations, and call for the supplementation of epidemiological studies with high-resolution mapping and geospatial analysis.
Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad. Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trust relationship—a relationship on which the foundation of beneficent health care lies. The objective of the study is to examine the views of Canadian family physicians about the roles that trust plays in decision-making about medical tourism, and the impact of medical tourism on the therapeutic relationship.
We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia. Data were analyzed thematically using deductive and inductive codes that captured key concepts across the narratives of participants.
Family physicians indicated that they trust their patients to act as the lead decision-makers about medical tourism, but are conflicted when the information they are managing contradicts the best interests of the patients. They reported that patients distrust local health care systems when they experience insufficiencies in access to care and that this can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arise from shame, fear and secrecy about medical tourism.
Family physicians face diverse tensions about medical tourism as they must balance their roles in: (1) providing information about medical tourism within a context of information deficits; (2) supporting decision-making while distancing themselves from patients’ decisions to engage in medical tourism; and (3) acting both as agents of the patient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-party informational resources about medical tourism and the development of responsive policy.
Injury is a leading cause of the global disease burden, accounting for 10 percent of all deaths worldwide. Despite 90 percent of these deaths occurring in low and middle-income countries (LMICs), the majority of trauma research and infrastructure development has taken place in high-income settings. Furthermore, although accessible services are of central importance to a mature trauma system, there remains a paucity of literature describing the spatial accessibility of emergency services in LMICs. Using data from the Service Provision Assessment component of the Demographic and Health Surveys of Namibia and Haiti we defined the capabilities of healthcare facilities in each country in terms of their preparedness to provide emergency services. A Geographic Information System-based network analysis method was used to define 5- 10- and 50-kilometer catchment areas for all facilities capable of providing 24-hour care, higher-level resuscitative services or tertiary care. The proportion of a country’s population with access to each level of service was obtained by amalgamating the catchment areas with a population layer. A significant proportion of the population of both countries had poor spatial access to lower level services with 25% of the population of Haiti and 51% of the population of Namibia living further than 50 kilometers from a facility capable of providing 24-hour care. Spatial access to tertiary care was considerably lower with 51% of Haitians and 72% of Namibians having no access to these higher-level services within 50 kilometers. These results demonstrate a significant disparity in potential spatial access to emergency services in two LMICs compared to analogous estimates from high-income settings, and suggest that strengthening the capabilities of existing facilities may improve the equity of emergency services in these countries. Routine collection of georeferenced patient and facility data in LMICs will be important to understanding how spatial access to services influences outcomes.
Chronic cerebrospinal venous insufficiency (CCSVI) treatment is an unproven intervention aimed at relieving some of the symptoms of multiple sclerosis (MS). Despite limited evidence of the efficacy and safety of this intervention, Canadians diagnosed with MS have been traveling abroad to access this procedure as it is not available domestically outside of limited clinical trials. This paper discusses the experiences of Canadians with MS seeking CCSVI treatment abroad.
This paper presents a secondary analysis of 15 interviews with participants who had gone abroad for CCSVI treatment. Interviews were conducted over the phone between October 2012 and December 2012. All interviews were digitally recorded and transcribed verbatim. Transcripts were hand coded for: 1) why CCSVI treatment was sought and where it was obtained; 2) the role of having hope for a cure in seeking CCSVI; 3) the impact of MS on everyday life; and 4) the role other people played in the decision to go abroad.
The authors identified loss of faith, hope, and trust as themes emerging from the transcripts. The participants experienced a loss of faith with the Canadian health system and especially the neurologists who were responsible for their care and the classification of MS as a neurological disease. Access to CCSVI treatment abroad generated hope in these participants, but they were cautious in their expectations, focusing on symptom management rather than a cure. Trust in their caregivers abroad was generated through the recommendations of other MS sufferers and the credentials of their caregivers abroad.
By deciding to seek an unproven intervention abroad, these individuals took on responsibility for their care from the Canadian health system. While evidence of the efficacy of CCSVI treatment is limited, the participants felt that they were making a rational care decision, focusing on the empowerment and renewed hope generated by seeking this intervention. Health professionals and policy makers globally should consider the causes of loss of faith in their domestic care systems and balance the benefits of empowerment and renewed hope against concerns that unproven interventions may create new health risks.