"I Am the Last Priority": Factors Influencing Diabetes Management Among South Asian Caregivers in Peel Region, Ontario.

OBJECTIVE: In this study we aimed to identify sociocultural and systemic factors influencing diabetes management among South Asian (SA) caregivers in Peel Region, Ontario. METHODS: Twenty-one semistructured interviews were conducted with SA caregivers using a qualitative descriptive design. Data were analyzed using thematic analysis and intersectionality analysis. RESULTS: Themes identified included: 1) prioritizing family caregiving over diabetes self-management; 2) labour market impacts on diabetes self-management; and 3) challenges navigating Canadian health and social service systems. SA caregivers described social, economic, and systemic challenges impacting type 2 diabetes management. Systemic factors influencing diabetes management included discrimination and inequities in labour policies and lack of social and health resources funding. Recommendations by caregivers included whole-family, community-based, culturally tailored approaches to diabetes prevention and management strategies. CONCLUSIONS: Providing support with system navigation, encouraging family-based approaches, and addressing the social determinants of health could be beneficial for supporting SA families with diabetes management and prevention.

Digital storytelling online: a case report exploring virtual design, implementation opportunities and challenges.

BACKGROUND: Digital storytelling is an arts-informed approach that engages short, first-person videos, typically three to five minutes in length, to communicate a personal narrative. Prior to the pandemic, digital storytelling initiatives in health services research were often conducted during face-to-face workshops scheduled over multiple days. However, throughout the COVID-19 lockdowns where social distancing requirements needed to be maintained, many digital storytelling projects were adapted to online platforms. METHODS: As part of a research project aiming to explore the day surgery treatment and recovery experiences of women with breast cancer in Peel region, we decided to pivot our digital storytelling process to an online format. During the process, we observed that the online digital storytelling format had multiple opportunities and challenges to implementation. RESULTS: This paper outlines our promising practices and lessons learned when designing and implementing an online digital storytelling project including pre-production, production and post-production considerations. CONCLUSIONS: We provide lessons learned for future teams intending to conduct an online digital storytelling project.

Digital storytelling uses pictures, video clips and audio to create a short, first-person video, to share a person's story. Before the pandemic, digital storytelling workshops were often held in-person over multiple days to help members of the community create their own digital stories. However, throughout COVID-19, many digital storytelling workshops were held online instead. This paper outlines our lessons learned when hosting an online digital storytelling workshop series to capture women's experiences with breast cancer in our local community. We hope our lessons learned are helpful for other teams who are considering using online digital storytelling workshops for their own research projects.

A risk-based labelling strategy for supplemented foods in Canada: consumer perspectives.

NOVELTY: Risk-based labelling strategy for supplemented foods Strategy goes beyond the general requirements for prepackaged foods.

The Perceived Ease of Use and Perceived Usefulness of a Web-Based Interprofessional Communication and Collaboration Platform in the Hospital Setting: Interview Study With Health Care Providers.

BACKGROUND: Hospitalized patients with complex care needs require an interprofessional team of health professionals working together to support their care in hospitals and during discharge planning. However, interprofessional communication and collaboration in inpatient settings are often fragmented and inefficient, leading to poor patient outcomes and provider frustration. Health information technology can potentially help improve team communication and collaboration; however, to date, evidence of its effectiveness is lacking. There are also concerns that current implementations might further fragment communication and increase the clinician burden without proven benefits. OBJECTIVE: In this study, we aimed to generate transferrable lessons for future designers of health information technology tools that facilitate team communication and collaboration. METHODS: A secondary analysis of the qualitative component of the mixed methods evaluation was performed. The electronic communication and collaboration platform was implemented in 2 general internal medicine wards in a large community teaching hospital in Mississauga, Ontario, Canada. Fifteen inpatient clinicians in those wards, including nurses, physicians, and allied health care providers, were recruited to participate in semistructured interviews about their experience with a co-designed electronic communication and collaboration tool. Data were analyzed using the Technology Acceptance Model, and themes related to the constructs of perceived ease of use (PEOU) and perceived usefulness (PU) were identified. RESULTS: A secondary analysis guided by the Technology Acceptance Model highlighted important points. Intuitive design precluded training as a barrier to use, but lack of training may hinder participants' PEOU if features designed for efficiency are not discovered by users. Organized information was found to be useful for creating a comprehensive clinical picture of each patient and facilitating improved handovers. However, information needs to be both comprehensive and succinct, and information overload may negatively impact PEOU. The mixed paper and electronic practice environment also negatively impacted PEOU owing to unavoidable double documentation and the need for printing. Participants perceived the tool to be useful as it improved efficiency in information retrieval and documentation, improved the handover process, afforded another mode of communication when face-to-face communication was impractical, and improved shared awareness. The PU of this tool depends on its optimal use by all team members. CONCLUSIONS: Electronic tools can support communication and collaboration among interprofessional teams caring for patients with complex needs. There are transferable lessons learned that can improve the PU and PEOU of future systems.

Service Provider Perspectives on Exploring Social Determinants of Health Impacting Type 2 Diabetes Management for South Asian Adults in Peel Region, Canada.

OBJECTIVES: Individuals from South Asian communities are known to have a higher likelihood of developing type 2 diabetes (T2D), which is often attributed to individual lifestyle and behavioural factors. This focus on individual responsibility can position communities as complicit in their illness, compounding stigmatization and systemic discrimination. In this article, we explore the social determinants of health (SDOH) that influence health behaviours among South Asian adults with T2D from a service provider's perspective. METHODS: Using a qualitative descriptive design, we conducted semistructured interviews with 12 community, social and health-care service providers. We used thematic analysis and the analytical concept of intersectionality to explore how different social locations and SDOH impact T2D management for South Asian adults. RESULTS: Three themes were identified: 1) managing challenges with settlement process, labour policies and job market disparities take priority over T2D management; 2) poor working conditions and low socioeconomic status reduce access to health care and medication; and 3) there are social, economic and cultural barriers to implementing diet and exercise recommendations. CONCLUSIONS: Service providers identified social, economic and systemic factors as influencing the higher prevalence of T2D among South Asian individuals. They also identified their important roles in providing culturally appropriate supports to address SDOH and described advocacy for changes to policies and practices that reinforce systemic racism. The providers further suggested that more equitable employment policies and practices are needed to address the systemic factors that contribute to the higher risk of T2D among South Asian adults in the Peel Region.

Integrated Community Collaborative Care for Seniors with Depression/Anxiety and any Physical Illness.

BACKGROUND: We report on the feasibility and effectiveness of an integrated community collaborative care model in improving the health of seniors with depression/anxiety symptoms and chronic physical illness. METHODS: This community collaborative care model integrates geriatric medicine and geriatric psychiatry with care managers (CM) providing holistic initial and follow-up assessments, who use standardized rating scales to monitor treatment and provide psychotherapy (ENGAGE). The CM presents cases in a structured case review to a geriatrician and geriatric psychiatrist. Recommendations are communicated by the CM to the patient's primary care provider. RESULTS: 187 patients were evaluated. The average age was 80 years old. Two-thirds were experiencing moderate-to-severe depression upon entry and this proportion decreased significantly to one-third at completion. Qualitative interviews with patients, family caregivers, team members, and referring physicians indicated that the program was well-received. Patients had on average six visits with the CM without the need to have a face-to-face meeting with a specialist. CONCLUSION: The evaluation shows that the program is feasible and effective as it was well received by patients and patient outcomes improved. Implementation in fee-for-service publicly funded health-care environments may be limited by the need for dedicated funding.

Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms.

OBJECTIVES: Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population. METHODS: Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified. RESULTS: The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs. CONCLUSIONS: Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs.

All together: Integrated care for youth with type 1 diabetes.

OBJECTIVE: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression. RESEARCH DESIGN AND METHODS: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods. RESULTS: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. CONCLUSION: The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Efficacy of "High in" Nutrient Specific Front of Package Labels-A Retail Experiment with Canadians of Varying Health Literacy Levels.

BACKGROUND: In 2018, Health Canada, the Federal department responsible for public health, put forward a regulatory proposal to introduce regulations requiring a "High in" front-of-package label (FOPL) on foods that exceed predetermined thresholds for sodium, sugars, or saturated fat. This study evaluated the efficacy of the proposed FOPL as a quick and easy tool for making food choices that support reduction in the intakes of these nutrients. METHODS: Consumers (n = 625) of varying health literacy levels (HL) were assigned to control (current labeling with no FOPL) or one of four FOPL designs. They completed six shopping tasks, designed to control for internal motivations. Efficacy was measured with correct product selection and response time (seconds) to make food choices using repeated measures statistical modeling, adjusting for HL, task type, and task order. Eye-tracking and structured interviews were used to gather additional insights about participants' choices. RESULTS: Overall, FOPL was significantly more effective than current labeling at helping consumers of varying HL levels to identify foods high in nutrients of concern and make healthier food choices. All FOPL were equally effective. CONCLUSIONS: "High in" FOPL can be effective at helping Canadians of varying HL levels make more informed food choices in relation to sugars, sodium, and saturated fat.

Integrating a Health Literacy Lens into Nutrition Labelling Policy in Canada.

An increasingly important concern in public health practice is health literacy. Simply stated, it refers to the interactions between individuals and health related information to make informed decisions concerning their health. Research shows that consumers face many health literacy challenges in accessing, understanding and evaluating nutrition labelling information when making food choices. The systematic integration of health literacy considerations into social science and consumer behaviour research can help address these challenges and better meet the needs of the increasingly diverse Canadian population. This application of a health literacy lens should be considered for all future food and nutrition labelling research, to maximize the positive impact of subsequent health policies and regulations on health outcomes and health status of Canadians.

The Collaborative Care Model for Patients With Both Mental Health and Medical Conditions Implemented in Hospital Outpatient Care Settings.

With the increased concern regarding the negative impact that care in silos has on patients and the health care system, there is growing interest in integrated models of care especially for individuals with co-occurring physical and mental health conditions. Although generally applied in a community setting, we adapted and implemented an evidence-based integrated model of care, the collaborative care model (CCM) in an adult and a pediatric hospital-based outpatient clinic. Enrolment was criteria based and management was measurement driven. The model is team based and consists of new roles for its members including the patient, the care manager, the primary care clinician, and the psychiatric consultant. A key role was that of the care manager who worked with the patient and engaged primary care. The care manager also organized team-based treatment planning in systematic case reviews that contributed to the care plan. Support for training of the new and changes in roles is underscored. In this communication we comment on our initial experience of applying the CCM to the hospital outpatient setting.

Workplace accommodations following work-related mild traumatic brain injury: what works?

Background: Individuals who have experienced a work-related mild traumatic brain injury face a variety of challenges when returning to work. Research has demonstrated that the implementation of workplace accommodations can reduce the incidence of workplace disability. Few studies investigate work-related mild traumatic brain injury from injured workers' perspectives, and none examine workplace accommodations in detail.Purpose: This study explores the types of accommodations that individuals receive, and the factors that influence how they are provided and to whom.Materials and methods: This study is a qualitative secondary data analysis of 12 telephone interviews. ATLAS.ti software was used to facilitate coding and thematic analysis was used to analyze the data.Results: This study makes explicit various accommodations identified as being useful or required by individuals on return to work. Participants identified a gradual return to work, and modified duties, among other accommodations. Components of the workplace social and structural environment, and the occupational context influenced how accommodations were provided and to whom.Conclusions: Obtaining appropriate support is of great importance to injured employees, their employers, insurers, and healthcare providers. Stakeholders should be aware of how to successfully identify and access appropriate workplace accommodations to support injured workers on return to work.Implications for rehabilitation Return to Work Accommodations • Workplace accommodations reduce the incidence of workplace disability. • Workplace accommodations can be formal or informal. • Participants identified a gradual return to work, modified duties, self-directed compensatory strategies, and allowances for medical appointments, among other accommodations, as being useful or required. • Stakeholders, including healthcare providers involved in rehabilitation, should be aware of how to successfully identify and implement these accommodations to ensure injured workers are supported on return to work.

Welcoming Feedback: Using Family Experience to Design a Pediatric Weight Management Program.

OBJECTIVE: To describe an approach using principles of experience-based codesign (EBCD) and quality improvement (QI) to integrate family experience into the development of a pediatric weight management program. METHODS: Clinic development occurred in 3 plan, do, study, act (PDSA) cycles that were driven by family experience data. During these cycles, families were engaged in feedback sessions that informed program development. Staff reflected on feedback and designed and tested changes that would improve service delivery. RESULTS: The first PDSA cycle resulted in the fundamental program parameters and a formalized patient engagement strategy. The second cycle focused on pilot programming, and feedback was used to develop the structured group program. During the third cycle, feedback sessions were embedded into the structured group programs. Program changes included focusing on health rather than weight-based outcomes, adjusting the timing of program offerings, increasing experiential learning opportunities, and providing more opportunities for peer support. CONCLUSIONS: Both EBCD and QI methodologies informed the process of family engagement and program development. This pragmatic approach might be useful for the development of other family-centered pediatric programs.

Using an electronic tool to improve teamwork and interprofessional communication to meet the needs of complex hospitalized patients: A mixed methods study.

BACKGROUND: Teamwork and interprofessional communication are important in addressing the comprehensive care needs of complex hospitalized patients. The objective of this study is to evaluate the impact of an electronic interprofessional communication and collaboration platform on teamwork, communication, and adverse events in the hospital setting. MATERIALS AND METHODS: In this mixed methods study, we used a quasi-experimental design in the quantitative component and deployed the electronic tool in a staged fashion to 2 hospital wards 3 months apart. We measured teamwork, communication, and adverse events with Relational Coordination survey, video recordings of team rounds, and retrospective chart review. We conducted qualitative semi-structured interviews with clinicians to understand the perceived impacts of the electronic tool and other contextual factors. RESULTS: Teamwork sustainably improved (overall Relational Coordination score improved from 3.68 at baseline to 3.84 at three and six months after intervention, p = 0.03) on ward 1. A small change in face-to-face communication pattern during team rounds was observed (making plans increased from 22% to 24%, p = 0.004) at 3 months on ward 1 but was not sustained at 6 months. Teamwork and communication did not change after the intervention on ward 2. There was no meaningful change to adverse event rates on either ward. Clinicians reported generally positive views about the electronic tool's impact but described non-technology factors on each ward that affected teamwork and communication. CONCLUSION: The impact of using an electronic tool to improve teamwork and communication in the hospital setting appears mixed, but can be positive in some settings. Improving teamwork and communication likely require both appropriate technology and addressing non-technology factors.

Canadian adaptation of the Newest Vital Sign©, a health literacy assessment tool.

OBJECTIVE: The Newest Vital Sign© (NVS) was developed in the USA to measure patient health literacy in clinical settings. We adapted the NVS for use in Canada, in English and French, and created a computerized version. Our objective was to evaluate the reliability of the Canadian NVS as a self-administered computerized tool. DESIGN: We used a randomized crossover design with a washout period of 3-4 weeks to compare health literacy scores obtained using the computerized version with scores obtained using the standard interviewer-administered NVS. ANOVA models and McNemar's tests assessed differences in outcomes assessed with each version of the NVS and order effects of the testing. SETTING: Participants were recruited from multicultural catchment areas in Ontario and Nova Scotia. SUBJECTS: English- and French-speaking adults aged 18 years or older. RESULTS: A total of 180 (81 %) of the 222 adults (112 English/110 French) initially recruited completed both the interviewer-NVS and computer-NVS. Scores for those who completed both assessments ranged from 0 to 6 with a mean of 3·63 (sd 2·11) for the computerized NVS and 3·41 (sd 2·21) for the interview-administered NVS. Few (n 18; seven English, eleven French) participants' health literacy assessments differed between the two versions. CONCLUSIONS: Overall, the computerized Canadian NVS performed as well as the interviewer-administered version for assessing health literacy levels of English- and French-speaking participants. This Canadian adaptation of the NVS provides Canadian researchers and public health practitioners with an easily administered health literacy assessment tool that can be used to address the needs of Canadians across health literacy levels and ultimately improve health outcomes.

Physicians' accounts of frontline tensions when implementing pilot projects to improve primary care.

Purpose Canada's primary care system has been described as "a culture of pilot projects" with little evidence of converting successful initiatives into funded, permanent programs or sharing project outcomes and insights across jurisdictions. Health services pilot projects are advocated as an effective strategy for identifying promising models of care and building integrated care partnerships in local settings. In the qualitative study reported here, the purpose of this paper is to investigate the strengths and challenges of this approach. Design/methodology/approach Semi-structured interviews were conducted with 34 primary care physicians who discussed their experiences as pilot project leads. Following thematic analysis methods, broad system issues were captured as well as individual project information. Findings While participants often portrayed themselves as advocates for vulnerable patients, mobilizing healthcare organizations and providers to support new models of care was discussed as challenging. Competition between local healthcare providers and initiatives could impact pilot project success. Participants also reported tensions between their clinical, project management and research roles with additional time demands and skill requirements interfering with the work of implementing and evaluating service innovations. Originality/value Study findings highlight the complexity of pilot project implementation, which encompasses physician commitment to addressing care for vulnerable populations through to the need for additional skill set requirements and the impact of local project environments. The current pilot project approach could be strengthened by including more multidisciplinary collaboration and providing infrastructure supports to enhance the design, implementation and evaluation of health services improvement initiatives.

Clinician user involvement in the real world: Designing an electronic tool to improve interprofessional communication and collaboration in a hospital setting.

OBJECTIVES: User involvement is vital to the success of health information technology implementation. However, involving clinician users effectively and meaningfully in complex healthcare organizations remains challenging. The objective of this paper is to share our real-world experience of applying a variety of user involvement methods in the design and implementation of a clinical communication and collaboration platform aimed at facilitating care of complex hospitalized patients by an interprofessional team of clinicians. METHODS: We designed and implemented an electronic clinical communication and collaboration platform in a large community teaching hospital. The design team consisted of both technical and healthcare professionals. Agile software development methodology was used to facilitate rapid iterative design and user input. We involved clinician users at all stages of the development lifecycle using a variety of user-centered, user co-design, and participatory design methods. RESULTS: Thirty-six software releases were delivered over 24 months. User involvement has resulted in improvement in user interface design, identification of software defects, creation of new modules that facilitated workflow, and identification of necessary changes to the scope of the project early on. CONCLUSION: A variety of user involvement methods were complementary and benefited the design and implementation of a complex health IT solution. Combining these methods with agile software development methodology can turn designs into functioning clinical system to support iterative improvement.

Assessment of sex analysis in studies of technology-based interventions to alleviate caregiver burden among caregivers of persons with dementia.

BACKGROUND: With an increase in the number of family caregivers for persons with dementia, caregiver burden is a major concern. Defined as computer-based devices and programs, technology has been identified as an intervention to address this issue. However, to date, there is little consideration of sex differences among caregivers in the design and planning of these interventions. OBJECTIVE: To systematically review the literature on technology-based interventions for caregivers of persons with dementia and report the frequency and approaches of sex-based analysis. METHODS: The literature was systematically searched for reviews of technology-based interventions for caregivers of persons with dementia. All titles and abstracts of publications included in the retrieved reviews were screened using pre-determined inclusion and exclusion criteria. Full text articles that met the inclusion criteria were included for analysis. RESULTS: Four reviews were identified and 19 articles representing 17 studies were retrieved. Among these studies, only four examined outcomes by sex. In the studies that examined outcomes by sex, three reported significant differences (p < 0.05) between male and female caregivers. CONCLUSIONS: There is currently a lack of (1) sex-based analyses, (2) inclusion of males and (3) provision of sex-specific information in studies of technology-based interventions for caregivers of persons with dementia.