Denise Cloutier-Fisher

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.

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.

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

BackgroundResearchers 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.MethodsAnalyses 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.ResultsGenerally 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.ConclusionThese 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.

Examining social isolation by gender and geography: conceptual and operational challenges using population health data in Canada

In 2003, the Canadian Federal/Provincial/Territorial Task Force on Seniors identified social isolation as an important issue for further study and policy development given that socially isolated persons are considered to be more vulnerable to both inappropriate use of the health care system and poorer health outcomes. In order to provide adequate support to this vulnerable population, it is critical to untangle the complex web of relationships that influence the need for care, and the health status and service utilization patterns of socially isolated older adults. Using data from the 2000–01 Canadian Community Health Survey (CCHS), this article explores social isolation as a multidimensional social construct examining in particular the axes of gender and geography to try to tease out some of this complexity and its relationship to health status and service utilization. When individual characteristics like gender are considered together with broader contextual variables like place of residence, a more comprehensive and layered portrait of vulnerability among socially isolated persons begins to emerge with insights into their unique patterns of health and service use. For example, home care may be an extremely critical resource for keeping older women in their homes and out of hospital. On the other hand, among socially isolated older men, those living in rural communities may be particularly ‘invisible’, neither benefiting from home care nor having strong social supports. It seems plausible then that both men and women may be in need of special interventions or targeted programmes to help them to remain, or to become, more socially integrated in their communities as they age in place. In addition, this article addresses some of the limitations of using both a quantitative analytic approach and the CCHS dataset itself in grappling with such complexity.

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.

Backyard bounty: exploring the benefits and challenges of backyard garden sharing projects

Backyard garden sharing projects can be viewed as a small-scale alternative to traditional community gardens. These shared spaces are able to overcome some of the pressures on community gardens such as competing demands for housing and other services and amenities while still providing many of the health-promoting benefits community gardens are noted for. This study is a small-scale participatory qualitative project that explores three backyard garden sharing partnerships. The aim of this study is to explore the benefits and challenges of these shared spaces and to discuss the overall feasibility of shared backyard gardens. Partnerships comprised an older adult homeowner (i.e., greater than age 65) and a non-senior gardener. At an individual level, the results suggest that backyard garden sharing can promote physical activity, psychosocial well-being, and social connectedness for both older adult homeowners and volunteer garden partners. To be successful, partners benefit from an established agreement about what to grow and how to share the gardens produce. In addition, a dedicated project coordinator and a limited amount of community resources can ensure the viability of these small-scale projects.

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.

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

BackgroundChronic 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.ResultsTwo sources of spatial variability in exposure to traffic-related nitrogen dioxide were identified. Median estimates of total exposure ranged from 8 μg/m3 to 35 μg/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.ConclusionThe 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.

Gender Differences in Chronic Exposure to Traffic-Related Air Pollution—A Simulation Study of Working Females and Males

The objective of this study was to identify spatial variability in exposure to outdoor traffic-related air pollution with specific emphasis on comparing exposure estimates for working females and males across a metropolitan area. A spatial exposure simulation model was used to estimate annual average exposure to traffic-related nitrogen dioxide for males and females reporting regular work in census tracts other than that of their residence, in Vancouver, British Columbia. The model produced estimates of annual average exposure in six microenvironments (home indoor, work indoor, other indoor, outdoor, in-vehicle to work, and in-vehicle other) using time-activity patterns and work flow data, for males and females in each of 382 census tracts. This allowed for the identification of spatial variations in exposure estimates for each gender, due to mobility within the study region. Indoor sources of nitrogen dioxide were not included in the simulation. No significant differences in estimated total exposure were found between working females and males in general. Small but observable spatial differences, however, were found between working females and males at the 90th percentile of the exposure distributions associated specifically with the work indoor microenvironment. These were highest in suburban areas (+3 μ g/m3 for females, relative to total exposures in the range of 26 to 37 μ g/m3 annual average hourly nitrogen dioxide). These results identify specific geographic locations in the study area where personal monitoring studies might be warranted and suggest that the inclusion of workplace locations in multivariate modeling could be useful to further understand differences in estimated exposures.

Change in Beliefs about Older Drivers through Applied Theater

To address the highly-complex and emotionally-charged nature of issues concerning older drivers, we engaged in the development and evaluation of a research-based applied theater production. A quasiexperimental pretest–posttest group design was used to assess change in attitudes and beliefs, derived from social science theories, of older drivers and other stakeholders. After viewing the play, older adults showed decreases in their positive attitudes toward driving and intention to continuing driving. The findings for the older adults appeared to be driven by the responses of the women in the group. Stakeholders showed no change in attitudes about older drivers. Data collected two weeks after the play was viewed confirmed that audience members found the play informative and that it promoted discussion about the topic. The findings from this study provide important new information about how exposure to an applied theater production brings about attitude change.