Core aspects of "empowering" caregivers as articulated by leaders in home health care: palliative and chronic illness contexts.

Home-based family caregivers are often assisted by home care services founded upon principles of health promotion, such as empowerment. Using an interpretive approach and in-depth qualitative interviews, the authors examine descriptions of family empowerment by leaders and managers in the field of home health care in the province of British Columbia, Canada. In a culture of fiscal restraint, dying at home, and self-care, participants described how home care nurses empower family caregivers to meet these objectives. This involves educating and informing caregivers, engaging them in planning and decision-making, and reassuring them that their role is manageable and worthwhile. Though some participants viewed providing supports as empowering (e.g., during times of crisis), others viewed them as disempowering (by promoting dependence). Empowered caregivers were characterized as able to provide home care, confident of their capabilities, and believing that their work is positive and beneficial. The long-term goal of empowerment was characterized as client self-care and/or family care and decreased dependence on formal services.

Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1).

Existing research on the health care utilization patterns of older Canadians suggests that income does not usually restrict an individual's access to care. However, the role that income plays in influencing access to health services by older adults living in rural areas is relatively unknown. This article examines the relationship between income and health service utilization among older adults in rural and urban areas of British Columbia. Data were drawn from Statistics Canada's Canadian Community Health Survey, Cycle 3.1. Multivariate regression techniques were employed to examine the influence of relative income on accessibility for 3,424 persons aged 65 and over. Results suggest that (1) relative income does not influence access to health care services; and (2) this is true for both urban and rural older adults. The most important and consistent predictors of access in all cases were those that measured health care need.

Strengths and weaknesses of using conferencing technologies to support drug policy knowledge exchange.

This paper outlines the experiences with and lessons learned from the use of conferencing technologies in supporting knowledge exchange groups. We discuss the strengths and weaknesses of these technologies when used to support distant knowledge exchange activities within drug policy groups. The strengths and weaknesses of face-to-face meetings are also discussed.

Home care nurses' decisions about the need for and amount of service at the end of life.

AIMS: We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice. BACKGROUND: Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care. METHODS: Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison. FINDINGS: Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care. CONCLUSION: Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

The impact of daily mobility on exposure to traffic-related air pollution and health effect estimates.

Epidemiological studies of traffic-related air pollution typically estimate exposures at residential locations only; however, if study subjects spend time away from home, exposure measurement error, and therefore bias, may be introduced into epidemiological analyses. For two study areas (Vancouver, British Columbia, and Southern California), we use paired residence- and mobility-based estimates of individual exposure to ambient nitrogen dioxide, and apply error theory to calculate bias for scenarios when mobility is not considered. In Vancouver, the mean bias was 0.84 (range: 0.79-0.89; SD: 0.01), indicating potential bias of an effect estimate toward the null by ~16% when using residence-based exposure estimates. Bias was more strongly negative (mean: 0.70, range: 0.63-0.77, SD: 0.02) when the underlying pollution estimates had higher spatial variation (land-use regression versus monitor interpolation). In Southern California, bias was seen to become more strongly negative with increasing time and distance spent away from home (e.g., 0.99 for 0-2 h spent at least 10 km away, 0.66 for ≥ 10 h spent at least 40 km away). Our results suggest that ignoring daily mobility patterns can contribute to bias toward the null hypothesis in epidemiological studies using individual-level exposure estimates.

Technology enabled knowledge exchange: development of a conceptual framework.

As the need for knowledge exchange grows, so does the need to find new ways for researchers, decision makers, and educators to communicate and collaborate with each other on how to improve drug prescribing and use. In this paper, we introduce a conceptual framework for evaluating knowledge exchange activities within drug policy groups. The framework is grounded in the information and communication technologies (ICT) and knowledge exchange literature and is composed of various inputs, processes, and outputs. Inputs into the framework are research task, communication medium (face-to-face, teleconferencing, and web-conferencing), group characteristics (size, experience, goals, and roles), and context (description of linkage and exchange within the policy domain and group type). The inputs will affect how the social interaction process, knowledge brokering process, and information exchange process between drug policy groups (decision-makers, researchers, and educators) develop as part of the linkage and exchange knowledge exchange process. The inputs and how they shape the linkage and exchange knowledge exchange process will lead to different levels of engagement outputs and linkage and exchange outputs. Results of a refined conceptual framework based on a 2-year case study are also provided in the model where new inputs and processes are introduced.

A literature review on distance knowledge exchange in healthcare groups: what can we learn from the ICT literature?

As healthcare groups continue to communicate and collaborate at a distance on knowledge exchange activities, Information and Communication Technology (ICT) has come to play an increasingly important role in supporting such interactions. However, to date, the literature on knowledge exchange appears disconnected from that of ICT. Research on the effects of ICT on knowledge exchange activities is needed. The literature review explores the potential impacts ICTs can have on knowledge exchange groups, and especially, the social interaction process. A discussion of how ICTs could impact the social interaction process of knowledge exchange activities is made.

The use of conferencing technologies to support drug policy group knowledge exchange processes: an action case approach.

OBJECTIVES: To describe experiences, lessons and the implications related to the use of conferencing technology to support three drug policy research groups within a three-year period, using the action case research method. DESIGN: An action case research field study was executed. Three different drug policy groups participated: research, educator, and decision-maker task groups. There were a total of 61 participants in the study. The study was conducted between 2004 and 2007. Each group used audio-teleconferencing, web-conferencing or both to support their knowledge exchange activities. MEASUREMENTS: Data were collected over three years and consisted of observation notes, interviews, and meeting transcripts. Content analysis was used to analyze the data using NIVIO qualitative data analysis software. RESULTS: The study found six key lessons regarding the impact of conferencing technologies on knowledge exchange within drug policy groups. We found that 1) groups adapt to technology to facilitate group communication, 2) web-conferencing communication is optimal under certain conditions, 3) audio conferencing is convenient, 4) web-conferencing forces group interactions to be "within text", 5) facilitation contributes to successful knowledge exchange, and 6) technology impacts information sharing. CONCLUSIONS: This study highlights lessons related to the use of conferencing technologies to support distant knowledge exchange within drug policy groups. Key lessons from this study can be used by drug policy groups to support successful knowledge exchange activities using conferencing technologies.

Articulating the role of relationships in access to home care nursing at the end of life.

In this article, we draw on data collected from two samples of home care nurses to examine how relationships between nurses and family caregivers intersected with access to palliative home care nursing services. Participants referred to relationships as important for their practical benefits and for access to care: good relationships enhanced the nurse's ability to assess clients and families and fostered the family's trust in the nurse's care. Although emphasizing the need to build and maintain relationships (often requiring time), participants simultaneously referred to beliefs about the need to control the personal emotions invoked in relationships so as to ensure appropriate access for clients and families. Future research should further explore how the organizational and resource context, and the culture of palliative care, shape nurses' beliefs about relationships in their practice, the nature and types of relationships that can develop, and both client and family caregivers' access to care.

An interdisciplinary team communication framework and its application to healthcare 'e-teams' systems design.

BACKGROUND: There are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication. METHODS: An ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes. RESULTS: We present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'. CONCLUSION: The structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function.

A case study examining the impacts of conferencing technologies in distributed healthcare groups.

As healthcare groups continue to communicate and collaborate at a distance, information and communication technology (ICT) has come to play an increasingly important role in supporting such interactions. In this paper, we describe key lessons learned from a two-year case study (2004-2006) on the impacts of conferencing technologies on social interaction norms within knowledge exchange groups.

Making meaningful connections: a profile of social isolation and health among older adults in small town and small city, British Columbia.

OBJECTIVE: The objectives of the study are: (a) to develop a profile of socially isolated older adults (SIOA) in British Columbia (BC) based on sociodemographic and health characteristics and (b) to examine whether SIOA under-or overutilize health care services. METHOD: This study uses telephone interview data collected from a random sample of 1,064 older adults (65+) in BC. The sample was identified using established criteria from the six-item Lubben Social Network Scale. RESULTS: The results indicate that 17% of the sample is socially isolated. To summarize, the strongest predictors of social isolation are income, gender, marital status, self-rated health, length of residence, and home ownership. Further analysis indicates that SIOA were not more inclined to overuse health services. DISCUSSION: The findings underscore the importance of understanding differential profiles of need and service use for SIOA within broader social contexts, and are discussed in terms of their implications for health care policy and program planning for this vulnerable population.

Spatial variations in estimated chronic exposure to traffic-related air pollution in working populations: a simulation.

BACKGROUND: Chronic exposure to traffic-related air pollution is associated with a variety of health impacts in adults and recent studies show that exposure varies spatially, with some residents in a community more exposed than others. A spatial exposure simulation model (SESM) which incorporates six microenvironments (home indoor, work indoor, other indoor, outdoor, in-vehicle to work and in-vehicle other) is described and used to explore spatial variability in estimates of exposure to traffic-related nitrogen dioxide (not including indoor sources) for working people. The study models spatial variability in estimated exposure aggregated at the census tracts level for 382 census tracts in the Greater Vancouver Regional District of British Columbia, Canada. Summary statistics relating to the distributions of the estimated exposures are compared visually through mapping. Observed variations are explored through analyses of model inputs. RESULTS: Two sources of spatial variability in exposure to traffic-related nitrogen dioxide were identified. Median estimates of total exposure ranged from 8 microg/m3 to 35 microg/m3 of annual average hourly NO2 for workers in different census tracts in the study area. Exposure estimates are highest where ambient pollution levels are highest. This reflects the regional gradient of pollution in the study area and the relatively high percentage of time spent at home locations. However, for workers within the same census tract, variations were observed in the partial exposure estimates associated with time spent outside the residential census tract. Simulation modeling shows that some workers may have exposures 1.3 times higher than other workers residing in the same census tract because of time spent away from the residential census tract, and that time spent in work census tracts contributes most to the differences in exposure. Exposure estimates associated with the activity of commuting by vehicle to work were negligible, based on the relatively short amount of time spent in this microenvironment compared to other locations. We recognize that this may not be the case for pollutants other than NO2. These results represent the first time spatially disaggregated variations in exposure to traffic-related air pollution within a community have been estimated and reported. CONCLUSION: The results suggest that while time spent in the home indoor microenvironment contributes most to between-census tract variation in estimates of annual average exposures to traffic-related NO2, time spent in the work indoor microenvironment contributes most to within-census tract variation, and time spent in transit by vehicle makes a negligible contribution. The SESM has potential as a policy evaluation tool, given input data that reflect changes in pollution levels or work flow patterns due to traffic demand management and land use development policy.

The devil is in the details: trends in avoidable hospitalization rates by geography in British Columbia, 1990-2000.

BACKGROUND: Researchers and policy makers have focussed on the development of indicators to help monitor the success of regionalization, primary care reform and other health sector restructuring initiatives. Certain indicators are useful in examining issues of equity in service provision, especially among older populations, regardless of where they live. AHRs are used as an indicator of primary care system efficiency and thus reveal information about access to general practitioners. The purpose of this paper is to examine trends in avoidable hospitalization rates (AHRs) during a period of time characterized by several waves of health sector restructuring and regionalization in British Columbia. AHRs are examined in relation to non-avoidable and total hospitalization rates as well as by urban and rural geography across the province. METHODS: Analyses draw on linked administrative health data from the province of British Columbia for 1990 through 2000 for the population aged 50 and over. Joinpoint regression analyses and t-tests are used to detect and describe trends in the data. RESULTS: Generally speaking, non-avoidable hospitalizations constitute the vast majority of hospitalizations in a given year (i.e. around 95%) with AHRs constituting the remaining 5% of hospitalizations. Comparing rural areas and urban areas reveals that standardized rates of avoidable, non-avoidable and total hospitalizations are consistently higher in rural areas. Joinpoint regression results show significantly decreasing trends overall; lines are parallel in the case of avoidable hospitalizations, and lines are diverging for non-avoidable and total hospitalizations, with the gap between rural and urban areas being wider at the end of the time interval than at the beginning. CONCLUSION: These data suggest that access to effective primary care in rural communities remains problematic in BC given that rural areas did not make any gains in AHRs relative to urban areas under recent health sector restructuring initiatives. It remains important to continue to monitor the discrepancy between them as a reflection of inequity in service provision. In addition, it is important to consider alternative explanations for the observed trends paying particular attention to the needs of rural and urban populations and the factors influencing local service provision.

Health service utilization among older adults in British Columbia: making sense of geography.

The utilization of health services by older adults has received increased attention over the past decade, but little is known about how service utilization varies between rural and urban areas. In an era of restructuring and downsizing within the Canadian health care system, there are concerns that rural older adults may be increasingly disadvantaged when it comes to accessing health care. This article examines the utilization of a range of health services by older adults living in urban and rural communities in British Columbia. A major strength of this article is its concurrent focus on a continuum of geographic communities and a broad range of services needed and used by older populations. The research utilizes provincial administrative health data from 48,407 older residents of British Columbia who used services in 1998-1999. Multivariate analyses of co-variance reveal some unique service utilization patterns by geographical area and population.

Levelling the playing field? Exploring the implications of managed competition for voluntary sector providers of long-term care in small town Ontario.

This paper considers how long-term care restructuring, under the rubric of managed competition, has increased pressure on voluntary sector providers of long-term care to elderly populations in small, rural places. Drawing on in-depth interviews with key-informants from non-profit organizations, we present a case study set in rural Ontario to develop a situated understanding of the impact of restructuring on voluntary sector providers of long-term care. We contend that managed competition (underway in Ontario since 1995) has constrained providers, eroded service choices, and reduced access to long-term care in rural areas leaving rural populations more disadvantaged than ever before when it comes to public service provisioning.

Different strokes: need for help among stroke-affected persons in British Columbia.

BACKGROUND: Cerebrovascular disease (CD) is a leading cause of disability and death in British Columbia, as in much of the developed world. Provision of care for stroke-affected persons depends upon accurate estimates of prevalence, but also on a clearer understanding of the specific characteristics and needs of this population. METHODS: Data are drawn from the Canadian Community Health Survey, Cycle 1.1, 2000 - 2001. Bivariate analysis examines older populations age 55+ living in BC to determine how stroke-affected persons differ from non-stroke-affected persons according to sociodemographic factors, health, co-morbid conditions, need for help, and service use. Multivariate logistic regression was used to assess the impact of stroke status on need for help with regular and instrumental activities of daily living. RESULTS: Risk of stroke rises every decade after age 55. The prevalence of CD in British Columbia is 3.7% among those age 55+ and 5.2% among those age 65+. Stroke survivors use more acute care services (i.e., they spend more nights in hospital and consult physicians more often on an annual basis). Being older and female, as well as having lower income and poor health are characteristics of stroke survivors. Even after controlling for these variables, the odds of needing help with regular tasks of daily living are still higher for stroke-affected persons because of the high level of disability associated with stroke. CONCLUSION: Ultimately, while it is appropriate to target acute care resources to treat stroke and to minimize negative stroke outcomes, these data support the need to develop a clearer understanding of the needs and service utilization patterns of community-dwelling stroke survivors to ensure access to a full continuum of care.