To address concerns about disruptions in the continuity of health care delivered to residents in three remote aboriginal communities in northern Ontario, Canada, the local health authority initiated a study in collaboration with the department of Health Canada responsible for ensuring that aboriginal reserves receive mandatory health services, and an inter-disciplinary team of researchers from two universities. The study focussed on the delivery of oncology, diabetes and mental health care, specifically, as well as systems issues such as recruitment and retention of health human resources and financial costs. The paper discusses the procedures involved, the benefits derived and the challenges encountered in doing this as a community driven participatory action research project. It also summarizes the findings that led to community formulated policy and program recommendations.
Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto Rehabilitation Institute and Holland Bloorview Kids Rehabilitation Hospital, 160-500 University Ave., Toronto, ON, Canada, M5G 1V7. michelle.keightley@utoronto.ca
There is a lack of knowledge about how cultural ideas affect First Nations peoples' perception of rehabilitation needs and the ability to access services.
The study explored the perceptions of treating and healing brain injury from First Nations elders and traditional healers in the communities served by Wassay-Gezhig-Na-Nahn-Dah-We-lgamig (Kenora Area Health Access Centre).
A participatory action approach was used, leading to a focus group with elders and traditional healers. Findings, established through a framework analysis method, were member checked prior to dissemination.
Four themes arose from the data: pervasiveness of spirituality, "fixing" illness or injury versus living with wellness, working together in treating brain injury, and financial support needed for traditional healing.
Funding is required for traditional healing services to provide culturallysafe and responsive occupational therapy services to First Nations individuals with brain injury.
Canada's rural shortage of health professionals can be offset by employing specially trained, locally-based paraprofessionals to implement professionally developed plans of care. Ontario's Integrated Services for Northern Children Program demonstrated the viability of this option. A review of 327 patient records and interviews with 100 parents, paraprofessionals, and professionals found that there was good continuity of care and satisfaction with care quality because the multidisciplinary professional team of consultants provided constant and consistent monitoring of the paraprofessionals. Ongoing treatment occurred in the community, eliminating the disruption to the children's lives that repeated trips to the city would cause. Rural residents place a premium on care at home. Liability issues for employers and for professionals who delegate caregiving tasks currently restrict the use of paraprofessionals; these can be addressed through certification based on practice standards and improved education programs.
The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs.
We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario.
The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications.
Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.
Many of Canada's northern First Nation communities experience difficulty recruiting and retaining appropriate nursing staff and must rely on relief nurses for short-term coverage. The latter often are not adequately prepared for the demanding nature of the practice. This study examined the consequences of nursing turnover on the continuity of care provided to residents of three Ojibway communities in northern Ontario. The findings are based on a review of 135 charts of oncology, diabetes, and mental health clients, and on interviews with 30 professional and paraprofessional health-care providers who served the communities. Nursing turnover is shown to detrimentally affect communications, medications management, and the range of services offered; it also results in compromised follow-up, client disengagement, illness exacerbation, and an added burden of care for family and community members.
To address a recurring shortage of nurses in the aboriginal communities of Northwestern Ontario, the First Nations and Inuit Health Branch, Health Canada, commissioned a study to explore the viability of establishing a relief pool among nurses from nearby small industrial towns. An open/close-ended survey completed by a random sample of 237 nurses from the target population documented levels of awareness, willingness, and preparedness for northern practice, as well as recruitment incentives and disincentives. Findings demonstrate an awareness of the overlap between the professional and personal dimensions characteristic of such practices, and suggest support for innovative rotations that would cut across federal/provincial/community jurisdictions. Although complex, given time and willingness, a regional relief system seems viable.
To explore the barriers and enablers surrounding the transition from health care to home community settings for Aboriginal clients recovering from acquired brain injuries (ABI) in northwestern Ontario.
Participatory research design using qualitative methods.
Focus groups conducted with clients with ABI, their caregivers and hospital and community health-care workers. The Framework Method of analysis was used to uncover emerging themes.
Six main categories emerged: ABI diagnosis accuracy, acute service delivery and hospital care, transition from hospital to homecare services, transition from hospital to community services, participant suggestions to improve service delivery and transition, and views on traditional healing methods during recovery.
A lack of awareness, education and resources were acknowledged as key challenges to successful transitioning by clients and healthcare providers. Geographical isolation of the communities was highlighted as a barrier to accessibility of services and programmes, but the community was also regarded as an important source of social support. The development of educational and screening tools and needs assessments of remote communities were identified to be strategies that may improve transitions.
Findings demonstrate that the structure of rehabilitation and discharge processes for Aboriginal clients living on reserves or in remote communities are of great concern and warrants further research.
The majority of First Nations, Metis, and Inuit people living in the Canadian province of Ontario have less access to quality health care than the population as a whole. Yet improving the situation is hampered by the lack of an information system that documents fundamental facts about Aboriginal people's health status and services utilization. Without a means to collect such data, these knowledge deficits will persist, making the planning and provision of culturally appropriate services impossible. The Ontario Health Quality Council commissioned a study to (1) review data collection systems in other Canadian jurisdictions and (2) determine what Ontario needs in order to have a comprehensive Aboriginal health information system. The study involved a review of 177 policy and technical documents and interviews with 20 key informants in Ontario, as well as Canada's other provinces and territories. Results showed that the capacity to document Aboriginal peoples' health and service utilization varies significantly, depending on existing provincial/territorial health data sets and the ability to cross-link health data using unique identifiers. Some jurisdictions can locate Aboriginal data using health cards, health benefits payment information, or vital statistics identifiers; others rely on linkages using federal or provincial Aboriginal registry and membership lists. All have the capability to conduct geographical analyses to identify health and service utilization for communities or regions that have significant Aboriginal populations. To improve health information in Ontario, Aboriginal people's collective entitlements to information about their communities must be recognized. The authors outline implications of a set of principles that Canada's First Nations have adopted, commonly referred to as OCAP (Ownership, Control, Access, and Possession), on the collection, storage, use, and interpretation of health data. Only through negotiation with Aboriginal peoples can health information systems be established that meet their needs, as well as those of decision-makers and care providers.
Realizing potential: improving interdisciplinary professional/paraprofessional health care teams in Canada's northern aboriginal communities through education.
To address a shortage of health professional human resources and to overcome cultural barriers, the interdisciplinary health care teams practicing in most northern Canadian aboriginal communities include a number of paraprofessionals recruited locally. This model has great potential to fill service gaps in many rural contexts; there are challenges, however. Drawing from an extensive program of research in indigenous communities in the northwestern part of the Province of Ontario, we identify factors fundamental to effective team functioning: members' clarity about their own and others' roles, appreciation of their respective 'equal but different' knowledge bases, and confidence in one another's competence. We argue for an extension of the information on interdisciplinary practice included in health science education programs to address these issues, thereby enhancing the utility of paraprofessionals within the health human resource mix in rural areas.
To explore the experiences of health care practitioners working with Aboriginal clients recovering from acquired brain injury (ABI).
Participatory research design using qualitative methods.
Fourteen in-depth, semi-structured interviews were conducted. The Framework Method of analysis was used to uncover emerging themes.
Five main categories emerged: practitioners' experience with brain injury, practitioners' experience with Aboriginal clients, specialized needs of Aboriginal clients recovering from brain injury, culturally sensitive care and traditional healing methods. These categories were then further divided into emergent themes and sub-themes where applicable, with particular emphasis on the specialized needs of Aboriginal clients.
Each emergent theme highlighted key challenges experienced by Aboriginal peoples recovering from ABI. A key challenge was that protocols for rehabilitation and discharge planning are often lacking for clients living on reserves or in remote communities. Other challenges included lack of social support; difficulty of travel and socio-cultural factors associated with post-acute care; and concurrent disorders.
Results suggest that developing reasonable protocols for discharge planning of Aboriginal clients living on reserves and/or remote communities should be considered a priority.
