Public health human resources: a comparative analysis of policy documents in two Canadian provinces.

BACKGROUND: Amidst concerns regarding the capacity of the public health system to respond rapidly and appropriately to threats such as pandemics and terrorism, along with changing population health needs, governments have focused on strengthening public health systems. A key factor in a robust public health system is its workforce. As part of a nationally funded study of public health renewal in Canada, a policy analysis was conducted to compare public health human resources-relevant documents in two Canadian provinces, British Columbia (BC) and Ontario (ON), as they each implement public health renewal activities. METHODS: A content analysis of policy and planning documents from government and public health-related organizations was conducted by a research team comprised of academics and government decision-makers. Documents published between 2003 and 2011 were accessed (BC = 27; ON = 20); documents were either publicly available or internal to government and excerpted with permission. Documentary texts were deductively coded using a coding template developed by the researchers based on key health human resources concepts derived from two national policy documents. RESULTS: Documents in both provinces highlighted the importance of public health human resources planning and policies; this was particularly evident in early post-SARS documents. Key thematic areas of public health human resources identified were: education, training, and competencies; capacity; supply; intersectoral collaboration; leadership; public health planning context; and priority populations. Policy documents in both provinces discussed the importance of an educated, competent public health workforce with the appropriate skills and competencies for the effective and efficient delivery of public health services. CONCLUSION: This policy analysis identified progressive work on public health human resources policy and planning with early documents providing an inventory of issues to be addressed and later documents providing evidence of beginning policy development and implementation. While many similarities exist between the provinces, the context distinctive to each province has influenced and shaped how they have focused their public health human resources policies.

Fading vision: knowledge translation in the implementation of a public health policy intervention.

BACKGROUND: In response to several high profile public health crises, public health renewal is underway in Canada. In the province of British Columbia, the Ministry of Health initiated a collaborative evidence-informed process involving a steering committee of representatives from the six health authorities. A Core Functions (CF) Framework was developed, identifying 21 core public health programs. For each core program, an evidence review was conducted and a model core program paper developed. These documents were distributed to health authorities to guide development of their own renewed public health services. The CF implementation was conceptualized as an embedded knowledge translation process. A CF coordinator in each health authority was to facilitate a gap analysis and development of a performance improvement plan for each core program, and post these publically on the health authority website. METHODS: Interviews (n = 19) and focus groups (n = 8) were conducted with a total of 56 managers and front line staff from five health authorities working in the Healthy Living and Sexually Transmitted Infection Prevention core programs. All interviews and focus groups were digitally recorded, transcribed and verified by the project coordinator. Five members of the research team used NVivo 9 to manage data and conducted a thematic analysis. RESULTS: Four main themes emerged concerning implementation of the CF Framework generally, and the two programs specifically. The themes were: 'you've told me what, now tell me how'; 'the double bind'; 'but we already do that'; and the 'selling game.' Findings demonstrate the original vision of the CF process was lost in the implementation process and many participants were unaware of the CF framework or process. CONCLUSIONS: Results are discussed with respect to a well-known framework on the adoption, assimilation, and implementation of innovations in health services organizations. Despite attempts of the Ministry of Health and the Steering Committee to develop and implement a collaborative, evidence-informed policy intervention, there were several barriers to the realization of the vision for core public health functions implementation, at least in the early stages. In neglecting the implementation process, it seems unlikely that the expected benefits of the public health renewal process will be realized.

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.

Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care.

BACKGROUND: Seriously ill patients and their physicians often avoid discussing prognosis, which may compromise optimal end-of-life (EOL) care planning. The relation between prognosis discussion and patient and family satisfaction with EOL care is unknown. METHODS: Using a 5-domain questionnaire, we surveyed inpatients with cancer or end-stage medical disease and their families on their satisfaction with specific aspects of EOL care and their overall satisfaction with EOL care. Scores were standardized to 0-100 points. We compared the results based on whether or not a physician had discussed the patient's prognosis with them, as well as on whether the patient and family member agreed on whether the patient was nearing the end of life. Supplementary questions were also asked (e.g., preferred location of death, willingness to discuss cardiopulmonary resuscitation). RESULTS: Of 569 eligible patients and 176 eligible family members, 440 (77%) patients and 160 (91%) family members participated in the study. Overall, 18% of patients and 30.1% of families recalled a prognosis discussion with a physician. Patients who recalled such a discussion were more satisfied with overall care (76.1 v. 73.1 points, difference 3.0, 95% confidence interval [CI] 0.40 to 5.67, p = 0.02) and with communication and decision-making aspects of care (77.9 v. 72.4 points, difference 5.5, 95% CI 1.43 to 9.52, p = 0.008), and were more willing to discuss cardiopulmonary resuscitation status (69.6% v. 55.3%, difference 14.3, 95% CI 2.15 to 26.45, p = 0.03), than those who did not. Patients who were in accord with their family member as to whether they were nearing the end of life also showed significant satisfaction in these 3 areas. Family members' overall satisfaction was also higher among those who recalled a prognosis discussion (75.3 v. 70.4 points, difference 4.9, 95% CI 0.53 to 9.24, p = 0.03). Multivariate analyses confirmed the significance of the relation between the prognosis discussion and overall satisfaction with care for both patients and family members. CONCLUSION: Although discussions about prognosis occur infrequently for patients who have advanced terminal disease, such discussions with patients and their families may facilitate advance care planning and improve satisfaction with EOL care. Encouraging discussion regarding EOL status between the patient and family members may also lead to greater satisfaction with EOL care for patients.

Palliative family caregivers' accounts of health care experiences: the importance of "security".

OBJECTIVE: When providing care for a loved one with a terminal illness, family members often look to health care providers for guidance and expertise. The objective of this study is to explore family caregiver accounts of their experiences within the health care system and with individual providers. METHODS: A thematic analysis of secondary qualitative data was performed. Data are from a subsample of bereaved and current family caregivers (N = 31) in a prior study of coping in end-of-life cancer situations. Data from these participants referring to experiences with health care providers was thematically coded and the concept of "security" was used as an analytic lens to facilitate conceptual development and exploration. RESULTS: Considered together, the findings can be viewed as manifestations of a need and desire for security in palliative family caregiving. Specifically, family caregivers' accounts illustrate the importance of feeling secure that health care services will be provided by competent professionals; feeling secure in their timely access to needed care, services, and information; and feeling secure in their own identity and self-worth as a caregiver and individual. In addition, the findings suggest a conceptualization of security that extends beyond trust in individuals to include a generalized sense of institutional trust in the health care system. SIGNIFICANCE OF RESULTS: The concept of security moves beyond description of individual satisfaction or dissatisfaction with health care to identify a common, foundational need underlying such evaluations. Further empirical research is needed that explicitly focuses on caregivers' experiences of security and insecurity in the domains identified in this article. This will contribute to theory building as well as assist in identifying the causes and consequences of security.

Use of palliative care services in a semirural program in British Columbia.

INTRODUCTION: Although specialized palliative care services in rural areas are scarce, many people who are dying, and their families, want to remain in their homes or within their own community. As such, semirural communities across Canada have developed a variety of initiatives to address this need. The purpose of our paper is to describe a semirural palliative care program located in British Columbia. METHODS: We used univariate and bivariate analyses to examine all patients for whom a palliative care bed was requested in the Saanich Peninsula Hospital Palliative Care Unit (PCU) between Jan. 1, 2005, and Dec. 31, 2006. RESULTS: Data suggest that there is provision of care for local residents in this semirural community. Throughout 2005 and 2006, SPH received a total of 411 requests for a palliative care bed with about three-quarters of admissions coming from other units within the hospital and from local residents. CONCLUSION: Use of services data collected from hospital charts can provide valuable information to help inform program and policy decision-makers. Yet such information is limited in relation to answering the question of whether the end-of-life needs of local residents are being met. Future studies should consider input from families and patients to enhance our understanding of the role of a PCU in a semirural environment.

Preferences for location of death of seriously ill hospitalized patients: perspectives from Canadian patients and their family caregivers.

Previous studies involving palliative patients suggest a preference for dying at home. The purpose of this paper is to examine, prospectively, patient and family caregiver preferences for, and congruence with, location of death for hospitalized patients with cancer and end-stage medical conditions. Questionnaires were administered to 440 eligible in-patients and 160 family caregivers in five hospitals across Canada. This paper reports results of 138 patient/family caregiver dyads who answered a question about preference for location of death. The results suggest that only half of all patients and family caregivers report a preference for a home death. Furthermore, half of the patient/family caregiver dyads disagree on preferred location of death. If one of the primary goals of end of life care is to enhance the quality of life of dying patients and their family caregivers, policies directed towards ensuring that patients die in their location of choice ought to be a priority and resources should be allocated to promote the development of excellent care, not only in the home, but also within our institutional settings.

The information transfer and knowledge acquisition geographies of family caregivers: an analysis of Canada's Compassionate Care Benefit.

The authors explore an underdeveloped area of health geography by examining information transfer and knowledge acquisition for a health-related social program. Specifically, they discuss the findings of a small-scale utilization-focused evaluation of Canada's Compassionate Care Benefit (CCB). The CCB allows workers who are eligible for employment insurance to leave work to care for family members at end-of-life. Using the findings of 25 interviews with family caregivers, the authors explore their geographies of information transfer and knowledge acquisition. First, however, they introduce their respondent group and provide an overview of their socio-spatial lives as family caregivers. They then examine 3 specific thematic findings: awareness of the CCB, access to information related to the CCB, and the application process. The authors discuss the implications of the findings for the information needs and burdens of family caregivers and for Canadian nursing practice. They also consider directions for future CCB research.

Home care and health reform: changes in home care utilization in one Canadian province, 1990-2000.

PURPOSE: This study examines population-based trends in home care service utilization, alone and in conjunction with hospitalizations, during a period of health reform in Canada. It focuses on the extent to which observed trends suggest enhanced community-based care relative to three competing hypotheses: cost-cutting, medicalization, and profitization. DESIGN AND METHODS: Analyses drew on administrative health data from the province of British Columbia for the period from 1990 through 2000. Annual trends in age- and gender-adjusted utilization rates are examined by use of joinpoint regression; multivariate analyses draw on generalized linear modeling. RESULTS: Home support claims decreased significantly during the study period. There was less evidence of decline with regard to home nursing care claims and the extent of both home support and home nursing care. Intensity of care increased for home support services but decreased somewhat for home nursing care. Multivariate analyses revealed a decline in joint use of home support and hospital care and little change in joint use of home nursing and hospital care. Similarities as well as differences in trends are evident across age groups. IMPLICATIONS: The findings suggest a reduction and reallocation of health services in general rather than a shift of focus toward community-based care. In this way, they appear more consistent with a cost-reduction hypothesis than with expectations of enhanced community-based care that are generated by recent health reform initiatives.

Care-receiver and caregiver assessments of functioning: Are there gender differences?

In situations where care-receivers cannot respond to questions about their functional status, caregiver proxies are often substituted. Yet studies addressing caregiver-care-receiver agreement remain limited in scope, focusing primarily on cognitive functioning and caregiver relationship. This study broadens the range of research in this area by examining caregiver and care-receiver reports of individual IADL and AADL items by gender of care-receiver. As well, the degree to which the care-receiver's age and mental and physical health status influence agreement are investigated. Data for this study come from a sample of 388 Manitoba older adults aged 65 and over. Results (using Cohen's kappa) suggest less agreement on the presence of disability for men than for women, particularly among those aged 75-84. Differences by health status were also revealed. The implications of the findings for assessments of functioning are considered.

The uses of provincial administrative health databases for research on palliative care: Insights from British Columbia, Canada.

BACKGROUND: Research indicating that people increasingly prefer to die at home suggests that palliative care is likely to play a more prominent role in the future of Canada's health care system. Unfortunately, at a time when research evidence should be informing policy and service delivery, little is known about health service utilization by Canadians at the end of life. One existing mechanism that can help address this gap is provincial administrative health data. The purpose of this study was to explore the potential of administrative health data to identify characteristics of palliative care users, patterns of formal service utilization and predictors of palliative care use. METHODS: Bivariate and multivariate analyses were used to examine data from the Capital Health Region, British Columbia Linked Health Databases for the period 1992/93 to 1998/99. The databases examined include continuing care, physician claims, hospital separations, and vital statistics. As the name implies, these databases can be linked at the individual level using unique identifiers so that health services utilization can be tracked across sectors. RESULTS: General patterns of service use among palliative care patients suggest that general practitioner and medical specialist visits have decreased over time and the utilization of hospital beds has increased. Utilization of community-based services (i.e. home support and home nursing care) shows an overall pattern of decline. However, when compared to non-palliative care patients, palliative care patients spent fewer nights in hospital, used fewer hours of home support, and had a greater number of home nursing care visits. CONCLUSIONS: Administrative health databases can provide valuable information for examining service utilization patterns over time. However, given that decisions surrounding the designation of palliative care include factors beyond the scope of administrative databases (such as quality of life, personal preferences, social support), these databases should only be seen as one source of information to inform service delivery and policy decision making.