The complex nature of transportation as a key determinant of health in primary and community care restructuring initiatives in rural Canada.

It is well recognized that transportation is a barrier to healthcare access for rural-dwelling residents, particularly older adults. Healthcare restructuring initiatives seldom take into consideration the complexity of transportation, which acts as a barrier to appropriate and timely access to healthcare services for older adults in rural communities. This article presents findings of a qualitative research study that explored the complex nature of transportation challenges that rural-dwelling older adults experience in Western Canada when trying to access primary and community care services. Data were derived from a larger study of service user views on a healthcare restructuring initiative intended to facilitate aging-in-place. We conducted 15 focus groups and 9 interviews with a diverse sample of 83 older adults living in one urban centre and nine rural and small rural towns in British Columbia (BC)'s interior. We used content analysis to determine codes and derive themes. Study findings showed that transportation was a top priority for improving primary and community care. Older adult participants identified a range of transportation challenges in trying to get to healthcare services and care providers getting to them. Transportation was a social determinant of health (SDOH) for all participants, regardless of whether they lived in the urban centre or in a rural or small rural town. Our study provides more evidence to support that transportation is a key SDOH for rural-dwelling older adults. As such, transportation should be specifically addressed in healthcare restructuring initiatives that aim to support aging-in-place. Service providers need to advocate for system-wide solutions such as integrating transportation into the healthcare system, while it is imperative that decision-makers act on these solutions.

Culturally safe dementia care: Building nursing capacity to care for First Nation Elders with memory loss.

BACKGROUND: Nursing staff require culturally relevant and dementia-specific education to care for the increasing number of First Nation Elders experiencing memory loss. The culturally safe dementia care (CSDC) research team, composed of researchers, decision makers and Secwepemc Elders, was formed to address this. OBJECTIVES: To increase the capacity of nurses to care for First Nations Elders with memory loss in a culturally safe way. METHODS: Our community-based research used purposive sampling and mixed methods to create, implement and evaluate an education programme for nurses. Thirty-four Elders from six Secwepemc communities participated in roundtables to share views and stories of dementia and nursing care. These data were used to create four teaching stories for the storytelling sessions and talking circles with Elders which, together with the Indigenous Cultural Competency (ICC) training, comprised the CSDC education programme. Thirty-eight nurses (healthcare aides, licensed practical nurses and registered nurses) working in Central British Columbia began the CSDC study and 15 nurses took part in the education programme, evaluated the storytelling session and completed the three pre- and post-measures (Approaches to Dementia Questionnaire (ADQ), ICC knowledge quiz and self-assessment, and Care Plans). The pre- and post-tests were scored, and the data were analysed statistically. The data from the roundtables and talking circles were analysed thematically through a collaborative process. RESULTS: The scores for the ADQ Hope sub-scale, the ICC knowledge quiz and the Care Plans increased from pre- to post-test. All nurse participants judged the storytelling session to be effective and their learning outcomes reflected culturally safe dementia care. CONCLUSIONS: This programme can improve the knowledge, skills and values of nurses to provide culturally safe dementia care.

Older Adults' Views on the Repositioning of Primary and Community Care.

Older adults are rarely consulted on health care restructuring. To address this gap, our study explored older adults' views on "repositioning", a restructuring initiative to support independent living for older adults with complex chronic disease (CCD). We collected and analysed data from 83 older adults living in one small city and nine rural small towns where "repositioning" of primary and community care was occurring. Average participant age was 75 years; 56 (67%) were women, 44 (53%) had CCD, and 20 (24%) identified as Indigenous or South Asian. The four themes were: unfamiliarity with repositioning; optimism versus skepticism; improving primary and community care (through better home care, improved transportation, and more doctors); and, playing an active role to effect change. For repositioning to be successful, diverse service users must be fully included; rural-dwelling older adults' priorities for primary and community care need to be addressed, rather than using a "cookie-cutter" approach.

Intersectionality in the Lives of LGBTQ Youth: Identifying as LGBTQ and Finding Community in Small Cities and Rural Towns.

This article presents an analysis of the views of younger bisexual and lesbian women and transgender youth living in a western Canadian small city on their sexual and gender identities. Data were collected through focus groups and interviews and analyzed thematically through an intersectional lens. The purposive sample was composed of 13 youth who identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ) and whose average age was 19.8 years. The analytical themes of (1) living in a small town, (2) identifying and being identified, and (3) talking intersectionality indicate that the sexual identities and gender identities and expressions of LGBTQ youth change across time and context and are impacted by often overlooked factors including faith, Indigenous ancestry, disability, and class. Further, the size and character of the community significantly impacts LGBTQ youth identity development and expression. This research demonstrates the uniqueness of individual youth's experiences-opposing notions of milestone events as singularly important in queer youth identity development.

Verbal and nonverbal indicators of quality of communication between care staff and residents in ethnoculturally and linguistically diverse long-term care settings.

Linguistic and ethnocultural diversity in long-term residential care is a growing trend in many urban settings. When long-term care staff and residents do not share the same language or ethnocultural background, the quality of their communication and care are jeopardized. There is very little research addressing how staff and residents communicate when they experience a mismatch in their language and ethnocultural backgrounds. Thus, the goals of the present study were to 1) document the verbal and nonverbal behaviours used by staff and residents in diverse interactions, and 2) identify and account for behaviours that either promoted or detracted from positive communication by drawing on principles from 'Communication Accommodation Theory'. Two long-term care facilities in British Columbia Canada were selected due to the diverse linguistic and ethnocultural backgrounds of their staff and residents. Twenty-seven staff and 27 residents consented to being video-recorded during routine activities (e.g., mealtimes, recreational activities). The recorded observations were transcribed, translated, and coded using qualitative descriptive and interpretive analyses. A number of verbal and nonverbal behaviours were identified and interpreted in relation to whether they promoted or detracted from positive communication. The findings point to considering a variety of proactive strategies that staff and administrators could employ to effectively accommodate to language and ethnocultural diversity in long-term care practice.

Developing CIRCA-BC and exploring the role of the computer as a third participant in conversation.

The Computer Interactive Reminiscence Conversation Aid (CIRCA) is a software program using touch screen technology and digital materials from public archives to support conversation between people with dementia and their carers. In this 2-phase study, we first worked with seniors' focus groups to identify and select relevant content for a regional adaptation of CIRCA (British Columbia version of CIRCA [CIRCA-BC]). We then pilot tested CIRCA-BC with 3 participants having dementia and a conversation partner, analyzing their interactions to explore how they drew on program content and format to shape their conversations together. Findings provide insight into, first, how participants' shared and distinct social histories influence reminiscence-based conversations and, second, how the computer can be viewed as a third "participant" in the interaction. These findings offer guidelines for ongoing adaptation and application of the CIRCA program in addition to contributing further evidence regarding the role of technology in facilitating meaningful interaction between people with dementia and their carers.

Views of First Nation elders on memory loss and memory care in later life.

Little is known about Indigenous communities and dementia and Elders have not been involved as advisors or participants in most research to date. This exploratory research sought to address this gap through a constructivist grounded theory project on the views of First Nation Elders on memory loss and memory care in later life, conducted in collaboration with decision-makers from the local Health Authority and Elders from three First Nation communities in British Columbia, Canada. Elders served as advisors to this research and research agreements were negotiated and signed with each community. Data collection occurred through a series of sharing circles and interviews with a total of 21 Elders, four of whom were experiencing memory loss, and two community members. Four themes arose through the constant comparative data analysis process: Being Secwepemc, growing older, losing memory, and supporting one another. These themes indicate that memory loss and memory care in First Nation communities has changed over the past century, including the causes attributed to memory loss in later life and community responses to those affected. Elders hold differing views about memory loss, including the traditional--'going through the full circle' [of life]--and the shémá [white] way--'your dementia', with the latter being much more common. This research indicates the importance of protecting and reviving traditional knowledge and ways of life in order to prevent 'your dementia' and avoid the adoption of health care practices that may be culturally unsafe for First Nation Elders.