Relevant Degree Programs
Graduate Student Supervision
Doctoral Student Supervision (Jan 2008 - Mar 2019)
This dissertation develops the concept of treatment intensity of asymptomatic conditions (such as hypertension) by examining the potential link between drug treatment for asymptomatic conditions and polypharmacy. Research addressing overtreatment has typically focused on reducing either the total number of medications or identification of potentially inappropriate medications. Multi-morbidity, including both symptomatic, e.g. arthritis, and asymptomatic conditions, e.g. hypertension, increases with age and may be an important driver of increased polypharmacy. Hypothesis #1: There is an association between treatment intensity of hypertension and general polypharmacy. Treatment of hypertension has shown that it can reduce the risk of morbidity and mortality in studied populations. However, the evidence for benefit of treatment in people ≥70 years old has not been consistent. To explore how hypertension is treated and the possible relationship to polypharmacy, I designed two cross sectional studies: a cohort of 214 nursing home patients where I found that patients with treated systolic blood pressure (SBP)
The aging Canadian population, increasing incidence of chronic conditions, and rising healthcare costs have contributed to concerns that the current healthcare system may not meet healthcare needs. Canada has sought innovative ways to meet patients’ healthcare needs through reforms such as group medical visits (GMVs) and care by nurse practitioners (NPs). While studies have shown that care with NPs and GMVs is effective, there is limited evidence examining how NPs engage in innovative care delivery. The purpose of this study was to examine the impact of NP-led GMVs for patients with chronic conditions in primary care. This study used multiple methods, including a systematic review and meta- analysis and a multisite case study (N=3). The systematic review and meta-analysis included studies published between 1947 and 2012 for patients with type 1 or 2 diabetes who attended GMVs. Of the 94 studies identified, 13 met final inclusion criteria. Group medical visits had a positive effect on clinical and patient-reported outcomes, with significant reductions in glycated hemoglobin (HbA1c reduction −0.46%, 95% confidence interval −0.80% to −0.31%).The case study consisted of two cases where NPs were using GMVs and one where NPs were not using GMVs. Open-ended interviews with patients (N=12), providers (N=14) and 10 hours of direct observation were completed. Analysis of the data suggests that GMVs facilitated an environment that was patient centered, interprofessional and increased patients’ confidence managing chronic conditions. Furthermore, the processes of care within the GMVs disrupted power differentials in primary care, between patients and providers and amongst healthcare providers.Yet, these same power differentials constrained NPs’ ability to adopt GMVs, with NPs indicating that they had limited agency to diffuse healthcare innovations. Unique contributions of this study were a systematic review and meta-analysis of GMVs among those with diabetes and new knowledge on how power differentials influence the diffusion of innovations in primary care. These findings demonstrate that GMVs provide opportunities to meet clinical, team-based, and patient-centered healthcare objectives. Ongoing research that considers the context of practice environments, power differentials, and conditions that limit NPs ability to diffuse healthcare innovative is needed.
Infants’ sleep problems, especially, nighttime awakenings, are common concerns of parents and may have developmental implications for infants, particularly infants born prematurely. Between one quarter and one third of all children aged six months to five years of age experience sleeping problems. Many factors have been associated with the development of these problems, although none has been shown to be causal. Although theorists have hypothesized that insecure attachment between a mother and her child may lead to intense maternal involvement at bedtime (e.g., active physical comforting), which may be linked to the infant’s inability to develop sleep self-initiation skills, mothers’ styles of attachment with their infants, particularly an anxious style, have not been researched. France and Blampied’s model of infant sleep was used as the guiding framework to examine relationships between mothers’ attachment and bedtime behaviour and premature infants’ sleep. Using a cross-sectional design, data were collected from a community-based sample of 105 mothers of premature infants aged 5-6 months (gestationally corrected age). Boys represented 61% of the sample and 63% of the infants were first-born children. The main outcome measures were infants’ nighttime awakenings (frequency and duration) and mothers’ perceptions of the quality of their infants’ sleep. The mothers reported that 55% of their children had sleep problems (17% were considered serious). The reported mean frequency of awakening was 2.1 times per night and the mean duration was 45.7 minutes. Preterm infants’ nighttime awakening was associated with their mothers having an anxious style of attachment and intense involvement at bedtime. The mother’s style of attachment (anxious) and a maternal history of sleep problems were predictors of the duration of infants’ nighttime awakening. Intense maternal involvement and the infant’s birth order were significant predictors of the infants’ frequency of nighttime awakenings. This study directs healthcare providers to focus on maternal factors such as having an anxious style of attachment and over involvement in bedtime settling when assessing infants’ sleep problems. More research is warranted to explain the mechanisms of these associations and to determine whether they are causal in nature.
Master's Student Supervision (2010-2017)
Heart failure (HF) is a debilitating syndrome affecting thousands of Canadians every year. It is one of the leading causes of death in Canada and has been found to be the leading cause of readmission to hospital in North America. We sought to determine if home visits by a cardiac nurse clinician reduced heart failure readmissions to hospital in Canada. A retrospective cohort study design examined the effect of an existing post-discharge home visit intervention program for patients with heart failure. The study sample consisted of 215 patients, each hospitalized with a “most responsible inpatient diagnosis of heart failure.” Between 2011 and 2013, 103 patients were referred to the home visit intervention program and seen by the cardiac nurse clinician at home. The usual care group 112 patients was randomly extracted from Discharge Abstract Database between 2009 and 2011. Meleis’ Transitions Theory informed and guided the study, and Wagner’s Chronic Care Model guided the intervention. The main outcome measure was 30-day hospital readmissions for heart failure. The intervention group had fewer readmissions to hospital for heart failure and a higher number of referrals to cardiac rehabilitation than usual care group (p ≤ 0.001). No significant differences were found between all-cause readmissions, length of stay of readmissions, or all-cause emergency visits between the two groups. Our results suggest that there may be a relationship between home visits by a cardiac nurse clinician and heart failure readmissions with patients who are diagnosed with heart failure. Furthermore, we believe the model may be beneficial for treatment of other cardiac patients. There may be a cost saving for the healthcare system in reducing heart failure readmissions to hospital; however, we recognize that a proper cost analysis is needed to confirm the economic benefits of the model. More work is needed in testing this intervention in other geographic areas (e.g., rural), as well as with patients who have different socioeconomic characteristics. A more rigorous study design, such as a randomized controlled trial or interrupted time series, is needed to further test the model of home visits with those patients who suffer from heart failure.
PURPOSE: As the British Columbia (BC) government works to improve primary care (PC) performance, attention to collaboration between PC and Public Health (PH) has been studied, especially improving health promotion in PC. Human resources and role optimization considerations are needed to operationalize this strategy. Nurses are the largest health care provider in BC, and yet nurses are an underutilized resource in the PC system in BC. This research aims to identify the roles of registered nurses (RN) in PC and PH collaboration and confirm if the BC RN scope of practice sufficiently covers the identified roles. METHODS: A scoping review of the current literature from North America, Western Europe and Australia/New Zealand from Jan. 2009 to Jan. 2016 was conducted. RESULTS: Twenty-three articles were obtained. Various nursing roles were identified that benefit PC/PH collaboration including: relationship builder, outreach professional, program facilitator and care coordinator. Through these roles, nurses supported vertical and horizontal transitions in chronic disease, communicable disease care and maternity care. Nurse’s roles were enacted at various levels from intrapersonal to organizational and systemic levels. The BC RN scope of practice supports the roles identified in this review, reaffirming that nurses are qualified to enact the roles.CONCLUSIONS: Based on their ability to work in a variety of roles and settings to promote collaboration between PC and PH, nurses could be more optimally utilized to support health care system change. Recommendations include political directives that support using nurses in system change. Health authorities could operationalize this by supporting more team-based nurses with an outreach role, especially for vulnerable populations, and utilizing nurses in inter-organization (such as PH to PC) program facilitation in chronic disease management. Education institutions need to ensure RN students are exposed to outreach experiences, and have practice working in the PC system, as well inter-organizational collaborative skills.
PURPOSE Parkinson’s disease is a complex neurodegenerative disease with depression as a common comorbidity known to negatively affect quality of life. Yet, limited evidence exists on how the two chronic conditions are treated simultaneously in Canadian primary care. This study aimed to describe the demographic and health characteristics of men and women with Parkinson’s disease and examine the differences in the number and type of medications for depression between men and women with Parkinson’s disease and depression.METHODS This retrospective cohort study analyzed available electronic medical records of patients with Parkinson’s disease who had at least one encounter with a primary care provider between September 30, 2012 and 2014 from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). In addition to descriptive statistics, Poisson and logistic regression were conducted to examine gender differences in depression treatments. An advisory group comprised of five primary care providers provided additional interpretation of the results.RESULTS A total of 1,815 patients (54.9% male) with Parkinson’s disease were found to be older, living in urban areas, overweight, non-smokers, and had an average of 15.5 encounters with a primary care provider over a two-year period. About 83.6% had at least one comorbidity with hypertension (64.1%) and depression (38.1%) as the most common. Of those who also had depression, 86.2% had at least one medication prescribed for depression; no significant difference was found in the number of medications prescribed by gender. The most frequently prescribed antidepressants were selective serotonin reuptake inhibitors (52.2%). CONCLUSIONS This study is unique in its reporting of antidepressant medication management for those with concurrent diagnoses of Parkinson’s disease and depression in primary care. It is the first pan-Canadian study to examine clinical electronic medical record data. The comorbidity of depression in those with Parkinson’s disease needs to be routinely assessed in primary care. Findings highlight the possible need for better decision-support tools consistent with Canadian guidelines to appropriately manage comorbid depression. While more population-level research is warranted, this study provided theoretical and practical knowledge for health care providers to holistically care and positively influence the quality of life of people with Parkinson’s disease.
Purpose: Current literature identifies protective factors to healthy eating within the adolescent population, such as family meals, yet it fails to acknowledge variation between families and the difference in family structure associated with South Asian culture. The purpose of this descriptive study is to examine the food choices of South Asian adolescents and the extent to which food choices among Canadian-born South Asian adolescents are influenced by their home environment.Methods: A secondary analysis was conducted of the 2013 Adolescent Health Survey. The sample included adolescents who self-selected as South Asian. Measures included sex, immigrant status, yesterday food and drink choices, cultural connectedness and parental presence at evening meals. Differences in food and drink choices were analyzed for foreign-born and Canadian-born adolescents by sex using cross tabulations. Overall healthy versus less healthy eating was analyzed for foreign-born and Canadian-born adolescents by sex using logistic regression adjusting for significant variables,Results: Canadian-born South Asian adolescent males (p<.01 were="" half="" as="" likely="" to="" eat="" healthy="" than="" their="" foreign-born="" peers="" when="" controlling="" for="" parental="" presence="" at="" evening="" meals="" and="" engagement="" in="" cultural="" activities.="" even="" after="" immigrant="" status="" both="" south="" asian="" adolescent="" males="" females="" who="" engage="" activities="" of="" school="" weekly="" are="" times="" more="" those="" never="" with="" consistent="" inconsistent="" meals.discussion="" implications:="" this="" study="" draws="" attention="" the="" heterogeneity="" that="" exists="" within="" group="" adolescents.="" country="" birth="" was="" an="" important="" variable="" particularly="" males.="" although="" relationship="" not="" seen="" value="" family="" meal="" over="" demonstrates="" addition="" key="" sex="" differences="" exist="" regards="" dietary="" choices="" population.="" future="" research="" should="" seek="" understand="" complex="" mechanisms="" which="" increase="" risk="" less="" eating="" canadian-born="">
In British Columbia (BC), as many as one in five women will experience some form of depression in the pregnancy and postpartum period. Perinatal depression, which refers to both the prenatal and postpartum period, is a crippling disorder with harmful repercussions for the mother, fetus, infant, and close family members. Of women diagnosed with postpartum depression, 30% have the initial onset of depression during pregnancy. Most importantly, depression and anxiety in pregnancy is one of the strongest predictors of postpartum depression. Immigrant women are at a particularly high risk for prenatal depression due to the numerous stressors associated with migration and acculturation. As South Asian immigrant women comprise a large proportion of Canadian immigrants, prenatal depression within this group needs to be more clearly understood. In this study, the research questions were: 1) What are the prevalence rates for prenatal depressive symptoms? 2) What socio-demographic or other factors are associated with prenatal depressive symptoms? and 3) What is the role of gender and culture in women with prenatal depressive symptoms? A mixed methods study design was used to analyze in-depth interviews, with interpretive description, in relation to a secondary analysis of data from the Fraser Health prenatal registration database. The findings suggest that South Asian immigrant women are at a higher risk for perinatal depression and demographic factors play a role. Punjabi-speaking women, particularly those who indicate the need for an interpreter, are more likely to report prenatal depressive symptoms compared to English-speaking women. Themes were generated from the interviews such as: disruption of family and social supports, triggers of depression: the intersection between biology and life events, social and structural conditions, psychosocial stressors: immigration process, and South Asian cultural roles and dynamics.
Living with a chronic illness such as diabetes or heart disease and accessing health care over many years can be a challenge for anyone. This experience is further impacted by experiences associated with being an ethnic minority where challenges in communicating with health care providers or encountering different views on health care can make navigating the system more difficult. Within the current health care system in British Columbia, the Primary Health Care (PHC) Charter articulates a clear role for PHC as the setting in which chronic illness care is organized and delivered. Unfortunately, interactions in PHC can be both a source of support and of stress for individuals. In order to provide care which supports individuals to self manage their health, it is important that PHC providers understand common experiences and priorities for diverse populations when seeking care in the ongoing management of their condition. Through secondary analysis, this study analyzes data from a recent research project exploring the experiences of ethnic minorities in PHC by Dr Wong. Data from twelve focus groups with a subset of participants with chronic illness was examined to further advance aspects of chronic illness management within the context of the current health care environment in British Columbia (BC). This data was viewed within a critical cultural perspective to inform both current and future practice in order to promote care which is culturally safe and at the same time supports individuals in adopting healthier lifestyles and maximizing their confidence in managing their health. Results from this study highlight the challenges encountered by anyone managing a chronic illness but also how ethnic minorities may face an increased burden of illness. This study also explores how approaches in the charter, specifically the expanded chronic care model, need to be viewed critically in terms of the potential to promote a sense of individual responsibility for care or further racialization through subcategorizing individuals based on ethnicity. This study also highlights benefits in the approaches to CDM especially in the investments in resources in multiple languages and potential for building stronger linkages to community programs.
Background and Purpose: According to the Canadian Community Health Survey conducted in 2000-1, 12% of Canadians reported experiencing an unmet health need compared to four percent in 1994-5. There is growing reason to investigate the increasing number of Canadians reporting unmet health needs, particularly among young adults (between 18 and 30 years of age) who access health services less frequently than any other age group. In particular, the growing population of Chinese living in Canada present unanswered questions regarding the health needs of Chinese young adults. The purpose of this study was to examine: 1) if Chinese young adults who primarily speak Chinese experience more unmet health needs when compared to English-speaking Chinese young adults and, if there are, 2) the reasons why Chinese young adults have unmet health needs. Methods: A mixed methods approach was taken; in-depth interviews (n=8) with Chinese young adults were used to complement and explain findings from a secondary analysis of a larger cross-sectional survey of the primary health care seeking behaviours of Chinese-, English-, and Punjabi-speaking Canadians. Findings: Fifty-eight Chinese young adults participated in the primary health care survey; ten percent (n=6) reported having an unmet health need related to the availability and accessibility of health care. Language preference was not found to be associated with unmet health needs. Close to two out of three young adults reported seeing a physician in the past year. Twenty-four percent reported accessing health care outside of Canada. In-depth interviews revealed that Chinese young adults had unmet needs due to the lack of a primary care provider and not accessing preventive care. Acculturation and health behaviour was found to be more predictive of unmet health care needs than language.
The experiences of men and women receiving primary care by attending Group Medical Visits are poorly understood. The purpose of this secondary analysis of nine in-depth interviews was to seek understanding of their experiences. The men and women in this analysis sought treatment for their chronic conditions by attending heterogeneous Group Medical Visits. A gender lens provided the necessary framework to move forward in seeking further understanding of why the men and women's experiences in this study were similar, rather than different. This study revealed six themes common to both the men and women: overcoming vulnerability and emotional isolation, connecting and creating community, reciprocal learning, increased feelings of safety, building relationship with the physician, and efficiency of time. It appears irrelevant that the audience was of mixed sex; what seemed to matter was the common link of living with a chronic condition and having someone truly understand the experience. Gender does not seem to make a distinction regarding the basic experiences shared by men and women of this age group, living with chronic conditions: the need to tell their story, and the satisfaction in and support received from telling one's illness story. A second finding was the leveling of the power structure between patients and providers, which is often inherent in traditional one-on-one physician-office appointments. The leveling of power created an increased trust between the client and physician leading to improved relationships and the creation of a safe environment to receive primary care. The men and women found the ability to express their illness story, especially to their physician and to an understanding audience of like individuals, to be very beneficial.
Recent Tri-Agency Grants
The following is a selection of grants for which the faculty member was principal investigator or co-investigator. Currently, the list only covers Canadian Tri-Agency grants from years 2013/14-2016/17 and excludes grants from any other agencies.
- Innovation in community based primary healthcare supporting transformation in the health of First Nations and rural/remote Manitoba communities: iPHIT - Canadian Institutes of Health Research (CIHR) - Team Grant: Community Based Primary Healthcare - IAPH (2015/2016)
- Validation of administrative and primary care electronic medical record derived frailty algorithms - Canadian Institutes of Health Research (CIHR) - SPOR Network in Primary and Integrated Health Care Innovations (2015/2016)
- BC's primary health care research network - Canadian Institutes of Health Research (CIHR) - SPOR Network in Primary and Integrated Health Care Innovations (2015/2016)
- Developing the BC SPOR network: a consultative process - Canadian Institutes of Health Research (CIHR) - SPOR Network in Primary and Integrated Health Care Innovations (2013/2014)
- Transforming CBPHC delivery through comprehensive performance measurement and reporting - Canadian Institutes of Health Research (CIHR) - CIHR Team Grant Program (2013/2014)
- Equity-oriented primary health care interventions for marginalized populations: addressing structural inequities and structural violence - Canadian Institutes of Health Research (CIHR) - Operating Grant: Programmatic Grants in Health and Health Equity (2013/2014)