Mark W. Rosenberg

'Gentle caring experience'. Seeking alternative health care in Canada.

The starting point for this paper is a review of the literature, which seeks to explain the use of alternative medicines, therapies and practices in developed countries. Using the Statistics Canada 1996-97 National Population Health Survey--Health File, we then examine the profile of alternative service users. Our analysis shows that use of alternative health care is still limited to a relatively small segment of Canadians whose profile is similar to those in other developed countries. Women are more likely than men to use alternative medicines, therapies and practices, as are those who have higher incomes and are better educated. To move what has been an essentially empirical discussion forward, we explore critiques of conventional medical practice and propose that the analysis of alternative health care be situated within the geographies of consumption.

Accessibility and the Canadian health care system: squaring perceptions and realities

The 1984 Canada Health Act (CHA) is the major piece of Federal legislation that governs health care accessibility in the provinces and territories. According to the CHA, all provinces and territories in Canada must uphold five principles in order to receive federal funding for health care (universality, comprehensiveness, portability, public administration, and accessibility). In Canada, there are competing views among policy makers and consumers about how the CHAs principle of accessibility should be defined, interpreted and used in delivering health care. During the 1990s, the health care perceptions of Canadians and their health care behaviours were measured through both public opinion polls and Statistics Canadas National Population Health Survey (NPHS). The goal of this paper is to examine perceptions of accessibility in public opinion polls and actual accessibility as measured through the NPHS. Public opinion polls demonstrate that while Canadians want to preserve the principles of the CHA, a majority of Canadians are losing confidence in their health care system. In contrast, the results from the NPHS reveal that only 6% of Canadians aged 25 years and older have experienced accessibility problems. Among those who report access problems, the barriers to accessibility are linked to specific socio-economic, socio-demographic and health characteristics of individuals. We discuss these findings in the context of the current debates surrounding accessibility within the CHA and the Canadian health care system.

Planning for aging populations: inside or outside the walls

Abstract Over the past 15 years, OECD countries have come to recognise that their elderly populations are already, or will be, the fastest growing segments of their populations in the coming decades. In recognition of these demographic facts, public and private sectors planners with responsibility for housing, health and social services and transportation have divided into two camps. In one camp are those who believe that the full integration of the elderly population within their communities is the best way to insure the maximum life satisfaction of the elderly population over the longest period of time. This view manifests itself in proposals to allow ‘in-law suites’ to be built in areas zoned for single-family dwellings, deinstitutionalisaton and concomitant development of community-based care, and public transit systems made fully accessible to seniors regardless of their level of physical ability. In the other camp are those who believe that the elderly population wants and seeks a built environment which specifically caters for their particular needs. The most visible manifestations of this perspective are the ‘seniors only communities’ with their separate health and social services, and transportation systems. This paper focuses on integration versus segregation in planning housing, health and social services and transportation for seniors over the past 15 years (1986–2000). We emphasise that the planning outcomes of integrated-based and segregated-based solutions need to be understood within the broader socio-economic and legal contexts in which planning takes place. Underlying the integration-segregation dichotomy is the broader theoretical dichotomy of equity-efficiency. We have divided our paper into the main chapters. In the introductory chapter, the themes of integrated-based planning and segregated-based planning are explained. In addition, the current size and the future growth of elderly populations in OECD countries are reviewed. Chapter 2 focuses on housing. Chapter 3 examines the literature on health and social services and transportation. We conclude with an assessment of the implications of integrated-based and segregation-based planning for elderly populations in the next century.

Ontario's underserviced area program revisited: An indirect analysis

Financial incentive programs are used in various developed and developing countries to effect change in the geographic distribution of physicians. The Underserviced Area Program of Ontario is the longest running financial incentive program in Canada. It is described in detail and analyzed for its effectiveness in solving the problems of the maldistribution of physicians in northern Ontario. Using location quotients as an indirect measure shows that the maldistribution of physicians continues despite the implementation of the program. It is argued that the unidimensional solution of financial incentives cannot be used to solve the multidimensional issue of accessibility to health care in rural and remote areas.

Ethnicity and utilization of family physicians: A case study of Mainland Chinese immigrants in Toronto, Canada

This paper seeks to examine how immigrants in a multicultural society access and utilize culturally- and linguistically-diverse family physicians. It focuses on Mainland Chinese (MLC) immigrants - the most important source of immigrants to Canada since 1996 - in the Toronto Census Metropolitan Area (CMA), Canada. Specifically, the paper aims to explore the choice between Chinese-speaking and non-Chinese-speaking family physicians by MLC immigrants and to determine the underlying reasons for MLC immigrants use of ethnically- and linguistically-matched family physicians. A wide range of data are analyzed including survey and focus group data, physician data from the College of Physicians and Surgeons of Ontario (CPSO) and geo-referenced 2001 Canadian Census data. A mixed-method approach is employed combining quantitative analysis of survey data and Census data, spatial analysis of patient travel behaviour based on the survey and qualitative analysis based on focus groups. The paper reveals an overwhelming preference among MLC survey respondents for Chinese-speaking family physicians regardless of study areas and socioeconomic and demographic status. The focus groups suggest that language, culture and ethnicity are intertwined in a complex way to influence the choice of health care providers and health management strategies in the host society. The paper yields important policy implications for identifying health professional shortage areas for culturally-diverse populations, addressing issues related to foreign-trained physicians and enhancing primary care delivery relevant for immigrant populations.

The impacts of distance to hospital on families with a child with a chronic condition.

Children with chronic conditions and their families face many similar challenges that can be stressful for the family including, daily caregiving activities, financial difficulties caused by unexpected expenses, and increased use of health services to treat and help manage the condition. Many of these families, in addition to facing daily caregiving responsibilities, must travel substantial distances to access some of the necessary aspects of their childs health care. In this study, the Burke et al. (1994-1996) data of repeatedly hospitalized children and their families are used to explore a geographical dimension of family impact, distance. Outcome measures from the Feetham Family Functioning Survey and the Questionnaire on Resources and Stress are analyzed using exploratory and multivariate analysis. Results show that distance to hospital plays a role in the two areas of family life regarding relationships within the immediate family, and issues surrounding the ability to maintain the child in the family home. The implications of the results for family, health care intervention, and government policies and guidelines are discussed.

Medical or health geography? Populations, peoples and places.

While medical geography has grown eclectic to the point where a growing number of medical geographers prefer the terms health geographer, health geography, or the geography of health, schisms have nonetheless developed between Mayer et al. and those who have urged medical geographers to seek new epistemologies. Lost in this debate is the rapid and considerable growth of research by medical and health geographers. The author first reviews recent research on the mapping and modeling of diseases, then examines the literature on the access, delivery, and planning of health services. He then considers the debate over medical geography versus a geography of health. Opportunities are identified where medical, health, and population geographers can productively collaborate. Sharing many of the same theoretical and methodological strengths, weaknesses, and frustrations, medical, health, and population geographers need to work together toward creating inclusive geographies.

Access and utilization: a continuum of health service environments.

Birch and Abelson [1] argue that non-income based barriers might explain differences in utilization of health services within and between income groups. Databases which contain utilization data rarely allow for the modelling of geographic variation. In the Ontario Health Survey (OHS), individual observations are georeferenced at the Public Health Unit (PHU) scale, but PHUs cannot easily be used because of the large coefficients of variation. To overcome this problem, a cluster analysis is performed to create a service environment variable, which reflects differences in service availability, population size and rurality. Utilization of health services is then modelled as a logistic regression equation where the independent variables are age, sex, service environment and income to test the Birch and Abelson argument. This argument is then extended by controlling for age, health and income status. Based on the modelling results, the importance of geography to access and utilization is assessed.

Gender, poverty and location: how much difference do they make in the geography of health inequalities?

It is often said that women live longer than men, but suffer more illnesses throughout their lives. It has also been demonstrated in various studies of womens health that measures of health and health behaviour vary over different geographic scales. Added into this mix is the fact that historically more women than men in relative terms are found on the lower rungs of the socio-economic ladder. What has not been so well-developed is our understanding of the connections among health, gender, poverty and especially location. In 1998, Statistics Canada released the second wave of the National Population Health Survey (NPHS-2). Included with the NPHS-2 public use microdata file are measures of health status, gender, income and location which can be analyzed in the form of logistic regression models. Results are reported which provide a better understanding of the relative roles that gender, poverty and location play in the geography of inequalities.

Physical activity, body mass index, and health-related quality of life in Canadian adults.

PURPOSE Physical activity (PA) positively influences health-related quality of life (HRQL), whereas obesity is associated with significant HRQL impairments. Active-obese persons often have similar or lower risk of cardiovascular outcomes and mortality than inactive-healthy weight persons; however, the combined PA-weight status effects on HRQL are unclear. The aim was to investigate the combined association of PA and body mass index (BMI) with HRQL in Canadian adults and older adults. METHODS Cross-sectional data included 110,986 participants ≥ 18 yr from the 2005 Canadian Community Health Survey, representing an estimated 22,563,527 Canadians. HRQL indicators included: Self-Rated Health (SRH), Participation and Activity Limitation due to illness/injury (PAL), and Total Disability Days (physical + mental) during the past 14 d (TDD). Prevalence of adverse HRQL was estimated by BMI, PA, and combined BMI-PA categories. Adjusted logistic regression was used to assess the odds of adverse HRQL by BMI, PA, and BMI-PA. Analyses were stratified by sex and age (18-44, 45-64, ≥65 yr). RESULTS In both men and women of all ages, inactive individuals had greater likelihood of fair/poor SRH, and sometimes/often PAL, at all BMI levels; conversely, in active individuals, being underweight, overweight, or obese had little effect on SRH and PAL. Associations were weaker for TDD, where the greatest influence was in older adults from inactivity combined with underweight. Overweight showed less association to HRQL in males and older adults, whereas underweight showed stronger association in males and older adults. CONCLUSIONS When examining BMI-PA in combination, PA emerges as the more important correlate of HRQL, regardless of weight status. This reinforces the importance of PA to health outcomes over and above the benefits related to weight loss or maintenance.