To explore how Canadian family doctors understand their roles and responsibilities toward patients who seek health care abroad.
Six focus groups were held with family doctors across British Columbia to explore their experiences with and perspectives on outbound medical tourism. Focus groups were digitally recorded, transcribed, and subsequently thematically coded to discover common issues and themes across the entire data set.
Focus groups were held with family doctors in 6 cities in British Columbia that provided representation from all provincial health authorities and a range of urban contexts.
A total of 22 currently practising family doctors participated across the 6 focus groups, with groups ranging in size from 2 to 6 participants (average 4 participants).
Thematic analysis of the transcripts identified cross-cutting themes that emerged across the 6 focus groups.
Participants reported that medical tourism threatened patients’ continuity of care. Informational continuity is disrupted before patients go abroad because patients regularly omit family doctors from preoperative planning and upon return home when patients lack complete or translated medical reports. Participants believed that their responsibilities to patients resumed once the patients had returned home from care abroad, but were worried about not being able to provide adequate follow-up care. Participants were also concerned about bearing legal liability toward patients should they be asked to clinically support treatments started abroad.
Medical tourism poses challenges to Canadian family doctors when trying to reconcile their traditional roles and responsibilities with the novel demands of private out-of-country care pursued by their patients. Guidance from professional bodies regarding physicians’ responsibilities to Canadian medical tourists is currently lacking. Developing these supports would help address challenges faced in clinical practice.
To measure primary care access on an ongoing basis, the Ontario Ministry of Health and Long-Term Care implemented the Primary Care Access Survey (PCAS) in 2006. The PCAS, a cross-sectional telephone survey, samples approximately 8,400 Ontario adults each year. It collects information on access to a family doctor, use of services, health status and socio-demographics. Analysis of the 2007—2008 PCAS (n=16,560) shows that 7.1% of Ontario's adults were without a family doctor (i.e., unattached). The attached and unattached populations differed on socio-demographic and health characteristics. Emergency department use was similar between the two groups, but walk-in clinic use was higher among the unattached. The unattached were less likely to have used care for immediate issues but accessed care in a more timely fashion than the attached. This initial exploration of the PCAS provides a better understanding of some of the differences between the attached and unattached populations in Ontario.
Medical tourism—the practice where patients travel internationally to privately access medical care—may limit patients’ regular physicians’ abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors’ typical involvement in patients’ informed decision-making is challenged when their patients engage in medical tourism.
Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants’ perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians’ abilities to support medical tourists’ informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance.
Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician’s role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician’s reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians’ concerns that treatments sought abroad may not be based on the best available medical evidence on treatment efficacy.
Medical tourism is creating new challenges for Canadian family physicians who now find themselves needing to carefully negotiate their roles and responsibilities in the informed decision-making process of their patients who decide to seek private treatment abroad as medical tourists. These physicians can and should be educated to enable their patients to look critically at the information available about medical tourism providers and to ask critical questions of patients deciding to access care abroad.
OBJECTIVES: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. DESIGN: Random sample mailed survey. SETTING: Private primary care practices in British Columbia. PARTICIPANTS: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. OUTCOME MEASURE: Compliance with preventive practices recommended by the task force. RESULTS: Preventive practice complied with the task force's recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in beta-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. CONCLUSIONS: The task force's carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.
Objective To obtain feedback from patients receiving palliative care and their relatives from various ethnic backgrounds about their experiences of the disclosure process and their satisfaction with information sharing during the illness.
Design A qualitative study with semistructured single interviews.
Setting Perth, Western Australia, and Winnipeg, Manitoba, Canada.
Participants 72 participants registered with palliative care: 21 patient-family dyads in Perth and 14 dyads and 2 patients in Winnipeg.
Results Participants described their experiences in great detail. The analysis indicates that in information sharing the process is as important as the content. The timing, management, and delivery of information and perceived attitude of practitioners were critical to the process. This applied to information interactions at all stages of the illness. Main content areas mentioned related to prognosis and hope. Hope can be conveyed in different ways. Secondary information from various sources is accessed and synthesised with the primary information. All patients, regardless of origin, wanted information about their illness and wanted it fully shared with relatives. Almost all patients requested prognostic information, and all family members respected their wishes. Information was perceived as important for patient-family communication. Information needs of patient and family changed and diverged as illness progressed, and communication between them became less verbally explicit.
Conclusions Information delivery for patients needs to be individualised with particular attention to process at all stages of illness. Patients and families use secondary sources of information to complement and verify information given by health carers.
This study was designed to investigate personal and social factors associated with demand for care by women aged between 20 and 44 years, a group unlikely to suffer from chronic illness. A random sample of women was drawn from the age-sex register of a south London group practice, and information was obtained concerning their daily symptom perception, anxiety level, social and health characteristics, and their consultations for one year. Social class, family involvement, number of children in household, satisfaction with the housing, and use of other health and social services were not associated with demand for general practitioner care. Absence of basic housing amenities, difficulties in running the household, brevity of stay in the house or neighbourhood, and lack of attachment of the neighbourhood were related to a high patient-initiated consultation rate. Some of the possible interpretations of these results are discussed together with their implications for social policy planning.
To clarify the need for an advanced child health training program for Canadian rural family physicians, and to determine the key learning objectives to enable graduates to become community leaders in child and youth health care.
Qualitative educational research study.
Canada and Australia.
To gather data, the authors carried out semistructured interviews and focus groups with child care consultants, Canadian rural family physicians, child patients and parents, family medicine residents and Australian rural family physicians. Standards of qualitative methodology were applied to identify themes and subthemes.
It was determined that a family medicine child health program would provide the following benefits: enhanced care by family physicians, improved access to child care, increased attractiveness of family medicine as a career and reduced ‘specialty burden’.
Five key learning objectives for graduates were identified: the ability to provide child-centred care, to care for acutely or critically ill children, to care for children with complex needs, to recognize and act on ‘red flags’, and to provide behavioural and mental health care.
The Australian general practitioners confirmed that their training provided most of these benefits, and enabled them to achieve the objectives identified.
The present study showed that multiple stakeholders believed that advanced training in child health for rural family physicians would provide better care for children. The study also identified key learning objectives for the program. The present research led to the establishment of a Family Medicine Child Health Residency Program (www.familymedicineuwo.ca/PostGrad/PGY3/ChildHealth.aspx) at The University of Western Ontario (London, Ontario).
Family practice; Medical education; Paediatrics; Qualitative research
In response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software.
Patients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication.
Findings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.
To assess whether regular care from a family physician is associated with regular participation in screening mammography.
Secondary analysis of the 2006 Canadian Community Health Survey data.
Cross-sectional sample of 15 195 Canadian women aged 50 to 69 years.
MAIN OUTCOME MEASURES
The outcome of interest was screening mammography within the past 2 years; the key explanatory factor was active interaction with a family physician. Control factors included sociodemographic characteristics, other cancer screening behaviour, and other cancer risk habits.
Active interaction with a regular family doctor doubled the odds that a woman had received a recent screening mammogram. Other cancer screening and preventive measures were also strongly associated with that outcome. A woman who had had a recent Papanicolaou test was more than 3 times as likely to have had a recent mammogram; nonsmokers were much more likely to have had a recent mammogram than smokers.
Adults who receive regular care from family physicians are more likely to participate in screening mammography within the recommended time frames.
Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.
To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships.
Design and setting
A qualitative study in urban and suburban areas of north west England.
Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.
GP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.
Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.
chronic illness; doctor-patient relations; continuity of care; qualitative research
Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.
Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression;
A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers;
All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness;
Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.
The Canadian Heart Health Initiative began in 1987 as an 18-year undertaking to address the epidemic of cardiovascular disease in Canada. There is growing recognition in Canada of the need for an integrated approach to prevention that addresses common risks for many chronic diseases.
Research and intervention activities of the Canadian Heart Health Initiative have shifted toward chronic disease prevention and health promotion. This study explores the contributions of the Canadian Heart Health Initiative to document how single-disease strategies can evolve into integrated chronic disease prevention efforts.
Key informant interviews were conducted with project researchers and health system stakeholders from seven Canadian Heart Health Initiative provincial projects. A review of provincial health policy documents was also performed.
Findings indicate that the Canadian Heart Health Initiative projects contributed to public health capacity development, including coalition and partnership building, and development of health knowledge and resource infrastructure. The Canadian Heart Health Initiative projects helped put chronic disease prevention issues onto local and provincial health agendas and provided community-based models to help develop public health policies.
Experience with the Canadian Heart Health Initiative shows the need for integrated health programs to build on existing infrastructure. Other requirements for integrated chronic disease prevention programs include shared goals, partnerships at various policy levels and in multiple sectors, ongoing information sharing, and funding that is flexible and long-term.
Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada.
This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures.
A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013.
With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.
Canada lags behind other countries when it comes to investing in families with children. Canada, therefore, fails to promote health by not optimizing early development. The authors diagnose the Canadian failure. The problem is not research or fiscal capacity, but rather a sickness in Canadian culture. Four ailments are identified: Canadians are convinced they cannot afford new social investments, tend to treat illness rather than promote health, ignore that good family policy requires gender equality, and discount intergenerational justice. In response, the authors propose four policy solutions. Their pan-Canadian framework would cost $22 billion annually, not even one-half of current elderly and pension benefits. The new investment would reduce child vulnerability from approximately 30% to just 10% of children within 10 years. This reduction in early vulnerability would increase gross domestic product 20% more over 60 years than if Canadians tolerate the status quo.
Early childhood development; Outcomes; Social paediatrics
Improving access to healthcare has been a consistent priority for Canadians. In particular, reducing patient waiting times for health services has been a prominent policy issue. Across the country, governments are using a range of strategies to reduce patient waiting times for care, with a particular focus on reducing waits for specialized services. Although information is emerging on waits for selected procedures, there is limited information on whether the utilization of services or waiting experiences of Canadians with health problems are different from those of the general population. Data from the Health Services Access Survey (2001–2005) were used to compare waiting experiences for specialized services between adults with health problems and healthier adults. The specialized services included specialist visits for a new illness or condition, non-emergency surgery and diagnostic tests. National-level estimates revealed that adults with health problems were more likely to self-report that they required specialized services. However, the median waiting times for these services were comparable to those of healthier adults.
OBJECTIVE: To determine the extent to which policies and practices of Canadian hospitals providing maternity care are consistent with the World Health Organization (WHO)/UNICEF 10 Steps to Successful Breastfeeding, the WHO International Code of Marketing of Breast-Milk Substitutes and the WHO/UNICEF Baby Friendly Hospital Initiative. DESIGN: Cross-sectional mailed survey. SETTING: Canada. PARTICIPANTS: Representatives of 572 hospitals providing maternity care across Canada were sent a questionnaire in the spring and summer of 1993, 523 (91.4%) responded. OUTCOME MEASURES: Self-reported implementation of policies and practices concerning infant feeding; hospitals were grouped according to location, size (number of live births per year) and university affiliation status. MAIN RESULTS: Although 58.4% (296/507) of the respondents reported that their hospital had a written policy on breast-feeding, only 4.6% (21/454) reported having one that complied with all of the WHO/UNICEF steps surveyed. This figure dropped to 1.3% (6/453) when compliance with the WHO code (distribution of free samples of formula to formula-feeding and breast-feeding mothers) was added. Hospitals in Quebec and the Prairie provinces were significantly more likely than those in Ontario to give free samples of formula to both breast-feeding (OR 2.39 [95% confidence interval (Cl) 1.39 to 4.09] and 20.22 [95% Cl 9.27 to 44.33] respectively) and formula-feeding mothers (OR 1.82 [95% Cl 1.07 to 3.11] and 8.03 [95% Cl 3.29 to 19.6] respectively), after adjustment for hospital size and university affiliation status. CONCLUSION: There are considerable variations in the implementation of individual WHO steps and provisions of the WHO code according to hospital location, size and university affiliation status. Very few Canadian hospitals meet all of the criteria that would enable them to be considered "baby friendly" according to the WHO/UNICEF definition.
Medical tourism involves patients’ intentional travel to privately obtain medical care in another country. Empirical evidence regarding health and safety risks facing medical tourists is limited. Consideration of this issue is dominated by speculation and lacks meaningful input from people with specific expertise in patient health and safety. We consulted with patient health and safety experts in the Canadian province of British Columbia to explore their views concerning risks that medical tourists may be exposed to. Herein, we report on the findings, linking them to existing ethical and legal issues associated with medical tourism.
We held a focus group in September 2011 in Vancouver, British Columbia with professionals representing different domains of patient health and safety expertise. The focus group was transcribed verbatim and analysed thematically.
Seven professionals representing the domains of tissue banking, blood safety, health records, organ transplantation, dental care, clinical ethics and infection control participated.
Five dominant health and safety risks for outbound medical tourists were identified by participants: (1) complications; (2) specific concerns regarding organ transplantation; (3) transmission of antibiotic-resistant organisms; (4) (dis)continuity of medical documentation and (5) (un)informed decision-making.
Concern was expressed that medical tourism might have unintended and undesired effects upon patients’ home healthcare systems. The individual choices of medical tourists could have significant public consequences if healthcare facilities in their home countries must expend resources treating postoperative complications. Participants also expressed concern that medical tourists returning home with infections, particularly antibiotic-resistant infections, could place others at risk of exposure to infections that are refractory to standard treatment regimens and thereby pose significant public health risks.
Beyond well-documented credentialing issues, internationally-educated nurses (IENs) may need considerable support in transitioning into new social and health care environments. This study was undertaken to gain an understanding of transitioning experiences of IENs upon relocation to Canada, while creating policy and practice recommendations applicable globally for improving the quality of transitioning and the retention of IENs.
A focused ethnography of newly-recruited IENs was conducted, using individual semi-structured interviews at both one-to-three months (Phase 1) and nine-to-twelve months post-relocation (Phase 2). A purposive sample of IENs was recruited during their orientation at a local college, to a health authority within western Canada which had recruited them for employment throughout the region. The interviews were recorded and transcribed, and data was managed using qualitative analytical software. Data analysis was informed by Roper and Shapira's framework for focused ethnography.
Twenty three IENs consented to participate in 31 interviews. All IENs which indicated interest during their orientation sessions consented to the interviews, yet 14 did not complete the Phase 2 interview due to reorganization of health services and relocation. The ethno-culturally diverse group had an average age of 36.4 years, were primarily educated to first degree level or higher, and were largely (under) employed as "Graduate Nurses". Many IENs reported negative experiences related to their work contract and overall support upon arrival. There were striking differences in nursing practice and some experiences of perceived discrimination. The primary area of discontentment was the apparent communication breakdown at the recruitment stage with subsequent discrepancy in expected professional role and financial reimbursement.
Explicit and clear communication is needed between employers and recruitment agencies to avoid employment contract misunderstandings and to enable clear interpretation of the credentialing processes. Pre-arrival orientation of IENs including health care communications should be encouraged and supported by the recruiting institution. Moreover, employers should provide more structured and comprehensive workplace orientation to IENs with consistent preceptorship. Similar to findings of many other studies, diversity should be valued and incorporated into the professional culture by nurse managers.
Previous U.S. studies suggest that the incremental (“marginal”) use of the aggressive approach to care for acute myocardial infarction (AMI) in patients differing only in their distance to hospitals offering aggressive care may be associated with small mortality benefits. We hypothesized that the marginal benefits should be larger in Canada, as the country is operating on a lower margin because the approach to care is more conservative overall.
This retrospective study used administrative data of hospital admissions and health services for all patients admitted for a first AMI in Quebec in 1988 (n=8,674). We used differential distances to hospitals offering aggressive care as instrumental variables when measuring mortality up to four years after AMI.
Of the 4,422 subjects who were ≥ 65 years old, 11 percent received cardiac catheterization within 90 days after admission. In a previous study that applied similar methodology to the 1987 U.S. Medicare population, 23 percent of subjects received catheterization within 90 days. As in the U.S. study, we found that subjects living closer to hospitals offering aggressive care were more likely to receive aggressive care than subjects living further away (26 percent versus 19 percent received cardiac catheterization within 90 days; 95 percent CI: 5 percent to 9 percent). Unlike the U.S. study, we found no differences in mortality across the “close” versus “far” differential distance groups (unadjusted differences at one year: 1 percent; 95 percent CI: −1 percent to 3 percent). This absence of association held in elderly (≥ 65 years) and younger age groups. Adjusted results also showed no differences between subjects receiving aggressive versus conservative care (at one year: 4 percent; 95 percent CI: −11 percent to 20 percent).
Contrary to our hypothesis, but consistent with results from numerous randomized trials and observational studies, we cannot confirm that, on the margin, the aggressive approach to post-AMI care is associated with mortality benefits in Canada.
Myocardial infarction; instrumental variables; administrative database; confounding bias; mortality; Canada; United States
Primary health care (PHC) encompasses an array of health and social services that focus on preventative, diagnostic, and basic care measures to maintain wellbeing and address illnesses. In Canada, PHC involves the provision of first-contact health care services by providers such as family physicians and general practitioners – collectively referred as PHC physicians here. Ensuring access is a key requirement of effective PHC delivery. This is because having access to PHC has been shown to positively impact a number of health outcomes.
We build on recent innovations in measuring potential spatial access to PHC physicians using geographic information systems (GIS) by running and then interpreting the findings of a modified gravity model. Elsewhere we have introduced the protocol for this model. In this article we run it for five selected Canadian provinces and territories. Our objectives are to present the results of the modified gravity model in order to: (1) understand how potential spatial access to PHC physicians can be interpreted in these Canadian jurisdictions, and (2) provide guidance regarding how findings of the modified gravity model should be interpreted in other analyses.
Regarding the first objective, two distinct spatial patterns emerge regarding potential spatial access to PHC physicians in the five selected Canadian provinces: (1) a clear north–south pattern, where southern areas have greater potential spatial access than northern areas; and (2) while gradients of potential spatial access exist in and around urban areas, access outside of densely-to-moderately populated areas is fairly binary. Regarding the second objective, we identify three principles that others can use to interpret the findings of the modified gravity model when used in other research contexts.
Future applications of the modified gravity model are needed in order to refine the recommendations we provide on interpreting its results. It is important that studies are undertaken that can help administrators, policy-makers, researchers, and others with characterizing the state of access to PHC, including potential spatial access. We encourage further research to be done using GIS in order to offer new, spatial perspectives on issues of access to health services given the increased recognition that the place-based nature of health services can benefit from the use of the capabilities of GIS to enhance the role that visualization plays in decision-making.
An analysis of 98 health visitors and district nurses attached and non-attached to general practitioners in three local authority areas showed that most of them were aged over 40 and that many had entered domiciliary work because of the convenient hours or because of its intangible attractions. Adequate preparation for attachment was considered important, particularly a clear definition of the roles of the attached staff and their relationships to other workers in the practice.
Attached staff were found to be much more satisfied with the information given by the general practitioner about their patients than were unattached staff, and the former usually had access to the patients' medical records. The principal advantages of attachment were listed as access to family history; improved co-ordination within the practice and co-operation with the social services; favourable patient response; and increased mileage and work-load; the impossibility of crossing local authority boundaries; and having to deal with families registered with more than one doctor.
The association between a number of socio-economic determinants and health has been amply demonstrated in Canada and elsewhere. Over the past decades, women's increased labour force participation and changing family structure, among other changes in the socio-economic environment, have altered social roles considerably and lead one to expect that the pattern of disparities in health among women and men will also have changed. Using data from the CCHS (2000), this chapter investigates the association between selected socio-economic determinants of health and two specific self-reported outcomes among women and men: (a) self-perceived health and (b) self-reports of chronic conditions.
The descriptive picture demonstrated by this CCHS dataset is that 10% of men aged 65 and over report low income, versus 23% of women within the same age bracket. The results of the logistic regression models calculated for women and men on two outcome variables suggest that the selected socio-economic determinants used in this analysis are important for women and for men in a differential manner. These results while supporting other results illustrate the need to refine social and economic characteristics used in surveys such as the CCHS so that they would become more accurate predictors of health status given that there are personal, cultural and environmental dimensions to take into account.
Because it was shown that socio economic determinants of health are context sensitive and evolve over time, studies should be designed to examine the complex temporal interactions between a variety of social and biological determinants of health from a life course perspective. Examples are provided in the chapter.
A society that values mental health and helps people live enjoyable and meaningful lives is a clear aspiration echoed throughout our Canadian health care system. The Mental Health Commission of Canada has put forth a framework for a mental health strategy with goals that reflect the virtue of optimal mental health for all Canadians (Mental Health Commission Canada, 2009). Canadian nurses, the largest group of health care workers, have a vital role in achieving these goals. In Canada, two-thirds of those who experience mental health problems do not receive mental health services (Statistics Canada, 2003). Through a gendered, critical, and sociological perspective the goal of this paper is to further understand how the past has shaped the present state of psychiatric mental health nursing (PMHN). This integrative literature review offers a depiction of Canadian PMHN in light of the intersections of history, gender, education, and quality of nursing work life. Fourteen articles were selected, which provide a partial
reflection of contemporary Canadian PMHN. Findings include the association between gender and professional status, inconsistencies in psychiatric nursing education, and the limitations for Canadian nurse practitioners to advance the role of the psychiatric mental health nurse practitioner.
Immigration is not a new phenomenon but, rather, has deep roots in human history. Documents from every era detail individuals who left their homelands and struggled to reestablish their lives in other countries. The aim of this study was to explore and understand the experience of Iranian immigrants who accessed Canadian health care services. Research with immigrants is useful for learning about strategies that newcomers develop to access health care services.
The research question guiding this study was, “What are the processes by which Iranian immigrants learn to access health care services in Canada?” To answer the question, a constructivist grounded theory approach was applied. Initially, unstructured interviews were conducted with 17 participants (11 women and six men) who were adults (at least 18 years old) and had immigrated to Canada within the past 15 years. Eight participants took part in a second interview, and four participants took part in a third interview.
Using a constructivist grounded theory approach, “tackling the stumbling blocks of access” emerged as the core category. The basic social process (BSP), becoming self-sufficient, was a transitional process and had five stages: becoming a stranger; feeling helpless; navigating/seeking information; employing strategies; and becoming integrated and self-sufficient. We found that “tackling the stumbling blocks of access” was the main struggle throughout this journey. Some of the immigrants were able to overcome these challenges and became proficient in accessing health care services, but others were unable to make the necessary changes and thus stayed in earlier stages/phases of transition, and sometimes returned to their country of origin.
During the course of this journey a substantive grounded theory was developed that revealed the challenges and issues confronted by this particular group of immigrants. This process explains why some Iranian immigrants are able to access Canadian health care effectively while others cannot. Many elements, including language proficiency, cultural differences, education, previous experiences, financial status, age, knowledge of the host country’s health care services, and insider and outsider resources work synergistically in helping immigrants to access health care services effectively and appropriately.
Immigrants; Refugees; Health care; Access; Iranians; Canada; Constructivist grounded theory