Methods in Health Geography

1
Methods in Health Geography

• QUANTITATIVE REVOLUTION
• In 1950s geographers generally adopted
  statistical methods/quantitative methods
• Descriptive statistics ? mathematical modeling
• spatial analysis
• QUALITATIVE EXPLORATION
• - Late 1960s, early 1970s concern focused on
  the peopling of human geography (Cloke et al.,
  1991)

2
Humanism

• Based in humanist thought (humanities)
• Reaction to positivist spatial science
• Behavioural geography was the bridge to the
  development of a real evolution of humanistic
  geography
• Shift in focus from humans acting in the world to
  humans simply reacting to it (environmental
  determinism)
• Humanistic geography came into existence in late
  1960s early 1970s

3
Humanism

• An approach in human geography distinguished by
  the central and active role it gives to human
  awareness and human agency, human consciousness
  and creativity
• at once an attempt at understanding meaning,
  value and the human significance of life
  events (Buttimer, 1979) and
• an expansive view of what the human person is
  and can do (Tuan, 1976)

4
Humanism

• Attention paid to geographer (actively
  participating in research writing)
• Attention given to the crucial role played by
  humans (perceiving, interpreting, shaping)
• Focus on place ways in which people relate to
  the places around them
• Intimate emotional, practical, political other
  attachments

5
Holistic

• Geography of everyday life anchored in the
  differing
• Economic
• Social
• Political circumstances of different places
• Attention paid to context

6
Qualitative Research, defn.

• Ways of examining the social world, whereby
  central importance is given to the actors
  definitions and behaviour. The term covers a
  wide variety of approaches and is used
  interchangeably with field, research, ethnography
  interpretative research.

7
Methods

• Qualitative (interpretative/ethnographic)
• Participant observation
• Key-informant interviews
• In-depth interviewing
• Non-structured, Semi-structured, Structured
• Focus groups (as above)
• Case studies
• Videography/photography
• Field notes
• other

8
Methods of Data Analysis

• Develop a preliminary coding system
• Prepare the transcript for analysis
• Ascribe codes to text
• Retrieve similarly coded text
• Review the data by themes

9
Changing Geographies of Care Examining
Palliation on Home Space
10
Caregiver Burden Increasing

• In quantity and quality (becoming more intense)
• Move toward community care/hospital-in-the-home
• 3 aspects of caregiving identified (Qureshi
  Walker1989)
• physical labour,
• emotional labour
• management of care

11
Research Objective Methods

• explore the impact, experience, and meaning of
  home-based palliative care on informal caregivers
  living caring for a dying patient at home
• caregivers perspective sought
• assisted by formal (publicly provided) home care
• Comparative rural/urban sample frame employed to
  capture service differentiation
• qualitative research techniques used to capture
  the representations of home space holistically

12
Case Study Research

• defined by interest in phenomenon studied rather
  than method of inquiry
• seeks to learn what is common (generalizable)
  across cases, as well as what is particular in
  each case
• mixed methods employed
• orient to complexities connecting ordinary
  practice in natural habitats to the abstractions
  and concerns of diverse academic disciplines.
  (Stake, 2000)

13
Qualitative Methods

• Collective case study using a thematic analysis
  approach
• ideally semi-structured in-depth interviews
  videography (for descriptive purposes)
• defined by each of Pattisons (1978) three
  clinical phases of dying (1) Acute crisis phase,
  (2) Chronic living-dying phase, (3) Terminal
  phase
• defined by Randos (1995) three bereavement
  periods (1) Avoidance phase, (2) Confrontation
  phase, (3) Accommodation phase
• palliative Home Care Case Managers with Saskatoon
  Palliative Home Care Program (SDH) employ
  purposive sampling definition of phases/periods
• 3 cases in total two contrasting cases presented

14
Results Thematic Categories

• Home Place
• Intra-Household Adjustments
• Material Culture
• Services
• Caregiver Role

15
CASE 1 Home Place (1 bedroom apartment)

• apartment chosen for convenience, location, cost
• very small, not wheel-chair accessible
• patient originally from farm and has lived in
  northern city for vast majority of life
• caregiver grew up in northern city, lived in
  Saskatoon for university, overseas since

16
Meaning of Home (lt1 year)

• The apartment is just a building, it is what
  inside, this energy inside. You can have a home
  anywhere -- we can be living on the street, but
  if it doesnt have good energy and happiness it
  is not a home. (I1)
• It is still the same it is still where the
  heart is. Still where the heart is, still where
  the cat is, very important. (I2)

17
Home as Sanctuary

• I do not like people in the house with negative
  energy. People coming to visit Mom, if they are
  going to cry we just say excuse me, you have to
  leave because this is a home of happy energy .
  And they have to respect that. They just say
  Well, you are not allowing us to grieve, I am
  like Well, you have to respect the dying person
  here. She doesnt need this and she doesnt want
  this. It brings her down, it destroys her energy
  and it destroys energy in the house. (I1)

18
Intra-Household Adjustments (Physical Environment)

• living room focus of home (TV, telephone)
• medicalization of the home
• electric condenser with 25 ft of hose, wheelchair
  (later with tray, I2), Hoyer lift (later, I2)
• most change in bathroom -- support bars on
  toilet, hydraulic bath lift

19
(No Transcript)
20
(No Transcript)
21
Placement of Furniture

• She (mother) likes to see the sunsets and the sun
  rises. That is very spiritual for her. And for
  us too, another spiritual one for both of us is
  looking at the sky. You know, she says if I see
  the sky, I know God is there. When you see the
  sky, you know God is happy you know coming from
  the farm (I1)

22
Limitations of Home

• It Hoyer lift a patient lifting device is a
  very cumbersome, clumsy machine used for lifting
  people. It is not practical in the house . It
  takes longer to hook it up and everything than to
  just pick her (mother) up. If she was a lot
  heavier okay, but she is heavy so it was just
  pick and drag. And so if she has to go to the
  bathroom, the Hoyer lift, you know, take five
  minutes up you need a big room to manoeuvre it
  into. (I2)

23
Outcome

• Patient put in a long-term care facility and died
  within 6 months
• Belongings put in storage apartment vacated
• Caregiver returned overseas after a lengthy
  vacation returned for the funeral
• Caregiver is very unsatisfied with the outcome
  and is particularly disappointed with the public
  health care system

24
CASE 2 Home Place

• large home designed by couple
• built as wheel-chair accessible although shower
  garage not fully accessible
• residence for 5 years previously lived in
  Saskatoon for the majority of their adult life
• both originally from rural farm communities

25
(No Transcript)
26
Meaning of Home

• Home is where the heart is. I love our home I
  love the outdoors in particular. Our house is
  wonderful. Its wonderful that (patients name)
  is able to enjoy it. (I1)
• I like to come home. (I2)

27
Home as Sanctuary

• I think when we first found out he had lung
  cancer, well initially we did a lot of bawling
  and that didnt please (patients name) so we
  dont do that anymore. (I1)

28
Intra-Household Adjustments (Physical
Environment)

• kitchen focus of home 90 waking time spent
  there (TV telephone)
• medicalization of home
• reclining chair, wheeled walker (purchased),
  electric bed (purchased), multiple floor disks,
  support poles, cushions/sheepskin, Hoyer lift,
  oxygen machine
• most change in bathroom -- wheeled commode, bath
  bench

29
Outcome

• Patient died at home with caregiver present
• Celebratory atmosphere with family and friends
  present
• Caregiver sorry to see lazy-boy chair returned to
  Health District (removed from kitchen)
• Ongoing support throughout bereavement by
  family/church/friends
• Maintains residence possibility of renting
  lower-level as an apartment

30
Summary Home Place

• SIMILARITIES
• Meaning of home home as sanctuary
• DIFFERENCES
• Size comfort of physical home
• Longevity of residence (1yr vs. 5 yr)
• Degree of personalization

31
Summary Intra-Household Adjustments

• SIMILARITIES
• Most change in bathroom
• DIFFERENCES
• action centre room, where care focused
• (living room vs. kitchen)
• Ability to purchase aides (walker, electric bed)
• Access to physical aides (chair, disks, support
  poles, etc.) due to occupational therapy visits
  informal support

32
Discussion Confirmations

• Brown et al.s work (1990) that illustrated the
  benefits of palliative home care occur only when
  
• there is a willing and able caregiver
• when home care services are provided to the
  extent required
• when the physical environment of the home can be
  adapted to meet the patients needs
• Aranda Knights work (1997), suggesting
  caregiver burden is multidimensional, where
  stress and coping models include numerous
  categorical variables
• socio-economic status
• primary stressors and secondary strains

33
Policy Contributions

• prevention of caregiver burnout
• provision of appropriate home care services to
  the extent required
• need for uniform and comprehensive use of allied
  health professionals for specialist support
• social workers for mental well-being/self-care
• OT for ergonomics/physical health
• meet need for communication around
  availability/accessibility of programs/services
• what is available how can it be accessed? What
  costs and what doesnt? i.e. palliative drug
  plan, nurses versus homemakers,
  equipment/supplies

34
Rigour

• Credibility
• purposive sampling
• prolonged engagement
• investigator triangulation
• Transferability
• purposive sampling

• Dependability
• mechanically recorded data (audio-taped)
• multiple researchers
• participant checks
• Confirmability
• - SDH Palliative Care Team checks
• - analytical notebook

35
Rigour

• Credibility
• purposive sampling
• prolonged engagement
• investigator triangulation
• Transferability
• purposive sampling

• Dependability
• mechanically recorded data (audio-taped)
• multiple researchers
• participant checks
• Confirmability
• - SDH Palliative Care Team checks
• - analytical notebook

36
Qualitative VS Quantitative

• QUALITATIVE
• Focus is on quality the what, how, when where
  the essence ambiance
• The meanings, concepts, definitions,
  characteristics, metaphors, symbols, and
  descriptions of things
• Depth of understanding
• Time consuming
• Requires greater clarity of goals during design
  stages

• QUANTITATIVE
• Focus in on quantity counts measures of
  things
• Variables (units of measurement)
• Clinically collected
• Collected via survey
• Collected orally
• Breadth of understanding
• Technically dependent
• Statistical analysis determines relationships
  among variables
• Tests carefully constructed causal hypotheses