Underemployment, Unemployment, and Mental Health

Inadequate employment, through unemployment or underemployment is expected to have consequences for the health and well-being of Canadians. This dissertation presents three studies centered on the relationship between underemployment and mental health. In the first study, ideal indicators for underemployment are described, and the stress process model is proposed as a theoretical framework for understanding the relationship between underemployment and adverse health outcomes. The second and third studies use data from a community-based survey conducted in London, Ontario, Canada in 1994/5 and 1996/7. Four indicators of underemployment are used including: lower income or benefits than in a previous job, involuntary part-time work, or over-education. The second study tests for the effects of social selection or social causation between psychological distress and employment status using both survey waves. A reciprocal process is found only for unemployment, where elevated psychological distress increases the odds of job loss by the second interview, and losing adequate employment is associated with elevated psychological distress. The transition into or out of underemployment is not associated with psychological distress. The third study focuses on over-education and its association with psychological distress using a stress process model. Potential mediators are tested including chronic strain, financial strain, work-satisfaction, self-esteem, and mastery. Among males, over-education is a significant predictor of elevated psychological distress and lower self-esteem and work satisfaction. For females, over-education is only associated with elevated psychological distress and lower work satisfaction until household income is controlled for. Gender differences are highlighted in this study, demonstrating that males and females experience underemployment differently, and the greater salience of employment status for men’s mental health. In addition, support is found for the stress process model as a framework for investigating the mechanisms that link the experience of employment to adverse health outcomes

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

Background: A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective: To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location. Proportion of variance in referral rates attributable to the patient and practice levels. Results: On average, males had 0.26, and females 0.31 referrals in a 12-month period. Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p\u3c.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions: Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time

Research Brief No. 1 - Social Inclusion of the Oldest-Old: Toward Supportive Housing Policies

Although most seniors aged 85+ live relatively independently in the community, research on this age group tends to focus on the negative aspects of aging. This study looks instead at seniors aged 85 and older who are living well and semi-independently in their communities with the help of an informal care provider. The study aims to identify the mechanisms that allow them to live with dignity and autonomy in their own homes and remain socially included in their communities. We conducted in-depth, semi-structured interviews with 16 individuals aged 85 to 94 years and their primary informal support-persons in Southwestern Ontario, from Hamilton to Chatham. The result is evidence-based information about how the “oldest-old” and their caregivers manage to overcome problems seniors experience with daily tasks such as mobility, transportation and cooking. The research identifies optimal environments in which these “caring relationships” can be sustained and in which seniors can flexibly manage daily life and continue to stay in their own homes

Patterns of referral in a Canadian primary care electronic health record database: retrospective cross-sectional analysis

Background Databases derived from primary care electronic health records (EHRs) are ideally suited to study clinical influences on referral patterns. This is the first study outside the United Kingdom to use an EHR database to describe rates of referral per patient from family physicians to specialists. Objective To use a primary care EHR database to describe referrals to specialist physicians; to partition variance in referral rates between the practice and patient levels. Methods Retrospective cross-sectional analysis of de-identified EHRs of 33 998 patients from 10 primary care practices in Ontario, Canada. The study cohort included all patients who visited their family physician 1 April 2007 to 31 March 2008 (n_24 856). Specialist referrals for each patient were counted for 12 months following their index visit. Rates of referral were compared by sex, age, number of office visits, practice location and specialist type using t-tests or Pearson's correlation. Variance partitioning determined the proportion of variance in the overall referral rate accounted for by the practice and patient levels. Results In total, 7771 patients (31.3%) had one or more referrals. The overall referral rate was 455/ 1000 patients/year (95% CI, 444_465). Rates were higher for females, older patients and rural practices. The referral rate correlated with thenumber of family physician office visits. Ninety-two percent of the total variance in referral rates was attributable to the patient (vs. practice) level. Conclusions A Canadian primary care EHR database showed similar patterns of referral to those reported from administrative databases. Most variance in referral rates is explained at the patient level

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

Background:  A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective:  To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location.  Proportion of variance in referral rates attributable to the patient and practice levels. Results:  On average, males had 0.26, and females 0.31 referrals in a 12-month period.  Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions:  Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time

Feedback and training tool to improve provision of preventive care by physicians using EMRs: a randomised control trial

Background Electronic medical records (EMRs) have the potential to improve the provision of preventive care by allowing general practitioners (GPs) to track and recall eligible patients and record testing for feedback on their service provision. Objective This study evaluates the effect of an educational intervention and feedback tool designed to teach GPs how to use their EMRs to improve their provision of preventive care. Methods A randomised controlled trial comparing rates of mammography, Papanicolaou tests, faecal occult blood tests and albumin creatinine ratios one-year pre- and post-intervention was conducted. Nine primary care practices (PCPs) representing over 30 000 patients were paired by practice size and experience of GPs, and randomly allocated to intervention or control groups. Physicians at the four intervention practices received a two-hour feedback session on their current level of preventive care and training to generate eligible patient lists for preventive services from their EMR database. Results One-year post-intervention results provided no evidence of a difference. The intervention was not a significant predictor of the one-year post-intervention test rates for any of the four tests. On average, the intervention practices increased postintervention test rates on all tests by 16.8%, and control practices increased by 22.3%. Conclusion The non-significant results may be due to a variety of reasons, including the level of intensity of the educational intervention, the cointervention of a government programme which provided incentives to GPs meeting specific targets for preventive care testing or the level of recording of tests performed in the EMR

Using volunteers to improve access to community rehabilitation in palliative care: the St Christopher's Living Well at Home Team

BackgroundUK hospices often provide outpatient rehabilitation services for people with advanced progressive illness. However, some people are unable to travel, leading to inequity in rehabilitation access.ObjectivesThe Living Well at Home Team (LWAHT) at St Christopher's Hospice aimed to evaluate whether using volunteers to support rehabilitation in peoples’ homes improved the reach of rehabilitation for people living in underserved localities and if it supported people to optimise their functional independence.MethodsThis service improvement project evaluated hospice rehabilitation uptake during the implementation of volunteer-supported community rehabilitation. Following assessment by an LWAHT therapist, eligible people were matched with a trained volunteer who supported four to eight rehabilitation sessions in the person's home. The evaluation assessed uptake of the rehabilitation sessions. Mobility, wellbeing, and goal attainment outcomes were assessed by the Life-Space Assessment (LSA), General Health Questionnaire (GHQ), and Goal Attainment Scale (GAS), respectively.ResultsIn the first year, 183 patients were referred to the LWAHT; 123 were assessed and 96 received rehabilitation including 56 who were matched with a volunteer. Following volunteer support, patients reported significant improvements in mobility [LSA median 20 (IQR, 3.5–27.8)], general health [GHQ −2 (−5.25 to 0)], and achievement of goals [GAS T-score +8 (0–18.4)].ConclusionsIt was feasible to support community rehabilitation using hospice volunteers for people with advanced progressive illness. The LWAHT service also increased the uptake of hospice centre-based rehabilitation. Further work should test efficacy and identify patients requiring additional professional input.Key messageThis is the first known study reporting on the use of trained rehabilitation volunteers to extend the reach of hospice rehabilitation services. People with limited access to the hospice, because of geographical location or personal circumstances, valued and benefited from tailored rehabilitation supported by the volunteers in their own homes

Exercise for men with prostate cancer : a systematic review and meta-analysis

Context: Exercise could be beneficial for prostate cancer survivors. However, no systematic review across cancer stages and treatment types addressing potential benefits and harms exists to date. Objective: To assess the effects of exercise on cancer-specific quality of life and adverse events in prostate cancer trials. Evidence acquisition: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, SPORTDiscus, and PEDro. We also searched grey literature databases, including trial registers. Searches were from database inception to March 2015. Standardised mean differences (SMDs) were calculated for meta-analysis. Evidence synthesis: We included 16 randomised controlled trials (RCTs) involving 1574 men with prostate cancer. Follow-up varied from 8 wk to 12 mo. RCTs involved men with stage I–IV cancers. A high risk of bias was frequently due to problematic intervention adherence. Seven trials involving 912 men measured cancer-specific quality of life. Pooling of the data from these seven trials revealed no significant effect on this outcome (SMD 0.13, 95% confidence interval [CI] –0.08 to 0.34, median follow-up 12 wk). Sensitivity analysis of studies that were judged to be of high quality indicated a moderate positive effect estimate (SMD 0.33, 95% CI 0.08–0.58; median follow-up 12 wk). Similar beneficial effects were seen for cancer-specific fatigue, submaximal fitness, and lower body strength. We found no evidence of benefit for disease progression, cardiovascular health, or sexual function. There were no deaths attributable to exercise interventions. Other serious adverse events (eg, myocardial infarction) were equivalent to those seen in controls. Conclusions: These results support the hypothesis that exercise interventions improve cancer-specific quality of life, cancer-specific fatigue, submaximal fitness, and lower body strength. Patient summary: This review shows that exercise/physical activity interventions can improve quality of life, fatigue, fitness, and function for men with prostate cancer