Challenges to the provision of diabetes care in first nations communities: results from a national survey of healthcare providers in Canada.

BACKGROUND: Aboriginal peoples globally, and First Nations peoples in Canada particularly, suffer from high rates of type 2 diabetes and related complications compared with the general population. Research into the unique barriers faced by healthcare providers working in on-reserve First Nations communities is essential for developing effective quality improvement strategies. METHODS: In Phase I of this two-phased study, semi-structured interviews and focus groups were held with 24 healthcare providers in the Sioux Lookout Zone in north-western Ontario. A follow-up survey was conducted in Phase II as part of a larger project, the Canadian First Nations Diabetes Clinical Management and Epidemiologic (CIRCLE) study. The survey was completed with 244 healthcare providers in 19 First Nations communities in 7 Canadian provinces, representing three isolation levels (isolated, semi-isolated, non-isolated). Interviews, focus groups and survey questions all related to barriers to providing optimal diabetes care in First Nations communities. RESULTS: the key factors emerging from interviews and focus group discussions were at the patient, provider, and systemic level. Survey results indicated that, across three isolation levels, healthcare providers' perceived patient factors as having the largest impact on diabetes care. However, physicians and nurses were more likely to rank patient factors as having a large impact on care than community health representatives (CHRs) and physicians were significantly less likely to rank patient-provider communication as having a large impact than CHRs. CONCLUSIONS: Addressing patient factors was considered the highest impact strategy for improving diabetes care. While this may reflect "patient blaming," it also suggests that self-management strategies may be well-suited for this context. Program planning should focus on training programs for CHRs, who provide a unique link between patients and clinical services. Research incorporating patient perspectives is needed to complete this picture and inform quality improvement initiatives.

Thinking about aboriginal KT: learning from the Network Environments for Aboriginal Health Research British Columbia (NEARBC).

OBJECTIVE: Creating effective and actionable research has become increasingly important for the health disciplines. Despite greater attention to knowledge translation (KT) in the health research, policy, and professional literature and the mounting need for strategic action to reduce the burden of ill health experienced by Aboriginal people in Canada, little time has been dedicated to understanding KT in Aboriginal health research contexts (Aboriginal KT). The purpose of this study was to explore and discuss the unique qualities of Aboriginal KT. METHODS: An exploratory case study of the Network Environments for Aboriginal Research British Columbia (NEARBC) was undertaken, in which qualitative interviewing with experts associated with the network was conducted. RESULTS: Four themes were revealed from the analysis of 10 semi-structured qualitative interviews: 1) Definitional debate, 2) "Aboriginal" KT, 3) Doing KT, and 4) KT roles. These themes highlight the definitional complexity, practical confusion, multidisciplinary nature, and lack of accountability related to Aboriginal KT. DISCUSSION: The information gained from the study participants adds some important insights to the current literature. It also identifies areas where future discussion may help improve the understanding and meaning of KT in Aboriginal health research contexts, as well as its application in practice. The health disparities of Aboriginal people in Canada are a call for action with regards to KT and this study provides some basic information and advice on ways to move the research and policy agenda forward.

Innovative approaches in public health research: applying life course epidemiology to aboriginal health research.

A life course epidemiology approach embraces the complexity of disease risk and acknowledges the long-term effects of physical, social, psychological, and behaviour pathways, operating across an individual's life, a community's generation, and a population's development, on health and well-being. Researchers who adopt a life course epidemiology approach broaden their ability to understand, explain, and prescribe ways to mitigate the effects of chronic diseases and reduce risk factor development and interaction. Although there are many diseases that explicate the importance and usefulness of a life course approach for Aboriginal health research, this commentary focuses on the benefits for understanding chronic respiratory diseases in Aboriginal populations. The hope is that this will expose the benefits of a life course approach for the study of Aboriginal health research and draw attention to the need for well-rounded, high-quality Aboriginal respiratory health research.

Methodologies to evaluate the effectiveness of knowledge translation interventions: a primer for researchers and health care managers.

OBJECTIVE: The evidence base for interventions to change clinical practice is modest but growing. Given the large variation in impact and costs, this review aims to highlight the importance of evaluating knowledge translation (KT) interventions by managers and researchers. STUDY DESIGN AND SETTING: To meet its objectives, this review article discusses how the need for local or generalizable information and the resources available guide the evaluations. Furthermore, we discuss how study designs can focus on establishing internal validity or applicability and how the choice of focus affects the study design. RESULTS: This review argues that managers should routinely incorporate simple evaluation designs into program implementation to assess and increase the impact of their services, whereas researchers should focus on creating cumulative knowledge through rigorous designs and rich descriptions of context and implementation to explore reasons for success and failure. CONCLUSION: We suggest that the combined effort of managers and researchers will provide a richer knowledge base to move the field of KT forward and increase the use of evidence-based implementation strategies to improve the quality of health care provided.

Providers' perceptions of barriers to the management of type 2 diabetes in remote Aboriginal settings.

OBJECTIVES: To examine providers' perspectives of the barriers to providing diabetes care in remote First Nation communities in the Sioux Lookout Zone (SLZ) of Northwestern Ontario, Canada. STUDY DESIGN: A qualitative study involving key informant interviews and focus groups was conducted with health care providers working in remote First Nation communities in SLZ. METHODS: Twenty-four nurses, doctors, diabetes educators and community health representatives (CHRs) participated in qualitative interviews and focus groups. Data collected from the interviews and focus groups was coded and thematically analysed using NVIVO software. RESULTS: Barriers to diabetes care were grouped into patient, clinic and system factors. Providers' perceptions of patient factors were divided between those advocating for a patient-provider partnership and those advocating for greater patient responsibility. Clinic-related barriers such as short staffing, staff turnover and system fragmentation were discussed, but were often overshadowed by a focus on patient factors and a general sense of frustration among providers. Cultural awareness and issues with clinic management were not mentioned, though they are both within the providers' control. CONCLUSIONS: This study characterizes a range of barriers to diabetes care and shows that patient-related factors are of primary concern for many providers. We conclude that patient-focused interventions and cultural competence training may help improve patient-provider partnerships. Funding and supporting quality improvement initiatives and clinic reorganization may increase the providers' knowledge of the potential for clinical strategies to improve patient outcomes and focus attention on those factors that providers can change. Future research into the factors driving quality of care and strategies that can improve care in Aboriginal communities should be a high priority in addressing the rising burden of diabetes and related complications.

Riding the knowledge translation roundabout: lessons learned from the Canadian Institutes of Health Research Summer Institute in knowledge translation.

BACKGROUND: Funding the education and training of the next generation of health researchers is a key mandate of the Canadian Institutes of Health Research (CIHR) knowledge translation (KT) portfolio. The field of KT is growing daily; thus, the training and development of a new generation of KT researchers is essential. METHODS: Using curriculum documents, participant evaluations, and self-reflection, this paper describes a unique Summer Institute hosted by the CIHR in Cornwall, Ontario, Canada. We outline the key aspects of a successful training initiative that could inform organizations and agencies worldwide with an interest in or who have a mandate for KT. RESULTS: This work provides potential funders, faculty, and students with an inside look into the purpose, process, and outcomes of such training initiatives. CONCLUSION: National and international KT organizations, research institutions, and funding agencies are encouraged to consider replicating the training model employed here, as investment into KT personnel will foster the advancement of the field within and beyond local borders. 'To the individual who devotes his/her life to science, nothing can give more happiness than when the results immediately find practical application. There are not two sciences. There is science and the application of science, and these two are linked as the fruit is to the tree.' - Louis Pasteur, 1871 (from presentation by Ian Graham, 2008 CIHR Knowledge Translation Summer Institute).

Canadian Thoracic Society: Presenting a new process for clinical practice guideline production.

A key mandate of the Canadian Thoracic Society (CTS) is to promote evidence-based respiratory care through clinical practice guidelines (CPGs). To improve the quality and validity of the production, dissemination and implementation of its CPGs, the CTS has revised its guideline process and has created the Canadian Respiratory Guidelines Committee to oversee this process. The present document outlines the basic methodological tools and principles of the new CTS guideline production process. Important features include standard methods for choosing and formulating optimal questions and for finding, appraising, and summarizing the evidence; use of the Grading of Recommendations Assessment, Development and Evaluation system for rating the quality of evidence and strength of recommendations; use of the Appraisal of Guidelines for Research and Evaluation instrument for quality control during and after guideline development and for appraisal of other guidelines; use of the ADAPTE process for adaptation of existing guidelines to the local context; and use of the GuideLine Implementability Appraisal tool to augment implementability of guidelines. The CTS has also committed to develop guidelines in new areas, an annual guideline review cycle, and a new formal process for dissemination and implementation. Ultimately, it is anticipated that these changes will have a significant impact on the quality of care and clinical outcomes of individuals suffering from respiratory diseases across Canada.