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Chronically Ill Canadians’ Experiences Of Being Unattached To A Family Doctor: A Qualitative Study Of Marginalized Patients In British Columbia

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2012
Abstract: 

Background

Unattached patients do not have a regular primary care provider. Initiatives are being developed to increase attachment rates across Canada. Most existing attention paid to patient unattachment has focused on quantifying the problem and health system costs. Our purpose is to qualitatively identify the implications of chronically ill patients’ experiences of unattachment for health policy and planning to provide policy-relevant insights for Canadian attachment initiatives.

Methods

Three focus groups were conducted with marginalized chronically ill individuals residing in a mid-sized city in British Columbia who are unattached to a family doctor. We use the term marginalized as a descriptor to acknowledge that by virtue of their low socio-economic status and lack of attachment the participants are marginalized in Canada’s health care system Focus groups were structured as an open conversation organized around a series of probing questions. They were digitally recorded and transcribed verbatim. Thematic analysis was employed.

Results

Twenty-six individuals participated in the focus groups. The most common chronic illnesses reported were active drug addiction or recovery (and their associated symptoms), depression, arthritis, and hepatitis C. Participants identified life transitions as being the root cause for not having a family doctor. There was a strong sense that unsuccessful attempts to get a family doctor reflected that they were undesirable patients. Participants wanted to experience having a trusting relationship with a regular family doctor as they believed it would encourage greater honesty and transparency. One of the main health concerns regarding lack of access to a regular family doctor is that participants lacked access to preventative care. Participants were also concerned about having a discontinuous medical record due to unattachment.

Conclusions

Participants perceived that there are many benefits to be had by having attachment to a regular family doctor and that experiencing unattachment challenged their health and access to health care. We encourage more research to be done on the lived experience of unattachment in order to provide on-the-ground insights that policy-makers require in order to develop responsive, patient-centred supports and programs.

Document type: 
Article

Canada's Compassionate Care Benefit: Is it An Adequate Public Health Response to Addressing the Issue of Caregiver Burden in End-of-Life Care?

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2011
Abstract: 

Background: An increasingly significant public health issue in Canada, and elsewhere throughout the developedworld, pertains to the provision of adequate palliative/end-of-life (P/EOL) care. Informal caregivers who take on the responsibility of providing P/EOL care often experience negative physical, mental, emotional, social and economicconsequences. In this article, we specifically examine how Canada’s Compassionate Care Benefit (CCB) - acontributory benefits social program aimed at informal P/EOL caregivers - operates as a public health response insustaining informal caregivers providing P/EOL care, and whether or not it adequately addresses known aspects ofcaregiver burden that are addressed within the population health promotion (PHP) model.Methods: As part of a national evaluation of Canada’s Compassionate Care Benefit, 57 telephone interviews wereconducted with Canadian informal P/EOL caregivers in 5 different provinces, pertaining to the strengths andweaknesses of the CCB and the general caregiving experience. Interview data was coded with Nvivo software andemerging themes were identified by the research team, with such findings published elsewhere. The purpose ofthe present analysis was identified after comparing the findings to the literature specific to caregiver burden andpublic health, after which data was analyzed using the PHP model as a guiding framework.Results: Informal caregivers spoke to several of the determinants of health outlined in the PHP model that areimplicated in their burden experience: gender, income and social status, working conditions, health and socialservices, social support network, and personal health practises and coping strategies. They recognized the need forimproving the CCB to better address these determinants.Conclusions: This study, from the perspective of family caregivers, demonstrates that the CCB is not living up toits full potential in sustaining informal P/EOL caregivers. Effort is required to transform the CCB so that it may fulfillthe potential it holds for serving as one public health response to caregiver burden that forms part of a healthypublic policy that addresses the determinants of this burden.

Document type: 
Article

Tracking the Evolution of Hospice Palliative Care in Canada: A Comparative Case Study Analysis of Seven Provinces

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2010
Abstract: 

Background: An aging population, rise in chronic illnesses, increase in life expectancy and shift towards care beingprovided at the community level are trends that are collectively creating an urgency to advance hospice palliative care(HPC) planning and provision in Canada. The purpose of this study was to analyze the evolution of HPC in sevenprovinces in Canada so as to inform such planning and provision elsewhere. We have endeavoured to undertake thisresearch out of awareness that good future planning for health and social care, such as HPC, typically requires us to firstlook backwards before moving forward.Methods: To identify key policy and practice events in HPC in Canada, as well as describe facilitators of and barriers toprogress, a qualitative comparative case study design was used. Specifically, the evolution and development of HCP in7 strategically selected provinces is compared. After choosing the case study provinces, the grey literature wassearched to create a preliminary timeline for each that described the evolution of HPC beginning in 1970. Keyinformants (n = 42) were then interviewed to verify the content of each provincial timeline and to discuss barriers andfacilitators to the development of HPC. Upon completion of the primary data collection, a face-to-face meeting of theresearch team was then held so as to conduct a comparative study analysis that focused on provincial commonalitiesand differences.Results: Findings point to the fact that HPC continues to remain at the margins of the health care system. Thedevelopment of HPC has encountered structural inheritances that have both sped up progress as well as slowed itdown. These structural inheritances are: (1) foundational health policies (e.g., the Canada Health Act); (2) servicestructures and planning (e.g., the dominance of urban-focused initiatives); and (3) health system decisions (e.g.,regionalization). As a response to these inheritances, circumventions of the established system of care were taken,often out of necessity. Three kinds of circumventions were identified from the data: (1) interventions to shift the system(e.g., the role of advocacy); (2) service innovations (e.g., educational initiatives); and (3) new alternative structures (e.g.,the establishment of independent hospice organizations). Overall, the evolution of HPC across the case studyprovinces has been markedly slow, but steady and continuous.Conclusions: HPC in Canada remains at the margins of the health care system. Its integration into the primary healthcare system may ensure dedicated and ongoing funding, enhanced access, quality and service responsiveness.Though demographics are expected to influence HPC demand in Canada, our study confirms that concerned citizens,advocacy organizations and local champions will continue to be the agents of change that make the necessary andlasting impacts on HPC in Canada.

Document type: 
Article

Fly-By Medical Care: Conceptualizing the Global and Local Social Responsibilities of Medical Tourists and Physician Voluntourists

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2011
Abstract: 

Background: Medical tourism is a global health practice where patients travel abroad to receive health care.Voluntourism is a practice where physicians travel abroad to deliver health care. Both of these practices often entailtravel from high income to low and middle income countries and both have been associated with possiblenegative impacts. In this paper, we explore the social responsibilities of medical tourists and voluntourists toidentify commonalities and distinctions that can be used to develop a wider understanding of social responsibilityin global health care practices.

 

Discussion: Social responsibility is a responsibility to promote the welfare of the communities to which onebelongs or with which one interacts. Physicians stress their social responsibility to care for the welfare of theirpatients and their domestic communities. When physicians choose to travel to another county to provide medicalcare, this social responsibility is expanded to this new community. Patients too have a social responsibility to usetheir community’s health resources efficiently and to promote the health of their community. When these patientschoose to go abroad to receive medical care, this social responsibility applies to the new community as well. Whilevoluntourists and medical tourists both see the scope of their social responsibilities expand by engaging in theseglobal practices, the social responsibilities of physician voluntourists are much better defined than those of medicaltourists. Guidelines for engaging in ethical voluntourism and training for voluntourists still need betterdevelopment, but medical tourism as a practice should follow the lead of voluntourism by developing clearernorms for ethical medical tourism.

 

Summary: Much can be learned by examining the social responsibilities of medical tourists and voluntouristswhen they engage in global health practices. While each group needs better guidance for engaging in responsibleforms of these practices, patients are at a disadvantage in understanding the effects of medical tourism andorganizing responses to these impacts. Members of the medical professions and the medical tourism industry musttake responsibility for providing better guidance for medical tourists.

Document type: 
Article

A Web-Based Graphical User Interface for Evidence-Based Decision Making for Health Care Allocations in Rural Areas

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2008
Abstract: 

Background: The creation of successful health policy and location of resources increasingly relieson evidence-based decision-making. The development of intuitive, accessible tools to analyse,display and disseminate spatial data potentially provides the basis for sound policy and resourceallocation decisions. As health services are rationalized, the development of tools such graphicaluser interfaces (GUIs) is especially valuable at they assist decision makers in allocating resourcessuch that the maximum number of people are served. GIS can used to develop GUIs that enablespatial decision making.Results: We have created a Web-based GUI (wGUI) to assist health policy makers andadministrators in the Canadian province of British Columbia make well-informed decisions aboutthe location and allocation of time-sensitive service capacities in rural regions of the province. Thistool integrates datasets for existing hospitals and services, regional populations and road networksto allow users to ascertain the percentage of population in any given service catchment who areserved by a specific health service, or baskets of linked services. The wGUI allows policy makersto map trauma and obstetric services against rural populations within pre-specified travel distances,illustrating service capacity by region.Conclusion: The wGUI can be used by health policy makers and administrators with little or noformal GIS training to visualize multiple health resource allocation scenarios. The GUI is poised tobecome a critical decision-making tool especially as evidence is increasingly required fordistribution of health services.

Document type: 
Article

Defining Rational Hospital Catchments for Non-Urban Areas Based on Travel-Time

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2006
Abstract: 

Background: Cost containment typically involves rationalizing healthcare service delivery throughcentralization of services to achieve economies of scale. Hospitals are frequently the chosen site ofcost containment and rationalization especially in rural areas. Socio-demographic and geographiccharacteristics make hospital service allocation more difficult in rural and remote regions. Thisresearch presents a methodology to model rational catchments or service areas around ruralhospitals – based on travel time.Results: This research employs a vector-based GIS network analysis to model catchments thatbetter represent access to hospital-based healthcare services in British Columbia's rural andremote areas. The tool permits modelling of alternate scenarios in which access to different basketsof services (e.g. rural maternity care or ICU) are assessed. In addition, estimates of the percentageof population that is served – or not served -within specified travel times are calculated.Conclusion: The modelling tool described is useful for defining true geographical catchmentsaround rural hospitals as well as modelling the percentage of the population served within certaintime guidelines (e.g. one hour) for specific health services. It is potentially valuable to policy makersand health services allocation specialists.

Document type: 
Article

Pedestrian Injury and the Built Environment: An Environmental Scan of Hotspots

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2009
Abstract: 

Background: Pedestrian injury frequently results in devastating and costly injuries and accountsfor 11% of all road user fatalities. In the United States in 2006 there were 4,784 fatalities and 61,000 injuries from pedestrian injury, and in 2007 there were 4,654 fatalities and 70,000 injuries. In Canada, injury is the leading cause of death for those under 45 years of age and the fourth mostcommon cause of death for all ages Traumatic pedestrian injury results in nearly 4000hospitalizations in Canada annually. These injuries result from the interplay of modifiableenvironmental factors. The objective of this study was to determine links between the built environment and pedestrian injury hotspots in Vancouver.Methods: Data were obtained from the Insurance Corporation of British Columbia (ICBC) forthe 6 year period from 2000 to 2005 and combined with pedestrian injury data extracted from theBritish Columbia Trauma Registry (BCTR) for the same period. High incident locations (hotspots)for pedestrian injury in the City of Vancouver were identified and mapped using geographicinformation systems (GIS), and the characteristics of the built environment at each of the hotspot locations were examined by a team of researchers.Results: The analysis highlighted 32 pedestrian injury hotspot locations in Vancouver. 31 of 32hotspots were situated on major roads. Likewise, the majority of hotspots were located ondowntown streets. The 'downtown eastside' was identified as an area with multiple high-incidentlocations, including the 2 highest ranked pedestrian injury hotspots. Bars were present at 21 of the hotspot locations, with 11 of these locations being judged to have high alcohol establishmentdensity.Conclusion: This study highlighted the disproportionate burden of pedestrian injury centred onthe downtown eastside area of Vancouver. The environmental scan revealed that important passive pedestrian safety countermeasures were only present at a minority of high-incident locations. More importantly, bars were highly associated with risk of pedestrian injury. This study is the basis forpotential public health intervention by clearly indicating optimal locations for signalized pedestrian crosswalks.

Document type: 
Article

Modelling Optimal Location for Pre-Hospital Helicopter Emergency Medical Services

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2009
Abstract: 

Background: Increasing the range and scope of early activation/auto launch helicopter emergencymedical services (HEMS) may alleviate unnecessary injury mortality that disproportionately affectsrural populations. To date, attempts to develop a quantitative framework for the optimal locationof HEMS facilities have been absent.Methods: Our analysis used five years of critical care data from tertiary health care facilities, spatialdata on origin of transport and accurate road travel time catchments for tertiary centres. Alocation optimization model was developed to identify where the expansion of HEMS would coverthe greatest population among those currently underserved. The protocol was developed usinggeographic information systems (GIS) to measure populations, distances and accessibility toservices.Results: Our model determined Royal Inland Hospital (RIH) was the optimal site for an expandedHEMS – based on denominator population, distance to services and historical usage patterns.Conclusion: GIS based protocols for location of emergency medical resources can providesupportive evidence for allocation decisions – especially when resources are limited. In this study,we were able to demonstrate conclusively that a logical choice exists for location of additionalHEMS. This protocol could be extended to location analysis for other emergency and healthservices.

Document type: 
Article

An Agent-Based Approach for Modeling Dynamics of Contagious Disease Spread

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2009
Abstract: 

Background: The propagation of communicable diseases through a population is an inherentspatial and temporal process of great importance for modern society. For this reason a spatiallyexplicit epidemiologic model of infectious disease is proposed for a greater understanding of thedisease's spatial diffusion through a network of human contacts.Objective: The objective of this study is to develop an agent-based modelling approach theintegrates geographic information systems (GIS) to simulate the spread of a communicable diseasein an urban environment, as a result of individuals' interactions in a geospatial context.Methods: The methodology for simulating spatiotemporal dynamics of communicable diseasepropagation is presented and the model is implemented using measles outbreak in an urbanenvironment as a case study. Individuals in a closed population are explicitly represented by agentsassociated to places where they interact with other agents. They are endowed with mobility,through a transportation network allowing them to move between places within the urbanenvironment, in order to represent the spatial heterogeneity and the complexity involved ininfectious diseases diffusion. The model is implemented on georeferenced land use dataset fromMetro Vancouver and makes use of census data sets from Statistics Canada for the municipality ofBurnaby, BC, Canada study site.Results: The results provide insights into the application of the model to calculate ratios ofsusceptible/infected in specific time frames and urban environments, due to its ability to depict thedisease progression based on individuals' interactions. It is demonstrated that the dynamic spatialinteractions within the population lead to high numbers of exposed individuals who performstationary activities in areas after they have finished commuting. As a result, the sick individuals areconcentrated in geographical locations like schools and universities.Conclusion: The GIS-agent based model designed for this study can be easily customized to studythe disease spread dynamics of any other communicable disease by simply adjusting the modeleddisease timeline and/or the infection model and modifying the transmission process. This type ofsimulations can help to improve comprehension of disease spread dynamics and to take bettersteps towards the prevention and control of an epidemic outbreak.

Document type: 
Article

Risk Communication and Informed Consent in the Medical Tourism Industry: A Thematic Content Analysis of Canadian Broker Websites

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2011
Abstract: 

Background:

Medical tourism, thought of as patients seeking non-emergency medical care outside of their homecountries, is a growing industry worldwide. Canadians are amongst those engaging in medical tourism, and manyare helped in the process of accessing care abroad by medical tourism brokers - agents who specialize in makinginternational medical care arrangements for patients. As a key source of information for these patients, brokers arelikely to play an important role in communicating the risks and benefits of undergoing surgery or other proceduresabroad to their clientele. This raises important ethical concerns regarding processes such as informed consent andthe liability of brokers in the event that complications arise from procedures. The purpose of this article is toexamine the language, information, and online marketing of Canadian medical tourism brokers’ websites in light ofsuch ethical concerns.

Methods:

An exhaustive online search using multiple search engines and keywords was performed to compile acomprehensive directory of English-language Canadian medical tourism brokerage websites. These websites wereexamined using thematic content analysis, which included identifying informational themes, generating frequencycounts of these themes, and comparing trends in these counts to the established literature.

Results:

Seventeen websites were identified for inclusion in this study. It was found that Canadian medical tourismbroker websites varied widely in scope, content, professionalism and depth of information. Three themes emergedfrom the thematic content analysis: training and accreditation, risk communication, and business dimensions. Thirdparty accreditation bodies of debatable regulatory value were regularly mentioned on the reviewed websites, anddiscussion of surgical risk was absent on 47% of the websites reviewed, with limited discussion of risk on theremaining ones. Terminology describing brokers’ roles was somewhat inconsistent across the websites. Finally,brokers’ roles in follow up care, their prices, and the speed of surgery were the most commonly included businessdimensions on the reviewed websites.

Conclusion:

Canadian medical tourism brokers currently lack a common standard of care and accreditation, and are widely lacking in providing adequate risk communication for potential medical tourists. This has implicationsfor the informed consent and consequent safety of Canadian medical tourists.

Document type: 
Article